1. IDDP 講演
古田 真里枝

2. 国際社会の問題
 世界の人々の5人に１人は１日１ドル未満で生活
 １０００万人の５歳未満の乳幼児が防ぐことが可
能であった病気で死亡
 ５０万人を超える女性が、妊娠・出産により死亡
 １億１，３００万人の児童が小学校に通っていない

3. ＭＤＧｓ
1. 極度の貧困と飢餓の撲滅
2. 初等教育の完全普及
3. ジェンダーの平等、女性のエンパワーメント
4. 子供の死亡率削減
5. 妊産婦の健康改善
6. HIV/エイズ、マラリアなどの疾病の蔓延防止
7. 持続可能な環境づくり
8. グローバルな開発パートナーシップの構築

4. Where is the “M” in MCH?
(Rosenfield & Maine 1985)

5. “Maternal mortality is a neglected
tragedy, neglected because those
who suffer it are neglected people
with the least power and influence
over national resources shall be
spent; they are the poor, the rural
peasants, and above all women”
(Mahler 1987)

6. Introduction
Maternal Mortality Ratio (1995)
(per 100,000 live births)
VERY HIGH - 600 or more MODERATE - 300-599 LOW – 100-299 LOW - less than 100 No data
Source: WHO,UNICEF, UNFPA, Maternal Mortality in 1995: Estimates developed by WHO, UNICEF, UNFPA. Geneva, 2001

8. http://www.unhcr.org/graphics/unhcr.gif
UNFPA/UNHCR Reproductive Health Services Joint Project
In full compliance with the ICPD spirit, and following the Memorandum of Understanding signed
between UNFPA and UNHCR earlier last April, a new joint project had been signed for the
provision of Reproductive Health services in the Refugee Camps of Kilo 26, Um Gargur, Wad
Sherifey, Shagarab 1,2,3, Girba, Wad Hilleaw, Abuda, and Suki where
107,000 Refugees live in Eastern states of Kas-sala and Gedaref. Although many Eritrean
refugees have gone back to their country, estimations show that still approximately 300,000
refugees remain in the Sudan of which 110,000 are camp-based, mainly in the two states of
Kassala and Gedaref. The situation of forced migration for a prolonged period of time and short-
term planning as dictated by refugee status, has a profound negative impact on the quality of
life. Due to donor fatigue, resources for the delivery of services to the camp based refugees has
been declining, over the years, leading to inadequate provision of social services including their
education and health care, which has contributed to their low health status in general. For new
arrivals who are at their early stage of reproductive age, they endure physical hardship and
fatigue as well as psychological trauma during the process of displacement. Women refugees,
however, face additional stresses. In addition to the high prevalence of early, un-timely and
poorly outcome of pregnancies and childbirths, the very high risk for STDs/HIV/ AIDS is coupled
by the potentiality of Gender-Based Violence (GBV), which may be pressured to exchange
sexual favors for food and thus increase the exposure to the risk of infectious disease including
sexual transmitted infections (STI) in refugees.

9. Objective
 To explore and develop effective
strategies to improve maternal health
among refugee women in
Eastern Sudan

10. Methods
 Situation Analysis
 In-depth interviews
- reproductive-aged women
 Informal discussion
- health workers, key informants
 Analytical & Planning tool
 PRECEDE-PROCEED MODEL

11. PHASE V
PRECEDE-PROCEED Model
PHASE IV PHASE III PHASE II PHASE I
ADMINISTRATIV EDUCATIONAL BEHABIORAL AND EPIDEMIOLOGICAL SOCIAL
E AND POLICY AND PROCESS ENVIRONMENTAL DIAGNOSIS DIAGNOSIS
DIAGNOSIS DIAGNOSIS DIAGNOSIS
PREDISPONSING FACTORS
HEALTH BEHAVIOR AND
PROMOTION
HEALTH
? LIFESTYLE
Low utilization of
EDUCATION - Family planning
COMPONENTS - Skilled delivery QOL
Care.
- EmOC Maternal
Practice of FGM death affects
HEALTH the children’s
•REINFORCING FACTORS High ratio of family’s and
ENVIRONMENT maternal mortality community’s
POLICY & morbidity
?
life
REGULATION •Population 7,282
ORGANIZATION •1 health centre High prevalence of
anaemia & Some
Not covered by •Nearest facility infectious disease morbidity
Sudan national with Com. EmOC is (Malaria)
MCH Program cause
50km away depression,
“1 Village Midwife ENABLING FACTORS •Road condition is stigmatization
for 2,000 bad One primary
population” etc. .
school one for each .
.
boy & girl
? •No electricity
•Homogeneous
community
Adopted from LW. Green and M.W.Kreuter,

