Improving Maternal Health in the World’s Youngest Nation

Katie Martin

Senior Project Associate

With a maternal mortality rate of 2,054 out of 100,000, South Sudan is one of the most dangerous places in the world to be a pregnant woman. One reason for this is the low availability of highly trained and qualified health workers. As of 2014, there are only 307 officially licensed midwives operating in the country. Combined with a few other cadres of health workers, the met need of reproductive health workers is only 6%. These statistics, while disheartening, demonstrate the critical need to strengthen South Sudanese midwives’ capacity to respond to workplace challenges and improve clinical outcomes.

Nyokuron Primary Health Care Center

Sign post near the entrance to the Nyokuron Primary Health Care Center in South Sudan. (Photo: Katie Martin)

Nyokuron Primary Health Care Center (PHCC) is a seven-bed facility in Juba, South Sudan. This popular urban clinic serves clients from within Juba as well as surrounding rural areas. It can hardly contain the volume of women who need antenatal care (ANC) services – many of whom wait for hours in the halls of the clinic. To improve the health outcomes of these women and their children, the South Sudanese Ministry of Health nominated Lucy Keji – a dynamic midwifery manager – to participate in the U.S. Agency for International Development-funded Leadership, Management, and Governance (LMG) for Midwifery Mangers certificate course.

The LMG for Midwifery Managers certificate course is a five-day workshop focused on six areas prioritized by a midwifery skills gap assessment, including: teamwork and communication, advocacy, coaching and mentoring, data use for decision-making, change management, and strategic problem solving. The course is delivered by a local facilitator trained during a Training of Trainers workshop by LMG Project staff. Following these workshops, participants apply their new skills by implementing a six-month action plan to improve a selected clinical outcome.

The Challenge: Male-Dominated Beliefs Preventing Women from Seeking Timely Care

After participating in the LMG for Midwifery Managers training, Lucy noted that her facility’s heavy client load was discouraging men from attending ANC services with their partners. This challenge, coupled with male-dominated local beliefs about the preference for home delivery, was resulting in a high rate of labor complications that not only threatened their lives, but also their infants’ lives. Unfortunately, many women delayed coming to the clinic because of their partners’ preferences to deliver at home.

Lucy’s years of midwifery experience suggested that increased male involvement in ANC might catalyze a change in beliefs surrounding the importance of facility delivery. At the time of her training, fewer than one percent of women (6/800) were accompanied by their partners to their first antenatal care visit at Nyokuron PHCC.

The Intervention: Instituting a Client Prioritization Scheme to Encourage Male Accompaniment to Antenatal Care Services

Photo of UN Population Fund artwork encouraging engaged partners in ANC services. (Photo: Katie Martin)

Lucy identified the largest barrier to male accompaniment in her facility as male partners’ work schedules. Men were unable to remain with their partners during the long waiting periods at the clinic without missing work and risking the livelihood that sustains their families. As a result, Lucy piloted a client prioritization scheme that ensured that accompanied women would be seen first by midwifery professionals. As soon as it was implemented, the wait time for couples reduced dramatically and male involvement began to steadily rise. To promote the change in services, Lucy worked with the Ministry of Health to petition the United Nations Population Fund (UNFPA) to create artwork promoting male involvement in ANC. She posted this artwork in the clinic and used it to spark conversations with her clients regarding the client prioritization scheme.

The Results: Rapidly Increasing Male Accompaniment Rates across Juba

The results did not disappoint: By September 2015 (five months after implementation), 8% of women (47/581) were accompanied by their partners at their first antenatal care visit. In addition, a number of male partners showed sustained interest in their wives’ health by continuing to accompany them to follow-up antenatal care visits.

Due to Lucy’s success in catalyzing interest in male involvement in reproductive health, a number of midwives from other clinics have tried to emulate her successes. Client prioritization schemes are now being piloted in other clinics in Juba, including Malakia PHCC and Munuki PHCC. With any luck, male involvement will soon become the standard for quality antenatal care.