Somaliland: Reversing the trend of home births in Sahil by strengthening referral systems


Jimale Ali Nour

(Somalilandsun) – Maternal and infant mortality and morbidity rates within Somaliland are amongst some of the highest in the world due to limited access to primary health care facilities, and poor financial and human resources for health services. This, coupled with a high fertility rate, harmful traditional practices such as FGM/C and home deliveries, results in poor health seeking behaviour and impacts negatively on maternal and child health (MCH).
Through the implementation of the DFID funded programme of Essential Package of Health Services (EPHS) in the Sahil region of Somaliland, Health Poverty Action (HPA) has made huge improvements that directly tackle some of the underlying issues contributing to high maternal and infant mortality.

The EPHS introduced a common framework and minimum standard of health service delivery to ensure that vulnerable women and children in Sahil enjoy a comprehensive approach to health care. What makes the EPHS programme unique is its approach at three key levels – the community level, the facility level, and the institutional level – whilst an integrated referral system improves the accessibility component within Sahil’s health care service.

HPA Sponsored ambulance in Sahil operate 24hours to collect patients to the nearest health facility

HPA Sponsored ambulance in Sahil operate 24hours to collect patients to the nearest health facility
Health Poverty Action (HPA) has successfully implemented a strong referral system that enables women and young children in the remotest areas of the Sahil region to gain access to free essential health care. Three dedicated land ambulances refer on average 180 cases per month to health facilities free of charge and HPA is committed to ensuring that residents of Sahil continue to have accessible health services.
In an attempt to upscale the referral system, HPA with the support of DFID, unveiled Sahil’s, and probably Somaliland’s, first ever boat ambulance in September 2014. The boat will greatly reduce the delay in accessing health care services and contribute to the continued reduction of maternal mortality in the Sahil region, especially amongst residents of remote and hard to reach coastal areas. The boat will transport patients to the Berbera port where the land ambulance will await the patient and transfer them to the nearest health facility.
Health facilities and health workforce development
When the EPHS rolled out for the first time in the Sahil region of Somaliland, the maternal mortality rate was as high as any other region in Somaliland. However, Sahil had the fewest health facilities, with only two facilities staffed by a few qualified midwives conducting deliveries in 2011 (Sheikh health center and Berbera regional hospital). Sahil also suffered from a lack of skilled birth attendants, nurses and other health professionals, as well as harsh costal climates, geographical challenges and inaccessible roads. All of which contributed to poor health indicators across the region. To address these issues HPA procured to build and equip 25 new health facilities across the Sahil region including 3 referral health centres (mini hospitals), 5 health centres and 16 primary health units. In addition to that HPA trained 15 qualified nurses and 12 community mid-wives from the Sahil community to reduce dependency on skilled staff from other regions of Somaliland.
The role of Traditional Birth Attendants (TBAs)

Fadumo Jama Hassan TBA
HPA in collaboration with the Sahil Regional Health Office has registered Traditional Birth Attendants (TBA) in remote villages in Sahil. The registered TBAs are trained in identifying early warning signs of a complicated labour to reduce the delay in receiving assistant. TBAs are also informed on the dangers of home delivery and are encouraged to refer women to the nearest health facility early on in their pregnancy for prenatal health checks. HPA gave all the registered TBAs a free mobile phone to communicate with the health workers in their nearest health facility and to communicate with the ambulance drivers during emergency cases. TBAs are also given a small incentive for every referral they make that enables a delivery to be assisted by a qualified health worker. Referrals made by TBA’s have contributed to the increase in the number of women giving birth in the presence of a qualified health worker which has significantly reduced the likelihood of a mother dying during labour morbidity
Demand creation
However much money is spent on health services, they will only work effectively if people use those services and behave in life-protecting ways. Creating demand for healthy behaviours is a key area for HPA, and we work to change attitudes through community engagement and ownership of services. Information, education and communication (IEC) materials such as leaflets, posters, billboards, newsletters, health education videos, radio programmes and regular outreach dramas are made available to people in many different public places (health facilities, high ways/streets, youth clubs and the community gathering places).
HPA also has a very popular radio programme called Saxansaxo to reach out to our target audience. The programme is aired twice a week on radio Hargeisa (the only radio channel in Somaliland) and allows us to reach the largest possible number of people within our target audience at the lowest cost.

Demand creation posters and billboards in Berbera

Health management information system (HMIS) data from ministry of health, shows significant increase in the number of women giving birth within a health facility, from 6% in 2011 to 56% by December 2014. The number of pregnant women visiting the health centres for Antenatal care (ANC3+) also increased from 23% in 2011 to 62% in December 2014. Such increases were made possible through health service demand creation at the community level (with the TBAs) and by strengthening the referral system consisting of ambulances that enable mothers from remote areas to access a health facility for delivery.

By: Jimale Ali Nour
HPA communication & knowledge management officer