1. Improving Maternal and
Neonatal Health in
Kassala State:
Strengthening Primary Health Care and Community Mobilization
in Kassala Town and Rural Kassala Localities

2. Improving Maternal and Neonatal Health in Kassala State:
Strengthening Primary Health Care and Community Mobilization in Kassala
Town
and Rural Kassala Localities
Project funded by Italian Co-operation
Implemented by UNFPA, AUW and SMoH
Research monograph of baseline surveys in two localities:
Community baseline survey of women’s KAP on RH issues
VMWs baseline KAP survey on RH issues
Prepared by:
Dr. Dina M. Sami Khalifa MBBS,MSc
Dr. Nafisa M. Bedri PhD
Dec. 2012

3. LIST OF CONTENTS
Introduction 4
Project objectives 4
Baseline survey on KAP of all VMWS in Kassala state 13
Baseline survey on KAP of women in communities 5 Objectives 13
of the two targeted localities Methodology 13
Objectives 5
Methodology 5 Results 14
Demographic characteristics and work experience 14
Results 7 Knowledge on danger signs during pregnancy, 15
General demographic characteristics of sampled women 7 labour and puerperium
ANC Experience 7 ANC practices (skills) 16
Family planning experience 8 Delivery and post-delivery practices (skills) 16
Knowledge on danger signs during pregnancy 9 Hygiene practices 16
Knowledge on danger signs during labor 10 Role in birthing plans 17
Knowledge on danger signs during puerperium 10
Knowledge on danger signs for newborns 10 Conclusion 18
Knowledge on HIV/AIDS 11
Birth experience and birthing plans 11 Recommendations & way forward 19

4. INTRODUCTION
Project objectives:
The overall goal of the project is to contribute to im- d) Developing a generalizable and replicable
proving the health and wellbeing of mothers, new- model that enhances reproductive health (RH) ser-
borns and their families in two localities in Kassala vices to address MDG 5 and MDG 4 through thorough
state, Kassala town and rural Kassala. documentation and monitoring of the implementa-
tion process, use of evidence-based interventions
Specific objectives of the project include the follow- and taking into account lessons learned.
ing:
1. Improving the quality and uptake of maternal 2. Contributing to ensuring that all pregnant wom-
and neonatal health care in 19 health facilities and en and their newborns in the two localities are cared
surrounding communities. This will be accomplished for by a trained health worker during pregnancy and
through: childbirth. This will be done through provision of im-
a) Development of an assessment framework proved health care at community and primary health
for a rapid baseline assessment of existing local Pri- care levels, backed up by a functioning referral sys-
mary Health Care Units (PHCUs). tem.
b) Building the capacity of the PHCUs, i.e. im-
proving the competency of relevant health cadres To assess the community baseline status, two surveys
through a series of in-service trainings and refurbish- were conducted; a KAP survey among community
ing and equipping health facilities. women and a KAP survey among all registered VMWs
c) Sensitizing and organizing the communities to in Kassala state.
take an active part and support the sustainability of
the project interventions.
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5. BASELINE SURVEY ON KAP OF WOMEN IN COMMUNITIES OF THE TWO TARGETED LOCALITIES
1. OBJECTIVES Therefore, both localities acted as one target popu-
To assess the knowledge, attitudes and practice (KAP) lation, but differences in the average size of house-
of women in the community regarding various RH is- holds between the localities had to be considered in
sues (use and knowledge of FP methods, pregnancy the sampling procedure.
danger signs, opinion on home delivery versus facil-
ity delivery, birthing plans, HIV/AIDS and opinions The two localities are significantly different in terms
on midwives’ capabilities). The target women were of the number of households, so the total sample was
mothers with a delivery event not more than 5 years divided between the two localities proportionally to
ago. size (PPS).
