Somalia & Somaliland

Strengthening Midwifery Education and Practice in Somalia and Somaliland (SMEPS)

Our biggest goal is to provide a safe place for mothers. A safe place for babies. Above all, this is what we, as midwives, want.

– Faduma Mohamed Abdirabi, Senior Midwife, SOMA

In Search of a Safe Place for Mothers and Babies

Due to low resources and lack of choice women often have in determining their health outcomes, Somalia and Somaliland have one of the higher maternal mortality rates in the world. Despite these challenges, the situation is improving, as a result of the dedication and hard work of Somali midwives.

“Safe place” means that a mother...

• gives birth in a good facility, with a skilled midwife

• has the choice for her care

• has everything she needs to have a safe delivery.

All efforts need to be made to make her have a safe delivery, because it is for everyone’s future.

The Somali Midwifery Association (SOMA), the Somaliland Nursing and Midwifery Association (SLNMA), and the Puntland Association of Midwives (PAM), in partnership with the Canadian Association of Midwives (CAM), aim to address the many challenges facing midwives and to help provide a safe place for mothers and babies.

Strengthening Midwifery Education and Practice in Somalia and Somaliland (SMEPS)  is a United Nations Population Fund (UNFPA)‑led project with funding from the government of Canada through Global Affairs Canada.

First three photos (school girls, beach, classroom) by Fardosa Hussein

Strengthening Midwifery Education and Practice in Somalia and Somaliland (SMEPS)

SMEPS (2020-24) aims to reduce maternal mortality by addressing the critical shortage of skilled midwives through enhancement of midwifery education and practice, regulation, and association strengthening. The project also aims to increase Sexual and Reproductive Health and Rights (SRHR) for women and girls aged 14-49. SMEPS is being implemented in Somalia, Puntland, and Somaliland.

Overall, the project activities focus on :

  • Improving midwifery education by strengthening clinical skills, knowledge, and practice of pre‑and in‑service midwives.
  • Promoting community advocacy by positively influencing gender equality norms concerning GBV, SRHR, consent and access to healthcare.
  • Developing midwifery leadership in the health sector by empowering professional midwifery associations in the Somali region.
  • Improving the ability of the Ministry of Health to manage and regulate midwifery education and practice, recognizing midwives’ associations’ technical expertise in the profession.
  • Utilizing technologies in mHealth to increase communities’ access to healthcare information.

SOMALIA & SOMALILAND

The SMEPS project works with three midwifery associations: PAM (Puntland Association of Midwives), SLNMA (Somaliland Nursing and Midwifery Association), and SOMA (Somali Midwifery Association). Each association advocates for sexual and reproductive health, and the rights of women and girls, through their respective midwifery practices, public engagement, community sensitization campaigns, interpersonal counselling at maternal health centres/clinics, and at IDP (Internally Displaced Persons) camps.

Puntland Association of Midwives (PAM)

Puntland is located in the Northeastern part of Somalia. More than half the population are nomadic, which makes reaching families a challenge.

“It is a magic environment… desert and mountains. It is surrounded by the Red Sea to the North, and the Indian Ocean to the east.”
– Rosine Rugorirwera, midwife, PAM

PAM was established in 2013 and, as of 2020, has over 600 members. Puntland midwives volunteer as focal points in every region of Puntland.

Midwifery is a 24/7 job. You need to be mentally and physically fit. It’s exhausting. It is exhilarating. Some days a pregnancy ends with normal birth, and a healthy baby and the smile on the mother’s face, and it makes the midwife feel triumphant. When the mother and her family members express gratitude to her, some parents may even suggest naming the baby girl after the midwife, hoping the newborn may borrow a little kindness and hard work from their midwife who supported them.

– Rosine Rugorirwera, midwife, PAM

Sometimes a midwife will find herself in a position where the necessary items needed to care for a mother and baby may not be at hand. She embarks on a series of interventions to save her… but once we have exhausted all options, there is nothing else to do. And the mother dies.

– Najma Hussein, Chairperson, PAM

The work for midwives isn’t always joyous. Many midwives work under very difficult conditions. The situation is made more challenging due to a lack of a proper referral system for complicated births, lack of necessary medical equipment, and competition with traditional birth attendants.

Research Study on The Three Delays >>>

“The three delays are a major cause of death for mothers and babies in Somalia.

Delay 1: When to and how they are deciding to seek care.
Delay 2: Reaching a healthcare facility in time.
Delay 3: Receiving the care needed.

The majority of women who died in childbirth was caused by decision-making and delay in reaching hospital.

If they converted Traditional Birth Attendants (TBAs) into community health workers… It is a source of income for them. It’s how they feed their children. Now the best way, is to convert the community health workers. Most women pass by TBAs. They trust them. They KNOW them. She could instruct the women to go to the health facility. Use that leadership in another way. This could help with decisions.”

– Rosine Rugorirwera, midwife, PAM

PAM 2021 Highlights

In 2021, PAM coordinated the midwifery curriculum review workshop and lead a public outreach campaign whose aim was to raise awareness about the importance of informed consent. In addition, PAM has also been involved in updating midwifery regulation. As part of this process, a training for midwives and health officials will be held in January 2022. PAM’s other 2021 highlights have been BeMONC (Basic emergency obstetric and newborn care) training and organizing events for International Day of the Midwife. For IDM, PAM added rewards for senior midwives who have been working during this challenging time.

Newly graduated midwives have pledged to never support or perform FGM (Female Genital Mutilation) in health centres and promised to encourage mothers to abandon the practice.

