11 Mothers from one Village in Somalia Died Giving Birth in One Week!

Jamila helping a woman in labour

Jamila Garad Ali, 23, is devastated; 11 women from just one rural Somali village, Tulo Ano, died of pregnancy-related causes during the first week of October alone. As a professional midwife who works in the closest facility in Guri’el, they came to her for help but it was too late.

I have faced a real maternal mortality crisis. All the 11 mothers came seeking care from me but I couldn’t save them. They all died as a result of their complications, having reached professional care too late,” said Jamila, who works voluntarily for her community without pay.

Somalia already has one of the highest maternal mortality rates in the world, with one in every 22 mothers dying from pregnancy related causes. This had never been so apparent in Guri’el, in the Galguduud region of Galmudug state until this month, according to Jamila.

The young midwife only graduated in December 2017 as one of the first qualified midwives working in the area from Dhusmareb, a school run by the Ministry of Health funded by the People of Japan through UNFPA.  She is a focal person of the Somali Midwifery Association in Guri’el and leads a group of other midwives.

Each of the 11 mothers had arrived after prolonged labour as they tried to manage the births themselves at home with unskilled traditional birth attendants. The warning signs and opportunities to manage the labour effectively were missed, and each mother was in a very bad state before the family brought them to seek professional care,” explained Jamila.

One mother from Tulo Ano bled excessively at the hands of a traditional birth attendant who mishandled the placenta, according to Jamila. “The mother arrived with her family to seek help from me but she was already struggling to breathe. Having lost excessive amounts of blood, she needed a blood transfusion to save her life. One of her relatives who accompanied her was found to be the correct blood type, and was willing to donate blood to save her life, but it was too late to save her by then,” said the midwife.

There was no bag to collect the blood donation available in the facility to be able to give the life saving treatment to the dying mother. “She passed away soon after, leaving seven children without a mother,” the young midwife sadly said.

Jamila and colleagues carrying out an outreach campaign

Jamila, together with other midwifery graduates, has been carrying out community awareness on midwifery services and skills since she returned to her home area as a volunteer after her graduation. The midwives frequently conduct outreach services to access the hard to reach communities and ensure that families know about the professional midwifery care that is available. “We walk up to five hours to reach some villages to be sure that awareness reaches all,” she said.

Hawa Abdullahi Elmi, the Principal at the Mogadishu Midwifery Training Institute who also leads midwifery in the Ministry of Health in the Federal Government of Somalia, said midwives like Jamila have the professional skills to prevent and manage complications in pregnancy and birth, but that many families reach them too late when services are so few and far between as is the case in most parts of Somalia.

“The sheer numbers of maternal deaths in one area in just one week shows how much more remains to be done in order to end preventable maternal deaths. Lives can only be saved with the right equipment in the hands of well supported trained professionals,” said Hawa.

In Guri’el, volunteer professional midwives are striving to give appropriate and life saving care and raise awareness of their services to be able to assist more mothers in pregnancy and birth, according to Hawa. “But without the right equipment, lives will still be lost, and without pay, midwives may not be able to stay in the area for long. Investment in midwifery care and appropriate health system infrastructure could save lives, and end preventable maternal deaths,” she said.

------Emily Denness

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Somali Medical Pioneer Continues Battle to Stop FGM

FILE - Edna Adan Ismail, founder of the Edna Adan Hospital in Somaliland.

When she was a young girl, Edna Adan Ismail’s mother and grandmother circumcised her in a traditional ceremony while her father, a doctor, was away.

That evening, he returned home, enraged at what had happened. “What have you done?” he asked Ismail’s mother and grandmother. Cutting the young girl, he said, was “haraam” — a sin.

She was only seven or eight, but Ismail knew what had happened was wrong. The event, and her father’s reaction, would have a lasting impact.

Medical trailblazer

Years later, Ismail followed in her father’s footsteps, pursuing a career in medicine. She studied abroad and became a pioneer in health care in Somaliland, an autonomous region of Somalia.