2. METHODOLOGY • Sampling within each locality was multi-stage sam-
• Study population: Women of reproductive age in pling:
the two localities who had a pregnancy experience 1. From the catchment villages, the 10 most popu-
during the past 5 years. lated villages in each locality were chosen, and from
• Sample size: 800 women, 500 from rural Kassala these, 5 villages were chosen randomly (primary
and 300 from Kassala town. sampling units).
• Sampling methodology: Both localities, although 2. Since the 10 villages in each locality are not equal
classified as urban and rural, are considered similar in size, the 5 chosen villages were selected using PPS.
(in terms of demographic and household characteris- To do that, the cumulative frequency of number of
tic features) and the comparison was within the state, households of the 10 villages in each locality was cal-
not between states (i.e. no clustering features). culated. Then, random numbers using the number
5

6. of digits equivalent to the total number of households themselves or via interview. The questions are spread
to be sampled were obtained from tables of random over five sections. Options included both open and
numbers (not computerized tables). The villages con- closed questions. Responses to the questions did not
taining the random numbers were the villages from contain long recall periods but concentrated mostly
which samples were taken. on current practices. The questions were easy, non-
threatening and not sensitive. They started off with
3. Then, an equal number of households with 1 wom- simple demographic questions about the sampled
an/household (secondary or main sampling units) women. Then the questionnaire explored the RH ser-
were selected from the chosen villages by simple vices the women received during their pregnancies
random sampling (SRS) (or using methods the ground (ANC, birth, abortion care and FP). Then their knowl-
team found more feasible). edge of various RH topics was explored (FP, danger
signs, birth planning).
• Response rate: 90%.
• Quality assurance: Interviewers were chosen
• Data collection tool: A questionnaire was de- according to significant past experience of conduct-
veloped by the AUW team to be filled in by trained ing interviews. 10 interviewers were chosen and re-
interviewers. Interviewers were recruited and trained ceived one week’s training before the survey. Pretest-
to interview the target women. A pretest was per- ing of the questionnaire was done on a sample of
formed on a sample of 100 households. Data collec- 50 households and necessary changes were made ac-
tion commenced on 23rd Dec 2011 and concluded on cordingly. The following points were assessed in the
7th Jan 2012. pretest:
• Questionnaire design: The questionnaire was
written in Arabic. The questionnaire was long but sim- • Whether or not the respondents understood
ple, and could be administered by the respondents the questions as intended
6

7. • How respondents reacted to some questions have at least one female of reproductive age (SHHS
perceived as sensitive 2012). 60% of them have had at least one birth,
• Whether questions were in logical order and 35% of them are not educated. This reflects the
• Whether skip rules for the questions were importance of safe motherhood and RH issues in a
correct country like Sudan. Kassala has one of the worst RH
• The length of the questionnaire and childhood indicators.
ANC EXPERIENCE
2. RESULTS
The first section of the questionnaire examined the
GENERAL DEMOGRAPHIC CHARACTERISTICS OF ANC experience of the sample women and the type
SAMPLED WOMEN and quality of care they received during their last
The questionnaire started with basic demographic pregnancy. Almost 44% of the women said they had
questions. The sample women consisted of women of ANC during their last pregnancy in a health facility
reproductive age who have given birth at least 5 years (HF) only, while 21% had ANC both in a HF and from
ago. Almost 30% of the sample were young mothers a midwife. Just 5% stated they had ANC from a VMW
(less than 25 years old) and almost 70% of the sample only, mainly because it was a family tradition (98%).
women had a very low level of education (illiterate or Regarding frequency of visits, 66.6 % of women stated
primary level education). Almost 60 % had a child less that they went to ANC every month during their last
than 3 years ago, 15 % were pregnant at the time of pregnancy. A small percentage stated they received
the survey and 25 had a child less than 5 years ago. no ANC during their last pregnancy (2.4%), while 4.4%
Therefore, the survey reflected recent rather than old had one ANC visit. 17% said they had one visit every
experiences. Nationally, 90% of households in Sudan trimester and 10% had one visit at the beginning of
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8. pregnancy and one towards the end of pregnancy. occurring during birth rather than during pregnancy.
