Within six weeks 20 interviews with key informants, 14 in-depth interviews, and 23 group discussions were undertaken (table ), either at the two main towns in the area or in nine of the surrounding villages. CAP was present at all except a few group discussions that were run by local leaders or non-governmental workers after a short training period. The group discussions had an average of 11 people, with a minimum of four and a maximum of 23. Groups were made up of people of the same sex and a similar age (with the exception of one mixed sex group). All tribes in the area were represented, and one group discussion was held with soldiers. The key informants included 12 health providers, five local leaders, two representatives from non-governmental organisations (non-health), and one teacher.
Demographic data of both groups and individuals interviewed
All the results cannot be presented in detail here, but a selection have been chosen that illustrate the four main themes identified: (a) there were clear needs in reproductive health; (b) there was a mismatch between the views of service providers and the community; (c) there was variation in the perception of need according to age, sex, and whether the community was settled or displaced; and (d) the lack of supplies coupled with numerous barriers to accessing services.
Clear needs in reproductive health
The most consistent reproductive health problem identified, often spontaneously, was that of sexually transmitted diseases. Perceived prevalence was very high. Of 11 key informants who ranked diseases in their community in order of prevalence, nine placed sexually transmitted diseases in the top four. Men and women of all ages were concerned about sexually transmitted diseases and their sequelae.
“Sexually transmitted diseases are very common here. Maybe of all of us here, some of us have it.”(Group discussion; displaced man.)
The matrix ranking exercise undertaken by some of the groups also showed much concern about sexually transmitted diseases (table ). The most commonly listed ones were syphilis and gonorrhoea. The symptoms described were often severe, and people described complications such as stillbirth and infertility. Several reasons for the increase in prevalence were given.
Ranking of condition according to settled and displaced communities
“The movement of people and the war has contributed to the spread of these diseases and young men forcing girls to go with them.” (Group discussion; settled man.)
Data from the health service confirmed the perceived high prevalence of sexually transmitted diseases. They were the fourth most common reason for attendance at the main hospital. Altogether 7437 consultations at outpatient departments were for venereal disease (13% of 33
140 total consultations). A survey undertaken in 1995 among attenders of antenatal clinics attenders tested 100 consecutive women for syphilis using the “Macro-Vue” rapid plasma reagin test.25
They were also tested for HIV using the ELISA (Detect) and confirmed positive using recombinant HIV-1 and HIV-2 kit (Recombigen). Eleven women (11%) tested positive, and 4% of the women tested positive for HIV.
Miscarriages were the most commonly mentioned problems in reproductive health after sexually transmitted diseases. Among the 14 women interviewed in depth a total of 69 pregnancies were reported. Of these, nine pregnancies were said to have ended in miscarriage, one ended in a stillbirth, and 10 children who were born alive had since died.
“In April and May  the number of miscarriages were very high—about three quarters of pregnant women. (Key informant; community leader.)
The reasons given for the large number of miscarriages included sexually transmitted diseases, other infections, lack of good nutrition, and finally the war itself.
“In 1991 the guns were suffocating, and the sounds of the guns may lead to a miscarriage. The fear of the Antonov [bomber] and the running may also lead to back pain and then miscarriage.” (Key informant; community leader.)
Perceptions about the incidence of sexual violence were conflicting. Some key informants thought that the incidence was falling, but others disagreed. Few women were prepared to discuss this issue; those that did stated that the perpetrators of violence were deserters from the army. One group of internally displaced people had moved their homes away from the road to avoid contact with these people,
“The other problem women face is deserters. They can do anything and force you to sleep with them. Sometimes three or four of them one after the other.” (Key informant; outreach worker.)
Although the judicial system was apparently working, women would not always admit to violent incidents.
“The other thing is this silent rape. Women go to the bush, and they get raped. They don’t say anything.” (Key informant; health service provider.)
During discussion of a scenario about rape those at risk were identified and so were possible outcomes.
“Younger girls and women collecting water and firewood away from the house are at risk [of rape] … She will be happy if the husband agrees to stay with her. If he refuses, it will make her unhappy and ashamed to stay in that community.” (Group discussion; displaced men.)