Somaliland Nursing and Midwifery Association (SLNMA)

Somaliland is an autonomous region in northern Somalia, which broke away and declared independence from Somalia in 1991. As of 2022, however, no foreign power officially recognises Somaliland’s sovereignty. Somaliland is self-governing — with an independent government, Ministry of Health, democratic elections and a distinct history.

The SLNMA has worked tirelessly to build a credible and competent nursing and midwifery profession in Somaliland. Their declared mission is to work to advance nursing and midwifery education, and service delivery capacity to offer quality healthcare services. The objective is to promote quality nursing and midwifery education at diploma, degree and postgraduate levels, in order to ensure positive health outcomes for the population.

When a mother comes to you from a remote area, and she delivers safely. Is healthy. And you help her. And she delivers normally and you let her lay down in her bed, healthy and safe. It makes you very happy. However, women do not have decision-making power when it comes to their own health. Even in childbirth.

Once, a mother was pregnant with twins. The first was born in the morning, then she rested in the hospital. The second twin was not ready to come. They checked with ultrasound. The doctors insisted on a Caesarean. The husband said, “No, no. She delivered the first normally, the second will be normal also.” We tried to intervene. The doctors said, “If you wait three more hours, she will die.”

It was night, he was out. No one could reach him… Finally, he responded. He was chewing khat on the phone. He said no Caesarean. The doctor argued. “This mother is dying”… eventually, she died in terrible pain... We need to talk to the fathers and husbands. They need to know. They don’t even know how much danger their wives, the mothers, are in. The second twin died. The mother died.

– Fouzia Ismail, Chief Executive Director, SLNMA

SLNMA 2021 Highlights

Noted Nurse-Midwife and activist, Edna Adan Ismail, makes powerful demand for midwives advocating for women having choice in their reproductive health. Adnan was the first female Foreign Minister of Somaliland from 2003 to 2006. She previously served as Somaliland’s Minister of Family Welfare and Social Development. She is a pioneer in the struggle for the abolition of female genital mutilation. She is also President of the Organization for Victims of Torture.

SLNMA, in collaboration with UNFPA, prioritized the needs and responded to improve Emergency Obstetric Care Service for the Erigavo region. The aim was to secure the right to good reproductive and sexual health among Internally Displaced Persons (IDP)/returnee women, men and adolescents.

SLNMA supported the distribution of 1,800 Dignity Kits in Las Anod, and gave out cash vouchers to a total of 75 women and adult girls. The Dignity Kits include the basic necessities that displaced women and girls require to maintain feminine hygiene, dignity and respect in their daily lives in spite of displacement.

One-day policy event, on November 3, 2021 in Hargeisa, to review the guidelines/protocols of Sexual and Reproductive Health (SRH) emergencies case response. In total, 30 participants attended the workshop. The objective was to review and advocate for the updating of the existing SRH emergencies case response policy and guidelines, and to strengthen the capacity of the community, including brothers, fathers, wives, husbands, to gain more information about informed consent of emergency obstetric issues.

— Highlights offered by Farah Mohammed, SMEPS Project Co-ordinator, SLNMA

Somali Midwifery Association (SOMA)

SOMA is a professional midwifery association with a board of directors and volunteer staff, who have considerable expertise in running the association and working with civil society and health officials. They are located in the capital of Mogadishu. Somalia is officially called the Federal Republic of Somalia. The country is bordered by Ethiopia to the west, Djibouti to the northwest, the Gulf of Aden to the north, the Indian Ocean to the east, and Kenya to the southwest.

I love being a midwife… to welcome a new life of a baby and a mother with no complication. A healthy alive baby. To ensure that all the women and babies feel safe in our hands. We like to ensure they all feel safe. I am happy to work in the community, to BE in the community.

– Faduma Mohamed Abdirabi, Senior Midwife, SOMA

SOMA 2021 Highlights

SOMA, along with PAM and SLNMA, collaborated on midwifery curriculum review, and will continue to work on midwifery regulation in January 2022.

SOMA conducted two community sensitization campaigns about the importance of when expectant mothers decide to seek care. 150 mothers were reached and told about the importance of avoiding first delay and seeking care by their own decision. Youth were also engaged about the value of the profession of midwifery.

SOMA delivered Dignity Kits to women in IDP camps on the Afgooye Corridor, an urban area with a large population of Internally Displaced People.

Right now we have no real health infrastructure… We have no regulation. We need regulation. We need to know how to raise funds. How to sustain the organization. We need to reach remote communities, marginalized women.

Our major objectives for SOMA are to prepare midwives, in order to provide effective and appropriate primary, secondary, tertiary care… in order to improve the health of women and newborns and families in various settings. The accomplishment we, at SOMA, are most proud of is coming up with new strategies to address the concerns of midwives and developing or implementing new procedures or systems.

– Faduma Mohamed Abdirabi, Senior Midwife, SOMA

Strengthening Midwifery Education and Practice in Somalia and Somaliland (SMEPS)

PROJECT HIGHLIGHTS: 2020-21
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3 MACAT (Member Association Capacity Assessment Tool) trainings
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2 midwifery regulation assessments
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2 midwifery education and practice assessments
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2 curriculum revision workshops
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3 communication advocacy trainings
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2 organisational development capacity trainings
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2 foundations of midwifery regulation workshops
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2 SRHR (Sexual and Reproductive Health and Rights) campaigns within targeted communities by the midwives’ associations

The development of the SRHR mobile app for Somali youth was also initiated this year. Throughout next year the Canadian Association of Midwives (CAM) will be working closely with Somali youth and a mobile app developer to create this product as a way to support increased knowledge of sexual health and reproductive rights.

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