In 1965, the World Health Organization made Ismail the first Somali appointed to a senior civil servant position. She spent decades with the organization working in Somalia, Somaliland and Djibouti, and caring for patients from across the Horn of Africa, many of whom were refugees.

In 1976, Ismail attended a health conference in Sudan that changed her next steps. Ismail, then a director in Somaliland’s Ministry of Health, had traveled with a team of doctors to learn about developments in the field.

At the conference, Ismail heard, for the first time, people in a Muslim country openly discuss the harm caused by female circumcision, also called female genital mutilation, or FGM.

Edna Adan Ismail (R) is seen in a 1959 photo as a nursing student at a hospital in West London, Britain. (Courtesy - Edna Adan Hospital)

For Ismail, the discussions were a revelation. Back home, talking about FGM, let alone its harms, was taboo.

But Ismail knew there was another way. In England, where Ismail studied and practiced medicine, women weren’t subjected to FGM, and they gave birth with few complications.

But Ismail didn’t believe the practice could be stopped in Somaliland, where she had returned in 1961 as the country’s first qualified nurse and midwife.

“I saw the difficulties, and the tears, and the lacerations, and the fistulas,” Ismail said. “This created in me this anger about this damage.”

Ismail knew the practice was wrong. But she couldn’t break through the silence.

That changed after the Sudan conference, where doctors, nurses and midwives discussed the physical and psychological toll of the traditional practice. They shared steps that health care workers could take to lessen suffering. They made FGM defeatable.

Ismail knew she could do more. She returned home and co-founded a group to eradicate the procedure. She also began speaking up.

“I was the first person who publicly spoke about the harmful effects of female circumcision,” Ismail told VOA in a recent studio interview in Washington. The practice, she added, “is the most harmful thing that can happen to a girl.”

‘Little girls are still being cut’

Ismail retired in 1997 and built a hospital a year later in Hargeisa, Somaliland, with her personal savings. The facility opened in 2002. “It was a natural thing to do,” Ismail said.

FILE - The front of the Edna Adan Hospital is seen in an undated photo in Hargeisa, Somaliland, Somalia. (Courtesy - Edna Adan Hospital)

Doctors and nurses at the facility, also a teaching hospital, treat patients from Somaliland, Somalia and Ethiopia. As a center for learning and caring, the hospital is “a symbol of what we need to do in our countries,” Ismail said. “I’m so privileged and so happy that I could also influence so many others and be an example for others to come back,” she added.

After retirement, Ismail contributed in other ways. In 2003, she became Somaliland’s foreign minister, a post she held until 2006. Now in her 80s, Ismail continues to direct the hospital.

But she knows there’s work left to do. “Little girls are still being cut,” she said.

Often, it’s women — mothers, grandmothers, aunts — directly responsible for FGM, which 200 million women and girls alive today have experienced, the World Health Organization estimates.

But men have a vital role to play in stopping the practice. “Fathers must come into it,” Ismail said, “the same way my father objected.”

Legal mechanisms must also be used, Ismail said. Countries where FGM rates remain high have, in some cases, passed laws banning at least the most severe forms of the procedure, but enforcement is key.

Fathers should be taken to court if their daughters are harmed, Ismail said, forcing all parts of society to face the issue. “It’s a battle that needs to be fought by both men and women — and communities and governments — together.”

At her own hospital, Ismail has seen progress. In 2002, 98 percent of the women who delivered babies had experienced FGM. That number had fallen to 76 percent several years later.

But Ismail isn’t satisfied. “Zero percent is what we want,” she said.

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Puntland First Lady leads in the fight against maternal and neonatal deaths

Puntland First Lady with Minister of Women Development & Family Affairs

The Puntland State of Somalia continues to step up the fight against maternal and newborn deaths by carrying out high level advocacy events through the Campaign for Accelerated Reduction of Maternal Mortality in Africa (CARMMA).

