by JANE DIAMOND

Jane Diamond is Marie Stopes International’s Programme Manager for Yemen.

The new Marie Stopes International (MSI) programme in Yemen began in June 1998.There is no doubt that it has a huge task ahead. Apart from tackling the problems of delivering reproductive and sexual health services in a male-dominated society. Yemen has the worst health indicators in the Middle East and North Africa:

• A maternal mortality rate of 1,400 deaths for every 100,000 live births.
• An infant mortality rate of 93 deaths for every 1000 births.
• A female primary school enrolment rate of only 37%.
• Life expectancy at birth of just 57 years, one of the lowest in the world.

Only 6% of the population use modern methods of contraception and on average women have about 7 children. One of the most alarming statistics is that over 90% of women deliver their babies at home, often without the assistance of a trained attendant, which goes some way to explain the appallingly high maternal mortality rate.

Health professionals are also becoming increasingly concerned at the number of sexually transmitted infections in Yemen. No research has yet been done into the incidence of HIV/AIDS, but in the light of developments elsewhere the outlook is not encouraging: untested blood is used for transfusions; Hepatitis B infections are high and increasing; other sexually transmitted infections are also on the increase. The Yemeni government has a policy of testing non-nationals entering the country for HIV, but what is really needed is a study of HIV transmission within the country.

So where does a team, determined to improve reproductive health in Yemen, begin? Obviously the location of the MSI clinic was of prime importance. It is centrally situated in Sana’a. Government ministers, officials and MS staff from London attended the clinic launch. The fact that this was shown on national TV was a morale boost for the clinic’s six locally engaged staff under Dr Hind Khalid, the project leader. But, more importantly, it informed the Yemeni public that the MSI clinic was fully operational and in business. And the strong support which MSI has received from the President’s Office is obviously most beneficial to the programme.

In its clinic in Sana’a, as in all its clinics around the world, MSI makes ‘quality of service’ a priority for all clients. This is particularly important in Yemen where one reason for the low take up of family planning is the problem of access to services and their quality The team at the MS clinic is determined both to attract clients and to keep them.

Clients coming to the Sana’a clinic are therefore assured a confidential, quality service delivered by sensitive and non-judgmental staff. This is manifestly important with regard to sexually transmitted infections (STIs) — a growing problem in Yemen. In July 1998, 41% of clients at the MS centre were treated for STIs and 51% of clients were seen for follow-up STI treatment. The main difficulty was that husbands did not want to come to the clinic for treatment with their wives, resulting in re-infection of the female partner. Fortunately recent figures demonstrate that this situation is slowly changing and some couples have been coming to the clinic together. There is a clear need for extensive counselling on an individual level as well as for a nation-wide effort to raise public awareness of sexual health matters.

The clinic has seen a higher incidence of STIs and urinary tract infections (UTIs) amongst women who have been circumcised. Female circumcision is a growing problem in Yemen mainly due to Somali, Sudanese and Egyptian migrants marrying into Yemeni families. The practice is not legal but is being performed covertly

The services provided by the clinic can be divided into two broad categories:

SERVICES INSIDE THE CLINIC

• Family planning including a full range of contraceptive services (the clinic prides itself on offering some of the most up-to-date methods).
• Vaccination for women and children including BCG, DPT, polio, measles and anti-tetanus.
• Ante-natal care. Pregnant women are monitored at regular intervals so that any complications can be dealt with. This gives the women the best chance of having a safe delivery The Sana’a team can also use this opportunity to talk to them about family planning and the health benefits of spacing births.
• Screening for malnutrition.
• Health education provided by a male and a female health educator.
• Obstetrics.
• Laboratory services.
• The clinic has its own pharmacy because supplies from Ministry of Health centres are erratic.

OUTREACH SERVICES

OUTREACH SERVICES

The health educators also visit schools, colleges and places where men and women gather in rural and urban areas, to talk to them about the benefits of family planning and other reproductive health issues.

MSI/Yemen has got off to an excellent start and the number of clients is increasing. The operation is, of course, a small step in relation to the huge number of health problems which exist in Yemen. MS recently completed a baseline survey into community needs which it will use in planning future services. One of the team’s priorities is to carry out research into the growing problem of STIs.

In order to expand its programme, MS are collaborating on various projects with a number of donors such as the European Union, the UN Population Fund and the Yemeni Ministry of Health. The Sana’a clinic has also been working with the pharmaceutical company Proctor and Gamble which have sent their health education team to the clinic to provide training in the use of sanitary products. Meanwhile, funding has recently been received from the British Embassy in Yemen to develop a national family planning training course for Ministry of Health personnel.

In due course MSI hopes to see the Sana’a centre acting as a model clinic, piloting new initiatives for the Ministry of Health; and it also hopes to see clinics offering high quality and affordable reproductive health services open in other parts of the country.

November 1998