Special Supplement: Development of Nursing and Midwifery Services in South Sudan
Stengthening nursing and midwifery in Southern Sudan: A key strategy for improving healthcare beyond independence
Southern Sudan has been experiencing civil war for many years before the historic peace agreement reached in 2005 and the subsequent referendum in 2011. The successful outcome of the referendum has resulted in Southern Sudan preparing to celebrate independence in July 2011.
With a population of over 8 million scattered over ten states and covering an area of approximately 640,000 square kilometres, Southern Sudan has some of the worst socio-economic indicators in the world. According to the 2006 Sudan Household Health Survey (SHHS), the maternal mortality ratio (MMR) is 2,054 per 100,000 live births as a consequence of low coverage of skilled birth attendance. About 90% of deliveries occur in the rural areas and only about 10% of them occur in the presence of a midwife or person with midwifery skills. Furthermore, the infant mortality rate is 102 per 1,000 live births and the under-five mortality rate is 135 per 1,000 live births.
Anecdotal evidence suggests that a lack of gender sensitivity in healthcare provision, together with lack of women’s empowerment, has a direct impact on uptake and access to healthcare in Southern Sudan.
Nursing and Midwifery in Southern Sudan
According to the Southern Sudan National Health Facility Mapping (2009/2010) estimations, there are 83 registered nurses, 1,110 certified nurses, 19 Registered Midwives and 132 community/ certified midwives (CMW) deployed within the health care system.
Nursing and midwifery continue to be struggling professions with many challenges and issues that need to be addressed. Midwives in particular have low recognition and status and are not empowered to effectively perform the core functions and deliver quality midwifery services. The absence of a Nurses and Midwives Act and Regulations contribute to the lack of knowledge regarding their scope of practice and inability to guarantee quality nursing and midwifery care to the general population. There is also no formal mechanism in place for the continuous professional development of midwives and nurses.
While there is recognition that strengthening human resources for health including nursing and midwifery is a major priority, progress has been slow on addressing the acute shortage of this skilled workforce. There is no formal system in place for supervision and support of nursing and midwifery practice at state level.
Strategies for strengthening nursing and midwifery in Southern Sudan
Available evidence suggests that the issues to be considered when planning for the scaling up human resources for health, including building the capacity of the nursing and midwifery workforce are:
- Strengthening policy, legal and regulatory frameworks – this is critical and should be done using a rights based approach. Clearly outlined policies and a legislative framework governing nursing and midwifery practice and education will contribute to uplifting standards and better help in the provision of quality health care services.
- Ensuring competency based education and in-service training of nurses and midwives using an up-to-date curriculum and well developed education standards. This will also be critical after independence. Strong health training institutions will help to develop the cadre of nurses and midwives needed to boost the health care delivery. A formal mechanism and system for continuing education and in-service training is also needed to ensure that health workers including nurses and midwives continually update themselves with new information and knowledge.
- Creating and maintaining an enabling environment for nurses and midwives to practice. This includes safe practice sites; safe living conditions; fair compensation, access to basic amenities including schooling and childcare; an adequate supply of essential drugs and equipment, and reliable transportation to an Emergency Obstetric and Newborn Care (EmONC) facility;
- Supervision and support for setting up and maintaining standards and quality improvements–including links, support and backup from the local community
- Stewardship, resource mobilization and management for improvements in the delivery of nursing and midwifery services to all.
- Ministry of Health, Southern Sudan (2009/2010) Southern Sudan National Health Facility Mapping (2009/2010) Estimations. Juba: Ministry of Health
Midwifery planning, regulations and association: Important components when building a strong profession
Gillian Garnett, UNFPA Midwifery Specialist
The World Health Report 2005 (1) ‘Make every woman and child count’ called for the scaling up of midwifery services, recognizing that many more midwives are needed to curb maternal death and illnesses. The report indicated that while governments are ultimately responsible for ensuring that there is access to skilled care, other partners and civil society are essential for consensus building and political action.
