_Family Planning Programs in Sub-Saharan Africa_ _13_

# IV. The Sudan Community-Based Family Health Project

## _Background_

Sudan, the largest African country, varies geographically from the desert or semi-desert covering the northern third of its 2.5 million square kilometers to dense equatorial jungle in the south. The 1988 population is estimated at 23.8 million (World Bank, 1990, Table 1) Approximately 80 percent of the economically active population are in the agricultural sector, the majority in subsistence production (Europa Publications, 1986). Droughts, civil war between the Islamic north and the Christian and animist south, development policies and heavy borrowing brought this country to the verge of economic collapse in the early 1980s when the Family Health Project was initiated. The available resources for building up the public health services infrastructure were directed primarily to the most densely populated areas in and around the capital, Khartoum, and the central and eastern provinces (Farah, 1983).

The national primary health care programs of the late 1970s were limited in the range of services to be provided as well as in the area to be reached. There was no organized center for MCH within the MOH. The main providers of MCH services were health visitors (trained nursts) in urban health centers and village midwives who attend home deliveries (UNFPA, 1986). Family planning for birth spacing was nominally part of MCH services although it was not a priority. A non-governmental family planning association, an affiliate of the International Planned Parenthood Federation (IPPF), was founded in 1965 but services in the early and mid-1980s were in general available to those who could pay a physician or a private clinic. Some training for services and public education were undertaken, with assistance from UNFPA, WHO and other agencies, but major constraints identified by a 1985 UNFPA needs assessment mission included the lack of an institutional base for MCH and family planning within the MOH and other levels of administration, lack of management and supervisory capabilities, absence of guidelines for service delivery, and the difficult economic situation (UNFPA, 1986). Public health officials were cautious in view of presumed negative attitudes toward birth control held by Sudanese women and traditional values favoring high fertility. The official position in the Sudan was that the annual population growth rate of about 3.3 percent was satisfactory for the nation and for family well-being. Intervention to moderate growth was not deemed necessary (UNDIESA, n.d.).

More than three-fourths of the population of North Sudan are Muslim and traditions and practices support the bearing of many children as a religious duty as well as a safeguard against a destitute old age (Saghayroun, 1983). A summation of difficulties anticipated for family planning promotion in the Sudan included "illiteracy and ignorance, the ancestral need for sons, the social-security need for sons, social pressure toward parenthood, the superstitions and customs attached to menstruation, the sensitivity of sex-related behaviour, the invisibility of social support on so private a matter and in addition to that, the remoteness of rewards" (Adam, 1983).

Women's fulfillment of their primary role as reproducers in Arab countries was examined in Farid's comparison of the results of fertility surveys in the Sudan (North), Egypt, Jordan, Mauritania, Morocco, Syria, Tunisia, and Yemen (1984). These surveys were conducted in cooperation with the World Fertility Survey Program in the late 1970s and early 1980s. Sudan's reported total fertility rate (TFR) in the five years preceding the survey was 6.02, midway among the eight countries where TFR ranged from 5.27 (Egypt) to 8.51 (Yemen). Sudanese women aged