Family dynamics and the refugee experience
Our FGDs participants reported preferences for a large number of children (often 10 or more) in order to help with household chores, increase family income, and gain status within the community. However, restrictions of refugee camp life appear to be impacting desired family size. Housing, food, and livelihoods are severely restricted in the camps, and refugees are dependent upon humanitarian aid to meet their basic needs. Violent conflicts between refugees and the host population over resource use, such as collecting firewood, have placed further strains on the population. As one participant in the FGD with mothers explained, “In the north [Blue Nile State] there was no problem – you could have as many as you wanted, but here in Doro it is difficult to have many children. We lack income – they cannot all eat well.”
Groups discussed the issues of birth spacing and use of contraceptives openly. Although most participants stated that the number of children was “God’s will” and contraceptive prevalence rates are low, family planning did not seem to be a stigmatizing subject. Both men and women extolled the benefits of family planning, including increasing the time to breastfeed a child, allowing the child to grow and be healthy, allowing the woman time to rest, and creating less financial burden for the family. Many participants referenced a two-year space between babies as optimal and birth spacing methods used included the tradition of postpartum abstinence, breastfeeding, and the “injectable.” As one participant in the FGD with fathers in Yusuf Batil notes, “Some women are tired from delivery. If so, she can use the injectable.” In our discussions with both mothers and grandmothers, some women raised perceptions of contraceptive coercion by health service professionals. As one mother in Doro camp explained, “They never ask us about family planning, but sometimes they give it to us without permission, when we don’t want it. If they see your children are too close in age they take you and inject you without your permission.”
Both FGD participants and key informants reported that decisions around family planning and other family decisions are generally under the authority of the husband, although many noted the importance the husband and wife making joint decisions. However, men rarely, if ever, attend postnatal visits where family planning is discussed.
Nutrition and livelihoods
Participants in all discussion groups reported that nutrition was both the predominant “general health concern” as well as the main method of “self care” during pregnancy. Lack of food was a significant stressor for FGD participants and was raised frequently in the groups. At the time of our study the population relied heavily on food aid, however allocated food rations had been cut by 30% due to funding constraints. Camp residents had few options for self-sufficiency, such as collecting of firewood for sale, leaving much of the camp population hungry. Community members recognized the need for pregnant women to eat nutritious foods, avoid heavy work, and reduce household chores but women struggled to do so. As a pregnant participant in an FGD in Doro camp explained:
We need good nutrition but we have no money to buy food. You can force yourself to go into the woods to get firewood to get some to sell, but you may fall, you are carrying heavy things, and you may also get arrested and your axe taken away for cutting wood.
Cuts in funding also resulted in the cancellation of the Blanket Supplementary Feeding (BSF) program for pregnant and lactating women. One of the mothers in Doro Camp lamented the diminished services:
These days they have stopped everything. They just take the MUAC [mid-upper arm circumference] and then say: ‘You are ok, you are not malnourished, just go home.’ Why don’t they provide the food in time, before there is a problem?
Material incentives and facility use
Given the dire poverty in the camps, uptake of preventative care and facility-based childbirth services appears to be closely linked to the receipt of material incentives for attendance. Mothers acknowledged the importance of attending antenatal care (ANC) visits and highly valued the incentives they received, including mosquito nets and BP5 (high energy) biscuits; the amount and type of incentive varied depending on the provider. Staff at the local Ministry of Health hospital, who were not currently able to provide incentives due to funding issues, reported decreasing attendance:
In 2012–2013 we were having a high number of antenatals. But nowadays we have no soap, no mosquito nets, no mamma kits, so the number of ANC visits are reducing. They are now going to the others. The NGOs are having all these things but we don’t.
Postnatal care visits, which are not incentivized, notably saw lower attendance than antenatal care visits.
Similarly, the most frequently mentioned reason for choosing facility delivery over home delivery was due to the receipt of the birth notification certificate. Getting this directly from the hospital facilitates the child’s registration with UN agencies and eases acquisition of a ration card. Secondly, receiving “mamma kits” containing basic supplies like mosquito netting, soap, a basin, and cloth were highly sought after. Participants in our FGDs also acknowledged that the skill of doctors and midwives in providing safe care also motivated women to deliver in facilities.
Despite the successes, the incentivizing of facility delivery has added to tensions between health workers and parents. Mothers and fathers in our FGDs expressed feeling discriminated against for delivering “on the way” to the facility or at home, regardless of the reason for the delivery site or their intentions. Mothers and fathers also reported being turned away and scorned by health facility staff when arriving at the facility with their freshly birthed newborn, and not receiving immediate postnatal care. As one mother in a Doro camp FGD explained, “Many of them [pregnant women] try to go by foot but give birth on the way. If you deliver at home there is no help. They [health facility staff] will say, ‘It’s up to you. It’s not our problem, because you delivered at home.’” A father, also in Doro camp, stated, “If your wife has contractions, take her to the health centre. But if she delivers on the way they won’t accept her.”
A number of the health workers that we spoke with, both key informants and FGD participants, reported that they believe some parents are purposefully coming late in order to access some of the material incentives offered to promote facility births without actually delivering in-facility. Regardless of the validity of this belief, this dynamic appears to be restricting access to immediate postnatal care for the mother and newborn, as well as creating a reciprocal mistrust between patients and providers.
