Although in parts of South Sudan the situation is unstable which necessitates humanitarian action, in other parts of the country development programmes are taken up with the communities. In Northern and Western Bahr el Ghazal states, Aweil North and Wau county respectively, the South Sudan Health Action and Research Project (SHARP) works on improving reproductive health. Besides efforts to improve service delivery, including construction and equipment of health facilities and recruitment and training of midwives and other staff, SHARP runs a community participation programme, with the objectives to:
- Stimulate dialogue between generations and sexes, mutual respect and discussion about delays to seeking maternal health services and other problems related to reproductive health, such as early marriage and teenage pregnancy;
- Facilitate critical reflection on the social norms, values, practices and beliefs that hinder sexual and reproductive health (SRH);
- Make communities aware of their rights to quality reproductive health services, in particular antenatal care (ANC), delivery care and postnatal care;
- Discuss and stimulate learning about identifying dangers to a healthy pregnancy, delivery and recovery after delivery, the risks of early pregnancy and lack of birth spacing.
Why is this project needed?
The state of reproductive health is poor in South Sudan. The fact that one out of seven women die during child birth says enough. Only 9.5% of pregnant women complete the fully recommended protocol of four or more ANC visits. Most women deliver at home (81%) and more than 40% deliver without assistance. The use of modern contraceptives is extraordinarily low, with only 1.5% of women reporting using them. Early marriage is common and about 45% of the girls marry before the age of 18. Reproductive health problems can be a result of interrupted or low quality health services, however, this is never the full story. In South Sudan, as in many other countries, community level norms, values, practices and beliefs can hinder people from seeking those services. This is why the community participation programme was launched, to complement SHARP’s investments in the supply of reproductive health services.
How does it work?
The programme was developed by KIT, who trained relevant staff. There are two community participation officers (CPOs) in both Aweil North and Wau county. They are part of the NGO leading health services at the county level: HealthNet TPO and the International Medical Corps (IMC) respectively. They first launch a stakeholders meeting at the payam level, where participating communities are selected. From each community, four voluntary community facilitators are selected by the community. They receive a training of trainers in the facilitation of community dialogue sessions. These trainings are conducted by the CPOs and other NGO staff. The four trained community facilitators assist the CPOs in conducting the sessions in their own communities. They comprise of one older man, one older woman, one young man and one young woman. Five dialogue sessions are conducted on a weekly basis, each having their own focus. Participants from the community are the same four generational groups of men, women, youth and elderly, 40 participants in total. The programme is following a Participatory Action Research approach. After the five sessions, participants present their action plans in a public meeting in which the whole community is present. They follow-up on the proposed actions, and communicate on the issues that transpired in the dialogues sessions with their peers in the community. The project includes base and end line consultations. As the project is ongoing, an evaluation is not yet available. However, we share some experiences and preliminary results.
Delays in seeking maternal health care
Several traditional customs and believes that negatively influence women’s health were discussed among the generations and sex groups. When a pregnant woman bled, an elderly woman was supposed to tie a rope around the small toe of the pregnant woman in order to stop bleeding. Others reported that a stone was thrown in water and once it sunk, they believed that the blood would clot. If bleeding persisted, they would have to look for a woman with twins to tie the small toe again. Only if these procedures would not yield a positive result, the villagers would look for a stretcher to carry the woman to the hospital. Extensive discussions about these procedures and the risks of child delivery increased awareness of young and old, men and women, on the importance of facility delivery. Action plans that were made included the development of birth preparedness plans and arrangements of emergency transport at the community level. Despite reproductive health being seen as an issue concerning women, the men started to see the importance of their role in stimulating facility delivery, as they are the decision makers in the family.
Family planning and teenage pregnancy
Many communities believed that contraceptives cause infertility that they are only appropriate for sex workers. It was believed that contraceptives promoted promiscuity among young girls and married women. Some elder people refused to talk about contraceptives, because they believed that they would reduce the number of children a person will bear in life, which is not desired. Some young girls were being forced into marriage, because young girls yield more cows, money or goods for the family; important in times of economic hardship. Many participants never thought about negative effects of early pregnancy for the young women, such as maternal deaths due to complications like fistula. In several (but not all) communities, agreements were made about reducing child marriage, with a role of village chiefs in the regulation. The issue of access to family planning remained difficult in many communities, the young were much more open about it than the elder participants.
The participatory action research is a multi-faceted learning experience for all actors involved. The involvement of County Health Department (CHD), payam administrators, traditional and religious leaders and communities brings in different perspectives. The involvement of the community in the selection of community facilitators ensures that they are trustworthy to become ‘agents of change’ and help attainment of the programme’s goals. Research staff, NGO staff, health workers, local authorities and communities resolve and act on issues that affect reproductive health in order to improve health at the community level. Feedback from participating actors shows that the utilization of reproductive health services went up in the participating communities. However, follow-up is needed to ensure that these results retain. The project yields other important results as well. Communication between young and old, men and women, communities and health workers seemed poor; this project improved dialogue and communication as stated by many participants. This is an important asset of the project, and can be the start of improved communication and dialogue on health and other community development issues.
By Kingsley Rex Chikaphupha and Maryse Kok
More information on SHARP can be found here.