The subsequent questions assessed the quality of the Post partum mortality also contributes significantly
visits they received. More than 94% of the women to MM in developing countries. According to this sur-
stated that they had received good care, in terms of vey, women in Kassala state did have regular ANC vis-
checking their history of previous pregnancies and its as recommended but it is clear the quality of the
deliveries, measuring blood pressure, and abdominal visits was substandard. They received services dur-
examinations. 42% did not have an eye examination ing the visits that clearly are not designed to identify
for anaemia or chest examination, 90.4% did not women who are at risk. Women, especially seen by
receive a breast examination, and 89.9% did not re- VMWs in the community, did not regularly have their
ceive advice or info on HIV/AIDS prevention and test- blood and urine monitored. Also, the VMW survey
ing. 61% did not have their lower limbs examined for and training executed during this project highlighted
oedema. 89% stated that their caregiver did request deficits in skills for BP measuring and anaemia detec-
laboratory tests for urine and Haemoglobin. tion. ANC seems to be just a routine procedure and
has failed to accomplish its purpose as a mechanism
Antenatal care’s effect on maternal mortality has of early detection, counselling and advice.
been under great debate. More and more systematic
reviews of ANC in developing countries illustrate that
a greater frequency of ANC visits does not necessarily FAMILY PLANNING EXPERIENCE
reduce maternal mortality. They highlight the effect
of the quality of the visits as more significant. ANC The second section of the questionnaire explored the
should be a means to detect women at a higher risk experience and knowledge of women regarding dif-
of developing complications during pregnancy and/ ferent types of family planning methods. The types
or birth. Maternal mortality in developing countries of FP most used by the women were oral contracep-
has been shown to be more obstetrical-related and tive pills (CoP & PoP) (48%).
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9. In terms of knowledge, oral contraceptive pills were maining demand for FP and to strengthen supply
the best known FP method among women (62%) fol- chain management and logistics in its health systems.
lowed by breastfeeding (LAM) (56%). 82% of women
did not know about condoms as a FP method, 49% did We also need to create demand by awareness-raising
not know about hormonal injection and 74% did not in the community with an emphasis on the benefits
know about “safe period” as a contraceptive method. of family planning, and we need to increase access to
These results go hand in hand with SHHS 2012 that FP commodities at the community level.
showed Kassala as one of the states where FP was
least used (95.6 % of women were not using FP at the
time of the survey). KNOWLEDGE ON DANGER SIGNS DURING PREG-
NANCY
Based on the facility survey, the limited knowledge
and access women have to various types of family The third section of the questionnaire explored the
planning was not surprising. The FP methods most knowledge of the surveyed women regarding danger
widely available in the targeted PHCUs were oral signs during pregnancy, labour and newborns. The
contraceptive pills. These centres periodically lack best-known danger sign during pregnancy was vagi-
supplies due to inefficient supply chain management. nal bleeding (92.5%), followed by decreased or no
When these commodities are available, they are pro- foetal movement (79%), dizziness and/or loss of con-
vided at a charge. Women have to purchase FP prod- sciousness (74%), and convulsions (74%). Sudden
ucts from their own pocket. generalized oedema was recognized as a danger sign
by 72% of the women. Knowledge of important signs
Currently, according to the latest RHCS assessment of pre-eclampsia was low; 67% did not know that se-
2007, UNFPA satisfies 12% of the country’s demand vere headaches are a danger sign, 64.3% did not know
for family planning. MOH needs to provide the re- that severe vomiting is a danger sign, and 53.3% did
9

10. not know that blurring of vision is a danger sign. 62% KNOWLEDGE ON DANGER SIGNS DURING PUERPE-
of women did not know that “burning micturition” or RIUM
fluids escaping from the vagina are danger signs dur-
ing pregnancy. The best-known danger signs during puerperium
were severe vaginal bleeding (84%), convulsion
(79%), difficulty in breathing (66%) and fever (64%).
