In-depth: HIV/AIDS in Southern Sudan

SUDAN: The risks of childbirth in southern Sudan

Photo: UNICEF/Roger Lemoyne (2001)
Baby Abou, Malual Kon, southern Sudan
NAIROBI, 20 August 2003 (IRIN) - Once a pregnant woman goes into labour in rural southern Sudan she is taking a serious risk with her long-term health. Should she undergo a difficult labour there is no taxi waiting to rush her to the nearest obstetric unit; there is no skilled surgeon to deliver the child by caesarean; and there are few drugs available to dull the pain. More often than not, she will just have to submit to the forces of nature, and hope for the best.

So, when Nyanut Deng began to experience complications while giving birth in a rural area of northern Bahr-al-Ghazal, there were no doctors to turn to. She had to endure the excruciating pain caused by a prolonged obstructed labour, and as a result suffered an obstetric fistula, a debilitating pregnancy-related condition.

According to the United Nations Population Fund (UNFPA), fistula usually occurs when a woman is in obstructed labour for days on end without medical help. The prolonged pressure of the baby's head against the mother's pelvis cuts off the blood supply to the soft tissues surrounding her bladder, rectum and vagina. The injured tissue soon rots away, leaving a perforation, or fistula.

In some of the worst cases, women who remain untreated can suffer a slow, premature death from infection and kidney failure, UNFPA says.

The World Health Organisation estimates suggest there are over two million obstetric fistula sufferers worldwide, with some 50,000 to 100,000 new cases every year.

Photo: UNICEF (1998)
As a result of Sudan’s civil war, many women have been left to support their families on their own
Prevention and Cure

Fistula is preventable and is virtually unknown in places where early pregnancy is discouraged, young women are educated, family planning is accessible and skilled medical care is provided at childbirth, UNFPA said in a recent report entitled: "Obstetric Fistula Needs Assessment: Findings from Nine African Countries".

A cure is also available. Reconstructive surgery can mend the injury; the procedure has a 90 percent success rate, and costs between US $100 and US $400. However, most women in southern Sudan, as well as in many other rural areas of sub-Saharan Africa, are either unaware that the treatment exists, or are unable to afford or access it. As a result of this, many women continue to suffer this painful and debilitating condition for the rest of their lives.

Having heard that she may be able to receive some professional medical assistance in Rumbek, Nyanut was able, through the status afforded her by her marriage to a rebel soldier, to arrange transport to the hospital there. The drive, a journey of several days along bush roads was very painful, she told IRIN.

Once she finally arrived, she was given palliative care, but was told she would have to wait for some time before she could undergo corrective surgery, as there was at that time no surgeon at the hospital trained in the necessary procedures.

In the end, she waited at the hospital for two years before the facilities and skills were available to treat her.

Since Nyanut's arrival some 3 years ago, there has been a modest improvement in access to surgery for fistula at the hospital. An experienced surgeon now visits Rumbek at least once yearly, and will also come if the number of patients requiring surgery reaches about 10, Chief Nurse Grace Kuria, told IRIN.

According to Kuria, there was currently one patient in the hospital requiring such surgery. Because of the dearth of local surgeons trained in the necessary procedures, she would either have to wait until some additional cases arrived, or until January 2004, when the surgeon's next visit was scheduled, Kuria said.

Professor Mayo of the Italian non-governmental organisation Comitato Collaborazione Medica (CCM), a group that is heavily involved in the work of the hospital, told IRIN some efforts were underway to train local surgeons to perform both caesarean sections to prevent fistula, and to carry out the reconstructive fistula surgery.

Mayo estimated that between 100 and 200 health centres with the appropriate facilities and skilled staff would be required to deal with the problems of obstructed labour across the whole of southern Sudan. The scale of the challenge becomes clear if one considers there are currently around 10 such centres, and the training programme for fistula surgeons takes around 3 years to complete, Mayo told IRIN.

Photo: UNICEF/Stevie Mann (2001)
Mother and child in Rumbek, southern Sudan
Education crucial

While establishing well-equipped clinics and training surgeons requires significant investment in time and resources, it is possible to make relatively fast improvements in simple preventive strategies by improving health education, and in providing basic assistance to women during pregnancy and childbirth.

Postponing the age of marriage and delaying childbirth can significantly reduce the risk of obstructed labour, UNFPA says. In addition, better education for women and their families about he dangers of child birth and pregnancy are ‘crucial’, it states.

Attempts to improve the situation in the rural areas around Rumbek have involved the Maternal and Child Health (MCH) services, developed as a partnership between the local communities and the United Nations Children's Fund (UNICEF).

The MCH aims to work, in part, through Traditional Birth Attendants (TBAs) and community health workers operating out of local Public Health Care Units (PHCUs). These workers are involved in disseminating information on maternal health, on nutrition, and on safe delivery practices. It is also hoped that TBAs should play a key role in helping women experiencing obstructed labour to reach a hospital, wherever this is possible.

Nyantoch Pouric, a TBA working at the PHCU in Amer village told IRIN that women from the nearby area would normally come to her health unit for assistance in delivering their babies.

If, however, a woman found herself experiencing a difficult labour in her home, the TBA would travel through the bush to attend her. She told IRIN she had been faced on at least two occasions with a labour which she had neither the expertise nor the equipment to deal with, and had sent the women to Rumbek hospital, located about one hour's drive away. Transport from the village was scarce, however, and the women had had to be carried to the hospital while in labour, she said.

In addition to physical pain, women suffering from fistula sometimes undergo the psychological trauma of being shunned by their community, rejected by their husbands and blamed for their condition.

"If she had gone back home with this problem she would have been an outcast because people think something strange has happened to her. She would have been abandoned," a local health worker, speaking about Nyanut's case, told IRIN.

Without any family support, without an income of their own, and without many marketable skills, this leaves many of the women in a desperate position. Some, despite their condition, are forced to turn to sex work to survive, further accentuating their social and physical vulnerability, according to UNFPA.

Because she is now cured Nyanut would be accepted back into her community if she were to return, but has decided to stay at the hospital. She has now become a valuable member of the hospital staff, and although she is living apart from her three children, she says she is happy at the hospital and has no plans to leave.

Web links
Unicef maternal mortality map worldwide
Millenium Development Goals: Maternal Health
UNFPA Fistula report
Engender Health (Women’s Health Organisation)

See also:
Special Report on women in the south
Women and children in prison
Lead Feature
Other IRIN Reports
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