Kassala — In Kassala, an oasis town in eastern Sudan that also lends its name to the surrounding state, the greenery can be deceptive. The flat desert sprawls for miles around, dotted with tiny villages where the only colors to be seen for miles are the bright clothes of women going about their daily work.
Prominent as these women are against the stark backdrop of the desert, they are also among the most vulnerable in the world. Women with health emergencies related to childbearing often die before they can be identified or referred to hospitals. But there is hope now, as trained midwives in these villages help the women around them and recognize complications before they turn life-threatening.
Training for village midwives
In Kassala state, home to nearly two million people, the Sudan MDTF-National Community Development Fund (CDF) project and the Decentralized Health System Development project (DHSDP) supported the establishment of midwifery training schools in early 2010 in localities such as Waggar and Hamashkoraib, where women are not usually allowed to move to the capital for training.
The DHSDP is also supporting construction of a midwifery school in Kassala town, for the continuous training of older village midwives, and the training of new students with a fresh two-year curriculum.
Before this effort, there were fewer than 100 trained midwives in these areas, and all of them were located in the main towns. With the new schools, there are now over 250 trained midwives deployed mostly in rural areas.
These graduates are paid a performance-based incentive by the DHSDP. This has led to a higher number of first ante-natal consultancies, deliveries and post-natal consultancies that are assisted by qualified staff. It has also reduced the financial burden on communities to access this type of care, mainly because the village midwives receive incentives from the project and do not charge for services.
The midwifery profession also contributes to women's empowerment and elevates the status of women because midwives are considered important figures in the villages, and contribute both socially and economically to their families and communities.
"My community has benefited"
Nora, a young graduate from the Tawaeet training school for midwives, is currently taking additional medical training in Kassala town. She comes from Tagher village, which is about two hours' drive from Kassala town, and is proud to be the first from her village to serve her community.
"I have benefited a lot, and also my community has benefited," says the 23-year-old Nora, who graduated recently from the midwives school, where graduates are supported by the project with supplies and supervision.
"When we graduated from the midwives school, they gave us a box of medical supplies and instruments such as scissors, thermometer, blood pressure instrument, anesthetic, gauze fabric and and also vitamins to give pregnant women who come for check-ups. Our supplies are replenished every month."
"We have learned a lot about personal hygiene and hygienic childbirth, and also about stopping harmful practices like female genital mutilation," she adds.
However, it was not all smooth sailing for young women like Nora.
"At first our parents didn't want us girls to come to Kassala" she recalls. "But we told them we needed to get training. There are women who are dying now during childbirth because they don't have trained midwives to help them. So we were able to convince them."
Largely due to the village midwives effort, the rate of assisted deliveries has gone up in Kassala from 17 percent between January and June 2010 to 37 percent between July 2010 and December 2011.
"I tell the pregnant women to come for check-ups and I see how their pregnancy is going. If I see that there are going to be complications with the delivery, I send them to the hospital, if I see that she can give birth without complications, I help her give birth at home," explains Nora.
A mix of factors may be contributing to falling maternal mortality
As recently as 2006, Sudan Household Survey data showed that women in Kassala state were dying of maternity-related causes at the tragically high rate of 1,414 deaths per 100,000 live births-one of the highest rates in the developing world. But the most recent survey in 2010 shows a much lower rate.
"Many factors have led to what appears to be a rapid decline in maternal mortality in Kassala, including support from development partners on training midwives who can refer risky cases to urban facilities on time, providing nutritional supplements to women, and raising awareness about reproductive health," said Dr. Mahjoub ElNour, Coordinator of Sudan's Decentralized Health System Development Project (DHSDP) in Kassala.
"Efforts to improve infrastructure such as rural roads have also been beneficial for women's health, but there are still great challenges ahead, especially when it comes to reaching women with complicated pregnancies in remote areas, so much more remains to be done," he added.
Isabel Soares, World Bank task team leader for the DHSDP, notes that more analysis is needed in Sudan to identify the drivers of the decrease in maternal mortality in Kassala and other areas.
An assessment of factors such as the functioning of the first- level referral system and the rural hospitals is also much needed, she said.
Support from development partners is paying off
Improvements in reproductive health in these and other parts of Sudan have been possible with the support of many development partners such as UNICEF, UNFPA, WHO, and some international NGOs such as Goal. UNICEF has adopted the midwives training as a model and replicated it by establishing a boarding school in 2010 for the training of 40 midwives.
"Providing basic services such as health, education, water, and power can play a major role in promoting peace and stability in post-conflict areas," said Endeshaw Tadesse, World Bank task team leader for the Community Development Fund. "We have seen this very clearly in Sudan."