S O M A L I A - Unicef

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Ê-/1/" Ê  9--Ê"Ê , *," 1 /6  /Ê April 2009

This document has beeen produced upon request and with collaboration of the health authorities of Somalia. This document has been developed with assistance from UNFPA, WHO and UNICEF. The views expressed herein cannot be taken to reflect the official opinion of UNFPA, WHO or UNICEF.

Ê-/1/" Ê 9-"Ê, *," 1 /6 Ê /Ê  Ê-"Ê April 2009 Ingvil Krarup Sorbye, MD Consultant WHO/UNFPA Somalia offices

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Table of Contents Acknowledgements. Abbreviations. .

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7 8

Executive summary.

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10

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1.

Introduction and methodology.

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1.1 1.2 1.3 1.4 1.5

Reproductive health rights. . . . Background: Somalia. . . . Reproductive health in a Somali cultural context. Reproductive health indicators for Somalia. Methodology. . . . . .

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15 18 21 23 28

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Service delivery. .

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2.1 2.2 2.3 2.4 2.5 2.6 2.7 2.8 2.9 2.10 2.11 2.12 2.13 2.14 2.15

Health systems, infrastructure and service delivery. Proposed framework for delivery of health services. General barriers to access. . . . . Quality of services. . . . . . Safety . . . . . . . Essential delivery care. . . . . Emergency Obstetric Care (EmOC). . . . Neonatal and postnatal care. . . . Antenatal care. . . . . . Postpartum care. . . . . . Family planning/birth spacing. . . . Obstetric Fistula . . . . . . Post-abortion care. . . . . . Prevention and treatment of STI/HIV-AIDS. . Medical response to survivors of sexual & gender-based violence (SGBV). . . . Adolescent and youth reproductive health. . . Infertility and cancer of the reproductive tract organs.

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32 34 36 36 36 37 43 51 53 58 60 63 65 66

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67 69 70

3.

Health work force.

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72

3.1 3.2 3.3 3.4

HR policy level. . . . . HR availability and production. . . Key human resource issues and concerns. . HR management. . . . .

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72 72 75 77

4.

Information.

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78

4.1

Health information systems. .

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78

5.

Finances.

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79

5.1 5.2 5.3

Healthcare finance and expenditure. . . Payment of RH services. . . . . Future financing of reproductive health services. .

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79 81 82

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Medical products and technologies.

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85

6.1

RH commodity supply and distribution.

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85

2.16 2.17

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7.

Governance.

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86

7.1

Governance in RH.

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86

8.

Discussion. .

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87

8.1 8.2 8.3

Addressing maternal and neonatal survival. . . Bridging the gaps. . . . . . . Community mobilization for reproductive health services.

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87 88 89

9.

Summary of conclusions and recommendations.

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90

9.1 9.2 9.3 9.4.

Essential and Emergency Obstetric Care. . . Antenatal, postpartum and neonatal care. . . Birth spacing/limiting and prevention of pregnancy. Obstetric fistula, post-abortion care and sexual- and gender-based violence, including FGM. . . Human resources, finances and governance. .

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90 90 91

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91 92

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9.5

REFERENCES. ANNEX A: ANNEX B: ANNEX C: ANNEX D: ANNEX ANNEX ANNEX ANNEX ANNEX ANNEX ANNEX ANNEX ANNEX

E: F: G: H: I: J: K: L: M:

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WHO shortlist of Reproductive Health Indicators for Global Monitoring. . . . . . . Institutions and persons visited in Hargeisa, 02/09. . Basic and Comprehensive Obstetric Care. . . . Monitoring and evaluation tools of obstetric and neonatal care: UN process indicators. . . . . . ([FHUSWVIURP³7KH(VVHQWLDO3DFNDJHRI+HDOWK6HUYLFHV´. Obstetric care Somaliland: information as at January 2009. Obstetric care in Puntland: information as at January 2009 . Obstetric care in Central South Zone as at January 2009. Reproductive health activities by implementing partners. . SGBV/FGM: Lessons learned and best practices . . . Organizational structure of the Ministry of Health(3 zones). Maternity waiting shelters. . . . . . Terms of Reference - Consultant Reproductive Health. .

96 98 99 100 101 109 111 112 114 121 122 125 126

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Acknowledgements The people and organizations below are acknowledged for their contributions at various stages of this work. -

Somalia Support Secretariat, Nairobi (Including Dr Kamran Mashhadi) Dr. Marthe Everard WHO Somalia Dr. Humayun Rizwan WHO Somalia Mr. George Nsiah UNFPA Somalia Dr. Rogaia Abuelgasim UNFPA Somalia Dr. Suraya Dalil UNICEF Somalia Austen Davis UNICEF Somalia Dr Geoffrey Acaye UNICEF Somalia

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Officers Officers Officers & Consultants

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Ministry of Health and Labour, Somaliland Somaliland Medical Association Somaliland Nurse and Midwife Association Staff and Director, Hargeisa Group Hospital, Hargeisa Staff and Director, Edna Adan Maternity Hospital, Hargeisa Staff and Director, Manhall Hospital, Hargeisa

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AAH CCBRS COOPI CISP COSV CRS GHC Health Unlimited IMC ICRC/IFRC/SRCS LATH MDM MSF H MSF B MSF CH MSF ES Muslim Aid SC/UK SOS Kinderdorf THET

WHO Somalia/Nairobi/Hargeisa/Garowe UNFPA Somalia/Nairobi/Hargeisa/Garowe UNICEF Somalia/Nairobi/Hargeisa/ Garowe/Bosasso

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Abbreviations AIDS ANC APH ART BCC BEmOC CDK CEmOC CFR CHW CISP COOPI COSV CPR CS CSZ EOC EPHS FGM FP FSAU GHC H HBV HC HGH HIV HMIS HPV HR IASC IBP ICRC IDP IFRC IMC IUFD IUD KABP KAP

acquired immune deficiency syndrome antenatal care ante-partum haemorrhage antiretroviral therapy behaviour change communication basic emergency obstetric care clean delivery kit comprehensive emergency obstetric care case fatality rate community health worker Comitato Internazionale Cooperazione Internazionale per lo Sviluppo Dei Popoli Comitato Di Coordinamento Delle Organizzazioni Per Il Servizio Volontario contraceptive prevalence rate Caesarean section Central South Zone emergency obstetric care Essential Package of Health Services female genital mutilation family planning Food Security Analysis Unit Gedo Health Consortium hospital hepatitis B virus health centre Hargeisa Group Hospital human immunodeficiency virus health management information system human papilloma virus human resources Inter-Agency Standing Committee Implementing Best Practices International Committee of Red Cross internally displaced person International Federation of Red Cross and Red Crescent Societies International Medical Corps intrauterine foetal death intrauterine contraceptive device knowledge, attitudes, behaviour, practices knowledge, attitudes and practices

