Healing the Wounds of War: Reducing Maternal Mortality in Darfur

Reducing maternal mortality rates in Darfur remains one of the major challenges to the healthcare system in Darfur owing to the on-going conflict, displacement of large number of population, poor transportation networks, destruction of primary healthcare facilities and the lack of solid mechanism to train village midwives. Under these circumstances, the United Nations—African Union Mission in Darfur (UNAMID) continues to invest in reducing the maternal and child mortality rates in Darfur by mobilizing the existing resources and advocating for availability of all services that are directed towards improving the maternal health in the region. The article highlights the positive changes and significant impact that these interventions have had on reducing the maternal mortality rates in Darfur and saving lives of children.

have considerably weakened Sudan's healthcare system. The country has a long way to go to revitalize its healthcare practices and to establish a proper and effective health service delivery system that benefits every citizen of the country.
In June 2011, the United Nations Population Fund (UNFPA) published a report on "The State of the World's Midwifery". The report presented new data on the midwifery workforce and policies relating to new-born and maternal mortality for 58 countries. The 2013 maternal mortality rate per 100,000 births for Sudan was 2,054. This is compared with 306.3 in 2008 and 592.6 in 1990. The number of midwives per 1,000 live births was reported to be one, and the lifetime risk of death for pregnant women was one in seven.
The causes and rate of maternal death in Sudan are aggravated by ongoing conflicts and resulting displacement of population. The key indicators related to maternal health, including maternal mortality, child mortality and child malnutrition, are all exacerbated by conflicts, especially in the Darfur region.
While the exact maternal mortality rates for the five Darfuri states are unknown, they are estimated to approach the higher estimate. In fact, Darfur is probably among the most dangerous places in the world in which to give birth.
Sudan's Federal Ministry of Health together with WHO, UNICEF and UNFPA launched on 28 August 2013 the "Sudan's National Acceleration Plan for Maternal and Child Health". Sudan was the first of the 10 high-burden countries in the region to launch an acceleration plan on maternal and child health, in line with the commitment expressed in the Dubai Declaration, adopted in January 2013. In parallel, international stakeholders, including the United Nations-African Union Mission in Darfur (UNAMID), have mobilized the available resources to assist the Government of Sudan in reducing the mother and child mortality rates in Darfur.

Methodology
The United Nations-African Union Mission in Darfur (UNAMID) was established on 31 July 2007 with the adoption of Security Council resolution 1769. UNAMID has the protection of civilians as its core mandate, and is also tasked with contributing to security for humanitarian assistance, monitoring and verifying implementation of agreements, assisting an inclusive political process, contributing to the promotion of human rights and the rule of law, and monitoring and reporting on the situation along the borders with Chad and the Central African Republic (CAR).
In addition, based on the dire humanitarian situation in Darfur, UNAMID has been also implementing Quick Impact Projects (QIPs) and Community-Based Labour-Intensive Projects (CLIPs) in the areas of water and sanitation, education, health, rule of law and livelihoods. Since 2007, UNAMID has implemented in all Darfur states over 500 QIPs, worth over US$15 million, in the areas mentioned above. A number of these projects have addressed the unsustainable exploitation of forest resources; increased conflict over scarce forest and tree resources; exposure of women and girls to Conflict-Related Sexual Violence (CRSV) and Sexual and Gender-Based Violence (SGBV) as well as www.scholink.org/ojs/index.php/ape Advances in Politics and Economic Vol. 3, No. 3, 2020 26 Published by SCHOLINK INC.
the high maternal mortality rates in Darfur.

Addressing Maternal Mortality in North Darfur State
North Darfur is one of the five Darfuri states located in western Sudan with El Fasher as its capital.
Population of North Darfur state is estimated to be approximately 2.1 million. The state consists of 18 localities and over 2,600 villages. The women of child bearing age are estimated at 501,000, with 74,000 pregnant women. There are 1,115 village midwives available in the state. Maternal mortality is higher in rural areas as well as in conflict-affected areas where healthcare structures are mostly affected, causing the death of women due to the lack of access to skilled routine and emergency healthcare services.

