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South Sudan: The challenges of providing healthcare to nomadic mothers
Much of the nomadic population of Pibor, in the east of South Sudan, have migrated with their cattle in search of grazing pastures and water. As they move towards and settle in ‘cattle camps’ which is their home for the on-going dry season, they move further away from what limited healthcare is available. This can leave expectant mothers without antenatal care or a safe place to give birth, particularly if there are medical complications.
Médecins Sans Frontières/Doctors Without Borders (MSF) has been providing basic healthcare, with a focus on maternal and reproductive services, in the Pibor area since 2005. Reaching patients in outlying regions is already difficult, but the current dry season presents the team with new challenges.
Dry season migration
“It’s dry season and many people have migrated to the cattle camps, so the number of women giving birth in our clinic here in Pibor is going down,” says MSF midwife Anna Regge Charles.
Before the arrival of the dry season, the antenatal clinic was crowded, with as many as 450-500 women coming for consultations each month. But once the seasonal migration begins, few women come back to give birth. For most, domestic responsibilities take priority, and travelling long distances to deliver at a health facility is not an option.
“When the women come to the antenatal clinic, we try to find out why they are not coming back to deliver,” says Anna. “They tell us they have just come to make sure the baby is well before moving onwards to the cattle camp. They say they cannot stay back and let the family go alone.”
Mothers’ waiting house
For those women who do stay in Pibor to give birth, or who are referred to Pibor from primary healthcare units managed by MSF in Gumuruk and Lekongwole, MSF has opened a facility known as the ‘mothers’ waiting house’.
Elizabeth John, from Gumuruk, delivered three of her ten children with the help of MSF midwives, and is now waiting in the mothers’ waiting house to deliver a fourth.
“Gumuruk is eight hours by foot and I walked here,” says Elizabeth. “I have ten children at home and I was facing difficulties delivering. You always have to deliver at home in Gumuruk unless referred to Pibor. I was afraid when I started having belly pains because my belly is so big that the delivery may be difficult, so I took the decision to come here.”
Because of the long distances women must travel to get medical care, and the time spent away from their families, women with complications often arrive late, when their condition is already serious.
“Malaria during pregnancy is one of the main medical conditions we deal with,” says Anna. “If not treated early enough with the appropriate treatment, it can cause pre-term delivery or stillbirth. Most women come when the malaria is very severe, and often the baby hasn’t grown properly or has already died in the womb.”
Another common complication among pregnant women is urinary tract infections. “A lot of women come late in the third trimester for their first antenatal consultation when the urinary tract infection is severe,” says Anna. “This can cause pre-term labour and premature rupture of the membrane, which puts the baby at risk of infection.”
During the dry season, the MSF team also see malnourished pregnant women, which can cause a low birth weight for their babies.
Women may also suffer from prolonged or obstructed labour – a particular problem amongst teenage girls whose pelvises may not be large enough to allow the baby a smooth passage out. “We see many young girls of 14 or 15 years old who come with complications during delivery like obstructed or prolonged labour,” says Anna. “The pelvis is still very small and it isn’t possible for the baby to be delivered normally, so they need to deliver here by caesarean.”
As well as caring for pregnant women, MSF teams in Pibor also provide reproductive healthcare, including the treatment of sexually transmitted diseases. Syphilis is common among the women seen at MSF’s clinic in Pibor. If left untreated, it can cause severe fetal abnormalities such as damage to the brain, heart and nervous system. It is particularly challenging to treat because of the culture of polygamy, which helps it to spread easily, and because of people’s limited access to healthcare.
“We have a challenge with syphilis treatment, because the woman is here, but the husband and co-wives are very far away at the cattle camp,” says Anna. “We ask the woman if it is possible to send someone to get the husband, because with syphilis, we cannot treat one and leave the husband and co-wives, or it means nothing. They usually can’t come, so we send the treatment with the woman, but we are not sure if they complete the treatment correctly.”
Providing healthcare to people who do not stay in one fixed place through the year presents problems. “One of the challenges we have is that we work with a nomadic population but our health facilities are fixed,” says Amandine Colin, MSF field coordinator in Pibor.
“Then when the rainy season comes we are faced with new challenges, we cannot just drive to our clinics in Lekongwole and Gumuruk. We have to use a helicopter, so logistically speaking it is quite hard to move. We use boats to go to Lekongwole and Gumuruk, but last rainy season the river was not possible to navigate so during six months we only had helicopter access to Gumuruk. Insecurity can also further limit our movements at times of clashes or elevated criminality in the area.”
To help reach pregnant women who need medical care, MSF is training traditional birth attendants at its clinic in Pibor to distinguish high-risk pregnancies from normal pregnancies, so that when they return to their communities, they can advise pregnant women who are at high risk to seek professional help.
Long term approach needed
Other than MSF, there are just two organisations providing healthcare in the area. Most of these services are provided in Pibor town or places accessible by road, and there are no health facilities close to the cattle camps leaving people without access to essential medical care.