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MCH MD MDM MDG M&E MICS MMR MoH MoHL MSF NEZ NGO NWZ OPD OT PAM PEP PMR PMTCT PNC PPC PPH RH RPR SC/UK SGBV SRCS STI TB TBA TFG TFR TPHA TT UN UNAIDS UNDP UNFPA UNICEF UTI VCT VDRL WHO

mother and child health medical doctor Médecins du Monde Millennium Development Goal monitoring and evaluation Multiple Indicator Cluster Survey maternal mortality ratio Ministry of Health Ministry of Health and Labour Médecins Sans Frontieres North East Zone non-governmental organization North West Zone outpatient department operation theatre pregnancy-associated malaria post-exposure prophylaxis perinatal mortality rate prevention of mother to child transmission postnatal care postpartum care postpartum haemorrhage reproductive health rapid plasma reagin Save the Children - United Kingdom sexual and gender-based violence Somali Red Crescent Society sexually transmitted infection tuberculosis traditional birth attendant Transitional Federal Government total fertility rate Treponema Pallidum Haemagglutination Assay tetanus toxoid United Nations Joint United Nations Programme on HIV/AIDS United Nations Development Programme United Nations Population Fund United Nations &KLOGUHQ¶V¶ Fund urinary tract infection voluntary counselling and testing venereal disease research laboratory World Health Organization

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Executive summary Background Reproductive health implies that people are able to have a responsible, satisfying and safe sex life and that they have the capability to reproduce and the freedom to decide if, when and how often to do so. In Somalia, the reality within reproductive health is far from this goal. Indicators show high maternal and perinatal mortality, a very high fertility rate and almost universal female genital mutilation. Poverty, low status of women, suboptimal nutritional status and widespread additional harmful practices further contribute to the high burden of ill-health among mothers and newborns. Due to poor basic education and lack of sexual education in schools, levels of information on risks related to pregnancy and childbirth are low, and are more likely to derive from traditional beliefs than from informed health staff. Awareness of beneficial effects of preventive health services such as vaccination and birth spacing is poor and many misconceptions prevail.

Rationale for the study A comprehensive situation analysis of reproductive health in Somalia at this point in time was identified from the need for relevant background information in order to be able to assess needs, gaps and possibilities for intervention. Based on this, the plan is to formulate a prioritized action strategy in a setting where needs are widespread and restraints concerning access to population, security and financial means are many.

Methodology The core findings of this report are based on an extensive literature review, interviews with key implementing actors at field and headquarter levels. Restrictions on access to Somalia due to poor security made it necessary to conduct the majority of the work from Nairobi (Kenya) and Hargeisa (Somaliland).

Key findings There are considerable unmet needs in all major fields of reproductive health in Somalia. Due to years of war, conflict and lack of an effective government, the health system is fragmented, highly privatized and underperforming, and suffers from major deficiencies in basic funding, qualified human resources and management mechanisms. Concerning maternal and neonatal health, more than 90% of women deliver at home and more than half are assisted by a traditional birth attendant. Access to skilled delivery care and emergency obstetric care is poor, and the

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rural and nomadic populations are virtually without access to timely obstetric intervention should the need arise. There is a major lack of facilities able to handle basic emergency obstetric care, and a dire shortage of qualified midwives to staff and manage these. Referral centres for caesarean sections are under-utilized and the services are of poor quality with a high case fatality rate. Newborn care is neglected, with major missed opportunities to secure immediate survival. Only one out of four pregnant women attends antenatal care where services are of poor quality, constituting another missed opportunity. Concerning birth spacing and limiting, 26% of women have unmet needs yet only 1% of Somali women uses a modern method of family planning. Postabortion care and medical treatment for victims of sexual and gender-based violence and STIs are not universally available. The special needs of adolescents are presently not being addressed. Barriers to accessing reproductive health care are many: low awareness among the population of beneficial effects; financial obstacles in the form of almost universal user fees and expensive transport; logistic obstacles such as long distances and lack of transport to health service providers for rural and nomadic populations, all play a part. Poor quality of services, a high number of unskilled staff, incoherent running of services and breaks in supplies, harm trust in the public sector and further aggravate the situation. The present pool of qualified reproductive health staff is small, aged and under-trained, with a grave shortage of qualified midwives. Urban clustering of qualified midwives and doctors leaves rural areas relying heavily on auxiliary staff, most of who are inadequately trained for their job. Doctors are presently graduating in small numbers, whilst midwifery education is ongoing only in one zone, on a small scale. Few systems are in place for enforced deployment of new staff within the public system, and there are few effective mechanisms for motivation and retention, especially for the rural or difficult-to-reach areas. Reproductive health financing has been neglected for many years. The current trend of vertical programs does not favour maternal health programs due to the need for a health system approach. Innovative service financing mechanisms are sorely needed to replace the present system of major outof-pocket payments for reproductive health services, which seriously hamper access, performance and utilization. There is a weak basis for governance, with weak structures and political will. As a result, projects are donor or NGO-driven and in many cases demonstrate a random approach to reproductive health rather than coordinating and aligning their programs according to strategy and needs.

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Conclusions and recommendations Looking at core findings and conclusions of this analysis alongside the recommendations of consultative workshops held in Nairobi and Somalia with different UN, NGO and Somali medical staff, we can define the following areas for action in order to ensure appreciable progress. 1. Essential and emergency obstetric care Skilled attendance at birth is the ultimate goal Dramatically increase the number of midwives for the public sector by up-scaling post-basic midwifery and community midwifery pre-service training in all three zones, linked to mechanisms for deployment, motivation and retention Increase number of professionals able to practice obstetric surgery by establishing 3-6 months in-service training in Emergency Obstetric Care for newly graduating doctors Comprehensive refresher EmOC in-service training for all doctors and midwives Increase access to EmOC by upgrading existing MCHs to health centres able to provide Basic Emergency Obstetric Care, within referral distance of a facility offering Comprehensive Emergency Obstetric Services and appropriate referral mechanisms Initiate maternity waiting shelters to improve access for rural and nomadic populations to Emergency Obstetric Care Ensure affordable services by free referral vouchers for major obstetric interventions and facility-based births Intermediate-term measures to assure skilled attendance at home births such as scaling up training of community midwives Explore innovative practices such as incentivized referral and new roles for unskilled staff, such as a role in newborn care and recruitment into other cadres such as the CHW Classic traditional birth attendant training in safe delivery to be phased out. Due to the gap in skilled care at delivery to be expected during the intermediate period, strategies to bridge the gaps whilst waiting for output of human resources must remain. In areas where skilled care is unavailable, the role of the TBA will be transformed to one of prepartum referral to facility-based care, a role in newborn care and possibly in piloting community-based distribution of new RH technologies, such as Misoprostol to prevent postpartum haemorrhage. Exploration of innovative practices such as incentivized referral and recruitment into other cadres, such as CHW.

