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Promoting Maternal Health Care Through Community Sensitization

The Case of Maper Village in Northern Bahr el Ghazal, South Sudan

The role of patriarchy in South Sudan was clear when Maper Village community chiefs and members resisted male midwives being deployed to Aweil Hospital’s Maternity Ward. To combat the stigma, the South Sudan Nurses and Midwives Association (SSNAMA) piloted the “Safe Motherhood Campaign” for community engagement. They addressed misconceptions about maternal health care, helping to change attitudes about male midwives and nurses.

Traditionally, patriarchy has been a dominant force in South Sudan. Male family members have always played an overriding role in family matters, including finding necessities, providing security, and making decisions about livelihoods. While most caregiving roles fall to women, men are responsible for reproductive health decisions in the household. Therefore, it was not surprising to encounter resistance from community chiefs and some members of Maper Village in Northern Bahr el Ghazal State to male midwives being deployed to Aweil Hospital’s Maternity Ward.

“Why is the South Sudan Nurses and Midwives Association and the Ministry of Health deploying male midwives in our hospital? This is not culturally acceptable.”

Akot Akot Dut, a chief of Maper Village

Safe Motherhood in South Sudan

South Sudan has registered significant improvements in its health indicators in the past 17 years. Mortality among mothers dropped from 2,054 per 100,000 live births in 2000 to 789 per 100,000 live births in 2017 according to the 2017 UN Maternal Mortality Inter-Agency Group estimates. The country had fewer than eight trained midwives in 2011 (SSHHS, 2011); today, it has over 1,436 trained midwives (765 nurses and 671 midwives), according to the South Sudan Ministry of Health 2018 SMS project II tracking report. As the gender mainstreaming effort in health education continues, more males are registering as midwives and nurses. As a result, some communities do not have sufficient professional female midwives available during deployment, resulting in women and mothers having to rely on male midwives for care.

Six pillars of family planning, antenatal, obstetric, post-natal, abortion, and STI/HIV/AIDS prevention and control compose safe motherhood. Every woman who has reached reproductive age will, at some point, require one of these services. For instance, when she becomes pregnant, she will require antenatal care and, during delivery, obstetric care. In the event of an abortion, she will need post-abortion care, and she will need protection against sexually transmitted diseases. Therefore, a break or alteration in this link can put a woman’s life at risk.

The World Health Organization launched the Safe Motherhood Initiative (SMI) in 1987 as a way of improving maternal health and reducing maternal deaths by half by the year 2000. This would be achieved by improving the health of mothers through a comprehensive strategy of providing, preventing, promoting, curative, and rehabilitative health care.

Addressing Cultural Sensitivities

The South Sudan Nurses and Midwives Association (SSNAMA) piloted the “Safe motherhood campaign” for community engagement including an open maternity day dialogue at Aweil hospital. This was in recognition of the community’s strong resistance to male midwives providing reproductive and maternal health care to women and young girls in Maper Village. SSNAMA carried out the interventions in partnership with the Reproductive Health Association of South Sudan, Amref Health Africa, and UNFPA.

Community sensitization on safe motherhood.
Community sensitization on safe motherhood.

During the dialogue, myths and misconceptions about reproductive and maternal health care were addressed. The most worrying concern raised by the community chiefs and the Boma health workers during the dialogue was that of male persons performing midwifery functions at the hospital. This seemingly resulted in fewer women seeking maternal health care services at the hospital. Further, the community (especially men) felt that family planning practices promoted promiscuity. They did not know why mothers and their newborns spend time in the hospital after delivery. In addition, they did not appreciate how crucial antenatal care is to a pregnant woman and her unborn baby.

Community sensitization on safe motherhood.
Community sensitization on safe motherhood.

Community Leadership Sensitization

There was a need to sensitize the community on safe motherhood in general and, in particular, ensure that health workers across the gender divide are appreciated as critical health care service providers. To demystify misconceptions around male midwives, 10 community representatives, comprising the chief, village elders, and other Maper Village community members, participated in an experiential educational tour of the maternity section of the hospital. They were sensitized about each pillar of safe motherhood. At every station of the maternity ward, the midwife or nurse in charge explained the routine interventions that take place and how they were important for the wellbeing of the unborn baby and the mother.

One midwife specifically spoke about anemia as one of the most common complications among pregnant mothers. This was because there was a general reluctance among community members to donate blood. Community members witnessed how hopeless and despairing the mothers were in the ward with such cases, and yet, there was no blood in the blood bank.

Impact on the Community

“Now I understand why you keep these mothers longer after delivery. Even in the old days, mothers had jaundice, anemia, but these were treated as cases of witchcraft, and many mothers succumbed to death. Today, the same complications are managed from the hospital, and the mothers survive and live longer. Thank you for the great work! I will not anymore allow women with such a condition to go for witchcraft; they must all seek medical help as the best practice. I will also mobilize our community to donate blood to save our women.”

Deng Yak Yaxg, an elder of Aweil Village

At the end of the experiential tour, it was clear that the community’s resistance to male midwives or nurses was due to limited knowledge of what they offer at the health facilities. The tour was crucial in helping community leaders appreciate the fact that male midwives provided quality health care services just like their female counterparts.