Somalia has one of the highest lifetime risk of maternal deaths in the world, with women facing a one in 22 lifetime risk of maternal death. The maternal mortality ratio is estimated at 732 deaths per 100,000 live births.

On 9 August 2018 the CARMMA Ambassador in Puntland First Lady Dr. Hodan Said Isse led a high-level advocacy event, which was held in Garowe to enhance political leadership, commitment, and ownership at all levels to invest in maternal health as well as increase public awareness on the issue of maternal mortality.

“It is essential that women can should have access to life-saving high quality antenatal, delivery care and postnatal care, wherever they live. In this regard, ensuring health facilities are up to standard and promoting the benefits of up taking maternal health services is critical,” said Dr. Isse.

The CARMMA Goodwill Ambassador also highlighted the importance of engaging all actors to increase accountability and investments in support of maternal and child health. She also emphasized the need to address obstetric fistula in Somalia. “I am concerned about the plight of women and girls living with obstetric fistula in Somalia. It is our collective duty to eradicate this devasting condition so that our daughters, mothers and sisters can have a dignified and full life,” said the first lady.         

The State Minister of Health Mr. Sayed Omar Adam Guleed commended the CARMMA Goodwill Ambassador, parliamentarians, religious leaders and other key stakeholders for their tireless support towards maternal and child health issues.

“It is our responsibility to sustain the momentum gathered in the aftermath of the CARMMA launch and ensure that we can provide maternal and child health services to those with the least access, the most marginalized, disadvantaged and under-served populations,” said Mr. Guleed.

UNFPA's Ms. Nzau speaking at the event

The Minister of Women Development and Family Affairs (MOWDAFA) of Puntland State of Somalia, Ms. Maryan Ahmed Ali was also in support of the efforts to end maternal and new born deaths. “In our consolidated efforts to tackle maternal mortality, it is key to continue investing in Gender-Based Violence (GBV) prevention, as GBV during pregnancy puts the health of both the mother and child at serious risk, and may subsequently contribute to maternal and child mortality,” said Ms. Ali.

During the CARMMA event, Ms. Su’di Hamid, Reproductive Health Manager for the Ministry of Health presented the current reproductive health status, achievements and lessons learnt in Puntland. “A total of 40 midwives graduated from our midwifery schools in Garowe and Bossaso this year,” said Ms. Hamid. She stated the Ministry of Health has been doing a lot of work to expand Comprehensive Emergency Obstetric and Newborn Care (CEmONC) service provision to remote and hard to reach areas, including in Nugaal, Bari, Mudug and Sanaag regions. “Two new boat ambulances were procured in the coast of Bari and Karkar regions and there are functional ambulances at all regional levels,” stated Su’di Hamid.

Ms. Juliana Nzau, UNFPA’s project manager for Integrated Community Reproductive Health highlighted the commitment of UNFPA towards improving human resources for health service delivery, especially in midwifery and integrated quality reproductive, maternal and neonatal health services, at rural, community and urban level. “In developed countries, pregnancy and childbirth are normal phases in the life of a woman. In Somalia however, the most common cause of death of women of childbearing age is preventable complications of pregnancy and childbirth,” said Ms. Nzau.

During the event parliamentary members pledged their commitment to advocate for greater investments in maternal and child health while emphasizing the importance of involving local and diaspora communities to improve the availability, accessibility, acceptability and quality of maternal health services in Puntland State of Somalia. “We need to explore ways to improve the collection of funds from the public and from the diaspora to enable the procurement of equipment, train health professionals and support service delivery on maternal and child health”, stated Ms. Faiza Artan Boos, one of the parliament members.

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Meet Dr. Evan Atar, the winner of 2018 Nansen Award: His Work Is 'a Great Humanitarian Achievement'

Dr. Evan Atar Adaha won the 2018 Nansen Refugee Award from the UN Refugee Agency (UNHCR) in Switzerland on Monday — and Cate Blanchett, a UNHCR Goodwill Ambassador, was on hand to honor him.