Midwives and others with midwifery skills should be empowered to provide a minimum of basic emergency obstetric and newborn care (BEmONCf7). While policies are essential to achieve increased access to quality midwifery services, regulatory frameworks and implementation plans are needed to make policies workable (2). For progress in the achieving improved maternal health, there must be:
- comprehensive plans to provide the overall framework for the provision of quality midwifery services;
- legal and regulatory systems to protect midwives and ensure that their practice covers providing essential life saving interventions.
Midwifery associations could play a key role in generating political action and advocating for improved midwifery services.
Current needs and issues
The midwifery profession in South Sudan has a poor status and image. Many midwives are working for low pay and have limited recognition for the work they do. This is a disincentive for young people to become midwives. There is a huge shortage of registered midwives - most practicing midwives have been trained for only 18 months as Community Midwives.
Currently midwives are registered through the re-activated Sudan Medical Council, Southern Sudan Branch. However there is no legal or regulatory framework guiding midwifery practice. It is the international standard for nurses and midwives to be regulated by a Nurses and Midwives Council/Board affiliated to a regional institution. Also there is no midwives association or any formal mechanism for mobilizing midwives or a strategy for scaling up midwifery services. Midwifery practice is largely the responsibility of individuals and the health care facilities to which they are attached.
The importance and value of midwifery plans, regulations and associations
Professional midwives associations play key roles in advancing the midwifery profession and optimizing the value of midwives. They allow midwives to be positioned in the health care system so that they make a greater impact on the quality of health care and the reduction of maternal death and disability. Midwifery associations have been at the forefront of progress for achieving Millennium Development Goal 5 and reducing maternal mortality.
Many studies have shown that where there are no regulations, plans and policies, there is poor utilization of midwives’ skills, failure to delegate authority and continuous suffering of many women and newborns.
Efforts are being made to initiate a midwives association in South Sudan. This would help to raise the profile of midwives and contribute to improved reproductive health. It is also expected that South Sudan will have a Nursing and Midwifery Regulatory Council and a plan to guide the scaling up of midwifery services.
- World Health Organization (2005) The World Health Report 2005: Make every woman and child count. Washington: WHO
- UNFPA and ICM (2006) Investing in Midwives and others with midwifery skills to save the lives of mothers and newborns and improve their health: Policy and programme guidance for countries seeking to scale up midwifery services at the community level. New York: UNFPA
Figure 1. Future nurses and midwives who will have to advance the profession and make the difference in health care (current students pursuing nursing and midwifery at the Juba College of Nursing and Midwifery)
Improving midwifery services - through capacity placement of IUNV midwives at state level
Ulrika Rehnstrom, UNFPA Midwifery Specialist with interviews conducted by Julien Bucyabahiga, UNFPA Communications Officer
Midwives are central in addressing sexual and reproductive health care (SRH); including maternal health, family planning, skilled attendance at all births, basic Emergency Obstetric and Neonatal Care (EmONC), timely referrals for comprehensive EmONC and prevention of sexually transmitted infections including HIV. Midwifery services in the community offer the most cost-effective and high-quality path to universal access to maternal health care.
There is an acute shortage of midwives in South Sudan. Therefore the Ministry of Health (MOH) funded by the Australian Government through its agreement with UNFPA South Sudan introduced the placement of International United Nations Volunteer Midwives (IUNVs) within the health care system. This is aimed at rapid capacity placement to facilitate the reduction of the high maternal and neonatal mortality and morbidity. At the time of writing twelve Midwives have commenced their one-year assignment and been placed at their duty stations. Their role is to contribute to the improvement of quality Maternity/SRH Services, by providing clinical midwifery leadership and technical support to those managing these services.
The IUNV Midwives have initially a one-year contract and among the expected results are:
- Increased visibility for midwifery profession
- Midwifery competencies and performance improved
- Increased demand for Midwifery services provided to clients, families and communities
- Midwifery students practical placements mentored and supervised
- Increased delivery of Midwifery services where the IUNV is operational
- Midwifery workforce strengthened to contribute to reducing maternal and neonatal mortality.