Barriers to facility delivery
The main barriers to facility delivery related to unreliable transportation, security concerns, comfort with home delivery, and fears of an unfamiliar birthing environment. The camp-based emergency transport system for women in labour (a donkey-cart) was not working well in either camp resulting in delays or refusals of transportation. Women in labour are advised to first contact the traditional birth attendant (TBA), who then assists her to arrange a donkey cart, which is often kept at the home of the sheikh or umdah (clan leader). Security fears due to recent violent attacks in Yusuf Batil camp also made residents hesitant to leave home at when in labour at night. As one participant in an FGD with mothers explained, “It was night and I couldn’t get to the hospital. My husband went to the sheikh to call for the donkey cart, but he refused, so I delivered at home, with a traditional birth attendant. My plan was to deliver at the facility.”
Women and health workers also reported a fear of upward referral from the primary health centre in the camp to the secondary facility outside of the camp, related to lack of familiarity with the facility, fear of caesarean section, and fear of being treated by a male health worker.
The shifting role of the traditional birth attendant
The role of the traditional birth attendant is gradually shifting in the community. NGO health service providers discourage home deliveries and encouraged TBAs to act as “companions”, assisting the labouring woman to reach the health facility. However, the role of “companion” does not permit the TBA to remain with the woman once she is admitted to the health facility.
The TBAs who participated in our FGDs described their traditional role as a supportive one, with care extending from the antenatal period through delivery and into the postnatal period. During pregnancy they may provide porridge and extra food to the woman or advocate to her family and husband to do so. TBAs report that this has become increasingly difficult due to limited food availability in the camps. When the woman is in labour, TBAs provide porridge, hot water for the woman to bathe, help position the woman, and assist with the delivery. They described performing episiotomies with a razor blade if the baby’s head is big, and tying the umbilical cord with a piece of grass or thread from a sack. They use scissors or a piece of sharp grass to cut the cord, depending what they have on hand, and then apply charcoal from the Lalobe tree mixed with sesame oil, or charcoal from a burned coir sack, to the umbilical stump. They clear away any mucous from the baby’s nose and mouth and put the baby skin-to- skin with mother. If the baby is not breathing they describe holding the baby upside down and hitting him on the back or feet. If the woman is bleeding after delivery they “push on the abdomen to make the blood come out”.
TBAs in the FGDs stated that they support facility delivery and are happy in their new roles. However, they feel unfairly blamed by health care providers if a woman decides to deliver at home and later requests their help. They would like to be able to remain with the mother during the delivery in the facility and are also eager to learn more skills from the midwives.
Infant feeding practices
Both key informants and FGD participants described early, but not exclusive, breastfeeding as the traditional newborn feeding practice in this community; women typically supplement breast milk with animal milk, water, and porridge. Commercial infant formula and bottles are generally not used or available. Prior to arriving in the camps (within the last 4 years), the norm was to discard the colostrum. As one TBA in Yusuf Batil camp explained, “In Blue Nile [source location] we wouldn’t breastfeed the baby until it reaches one week of age, and give water and porridge until then.”
Mothers and grandmothers described how their understanding of infant feeding practices have changed considerably since arrival in the camps as a result of health promotion messages. Colostrum is increasingly recognized to be healthy and both grandmothers and mothers in FGDs stated that they now wait until 6 months before introducing solid foods.
Umbilical cord and thermal care
The most common method of newborn umbilical cord care is burning the seed of the Lalobe tree then grinding it, mixing the resultant charcoal with sesame oil, and applying the mixture to the umbilicus. Health workers appear to give little advice to families on how to care for the umbilicus at home.
Mothers and grandmothers expressed a good understanding and appreciation for thermal care practices in the newborn period and described keeping the baby well wrapped, using warm water to wash the baby, and keeping the newborn close to the mother at all times. Although extended skin-to-skin (Kangaroo Mother Care or KMC) for premature babies was initially unfamiliar to community members, word-of-mouth and observation of the practice in the postnatal ward in Doro camp has increased its acceptability among community members. As one mother described, “If the baby is born in the seventh month, put the baby between your breasts so it can get warm. [The NGO] will give you blankets to cover you.”
There were no specific cultural barriers raised to the practice of KMC by community members. Potential barriers raised by health workers include fatigue or illness of the mother, lack of understanding of the method, and lack of private space in facilities.
Care-seeking and traditional medicines
Women generally follow the traditional practice of 40 days of rest in the home following delivery, during which time women are able to recuperate from the birth, bond with the baby, and receive help with newborn care from elder female family members. Community members also described a tradition of a three-month home confinement for premature babies. Women do not perceive the preventative care offered as part of routine postnatal care (PNC) as a priority. However, curative health services are well regarded in the camps and participants noted the kindness of doctors and their good skills and knowledge. Long waiting times due to overcrowding and dissatisfaction with the medications were the main deterrents to clinic care. While the health clinic was the first choice of care provider for a sick newborn, grandmothers continue to prefer the care of traditional healers. Both key informant and FGD participants report that traditional medicines are commonly used in routine home care of the newborn. In addition to using the charred Lalobe seed for umbilical care, a variety of local seeds and roots are used for newborn illnesses such as diarrhoea (Nabak tree roots or Kirua bush roots pounded and mixed with water to form a paste for ingestion), malaria (Ceremarium tree seeds), and fever (topical application of Kamun seeds in oil). A cloth bracelet filled with Kamun (cumin) seeds may also be tied around the baby’s wrist to be sucked upon. Another traditional practice described includes feeding soil from an ancestor’s grave to the baby to prevent diarrhoea. Similarly, when moving to a new place, parents feed the baby a small amount of dirt from the ground of the new location to prevent diarrhoea.