SAFE MOTHERHOOD PROJECT, SOUTH SUDAN
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TITLE: Combining Tradition and Technology for Safe Motherhood: Success with
TBAs in Bridging the Human Resource Gap in very Resource Limited Emergency
Setting in South Sudan
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CCIH Presentation, Arlington VA, USA
June 2014
Combining Tradition and Technology for Safe Motherhood: Success with TBAs in Bridging the
Human Resource Gap in very Resource Limited Emergency Setting in South Sudan
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Abstract
Key words: TBA – Deliveries – Referrals – Communication - EmONC
Authors: Juma Hayombe, Marko Ngwenya, Tangun Stephen, Musiimenta Berna and Apili Annet
Issues: Decades of political unrest and lack of resources has left few programs or sites for
preventing and treating maternal complications in Ezo County, Western Equatoria State, South
Sudan. Maternal mortality is recorded to be the highest in the world at 2,327 per 100,000 live
births. Yet many barriers exist that prevent pregnant mothers from seeking and accessing
maternal care. To address these challenges, the Catholic Medical Mission Board (CMMB)
launched a two-year Safe Motherhood project in January, 2013.
Description: The project has four objectives: renovating and equipping Ezo PHCC to offer
EmONC services; improving knowledge base and skill set of health care workers; creating
formal communication systems between primary and referral health facilities; and initiating and
successfully operating emergency transport services.
Lessons Learned: With training, the TBAs are very resourceful. They use of solar-charged
mobile phones to call ambulance that evacuate the mothers to a secondary facility for EmONC
services. To date, there are about 350 pregnant mothers are on monthly ANC follow up, over
180 monthly safe deliveries, a considerable number of referrals, TBA home visits, ambulance
services, and surgical interventions.
Challenges and Next Steps: There are cultural issues favoring home deliveries, unreliability of
mobile network, supply-chain logistics, and managing prematurity in the setting. To maximize
the reach and effectiveness, the program is exploring increasing sensitization and mobilization
by employing novel BCC approaches including male involvement initiatives, and initiating
mobile ANC outreaches.
Conclusion: Model combining technology with tradition can be very effective in altering
maternal outcomes in resource-constrained settings.
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Introduction and Background
Globally 287,000 women die annually during child birth, 2.6 million babies are still born, and 3
million babies die within the first month of life accounting to 44% of under-five mortality. Eighty
per cent (80%) of maternal deaths occur in 20 countries in the developing world. These deaths
are associated with emergency and humanitarian conditions; inadequate infrastructure and
lack of personnel; and cost of services. Millennium development goals (MDG) 4 and 5 remain
unmet (UN, WHO 2013).
Maternal and neonatal outcomes are worse in South Sudan where despite the temporary
cessation of war and signing of Comprehensive Peace Agreement (CPA) in January 2005 that
culminated into independence in July 2011, decades of political unrest and lack of resources has
left few programs or sites for training and providing maternal health services. According to
ministry of health (MoH), there are only about 120 doctors and an equal number of nurses
among the many barriers that exist and prevent people from accessing health care including
long distances, lack of public transport, and poor health infrastructure 1,2,3,4. According to HMIS
2012, a paltry 11% of the deliveries occur at the health facilities, out which only 26% are
manned by skilled birth attendants. This translates to 97.5% of the deliveries being manned by
unskilled birth attendants including traditional birth attendants (TBAs), community midwives,
maternal and child health workers (MCHWs) and relatives.
