An innovative task-shifting project is training nurses to perform procedures traditionally done by doctors.

Masna, a mother in a bright orange hijab, sits on a hospital bed at Abdal Referral Health Centre in Somaliland recounting the birth of her first two children:

For the first child I was alone at home when I got the labour and later a midwife was called to receive the baby. That baby boy was delivered forcefully and the placenta did not come out from the uterus and I also had bleeding. The same situation happened to me when I was delivering the second child because there was lack of health facility in our village, so I bled again and I was faced with difficult situation.

Masna’s situation is common in Somaliland, where the majority of the population lives in isolated rural parts of the country with little or no access to healthcare.

The same that happened to me has also happened to many others in the rural areas. They either died lonely or faced risk of death during delivery. Some of them had the placenta remain inside the uterus for five to six days and eventually they were taken to Berbera Hospital.

Masna Ali Jama

Maternal and child mortality is extremely high in Somaliland due to the lack of skilled birth attendants, the lack of qualified doctors to perform emergency procedures such as caesarean sections, and limited health centres for mothers to deliver in. With a maternal mortality ratio of 1044/100,000 it is one of the worst in the world.

To address this situation, THET, in collaboration with the Ministry of Health, Somaliland Medical Association, and Somaliland Nursing and Midwifery Association, have delivered an innovative task-shifting project that has trained seven nurses in Comprehensive Emergency and Obstetric and New Born Care (CEMONC). These nurses will be based at referral health centres across the region and will have been trained to diagnose, treat - including performing c-sections, and refer more complicated cases onto Berbera Hospital, the largest hospital in the Sahil region.

Referral centres are meant to be staffed by at least one doctor, but in Somaliland, the lack of skilled doctors means this is not possible, and so other health workers like nurses are stepping into the role in order to carry out life-saving care for pregnant mothers.

Somaliland lacks a suitable training institution to train the selected nurses so THET partnered with the Tanzanian Training Centre for International Health in Ifakara, an agency that specialises in developing CEMONC training programmes, not just for Somaliland but across Africa.

Saed Abdi Farah was one of the nurses trained in Ifakara and is now working at Abdal Referral Health Centre:  

The training provided us with new knowledge and skills that we did not have before. Previously, even though we might have known the skills and knowledge we lacked the confidence to apply it, but when we went there we received a lot of practical lessons and have seen real cases consisting of medical, operations, and cases which needed real decision making.

Every morning Saed attends to the long queue of mothers waiting for check-ups. Abdal is the only health centre for miles so patients travel long distances to access care. Since the training, the referral pathway has improved and when Saed cannot perform interventions himself he refers patients to Berbera Hospital.

In the last month 50 deliveries were made here, of which there were different levels of complicated delivery. We treat about 20 such cases here, and what we can’t do we refer to Bebera General Hospital where doctors performed operations for the mothers. After the operation, we took responsibility in taking care of these patients and doing follow ups on them.

Saed Abdi Farah

In tandem with the training, THET worked closely with partners and NHS volunteer Peter Jackson to develop a standardised training curriculum and manuals around CEMONC. Institutions like the Somaliland Medical Association are using those manuals to train medical doctors in CEMONC, as many medical doctors in Somaliland do not have the skills to perform these types of interventions. That’s why, along with training nurses and developing training manuals, THET has been working with the Ministry of Health to train doctors and improve their skills in emergency obstetric care.

The broad scope of the project means many levels of health worker are benefitting from the training, which in turn means more mothers will be able to access safe and professional care. As Masna notes:

There is a big difference between the delivery of my first two children and the last two because the later deliveries happened at Abdal health facility and I had access to health workers who took good care of me during my labour.  We are hopeful that more  health workers will be hired for us and trained adequately in order to provide safe care for mothers and children both in the urban and rural areas as much as possible.


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health workers in Somaliland.