Why South Sudan must churn more midwives to fix maternal deaths

South Sudan yesterday joined the world in celebrating the International Day of the Midwife, which is commemorated annually on May 5, to provide an opportunity to honour the work of midwives and promote awareness of the crucial care that midwives provide to mothers and their newborns.

Midwives play an essential role in the promotion of health and in the provision of primary and community health care. They provide care in emergency situations and play a major role in making universal health coverage a reality. The International Day of the Midwife, celebrated on May 5, highlights the importance of the role of midwives for the health of mothers, children, and their families.

But the world figures with reference to maternal mortality deaths put South Sudan in a tight spot when her maternal mortality rate is compared with the neighbouring East African countries.

According to Unicef, it is only South Sudan, Chad, and Sierra Leone that have extremely high maternal mortality rates—that is, more than 1,000 maternal deaths per 100,000 live births.

Midwifery, a profession that equally comes with many challenges, among them the lack of equipment and treatment materials, is the first step towards saving the lives of mothers and unborn children.

South Sudan, which had only eight midwives and the world’s highest maternal mortality rate when it gained independence in 2011, has made significant progress in making maternal health care more accessible to women.

In order to reduce the high maternal mortality rate in the country, the United Nations Population Fund (UNFPA) established the midwifery initiative, a sexual and reproductive health organization, with the backing of the governments of Canada and Sweden, and in collaboration with the Ministry of Health. Because of the combined initiative, South Sudan now has over 1,000 midwives.

Problems during pregnancy and childbirth are leading causes of death among women in the region, which has the highest maternal mortality rate in the world.

Dr Demola Olajide, UNFPA country representative to South Sudan, noted the significant progress made to increase the number of midwives in the country.

 “South Sudan now has a midwifery and nursing association with over 1,200 registered members.” So there has been progressing, but as we know, we still have a significant journey to make, “said Dr Olajide.

 Marko Ayuel, the sole male midwife at Aweil Health Centre, notes that the hospital has just a few midwives who go to great efforts to ensure that women have a safe delivery.

 “The working situation is not really good, but we are just working and coping because we are helping our community. That is the main priority, not that the working conditions are favouring us,” said Ayuel. “The number of midwives in the hospital is not enough, which makes the limited number of midwives overloaded with work.”

 “There is no proper remuneration for midwives assigned to the hospital.” Secondly, there is no capacity building like training. And lastly, there is no technician assigned to operate a scanning machine and this one affects the work of the midwife, “he added.

 Shortage of personnel

Taya Aidha, a midwife in Yei says an inadequate number of midwives at Yei Civil Hospital contributes to the inability to achieve effective maternal service.

 “We don’t have enough midwives. You will find that managing this ward becomes difficult because in a shift we may have only two midwives and we have rooms like the post-operative room, we have a gynaecologist, and we have labour and post-operative. At the same time, you will find that there are deliveries, and you will find that these two midwives can not push. We have inadequate human resources, “she says.

 It is not just about the scarcity of human resources. Rampant power blackouts and inconsistent water supply have become a daily concern for midwives assisting mothers in childbirth.

 “One day I was conducting a delivery, but there was no light. I had to use a phone torch to provide us with light so that I could deliver the mother. This was desperation at a whole new level, with dire consequences should anything wrong happen. I had to be careful when examining the baby, but if there is no light, it might affect you. It is really painful if the light is not enough. ”

 The midwives are pleading with the government of South Sudan and partners to provide greater assistance in order to enhance working conditions and increase capacity.

  Aidha told The City Review that she was looking upon the government and the other organizations so that they could support them in terms of fuel supply and power supply to the hospital.

Ayuel also says that they need capacity building so that they can get knowledge to help them give quality services to the people. 

 The UNFPA- South Sudan feels that training and refresher courses are necessary to increase midwifery capacity. 

“You need to have training and retraining so that people continue to learn new skills for them to be able to deploy. We need to strengthen regulation so that we regulate capacity, we regulate the health facilities. A midwife needs to have access to the commodities that she requires to be able to function effectively. That is also important.”