KNOWLEDGE ON DANGER SIGNS DURING LABOR The least known signs were signs of puerperal sep-
sis: foul-smelling lochia (68.2%), and pus from episi-
Exploring the women’s knowledge of danger signs otomy (65.6). Knowledge of signs of pre-eclampsia
during labour revealed that the best-known danger during puerperium was also low: 70.5% did not know
sign during labour was severe vaginal bleeding af- nausea and vomiting, and 63% did not know severe
ter placental removal (82%), followed by delay in headaches. Knowledge of signs and symptoms of
placental removal by more than half an hour (75%). fistula formation was low, as 56% did not know that
Knowledge of risks for precipitating vaginal fistula urine/stool incontinence is a sign.
was low; 57% did not know that being in labour for
more than 12 hours is a danger sign, while 48% did
not know that pushing out the baby for more than 3 KNOWLEDGE ON DANGER SIGNS FOR NEWBORNS
hours is a danger sign. 54% did not know that sudden
loss of the feeling of bearing down during labour (a The best-known danger signs for newborns were
sign for ruptured uterus) is a danger sign. slow breathing or difficulty in breathing (82%), de-
creased or refusal of feeding (80%), tremors or
convulsions (80%), yellow skin/eyes (62.5%) and
pus from the umbilical cord stump (51%). 76% did
not know that blue lips/nails are a danger sign
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11. that warrants prompt referral to a health facility. routine testing. These results are worse compared
Also, 60% did not recognize that lower conscious- to the findings of SHHS 2010 about knowledge on
ness or stuperosis in a newborn is a danger sign. mother to child HIV transmission. SHHS 2010 also
Women in Kassala showed very modest knowledge revealed that only 2% of women in Kassala state
on various danger signs they may encounter dur- have been tested, and only 0.6% of these have ac-
ing after their pregnancies. They are receiving mini- tually received their results. This indicates the press-
mal information from health care providers, in this ing need to target these localities with interventions
case mostly VMWs or PHC in general. It is clear to spread knowledge and provide VCT services.
that the role of PHC in providing education and dis-
seminating knowledge is not met in these localities.
BIRTH EXPERIENCE AND BIRTHING PLANS
KNOWLEDGE ON HIV/AIDS The questionnaire explored the women’s latest birth
experience and the existence of a birthing plan if they
93% of the women had heard about HIV/AIDS. 22% were currently pregnant. Almost 66% had home de-
did not know that the virus could be transmitted liveries in their last pregnancy and 70 % of them gave
from an infected mother to her unborn child. 40.7% the reasons as being because they themselves insist-
did not know it could be transmitted to the unborn ed to deliver at home. For women who did deliver in
child during vaginal delivery, and 53.4% did not know a health facility, the topic on which they received the
it could be transmitted via breastfeeding. 83% did most advice after delivery was on breastfeeding (83%).
not know that there are drugs that prevent mother The topic on which they received the least advice was
to child transmission of the virus. 43% did not on was FP (83% did not receive advice on FP), cleaning
know that pregnant women should undergo rou- episiotomy (66%) and on danger signs during pu-
tine VCT for HIV, and 20% did not approve of this erperium (65%). 41% of women who were preg-
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12. nant at the time of the survey did not have a birth- deliveries. Programmes should concentrate more on
ing plan. 80% of those that claimed they did have altering this mentality. Women still need to be en-
a birthing plan only did so by preparing emergency couraged to have a birthing plan, especially in terms
funds. Midwives had inputs in only 30% of those of putting aside funds for emergencies during labour
birthing plans. For any future pregnancy, 60 % of or pregnancy. Women still feel satisfied with the ser-
women still insisted that they preferred home de- vices of midwives. The best-known types of FP among
livery. 86% of the women thought that their VMWs women were injections and combined pills. Women
were capable of handling pregnancy complications. did not know the various danger signs related to ec-
lampsia. Knowledge about danger signs during labour
Women in the two localities had a high rate of home de- was low compared to danger signs during puerperi-
liveries, with a strong conviction in their value among um. The women showed the most knowledge regard-
the mothers themselves, who insisted on doing the ing danger signs in a newborn. Knowledge on HIV/
same in the future. This, coupled with the absence of AIDS was alarmingly poor. They wanted to use FP, but
birthing plans prepared by the women, is an alarming they could not have access to methods through mid-
fact. Women are insisting on delivering at home with wives and had to travel to the nearest HF to get them.