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2. Antenatal, postpartum and neonatal care Addressing underutilisation of public sector health staff, paying realistic salaries according to an accepted scale, expanding opening hours at health centres and improving performance Explore performance-based financing and incentives Improved supply chain with revised kits and shared logistics between partners Scale up in-service training capacity, with a focus on major gaps Adapted and updated protocols and guidelines in place Improve quality and comprehensiveness of antenatal and neonatal care by addressing missed opportunities Explore innovative practices such as incentivized referral and new roles for unskilled staff, among them TBAs, such as a role in newborn care and recruitment into other cadres such as the CHW Integrate prevention of STI and HIV-AIDS at health centre level Ensure increased community demand for services by reinventing the role of the community health worker to one of a trained, paid, extended arm of the health centre 3. Birth spacing/child limiting and prevention of pregnancy Universal affordable access to and choice of a reasonable mix of contraceptive methods at each level of health facilities Addressing training needs of health staff Introducing national guidelines as well as protocols for facilities Early involvement of men and key community actors, including religious leaders, for programmatic sanction Expanding demand by extensive behaviour change communication through community health workers and health facilities emphasizing the positive health benefits of birth spacing 4. Obstetric fistula, post-abortion care and sexual and gender-based violence including FGM Prevention a priority by increasing access to quality Emergency Obstetric Care services Prepartum referral to waiting shelter for primiparas in rural and nomadic areas Adequate family planning program to delay first pregnancy beyond early adolescence Increased access to and quality of health services, and commodities for comprehensive management of post-abortion care, fistula, sexual

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and gender-based violence including complications of female genital mutilation (FGM) Increase awareness among decision-makers in the community, of the harmful effects of FGM 5. Human resources, finances and governance Scaling up graduation of quality post-basic and community midwives in all three zones Recruit new doctors to in-service emergency obstetric care training Ensure more equitable coverage of rural and underserved areas, by recruitment from such areas linked to deployment and commitment to placement for a defined time period, with adequate reimbursement and career opportunities Innovative and sustainable RH financing mechanisms necessary Explore performance-based financing to increase output and efficiency of existing facilities and health staff Establish reproductive health national policies and develop strategies for each zone Establish governance structures and consortiums to ensure national programme ownership Improved interagency collaboration, coordination and convergence of RH services at all levels. Way forward This document is an element of a planned consultative process with all stakeholders and partners to ensure a concerted, coherent future effective approach to reproductive health by agreement on a National Policy and consequent Strategy for Somalia, leading to development of a prioritized Plan of Action.

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1.

Introduction and methodology

Poverty, low levels of female literacy and lack of female empowerment are factors that correlate strongly to poor reproductive health outcomes in different countries. In Somalia, matters have been worsened by chronic war and conflict over almost two decades, lack of a functional central government, and poor access to quality reproductive health services. Despite increases in knowledge of HIIHFWLYHPHDVXUHVDQG³ZKDWZRUNV´ in reproductive health, progress in maternal health towards MDG 5 is not on track. The majority of deaths and disability among females of reproductive age is related to pregnancy and childbirth. Optimal pregnancy care depends on all levels of the health system, from basic preventive services such as vaccination and birth spacing services, to highly technical emergency obstetric care at referral level. Assuring support to maternal survival requires an approach different to that for child survival, in which major improvements can be made with low cost technology at the community level. Good obstetric care is thus crucially dependent on a well-functioning, interlinked health care system at all levels. This is non-existent in Somalia today. Firstly, securing reproductive health will require a focused, consistent, longterm effort to strengthen health systems. Any ³PDJLFEXOOHW´RUVLQJOH intervention is unlikely to produce desired results, and might function as a detour rather than a shortcut to maternal health (Maine, 2007). Secondly, there is a constraint in Somalia where access to the population is restricted. There is thus an urgent obligation to focus on what is possible and effective in improving maternal survival within the current situation, using current knowledge and best practices in order to formulate a prioritized and focused plan of action. In this report issues of poverty, female literacy and empowerment as important determinants of reproductive health within the general area of interest, but the focus is centred around PHGLFDODVSHFWVRIZRPHQ¶V reproductive health and events during ZRPHQ¶Vreproductive ages between 15 and 49 years that can be dealt with or improved by effective health systems.

1.1

Reproductive health rights

The securing of reproductive health (RH) rights is a relatively new agenda, with the first international resolution to mention reproductive health rights emerging in 1994 at the International Conference of Population and Development, in Cairo. More specifically, reproductive health (according to WHO) is the right of men and women to be informed of and to have access to safe, effective, affordable and acceptable methods of fertility regulation of

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their choice, and the right of access to appropriate health care services that will enable women to pass safely through pregnancy and childbirth, and provide couples with the best chance of having a healthy infant.

Box 1.1 ³Reproductive health implies that people are able to have a responsible, satisfying and safe sex life and that they have the capability to reproduce DQGWKHIUHHGRPWRGHFLGHLIZKHQDQGKRZRIWHQWRGRVR´ (WHO website, 2008).

In most countries reproductive health rights are still in the process of being secured, ranging from fulfilment of most rights in some countries and a mere utopia for others. The major elements of reproductive health focused on in this report are: Essential delivery care/skilled attendance at birth Emergency Obstetric Care Neonatal and Postnatal Care Antenatal Care Postpartum Care Family planning/birth spacing Obstetric fistula Post-abortion care Prevention and treatment of STIs/HIV-AIDS Medical response to survivors of sexual and gender-based violence, including FGM Adolescent sexual and reproductive health and rights Infertility and cancer of the reproductive organs Actions addressing female empowerment, gender equality and female education are considered beyond the general scope of this document, but will be dealt with where relevant for health programming. 1.1.1

Evidence-based practices: What works for maternal and newborn survival?

There is general agreement among members of the international Safe Motherhood community, as well as most global maternal health initiatives, that knowledge on what works for maternal survival is already established. The challenge that remains is to put knowledge into practice, and scaling up already effective interventions. Cost-effectiveness is documented for a number of interventions in East Africa (Box 1.2).

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Box 1.2 Selected cost-effective interventions for maternal and neonatal care for the East African region (Taghreed et al, 2005). TT - vaccination Nutritional supplementation for undernourished pregnant and lactating women Community-based neonatal care package Screening and treatment for preeclampsia Screening and treatment for asymptomatic bacteriuria Screening and treatment for syphilis Skilled maternal care and immediate care of the newborn Management of obstructed labour, breech presentation and foetal distress Steroids for preterm birth Management of maternal sepsis Antibiotics for premature preterm rupture of membranes Referral for postpartum haemorrhage

There is general agreement that three elements are important for reducing maternal and neonatal deaths: 1) Reduce numbers of pregnancies and unsafe abortions 2) Reduce incidence of pregnancy complications 3) Treat pregnancy complications in a timely and optimal manner 1) Reduce numbers of unwanted pregnancies and unsafe abortions Reducing the number of pregnancies that women have during their lifetimes substantially reduces their risks of maternal mortality and morbidity, particularly where fertility rates are high and health facilities are poor or unavailable1. Concerning child survival, couples can reduce their FKLOGUHQ¶V¶ health risks by spacing births. Children born within 17 months after the preceding birth are about twice as likely to die before the age of five as those born 24 to 47 months after the preceding child. The risk of dying decreases with increasing birth interval lengths up to 36 months, at which point the risk plateaus (Rutstein, 2005). Birth spacing does not seems to have a net positive effect on maternal health other than reduced overall fecundity. A net positive effect of the benefits of 1 The study in Matlab, Bangladesh, illustrates how fewer pregnancies results in fewer maternal deaths. In 1977 more intensive family planning services, including home visits by trained female family planning workers, were introduced in selected villages. In these test villages the percentage of married women using contraception rose from 8% in 1976 to almost 40% by 1985. In comparison areas where services were not expanded, the rate rose much less, (5% to 17%.) By the end of the study maternal mortality in the test villages had fallen to less than half that in the comparison villages, even though there was no change in the risk of dying from any one pregnancy.