Interviews with IUNV midwives
Mrs. Eno Inyang and Sitara Khatiwada are among the 12 IUNVs Midwives working in State hospitals. Julien Bucyabahiga, UNFPA Communications Officer in UNFPA Southern Sudan Office asked them about their experiences and challenges.
Mrs. Eno Inyang is a Nurse Midwife, registered with the Nursing and Midwifery Council of Nigeria and a member of the National Association of Nigerian Nurses and Midwives. Before becoming an International Midwife in December 2010, she worked with a private Hospital as a Ward Supervisor. She currently works in Juba Teaching Hospital (JTH) Maternity Ward and believes that much needs to be done in order to improve the facilities and save mothers’ and newborns’ liives. In South Sudan, only 10 per cent of all pregnant women deliver in hospitals due to the lack of trained midwives and high cost of medical equipment. Midwife Inyang has made many inputs because of her experiences in the area of midwifery, nursing, and sonography.
How many registered midwives are working with you? What challenges are they facing in their daily work?
Currently, there are four midwives with different education background and four community midwives (CMWs). The challenges they face every day include, contact with body fluids, contaminated liquids and solid waste management.
It is believed that most of South Sudanese women give birth at home. Do you believe in that? What would you suggest could be done to encourage more deliveries by skilled birth attendants in South Sudan?
The last Southern Sudan Household Survey indicates that most women give birth at home without access to skilled birth attendants. I believe that there should be increased awareness and education on the dangers of home delivery and the advantages of hospital delivery. It is also important that health care facilities including access to skilled attendants at birth should be a priority for people in the rural areas.
Are South Sudanese women visiting Health Care Centres for laboratory tests during their early pregnancy? What types of services are they receiving during the Antenatal care (ANC) visit? How many times does a South Sudanese woman visit the Health Facility during her pregnancy?
During the antenatal visit, pregnant women undergo laboratory tests to check the haemoglobin level, blood grouping VDRL, routine urine check for protein, HIV testing and sometimes an ultrasound test. They receive health education sessions on nutrition, dressing, harmful traditional practices, changes that occurs in pregnancy, safety tips, signs of labor and a lot more. According to the Southern Sudan Household Health Survey (2006), the percentage of ANC attendance is less than 40%. World Health Organisation (WHO) recommends a minimum of four antenatal visits based on a review of the effectiveness of different models of antenatal care. I would want these tests to be given priority: ultrasound scan for every pregnant woman twice before delivery and hepatitis B and HIV testing.
Is Juba Teaching Hospital Maternity Ward well equipped?
In terms of Infrastructure, equipment and human resources, the answer is no but this is work in progress and our expectations are that things will continually improve.
You have never worked in a post conflict environment before, tell us about the challenges you face in your daily work.
The challenges I face are many but not insurmountable. Some are communication gaps, shortage of staff, etc.
How do you think the Ministry of Health should solve these problems? Or what roles should the Government play to improve health care delivery in general?
The Government can improve healthcare in the following ways: in-service training to update staff on current trends in the health delivery, training and employment of health care professionals, i.e. redeploying the trained Community Midwives (UNFPA has supported their training), provision of funds to maintain existing equipment, looking for financial support from other NGOs, development agencies and religious bodies, building hospitals and health centers, provision of drugs, and partnership with private sector, etc.
Mrs. Sitara Khatiwada arrived in January 2011 and is working in Maridi County Hospital. She comes from Nepal and has an advanced degree in Midwifery.
Tell us about your experience before joining UNFPA in South Sudan
I served in various capacities with different national and international organizations, facilitating the delivery of health care at hospital and community settings. My previous roles have included working as clinical nurse, matron, Instructor for midwifery, health officer, community medical assistant, community midwife and IUNV nurse/midwife tutor at Hargeisa, Somaliland/Somalia. I also worked as Program officer for Save the Children (UK), field coordinator for Gender Based Violence/torture victims and health technical trainer for Peace Corps volunteer, US Peace corps, US Embassy Nepal.
