Strengthening maternal and child health in conflict-affected South Sudan
IDRC-supported research has been underway in South Sudan and northern Uganda since 2015 to improve maternal and child health. In these post-conflict settings, researchers are strengthening local health systems, reducing barriers to access, empowering women, and mobilizing communities to take action on their health needs.
When the project began, Torit County in South Sudan (one of the locations of the research) was relatively untouched by the civil war, but renewed violence broke out in 2016. Despite this difficult context, the experience proved that not only is it possible to conduct research in conflict-affected areas, it can actually play a vital role in reinvigorating local communities and strengthening health systems.
Documenting the impact of conflict on maternal and child health
Following decades of conflict, South Sudan gained its independence in 2011. One of the world’s poorest countries, its emergence has been stymied by civil war since 2013. Nearly one in five people have been displaced, infrastructure and livelihoods are lacking, and few roads connect the largely rural population to hospitals, clinics, and other services.
South Sudan has some of the world’s worst health indicators, including for maternal health. In 2017, an estimated 1,150 women died for every 100,000 live births — more than twice the average for sub-Saharan Africa. Women have little say in determining family size and child spacing. As a result, only about 5% of women use modern contraceptives.
The project’s research team members — from South Sudan’s Ministry of Health, St. Mary's Hospital in Lacor, Uganda, and from the Université de Montreal in Canada — sought to improve understanding of the conflict’s impact on the experience of pregnant women. They analyzed data collected at health facilities in Torit County between January 2015 and December 2016, which found a clear drop in institutional care for expectant mothers during this two-year span. Antenatal visits fell by 21%, while the share of expected births that occurred in facilities declined from 24% to 17%. In addition, the percentage of high-risk mothers delivering in clinics or hospitals fell from 59% to 44%.
Using evidence to improve health services
Supported by the Innovating for Maternal and Child Health in Africa initiative, the project included a scoping review of health policies and systems that underscored many gaps in South Sudan’s health system that undermine reproductive, maternal, neonatal, child, and adolescent health. It pointed to a critical shortage of skilled healthcare workers, a lack of medicines and supplies, and low levels of national funding.
With few trained primary healthcare workers to meet basic needs, facilities rely on traditional birth attendants and community health workers who do not have the skills to detect or manage major complications or offer effective sexual and reproductive health services. To address this crucial need, the research team supported the training of eight midwives, who are now posted to rural health facilities in Torit County.
The research also identified barriers to women’s access to care. Faced with chronic underfunding, Torit hospital charged clients minimum fees for some services. Occasionally, some staff members illegally charged patients or accepted gifts to supplement their low and irregular pay — all of which hindered access to healthcare. A study on community attitudes found that women were deterred from seeking care because they expected to pay to deliver in a health facility and to provide items such as soap and sweets. Women who had made previous payments to a health facility were twice as likely to choose to give birth at home.
When the research team used evidence from the project to raise these issues with the state Ministry of Health and non-governmental organizations, a system of performance-based allowances was initiated to motivate the staff. Other reforms included increasing basic supplies and forming committees to strengthen governance and oversight of healthcare services. The team advocated for free services and, by raising community awareness, reduced informal fees in the hospital.
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Empowering women and mobilizing communities
The study on community attitudes also found that women — especially those who had previously given birth — were more likely to plan a home birth. In addition to doubting the quality of institutional care, they feared they would face discrimination based on their social and economic status. However, they were not aware of all the risks of home delivery. Given their skepticism of health facilities, it would take trusted facilitators to raise awareness of these risks and community mobilization to identify and address health priorities.
The research team implemented a series of participatory, community-based interventions focused on women’s empowerment. Rather than create new structures, the interventions worked with 15 existing women’s savings groups, encouraging members to shape their own strategies to tackle local health priorities. Trained facilitators (selected by each group), led the women in identifying priorities and developing strategies they could carry out with the support of local community members. For example, some groups chose to fight malnutrition by growing nutritious foods, while others repaired roads to improve access to healthcare services and schools. All groups were encouraged to evaluate and reflect on their progress.
The COVID-19 pandemic delayed end-of-project data collection, but preliminary findings suggest that women are gaining confidence and leadership abilities and adopting healthier behaviours. Other encouraging signs of change are women’s ability to contribute to their family’s finances and greater confidence in speaking publicly and approaching doctors.
“Women are now aware of their rights, and I also think they have the courage to ask questions,” says the project’s co-principal investigator in South Sudan, Elijo Omoro, director general of Torit State Ministry of Health. “We are trying to impress on them that they could be leaders.”
Lessons about improving health in conflict-affected regions
Fellow team member Loubna Belaid, a research associate at Canada’s McGill University, attributes the success of the interventions to strong local partners and facilitators who interact and build trusting relationships with the women’s groups and let them make their own decisions. She also points to participatory research as an effective means of empowering women to tackle health challenges in conflict and post-conflict settings.
“Women’s groups were ready to address their health issues through mobilizing local resources and using their leadership to implement strategies to address problems that they prioritized,” she explains.
Involving decision-makers and communities from the start was crucial to ensure that local needs and experience shaped both the research and interventions. This included decision-makers from South Sudan’s Ministry of Health, which meant that officials could directly access evidence on how to strengthen primary healthcare services.
Research has shown that it is possible — and important — to improve health in conflict-affected regions by working with both communities and health facilities. Although challenging to work in, fragile and conflict-affected zones such as South Sudan offer an opportunity to do things differently: “Fragile settings can easily be left behind,” says Dr. Emmanuel Ochola of St. Mary's Hospital in Lacor, the co-principal investigator in Uganda, “but they also offer the potential to get things done.”