low access to qualified health personnel and a lack
of access to nearby EMOC facilities. Interventions tar- Programmes should focus on changing the mental-
geted at social and cultural beliefs should be initiated ity of women towards facility birth. We believe that
to encourage to the use of health facilities for birth. if VMWs were officially employed by nearby health
facilities, women could be gradually persuaded
Women in rural and urban Kassala still believe that to deliver in facilities. More support for VMWs in
their VMW is capable of handling any emergency terms of FP methods and education on informa-
that could happen to them during pregnancy or la- tion related to HIV/AIDS and training on knowl-
bour, and the women still have a preference for home edge transfer to women during ANC is also needed.
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13. BASELINE SURVEY ON KAP OF ALL VMWS IN KASSALA STATE
1. OBJECTIVES • Questionnaire design: The questionnaire was
General objective: To assess the knowledge, atti- written in Arabic. The questionnaire was long but sim-
tudes and practices of VMWs in the community on ple, and could be administered by the respondents
various RH issues (knowledge and distribution of FP themselves or via interview. The question was distrib-
methods, pregnancy danger signs, delivery emer- uted into five sections. Options included both open
gency procedures and referral mechanisms, opinion and closed questions. Responses to the questions did
on home delivery versus facility delivery, birthing not contain long recall periods but concentrated on
plans, HIV/AIDS and pregnancy, training and support mostly on current practices. The questions were easy,
requirements, decision-making capabilities). The tar- non-threatening and not sensitive. They started off
get midwives were all working in rural Kassala and with simple demographic questions, then moved to
Kassala town, with priority given to those working in work and training history including the scope of mid-
the catchment populations of the targeted facilities. wives’ current functions in the community.
2. METHODOLOGY The questionnaire then investigated midwives’ knowl-
• Target population: All registered village mid edge on danger signs during all stages of pregnancy,
wives in Kassala state. and their skills in day-to-day work. The questionnaire
• Sample size: 154 midwives also asked about their needs.
• Survey sites: Midwives were interviewed
before they had undergone training as part of • Administration of questionnaire: 98% were
the project activities. self administered, and the remaining was filled in by
• Response rate: 100% trained interviewers.
• Data collection tool: Questionnaire
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14. • Quality assurance: pretesting of the question- while the rest worked exclusively in the community.
naire was done on a sample of health personnel in 83% of the VMWs stated that they did not receive
Ahfad Health Centre. Necessary changes were made a regular salary for their midwifery services. Of the
accordingly. The following points were assessed in midwives that did receive a regular salary, 56% did
the pretest: so from the MoH and 44% from other sources (NGOs
and UN agencies). The type of support that they re-
• Whether or not the respondents understood ceived the least from the MoH or NGOs was provision
questions as intended of midwifery supplies (11%). They especially lacked
• How respondents reacted to some questions support in obtaining midwifery supplies, e.g. dispos-
perceived as sensitive able materials (gloves, suture materials, etc.), and
• Whether questions were in logical order equipment, as well as FP methods. 73% declared that
• Whether skip rules for the questions were they replenished their midwifery supplies by buying
correct them out of their own pocket, while the others man-
aged to get most of their supplies free from the MoH,
NGOs and UN agencies. 91% of midwives expressed a
3. RESULTS need for more support, specifically in terms of sup-
plies (98%), supervision (96%) and salaries (90%).