As a midwife who has served in Somalia in conflict/post conflict period, how do you find South Sudan health facilities? South Sudan does not have enough registered midwives/nurses, are you working as a midwife and nurse at the same time?
I do not have much knowledge about other parts of South Sudan, but Maridi County Hospital has some basic facilities, although this is far from ideal. Although my primary job is that of a Midwife, I function both as Nurse and Midwife. In addition to this, I also support the Maridi School of Midwifery as a Midwife trainer and act as mentor in clinical areas when trainees are in the hospital.
How many South Sudanese midwives are working with you? What challenges are they facing in their daily work?
There are probably eight midwives with different training backgrounds. The challenges are:
- Lack of manpower to cover the duties and continuing professional development which is instrumental in delivering good quality care.
- The long working hours with very little prospect for natural breaks, compounded by the high temperature and lack of basic equipment and supplies often reduce morale and enthusiasm. Sometimes especially on night duties, there is only one midwife to handle the whole maternity unit.
- Working with Traditional Birth Attendants (TBAs) and convincing expectant mothers about the significance of hospital delivery. This is in the face of the midwives own struggle for survival, as their income is often insufficient to meet basic family and children’s educational needs.
Are South Sudanese women visiting Health Centres during their early pregnancy for laboratory tests such as Complete Blood Count (CBC), Blood Type and Rh Factor, Antibody Screen, RPR (VDRL) test (for syphilis), and Hepatitis B screen? What other types of services are women receiving during antenatal care/pregnancy visits? Do you have any statistics per month?
Most women visiting ANC are advised to undergo routine laboratory investigations. However due to lack of enough technicians and laboratory supplies, some of the basic tests like haemoglobin and blood grouping are not done routinely. Yes!! The monthly reports are done and service statistics are definitely in place.
Do you have any records about maternal deaths in your area?
Yes!! They are all recorded and registered.
Is the Hospital Maternity Ward well equipped for antenatal care services and labor?
It is partly equipped with plenty of room for improvement. The infrastructure needs renovation.
Tell us about the challenges you face in your daily work at the hospital? Can you compare the health care services here and in your country? What can South Sudanese Midwives learn from your country, Nepal?
I face two main challenges here. Firstly, working with poorly-trained midwives with limited facilities. Secondly, communicating with some midwives who were taught in Arabic. People can learn a lot from Nepal. Nepal reduced its maternal mortality rate from 549 to 281 per 100,000 live births due to provision of Skilled Birth Attendants (SBA), training and continuing health education/awareness programmes. South Sudanese midwives can take inspiration from this.. However, this will only be possible if every midwife considers an expectant mother as her own sister and every new born as her own baby. The working environment has to be favorable to motivate and promote staff satisfaction.
How do you think the Ministry of Health should solve these problems and strengthen the health system in the country?
As we know the major causes of maternal mortality in a developing country like South Sudan are due to the three Ds:
- Delay in decision making
- Delay reaching hospital (due to lack of transport, bad roads, economic status), and
- Delay in receiving care from skilled manpower at the health facility.
If the government can take care of all the Ds mentioned above, I believe very soon there will be a decrease of maternal
The Juba College of Nursing and Midwifery: Lessons learnt after one year
Dr Margaret Itto, Director General Training and Professional Development; Petronella Wawa, Principal Juba College of Nursing and Midwifery and Sophia Nyame, UNFPA Project Manager, Juba College of Nursing and Midwifery
The Juba College of Nursing and Midwifery was established in May 2010. This is the first college in Southern Sudan to train nurses and midwives at the Diploma level. The inception of the college was timely as the Ministry of Health was striving to improve health care services.
Several partners collaborated to provide financial and technical support for this initiative. These partners include St Mary’s Hospital Link, Isle of Wight, UK; Real Medicine Foundation; UNFPA; World Health Organization, the Japanese International Cooperation and the United Nations Development Program through the Global Fund Health Systems Strengthening Initiative .
