The Mothers and Midwives Behind South Sudan’s Maternal Mortality Crisis

JUBA, South Sudan – Cecilia Steven was supposed to give birth to triplets. But she lost two of her babies during the delivery, and then nearly died herself. Steven’s story is by no means an anomaly at Juba Teaching Hospital.

The maternal mortality rate in South Sudan is one of the worst in the world. The country’s health services are crippled by failing infrastructure and an acute shortage of trained medical personnel – the United Nations^[1] estimates thatthere is only one doctor for every 65,000 patients and one midwife for every 39,000 people. Add to that an ongoing civil war and persistent famine, and today every mother in South Sudan has a one-in-50 chance of dying in childbirth^[2], according to the World Health Organization.

The government has taken steps to help more women survive childbirth with a program that has trained more than 400 midwives^[3] in the past five years. But it’s too early to tell how much the program has improved the nation’s maternal mortality rate, if at all.

Since May 2016, photojournalist Sara Hylton has been documenting maternal health issues in Juba, capturing images that reveal the worries and struggles women face as they become mothers and the challenges of the health workers who are trying to make it safer for them to give birth.

High Risk for Young Mothers

Cecilia Steven, 24, holds her baby, Joyce, who was born two months premature weighing just 3.3lb (1.5kg). (Sara Hylton)

When Cecilia Steven, 24, arrived at Juba Teaching Hospital to deliver her triplets, she was suffering from malaria. Joyce was the only baby to survive the delivery.

Fatima Joseph, head nurse of the nursery at the hospital, says many women experience complications during childbirth due to HIV and diseases such as malaria, anemia and gonorrhea. Many pregnant mothers also don’t have access to skilled birth attendants – nearly 90 percent of women^[4] in South Sudan deliver at home, increasing the risk of complications and death.

Nurses attend to a woman in labor at the Nyokuron Primary Health Center in Juba. At the age of 32, the woman was having her fifth baby. (Sara Hylton)

In South Sudan, only a minority of women are able to access a health facility staffed by trained medical professionals. Those who do still have to endure overcrowding, long wait times and inadequate treatment.

Young girls rest outside the maternity clinic at Juba Teaching Hospital. (Sara Hylton)

The maternity clinic at Juba Teaching Hospital, the only referral hospital^[5] in the country, has fewer than 50 beds. The hospital provides care for free, but power cuts are frequent and resources, medicine and trained medical attendants are scarce. Skyrocketing inflation rates since the start of the civil war mean many expectant mothers can’t afford the cost of transportation to the hospital to seek medical care for themselves and their babies.

Joseph, the head of the nursery, says young pregnant women are particularly vulnerable to complications^[6] during childbirth, as many arrive at the hospital anemic and malnourished – some stop eating in order to hide their pregnancies. Young mothers are at higher risk of post-partum hemorrhage and are more likely to need cesarean sections, she says, which puts a strain on the hospital’s already inadequate blood supply. Hospital staff report major shortages as cultural stigma discourages people from donating blood and any supplies the hospital does have can spoil in the fridges every time the power cuts.

Maria Kiding, 17, waits to see a nurse at the Munuki primary health facility in Juba. Unmarried and pregnant with her first baby, she is one of many young single mothers in South Sudan who will face the challenge of supporting her child without an education or skill. (Sara Hylton)

Understaffed and Unpaid

At the age of 30, Regina Akur is already head of the maternity unit at Juba Teaching Hospital. She is among the more than 400 midwiveswho have graduated from the government’s recent midwifery training drive, but she is one of only two midwives currently employed at the hospital.

As of August 2017, maternity unit head Regina Akur had not been paid for six months. (Sara Hylton)

Midwives and nurses across the country are paid between $10 and $30 a month, when they are paid at all. Critics point to factors such as understaffing and low wages as signs that maternal health is not a priority for South Sudan’s government, which has committed only 2 percent of its national budget to health^[7]. Most midwifery programs are funded by other countries and nonprofit organizations.

Men and women of the midwifery program at Juba Teaching Hospital attend class. (Sara Hylton)

The midwifery program at Juba Teaching Hospital, for example, is mostly supported by the governments of Canada and Sweden. Once students graduate, the job prospects at national health facilities are bleak; many students end up taking positions with nonprofit organizations instead.

Esther Juma and Pricilla Benjamin, two midwives working at a local maternity clinic in Juba, say salaries have remained the same since the 1980s. Sometimes, they can go months without ever seeing a paycheck.

But, still, they come to work every day. “This job, it’s just like how you work in church, just like how you preach the word of God. It’s the way you can help people here,” Juma says. “We want to help our people.”

References

1. ^{^} United Nations (reliefweb.int)
2. ^{^} a one-in-50 chance of dying in childbirth (www.who.int)
3. ^{^} trained more than 400 midwives (www.newsdeeply.com)
4. ^{^} nearly 90 percent of women (www.smallarmssurveysudan.org)
5. ^{^} the only referral hospital (www.realmedicinefoundation.org)
6. ^{^} vulnerable to complications (www.huffingtonpost.com)
7. ^{^} only 2 percent of its national budget to health (www.ss.undp.org)