Rehabilitation of El Fasher Maternity Hospital
El Fasher Maternity Hospital is the only maternity hospital in North Darfur state. All women in different parts of North Darfur receive medical treatment in this hospital, especially pregnant females.
In addition, it also functions as a teaching hospital for students of the medical faculty from El Fasher University. Nevertheless, the Maternity Hospital has been suffering a lot, especially from the lack of effective power-supply system and the acute shortage of uninterrupted power which is so important to have during complicated operations. While the climatic conditions in North Darfur are extremely hot, the hospital had no ceiling fans and air conditions. Even sockets, plugs and electric line connections were in miserable conditions and required urgent maintenance and repairs. The hospital targets more than 50,000 patients a year to receive quality medical services, in particular pregnant women and newly born children.
Therefore, improving the conditions of the maternity Hospital became a high priority in view of the large number of female patients seeking medical treatment. In 2017, UNAMID visited the Maternity Hospital to assess the needs and developed a project proposal, through the National Non-Governmental Organization (NNGO) "Sudan Organization for Recovery and Development" (SORD). The project was designed to improve and upgrading the power unit services and the power network of the maternity hospital, which provides essential support to the vulnerable population in particular women and children.
The overall objectives of the project were to improve the work environment for medical staff as well as ensure good heath environment for patients; provision of a generator to improve power supply, especially for the maternity operations room; provision of light and power for the hospital; provision of power for medical equipment and devices to ensure effective and uninterrupted medical service provision to the patients; reduction of the mortality rate among pregnant women who lost their lives during delivery operations as a result of the lack of power; provision of conducive environment for students of the El Fasher University's medical faculty.
The project targeted a total of 75,000 women and children as direct beneficiaries of the project, including 60,000 females and 15,000 children with the age ranging from 20 to 50 years, in addition to localities in Krenek and Beida to provide midwifery services to local community members.

Addressing Maternal Mortality in Central Darfur State
The state of reproductive health in Central Darfur state is appalling. In 2010, the maternal mortality rate was 322 deaths per 100,000 live births; the infant mortality rate was 80 deaths per 1,000 live births; and under-five mortality rate was 66 deaths per 1,000 live births. Lack of knowledge on reproductive health among the local community members, scarcity of economic resources, and significant displacement of population due to insecurity, are all the contributing factors. However, a key reason for this situation is the lack of community/village midwives. Central Darfur state is well below its target coverage of 1 community midwife for every 1,000 people, and has identified a gap of 750 community midwives for the state. Presently, most of the women in Central Darfur state are only able to access traditional antenatal care which is not evidence-based.
To  Sanitation and Hygiene (WASH) package (water points, latrines, social marketing at the community level on basic hygiene), education (school), and health (clinic) were proposed.
There is only one rural hospital/basic health centre in Abu Matariq town, Bahr Al Arab locality in East Darfur which serves over 300,000 individuals in addition to 30,000 refugees from South Sudan residing at Kario refugee camp, and 2,700 refugees living with the host community. This dire situation is compounded with the absence of a maternity unit to receive expectant mothers and their babies. Until now, the deliveries were taking place at the doctor's office with maternal and infant deaths on the rise, as a direct consequence of absence of the much-needed appropriate health services.
Linked to this need is the high prevalence of malnutrition among children in the Bahr Al Arab locality.
According to the Locality Commissioner, official data provided by the State Statistics Centre indicate that there are 25,000 malnutrition cases among children in the locality. Based on these needs, the state authorities requested UNAMID's assistance for construction of maternity and malnutrition units in Abu Matariq since the maternal care and malnutrition are closely interlinked-the absence of the latter may have serious implications not only for affected children but also for expectant mothers who require continuous monitoring of their weight to ensure healthy babies are born.
In mid-2018, UNAMID provided funds to the implementing partner, local Non-Government Organization (NGO), for construction of maternity and malnutrition units in Abu Matariq town and provision of beds. The project implementation is currently ongoing and is expected to result in the reduction of morbidity and mortality rates to below emergency thresholds in Bahr Al Arab locality of East Darfur state; better access to quality primary healthcare services and strengthened referral services; strengthened national and local capacity in early detection, preparedness and response to emergencies and public health threats; reduction of maternal and child mortality rates; and provision of basic healthcare to pregnant women, children, elders and refugees.

Conclusion
Health services play a crucial role in preventing avoidable morbidity and mortality in emergencies.
However, emergencies affect health facilities and services too. With many been damaged, left without medicines, equipment, basic amenities or health workers, cannot serve the population which may even have heightened healthcare needs due to the emergency.
Reducing maternal mortality is one of the major challenges to the healthcare system in Darfur. The situation in the region is aggravated by the on-going conflicts and displacement of large number of population, poor transportation networks, destruction of primary healthcare facilities and the lack of solid mechanism to train village midwives. There are relatively simple, safe and affordable approaches to successfully prevent or treat most obstetric complications and thus save women's lives.
In the current circumstances, UNAMID and other international organizations should continue to invest in reducing the maternal and child mortality rates in Darfur, by mobilizing the existing resources and advocating for availability of all services that are directed toward improving the maternal health in the region. At the same time, it has to be admitted that eradicating or reducing maternal deaths require more than midwifery skills training and deployment of new midwives to remote and isolated areas. To achieve this objective, women will need to be taken out of poverty, gender inequalities will have to be eliminated, and stronger health systems should be established.
High female mortality rates are also common in other countries, especially in Africa (South Sudan, Chad, Sierra Leona, Nigeria, Central African Republic, Somalia, Liberia, Mali, Niger, Mauritania, Cote d'Ivoire, Central African Republic, Cameroon, Burundi, Lesotho, Tanzania, Guinea and Guinea-Bissau) (Note 2). Therefore, the implementation of UNAMID's successful initiatives could be replicated in those countries provided they are tailored to country-specific conditions on the ground.