Based on the analysis of the critical incident cases and stakeholders’ interviews four patterns of pathway to reach CEmONC were identified: (1) Late referrals to appropriate facilities, (2) Zigzagging referral, (3) Multiple referrals, and (4) Bypassing non-functioning healthcare facilities (Fig. 1). The main causes of the identified MD and MNM were bleeding (2MD & 3MNM), eclampsia (1MD & 2 MNM) and obstructed labour (2MD & 3 MNM). However, underpinning all the pathways was the functionality of BEmONC facilities and competency of their health providers.
Functionality of BEmONC
Depending on the geographical location, the nearest healthcare facility at the level of the community for a pregnant woman could be a village PHCU serviced by a professional midwife or a nurse, or a PHCC serviced by a medical assistant. Women with emergency obstetric conditions (such as severe bleeding or convulsions) seek help at these rural facilities. When PHCCs cannot manage emergency cases, they refer women to the County Hospital (CH) in Renk city which provides CEmONC. However, Renk hospital at the time of the study did not have a blood bank, and staff relied on family members to donate blood. Failure to secure a blood donor usually resulted in the family being referred to Rabak hospital or Kusti hospital in White Nile state in North Sudan, where blood bank facilities were available, but this was not feasible for everyone referred.
According to a senior manager at Renk County’s health department, each village in Renk County should have an appropriate number of PHCCs, to implement the basic package services and ensure community participation. A senior manager at the Reproductive Health and Midwifery Department in Renk County stated that each health centre in the county should provide BEmONC and should have at least one trained midwife to provide antenatal care and delivery, yet most of the centres have only a medical assistant or a male nurse. Thus PHCCs were not in a position to provide a supportive system linked to Renk hospital as a referral hospital if CEmONC was required.
The health facilities in the county are not evenly distributed geographically. For example, there are more than 15 villages in Shomodi Payam in the south east area of Renk town, all of them are served by only one pharmacy and two health units. Some areas have no health facilities at all. On the other hand, most of the functioning healthcare facilities are concentrated in Renk town. There are two centres for antenatal care around Renk town. The midwifery school manages the first one, which is part of Renk hospital. The second one is attached to and run by the Episcopal Church.
“There is no planning for distribution of the health facilities. Facilities are built according to the available fund and what people want. In the Catholic church in Renk there are 20 midwives and one of them is the head of the midwifery services. They play an important role in providing midwifery services in the Renk city. Pregnant women call them to come to their house to help them with delivery.” (Employee in a FBO)
According to a senior manager of the county’s vaccination programme, many of the health centres in villages are not functioning and most of the services are provided by Renk hospital. In the periphery of Renk Payam (Geiger, Jalhak and Shomodi), there are 16 PHCUs and PHCCs, but 8 of them (50%) are not functioning. Additionally, the working environment in the poorly functioning PHCUs and PHCCs is not suitable for providing an acceptable level of health service:
“They come to me. I help as much as I can, but sometimes I don’t have medications. If there is something I can’t handle I take her to the medical assistant. If we had a doctor, we would not face such problems.” (Trained midwife in Jalhak)
The health centre in Jalhak, 80 km south of Renk town, was built in the 1980s. Before the war, the maternal health services in the health centre were provided by a doctor, midwives and nurses. However, due to the war, the centre was closed and its functions were never fully restored. It now provides very limited health services at a level of a health unit. There are also small private clinics, laboratories and pharmacies that are owned and run by health assistants and nurses:
“This health centre in Jalhak was there since the 1980s. There was a doctor who treated people for free. Before the war, there were not too many health problems. After the beginning of the war, people fled the area and the health centre was just a building. After the comprehensive peace agreement in 2005, some people tried to work at the centre but could not because they didn’t live here originally. They were from other places and didn’t know how to manage the problems. Their salaries didn’t arrive on time and sometimes not at all.” (Medical assistant in Jalhak)
Absenteeism of health workers was also raised as a main concern in the health centres. For example, some stakeholders indicated that a medical assistant in one of the peripheral health centres was not available most of the time because he worked in a private centre in Renk town. Another concern raised was the presence of unqualified personnel. The example was given of a person who worked in the pharmacy of one the villages who was not a qualified pharmacist, but who treated people for malaria and eye infections based on the peoples’ complaints.
