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. Mba hiadiana amin'ny fanilikilihana, 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. Ary noho izany, 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.”
South Sudan has registered significant improvements in its health indicators in the past 17 taona. Mortality among mothers dropped from 2,054 per 100,000 live births in 2000 ny 789 per 100,000 live births in 2017 according to ny 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 mpampivelona), 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. Vokatr'izany, 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. Ary noho izany, 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 fahasalamana reny 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.
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, SY UNFPA.
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. Ankoatry ny, they did not appreciate how crucial antenatal care is to a pregnant woman and her unborn baby.
There was a need to sensitize the community on safe motherhood in general and, manokana, 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.
“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. ankehitriny, 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.”
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.
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.