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birth spacing on maternal health is controversial, as both long and short pregnancy intervals are associated with increased risks of certain conditions (Conde-Agudelo, 2007; Ronsmans, 1998). 2) Reduce incidence of pregnancy complications Primary prevention is achieved by optimized care during pregnancy and delivery. This includes optimized pre-pregnant health status; four focused antenatal care visits2, skilled assistance at delivery and avoidance of harmful practices. 3) Treat pregnancy complications for mother and baby in a timely and optimal manner Physiologically, about 15% of pregnant women worldwide develop a potentially life-threatening complication that calls for skilled care; about 5% will require a major obstetric intervention for maternal or neonatal survival. Most obstetric complications can neither be predicted3 nor prevented, but if women receive effective treatment in time almost all can be saved. This requires timely access to emergency obstetric care for all women. Early newborn survival depends on the above elements. An estimated 3045% of newborn and intrapartum stillbirths can be averted through good obstetric care (Lawn et al, 1983). In addition to initial newborn care4 such as thermal protection, resuscitation, care of the preterm and early exclusive breastfeeding, avoidance of harmful practices are important. 1.1.2

Rationale for the study

The purpose of conducting a comprehensive situation analysis of reproductive health in Somalia at this point of time, was the identified need for background information to be able to assess needs, gaps and possibilities for intervention. Based on this, a coherent future approach to reproductive health in the form of a national strategy can be developed, as well a plan of concerted prioritized action for all actors in Somalia.

1.2

Background: Somalia

Somalia has been without an effective central government since the overthrow of President Siad Barre in 1991. EvHQLQWKH¶VGXULQJKLV regime, access to primary health care for the rural population was recorded as between 6-ZKLFKLVGLVPDOO\ORZDQGORZHUWKDQWRGD\¶VQXPEHUV 2 WHO recommends four focused antenatal visits. The same scale is considered in the MDG five monitoring indicators. 3 Screening of women according to their medical and reproductive history is not effective in identifying all those who will develop complications, as most women in the high-risk groups deliver normally and the majority of women with pregnancy or delivery complications have no risk factor in their medical or obstetric history. Therefore, all women should in principle have rapid access to life-saving emergency obstetric care. 4 WHO Essential Newborn Package.

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Comprised of a former British protectorate and an Italian colony, Somalia was created in 1960 when the two territories merged. Since then its development has been slow. After 1991 the country was plunged into lawlessness and warfare. Now considered a failed state, years of fighting between rival warlords and an inability to deal with famine and disease have led to the deaths of up to one million people. Somalia, comprising the three zones of North-West (NWZ = Somaliland), North East (NEZ = Puntland) and Central South Zone (CSZ), has an estimated population of 7.7 million people5, and an estimated 1.1 million Internally Displaced Persons (IDPs) (FSAU, 2008). Table 1.1 Population estimates for Somalia by zone (UNDP, 2006) Zone Males Females TOTAL NWZ 1.886.500 889.200 1.886.500 NEZ

455.400

433.800

889.200

CSZ

2.536.300

2.415.700

4.952.000

TOTAL 3.957.800 3.769.900 7.727.700

Overall, populations living in urban areas are estimated to comprise 35-40% of the population (ibid). The nomadic population comprises 10-20% of the population, depending on zone. The situation in Somalia has recently deteriorated to one of its worst levels in 17 years, particularly in the Central South zone. Currently 3.2 million people (43% of the population) are categorized as in crisis and in need of aid (ibid). 1.2.1

Current political context

Two administrations in the north, i.e. the North Western Zone of Somaliland and the North Eastern Zone of Puntland, have claimed regional jurisdiction and attempted to provide social services and maintain a level of law and order. Somaliland declared independence in 1991, and has until recently remained relatively stable and secure despite a lack of international recognition as a sovereign state. The relative security has attracted developmental activities and donor projects. Puntland declared itself an autonomous state in 1998, within the realms of the federal state of Somalia. Puntland and Somaliland have seen sporadic fighting over the disputed region of Sool and Sanaag. Deterioration in 5

81'3  6RPDOLD6HWWOHPHQW6XUYH\6HH-DUDEL%2³5HYLHZRIYDULRXVSRSXODWLRQHVWLPDWHG for Somaliland, Puntland and South-&HQWUDO6RPDOLD´  IRUDGHWDLOHGGLVFXVVLRQRQYDOLGLW\RI population estimates for Somalia.

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security over the last few years has hampered donor interest and investment in the zone, as has the emergence of piracy off the coast of Puntland. The zone has a majority of nomads among the population, as well as a large IDP population originating from the Central South Zone. Puntland is considered to have a high potential for eruption of conflict, also brought about by the recent increase in piracy along its coast. Few international NGOs work in RH in Puntland. With low or no capacity at governmental level, the Central South Zone has endured most of the fighting during the last few years and has contributed a high number of the IDPs and general population dependant on aid or diaspora remittances. This has left NGOs and UN bodies in charge of health coordination, and in some instances this has paradoxically eased implementation of work on the ground. NGOs are major actors in RH in the CSZ. The recent sharp deterioration in security has put a good number of planned interventions and projects on hold. The security events in Somaliland during October 2008 were followed by restricted access to this zone, which was previously considered a working base for all of Somalia. At the time of writing (February 2009), UN Security Phases IV and V were in place all over Somalia, with many expatriates relocated or evacuated. There is great uncertainty concerning the intermediate stability of Somalia, and especially the future humanitarian space. 1.2.2

RH health services and humanitarian assistance

(YHQEHIRUH%DUUH¶VIDOO, traditional areas of responsibility for the state - such as basic education and health systems - were poorly developed. Most health services were privatized and accessible to only a few, with a weak focus on public health. The level of government involvement and capacity in health is still weak, with some higher capacity in the northern zones. Present NGO programming on reproductive health tends to go beyond the Minimal Initial Service Package (comprehensive RH services for the first phase of an emergency or acute refugee situation) in some areas of care, but not in others. Due to the volatile situation few have moved on to comprehensive RH-frameworks developed and/or planned for post-conflict countries such as Afghanistan, Timor, the Congo, etc.

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1.3

Reproductive health in a Somali cultural context

A number of contributing factors influence reproductive health in Somalia (see Box 1.3). Box 1.3 Major socio-cultural factors influencing RH in Somalia Low levels of education and literacy High fertility and low demand/access to FP Gender status and the role of men Harmful traditional practices Poor health-seeking behaviour

1.3.1

Education, literacy and knowledge of RH issues

Knowledge of reproductive health rights and issues is very limited among Somali men and women, for many reasons. School enrolment remains low, with a gross enrolment in primary school of only 31%6. Overall female adult literacy rate is estimated to be 25% (45% in urban areas and 10% in rural areas), impeding their access to health information7. The majority of knowledge, attitudes and practices regarding RH issues are derived from traditional social networks, including traditional healers and sheiks (FSAU, 2007). 1.3.2

High fertility

A strong pro-natality culture where desired fertility is high, contributes to a considerable lifetime risk of obstetric death or disability for every woman. Children are highly valued, being seen as an asset to the lineage and an economic benefit. Birth spacing or limiting is a sensitive issue, often never discussed between husband and wife as children are considered as a gift from God. The teachings of the Koran are considered by many Somalis as being against the use of family planning methods. Many Islamic scholars have argued against this position, and the acceptance of FP is probably influenced more by current political and cultural (clan) streams than traditional religious taboo. There is a high level of misconceptions of modern family planning methods, such as it causing permanent infertility. 1.3.3

Gender status and the role of men

Due to the inferior status of women in Somali society, ZRPHQ¶V¶ health has traditionally received little in the way of attention or resources. Husbands and 6