Competency of birth attendants
The ability of birth attendants to know whether a patient needed to be referred to another facility influences maternal survival. Birth attendants can be trained midwifes or TBAs. The competency of these cadres varies.
Competency of TBA
The TBA is also called ‘the rope midwife’, because she uses a rope, which she fixes to the roof of the house or to a tree so that the delivering woman can hold it to help her in the delivery. TBAs claim that they inherit experience from their mothers and grandmothers. One TBA said that she got her experience from a dream. She dreamed about a woman who was in labour and asked her to help; she took a razor blade, cut the woman, and delivered a healthy baby to a healthy woman. TBAs do not use scissors, but prefer razor blades, which they buy from the market. They consider a new razor to be sterilised. They wrap one side with a cloth, and use the other side to cut the woman. They use straight sewing needles to suture the cuts. A senior manager at the Reproductive Health and Midwifery Department in Renk County complained about the ability of the TBAs to deal with complicated deliveries. It is difficult to convince TBAs to come and stay for one year in the midwifery school for training. Most of the TBAs refuse to stay in the town for a long time as they do not want to leave their families and husbands.
“In the past, TBAs have arrived to Renk hospital with pregnant women with their babies partly delivered; parts of the foetus, such as the head, the arm or the leg, outside the woman’s body and the rest of the body still inside.” (A senior manager at the Reproductive Health and Midwifery Department)
Many other stakeholders also indicated that TBAs have inadequate skills to manage labour. They stated that a TBA might give advice if there is no trained midwife available. The TBA’s role is to reassure the woman in labour about the baby and her health and to provide advice on taking rest, not doing strenuous housework. According to A senior manager at the Reproductive Health and Midwifery Department, the TBA cannot identify the severity or the magnitude of certain maternal and neonatal complications, or the appropriate actions to take. The TBA, after exhausting all her efforts, may call the trained midwife if the delivery is not progressing well. The trained midwife will take over and if the midwife fails to solve the problem, the woman should be referred to the hospital.
TBAs, however, feel that they have enough experience to do their job and some TBAs do not see the need for training. They know that people around them trust them and listen to their advice. TBAs claim that if they failed to manage a case and it became complicated, they would refer the woman to “those who are more experienced” than them in the hospital. Some TBAs expressed the desire to have access to certain drugs for use during pregnancy and labor, with some indicating the need for supportive training to enable them to use appropriately. The drugs that they mentioned are those ‘used to treat anaemia’, ‘stop bleeding during labour’, and ‘local anaesthesia’.
Competency of midwives
The training of midwives takes place in two midwifery schools in the Upper Nile state, one in Renk town and one in Malakal city. The midwifery school in Renk town contacts the executive director of each payam (local administrative division) to request community leaders to nominate women from their localities for midwifery training. Attendants are required to be aged between 26 and 39 years. They complete a one-year training course in order to be become a qualified midwife. There are two types of trained midwives: a nurse midwife who graduates without a ‘midwife’s medical bag’ because she will work in the hospital, and a village midwife who will be based in the community and graduates with a ‘midwife’s medical bag’, or ‘suitcase’, hence she may be called a ‘suitcase midwife’. She is also called the ‘legal midwife’, to differentiate between her and ‘the illegal’ non-skilled TBAs.