Dr. Evan AtarAdaha

Will Swanson/UNHCR

Atar, a South Sudanese surgeon who has experienced displacement himself, won the award for offering medical care to people escaping from strife in Sudan and South Sudan for two decades, according to a press release.
He operates a hospital for 200,000 people in Bunj in South Sudan, including 144,000 refugees from Sudan’s Blue Nile State.

Blanchett raved about his work in her keynote address. “The award tonight marks a great humanitarian achievement,” she said. “It is a formalized way of saying ‘thank you’ to one person specifically, but perhaps most importantly, it carries with it the inexpressible thanks to all who work in humanitarian fields — often at great personal cost.”

Cyril Zingaro/POOL/EPA-EFE/REX/Shutterstock

She continued, “Across the globe, hope comes with these individuals who dedicate their lives to the service of refugees and the internally displaced. Hope is embodied in the field workers and the volunteers, like our Nansen laureate tonight.”

In these people we have not just the ground force but the beating heart and moral impulse to achieve change,” Blanchett added.

Dr. Evan Atar Adaha and Filippo Grandi

Mark Henley/UNHCR

As he accepted the award, which once went to Eleanor Roosevelt, Atar said, “I am so humbled to receive this award … but the award is actually for my team back in Maban.”

“We need peace in that country, a true peace that comes out of our heart,” he declared. “The world has to continue searching for peace, so that we’ll have a better place for all of us to live and in harmony.”

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Hunger, disease and violence: Is Somalia the worst place in the world to be a child?

Somalis are used to hardship. Hunger, pestilence and violent death have brooded over their desiccated land ever since the first clans reached the Horn of Africa more than a millennium ago.

It is not in the Somali national character, enamelled by suffering, to complain. Setbacks are shrugged off and mortality contemplated with disdain. 

“I never saw a Somali who showed any fear of death,” wrote Gerald Hanley, the Irish author, who lived among them in the Forties.

Yet, even for the hardiest, the past decade has been testing. 

Somalia is a nation of nomads. Of every five Somalis, four are pastoralists, moving their flocks and herds with the weather.

Such a life is fragile. When the rains fail, as they often do, the livestock sicken and die. Competition between Somalia’s myriad clans and sub-clans often leads to conflict, but in barren times the clan is also a great source of strength: water, grazing and breeding stock are shared in order to save the community’s lives. so long and so relentless, failing over successive seasons, that even the old men say they cannot remember a time of such climate-related wretchedness.

Across great swathes of Somalia, 80 per cent of livestock has died as pasture withered and wells dried under skies that remained remorselessly blue — a cull, blamed on a deadly combination of climate change and overgrazing, that is unprecedented in living memory.

When animals die in such vast numbers, all go hungry — but Somalis, deprived of their livelihoods, know that it is their children, denied adequate sustenance, who are the least likely to survive.

There are many reasons why life is so precarious for Somali children. 

There is no one alive as tough as the Somali nomadGerald Hanley

Decades of civil conflict since the country’s implosion in 1991 have stunted development. For more than 20 years, Somalia did not have a government at all, depriving much of the population of life-saving services, from basic sanitation to rudimentary health care.

Insecurity, worsened in recent years by the Islamist militant group al-Shabab taking over substantial pockets of the country, meant that aid agencies often struggled to reach the most vulnerable communities.

As a result more than half of Somali children are unvaccinated, a figure that is one of the highest in the world and which also closely matches the number of children not in school.

Yet it is almost certainly the widespread drought of recent years that explains why Somalia emerged this year as the world’s deadliest place to be a child, a country where, according to UNICEF and the World Bank, one in seven children will not live to see their fifth birthday.

The arid bushland outside Dudubka, a village in the Sool region of Somaliland, once teemed with livestock. Now, save for a few hardy camels looming out of the harsh white light that bathes the plains, the landscape is bereft of life. 

Somaliland, a former British colony, broke away from the rest of Somalia in 1991 and has generally been much more stable, although there has been a surge of violence in the Sool region this year.

