Reducing Maternal Mortality in Sudan: a hybrid framework
Asaad Taha, Ph.D., MSP®, PRINCE2®
Sudan has been categorized as a humanitarian emergency for decades. Since its independence in 1956, Sudan has experienced the protracted trauma of armed conflict, political instability, and natural disasters. Living with geopolitical turmoil at each of its borders for more than 50 years has led to pernicious corruption, erosion of state infrastructure, and the collapse of the civic services and economy. During the continuing desperation, the women of Sudan suffer unparallel abuse, most evident in their maternal mortality. I find no easy fix, but this is an effort to build a framework to coordinate symptoms and remedies.
The extent of the maternal health crisis
The continuing national dysfunction has created the large-scale displacement of people from rural areas to city centers with already burdened and crumbling health systems. “Years of social conflict and civil war in Sudan have undermined investor confidence” (2019 Index of Economic Freedom) and have relocated massive numbers of citizens and impoverished more. “Poor governance, weak rule of law, rigid labor markets, and an inefficient regulatory regime have impeded economic diversification and created a large informal economy” (2019 Index of Economic Freedom). These circumstances have lowered Sudan’s economic freedom ranking to 41st among the 47th countries in the Sub-Saharan region and 145th in the overall Prosperity Index. And, “Since the Prosperity Index began in 2007, Sudan has moved down the rankings table by six places” (The Legatum Prosperity Index 2018).
Connecting more dots in the web of colliding factors, the inequality among Sudanese household incomes contributes to poorer health as measured by life expectancy, infant mortality, stunting, food consumption, teen births, and vaccination rates. According to the World Health Organization (WHO) (Sudan, 2019), the life expectancy at birth in Sudan is 63/87 years. But the probability of dying under the age of five is 63 in 1,000 births (0.06%) and between the ages of 15 and 60 years is 253/195 per 1,000 (23.3%/19.5%). This reflects the low total expenditure on health at 8.4% of Sudan’s GDP (2014).
Where income is less unequal, metrics report marginally better health outcomes. Nonetheless, in conflict zones, those metrics may not be trustworthy. The social capital created by or through inequality and conflict occasion poor health. Policy and decision-makers must consider actions “to prevent both war and economic inequality as equally important to other public health interventions. Living in a more equal society could be the best medicine for a healthier and better life” (Omer, et al., 2014, p. 1230).
The impact of violence against women on maternal health
Sudan continues to fail its Millennium Development Goals (MDGs) and now lags in its Sustainable Development Goals (SDGs). Its SDG Global rank is 143 out of 156, and global index score is 49.6, 6.1 below the regional average (52.8) (Sachs, Schmidt-Traub, & Kroll, 2018). For example, its maternal mortality is high at 311 per 100,000 live births (Sudan, 2019). The slight statistical improvement in recent years disappears in the context of intrastate variations shown in Figure 1 below (Maternal mortality ratio, 2019).
The highly-impacted States of Darfur, Blue Nile, South Kordofan, and East Sudan represent the least developed and most-conflicted areas in Sudan where pregnancy resulting from sexual violence and rape are weapons of war (Stone, 2017). Sudan’s Cabinet of Ministry, in conjunction with UNICEF, displays the Maternal mortality statistics in Figure 2 (Facts and Figures based on MDGs indicators, 2019).
Moreover, the accessibility and use of contraceptives are very low, standing at 12% (Contraceptive prevalence, 2019). This leaves demands for contraception at 26.60% unmet and the need for family planning by modern methods at 30% satisfied as shown in Figure 3 (Contraceptive prevalence, 2019).
There remain several barriers to access and utilization of family planning methods ranging from lack of awareness, religious and sociocultural factors, and Availability, Accessibility, Affordability, Appropriateness, Acceptability issues (A5) (Homer, et al., 2018). Exacerbating these adverse conditions, African women are subject to the continuing tradition of female genital cutting (FGC) or female genital mutilation (FGM) marking 87% of Sudan’s women aged 15–49 with 74% of them severely mutilated with “infibulation” (Female genital mutilation prevalence (%), 2019).
Female genital cutting poses severe physical and mental health risks for girls and women. WHO has shown the adverse obstetric and neonatal outcomes for the mutilated women and girls (WHO guidelines on, 2014). And, the FGC-affected women in conflict-affected states are exposed to higher maternal mortality risks due to the lack of access to emergency obstetric care. “In conclusion, improving quality of maternal and neonatal health services requires interventions that are quickly achievable, sustainable and cost-effective. It needs concerted efforts of governments, international organizations, civil society, media, corporate sector, and others to identify and implement cost-effective [sic] solutions that would save lives of thousand mothers and newborns in Sudan” (Abdel-Tawab & El-Rabbat, 2010, p. 13).
