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Outreach Health Activities Help Put Women in Control

© UNICEF/MLIA2010/Asselin
Women are encouraged to give birth at the closest health reference centre with the aid of skilled birth attendents.

Awa Sonta sits on her hospital bed in a stifling hot, stark, maternity ward staring into space, while two other young mothers nurse their newborn babies. Awa, who does not know her age, but looks about 20 years -- has just lost her baby.

Still in pain, she says in Bambara, the local language, “I was trying to push the baby out from Monday until Wednesday, but I didn’t manage. I pleaded with my mother -in-law, my husband and my brother-in-law to take me to the hospital because I was in so much pain. But they said it was normal for women to feel pain, and that I must suffer in silence.”

On the third day of labour, the family realized it was serious. They used the only transport available, a cart pulled by two bulls, to make the 15-kilometre journey to the community health centre (CSCOM) in the rural village of Mougna where the district ambulance picked her up to transport her 45 kilometres to the district hospital in Djenné, in central Mali. By the time Awa arrived at the hospital, her uterus had ruptured, her baby had died and she was unconscious. “She is lucky to be alive,” comments Dr Djamila Thiam, the doctor at the district health centre. Awa had to undergo an emergency caesarean.

It is not the first time Awa, a mother of a three-year old boy, has had problems during childbirth. Her first baby was delivered stillborn after a long, agonizing labour at home.
She is typical of many women in Mali. In the last Demographic and Health Survey carried out in 2006, 72 per cent of women said that their husbands make decisions about their wife’s health. Awa, who has never had any formal education, says, “I did not even know that there was so much help for pregnant women.”

UNICEF supports Government and community initiatives to provide outreach healthcare for women, like Awa, who are cut off from health services due to the remoteness of their villages and lack of information about available healthcare. Supporting and expanding these outreach services is key to reducing high child and maternal mortality rates in Mali, where for every1,000 live births 96 babies die before they reach one year of age and eight women die each day from pregnancy-related causes.

One such community initiative is taking place in Mougna, about 45 kilometres from Djenné. The CSCOM, or “Centre de Santé Communitaire”, is a health centre funded by the community through small charges for its use. It covers 12 remote rural villages, and a total population of 20,530. It is administered by a community health association, which is made up of elected community leaders in each village. “The village leader decides which day the CSCOM team visits, and then they are responsible for mobilizing the village,” explains Benjamin Bamba, the head of CSCOM. Each village receives two visits a month.

Community health volunteers, women’s groups mobilize the communities with the help of messages on the radio. Interest in outreach services is significant, if the experience of the village of Kossouma, some 10 kilometres away, is typical. As soon as the nurse and the midwife arrived on their motorbike, they were surrounded by over 100 women and children pushing into an enclosure made of straw and mud where the health activities took place. The two health workers efficiently organized the materials they had brought with them on the bike, including a cold box containing vaccines, as well as prophylactic malaria drugs for pregnant women and long lasting treated mosquito nets, and the registers. Children and women jostled forward waving their health cards as gusts of dust and hot air blew into the enclosure. “There are too many children and too much work to do,” said the auxiliary midwife, Oumou Diakité, who quickly took control over the chaotic situation. As she worked, she explained that she had received five months training to become an auxiliary midwife and work at the CSCOM.

The outreach health activities have made a huge impact, says the chief of the village, Diaiguina Krakan, who lost 6 of his 12 children to illnesses. “We used to have huge problems of whooping cough, measles and polio. Many children died. I see a big improvement now.”

Yet many obstacles remain. Community health centres, like that in Mougna, often struggle to sustain their activities. The rural communities are poor and they reduce their use of the services even more during the rainy season when roads become impassable and while they are waiting for the harvests.

Communication and transport is also a major problem. There is often no mobile phone network nor public transport; people frequently rely on ox-drawn carts for transport, which are of little use in an emergency, as testified by one father. Yussouff Natana’s wife had just given birth to her sixth baby –a breach birth – in the health centre and had returned home. But in the early hours of the morning she started to have severe pain and then haemorrhaged. Natana put his wife on the back of his ox-cart and rushed her as fast as possible to the health centre. She was dead on arrival. “The baby survived,” he says, looking like he is still in shock. It was only three days ago.

And other challenges are family attitudes and social norms as well as the importance given to the use of traditional birth attendants rather than trained providers. Awa knows only too well about family pressure, having paid the ultimate price of losing her baby. “Next time, if there is a next time, I will have my baby in hospital,” says Awa.

 

 
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