But the drought has been just as devastating, particularly in isolated places like Dudubka, which has no roads leading to it, just hard-to-find tracks cut through the scrub.

With no places of entertainment and just a smattering of shops, it is more a transient frontier settlement than a village, a place of respite for those too ill, too young or too old to sustain the demands of nomadic life.

In the past year it has also been a refuge, not just for herders with a link to Dudubka who lost their livestock but for relatives and strangers too.

In the past 18 months, Dubdubka’s population has doubled, growing from 108 families before the drought to 228 since, straining the village’s already scarce resources.

It is only in the most desperate times that the countryside empties and villages like Dudubka fill to overflowing. Nomads do not opt for a sedentary life out of choice. 

“There is no one alive as tough as the Somali nomad,” wrote Hanley, recalling a wounded Somali soldier who walked 14 miles through the bush “holding his guts in his hand.”

You can tell when the animals are going to die. They start bleeding through the nose. Then you know there is nothing you can do.Anisa Jama Hussein

Anisa Jama Hussein and her husband were not pushed to quite such extremes, but they did walk for three days to reach Dudubka, carrying their youngest children the whole way. Weak and emaciated, Halimo, who was two, and his four-year-old sister Katra were barely alive when they reached the village, their three older siblings, all malourished, trailing exhaustedly behind.

For two years the Jama family had tried to keep their herd — 300 sheep and goats, as well as 20 camels — alive as grazing vanished and the wells dried. 

One by one, the animals dropped.

You can tell when the animals are going to die,” Mrs Jama recalled. “They start bleeding through the nose. Then you know there is nothing you can do.

At first, members of their herding community did their best to help each other, sharing out what food there was, but soon everyone was in the same position, all engaged in a desperate struggle for survival.

“There was no place to run,” she said. “The whole country was in drought. We couldn’t save our animals and we didn’t know how to save ourselves.

“Our livestock were our only source of income and our only means of survival. We couldn’t give milk to our kids. We couldn’t give them food. Everyone was starving.”

When the children of other herders began to die, and with her own becoming ever weaker through constant diarrhoea, Mrs Jama and her husband decided to make for Dudubka, the nearest place of place of refuge. All their camels were dead and only five of their 300 sheep had survived.

Once, a place like Dudubka would scarcely have offered  a better prospect for survival for newly destitute families like Mrs Jama, the chances of finding food in the villages being only slightly better than out in the wilds.

But a relief effort mounted by the government and aid agencies supplied emergency food. Save the Children, a charity, runs a mobile clinic that still visits Dudubka twice a month.

But for the most malnourished children, even the medical care offered by mobile clinics can come too late.

Malnutrition is the biggest killer of children in Somalia, usually not because they starve to death but because their bodies are so emaciated their immune systems become too weak to fend off disease.

The Jama family were just in time. Hawa Salah’s son Ahmed was not. Like the Jamas, Mrs Salah, who is 25, watched her family’s herd slowly die. But as the drought reached its climax, she feel pregnant. With food, particularly the type of nutritious sustenance a pregnant woman needs, ever scarcer, she became malnourished and anaemic herself.

When Ahmed was born, prematurely, last November, he was already frail. The breast milk she produced was never going to be enough for him, however much she wailed.

“He was so tiny, so light” she recalled. 

Although she reached Dudubka shortly after giving birth and Ahmed was given supplementary food by Save the Children, he never really thrived, sometimes growing a little stronger only to weaken again.

For four months, he clung doggedly to life. “Then, one morning, we woke up and he was just dead on the bed,” Mrs Salah said.

The rains finally came this year, but for Dudubka’s new residents it was too late. With no breeding stock left, none can replenish their herds, leaving them dependent on food doled out by aid agencies to survive.

The charities do what they can to keep Dudubka’s children alive.

In a corner of the village, a rudimentary shelter erected from wood and covered in orange and green tarpaulin serves as Save the Children’s mobile clinic.

When the charity’s medics arrive for their twice-a-month visits, children from the village and settlements within a few hours walk queue to be vaccinated, weighed and measured. 

