Maternal and child healthcare services in South Sudan: the factors associated with non - use of antenatal care, skilled birth attendants, facility delivery services and child survival

Objectives The aim of this body of research is to examine the factors associated with non-use of maternal and child healthcare services in South Sudan. The specific aims include examining the associations between socio- demographic, economic and physical accessibility factors on utilization of maternal and child health care services. It also investigated the barriers facing healthcare providers to deliver appropriate services to their clients and the extent to which these barriers are associated with use or non-use of antenatal care, skilled birth attendance, facility delivery and neonatal services. Methods This research constituted both quantitative and qualitative methods. For the quantitative analyses, data were obtained from the South Sudan House- hold Health Survey second round (SSHHSII) carried out in 2010 that used the Multiple Indicator Cluster Survey (MICS) methodology developed by UNICEF. The logistic regression analysis (Chapter 4, 5 and 7) and multinomial logistic regression analysis methods (Chapter 6) were used. All statistical analyses were carried out using STATA/MP version 12. For the qualitative analyses, data were derived from a study conducted in Juba County, Central Equatoria State, South Sudan. The study participants involved were mothers and their partner, healthcare providers and trained traditional birth attendance. About 63 in-depth interviews were audio recorded and then transcribed. All the data were manually managed and a list of topical codes was developed followed by a content and thematic analysis (Chapter 8 and 9). Results Chapter 3 Identified the barriers and challenges of promoting maternal, newborn and child health (MNCH) gains, and identifies priorities that will contribute to addressing the Millennium Development Goals and the emerging health priorities for the post-2015 development agenda. Chapter 4 indicates that the prevalence of nonuse of antenatal care services in South Sudan were significantly higher among mothers who were in polygamous relationships, illiterate mothers, mothers who had limited knowledge of a newborns’ danger signs and those residing in Warap and Jounglei states. Chapter 5 shows that the use of skilled birth attendance at delivery was determinate by household wealth, place of residency, access to at least 1–3 antenatal care (ANC) visits during pregnancy, maternal education and mothers who experienced three and more complications during pregnancy. Chapter 6 indicates higher odds of unattended home birth among never-married single mothers, uneducated mothers, those with first birth order, those who never attended ANC visits and those who experienced lower quality of ANC services. In addition, household poverty, lacking knowledge about obstetric danger signs, and lacking experience with pregnancy complications were associated with unattended home birth. Chapter 7 identifies the determinants of neonatal, infant and under-five mortality in South Sudan. The risk of under-five mortality was found higher among low socioeconomic groups that included urban dwellers, children born to teenager mother, those born to mothers who ever had a child that died later, and male children. Chapter 8 identifies a combination of physical environment, socioeconomic factors or healthcare’s characteristic as contributory factors to a higher percentage of mothers giving birth at home unattended. Sudden labor and lack of safety and security were the main reasons for home delivery in this study. In addition, lack of essential medicines, supplies and equipment were linked to individual mother’s dissatisfaction with services they received. Furthermore, lack of access to transport and out of pocket fees for accessing the services further delayed women reaching health services for delivery or complications. In Chapter 9 the data from the qualitative study shows the challenges and barriers facing healthcare providers to deliver appropriate maternal and child health care services. The major barriers to health services provision were poor management of staff, stock out of medical supplies, lack electricity and water supply. In addition, lack of supervision, few training opportunities and low salaries were the major elements for health workers’ de-motivation and low performance. Furthermore, security instability as a result of political and armed conflicts further impacted on their services delivery. Conclusion The findings in this thesis highlight the urgent need to implement strategies that address barriers to access to maternal and child health care services in South Sudan. At the facility level, investment is needed to upgrade the existing health system infrastructure, ensuring adequately resourced services, training opportunities for the health workers and reliable disbursement of staff salaries are essential. Implementing strategies that target women at the community level, such as, deploying community health workers to identify women who need care, could increase the number of women who deliver with skilled birth attendant (SBAs). The government needs to address the socio-economic factors that prevent women from using maternal health services and provide free reproductive services and conditional cash transfers to encourage women to deliver with SBAs either at home or in a health facility. Implementing a cash transfer program targeting poor families to keep their daughters in school and unmarried throughout their secondary education is essential. Wider socio-political aspects such as safety and security must be considered in the long-term policies of the Government of South Sudan that will have direct and indirect impact on the use of maternal and child health service

Feasibility of engaging "Village Doctors" in the Community-based Integrated Management of Childhood Illness (C-IMCI): experience from rural Bangladesh

Results: Village doctors' knowledge on the assessment and management of childhood illnesses improved significantly after training; knowledge of danger signs of pneumonia and severe pneumonia increased from 39% to 78% (P