The evolution of a model framework
The Health Information Systems Strengthening Center lists no National Health Strategy for Sudan (National Health Strategy, 2019). The current reproductive health strategy, WHO’s “Road Map to Reduce Maternal Mortality,” is not reinforced in Sudan by supportive health policy and political will able to address the injustice and systems barriers. It is used by the government to mobilize the donors’ funding. Addressing health inequities starts at the national government level where resources are supposed to be allocated based on needs supported by robust national statistics. However, as The Guardian says; “Although aid saves lives, and warring parties in conflict have an obligation to allow the delivery of humanitarian assistance to civilians, preventing it from reaching people is rarely punished” (Wheeler, 2017).
The intervention to address the Sudanese complex health inequities proposed here begins with Wagner’s Chronic Care Model (WCMM) shown here in Figure 4 (Gee, 2015). It displays six interdependent components: (1) community resources, (2) health system support, (3) self-management support, (4) delivery system design, (5) decision support, and (6) clinical information systems.
Another reimagining of the process suggests the randomized or floating conditions and factors searching for interactive and integrated relationships to produce more effective outcomes desired by the community.
The S4F Solutions™ (Systems for Future Solutions) model proposed later evolves from the integrated values in the preceding visuals with the WCMM and MNCH (Health Systems Framework For Maternal, Neonatal, and Child Health) models in Figure 6 (Ergo, Eichler, & Shah, 2011).
The proposed expanded and integrated solution speaks to the evidence-based interventions to eradicate existing health inequalities making necessary changes in the health system, such as it is, and revamping the dynamic to reduce Maternal Morbidity and Mortality (MMM) in The Republic of Sudan.
- The first component was developed to describe South Africa’s (SA) efforts to integrate chronic disease management into its healthcare system (Davy, Bleasel, Liu, Ponniah, & Brown, 2015). SA resembles Sudan in health inequities and interstate variabilities (World Bank, 2017).
- The second and third components evolved from the findings of the National Committee on Confidential Enquiries into Maternal Deaths (NCCEMD) in SA (Saving Mothers 2011–2013, 2014). Adapting the standard 4-H and 5-Cs leadership models, the proposed framework tackle Sudan’s leading causes of maternal mortality (Figure 6).
- The fourth component is the MNCH framework, a combination of the health system and action orientated health system framework (Ergo, Eichler, & Shah, 2011). It delineates the required changes in the Sudanese health system and their roles in reducing MMM including the incorporation of prevention, promotion, community engagement, and patient activation.
Figure 7: The proposed tetra-components solution to address health inequality and maternal health issues.
The Tetra (4)-components solution is established within four parameters adapted from UNAIDS “Three Ones” principles to promote coordination between multiple stakeholders and ensure interventions are aligned and resources are invested wisely (“Three Ones” key principles, 2004).
The four parameters are labeled along the sides of the framework’s image:
- One National Overarching Action Framework,
- One Coordination Mechanism,
- One Agreed Monitoring, Reviewing, Evaluating, and Learning System (MREL), and
- One Stakeholders Engagement & Communication Mechanism (SECM).
The proposed intervention calls for the development of evidence-based policies, guidelines, process, and response.
As an example, we might focus on issues of maternal health and nutrition. The health of mother and newborn requires an adequate and appropriate diet to support rich blood, folic acid, calcium intake, milk supply, potassium/magnesium/zinc resources, and more. For instance, vitamin A deficiency alone “increases maternal mortality and causes night blindness. Infants born to women who consume too little vitamin A have low stores at birth. The breast milk of those women is also low in vitamin A” (Obaid, 2016). “Vitamin A deficiency is the leading cause of preventable blindness in children and raises the risk of disease and death from severe infections. Between 100 million and 140 million children are vitamin A-deficient and an estimated 250,000 to 500,000 vitamin A-deficient children become blind every year, half of them dying within 12 months of losing their sight” (Obaid, 2016).
Nestlè, the global producer of 2,000 brands across 150 countries, has made a paradigm shift in corporate values and practice that directly affects expectant mothers. Under the influence of Wendy Johnson, Ph.D., MPH, RD, Vice President, Nutrition, Health and Wellness at Nestlé, the mega-corporation has ranked first in a new index, ATNF (Access to Nutrition Foundation). The index monitors and measures the efforts of corporations in reconfiguring their goals to align with community-based nutritional needs.