12. Sample Characteristics of Interviews
No. Ag # of living Education Work Education Work
Children (wife) (wife) (husband) (husband)
e
1 28 6 None No Primary Farmer
2 28 4 None No Primary Baker
3 30 6 Primary No None Farmer
4 35 6 Primary No None Driver
(Come back home
twice/m)
5 27 6 Primary No Secondary Vegetable
6 28 6 Primary No Religious Seller
Vegetable
7 34 6 Primary No Sc
Secondary Seller
Farmer,
8 26 3 Primary No Secondary Teacher
Farmer
9 30 8 None No Primary Farmer
(polygamous union)
10 20 3 None No

13. Why do women receive FGM?
Who is conducting FGM?
“My mother and mother-in-law decided on
sunna for my daughter. We asked a midwife to
perform it, but she refused. She is new here,
having come from another camp, and she said
that sunna is not good for health. So my mother-
in-law did it. Although she had never done it
before, she knew how from her experience.
Women who don’t receive this practice cannot
marry because it creates a sense of identity and
belonging in our society.”

14. Result 1: What is preventing women
from receiving FP services?
 Belief that controlling fertility using
contraception is against God’s will
 Desire to have more children
 Gendered position requiring women to
follow their husband’s wishes and thus no
power to influence the decision-making
process
 Worries about side-effects of contraception

15. What is preventing women from
receiving FP services? (cont.)
“If I am healthy and if God likes, I want to have
more children, but now I want spacing because I
have just delivered a baby. But, I have never
discussed FP with my husband because I know he
doesn't want spacing. I don’t do anything that my
husband doesn’t want.”
(28-year old woman with 6 children)
“ I took pills (before), but I became sick because of
the side effects, so we changed to condoms. But
after my husband started to use condoms, I got
vaginal infections, so we stopped. Then I became
pregnant.”
(35-year old woman with 6 children)

16. What is preventing women from
receiving skilled delivery care?
 Limited number of skilled birth attendants
(Village Midwives: VMWs) who are not
always available
 Poor quality of delivery kits that midwives
use

17. Result 3: What is preventing women
from receiving EmOC?
Delay in decision to seek EmOC
 Lack of women’s decision-making ability
 Lack of preparedness of family members
for emergencies, and
 High cost of drugs and medical supplies

18. What is preventing women from
receiving EmOC? (Cont.)
“My mother died during labour while
delivering the next baby after me”
“Deaths related to labor are difficult to prevent,
even by midwives. Death or survival is up to
God.”
“I cannot decide to go to a health centre
without asking my husband”.

19. Why do women delay to receive
EmOC? (cont.)
Delay in arrival at the point of care
 Referral sites are far away, and travel
becomes very difficult during the rainy
season over poor roads.
 Lack of means of transportation such as
ambulances with obstetric first aid
equipment.

20. Why do women delay to receive
EmOC? (cont.)
“My anti died during labor last year because
of severe breeding. She was delivering at
home with a midwife. It was difficult to move
her because it happened suddenly and we
could not find transportation. So
she died at home”.

21. Why do women delay to receive
EmOC? (cont.)
Delay in provision of adequate care
 Lack of medical staff who can provide
EmOC.
 Lack of medical equipment for EmOC.