Ezo County, one of the ten (10) of counties Western Equitoria State (WES) is reported to have
the highest maternal mortality at 2,327 per 100,000 live births. Bordering the Democratic
Republic of Congo (DRC) and Central African Republic (CAF), the population is estimated at
310,000 including internally displaced persons (IDPs) and refugees following Lord’s Resistance
Army (LRA) rebel group sporadic attacks between 2008 to date. There were no trained
midwives and only seven (7) MCHWs were shared between the 3 primary health care centers
(PHCCs) and 28 primary health care units (PHCUs). In the absence of other qualified cadre, the
deliveries like in most parts of South Sudan were conducted by TBAs that were poorly trained
(SSHHS 2010). There were no formal linkage to public health system, no communication system
for emergency transport, and no hospital to address emergency obstetric and neonatal care
(EmONC). MCHW is a cadre trained mainly to assist in ANC and MCH-EPI clinics. Though they
can read and write, they have very limited knowledge of conducting deliveries.
In January 2013, and as part of emergency response to mitigate the highest maternal mortality
in the world, Catholic Medical Mission Board (CMMB) in partnership with African Mission
Healthcare Foundation (AMHF) and state ministry of health (MoH) launched the Safe
Motherhood Project in Ezo County. The project addresses three delays that result in poor
maternal outcomes. The three delays are in decision making at household, delay in accessing
health care facilities, and delay in provision and access to quality EmONC services at the
primary health care facilities.
The objectives of the project are;




Renovating and outfitting Ezo PHCC to offer EmONC services
Improving knowledge base and skill set for HCWs, TBAs and the community in general
on Safe Motherhood
Creating linkage, networking and referral systems between community, TBAs, PHCC/CU
and Ezo PHCC
Providing communication and transport in pregnancy , delivery and neonatal
emergencies;
Modeled on RESCUER (Rural Extended Services and Care for Ultimate Emergency Relief) project
implemented by MoH and UNFPA in Eastern Uganda that used TBA referral system, Safe
motherhood project sought the most cost-effective, integrated, and acceptable means of
mitigating maternal deaths.
Project Implementation
The project implementation started with hiring expatriate staff to provide project leadership,
followed by renovation of Ezo PHCC, and the activities cascaded to other primary health
facilities and to the community.
A new delivery suite was constructed and maternity wing renovated to support clean deliveries,
infection prevention, and improved quality service. The maternity wing serves admitted
mothers and babies, and observation after delivery. Other outfitting done includes provision of
basic laboratory capabilities for measuring hemoglobin, blood sugar and urinalysis; provision of
selected essential drugs for emergency obstetrics including key antibiotics such as ampicillin,
ceftriaxone, metronindazole, gentamycin and anesthetic drugs; procurement of essential
equipments and supplies including accurate weighing scales, Doppler Cardiotocograph,
resuscitation equipments and kits, and oxygen cylinders and delivery apparatus. Piped cleaned
water has been constructed and EmONC services are now offered on 24-7 basis.
Besides Ezo PHCC, the project work in nineteen (19) other primary health facilities (1PHCC and
18 PHCU), and with 40 trained TBAs selected by facility health committees. Community health
workers (CHWs), community health promoters (CHPs), and community leaders have been
trained on Safe Motherhood. Continuous on-job mentorship (OJT) for HCWs on quality service
provision is on-going at the facilities and has included training on triage, infection prevention
and control (IPC), and Post-exposure prophylaxis (PEP). Weekly work schedules that include
general scrubbing of the wards, sterilization of all instruments ensure a clean, hygienic
maternity and delivery space continue to be observed. Stock checks are regularly done to
maintain adequate supply of essential drugs and sundries. On quarterly basis, the Safe
Motherhood staffs provide support supervisory visits and mentorship to other primary health
centers and units. To enhance community interface, community leaders have been trained on
key Safe Motherhood educational messages, roles and responsibilities of the community and
the leaders on maternal health outcomes.
Picture 1: TBA with their new Bicycles Picture 2: Meeting with Facility Committee
Picture 3: TBA Outfitted
Picture 4: Meeting with Community Leaders
The TBAs are trained on recognition of high risk pregnancies and early detection of danger signs
in labor, post-partum, and in the newborn. The 5-day training covered among other things early
pregnancy signs and symptoms, pregnancy complications, focused ANC, HIV/AIDS-PMTCT,
management of labor, and baby friendly initiatives. An additional training has been conducted
for the TBAs to fill the gap observed in referral and reporting. To adequately support the
project, the CHWs have also under-went a 5-day training on Safe Motherhood.
