A plastic sheet, razor blade and jerry can

All you need to deliver a baby in South Sudan

By Pavithra S Rangan
Nyibol Mayen Ayual
UNICEF South Sudan
28 February 2018

TONJ SOUTH, South Sudan, 28 February 2018 – Nyibol Mayen Ayual lays out a ragged blue plastic sheet on the dirt floor of her crowded hut where she lives here with her five children, three goats and a few chickens. “This is where I will deliver my baby,” she says. Nyibol is 26-years-old and about to deliver her sixth child in a few days. “All my children were born here.”

Her mother-in-law, Anger Ajang Kon, is the only traditional birth attendant in the remote village of Kau in Warrap state in the west of the country. Almost every woman in the nearly 270 families living here has given birth with her help. None of them pay her, neither in cash nor kind, and she never asks for anything.

Anger walks and speaks with a firmness that defies her 80 years. “I was little girl like this one,” she says pointing to a girl not more than 15, “when my mother asked me to help her with deliveries.” Few in Kau have even been to a hospital. The nearest health center is in Thiet, at least an hour’s walk away if you are healthy.

A yellow jerry-can and the blue plastic sheet are the only delivery equipment Anger has access to. The nearest handpump is a kilometer away and a bundle of dried grass, lit on fire and held like a torch, is the only source of light. “I ask the women to buy a razor blade to cut the umbilical cord, along with a sheet for the baby,” she says. The nearest market to buy these goods is also over an hour’s walk away. In two of Nyibol’s five deliveries she had no blade. “A strip of cane was peeled and sharpened with a knife to cut the cord,” Nyibol says. “I was a little scared.”

After all these years, Anger says she can tell instinctively when exactly a woman in labour will deliver. “If it is time, I spread the plastic sheet and ask them to lie down. I boil water, wet my hands and begin,” she says. When the delivery is done, the newborn is cleaned with an old cloth. And the plastic sheet is washed and kept away safely for another delivery. When she assists women at their homes, dry mud is smeared all over the floor to clean the blood. “I want the instrument with which you can listen to the baby inside the stomach,” she says. “I also want gloves and scissors.”

In 2017, UNICEF provided 3,531 clean delivery kits, comprising a plastic sheet, soap, a two-sided clean razor blade, cord ties, and pictorial instructions on how to deliver a child, in a few regions that are unable to access health facilities. While there is no means of collecting rigorous data about the actual number of births taking place at the community, the use and demand for these kits could act as a proxy.

“It's better if all women give birth in the hospital where there is equipment and doctors are trained to deal with complications,” says Anger. “But the hospital is so far away that pregnant woman find it very hard to walk that distance while in labour. So, I help them.”

Both Anger and Nyibol say that they rarely witness maternal deaths, but they also say that they have seen several women bleed excessively after delivering, sometimes, for over three days. A neighbour intervenes and says that his sister-in-law passed away soon after delivering a healthy child in his house. Nobody knows why.

The estimated maternal mortality in South Sudan was 789 deaths per 100,000 live births in 2015.[1] A mere 9 per cent of deliveries are attended by skilled health professionals [2]. This percentage is highest in the State of Central Equatoria at 39 per cent and lowest, here in the Warrap region, at 9 per cent. Home deliveries being the norm, haemorrhage, prolonged/obstructed labour and hypertension are the leading causes of maternal deaths.

Tonj is one of the most populated counties in South Sudan. Yet, in 2016, only 191 deliveries were performed at the health center. With UNICEFs intervention, this number has doubled and to 393 deliveries taking place at health facilities in 2017. Besides providing access to outreach workers at the community level, UNICEF is supporting 21 health centers in this region, including the nearby Theit Primary Health Care Center (PHCC).

The Thiet PHCC is the only health facility accessible from Tonj South, as well as from parts of Tonj East and North. “Women don’t come here to deliver. They come only when they have complication after a home delivery,” says the in-charge of the PHCC, Dr. Nyok Bol Nyok. As a result, complications arising from home delivery, from post-partum haemorrhage to obstructed labour, are common.

Midwives at the hospital also say that several women, even while delivering for the first time, prefer to give birth at home and even cut the umbilical cord themselves. “Sometimes the cord is tied with a traditional rope. Many children come here with deadly bacterial (staphylococcal) infections because of such unhygienic delivery practices,” says Dr. Nyok.

By training midwives, deploying community-based home health providers, and supporting access to basic lifesaving health services, UNICEF is working to avert maternal and child deaths in this region and across South Sudan. As on November 2017, nearly 1.8 million individuals, including pregnant women and children, were provided access to primary health care services.

“If UNICEF wasn't supporting community-based outreach staff, the healthcare situation in South Sudan would be worse,” says Akech Tong Aleu, the first governor of the new Tonj state. “The government alone cannot afford these outreach services, which are so critical as most parts of the country are highly inaccessible and without any basic services,” he said.

(Provision of healthcare services at the facility, including clean delivery kits distributed to the community, in the Warrap region and elsewhere in South Sudan, are generously supported by the Belgium National Committee for UNICEF, the German National Committee for UNICEF and UKaid.)



1 World Health Organization et al., Trends in Maternal Mortality: 1990 to 2015 estimates by WHO, UNICEF, UNFPA, World Bank Group and United Nations Population Division (Executive Summary), 2015, at http://www.afro.who.int/sites/default/files/2017-05/trends-in-maternal-mortality-1990-to-2015.pdf

2 Health Management Information System, 6th Annual Report 2016