South Sudan is one of the worst places on Earth to give birth. By some measures, more women die in childbirth here than in any other country. Every mother has a one in seven chance of dying in childbirth, and many women have up to 12 or 13 children. For babies, the risks are also extremely high. As many as 25 percent of children die from common, often preventable, childhood illnesses before they reach their fifth birthday.
Health facilities in the world’s newest country were poor even before civil war broke out in 2013. The impact of the conflict has been devastating for maternal healthcare. There is only one midwife per 40,000 members of the population, which means many women are forced to give birth alone. Those who do reach medical help have often walked for days in labor to get there.
Here, two expat doctors tell Women & Girls Hub about their experiences working in maternal healthcare in South Sudan earlier this year.
Tekeselassie Gebreyohannes, an Ethiopian obstetrician with the American charity International Medical Corps, delivered three babies in a row as the U.N. compound in Malakal was under attack.
At least 18 people were killed in February when fighting erupted at the compound, where 50,000 civilians were sheltering from South Sudan’s civil war.
Several health facilities, including a surgical operating theater staffed by International Medical Corps, were severely damaged or destroyed. As the battle raged, Gebreyohannes delivered three babies one after another.
“When the fighting started, our facility … was looted and destroyed. The injured were flowing into the area looking for treatment, so we set up a temporary place to provide services to the causalities,” he says.
It was around that time the first woman turned up in labor. Dr. Tek, as he is also known, had nowhere to put her, so he cleared out an old shed. “We put a plastic sheet on the floor and conducted the delivery around 2 p.m.,” he says. During the delivery, the woman’s relatives held up a blanket to protect her privacy.
That night, as the number of injured and killed mounted, two more women came to Dr. Tek in labor. Once again, he set to work helping women give birth while death and destruction was everywhere around them.
“It was only afterward that I really contemplated what was going on,” he says. “We were attending patients of war, surrounded by people who were dying or seriously injured, and then we were also attending a delivery of a new life on the other side of a piece of plastic.”
Dr. Tek has worked in maternal health services across Africa, including Liberia at the height of the Ebola crisis. He says Liberia’s healthcare system was ruined by the disease but unlike South Sudan, Liberia had better infrastructure in place before the crisis started.
“[South Sudan] did not have a strong healthcare system prior to the outbreak of civil war in December 2013,” he says. “The maternal health system has been affected significantly by the conflict. In my experience here, the risk women face when giving birth is as bad as the statistics suggest, if not worse.”
He says the priority for the world’s youngest nation is first peace, followed by economic stability. Then the international community must help the country build the infrastructure it needs to keep more of its mothers and babies alive.
“My hope is that South Sudan will emerge from this crisis and build a stronger healthcare system so that more mothers can deliver safely and more babies are brought into the world healthy,” he says.
American obstetrician and gynecologist Veronica Ades, working with Medecins Sans Frontieres (Doctors Without Borders), was awake for four days during one bad stretch at the government hospital in Aweil, South Sudan.
“On my third night without sleep, I worked so hard to save the life of a woman but couldn’t save her,” Ades recalls. “When you work that hard on someone’s life, you get really attached. You’ll never really let them go.”
Ades was the only expat doctor working at the hospital and her job was to deal with the births that got complicated. In this case, the woman’s baby had already died and her hemoglobin level was dangerously low. “I spent hours trying to resuscitate her and trying to figure out what was wrong,” says Ades. “We finally managed to stabilize her, but a couple of hours later her oxygen went from 100 percent to 9 percent and she died. Later we decided she probably had preeclampsia, but it is often so hard to be sure.”
Another woman Ades saw on a different occasion turned up at the hospital with her baby’s arm hanging out between her legs. The baby had died after being caught in a transverse position, where the baby’s body is lying across the mother’s abdomen. In this position, it is impossible to deliver naturally. The woman had been in labor for more than 14 hours and had walked miles to her nearest health facility to get help. By the time she reached Ades she was exhausted and very weak.
“I was about to perform a C-section to remove the dead fetus, but I wanted to make sure the woman [had] been given informed consent for the procedure,” says Ades. “I was talking to her about the risks of bleeding and infections, and then I got to the part when I was explaining we would give her anesthesia and then medicine for the pain. The woman interrupted the interpreter, looked at me and said, ‘Bring on the pain.’
“Women in these areas are so strong. They deal with so much and they are very stoic about pain.”
After returning home to the United States, Ades struggled with what she had witnessed. “I saw a counselor in the immediate aftermath of the mission and I spent an hour crying in her office,” she says. “I felt I had done everything I could to help these women, but I also thought, Why am I here to witness these deaths?
“What I came to realize is these women deserve to have someone fighting for them. Maternal health in South Sudan is so bad. Nobody cares about their situation. It gave me comfort to think they knew a doctor was fighting to save them and their mothers could see I was doing everything I could to save their daughters before they died. That is dignity – to have people fighting for you as you die.”