TBAs map and link pregnant women to ANC, provide home visits to pregnant women, and postpartum mothers, and their babies. They assist CHWs in conducting ANC at the facilities. During
ANC, regular medicines such as TT, IPPT, folic/ferrous, and de-worming agents are provided.
Long lasting insect treated nets (LLITNs) are also provided when available. High risk mothers are
identified using standard criteria and referred to Ezo PHCC. Coded cards that don’t require
writing are used. The cards identify source –TBA and facility - of the referral. TBAs conduct
normal deliveries and administer misoprostol for PPH prevention. Emphasis is laid on facility
deliveries for timely reporting of adverse events and ease of evacuation in emergency. Bad TBA
practices including over-zealous massage, delay with prolonged labor, and over-examination of
women in labor, and use of other medicines including herbs in pregnancy or labor have been
openly discussed.
They are supplied with safe delivery kits modeled on UNFPA/maama kit with disposable single
use items that include sanitary pads, razor blades, spirit, cotton wool, cord ligatures,
Tetracycline Eye Ointments (TEO), anti-septic soaps, and paracetamol and misoprostolol
tablets. They are also provided with mobile phones and solar systems for lighting and phone
charging, call units, gumboots, aprons and bicycles to facilitate home visits.
To enhance networking, linkages, referral and reporting systems, two TBAs are attached to
each primary health facility. They primarily report to, and are supervised by the CHW in-charge
of the primary health facility. The TBAs are part of primary health facility management
committee and take part in day-to-day deliberations and running the facilities. They have been
provided with a simplified pictorial reporting tool. Reports from TBA and from the facilities are
submitted on monthly basis to the Safe Motherhood project offices based in the Ezo PHCC
maternity unit and to the County Medical office. We review every still birth and neonatal
deaths monthly to identify preventable causes of the mortalities.
The Tri-cycle (rickshaw) ambulances that are economical are used for transport in emergency.
The fuel consumption, availability of parts, and vehicle size make it efficient, pocket-friendly
and ideal for the setting. It is able reach to homes and villages with narrow roads and footpaths.
The ambulance drivers remain on call 24-7 and have been provided with cell phones. They pick
up patients when called by the TBAs or other health workers. The ambulance call lines have
been distributed to TBAs and health facilities, and vehicle log is maintained to monitor
utilization of these services.
Women in Ezo County like in most parts of Africa, rely mostly on their husbands for decision
making at household level. We initiated male involvement initiative where men are incentivized
with T-shirts to accompany their spouses for ANC clinics. Through the male involvement
initiative, we are reaching out to families and educating couples to empower them with basic
knowledge on MCH, create more awareness on EPI, Family planning, birth preparation, and
clean and safe deliveries. These have enabled timely decision making at household level,
improved community awareness, and knowledge base on Safe Motherhood. With these
trainings, we hope that more women will be able to identify danger signs early, improve timely
self referrals and outcomes, and to better immunization uptake.
Technology is used in choice of transport, solar-lighting in TBA deliveries, solar charging of
mobile phones, and in mobile telephone communication. This has enabled the project to
operate in a remote area without high power electricity supply, and with limited resources.
Picture 5: Labor suite under construction
Picture 7: Inside labor Suite
Picture 6: TBA visiting after referral
Picture 8: Rickshaw Ambulance
OUTCOME
The project had overall targets in training TBAs and CHWs, following up more than 2,000
mother-infant pairs, increasing in ANC and facility birth by 50%, and achieving 30% reduction in
maternal mortality and neonatal mortality.
We have recorded marked improvement in ANC attendance, birth records, and maternal and
neonatal outcomes. The TBA community follow-ups and home visits enable the project to
closely monitor maternal and neonatal outcome in the facilities and at home. The data is
further confirmed by meeting facility in-charges and facility health committee that represents
the community.