In the case of Nestlé, proud producer of sweets and chocolates in the past, this required some deep and broad approach to products and marketing. From its Swiss headquarters with its splendid view of Lake Geneva, Nestlé manages everything from bottled water to pizza. Its decision to improve the nutrition in their products, communicating the nutritional information and making products readily accessible to consumers is particularly relevant to their infant products like baby formula and baby food.
Nestlé’s move is fundamentally disruptive requiring the understanding, embrace, and commitment of the corporation’s stockholders and stakeholders throughout the world. What interests me is how the ATNF Index can motivate other organizations. “The thought is that investors may want to use commitments to nutrition to guide their investing and use the Index as a resource” (Lee, 2019). The ATNF Index is new, but its data will produce better information in time, enough direction to drive similar efforts by other providers.
A hybrid solution
The hybrid solution proposed here suggests structural changes in health system components, governance, organization, finance, structure, and processes across all interaction levels along with the intended outcomes. A vertical maternal health intervention alone cannot create a sustainable impact. A balance between the quick wins via a vertical program and systems response is critical for lasting impact. Deep system changes are needed in resource allocation equity and the removal of system barriers across the care continuum. These changes are essential for success and equity in coverage — availability, accessibility, affordability, appropriateness, acceptability (A5) — and utilization of health services.
Systems-level interventions are typically non-linear and complex. It requires a more extended period to yield a result. In contrast, the vertical program can deliver quick wins and often succeed initially; however, with increasing workloads beyond system capacity, the effect of the intervention flattens or declines over time. Also, changes in peoples’ behavior occur over a longer period beyond the known program’s life-cycle.
A Gender and Maternal Health Mainstreaming Programme (GMHMP) must tackle the expected challenges accompanying the necessary implementation of system intervention. It is based on an issue- and evidence-based Theory of Change (ToC) that continuously adjusts according to the ecosystem interaction and the balance between the expected quick wins and sustainable impact.
The ToC is developed within the same four parameters of the Tetra-components solution, the overarching-all stakeholders and the needed interventions for concerted gender and maternal health improvement. The ToC focuses on the role of human factors and creating an enabling environment at all levels. These are critical success factors for any Maternal Mortality Management improvement strategy.
A program focused only on maternal health services is susceptible to Risk 1: Lack of the required funding (See Figure 8). It is expected that the four ToC parameters will work in unison to address this challenge and create a unifying vision for all stakeholders along with the required accountability.
Assumptions 1 through 6 in Figure 8 are the bases for the enhanced value proposition for an integrated GMHMP producing Output 1/Outcome 1 and Output 2/Outcome 2, Output 3/Outcome 3, the General Outcome, and the envisioned impact (Figure 8). It is anticipated that the proposed inputs-results pathways will work intrinsically and proactively to manage Risks 2, 3, 4, 5, and 6 (Figure 8).
GMHMP intervention takes into consideration the required behavioral shift towards maternal health and gender in Sudan. Such transformation requires empowered “change champions” across the systems, regions and different sectors including the role of community-based organizations. For example, we must look at methods and measures to promote male involvement, how to motivate them as “change champions.” Research shows, “Male involvement interventions can improve care-seeking for essential MNH [Maternal and Neonatal Health] services, and home care practices for women and new-borns. Engaging men in MNH also affects couple relationship dynamics” (Tokh, et al., 2018). However, “available evidence does not directly demonstrate an effect on mortality or morbidity” (Tokh, et al., 2018). It remains to be seen how including men and women in the design and delivery of intervention would make a difference, but such responses can only strengthen effective systems.
Governance and MER2L (Monitoring, Evaluation, Research, Reporting & Learning), the two high leverage points in the transformational initiatives usually neglected in program and system change designing and implementing, are vulnerable to the most common cause of intervention malfunction in any MMM response. For instance, dysfunctional MER2L will jeopardize the evidence-based decision making and continuous improvement. Overstretched or incapable governance contributes to suboptimal performance cohesion among system building blocks and lack of accountability. It is therefore essential to understand the complementary roles of the four parameters which ensure the success of the proposed system intervention and GMHMP.
An alternative solution
There are values in moving this thinking to something less horizontal and vertical, something visually and effectively more dynamic. My work with S4F Solutions™ is committed to applying first-hand, in-depth, “shock and awe” experiences with the turmoil wrought by so many clashing issues in Sudan and other Sub-Saharan nations.
Sudan is not alone. For example, “Despite being the wealthiest country by Africa by GDP, it [Nigeria] ranks fourth in maternal mortality globally” (Baker, 2019, p. 56). Nigeria remains a risky place to be pregnant. “Around 58,000 mothers die in childbirth in Nigeria every year, and 240,000 new-borns within 28 days” (Baker, 2019). The region accounts for 19 percent of the world’s maternal deaths.