UNDP 2006 Multiple Indicator Cluster Survey (MICS), UNICEF 2006. The MICS studies from 2000 and 2006 are the most recent countrywide multiple-cluster surveys from all Somalia containing estimates of reproductive health indicators 7

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brothers, but also a womaQ¶VRZQPRWKHURUPRWKHU-in-law, are powerful figures who make most household decisions such as when to seek health care, and from whom, when and where to seek help for complications during pregnancy or during delivery, and the use of family planning. Influence on important choices concerning RH matters is executed via financial control over family resources. Men have traditionally had this control, but with an increasing proportion of households becoming headed by females or with economically active females, especially in IDP communities, this pattern might be changing. 1.3.4

Harmful traditional practices

Widespread traditional practices such as almost universal (98%) female genital mutilation (FGM) among women, are still present all over Somalia. FGM types II and III are associated with negative obstetric outcomes both for the mother and the neonate (WHO, 2006a). Early adolescent marriage and pregnancy before the age of 18 are common, increasing obstetric risk. Particular practices and taboos are in place in pregnancy, during birth and lactation. Added to strong preferences for home births and seclusion after birth, this is contrary to the use of modern health services for reproductive health. 1.3.5

Health-seeking behaviour

Most health-seeking responses are based on traditional knowledge, beliefs and perceived causes of specific illnesses. Across all livelihood zones, the initial response to disease is prayer. After that, traditional home health practice will often be tried, after which a traditional healer might be called. If this is not successful, medicine can be bought from a pharmacy. The next step could be getting a sheik to offer prayer and lastly, the option of seeking care at a health facility is used (FSAU, 2007). Illnesses which are not well understood are believed to be caused by the evil eye. Health-seeking behaviour is thus characterized by low confidence in modern medicine, especially regarding the benefits of preventive modern medicine such as vaccination. Misconceptions such as harmful effects of child vaccination, TT-vaccination in pregnancy causing infertility etc, are prevalent. Men, as major decision-makers regarding RH-services, might resort to violence or punishment should a wife disobey them and seek certain RH services such as family planning. Use of and trust in health facilities for reproductive health services such as facility-based birth is low for many reasons, and is often considered a last resort. Somalis generally value curative services such as surgical and medical interventions, with a strong emphasis on drugs. Health services are commoditized, and the understanding of public health is also low among decision makers within government bodies. Some services, such as antenatal care, seem to be in some demand despite their preventive nature.

22

1.4

Reproductive health indicators for Somalia

Table 1.2

Reproductive health indicators for global monitoring89. Somalilnd

Puntland

Central South Zone

All Zones

Source

5.9

6.2

7.1

6.7 /6.2

4.6%

0.1%

0.3%

1%

MICS 2006/ WHO Statistical Information System (WHOSIS) 2008 MICS 2006

Unmet Need Birth spacing/child limiting

29%

19%

26%

26%

MICS 2006

Maternal Mortality Ratio (MMR) Annual No.

No zonal estimate

No zonal estimate

No zonal estimate

1044 1400

MICS 2006/ WHO, UNICEF,UNFPA,World Bank, 2007

32% (10.3%)

26% (5.8%)

24% (5.2%)

26 % (7.1%)

MICS 2006

17%

21%

30%

26%

MICS 2006

21%

8%

6%

9%

MICS 2006

21%

7%

6%

9%

Derived estimate/MICS 2006

1.1

0.5

1.3

0.8

UNICEF/UNFPA 2006 (NWZ/NEZ)

1.7

2.2

1.7

1.9

UNICEF/UNFPA 2006 (NWZ/NEZ)

0.4%

0.6%

No zonal estimate

0.5%

UNICEF/UNFPA 2006 (NWZ/NEZ)

21%

33%

No zonal estimate

20-33%

UNICEF/UNFPA 2006 (NWZ/NEZ)

No zonal estimate

No zonal estimate

No zonal estimate

81

6%

11%

21%

17%

Neonatal and Perinatal Mortality. Geneva, MPS/HQ, 2007 Derived from MICS 2006

94%

98%

99%

98%

MICS 2006

1.4%

1.0%

0.6%

0.9%

WHO 2004

Indicator Total fertility rate (TFR) Modern Contraceptive Prevalence Rate (CPR) women 15-49 y

of maternal deaths /100,000 live births

Antenatal Care Coverage % women at least once during pregnancy. (% with at least 4 visits)

Coverage of tetanus vaccination (TT 2+) Proportion of births in a health facility Percent of births attended by skilled health personnel according to WHO def.

Availability of BEMOC No. facilities /500,000 population

Availability of CEMOC No. facilities /500,000 population Caesarean section as proportion of all live births Case Fatality Rate (direct obstetric morbidity in EmOC-facility)

Perinatal Mortality Rate Low Birth Weight Prevalence* Reported Prevalence of Women with FGM HIV prevalence among pregnant women

8

Due to lack of systematic population registration as well as figures for births and deaths, estimates concerning mortality and coverage are uncertain. For this report, population figures to estimate coverage RIVHUYLFHVDQGFRQGLWLRQVDUHWDNHQIURP81'3¶V6RPDOLD6HWWOHPHQW6XUYey. 9 For complete definitions of indicators, see Annex A

23

Indicator

Knowledge of HIVrelated prevention practices (% aware that

Somalilnd

Puntland

Central South Zone

All Zones

Source

No zonal estimate

No zonal estimate

No zonal estimate

11% (women) 24% (men)

HIV KABP 2004

No zonal estimate

1.9%

No zonal estimate

1.1%

WHO Sero-surveillance survey 2004/2007

No zonal estimate

No zonal estimate

condom use prevents transmission)

Positive syphilis serology prevalence in pregnant women Reported incidence of urethritis** in men Prevalence of anaemia in pregnant women Percent of obstetric and gynaecological admissions owing to abortion Reported prevalence of women with FGM, any type * **

No zonal 4.4% estimate No data

HIV KABP 2004

No data

94%

98%

99%

98%

MICS 2006

Estimated value (see MICS, 2006) Discharge in the past six months

Despite difficulties obtaining reliable statistics for Somalia, there is no doubt that core health indicators reflect a poor situation. Concerning maternal mortality, the shown estimates of an MMR of 1,044-1,400/100,000 live births is one of the highest in the region, corresponding to a lifetime risk of one in every 10 women. The methodology used in the MICS 2006 was the sisterhood method, and the numbers thus reflects the situation prevailing 10 to 12 years before the survey (1994-96). The MICS 2000 concluded with a MMR of 1,600, but confidence intervals are wide. Reaching MDG 5 concerning maternal mortality will require achieving a MMR of below 400 by 2015. 1.4.1

Obstetric factors contributing to high MMR

The high MMR is to a large degree rooted in obstetric factors among Somali women such as: a) Low age at first birth b) High fertility c) Low skilled attendance at birth/few institutional deliveries d) Limited access to emergency obstetric care e) Suboptimal nutritional status f) High prevalence of FGM