DEMOGRAPHIC CHARACTERISTICS AND WORK EX- 91% of the midwives stated that they have received
PERIENCE some sort of training during their services, and more
63% of VMWs interviewed were between 30 and 50 than 70% of that training was during recent years
years old. VMWs below the age of 30 constitute 11% (from 2010 onwards). 99% stated that they provided
of all Kassala midwives. Only 3% came from a fam- ANC services to their communities, and 97% stated
ily of midwives. 72% of the MWs stated that they that they also provided postnatal care. Midwives
worked both in the community and at a health facility, lack enough knowledge on counselling women on FP
14

15. methods other than oral pills and injections. Only KNOWLEDGE ON DANGER SIGNS DURING PREG-
36% stated that they managed to provide some kind NANCY, LABOUR AND PUERPERIUM
of FP services to women who need them, mostly OCP
(38%) and to a lesser extent condoms (8%). 84% of The VMWs’ knowledge was high on all major warn-
ing signs during all periods of pregnancy and for new-
midwives gave FP counselling (benefits, side effects)
before they provided the FP method. 66% stated thatborns (97%-100%), but when interviewed on their
they distributed prenatal vitamins to women dur- knowledge of HIV/AIDS, their knowledge dropped
ing ANC when it was available to them. They are notsignificantly: 30% did not know that the HIV virus
could be transmitted from mother to child during
able to constantly distribute prenatal vitamins since
they are not supported by the MoH due to their un- pregnancy, labour and birth, and 38% did not know
employment. They do get a sporadic supply of drugs there are drugs that could prevent mother to child
from UN or NGOs but this is not sustainable. Only HIV transmission. They showed a clear lack of knowl-
59% of midwives said they actually helped women edge on HIV/AIDS issues and on offering counselling
prepare birthing plans. on HIV/AIDS during pregnancy or voluntary testing.
The midwives are aware of most danger signs during
Concerning FGM issues, 77% said they did advocate pregnancy and labour but they lack support to verify
against FGM and re-infibulations, but 13% admitted these warning signs (e.g. no sphygmomanometer to
they performed it upon request. More than 90% of monitor blood pressure, no kits to monitor proteins
the midwives provided counselling and advice on in urine), especially if the delivery is a home delivery.
breastfeeding, immunization and early child care.
Only 39% provided counselling and offered HIV/AIDS
testing by referral.
15

16. ANC PRACTICES (SKILLS) low performance in the following: monitoring blood-
pressure during delivery (27% did it). Only 11% main-
The VMWs were interviewed about the services pro- tained an intravenous line. 89% of midwives stated
vided and the skills they practice during antenatal that they performed episiotomy routinely during each
care (ANC). They reported a high-level performance birth. 87% reported that they registered their deliver-
on most skills (history taking, signs and symptoms of ies in a log book. 94% reported that they were able
anaemia, breast examination, foetal heart sounds, to assess and recognize postpartum haemorrhage,
lower limb oedema, general prenatal and postnatal but 87% said they referred cases immediately to the
advice) (92% - 98%). Some skills were poorly reported nearest HF. Although the VMWs did not administer
by the midwives: 62% did not usually measure blood anti-convulsion drugs, 91% reported knowing how to
pressure, 30% did not offer prenatal vitamins, 40% place the patient in a safe position during the convul-
claimed they did not offer ANC to known HIV positive sions until referral. Concerning newborn care, 66% of
mothers. 86% did order lab tests for mothers in near- midwives performed nasal suction on newborns, 40%
by laboratories, and 59% did not register outcomes of offered BCG vaccination to newborns (by counselling
ANC visits for each client. and referral), and 40% of midwives did not take mea-
surements of newborns.
