Working in Somaliland – a land of possibilities

Forum committee member and midwifery and nursing teacher Gillian Barber represents the RCN on the Council of the International Confederation of Midwives. Here, she writes about a new project she has taken on in Africa. 

A world of difference

I am standing in a meeting room, surrounded by 20 veiled nurse teachers and a few midwives from Somalia and Puntland. Fans try to cool the hot air. We are trying out role play and drama as teaching methods and discussing evidence for practice. The teachers come from areas that are highly dangerous for them and the women they care for. Older ones were trained as midwives before Somalia’s civil war in 1991; most younger women are nurses with some maternity care training.

They tell me stories of women arriving first thing in the morning at their often bomb-damaged hospitals. Many women are dying on arrival because travel at night is just too dangerous. The staff can do little with not enough equipment, drugs or training and it is often too late. In the war-torn parts of Somalia, more women die than almost anywhere else in the world. In Somalia one in around every 10 women will die during their childbearing years. No midwives have been trained in Somalia or Puntland for 25 years. They want to start again now so have come to a workshop run by the United Nations Population Fund (UNFPA) to update their knowledge and skills and work with me on an appropriate midwifery curriculum for their circumstances in Somalia and Puntland.

We are not actually in Somalia holding this workshop. We are in Somaliland, which is safe enough for people like me to visit. Somaliland is very familiar to me. I have been there many times over the last four years. Having completed the midwife teacher workshops described above this year, for Somaliland teachers first, then for Somalia and Puntland, I am now on a new venture. Previously I have been involved with updating and developing curricula for nursing and midwifery. For midwifery it has been at three levels: for trained nurses, for young women from rural areas with lower education levels and no nursing, and a BSc in midwifery for trained midwives. This new work is at a different level entirely.

Training women in the community

For some years Somaliland has tried to meet the needs of its rural and nomadic populations by training mostly men from villages as community health workers (CHWs). Now this programme too needs to be updated. One of the key changes is to emphasise the training of women as well as men to improve access to care for women. It needs to be very practical, with as much learning as possible taking place in, or near, their home areas. Once trained, CHWs work in their own communities with supervision from nurses and midwives at nearby health centres (nearby might be 100 kilometres away).

The role of CHWs is to work as health advocates and promoters, working with the community and its leaders to identify changes people need to make to improve their health. They may look at water supply, sanitation, uptake of immunisation, child nutrition and growth. They have a special responsibility for children and childbearing women. For women, they encourage the use of skilled services at the nearest health centre. They encourage good nutrition for women and teach about danger signs and being ready for emergencies by planning transport before they start labour, putting aside a little money for transport costs and fees they may have to pay. CHWs don’t provide antenatal or labour care but know the basic things to do in an emergency. They will also visit newborn babies at home – a new global initiative for improving neonatal survival.

CHWs have a limited role in treating people with illness. They are trained to classify danger signs and identify children or adults who need to be referred to health centres. They teach families how to recognise danger signs and how to manage minor illness. They can give some treatment with a medicine kit supplied by the government. They help with nutrition and immunisation campaigns. Full-time government workers, they will have busy lives, caring for children, tending livestock, trading, maybe following their camel herds with their nomadic fellow-villagers as well as being a CHW.

Rewarding and challenging

For me, this is a new and fascinating adventure. Writing curricula and training manuals for people with low-level literacy and for their trainers is a very different experience from writing a diploma or degree curriculum. But it is just as challenging and the principle is the same – listen to what people say they need (villagers as well as health professionals, government staff and academics), and work with them to get it right.

The work I’ve undertaken here has been either through THET (Tropical Health and Education Trust), or the United Nations Population Fund (UNFPA). Funding has been variously through UK Department for International Development (DFID), the European Community, UNFPA and UNICEF.