24

a) Low age at first birth Perceived age at first sexual intercourse is 15 years in women, and age at first marriage for women is 17 years (UNICEF Somalia, 2004). Teenage pregnancies are not uncommon and carry an increased obstetric risk for both mother and baby. The age-specific fertility rate for the 15-19 years age group is 123/1,000 women10. Fertility peaks in the 25-29 years age group, with 306/1,000 women. The rural fertility rate for young women between 15 and 19 years is higher than the urban rate: 140 vs. 102 per 1,000 women. b) High number of pregnancies per woman The high fertility rate of 6.7, mirrored in the low rate of use of modern contraceptives, exposes a woman again and again to risk of dying or disability. Poor spacing exposes children to higher risks of dying. c) Low skilled attendance at birth Actual skilled attendance - defined as a skilled attendant at birth operating in an enabling environment - is low (discussed hereunder). d) Suboptimal health and nutritional status In childhood and during childbearing years, Somali girls and women are at risk of macro-and micronutrient deficiencies. Disease or malnutrition in childhood can cause stunting and skeletal deformities of the birth canal that can cause obstructed labour. Closely-spaced and many pregnancies deplete stores of iron, vitamin A and folate, and dietary intake is normally inadequate for replenishment. There is evidence of a practice of certain food reductions and food taboos, especially in the third trimester, as this is perceived to reduce the size of babies at birth (FSAU, 2007). Maternal malnutrition increases the risk of a low-weight baby, one of the main causes of neonatal deaths worldwide. In Somalia there are no nationwide data concerning the prevalence of anaemia in pregnancy or the percentage caused by iron deficiency. Large-scale prevalence studies on Vitamin A and iodine deficiencies and protein-energy malnutrition among pregnant and lactating women, are mostly missing. The incidence of pregnancy-associated malaria is currently unknown. UNICEF is planning and has started implementation of, a larger study addressing many of these knowledge gaps. e) High prevalence of FGM Ninety-eight percent of Somali women have undergone FGM (MICS, 2006). FGM types II and III, which account for 79% of all FGM in Somalia, is associated with increased obstetric complications for mother and baby. According to a WHO study WHO (2006a). of FGM in six countries11, women 10 11

MICS 2006 Burkina Faso, Ghana. Kenya, Sudan, Nigeria, Senegal.

25

with FGM are significantly more likely to have adverse obstetric outcomes than those without FGM, and risks are greater with more extensive FGM. The study documented increased risk of postpartum haemorrhage, need for Caesarean section, stillbirth or early neonatal death with FGM type II and III. Parity did not significantly affect these risks. Box 1.4 Types of FGM * Type I:

Excision of the prepuce, with or without excision of part or the entire clitoris.

Type II:

Excision of clitoris, with partial or total excision of the labia minora.

Type III:

Excision of part or all of the external genitalia and stitching/narrowing of the vaginal opening (infibulation).

Type IV:

Pricking, piercing or incising of the clitoris and/or labia. Stretching the clitoris and/or labia. Cauterization by burning of the clitoris and surrounding tissue. Scraping of tissue surrounding the vaginal orifice (anguriya cuts) or cutting of the vagina (gishiri cuts). Introduction of corrosive substances or herbs into the vagina to cause bleeding or for the purpose of tightening or narrowing it. Any other procedures that fall under the above definition.

*

UNFPA/The World Bank, 2005

In Somalia, re-suture after birth is reportedly not widely practiced, unlike in countries such as Sudan where it is almost universal Gordon et al, 2007). Survey data are presently not available. 1.4.2

Major causes of maternal death in Somalia

Worldwide, the main causes of maternal death and disability are complications arising intra-partum such as haemorrhage, eclampsia, sepsis and obstructed labour12. Unsafe abortion is the only major cause of death that does not occur in late pregnancy/ delivery/ postpartum.

12

In populations with high socioeconomic standards of living, with adequate nutrition and modern education and literacy that refuse modern obstetric care and modern family planning methods, the maternal mortality rate is much lower, usually around 100 /100,000 live births (King).

26

Figure 1.1 Percent distribution of maternal deaths in Africa, by cause, 19972002 (WHO, 2006b).

Most maternal deaths occur within 48 hours after delivery and the rapid development of certain conditions e.g. postpartum haemorrhage, explains why timely referral is so difficult to achieve (see Box 1.5) Box 1.5 It is estimated that, if untreated, death occurs on average within: 2 hours from postpartum haemorrhage (PPH) 12 hours from ante partum haemorrhage (APH) 2 days from obstructed labour 6 days from infection

There are no comprehensive data on causes of maternal deaths in Somalia, as only facility-based deaths are registered systematically, and there are no systematic verbal audits or autopsy done. The main causes of maternal deaths in Somalia are believed to be ante- and postpartum haemorrhage, obstructed labour, pregnancy-induced hypertensive disorders and puerperal sepsis. In an assessment of 384 hospital records from Northern Somalia in 2005, 48% of direct maternal deaths were due to obstructed labour (UNICEF/UNFPA, 2006).Other important contributors were retained placenta (31%) and eclampsia (10%). Cases of postpartum haemorrhage (PPH) are

27

unlikely to reach hospital level, and are thus under-registered. PPH is normally estimated to account for 25-30% of maternal deaths in low-income countries (WHO, 2006b). Causes of indirect maternal deaths in Somalia are pre-existing conditions such as malnutrition, malaria, anaemia (affecting around 20% of pregnant women) and hepatitis. Admission numbers from regional hospitals in the NWZ show intrauterine death and abortion as common pregnancy complications (Ministry of Health and Labour Somaliland). Pregnancy-associated malaria (PAM) is associated with placental infection, which can cause abortion, premature birth and low birth weight but which can also be lethal for the mother, especially for nulliparas who have not acquired immunity. Malaria is endemic in Somalia, but prevalent in the river areas of the south (Shabelle, Juba) as well as in the central areas of the country. Intermittent preventive treatment in pregnancy is the protocol in the CSZ, but due to low prevalence is not considered relevant for the two northern zones, according to WHO protocols, 2008. 1.4.3

Major causes of maternal morbidity after complicated deliveries

The most serious is obstetric fistula. Others are chronic infection, urinary disorders, chronic anaemia, secondary infertility and post-traumatic psychiatric disorders. 1.4.4

Peri- and neonatal mortality

Neonatal mortality is estimated at 41-49/1,000 live births in Somalia. Most early neonatal mortality13 is linked to conditions of pregnancy and birth, as well as congenital malformations. Causes of newborn deaths linked to conditions of care in Somalia are low birth weight and prematurity, birth asphyxia, birth injuries, septicaemia and neonatal tetanus, but exact prevalence figures do not exist. Intrauterine death or stillbirth is a common complication of pregnancy14. There are no reliable registration of perinatal deaths, as reporting of stillbirths and preterm births outside of facilities does not take place. However, WHO estimates that perinatal mortality rate in Somalia was 81 per 1,000 total births in 2006 (WHO, 2007).