The midwifery training curriculum in Renk midwifery school commences with basic instructions on instruments like scissors and forceps, and how to use and sterilise them. The course includes how to sterilise cotton and gauze, how to clean the midwife suitcase, and arrange the equipment inside it. Students are taught about ‘dry labour’, including drugs used during labour, cervix measurements and how to determine the level of cervical dilatation during labour. Then they are trained on ‘wet labour’, including how to cut using a scissors, and how to deliver and hold the baby and placenta. Each student must perform ten deliveries before graduating. After the training course, the trained midwives are recruited by their county councils to work in villages. Their monthly salary is about SDG 210 (USD 70). Recently the state government dismissed many of midwives recruited in this way and stopped their salaries due to budget limitations. The Director of Reproductive Health and Midwifery in Renk County acknowledged that the midwives who trained in these schools contributed to improving maternal health, because they know when to refer the pregnant women to hospitals. Funding to operate the midwifery school is the big challenge facing the sustainability of the training.
Competency of the birth attendant in crucial decision making emerged as a major influence on women accessing appropriate healthcare. One of the critical incident cases described showed that when a midwife sent the husband to the health centre to collect medication, the patient survived. If she had tried to refer her to Renk hospital the woman might have died. This is illustrated in Fig. 2.
Pathways to care
Late referrals to appropriate facilities
Late referrals to appropriate facilities were reported when TBAs were reluctant to refer women before acknowledging problems with the labour. The TBAs may have assured the pregnant woman that everything would progress well and that the delivery would be very smooth. The TBAs try to manage the delivery as much as they can. The TBAs tend to keep the women in labour with them for long periods. When the duration of labour exceeds two to three days, or if one of the two main danger signs (bleeding or convulsion) occurs, TBAs declare that they can no longer manage the labour. Sometimes, the father and pregnant woman might notice that the labour is not progressing well and decide to declare the TBA’s failure before she does so herself. The referral process is delayed until failure is declared, either by the TBA or family member. Two maternal death cases illustrate the variety of reasons that led to a late referral to appropriate healthcare facilities:
She had four children. Her family called for the TBA when her labour pains began. The TBA waited until the third day to ask the family to take her to the hospital. The family and pregnant woman went to the nearest rural hospital in Melut village. The woman presented to the casualty department at 8:00 am. The doctor examined her to discover that she had a ruptured uterus. (10RMD)
She was a very young primigravida living in a village on the outskirts of Palouge (170 km south of Renk town). When she was in labour, her family called for the TBA to come to help deliver her baby. Day after day passed until she became restless, febrile and no progress had been made with the labour. They decided to seek professional healthcare on the fourth day. (11RMD)
Another case was a mother who tried to manage the situation herself and a medical assistant in the health center failed to manage the case effectively and to reassure the family. The family ended up taking the decision themselves to transfer the critically ill patient to Renk hospital, but they arrived too late for the doctors to save her. Figure 3 illustrates this case.
Zigzagging referral
The second pathway pattern identified is the ‘zigzagging referral’ that occurs when a delivering woman is referred back and forth between two healthcare providers. Each provider refers her to the other after failing to manage the labour, both failing to refer her to an appropriate facility. Such a case is illustrated in Fig. 4.
Multiple referrals
Another referral pattern is where the patient visits several healthcare facilities before reaching the appropriate facility able to provide CEmONC. Women seek help at the nearest health centre and are often referred to a ‘non-functioning’ rural facility (without appropriate staff), from where they might in turn be referred to another ‘non-functioning’ rural hospital, before reaching Renk hospital. Renk hospital should be able to provide a caesarean section and blood transfusion if needed. However, Renk hospital might refer patients on again to another referral hospital (such as Kusti hospital) due to lack of blood, or inability to perform operations. Three cases illustrate this pattern of multiple referrals (Figs. 5, 6 and 7).
Bypassing non-functioning healthcare facilities
The fourth pattern of referral involved bypassing non-functioning healthcare facilities. This emerged in the case of a woman who experienced prolonged labour and bleeding. The woman survived because she bypassed these non-functioning facilities and were instead referred directly to Renk hospital. Figure 8 illustrates this case.