FIGURE 1: Map of South Sudan
Table 1: Aggregated Safe Motherhood activities
Parameter
Oct
Nov
Dec
Total
Jan
Feb
Mar
Total
Total TBA Follow Up
NR
393
411
804
252
273
257
782
ANC Visits
29
188
139
356
301
308
310
919
Home visits
NR
NR
246
246
145
263
215
623
Total Deliveries
157
154
222
590
158
157
188
503
Home deliveries
91
112
93
296
69
100
135
304
Facility deliveries
66
52
129
247
89
57
53
199
Emergency Phone use
6
7
12
25
2
8
9
19
Emergency Ambulance use
4
4
9
17
2
7
7
16
Emergency Referral to Ezo
4
4
9
17
2
8
10
20
Other referral to Ezo
35
37
22
94
47
59
45
151
Surgical interventions
2
3
2
7
3
6
2
11
Maternal deaths
0
0
0
0
0
0
0
0
Still births-home delivery
1
1
3
5
0
1
4
5
Still births-facility delivery
0
0
1
1
1
1
0
2
Total TBA reports
32
32
30
94
31
27
32
90
TBA follow up and linkage
TBAs follow up and linkage, and home visits form the core part the projects community
interface. Through this activity, the project is able to monitor closely maternal progress and
outcome. The TBAs have followed up and linked between 252 and 411 every month in Q2, 2013
and Q1, 2014, the period running from October 2013 and March 2014. An additional 246 and
623 home visits was conducted to pregnant women and in the post-partum in Q4 2013 and Q1
2014 respectively (Table 1).
ANC attendance
We have recorded significant improvement in ANC attendance. At the inception of the project
in January 2013, the ANC attendance was only 31 compared to 357 in April 2014. Total ANC
attendance was 356 in Q4, 2013 compared to 919 in Q1, 2014.
Table 2: ANC Attendance
Ezo PHCC
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Jan
Feb
Mar
Apr
31
46
32
52
48
79
62
28
54
44
70
32
70
27
100
41
29
188
139
231
281
210
316
73
258
171
301
308
310
357
Other PHCC
Total
31
46
32
52
48
79
62
28
54
This increment is attributed to community mobilization, initiation of more ANC clinics in other
facilities, and improved recording and reporting from the other 19 facilities (Table 2).
FIGURE 1: ANC attendance, Jan 2013-Apr 2014
400
350
300
250
Ezo
200
Other
150
Total
100
50
Apr
Mar
Feb
Jan
Dec
Nov
Oct
Sep
Aug
Jul
Jun
May
Apr
Mar
Feb
Jan
0
Deliveries
Deliveries are conducted in the facilities or at the homes of the pregnant mothers. Emphasis is
laid in facility deliveries for reporting of adverse event and ease if evacuation is required. The
project monitors both home deliveries and facility delivery outcomes. In quarter 4 (Oct-Dec),
2013, there were 590 reported Safe Motherhood supported deliveries in Ezo County, compared
to 503 in Q1 (Jan-Mar), 2014 totaling 1093 for the 6 months. The average monthly delivery is
173. Of this 600 (54.9%) deliveries occurred at home while 493 (45.1%) were conducted at the
facility. All these deliveries except 4 (1 in Q4, 2013 and 3 Q1, 2014) done by caesarian section,
were normal deliveries (Table 1).
Surgical Interventions
Surgical interventions form the crucial part of EmONC intervention without which the outcome
would be poor. A total of seven (7) surgical interventions were conducted in Q4, 2013 including
the caesarian section, laparatomy, manual removal of retained placenta, and evacuation of
incomplete abortions as compared to 11 surgical interventions in Q1, 2014.
