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Summary of Arwa Almodwahi’s internship in Yemen

May 20th-July30th 2005 Yemen:

62.9

Life expectancy at birth

6.48 Fertility Rate

3.02 Annual growth rate %

520 GNI per capita (US$), 2003

46.2 % Population under 15

19,721, 643 Population in 2004

Source: UNICEF

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Population lives on 2 percent of its total geographical area. 74 percent of the population lives in settlements of less than 5,000 people grouped in 41,800 villages and these are scattered mainly in steep mountains areas and in wadi beds. Only 9 percent of the population lives in eight settlements of more than 100,000 inhabitants and 16 percent of the population lives in cities of more than 10,000 inhabitants1

Millennium Development Goal (MDGs): Yemen is one of eight pilot countries under the UN Millennium Project’s (MP) umbrella program for achieving the MDGs by 20152. The population sector in the Ministry Of Health (MOH) is trying to reduce

maternal mortality (current ratio at 365 per 100.000) by: • Develop the 2006-2010 Reproductive Health (RH) strategy provided with

the technical support of some UN agencies and NGOs.

• Review and update the RH strategy focusing on Safe motherhood. • Advocate for RH and resource mobilization.

UN agencies and NGOs in Yemen dealing with RH and helping to achieve the MDGs are: ��

��NGOs: ADRA, Oxfam, ICD, Marie Stops International, DED and GTZ (German). ��Local NGOS: National Yemen Family Care Association, and Yemen Charitable Society. ��United Nations Agencies: UNFPA, WHO, UNICEF I participated with the RH department of the MOH in a workshop aimed to reduce maternal mortality in the MENA Region (middle east and north Africa) it was done by the Mailman School of Public Health from Columbia university and made possible by a grant started in 1999 by the Bill and Melinda Gates Foundation to

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support governments and international organizations to improve access to emergency obstetric care 3. UNICEF, UNFPA and the MOH organized the workshop. Four countries attended the workshop: Sudan, Djibouti, Syria, Yemen, and Algeria. I was given the opportunity to address the 52 participants for 20 minutes. My presentation was about the medication misoprostol and its significance and importance to be used in settings where it is not feasible to use oxytocin or ergometrin to prevent or stop Post Portum Hemorrhage. My presentation provoked many concerns and questions. I addressed the concerns by alluding to the various studies that proved the effectiveness of misoprostol; I used the recent study done in Tanzania by Dr. Ndola Parata et al. as a reference. The concerns raised about the misoprostol usage were similar to the ones I have heard from five gynecologists that I have interviewed in Sana’a major gynecology hospitals. Those concerns are summarized in the following points:

1. Midwives might get inpatient during delivery and use misoprostol to induce labor, which might cause uterine rupture.

2. Inability of some midwifes to differentiate between the different causes of bleeding which will cause the usage of misoprostol in cases other than uterine atony.

3. Abortion. 4. TBAs training are proved to be a bad investment.

The MOH, UNICEF and UNFPA workshop to achieve Safe motherhood. June/2005

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Many Yemeni obstetricians and the directors of the midwifery’s projects believe that midwives can be trained to use misoprostol effectively.

Misoprostol in Yemen: –It is identified and used by many Yemeni gynecologists and by some midwives. –It is administered by alternative routes but mostly rectally. –Its effectiveness compared with oxytocin and ergometrin is tested and documented on a small-scale study in a major public hospital. The study was to test the efficacy of misoprostol, it is conducted by Dr. Asmaa Abu taleb in the duration between June, 2001 and December, 2002 a summary of results are presented in the following table:

3.7-14.7

5.3-8.9

4.3-9.3

5.1-15.7

3.2-14.4

Duration of third stage of labor in minutes.

5 (6%) 0 (0%) 1 (3%) 2 (5%) 4 (7%) Manual removal of placenta

74-268 48-156 48-150 55-217 66-266 Blood loss (ml)

39

34

39

37

56

Total Study Group: 205 women

Oxytocin Rectal Misoprostol 400 micro grams

Rectal Misoprostol 200 micro grams

Oral Misoprostol 400 micro grams

Oral Misoprostol 200 micro grams

Medication given right after delivery as a prophylactic

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Availability of Misoprostol: It was introduced to the Supreme Board For Drugs and Medical Appliances (SBDMA) on the following years: � 1997; application denied due to the reason that it can induce abortion. ��2002; application is on hold, waiting for legitimate reasons to register the drug in the country. ��Despite it’s illegality it is found in pharmacies under the name cytotec selling for $1.30. ��Widely used by Gynecologists/Midwives in hospitals. ��TBA not trained for using Misoprostol. Target groups that will facilitate drug availability:

• The Supreme Board For Drugs and Medical Appliances is the

administration in charge to approve the registration of Misoprostol. • Sigma is the manufacture in Egypt that produces Misoprostol Under the

name Misotac. • Alkabos and Alameen” is the agent in Yemen that will export Misoprostol

from Sigma. Pricing for Misoprostol: The wholesale price adds an additional 55% to the manufacturers price: � 20% interest goes to the pharmacies. ��5% fluctuation in price. ��30% additional profit goes to the distributing agent. Pathways in Yemen in order for Misoprostol to be registered to treat PPH Statement of purpose must be submitted to the Supreme Board of Drugs and Medical Appliances (SBDMA). ��The national distributor applies to the SBDMA requesting approval for Misoprostol. ��If the application is approved by the General Director Office it is sent to the Registration Department. ��The RD test the drug in the laboratory. ��If the drug fits the constitution laws it is sent back for final approval where pricing takes place.

