JUBA, South Sudan – Nyomon Lilian will never forget the day she decided to become a midwife.
Two years ago, she had watched her neighbor bleed out while giving birth. “The woman helping her had no idea what she was doing,” says Lilian. By the time her neighbor was finally rushed from her rural village to a nearby hospital, it was too late. She’d lost too much blood and died, leaving behind five small children, including her newborn.
Now, Lilian, 25, is studying midwifery at Juba’s Teaching Hospital. “I’ve seen too many mothers die,” she says.
As South Sudan grapples with a four-year civil war and persistent famine, it is also struggling with one of the highest maternal mortality ratios (MMR) in the world. According to the United Nations and the World Bank, as of 2015, for every 100,000 live births in the country, an estimated 789 mothers die. Health experts attribute the high rate of maternal deaths to an ailing healthcare system, lack of infrastructure and an acute shortage of skilled health workers.
In recent years, however, the world’s youngest nation has taken strides to combat the epidemic. The Ministry of Health, the United Nations Population Fund (UNFPA) and local NGOs have been working together on a series of maternal health initiatives aimed at educating and reviving the country.
Before 2012, South Sudan had fewer than 10 midwives with skills on a par with international standards, serving a population of roughly 11 million people. Today, the number of skilled midwives has mushroomed to more than 400.
It is too early to know how that has affected the country’s maternal mortality rate. But health experts say the initiatives can only have improved things for South Sudanese mothers since the last national census, in 2006, which showed there were 2,054 women dying for every 100,000 births, making South Sudan the deadliest place to give birth at the time.
“It’s important to help mothers deliver and save entire populations,” says Margaret Itto, deputy governor and former minister of health for Imatong State. “If a lot of young [mothers] are dying, it’ll be a huge loss for a generation.”
Itto says one of the biggest challenges in lowering the MMR has been changing the narrative when it comes to who should assist mothers in childbirth. Most women, especially in rural areas, use traditional birthing attendants to help them deliver at home. These are untrained, usually older women without the knowledge or materials needed to safely deliver babies, particularly when complications arise.
In 2012, the Ministry of Health and UNFPA launched the Strengthening Midwifery Services project with a midwifery and nursing scholarship initiative. It operates in four schools across the country and has graduated more than 300 midwifery and nursing students so far. More recently, in 2015, the health ministry, together with the Canadian Association of Midwives and UNFPA, started a peer-to-peer mentorship program to exchange knowledge and experiences between Canadian and South Sudanese midwives.
As more South Sudanese men and women are becoming qualified to deliver babies, some hospitals are seeing a rise in the number of expectant women turning to midwives for help.
Jacqueline Kaku, a family planning practitioner at Juba’s Teaching Hospital, says in the past two years there has been a 30 percent increase in the number of women coming in for prenatal support.
“Thousands have now come in,” says Kaku, who attributes the influx to heightened awareness in rural areas as well as a deeper trust in the system. She also says that incentives are offered for women whose husbands come in with them.
“We tell women we’ll give them priority if they bring the men.”
Imatong State Deputy Governor Itto, who has over 30 years of experience in medicine, has seen huge changes in her town of Torit, in the South Sudanese state of Equatoria.
“Before 2012, we had zero midwives here,” she says. “We only had traditional birthing attendants.” Now the town has nine midwives.
As one of the first students to graduate the U.N.’s scholarship program, in 2013, Grace Achan says she switched from nursing to midwifery when she realized how grave the maternal health situation was.
“I saw a mother and her child die from uncontrolled bleeding,” she says. “I cried and prayed for them, but nothing worked.”
Today, Achan is in charge of family planning at one of Torit’s main hospitals and says that as a result of her training she is able to manage complications.
In addition to the lack of trained professionals in South Sudan, there is the issue of the country’s shoddy infrastructure. There are over 10,000 miles (1600km) of road network in South Sudan, yet only 125 miles (201km) of it is paved, according to a 2016 Oxfam report. The consequence is that women who want to deliver in a hospital are often unable to get there on time.
“Some women use donkeys to transport them,” says doctor’s assistant Ocan Walter. Walter, 32, says that when he was working in remote areas in South Sudan, he saw women being carried from their villages on wooden stretchers for days at a time in order to reach the clinic.
“They’d die from infection before they arrived,” he says.
To help address the problem, the U.N. and the ministry of health launched the Boma Initiative. As part of this task-shifting project, Walter is participating in a three-year program which will teach him how to deal with more complicated issues such as obstructed labor, fistula and cesarean sections.
The deal is that once he graduates, he must work in a rural village for at least two years. Eighty percent of South Sudan’s population live in rural areas, and putting trained midwives in their midst gives them easy access to services, training and information.
“We need young people to take over,” says Dr. Edmund Sebit, medical director of Wau Teaching Hospital.
Sebit says, as far as South Sudan has come far in terms of lowering the maternal mortality rate, the country still has a long way to go. Once the midwives graduate from the new programs, he says, they discover they can’t get a fair salary working within the country’s healthcare system – if they can get paid at all. So they usually take jobs with NGOs or the U.N., leaving local hospitals low on staff.
“The government needs to pay people,” says Sebit.
But South Sudan is a country in crisis and resources are severely limited. Although the government has technically allocated 15 percent of its budget to healthcare, the health ministry says it currently receives only about 1 percent of that funding.
“The aim is to decrease dependency on outsider funding,” says Riek Gai Kok, South Sudan’s minister of health. “But the biggest challenge right now is peace.”