Students were recruited with the minimum entry qualification being senior high school certificate with at least six credits in science. Forty qualified candidates were selected (20 for each programme - Midwifery and Nursing). The college also recruited five tutors, three international and two nationals with one of them being the Principal of the College.
Through the efforts of all partners, the college can boast of the following achievements since it has opened one year ago:
- Students have completed all foundation courses and have begun their clinical sessions. They are currently in their 7th week of practical sessions and will resume classroom lessons in May.
- With the support of the Department of Nursing and Midwifery, Ministry of Health, the college identified six clinical mentors at the Juba Teaching Hospital and four clinical mentors from El Sabah Hospital. Their main tasks are to instruct, supervise, monitor, assist and mentor the students in clinical settings. The students are currently placed at the Juba Teaching Hospital medical, surgical and paediatric wards where they are on weekly rotation among these wards. They are accompanied by their tutors who support the clinical mentors.
- The development of a draft document outlining clinical objectives to be used by the students during their clinical/ practical sessions. The objectives form part of the course content to be implemented by the students during their practical sessions and are a basis for evaluation of their work by the clinical mentors and tutors. A workshop is currently being organized for clinical mentors, tutors and several other stakeholders to review and endorse the document as part of the course content.
- The college library was boosted in February with a donation of 187 books, 37 DVDs and CDs, journals and other teaching aids in both nursing and midwifery from the British Medical Association. In addition, the Real Medicine Foundation donated 87 nursing and midwifery books that are to be used as classroom reference books by the students. A mini library to assist research work and learning among students has been established as a result this donation.
- In terms of infrastructure, the Japanese International Cooperation constructed new state of the art facilities including classrooms, faculty office and skills lab at the Juba Teaching Hospital. Office equipment and other assets including teaching materials, computers, multi-media projectors and skills laboratory equipment were acquired with support from UNFPA, JICA, WHO and RMF.
- The college Principal carried out a study visit to two other national health training institutes (Maridi National Health Training Institute and Kajo keji Health Training Institute). The main objectives of the visit were to identify commonalities and differences of the college with other institutes and build capacity to manage and supervise a college of nursing and midwifery.
- Completion of the draft Curriculum for Midwifery Diploma Programme. This is currently being reviewed and once completed is expected to be approved as the national standard curriculum for training midwives at the Diploma level.
- The college is currently recruiting international tutors under International United Nations Volunteer (IUNV) contracts. In addition, a Librarian/Information Technology Specialist and Finance and Administration focal person are being recruited.
- To strengthen internal structures within the college, the previous rules and regulations have been revised and updated. Other documents that are pertinent for the efficient functioning of the college including the Management and Advisory Board, College Committees, College Organogram and Memorandum of Understanding for all partners are under review and will be finalized in the second quarter of the year.
- The college in January 2011 welcomed an additional partner, the United Nations Development Programme (UNDP) through the Global Fund Initiative. Support will be provided for the construction of a kitchen, mess hall and hostels to accommodate 60 students.
Notwithstanding the many achievements, the college continues to face several challenges including:
- English as a means of teaching and learning is a challenge to some students who have limited English language skills and have been mostly taught in Arabic.
- Delays in the acquisition of equipment for the skills laboratory and other office equipment.
- Postponement of the admission of the second intake of students to January 2011 mainly due to inadequate classrooms and dormitories as well as to harmonize its calendar with all other National Health Training Institutes.
- Indiscipline is a major challenge to the college and some students have been expelled and some are facing suspension for various offences.
The first year of functioning of the Juba College of Nursing and Midwifery has demonstrated several key areas for learning and development including:
- Establishing and administering a school of Nursing and Midwifery needs detail planning, realistic timing and lots of resources. It is felt that it would have been more appropriate to start the school when most of the infrastructure was in place to promote effective teaching and learning.
- It is recognized that selection of candidates should be according to the set criteria so as to maintain standards and for quality assurance.
- There is need to ensure that adequate space, equipment and supplies for practical skills and an adequate number of clinical mentors are in place for effective learning.