Emergency Referrals and Ambulance Use
Emergency referrals are routinely made to Ezo PHCC with the aid of rickshaw ambulance. Ezo
PHCC has been renovated and outfitted, and is able to handle most emergency EmONC
interventions on 24-7 basis. Seventeen (17) and 20 emergency phone referrals were made to
Ezo PHCC for EmONC services between October 2013 and March 2014 totaling 37 for the two
quarters under review. Of these, 17 used ambulance in Q4, 2013 and 16 in Q1, 2014. These
figures exclude emergencies self referrals that find own means of transport to be attended at
the facility. The emergency referrals are essentially very sick patients whose outcome would
ordinarily and grievously result in morbidity and mortality without intervention.
Other Referrals
The Safe motherhood project also receives non-emergency referrals from other departments
within Ezo PHCC or from other primary health facilities. Such cases include high risk
pregnancies, and other non-obstetric conditions and complications. A total 245 referrals were
made between October 2013 and March 2014.
Maternal Mortality and Neonatal Deaths
The project has done exceptionally well and recorded no maternal death since its inception.
This information is further confirmed from facility reports, and community reports obtained
from health facility management committee. Ten still births were recorded for the 600 home
deliveries and 3 for the 493 facility deliveries between October 2013 and March 2014. This
translates into 17 still births per 1000 births, compared to 6 per 1000 births for facility
deliveries. Five (5) neonatal deaths after live births have been recorded, three (3) following
severe asphyxia, and two (2) after neonatal infection following home delivery from Bariguna, a
non-Safe Motherhood project area.
Other Parameters
Most babies born within Safe Motherhood Project are breastfeed in the first hour of life and
receive prophylactic tetracycline eye ointment. Three (3) premature babies received Kangaroo
Care in the two quarters under review.
CHALLENGES AND NEXT STEPS
Supply chain and logistical difficulties resulting in delays in delivery of medicines
inherent in such emergency situations.
Government supplies are insufficient and unpredictable resulting in regular stock outs.
Cultural/traditional practices, beliefs and norms of keeping newborns in the homestead
for 6 months encourage home deliveries and resulting in low immunization coverage.
Mobile communication is still under development thus providers are not able to offer
special mobile terminated billing for toll-free emergency calls.
Only about 25% mothers attend ANC four times or more, and ANC supplies are missing
in the facilities.
Low literacy levels of TBAs resulting in difficulties in filling cards and registers.
The roads are bad and other essential elements of dignified livelihood including peace
and security, food security, and functional education system are lacking.
With further support, the program will:
Engage men more through male involvement initiatives
Initiate mobile outreach services to improve quality of ANC
Up-grade more sites to offer BEmONC services
Train more skilled birth attendants
Have the TBA supplies and other commodities built into the government supply chain
system.
DISCUSSION
Reasons why women die in pregnancy and child birth in developing world have many layers tied
to resource base. There are logistical failures in the health care system, lack of transport, lack of
manpower, poor infrastructure, inaccessibility of EmONC services, and apathy towards patient
care. Millennium Development Goals 4 and 5 may not be achieved. Innovative and costeffective approaches are needed as an answer the perennial scarcity of resources for maternal
neonatal Care 1, ...8.
Yet, most African MOH policies are not tied to the reality of huge resource deficit and practice.
The draft South Sudan MOH reproductive health (RH) policy (2013) for example, advocates
facility deliveries conducted by trained midwives. However, available data indicate that there
are few facilities with the infrastructure required, there are very few midwives, and more than
74% of deliveries at the primary health facilities are conducted by TBAs in the absence of other
cadre. This leaves a huge gap in current care guidelines 6, 8, 10, 25.
Traditional birth attendance is centuries old practice and have been a subject of discussion in
the provision of maternal and newborn health care for many years, especially in developing
countries where lack of infrastructure and trained health personnel reigns 6,7,8. According to the
WHO Alma Ata definition, ‘a traditional birth attendant (TBA) is a person – usually a woman –
who assists the mother at child birth and who initially acquired her skills delivering babies by
herself or working with other TBAs. In many of these communities, TBAs are highly respected;
and provide essential social support to women during childbirth. In most cases, their beliefs and
practices are influenced by local customs and sometimes by religion 1, 6, 8, 18, 19, 23.