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Pharmaceutical Sectors: Private Sector (under the supervision of the SBDMA), PS has two types of pharmacies: ��Subagents; they buy the drug on demand. ��Agents; they have long-term weekly contracts. Public sector has its own regulations by the Drug Fund but it is not active recently. Midwives in Yemen: I conducted a focus group with 12 midwives; the impression I came up with is that those midwives are highly capable of diagnosing and treating post partum hemorrhage. Midwives work both at hospitals and home deliveries. Work in their own neighbor hoods some of them work in remote rural areas. Total midwives in Yemen are around 5500 they rank as follows;

• Professional Nurse Midwives. Three years training after high school. Mainly trained and located in the city of Aden. Less than 500.

• Community Nurse Midwives (CNM). Three years training after ninth grade. They constitute the largest number around 3000.

• Primary Health Care Worker. They are trained for one year training after elementary school. Number trained in Yemen from 1983-2004 is 1976. Those can be upgraded to CNM.

Yemen. The national CMW training Project 1998-200� has demonstrated

impact and success in meeting its’ targets

Training CMWs is a successful strategy in introducing RH Services to rural and remote deprived areas in Yemen4.

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��������������� �����������������������

• The NYMA association is established in Sep. 2004. NYMA is registered as an NGO with the Ministry of Social Affairs and Work. It focuses on issues of CMW rights, organizes training workshops to CMWs, and organizes refresher courses to CMWs 4

• The organization includes: General assembly, Managerial committee and Monitoring and supervision committee 4

They work on empowering midwives by updating/ revising job description, curriculum update, higher studies, study tours in Yemen and outside, and regular meetings with Population sector 4

Traditional Birth Attendance (TBAs): Total trained between 1984-2003 are 2252. 45 days of training. The World Health Organization (WHO) is carrying a project in Yemen called Basic Development Need (BDN); it works under the umbrella of the Community Based Initiative (CBI). One of the components is training Traditional Birth Attendants (TBA) by organizing with the Reproductive Health Department (RHD) in the Ministry Of Health (MOH). The standard for the WHO; is to have one TBA for a population of 1000. In the 11 villages under the BDN the percentage is more like 2-3 TBAs per 1000. It is less than one in the rest of the country. So under the BDN project 200-250 TBAs are trained serving a population of 92,000. WHO conducted a focus group with 8 TBA trained by BDN. They reported that the TBAs benefited from training in hygiene issues, referral service and informing the health unit of any deliveries.

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Family Planning: Percentage of contraceptive use in females ages 15-49 according to the recent Pap Fam study conducted in 20045:

Interviews I conducted with midwives and women in their reproductive age revealed the following myths about contraceptives:

• The pill will make women mad or over weight.

• IUD will cause excessive bleeding; ulcers in the uterus or even a woman can go blind. If the IUD device is lost in the uterus and a woman needs operational removal of it the thought is that they removed the IUD from her back.

• Male condoms are used but female diaphragm is totally refused by

women.

• According to the midwives observation males do not object to Family Planning (FP).

• There is unmet need of contraceptives spread due to low supply in

villages.

• Some people think that contraceptives are against Islamic religion although 4 years ago the imams in mosques became part of the FP campaign.

0 2 4 6 8 10 12

Traditional methods

Other modern contraceptives

Douching

IUD

Contraceptive pills

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Yemen consists of 21 Governorates and 333 Districts6. Contraceptives utilization differs among governorates according to the following table6:

Indicator Contraceptive prevalence Time Area Id Area Name Data Value/ % 1999 005YEM016 Al Jawf 14.1 1999 005YEM020 Dhamar 16.4 1999 005YEM015 Taiz 21.2 1999 005YEM018 Al Hodaida 9.4 1999 005YEM025 Lahij 9 1999 005YEM011 Ibb 16.9 1999 005YEM017 Hajja 5.3 1999 005YEM023 Sana'a 10.7 1999 005YEM027 Al Mahweet 10.4 1999 005YEM029 Amran 13.9 1999 005YEM021 Shabwah 6.1 1999 005YEM024 Aden 29.2 1999 005YEM030 Al Dhale' 5.5 1999 005YEM012 Abyan 4.3 1999 005YEM019 Hadramout 16.9 1999 005YEM014 Al Baidha 13.4 1999 005YEM026 Mareb 8.5 1999 005YEM022 Sa'ada 11.3 1999 005YEM028 Al Mahra 9.4

Al Jawf

Dhamar

Taiz

Al Hodaida

Lahij

Ibb

Hajja

Sana'a Al Mahweet

Amran

Shabwah

Aden

Al Dhale' Abyan

Hadramout

Al Baidha

Mareb

Sa'ada Al Mahra

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Traditional birth control methods used by some Yemeni women: • Midwives I interviewed; reported cases where women inserted herbs in

their vagina to prevent pregnancy. The herb is called shizab, it is similar to rosemary. This practice caused infections in few women seen in hospitals.