1.5

Methodology

The methodology used for this report was a combination of literature search, semi-structured interviews with focal points and key informants within UN bodies, NGOs and other actors active in the field of RH based in Nairobi and 13

Death during the first week after birth. IUFD, stillbirths and early neonatal deaths must be seen as a continuum; with better pregnancy and delivery care, more conditions will be diagnosed intrauterine leading to interruption of pregnancy by induction of labor or CS, but with a certain risk of postnatal death. An intrapartum birth asphyxia leading to fresh stillbirth in a setting with poor obstetric care might in another setting lead to emergency CS and thus a risk of neonatal death instead. The perinatal death rate is a common expression of this. 14

28

Hargeisa. During the time of the consultancy, access to the CSZ and NEZ was restricted. Many field staff from these zones were relocated, and thus became accessible for interviews in Nairobi. 1.5.1

Literature search Locally available information

The needs assessment was performed using a broad literature search. Most of the literature was gathered by contacting implementing NGOs and the main UN agencies (UNFPA, UNICEF, WHO) to get reports, assessments and evaluations. Websites of these agencies were assessed for relevant information. Comparable reference literature from other settings Internet searches were made to access reference literature and evidence-based interventions in the field through use of Pub Med and other search engines. Due to the scarcity of literature and research from Somalia, an effort was made to find evidence-based interventions, best practices and experiences from comparable settings in other countries. 1.5.2

Semi-structured interviews with key informants on RH

Major partners implementing core reproductive health activities in the three zones were contacted in Nairobi, and their recent and ongoing primary activities in the field of RH were mapped. Semi-structured interviews with focal points for RH from relevant NGOs, UN agencies, consultants and resource persons were also conducted. Key actors in Hargeisa were interviewed within the public and private sector, including professional associations. 1.5.3

Visits to health facilities and key actors in Hargeisa town, Somaliland

Visits were made to the Ministry of Health and Labout (MoHL), and to public and private health facilities within Hargeisa town. Key actors and individuals representing the medical community, facilities and organizations within reproductive health were interviewed. A list of institutions and persons visited and interviewed is included in Annex B. During the interviews, ongoing interventions were discussed against known efficient evidence-based practices, where these exist and where relevant in a Somali context. 1.5.4

Needs assessment

Needs assessment and gap analyses were conducted both by RH topic and by zone, using available monitoring and evaluation tools. For the definition of signal functions of emergency obstetric care; Basic Emergency Obstetric Care (BEmOC) and Comprehensive Emergency Obstetric Care (CEmOC), the UN process indicators were used (see Annexes C and D).

29

1.5.5

Period of data collection

Data collection was done during the period November 2008 ± February 2009, in both Nairobi and Hargeisa (four days). 1.5.6

Zonal differences in available information

For the North Western (Somaliland) and the North Eastern (Puntland) Zones, data from several assessments of emergency obstetric care were available, the most comprehensive and recent of which was conducted in 2006 by UNICEF/UNFPA15. For Central South Zone, no similar comprehensive assessment has been made and data have been mostly collected from reports, assessments, facility statistics and interviews with persons responsible for RH with major NGOs operating in the zone. Due to differences in reported indicators and statistics, numbers were not always comparable. Information on RH services offered by private health systems, such as private clinics or pharmacies, was extracted from secondary sources. For other areas of RH, written assessments of needs are patchy and do not follow the same methodology nor cover all zones, but give a qualitative indication of the status of RH needs. The private sector is underrepresented in assessments and reports, and information was difficult to obtain given the restricted access. 1.5.7

Limitations of the study

There is a general paucity of impartial information regarding health status and indicators in Somalia. As a mainly literature study, information for this report had to rely on secondary information from several often contradictory sources. No central library in the field of reproductive health in Somalia has been set up. Gathering of core documents, assessments, reports and/or evaluations from different actors had to be collected from original or secondary sources. As such, a lot is left to be desired when it comes to sharing of information. Institutional memory tends to be short and staff turnover in NGOs and UN bodies high, and several fairly recent reports referred to in the literature could not be located. As a primarily desk assignment to obtain data and information from the field it was necessary to rely on many different sources of data that sometimes did not agree. Most have been included so as to try and present as complete a picture as possible. Lack of access due to the security situation in the NEZ and CSZ made field visits to these zones difficult. There is disagreement regarding estimated population numbers for Somalia (UNDP, polio numbers, MoHL). Catchment populations of facilities are therefore not defined, and estimates of coverage of services are surrounded by a great deal of uncertainty. 15

UNICEF/UNFPA (2006). Needs Assessment of Emergency Obstetric Care in Somaliland and Puntland.

30

The situation in Somalia changes rapidly, and there is always a risk that information is out of date. This will nevertheless not have a dramatic impact on the central recommendations of this report. 1.5.8 Disclaimer This report reflects the views and opinions of the author only, and does not represent the views or positions of any public or private agency.

31

2

Service delivery

2.1

Health systems, infrastructure and service delivery

Figure 2.1 Health systems in Somalia

Ministry of Health

PUBLIC Public hospitals Health centers/MCH Health posts

PRIVATE Private hospitals Pharmacies Private clinics

INFORMAL Traditional healers Sheiks Community volunteers

Health systems do exist in Somalia, but in most parts of the country these are characterized by a general disintegration due to lack of a functioning central political authority and/or adequate public finances. The health system consists of a number of non-standardized facilities offering different levels of care, both private and public, with little formal organization. Furthermore there are no clear links between facilities at different levels and thus no systematic referral system. Some facilities are supported by NGOs or UN bodies, and some are not. Support takes place in varying degrees regarding rehabilitation of infrastructure, supply of medical drugs or equipment, incentives to staff, supervision and training. Community support is estimated to be considerable, but is disorganized and unpredictable. Community funds are from out-ofpocket expenditure, community pooled funds, business contributions, charitable/religious donations and diaspora remittances, and are often managed by community health committees. Staffing patterns and payments at different levels are highly variable. Rural facilities are commonly understaffed, particularly with respect to professional health staff. MoHL salaries are too low to support livelihoods and are often interrupted, accounting for poor staff motivation and engagement in dual work places. With regard to availability of services, there is generally better access to a broader range of higher quality services in urban than in rural areas. Special facilities have in some cases been set up to cater for needs of IDP-

32

populations, but mostly in the urban areas. Few services are specifically targeting nomadic or rural-nomadic populations. Health facility management systems are either non-existent, or rarely applied. NGO-supported facilities might have accountability systems in place, but are compromised by their reduced presence due to insecurity on the ground. Table 2.1

Health facilities for reproductive health in the three zones

Source: UNICEF Somalia, 2008

Somaliland Puntland CSZ Totals 2.1.1

Health Posts

MCHs

District Hospital

Referral Hospital

160 120 264 544

70 44 134 248

8 4 15 27

1 1 5 7

Referral/hospital level

Most hospitals were built 40-50 years ago, with outdated architectural designs and size, and are located in urban areas. Most are underutilized due to inadequate running of services and lack of qualified staff. Bed occupancy tends to be low. Some are private and some public, but with little distinction to the consumer in terms of user fees or the services provided. 2.1.2

Health Centres (HC = Maternal Child Centres (MCH))

A prototype HC or MCH has been defined according to the Essential Package of Health Services16, but has not yet been rolled out. Core activities of a HC are preventive and curative services such as ANC and OPD functions. The majority of services provided are curative, and volume-wise RH services constitute a minor activity. A minority of health centres function as normal delivery points. Regarding staff for RH, some are staffed by at least one qualified midwife but many are not. Most have several auxiliary midwives with varying qualifications and experience, any of whom might actually turn out to be a trained TBA. Concerning infrastructure, many operate without running water or electricity, but most have a cold-chain. There are usually no in-patient facilities or, if present, are not utilised. 2.1.3

Health posts

There are over 600 health posts, of which a few are supported by NGOs with very varying levels of functioning and staffing. Staff are unpaid, mostly untrained, unsupervised, and no health information is collected. Currently, regarding reproductive health, some health posts offer assistance to pregnant women such as giving out preventive drugs, but this is not a comprehensive ANC package. Very few serve as a delivery point. They are normally staffed by community health workers (CHW) or a TBA. Outreach

16

UNICEF Somalia (2008).The Essential Package of Health Services (EPHS). Final Draft.