Spotting malnutrition early means a child is much more likely to survive, says Guled Hussein, Save the Children’s local nutrition officer, as a coloured measuring tape is wrapped round a toddler’s forearm.

Those severely malnourished are often already sick, most frequently with pneumonia, the single biggest killer of children under the age of five in both Somalia and Somaliland.

Thanks to a high energy supplementary food called Plumpy’Nut, given out to all children diagnosed at the clinic as malnourished, survival rates have improved. The high-energy sachets, containing a calorie-heavy peanut-based paste, is easy to administer and because children like the taste they can regain weight rapidly.

But in a nomadic society, monitoring children over several months can be difficult because some families leave the village for other settlements in between visits by the mobile clinic.

“A mother brings in her malnourished child for treatment, but we can’t keep track of them,” Mr Hussein said. “They turn up at another mobile clinic in another village a month later without any records.”

Save the Children has trained community volunteers to try to track the movement of nomadic families. Next door to the clinic, other volunteers train Somali women in techniques that could often save lives.

Mothers are taught how to use the coloured tape measures so they themselves can see if their children have become malnourished. The importance of hygiene, breast-feeding and vaccinations are also emphasised.

Such interventions are saving lives, but even if there were no drought, both Somalia and Somaliland would struggle to bring down child mortality rates.

When a mobile clinic visits a village like Dudubka, the sickest and most malnourished children can be driven to the colonial-era hospital in Burao, the nearest substantial town.

But the hospital is several hours drive away, and with few cars available, getting to the hospital in time to save a child’s life is difficult.

Burao has the only referral hospital for 1.5 million people living in Somaliland’s three eastern regions. 

A healthy child might be able to fight off these diseases, but it is much harder for a malnourished childDr Abdullahi Ali, paediatrician

On a bed in the hospital’s small paediatric ward, Asha Mahmoud cradled her three-year-old son, Awal, painfully thin and visibly suffering.

He had been ailing for weeks, Mrs Mahmoud said, vomiting, listless and running a fever — but because they lived 12 hours drive away from the hospital reaching it seemed an almost impossible task.

“We waited for days and days before a vehicle finally came,” she said.

It is, according to Abdullahi Ali, one of Somaliland’s few paediatricians, all too common a story.

“Most of the people here are from the bush,” he said. “It is very difficult for them to reach here, and those that don’t manage it, their children often die.”

Nearly all the children on the ward came from families who had lost most of their livestock. Many were malnourished as a result, making them more susceptible to disease, but hunger alone was not the only issue. 

Marwo Mohamed’s eight-month-old twins were both suffering from acute diarrhoea, probably caused after they were given formula made with contaminated water.

“In some areas there is no safe water, so common parasitic infections abound,” said Dr Abdullahi. “A healthy child might be able to fight off these diseases, but it is much harder for a malnourished child.”A campaign to encourage exclusive breast feeding for the first six months of life is underway in Somaliland, and is beginning to have an impact, doctors say.

But until malnutrition can be brought under control, Somaliland’s children will still die in terrifying numbers.

Lying silently, as though too exhausted to cry, on a bed in the corner of the paediatric ward, Mohammed Chamo seems to personify both the travails and spirit of his people.

He weighs barely 9lb, even though he is four months old. Born to a mother, Leila Saeed, half-starved herself when he was delivered, Mohammed’s short life has been a pitiful one.

He was just a month old when, his immune system weakened by hunger, a common cold turned into pneumonia. Untreated, pneumonia then became sepsis.

Sepsis anywhere in the world is a killer. A third of people who contract it die. In Somaliland, the chances or survival are much more remote.

Remarkably, Mohammed appears to be recovering. He has, though it is hard to believe when looking at him, gained weight, a testament to the indefatigability of Burao Hospital’s medical staff in an under-staffed hospital with almost no resources.

“He has a small body, but he has a big heart,” his mother said. “Such miracles give hope to us all.”

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