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Women's Experiences with Abortion Complications in the Post War Context of South Sudan

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Women's Experiences with Abortion Complications in the Post War Context of South Sudan Women's Experiences with Abortion Complications in the Post War Context of South Sudan Author: Monica Adhiambo Onyango Persistent link: http://hdl.handle.net/2345/1836 This work is posted on eScholarship@BC, Boston College University Libraries. Boston College Electronic Thesis or Dissertation, 2010 Copyright is held by the author, with all rights reserved, unless otherwise noted. Boston College William F. Connell School of Nursing WOMEN’S EXPERIENCES WITH ABORTION COMPLICATIONS IN THE POST WAR CONTEXT OF SOUTH SUDAN A dissertation by MONICA ADHIAMBO ONYANGO Submitted in partial fulfillment of the requirements for the degree of Doctor of Philosophy May 2010 © Copyright by MONICA ADHIAMBO ONYANGO 2010 ii Women’s experiences with abortion complications in the post war context of South Sudan Monica Adhiambo Onyango Dissertation Chair: Rosanna Demarco, PhD, PHCNS-BC, ACRN, FAAN Committee Members: Sandra Mott, PhD, RNC and Pamela Grace, PhD, APRN Abstract For 21 years (1983-2004), the civil war in Sudan concentrated in the South resulting in massive population displacements and human suffering. Following the comprehensive peace agreement in 2005, the government of South Sudan is rebuilding the country’s infrastructure. However, the post war South Sudan has some of the worst health indicators, lack of basic services, poor health infrastructure and severe shortage of skilled labor. The maternal mortality ratio for example is 2,054/100,000 live births, currently the highest in the world. Abortion complication leads among causes of admission at the gynecology units. This research contributes nursing knowledge on reproductive health among populations affected by war. The purpose was to explore the experiences of women with abortion complications in the post war South Sudan. Using qualitative descriptive methodology, in-depth interviews were conducted with 26 women following treatment for abortion complications at the gynecology unit of a county hospital. Data was collected from March 2nd to April 26th, 2008. Spontaneous abortion was the most common among study participants. Post abortion care was nonexistent at the community level health facilities, but present at the hospital. The women interviewed were reluctant to reflect in-depth about their experiences with abortion complications. They described the process, signs, symptoms and the events that led to the pregnancy loss, and were more concerned about regaining their reproductive function, a societal expectation of a married woman in South Sudan. A female child in South Sudan is assigned a iii ‘special’ role in the family and community - that of getting married, attracting a high bride wealth paid as dowry to her parents and delivering children for the husband. Arranged and/or forced early marriage is common. A woman’s world view about reproductive health and experiences with abortion complications is therefore influenced by this cultural context. Implications of these findings include the need to develop the nurse midwifery profession in South Sudan. Nurse midwives can lead in providing gender and culturally sensitive reproductive health services including post abortion care. Plans for care must include opportunities to listen to women’s perspectives. iv Dedication I dedicate this work to my mother Katherine Okungu who loves me unconditionally and to my late uncle Dr. Raphael Onyango who believed in me and gave me a chance by providing for my education. v Acknowledgements Completing dissertation work takes encouragement and support from many people. To those whom I encountered during this process, I am profoundly grateful to each one of you. I deeply appreciate the financial support from Sigma Theta Tau Honor Society, Alpha Chi chapter at William Connell School of Nursing, Boston College. My deepest gratitude goes to my dissertation committee: Dr. Rosanna Demarco, dissertation Chair, Dr. Sandra Mott and Dr. Pamela Grace, committee members. Your unwavering support and dedication made it happen. Every class I took at Boston College prepared me for this work. Thanks to all the professors. To the women of South Sudan who participated in this research and whose courage is beyond our imagination, thank you so much. To Dr. Olivia Lomoro, Dr Hilary Okanyi, Dr. Kawa Tong, Ms. Carol Karutu, colleagues at the ministry of health-government of South Sudan and at the Norwegian People’s Aid in Yei, your support at various stages of this work was crucial for its success. I also thank my colleagues at Boston University School of Public Health who supported me in various ways. Thanks to my translators Ngire Zulufa and Lillian Aketch, and the nurse midwifery instructor, Rhoda Ndangire for assisting with the preparations at the study hospital and the gynecology unit. I am deeply grateful to Dr. Jennifer Beard, my colleague at Boston University School of Public Health for never being tired to edit my work. Finally, I would like to express my deepest gratitude to my friend Dr. Charles Onyango-Oduke for providing the intellectual challenge whenever I needed it and forever being so encouraging. Anybody else who supported or participated in this work in anyway and not mentioned here, thank you so much. vi Table of Contents Abstract .......................................................................................................................................... iii Dedication ....................................................................................................................................... v Acknowledgements ........................................................................................................................ vi Table of Contents .......................................................................................................................... vii CHAPTER 1 ................................................................................................................................... 1 Introduction ................................................................................................................................. 1 Background and Significance ..................................................................................................... 2 Impact of Armed Conflict on Health .......................................................................................... 4 Sudan............................................................................................................................................... 5 A Brief History ........................................................................................................................... 5 The Structure of Interim Government of South Sudan. .............................................................. 6 The On-Going War in Darfur. .................................................................................................... 7 Impacts of War on Population Health in South Sudan ............................................................... 8 Post War Socio-economic Determinants of Health ........................................................................ 9 The Population ............................................................................................................................ 9 Economic Context ..................................................................................................................... 10 Primary Education .................................................................................................................... 10 Health Assessment .................................................................................................................... 11 The Basic Health Service Package for South Sudan ................................................................ 14 Reproductive Health ..................................................................................................................... 14 Institutional Responses and Reproductive Health Policy ......................................................... 16 Abortion and Post Abortion Care Situation .............................................................................. 18 Purpose of the Study ..................................................................................................................... 19 Study Rationale ......................................................................................................................... 20 Research Question .................................................................................................................... 20 Implications to the Field of Nursing ......................................................................................... 21 Chapter Summary ..................................................................................................................... 21 CHAPTER 2 ................................................................................................................................. 23 vii Review of Literature ..................................................................................................................... 23 Introduction ............................................................................................................................... 23 Effects of Armed Conflict on Women ...................................................................................... 25 Gender Based Violence during Armed Conflicts ..................................................................... 26 Evolution of Reproductive Health
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