- It is recognized that many students may require counseling and support to address behavioral issues which may be as a result of the conflict/ war environment to which many of them have been exposed.
Figure 2. Launch of the new building for the Juba College of Nursing & Midwifery, December 2010
Community Midwifery: Fulfilling the need for maternal care services but much more is needed
UNFPA Communications Officer, Julien Bucyabahiga, interviews Eluzai Lou Loponi, the Principal of Maridi Health Training Institute
The National Health Training Institute (NHTI) Maridi is located in Maridi County in Western Equatoria State. It is the property of the Ministry of Health (MOH)/ Government of South Sudan and its mission is to train Community Midwives (CMWs) among others. The first training programme commenced in 2006 with support from the United Nations Population Fund (UNFPA) and the African Medical Research Foundation (AMREF). Through the MOH, AMREF was commissioned by UNFPA to conduct the training and is doing so until today. The opening of the school is in line with the health policy of the Government of South Sudan to reduce its maternal mortality rate and to achieve the Millennium Development Goals by 2015. Principal of the Institute, Eluzai Lou Loponi, believes that the school is surely achieving its goals.
How long have you been training community midwives in Maridi?
The National Health Training Institute (NHTI) in Maridi started the training of the CMWs in October 2006.
How many have graduated and where have most of them been deployed?
The NHTI enrolled 5 intakes, of which 3 have graduated with an output of 56 graduates (48 females and 8 males). They have been deployed in different parts of the South Sudan working in NGOs and Government health facilities.
In your opinion how have these community midwives contributed to midwifery services in South Sudan?
Although no trace study has been done yet but I believe they have contributed much to increased health facility safe deliveries, ,awareness in health related problems in pregnancy and so eventual reduction of maternal and infant mortality rate by some small percentage - especially given the small number of CMWs graduates.
What is your current intake and when will they complete their studies?
The 4th intake is in its second year while the fifth has just started the first year in early March 2011 witha total of 53 students. The 4th Intake will complete the course in July 2011 while the 5th one will complete in 2012.
How many tutors (faculty staff) do you have?
The Institute has 11 Tutors teaching in the 3 programs (Clinical Medicine, Public Health and Midwifery) but two are specifically for midwifery.
Tell us about the community midwives who have graduated from your programme? What skills and competencies do these community midwives have?
The community midwives here in the NHTI Maridi are trained to acquire skills in the following core competencies: history taking, general physical examination, obstetrics and gynecological physical examination, conducting deliveries (normal and abnormal), and labour management. The midwives have also skills in neonatal management, health education and counseling, record keeping, community needs assessment (community diagnosis), early detection of risk factors in pregnancy and early referral, etc.
What have been some of the challenges you have experienced at your training school?
The main challenges of the training institute at the moment are the inadequate medical supplies and drugs in the health facilities making it difficult for the students to practice the basic professional skills and the shortage of qualified midwives in the health facilities to supervise and guide the students during practicum placements. Other challenges include the following:
- Maridi hospital is far from the training school making it not possible for students to attend night shifts.
- Few mothers deliver in the hospital/health facilities.
- Some models are missing in the skills lab making it difficult for the tutors to demonstrate some of the procedures for the students to practice.
- The school has only two Midwifery Tutors reducing contact frequency with individual students more especially the weak ones.
What are the future plans for your training institute?
Like other health training institutes, the ambition of Maridi training institute is to have qualified CMWs who will continue saving mothers’ and newborns’ lives in South Sudan. Its ambition is to help the country achieve the Millennium Development Goal 5 (reduction of maternal mortality) through access to family planning (FP), access to skilled birth attendants (SBA) and access to basic emergency obstetric and neonatal care (EmONC). In addition, the future plans for the school include:
- Employment of two more Midwifery Tutors if funds are available.
- Provision of the lacking items, medical supplies and drugs, to the school and the health facilities.
- Continued placement of students in busy hospitals/facilities even outside South Sudan so they acquire the required skills.
 See SSMJ vol3 no3 for an Editorial and article of the college