As a result of this intervention, Aweil Hospital has experienced a 60% increase in women attending and seeking reproductive and maternal health care services at the hospital. From the radio talk shows facilitated by the chiefs and midwives, the hospital received positive comments and appreciation of the services being offered, and the community has positively responded to blood donation drives.

Lessons Learned

We learned that understanding the role male health workers play in FP/RH uptake is important in improving family planning policy and service delivery programs. By identifying the barriers that male health workers face, appropriate strategies can be devised. Equally important is the need to identify how male partners at the community level facilitate and promote adherence and use of FP/RH services. It is important that decision-makers and policymakers consider how these positive strategies can be incorporated into policy to improve the uptake and use of FP/RH.

The FP/RH community intervention activity in Northern Bahr el Ghazal state established a social behavior change model. It promotes safe motherhood by sensitizing the community and providing practical information about hospital services. The model appears to be a viable method of generating demand and changing attitudes. “I want to become a midwife; I want to become one so that I can also support the delivery of babies,” remarked Akot Akot Dut, a chief of Aweil Village. Following this success, the South Sudan Nurses and Midwives Association plans to scale up this approach to the rest of the country.

Promoting Maternal Health Care Through Community Sensitization
Doris Lamunu

Program Manager, South Sudan Nurses and Midwives Association

Doris Lamunu is a program manager at South Sudan Nurses and Midwives Association. She works as a capacity-building officer at AMREF South Sudan. Doris has over eight years of experience as a health officer, specifically on sexual and reproductive health, health system strengthening, health programming and implementation, medicine clinical practice, health tutorship, and HIV/AIDS counseling and testing. She is effective at advocacy and communication, result-oriented program design, delivery and management with particular emphasis on development of adolescent sexual and reproductive health (ASRH), and a trainer of trainees in ASRH and HIV/AIDS. Doris holds a bachelor’s degree in Public Health from Clerk International University, an advanced diploma in Community Health, a diploma in Clinical Medicine and Public Health, and a postgraduate diploma in Sexual and Reproductive Health and Rights from the Lund University. She is a member of the Global Academy, and she is currently pursuing a master’s degree in Public Health at Texila University in Guyana.

Irene Alenga

Knowledge Management and Community Engagement Lead, Advocacy Accelerator

Irene is an established social economist with over 13 years’ experience in research, policy analysis, knowledge management, and partnership engagement. As a researcher, she has been involved in the coordination and implementation of over 20 social economic research projects in various disciplines within the Eastern African Region. In her work as a Knowledge Management Consultant, Irene has been involved in health-related studies through work with public health and technology-focused institutions in Tanzania, Kenya, Uganda and Malawi where she has successfully teased out impact stories and increased visibility of project interventions. Her expertise in developing and supporting management processes, lessons learned, and best practices is exemplified in the three-year organizational change management and project closure process of the USAID| DELIVER and Supply Chain Management Systems (SCMS) 10-year project in Tanzania. In the emerging practice of Human Centered Design, Irene has successfully facilitated a positive end to end product experience through conducting user experience studies while implementing the USAID| DREAMS Project amongst adolescent girls and young women (AGYWs) in Kenya, Uganda, and Tanzania. Irene is well-versed in resource mobilization and donor management, especially with USAID, DFID, and EU.

Sarah Kosgei

Networks and Partnerships Manager, Amref Health Africa

Sarah is the Networks and Partnerships Manager at the Institute of Capacity Development. She has over 10 years’ experience providing leadership to multi-country programs geared towards strengthening the capacity of the health system for sustainable health in Eastern, Central, and Southern Africa. She also part of the Women in Global Health – Africa Hub secretariat domiciled at Amref Health Africa, a Regional Chapter that provides a platform for discussions and a collaborative space for gender-transformative leadership within Africa. Sarah is also a member of the Universal Health Coverage (UHC) Human Resources for Health (HRH) sub-committee in Kenya. She has degrees in Public Health and an Executive Masters in Business Administration (Global Health, Leadership and Management). Sarah is a passionate advocate for primary health care and gender equality in sub-Saharan Africa.

Alex Omari

East Africa KM Officer, Knowledge SUCCESS, Amref Health Africa

Alex is the Technical Family Planning/Reproductive Health Officer at Amref Health Africa’s Institute of Capacity Development. He works as the Regional Knowledge Management Officer (East Africa) for the Knowledge SUCCESS project. Alex has over 8 years’ experience in adolescent and youth sexual and reproductive health (AYSRH) program design, implementation, research, and advocacy. He is currently a Technical Working Group member for the AYSRH program at the Ministry of Health in Kenya. Alex is an elected Fellow of the Royal Society for Public Health (FRSPH) and a former Kenya Country Coordinator for the International Youth Alliance for Family Planning (IYAFP). He holds a Bachelor of Science (Population Health) and a Master of Public Health (Reproductive Health) from Kenyatta University, Kenya. He is currently pursuing his second Master's degree in Public Policy at the School of Government and Public Policy (SGPP) in Indonesia where he is also a public health and health policy writing scholar and website contributor for the Strategic Review Journal.

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