33

activities are not standardized and most surveys demonstrate poor coverage of nomadic and rural populations. 2.1.4

Pharmacies, private clinics & laboratories

There are a number of for-profit private medical clinics, some of which are attached to pharmacies and laboratories, which offer curative services. There are estimated to be more private facilities than public ones offering services ranging from consultation, lab, clinical exam and/or sale of drugs, to higher level interventions such as surgery. The quality of services has not been assessed in recent years, and are likely to vary greatly due to diverse staff qualifications. ANC and postnatal care are offered, and some private clinics run by midwives also offer delivery services. For major surgery such as a CS, the patient will in most cases be taken to either a private or public hospital. 2.1.5

Maternity waiting shelters

Developed as an alternative to decentralization of EmOC services, maternity waiting homes are residential facilities located near an established referral PHGLFDOIDFLOLW\ZKHUHZRPHQGHILQHGDV³KLJKULVN´FDQDZDLWWKHLUGHOLYHU\ or be transferred to shortly before delivery or earlier, should complications arise. Many consider maternity waiting homes to be a key element of a strategy to bridge the geographical gap in obstetric care between rural areas with poor access to equipped facilities, and urban areas where services are available. In Somalia, maternity waiting shelters exist in conjunction with a handful of referral facilities, but all are ad hoc in nature. Currently there is no existing national programme of maternity waiting shelters in Somalia.

2.2

Proposed framework for delivery of health services

The Essential Package of Health Services (EPHS) developed by UNICEF in 2008 is a comprehensive plan for the remodelling and creation of a future Somalia health system. It has been endorsed by the MoHL Somaliland and de facto by the MoH of the Transitional Federal Government in the CSZ. The EPHS has a strong focus on MCH. 2.2.1

Reproductive health components of the Essential Package of Health Services

The EPHS has established which levels of the health system will deal with maternal, reproductive and neonatal health (Table 3.9). For details, see Annex E. In this model, the first comprehensive contact point for all maternal and neonatal health services will be at health centre level (Level II). At this level basic services such as antenatal care, delivery care, BEmOC, postnatal care, FP and STI treatment will be offered. At a lower level (Level 1 ± Primary Health Unit) some elements of reproductive health will be included, such as aspects of family planning and promotion as well as prevention of STI and promotion of care seeking behaviour. The referral health centre (Level III)

34

will in addition offer CEmOC. Referral hospitals (Level IV) will offer the full range of reproductive health services, including gynaecological and fistula surgery. Figure 2.2

Table 2.1

Proposed reproductive health services and staff at different levels

Level Phase Services

Cadres

Primary health unit I II Maternal, reproductive & newborn health HIV,STI & TB

Community midwife Nursemidwife Doctor Prof. qual. for CS

FP & promotion Prevention & promote care seeking behaviour -

Health centre I II

Referral health centre I II CEmOC

BEmOC

Hospital I

II

CEmOC gynaecological & fistula surgery

HIV test

Increase VCT

VCT + PMTCT

Increase ARV

ART + PMTCT All regions

1-2

1

2

-

-

-

12 1

2

2

3

3

4

-

-

-

0 1

1 1

2 2

4 3

(For definition of health staff, health management structures, see Annex E).

The EPHS includes detailed plans for linkages between the different components of the health system and referrals between levels. It also describes health system support components such as drug supply, transportation, communication and physical maintenance and repair. Regional supervision and management structures have been developed (Annex E).

35

The emphasis of the EPHS is to improve the quality of service provision and not, in the first phase, the quantity of health facilities created. Once quality can be assured and further financing secured, services can be expanded.

2.3

General barriers to access

Barriers to accessing reproductive health services are many. There are demand-side barriers such as delay17 at household level due to poor understanding of reproductive health risks, and often justified low confidence in what health facilities can provide. There is a strong perceived association between hospitals and bad outcomes for the mother. Hospitals are viewed as a last resort, as costs and logistics concerning care and transport are forbidding. In addition, hospitals are frequently considered inappropriate for delivery care due to e.g. violation of privacy connected to vaginal exams and undesirability of Caesarean section. High transport and services costs, long distances and difficulties in finding transport and high out-of-pocket expenditures are among logistic and financial barriers that are met, even when the primary delay is overcome. There are supply-side barriers such as delays at facility-level in obtaining timely medical care, due to poorly functioning referral centres. Specific barriers will be discussed under each service delivery section.

2.4

Quality of services

In general, the quality of reproductive health services outside of a few (private) facilities is compromised by a lack of quality staff and human resource management, lack of equipment and/or training to use existing equipment, or inadequate, inefficient management and supervision mechanisms. There are no quality control mechanisms of services in place, neither in the private nor the public sector.

2.5

Safety

Regarding safety of services, there are no legal certification bodies for health staff cadres, and health staff continue to operate in the public and private sectors in areas outside their formal training and competencies. There is no existing ethical code of conduct for health personnel, and the private sector is completely unregulated. There are no protection mechanisms for patients FRQFHUQLQJWKHKHDOWKSURYLGHU¶VGHVLUHIRUSURILW,QERWKWKHSXEOLFDQG private systems there are high levels of case fatality rates in maternity wards, pointing to poor quality services (UNICEF/UNFPA, 2006). Access to safe blood services is poor outside the major urban areas. Blood transfusions often rely on the less safe option of immediate blood products of 17

The three delays were formulated by Thaddeus and Maine in 1991. Delay in seeking care is presented in three ways. The first is in the decision to seek care, the second is in reaching a facility after the decision is made and the third is in receiving needed care when at facility-level.

36

a relative, rather than a facility blood bank. In CEmOC centres in the NWZ, 55% of transfusions were from a relative/neighbour and in the NEZ 36% were from a relative/neighbour (ibid). Box 2.1Main reproductive health services 2.1 Essential delivery care 2.2 Emergency Obstetric Care 2.3. Newborn Care 2.4 Antenatal Care and Postpartum Care 2.6 Family planning/Birth spacing 2.7 Obstetric Fistula 2.8 Post-abortion Care 2.9 Prevention and treatment of STI/HIV-AIDS 2.10 Medical Response to victims of Sexual- and Gender-Based Violence 2.11 Adolescent and Youth Reproductive Health Programs 2.12 Infertility and cancer of the Reproductive Tract Organs

2.6

Essential delivery care

Table 2.3 Indicators Delivery in health facility

9.4 %

MICS 2006

Percent of Births Attended by Skilled Health Personnel*

33 %

MICS 2006

50.9 %

MICS 2006

TBA assisting at birth

*includes auxiliaries, nurses/midwives, doctors

2.6.1

Where do women give birth?

Over 90% of deliveries take place at home in Somalia. The MICS 2006 study showed that countrywide, 9.4% of births occur at health facilities. Around 25-50% of MCHs conduct normal deliveries within the facilities, but more commonly ELUWKVDUHDVVLVWHGLQWKHZRPDQ¶Vhome. The data below show registered numbers of deliveries by MCH staff or associated staff (TBAs)

37

Table 2.4 Number of deliveries reported by MCHs supported by UNICEF, by zone Source: UNICEF, 2008

Zone NWZ NEZ CSZ TOTAL

Attended* deliveries in facility

Attended* deliveries out of facility

Total deliveries attended*

% of expected deliveries attended

2200 1500 6000 9700

9800 2200 16400 28400

12000 3700 22400 38100

13
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