Mismatch between the views of service providers and those of the community
Some providers of health services stated that abortions were not taking place, but discussions with local people revealed that abortion was an issue.
“Some people don’t want to be pregnant, they take herbs and chloroquine injections by breaking the glass and drinking it. They also take Omo [a washing powder] … people die because of this.” (Key informant; community leader.)
These methods of abortion were described in response to a scenario.
“Sometimes girls use batteries—99% of the girls who do this will die. They pound the batteries, and then they put it in water and drink.” (Group discussion; young settled girls.)
Similarly, some service providers thought that domestic violence was not occurring.
“Violence against women is not occurring in southern Sudan as women are treasured.” (Key informant; health service provider.)
Group discussions with men and women, as well as in-depth interviews, showed that this was not always true.
“No stranger has been violent to me, but at home this violence is normal.” (In-depth interview; internally displaced woman.)
Responses to scenarios provided information on the context of the violence.
“The reasons for beating are mismanagement of funds, misconduct, if the woman refuses to have sex with her husband, improper way of receiving visitors, infidelity, abuse of her husband, rumour mongering, and theft …. Some husbands are always drunk and don’t provide for their wife or children ... when the wife asks him he just starts beating the wife.” (Group discussion; displaced men)
Perceptions of the prevalence of problems occurring in labour also varied. Some service providers thought that “not many women die in childbirth,” or said “I don’t think the problems are too bad.” There was a recognition, however, that it was difficult for them to obtain accurate information.
“I don’t think too many women are dying, but if a women dies in the village she will be buried, and there is no way of knowing.” (Key informant interview; health service provider.)
In group discussions maternal mortality and morbidity were perceived to be high.
“Yes, yes, yes, we know of many women who die in childbirth. We know of about nine in the last year.” (Group discussion; settled women.)
Secondary data collated from primary care centres suggested maternal mortality ratios as high as 845 per 100
000 live births.
Differences in perceived need according to age, sex, and degree of displacement
Different age and sex groups within the communities held different views. Older men in the settled community were least likely to think childbirth and miscarriage were common problems, ranking them last. Young women, however, ranked them third and sixth. Men thought that the extent of maternal mortality and morbidity was not great among their community.
“Some women die but it is not that common.” (Group discussion; displaced men.)
Women, however, thought that many women were dying and others suffering complications after birth.
“Many women die in childbirth. Seven to eight last year. Also there are cases of the child dying inside the mother. This problem was there before but has now increased.” (Group discussion; displaced women.)
Differences in views were also identified between whether people were settled or displaced. The ranking exercise showed that although the perceived occurrence of disease was similar in both communities, the availability of treatment and the impact of different diseases in terms of duration of sickness and death varied considerably (table ). When asked about general threats, people in the settled community were most likely to mention health, complaining about “continuous death” and “lack of medicines.” People in the displaced community were often more concerned about food and materials.
“Since we have returned from Congo we have had no proper food, nothing to cover the children, no cooking materials, no proper shelter, nothing to dress in so we are ashamed to meet people, and no salt or washing powder.” (Group discussion; displaced women.)
When people were specifically asked, however, to list common diseases aspects of reproductive health were spontaneously included by both settled and internally displaced populations. Those mentioned were sexually transmitted diseases, miscarriages, problems in childbirth, and infertility.
Paucity of supplies and numerous barriers to accessing services
Communities complained about a lack of medical supplies.
“Sometimes people go to the hospital for treatment but the medicine will not be there until you die.” (Group discussion; settled men, and a health provider agreed.)
“Every trained midwife gets a delivery kit and this needs replacing but this does not happen.” (Key informant; health service provider.)
Reported barriers to accessing services were: difficulties in obtaining transport; a reluctance to admit to sexually transmitted infections; traditional beliefs; and conflicting demands on women. The following information was given in response to a scenario.
“In most cases women are shy [to go for treatment for sexually transmitted diseases] and don’t go to the hospital unless the man also gets the disease. She will just stay with it.” (Group discussion; displaced men.)