DELIVERY AND POST-DELIVERY PRACTICES (SKILLS)
HYGIENE PRACTICES
The questionnaire then explored the midwives’ prac-
tices and skills during delivery. The midwives report- The questionnaire then explored the midwives’ hy-
ed good practices in the following skills (uterine mas- gienic practices. 82% of community deliveries oc-
sage, episiotomy repair, controlled cord traction and curred at women’s homes and 16% at the midwives’
monitoring of foetal heart) (92%-99%). They reported homes where a hygienic environment is more under
16

17. their control. 92% reported using disposable gloves means of transportation readily available and they
and 16% reported using re-usable gloves. 42% of sometimes have to deal with things on their own.
midwives reported using non-sterile suture material
on women after birth and 99% reported using sterile Midwifery cadre qualified as skilled birth atten-
objects to cut the umbilical cord. Concerning steril- dants are lacking in Sudanese communities. Full
izing methods, 84% reported using water boiling as midwifery care is actually provided by a number of
a sterilizing method, 16% used alcohol as a sterilizing health cadres in the system. The most qualified cad-
method, and 6% used direct heating over a flame as res who provide the full range of midwifery care
a sterilizing method. The longest duration reported are largely concentrated in Khartoum state. The Su-
for sterilizing instruments was 30 minutes (51%), fol- danese health system recognizes the need to im-
lowed by 20 minutes (31%). prove midwifery care both in numbers and quality.
Almost all the areas considered to be part of an
enabling environment are not present for com-
ROLE IN BIRTHING PLANS munity based midwifery services: village mid-
wives are not employed in the health system and
Finally, the questionnaire explored the midwives’ have no job security, there is poor supervision and
role in the preparation of birth plans with expect- monitoring, there is no career pathway and lim-
ant mothers. 56% of midwives claimed they assisted ited chances for continued education, there is no/
mothers in making birthing plans (mostly just by en- poor access to supplies and medications and poor
couraging women to save money for birth) (79%) and links with referral services. Facility based midwives
transportation arrangements (17%). They do have also face the similar limiting factors. Midwives in ru-
decision-making authority to decide when to refer ral Kassala and Kassala city are in dire need of training
a woman to a health facility but they reported that and support especially permanent employment.
most families, especially in rural areas, do not have
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18. CONCLUSION PHC in Kassala is weak. It is even weaker in rural parts of
Kassala. PHC in a country plays a major role in enhancing
The Sudanese health system provides a minimum or weakening a community’s sexual and reproductive
package of PHC that has reproductive health (RH) as health. Universal access to SRH services means equal
a central component. RH services in a primary care access for everyone with equal needs. To achieve uni-
setting should provide the following through a quali- versal access to sexual and reproductive health at the
fied and competent health team: level of primary care, equality and rights have to be core
components in designing any RH programmes. PHCUs
• Assessment of the sexual and reproductive in Kassala show numerous barriers to reach quality SRH:
needs of the community: surveys, screening,
treatment, referral system. • Run-down facilities and shortages of
• Sexual and reproductive health education and equipment
counseling. • Limited and inconsistent options for RH ser-
• Family planning: all options should be made vices available for communities
available with proper non-discriminatory • Shortages of motivated health workers and
counseling (benefits and side effects). unwillingness of qualified health workers to
• STI (including HIV), RTI work in remote areas.
• Reproductive tract cancers • Lack of awareness in the community of the
• Post-abortion care full range of services that their PHC should
• Quality ANC provide for them.
• Skilled care during birth and PP for the
mother and the newborn All the above factors coupled with social and traditional
barriers make universal access to quality SRH an impos-
sible goal.
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19. Recommendations & way forward:
• Community baseline assessment (services, • More commitment is needed from the MoH
needs, knowledge & attitudes) should be im- to establish Basic EmOc services closer to the
plemented before any action plan or budget is rural community (e.g incentives for doctors to
put forward for any community based initiate work in rural communities).
in RH.
• More advocacy is required for task shifting
• Intensify community awareness raising on among RH health personnel so as to improve
pregnancy danger signs and delivery pre- maternal health in Sudan.
paredness.
• Intensify VMW awareness raising on select-
ed topics and skills training (evidence-based
training).
• Intensify VMW awareness raising on the im-
portance of early referral as well as participa-
tory birth planning with mothers.
• Establish hospital-based health promotion
units that target women after ANC or birth to
educate them on danger signs/RH issues.
19