• Eat seeds of coffee right after delivery. • Soak a tissue with vinegar and insert in the vagina or insert a solid peace

of salt after sex. • Eat thyme or black seeds on the fifth day of the period.

Illegal abortion methods at home: Carrying the heavy butane tank. Inserting wooden sticks in the vagina are the most method practiced to induce abortion. THE UNITED NATIONS POPULATION FUND (UNFPA): The UNFPA is playing a major role in RH in Yemen; they are working in a project titled Improving Maternal and Newborn Health/Support to Reproductive Health for the duration 2005-2009. The output in that project for contraceptives to be7:

• National work: Demographic-based contraceptive estimation models updated annually and comparative analyses (supply-demand) prepared.

• In targeted areas: Governorate level contraceptive needs incorporated in

annual plans and budgets.

• District end of the year inventories of contraceptives conducted and results compared with services performed.

• Community midwives and TBAs report on continual availability of a range

of contraceptives (pills, condoms, IUDs, injectables) Field visit: I concluded my work in Yemen with a field visit to the governorate of Ibb. There, I had the opportunity to visit two districts, Odeen and Benygafer. The situation was totally different in both districts; Odeen had a well-equipped health center and many patients visiting for antenatal and postnatal care. In Benygafer the health center is abandoned with only one midwife who had no access to any utrotonic drugs in case of an emergency.

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In both districts midwifes and doctors I have met had similar opinions and visions for misoprostol and family planning as health professionals in Sana’a city. The road to Ibb

Conclusion: Misoprostol in the hands of trained midwives and well trained TBAs can be a life saving drug in Yemen due to the fact that less than half the population, particularly those in rural areas, has access to basic health services. Many health units are literally closed; others are open but are either not staffed, have inadequate supplies, or both. It may be difficult for women to seek care if they do not have an escort or if the service provider is not a female. Total fertility Rate (TFR) in rural areas is 23 percent higher than the overall total for the country8. Contacts in Yemen:

1. Dr. Arwa M. Al-Rabee, Deputy minister for Population Sector. Ministry of Public Health & Population. E-mail: arwaelrabee@yemen.net.ye.

2. Dr. Ali A. Al-Mudhwahi, General Director of Family Health. Ministry of Public Health & Population. E-mail: mudhwahiali@hotmail.com

3. Dr. Abdalla Al-Rukeimi, Professor in Obstetric and Gynecology at Sana’a University, Program officer of the RH department in the ministry of health. Cell Phone # 01196771118375.

4. Dr. Salwa Al-Eryani, National Program Officer, UNFPA. Yemen/ Sana’a Country office. E-mail: al-eryani@unfpa.org

5. Dr. Kamel Ben Abdallah, Health & Nutrition Officer. UNICEF. Yemen Country Office. E-mail: kbenabdallah@unicef.org

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6. Dr. Khan Aqa Aseel, Technical Officer, Basic Development Needs, WHO, Yemen. E-mail: aseelk@yem.emro.who.int

7. Suad Kassem Saleh, midwife, Program coordinator at CATALYST that work in improving access to health services in Yemen. Email Skassem52@YQHOO.COM.UK

8. Fatom Nour Aldeen, midwife, director of the technical department in the MOH population sector, reproductive health, also the manager for TBAs training program.

References: 1.World Bank, (May 2003), Implementing the poverty reduction strategy in rural areas, Republic of Yemen. P.37 2. Judith Appleton, (June 2005), Food and Nutrition in Yemen, mid-2005 Report to WFP Yemen on a consultancy visit to Yemen 3. Bailey & Paxton, (November 2001), Averting maternal death and disability, Program note using UN process indicators to assess needs in emergency obstetric services. P.300 4. Haddad, (March 05), The triad: Towards charting assets and creating changes and its sustainability in Yemen. 5. THE family Health Survey, 2004, league of Arab states, PAN ARAB PROJECT FOR FAMILY HEALTH PAPFAM. Yemen Arab Republic. 6. National poverty Survey, 1999, Central Statistical Organization. Source: C:\Program Files\MENA Info\Data\Yemen 2003.mdb 7. UNFPA, (June 2005), Improving Maternal and Newborn Health/Support to Reproductive Health, COMPONENT PROJECT AGREEMENT BETWEEN THE GOVERNMENT OF YEMEN AND THE UNITED NATIONS POPULATION FUND (UNFPA). P. 20 8. World Bank, (May 2003), Implementing the poverty reduction strategy in rural areas, Republic of Yemen. P.41