Nigeria has made some advances by getting midwives to mothers and mothers to clinics. But, limited education, training, communication, and resources amid hostile military and conflicting politics complicate results-realization.
Sadly, and ironically enough, maternal mortality knows no bounds. It is not limited to low-income environments. Four million women in the United States deliver babies every year. Still, with probably the most advanced obstetric and emergency care in the world, new mothers die at least twice a day.
As of 2018, the U.S. ranked 47th for maternal mortality with the highest percentage of maternal deaths in high-income economies. “The United States has actually seen an increase in maternal deaths between 2000 and 2014. … one of only eight nations, and the only industrial nation, that have seen rising maternal mortality rates in recent years” (Herrera Beutler & Krishnamooorhi, 2018).
The New York Times posed the question, “How is it that the United States, a country with some of the most cutting-edge medical treatments, has some of the worst maternal mortality rates in the developed world?” (Tavernise, 2016). The root causes of the U.S.’ continuing maternal mortality problem parallel those known to the low-income nations:
- A hodgepodge of hospital protocols for dealing with potentially fatal complications, allowing for treatable complications to become lethal.
- Hospitals — including those with intensive care units for newborns — can be woefully unprepared for a maternal emergency.
- Federal and state funding show only 6 percent of block grants for “maternal and child health” go to the health of mothers.
- In the U.S, some doctors entering the growing specialty of maternal-fetal medicine were able to complete that training without ever spending time in a labor-delivery unit (Martin & Montagne, 2017).
I have wrestled with the inability of intentions and results to mesh. The best-intentioned, the strongest goodwill, and the enormous financial efforts consistently fail to serve the communities and their needs as they see them.
- Suffering people bring their problems to interested parties: NGOs, CBOs, international aid sources, private foundations, and charities.
- These organizations process those problems and articulate them in formal grant requests.
- Grantors receive the requests and, after interpreting those needs, grant the request with restrictions like formal and frequent audits, extensive documentation, and more.
This linear system does transfer wealth, but it also wastes money and redirects activities, so the intentions are compromised at the start and finish.
Current “systems” suggest the parties to the process have fundamentally different senses of the Value for Money (VFM). In economics, VFM means “not paying more for a good or service than its quality or availability justify” (Glendinning, 1988, p. 1). When quality and availability are subjective, finding common ground can be difficult. “In relation to public spending, it implies a concern with the economy (cost minimisation [sic]), efficiency (output maximisation [sic]) and effectiveness (full attainment of the intended results)” (Glendinning, 1988). Defining the values perceived by the social impact actors involved is difficult. The challenge is satisfying those diverse values along the way. And, I believe in increasing the role of community-based voices in identifying their needs so providers can produce more sensibly, efficiently, and effectively. “The practical conclusion is that policymakers must frame precise aims so that at least there are some criteria with which to compare results” (Glendinning, 1988).
The donor-stakeholders never fully understand the requesting community’s needs. And, the community does not know why it has not been heard. Balancing and sharing these perceptions has eluded organizational frameworks in the past. The S4F™ solution pictures a dynamic energy that weaves the principles and frameworks already discussed in Figure 7.
The integrated gears shown here suggest the continuous improvement and sustainability in a system that links “producers” and “customers” more effectively and efficiently (Figure 9). The left gear includes the originators: financial resources, goodwill and commitment, technology and innovation, organizational best practices, calendar concerns, and formal systems.
This portfolio must mesh with a gear that circles: Monitoring, Evaluation, Reporting, Research, and Learning (MER2L). The core processes embrace and reduce the six originators to five actions: System Review, Planning & Alignment, Delivery & Change Management, Innovative Solutions, and Sustainment.
As these systems turn, they deliver Results. (“Results” is preferable to “outcomes” or “objectives” because the results may or may not approach desired outcomes.) The best results will reflect the implemented Capabilities, the activated Benefits, and realized Impact.
This graphic reflects the thought and work involved in a fluid dynamic, a framework that creates a resilient and sustainable flow ensuring satisfaction along its course. Success does depend on the meshing of gears. Interference and harmful intervention at those points will slow, disrupt, and even destroy the energy. And, it is there that NGOs, CBOs, Grantors, and more must focus their purpose and capabilities. Any vision or theory of change must accept maternal mortality is not a female issue; it is a global issue.
Author: Asaad Taha, Ph.D., MSP®, PRINCE2®, Social Entrepreneur | Futurist | Principal Advisor at S4F.Solutions™; firstname.lastname@example.org
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