Too many births, too many deaths.

In Yemen, where both population increase and maternal mortality are exceptionally high, a strategy for safe motherhood has been adopted. The authors outline the obstacles to progress and suggest ways in which the aims of the strategy might be realized, with particular reference to complete reorganization of the services of family planning and maternal and child health care.

PIP: Yemen's population is growing at an annual rate of 3.1%. Women on average have more than 8 children. Few pregnant women are well nourished. Women marry early. Many women are illiterate and know little about maternal health services. Harmful traditional practices and poor socioeconomic and environmental conditions threaten women's health (e.g., annual maternal mortality rate = 1000/100,000 live births). The Government of Yemen's Population Action Plan has a strategy for safe motherhood. It aims to reduce mortality by 50%, raise contraceptive use from 3% to 35% and the minimum marriage age to 18 years, provide accessible post- and prenatal care, and empower women through participation in development programs by the year 2000. The government needs to overcome various obstacles to achieve these goals. The key obstacle is lack of qualified health personnel, especially females. This weakness is worsened by the fact that well-trained personnel prefer to work in urban areas and to provide clinic-based modes of service. Few physicians work in rural areas where 75-80% of the population lives. Most health centers do not provide family planning and maternity services. The shift to vertical management of immunization and diarrheal disease programs has resulted in even fewer women having access to these services. Primary care units should provide them. The community should participate in the units. A well- trained female primary health care worker and a medical assistant should staff each unit. Each district health center should have a physician, a midwife, nurses, a lab technician, a radiographer, an assistant pharmacist, local primary care workers, and traditional birth attendants. Each hospital should have a family planning and maternity clinic. Integration of family planning into pre- or in-service training is needed. The Ministry of Public Health must assume leadership to motivate the nongovernmental sector to effectively participate in the safe motherhood strategy.

Family planning in the Sudan: a pilot project success story.

PIP: In 1980, the Department of Community Medicine of the University of Khartoum designed an operations research project to test the possibility of getting village midwives to be involved in the delivery of maternal and child health and family planning (MCH/FP) services. From 1981-1983 the project was implemented by the University of Khartoum in cooperation with the Ministry of Health. The project area covered 100 km. It encompassed a largely agrarian population of 93,000 in 90 villages north of Khartoum along the banks of the Nile. The focus was on training and supervising village midwives. Information was provided on contraceptives for birth spacing, distribution of oral contraceptives, and referral for other methods. Also provided to midwives was information for mothers on oral rehydration therapy for children with diarrhea, and distribution of oral rehydration solution packets. Nutrition education was given midwives with emphasis on breastfeeding and weaning procedures. Information was also supplied about vaccination for children under 5 years of age (in collaboration with the Sudan Expanded Program on Immunization). The project was expensive, particularly regarding incentive payments for supervisors and midwives. The project had a very good start, but when incentive payments were withdrawn, it almost collapsed. At first, what midwives could do to provide maternal and child health services was targeted, but as the project went on, there was more concern for involvement of midwives in broader rural health delivery. The project area was a conservative, Islamic one. An extension area was selected 5 hours travelling time from Khartoum in Shendi District of Nile Province. The project was begun in 60 villages of 75,000 inhabitants. The land stretched for 120 km along both banks of the Nile. In the extension area, a small fee (US$.025) was charged per cycle, half going to the midwives, and half towards the health teams' expenses. 21 health zones were created, and a health team created for each. Registers of women aged 15-49 and children 3 years have been set up for each health zone. There have been very good results in the management of diarrhea.^ieng

Community and individual acceptance: family planning services in the Sudan.

PIP: The Sudan Community-Based Health Project, initiated by the University of Khartoum in cooperation with the Ministry of Health in 1980, sought to test the proposition that government-trained village midwives could provide maternal-child health and birth spacing services in addition to their ongoing obstetrical duties. The project area encompassed 92,000 people in 93 villages. The 120 midwives serving the project area received training in 4 interventions -- oral rehydration therapy, maternal and child nutrition, immunization, and birth spacing -- and introduced these services by means of 3 rounds of household visits over a 5-month period. Comparison of pre- and post-intervention survey data indicates that village midwives can indeed be used successfully to promote not only contraceptive use, but also health attitudes and practices that are positively associated with fertility regulation. Between the 2 surveys, the percentage of women who ever used contraception increased from 22% to 28%, while the percentage of current users rose from 10% to 13%. Parity was significantly related to current use; each child born multiplied the likelihood of contraceptive acceptance (by a factor of 0.76 in the post-intervention sample). Maternal education was the socioeconomic variable that most enhanced receptivity to contraceptive acceptance after the project's interventions. In terms of community-level variables, village location along the Nile and proximity to a paved road were significant correlates of contraceptive use. When variables related to the project itself were analyzed, women with vaccinated children were found to be twice as likely to contracept as those with nonvaccinated children and women who believed breast feeding should be continued during diarrhea episodes were 1.5 times more likely to use birth spacing than those who did not. Although midwives did not specifically emphasize contraceptive use, it appears women who were encouraged by midwives to take positive steps in the area of child health were also likely to become more innovative in terms of fertility regulation.^ieng

Demographic intermediation between development and population redistribution in Sudan.

PIP: This article analyzes the causes of population distribution in various geographical regions of Sudan. Population distribution is a function of fertility, mortality, and net migration. These variables are primarily caused by changes in socioeconomic factors prevailing in each area. The analysis shows that the population distribution among the geographical regions is primarily shaped by the differential development actions during the last 2 decades. The regional variability of population growth and density largely reflects regional development. Provinces are classified into 3 groups according to stages of population growth. The 1st group is composed of the 3 southern provinces, characterized by the highest mortality, lowest fertility, a marginal volume of net migration, and the lowest overall population growth rate during the last 2 decades. These are the poorest provinces in terms of per capita income, education, communication, and health measures. The 2nd group comprises Dafur, Kordofan, Northern and Red Sea Provinces, which generally reflect an intermediate stage in the demographic evolution in the country. Fertility is positively correlated and mortality is inversely related to the level of per capita income, resulting in an inverse relationship between the 2 vital rates. Therefore, the natural growth will probably increase. However, there are also areas of out-migration. Their future population growth and density will depend on the extent to which the out-migration will affect their natural growth rates. The 3rd group is composed of Khartoum, Blue Nile and Kassala provinces. They have the highest fertility, lowest mortality and highest volume of in-migration. Therefore, they witnessed the highest population growth rate and population density during the period. They encompass the largest urban centers with the highest degree of modernization and family planning activities. It is postulated that their future fertility and mortality rates will decline in varying degrees and will depend on the pace of decline of each vital rate and the trend of migration. In conclusion, the regional patterns of population growth and redistribution are likely to be uneven in the foreseeable future, unless a genuine policy of regionalizing is effectively implemented.^ieng