For many years the value of TBA training has been questioned although there are still many
groups who remain enthusiastic. There often appears to be little common ground between the
proponents and opponents of TBA engagement, and outcomes from studies on the relevance of
TBAs present mixed and often controversial pictures. Yet, in sub-Saharan Africa, the presence of
skilled birth attendants at all births is still an unforeseeable goal. Ngala17, found that skilled
birth attendants conduct less than half of deliveries, with an estimated 22.2% of deliveries
attended by traditional birth attendants, 26.8% by family members, and 5.9% of women
delivering without assistance.
Primary Surgery, popular book authored by King23 and other renown medical specialists (1990,
reviewed 2008) supports use of TBAs and interventions based on TBA referral systems have
been successful in Uganda, Brazil and Guatemala. In rural Uganda, AMREF found TBAs
competent in assisting most deliveries. They recommend TBAs to handle normal births, but
notes that it is with the complicated births and pregnancies where they face challenges. While
WHO for example recognizes that it is not ideal to allow untrained persons to conduct
deliveries, they admit their value and point out that prohibiting or banning them is potentially
dangerous.
Why did previous TBA interventions fail? Could it have been due rudimentary communication
technology, lack of cheaper means of transport, and inaccessibility of EmONC services? Many of
the reviewed publications indicate that TBAs are highly trainable with simple pictorial methods
and could be useful including for complex intervention such as PMTCT 22. While some
observations found truly that some TBA activities were marred with risky interventions and
negative outcomes, it remains unclear whether trainings were standardized and non-TBA
related factors including lack of transport, long distances, and unavailability and affordability of
EmONC services were addressed 9…15
In Kenya, Cameroon, Nigeria and South Africa, studies have found TBAs useful with training and
support systems in rural and often remote areas where they fill the human resource gap 18,
19,17,…25. In Malawi, one writer recounts how banned traditional birth attendants, went
underground, were lost to regulatory authority resulting in increased maternal deaths. A few
years after the country reversed the ban and started training traditional birth attendants,
mortality was reported start falling again17, 18, 19.
None of the programs reporting positive outcome with TBA used technology in communication
and referral transportation, and making EmONC services more accessible and affordable.
Combining technology with tradition, the Safe Motherhood project has demonstrated that in
very resource limited settings, TBAs are not only resourceful, but invaluable. With additional
training, use of communication technology, and support systems, the project is showing that
TBAs can be used to bridge the human and infrastructure resource deficit in maternal and
neonatal care, and are empirical in mitigating maternal mortality in resource limited setting.
Conclusion and Recommendation
The huge resource gap in maternal care is a reality in Africa and the rest of developing world.
MDG goals 4 and 5 remain unmet. Immediate and mid-term cost-effective solutions need to be
found and put to scale. For decades to come the traditional birth attendant will continue to
have a substantial influence, maintain a role in filling the human resource gap, and determining
the health practices and life habits of rural underserved populations. It doesn’t matter how
simple or less sophisticated TBA interventions are – what matters is the number of women we
are able to save. Combining technology with tradition or community based approaches is an
effective response to maternal and neonatal mortality. This model can be applied in other
settings for short term and sustainable maternal outcomes by nurturing and harnessing this
community resource and further recommend operations research around such technologytradition based models.
Acknowledgements;
AMHF/Raskob - Funding the project
European Union - Basic Service Fund- Constructed most of the facilities we work in
USAID-ISDP/MCHIP - Staffing and supplies in the facilities
World Bank - Building the roads that make transport bearable
Medicines San Frontiers (MSF) - Referral unit at the state level
GOSS/MoH – Cooperation and Technical support
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