 Dr. Olajide reiterated the critical need for the government and partners to significantly enhance investment in midwifery education, recruitment, deployment, retention, and protection.

 He says this is necessary if South Sudan is to be able to improve maternity service coverage and quality while also responding effectively to health emergencies.

Why International Day of Midwives matters

The International Day of the Midwife is celebrated annually on May 5 to provide an opportunity to honour the work of midwives and promote awareness of the crucial care that midwives provide to mothers and their newborns.

This year marks the establishment, 100 years ago, of the International Confederation of Midwives (ICM). There are currently 143 midwives’ associations representing 124 countries worldwide, including the Confederation of African Midwives Associations (CONAMA), which was inaugurated in 2013.

Midwives, who have been an integral part of African medicine for centuries, are the front-line caregivers and backbone of maternal and child health care on the continent. They support women through pregnancy and childbirth, providing antenatal, intrapartum and post-natal care, and family planning services, as well as breast and cervical cancer screenings. In emergencies, they can also perform basic emergency obstetric care. 

According to the 2021 State of the World’s Midwifery report, by the WHO, the ICM and the United Nations Population Fund (UNFPA), the global shortage of midwives stands at 900, 000, and is particularly acute in Africa. With estimates that 75 per cent of essential needs for maternal and reproductive health care are met by midwives, it is concerning that the comparative figure for the WHO African Region is only 41 per cent.

Midwives are central to the prevention of maternal and newborn deaths, and stillbirths. With adequate investment in midwifery, the report says that 4.3 million lives could be saved annually by 2035. This has particular relevance for the WHO African Region, which records about 196 000 maternal deaths each year, along with the deaths of one million babies younger than one month.

Unfortunately, if current trends persist, only 300, 000 midwifery jobs are likely to be created in low-income countries, with the shortage of midwives set to increase to 1 million by 2030. This has serious implications for the Sustainable Development Goal target of reducing the global maternal mortality ratio to less than 70 per 100, 000 live deaths before 2030.

The contributions that midwives have to make towards achieving the Sustainable Development Goals and Universal Health Coverage cannot be overestimated. Midwives have been strengthening Primary Health Care for decades, acting as a critical link between women and the health system, and making pregnancy and childbirth safer and more secure.

Fully integrated into the health care system, and with the necessary enabling support, midwives have the capacity to provide a wide range of clinical interventions, so contributing to broader health goals. These include advancing primary health care, addressing sexual and reproductive rights, promoting self-care interventions, and empowering women. 

The African Region’s tragic record of maternal and infant deaths demands urgent interventions to expand the coverage of emergency obstetric and newborn services, along with a revision of the scope of practice to allow more task-sharing and task-shifting to mitigate the shortage of midwives.

WHO in the African Region, are working closely with our Member States to improve the quality of maternal and reproductive care. We are supporting the development and implementation of national strategies to accelerate the reduction of preventable maternal and newborn illness and death, and to improve every mother’s experience of care, by 2030. 

Despite significant progress in Africa to reduce preventable deaths related to pregnancy, childbirth, and the postpartum period, the interruption of services due to the COVID-19 response is only one of several challenges that still remain.

Governments and partners need to substantially increase investment in the education, recruitment, deployment, retention and protection of midwives. This is essential if African countries are to be capacitated to increase coverage and quality of maternal services, while still responding effectively to health emergencies. 

During the pandemic, midwifery has been impacted by restrictive practices introduced in maternal and newborn care to mitigate the risk of cross-infection. In collaboration with UNICEF and UNFPA, developed technical guidance for countries to enable continuity of essential sexual, reproductive, maternal, neonatal, child and adolescent health services while protecting and supporting midwives. 

In addition, WHO advocates for the adoption of policies to combat sexual harassment and promote a safe and respectful work environment, for midwives and other health workers.

On the International Day of the Midwife today, I urge governments, academic institutions, civil society and partners to invest in midwifery education, recruitment, regulation, and protection. An investment in boosting the number of midwives in Africa will contribute to better health, gender equality, and inclusive economic growth.

Let’s give these vital and cost-effective contributors to high-standard maternal care the attention they truly deserve.