Care in the desert
by Sean Deely

Fatima, a 17-year-old Somali woman, had been in labour for over 48 hours when Rugiyo Ahmed Musa was called to see her. Rugiyo is a midwife at the Somali Red Crescent Society's mother and child health clinic (MCH) in Qarhis, in the north-east of Somalia. Fatima had collapsed near the village after a three-hour trek. Her husband carried her to a house in the village and rushed to alert staff at the Red Crescent clinic.

This would be her first child. Like almost all Somali women, Fatima had been subjected to circumcision during childhood - or female genital mutilation. In this case, third degree or pharaonic circumcision, where the
clitoris and labia are removed and the vagina sutured closed. It is estimated that there are between 100 and 132 million girls and women worldwide who have been subjected to this practice.

Circumcision is usually done by a traditional birth attendant or healer often using razor blades or rudimentary tools instead of scalpels. As a consequence, safe childbirth requires an episiotomy - a surgical procedure to open the vagina during childbirth to allow the child to be born. Both lateral and vertical incisions are frequently required.

Examining Fatima, Rugiyo found that she was eight centimetres dilated, but the episiotomy performed by the local birth attendant a few days earlier was insufficient. In this case only a vertical incision had been made and the child was trapped in the birth canal. Rugiyo made a second, lateral incision and assisted with the birth.

Dying from inadequate health care

Midwife Serad Aden Mohamed, health officer at the Garowe Red Crescent branch supervises seven National Society MCH clinics. "We have many cases like this, because there are few clinics, women - especially nomads -rely on traditional birth attendants. Most of them have no formal training and some don't even know the basics about when to cut the umbilical cord, how to clean the baby's airway, or massage the chest. When complications arise they don't know what to do."
Many women die in childbirth as a result - at 1,600 per 100,000 live births, the maternal mortality rate in Somalia is the highest in the world. UNICEF estimates infant mortality at 132 per 1,000 live births and child mortality is as high as 224 per 1,000. Put simply, one child in every three dies before they reach the age of five.

Plagued by major health problems from acute respiratory infections, diarrhoea, measles and tuberculosis, Puntland's population of over a million people is spread out over a geographical area bigger than England, encompassing the north-east Somali regions of Mudug, Nugal, Bari, Sool and the eastern part of Sanaag. While the region is relatively calm, there are few roads and fewer health facilities. An estimated 60 per cent of this population is nomadic, which further complicates issues of access to the limited number of health services that exist. According to the director general of health in the regional administration in Garowe, there are 63 qualified doctors registered in Puntland, five functioning hospitals, three health centres, 25 MCH clinics, and 62 health posts (many of them not functioning).

In Qarhis, the range of health-care providers is typical of most of Puntland. Apart from the traditional birth attendants, there are five traditional healers in the village. Munina Osman, 63 years of age, is one. Her grandfather was a well-known traditional healer in the Qarhis area. Her grandmother was also a traditional healer. "I learned a lot of things about healing from them when I was young and have gained a lot of experience since I became a traditional healer when I was 20."

She has three main types of treatment: burning, cutting and orally administered herbal potions. "I always burn when there is a fever: it is necessary to stop the infection - otherwise it will spread and cause long-term damage."

Sometimes she 'cuts' her patients. This involves making small incisions at the point of pain - usually using a razor blade. She stressed that burning and cutting are superficial and that care is taken not to damage veins. Herbal 'medicine' is prepared by mixing certain herbs and sheep lard to make a potion that she prescribes to people with different ailments.

Additionally, there are two 'pharmacies' on the main street where a variety of different clothing, cosmetic and medical products are for sale. Stocks of medicine are very limited, and the owners have no medical training.

Contrasts from north to south

Since the collapse of central government in 1991, Somali society has been plunged into a downward spiral of violence. A low-intensity conflict persists in central-southern Somalia, thus impairing development and recovery efforts and leaving the population in a precarious environment. Elsewhere, in the north-east the Puntland state enjoys relative stability.

The emergency response of the Movement includes food, non-food and seed assistance. Being the only Somali structure that can still claim a degree of national representation, the Somali Red Crescent Society (SRCS) runs four hospitals and 45 primary health centres throughout the country, with major assistance from the ICRC and additional support from the Federation and various National Societies.

Sustaining the service

In 1993 the Somali Red Crescent, supported by the Federation, developed an integrated health-care programme within the mother and child health/ outpatient clinics and health posts. In the absence of a central health service the National Society runs four hospitals and 45 primary health clinics throughout the country serving 840,000 people with support from the ICRC and the Federation. Twelve of these clinics are located in the Puntland. Eight years on, the clinics provide a lifeline for thousands of vulnerable mothers and children, in communities like Qarhis - three hours' drive away from the nearest alternative health facilities.

The Somali Red Crescent also provides medical supplies to the clinics on a monthly basis. One kit of essential drugs with no injectables, and a supply of vaccines. The vaccines are essential in the battle to reduce child mortality. However many of the clinics are without refrigeration facilities and the cost is counted in lost opportunities to immunize nomadic children who may make only one visit before their family moves on.

The National Society also offers training and special kits to three traditional birth attendants each year, who then work in close collaboration with the clinic. Last year, three attendants received training in the Qarhis.

The Somali Red Crescent is dependent on outside aid from the Federation, ICRC and the World Bank to run these clinics, while UNICEF provides some drugs and training support for clinic staff. Today, the challenge is how to convert an essentially emergency-driven, relief health project, into a sustainable service that meets the needs of communities recovering from conflict and rebuilding their lives.

In a joint initiative between the Federation, the Somali Red Crescent and the World Bank, a health-sector rehabilitation study was done in April 2000. The purpose of it was to identify a system to share the cost of maintaining the clinics between those in the community who could afford to pay, the emerging directorate of health in Puntland state's Ministry of Social Affairs, and the international donors who have kept the programme going since 1993.

The first phase of the study concluded in March 2001 with the setting up of a one-year pilot project for sustaining primary health service provision in Qarhis clinic. This project establishes a partnership between the community in Qarhis, the directorate of health in Puntland and the Somali Red Crescent. Within this new project, the cost of running the clinic will be shared among the three partners, with the National Society and its donors assuming 80 per cent, the community 15 per cent and the directorate of health 5 per cent.

Thankfully for Fatima, the clinic continues to function - for now. The prolonged labour caused post-partum haemorrhaging or internal bleeding. The midwife, Rugiyo, had ergometrine on hand to contract the uterus and stem the bleeding. Neither diagnosis nor treatment would have been available from a traditional birth attendant. "We don't know what would have happened if the midwife had not been available today, but probably both Fatima and her child would have died" said Serad Aden Mohamed, health officer at the Garowe Red Crescent branch.