22. “We have only basic delivery equipment here. We
cannot provide blood transfusions. The equipment is
just a little better than what midwives use for home
delivery ”
“Problems often happen during the night…. If we
bring a patient to the health centre at night, we have
to treat her in darkness. We don’t have any lights…
it is difficult to see how much a woman is bleeding.”
(MWs)

23. PHASE V
PRECEDE-PROCEED Model PHASE IV PHASE III PHASE II PHASE I
ADMINISTRATIV EDUCATIONAL BEHABIORAL AND EPIDEMIOLOGICAL SOCIAL
E AND POLICY AND PROCESS ENVIRONMENTAL DIAGNOSIS DIAGNOSIS
DIAGNOSIS DIAGNOSIS DIAGNOSIS
PREDISPONSING FACTORS
The capacity of
•Controlling fertility is against God
•Contraception has side effects
do nothealth staff to
HEALTH •Pregnancy & childbirth are natural process that BEHAVIOR AND
PROMOTION require special attention LIFESTYLE
•Maternal deaths are not avoidable
HEALTH •FGM deliverof belonging to the society
create sense effective Low utilization of
EDUCATION •Knowledge of child-spacing methods is low - Family planning QOL
COMPONENTS
health education for
•Women reluctant to seek healthcare without - Skilled delivery
Care.
permission from husband or mother-in-law - EmOC
local people
•Men reluctant to marry women without FGM Practice of FGM
Maternal
death affects
HEALTH the children’s
•REINFORCING FACTORS High ratio of family’s and
POLICY
A supportive
•VMW refuse to practice FGM
•Elder teach young people that girl should be
ENVIRONMENT maternal mortality
& morbidity
community’s
life
REGULATION
ORGANIZATION environment for
married in the middle of teenage.
•Polygamy is widely acceptable
•Population 7,282
•1 health centre High prevalence of
•Men want children as many as possible anaemia & Some
Not covered by
Sudan national Safe Motherhood
•Voices of women are devalued.
•Nearest facility
with Com. EmOC is
infectious disease
(Malaria) morbidity
MCH Program cause
50km away depression,
“1 Village Midwife ENABLING FACTORS •Road condition is
for 2,000
population”
The capacities of HC to
•Iron/folic are freely available for pregnant women
•Women have good relationship with VMW
bad One primary
stigmatization
etc. .
school one for each .
deliver effective
•MAs and VMWs are 24 hours on call
•Bicycles are available for outreach services boy & girl
.
•No electricity
outreach services
•Some children are attending primary school
•Some people have donkeys and a few have camel •Homogeneous
More than half of women are illiterate community
•Cannot afford drugs even if it available
•Shortage of health workers with life saving skills,
A local capacity for
and family planning counselling skills
•Lack of satisfaction of MA with their working
accessibility of EmOC
condition
•Lack of medical equipments, drugs in HC
•No ambulance or cars with first aid
and for effective referral
•Lack of means of communication system
Adopted from LW. Green and M.W.Kreuter,

24. Project (SHARES) Matrix
Goal To improve QOL of refugees by contributing to
the sustainable improvement of Maternal Health
Purpose
To strengthen the capacity of health centres to promote maternal health, and
to deliver quality maternal health services
Outputs
Education Training course Strengthened Effective and
activities carried delivered to enhance capacity of health accessible referral
on in communities to provision of centres to deliver system and
to promote effective health effective outreach information for all
supportive social education for the services for women pregnant women
norms and community to adopt during pregnancy, and their families
environment for healthy behaviour childbirth, and the a
SM related to SM postpartum period a
Activities
•Clarify who the •Establish HET •Provide VMW •Set up DRF in HC
influential people •Conduct workshop training •Develop logistics
•Create HPC of HET on PLA •Provide delivery system for drugs
•Facilitate HPC to •Support HET to kits •Develop referral
link with others to facilitate PNA. •Provide CHV system for
integrate their •Integrate HET training on emergencies
activities activities with others maternal health •Develop
•Use child-to-child •Provide refresher community action
approach courses for health group to lobby for
a a staff better referrals
a

26. Conclusion
Capacity building in health education and
health services ensuring involvement of
local people and staff was considered
critical in improving maternal health in the
refugee setting.
A planned community-based project
reflecting this and implications for other
healthcare settings will also be considered.

27. Thank You!