Juma Hayombe, a Project Manager with Catholic Medical Mission Board in South Sudan, describes the organization's program to partner with traditional birth attendants to leverage human resources in the resource-limited nation of South Sudan.

1. Combining Tradition and Technology
for Safe Motherhood:
Success with Traditional Birth Attendants (TBAs) in
Bridging the Human Resource Gap in
a Very Resource Limited Emergency Setting in South Sudan
Juma Hayombe,
Project Manager,
Safe Motherhood Project
CCIH 2014

2. Presentation Contents
• Background
• Objectives
• Design and Implementation
• Outcome
• Success stories
• Next steps
• Discussion/recommendations

3. Introduction and background
• Globally, an estimated 287,000 women die in child
birth, there are 2.6 million still births, and 3 million
newborn deaths (WHO, UN 2013).
• 80% of the maternal deaths are in 20 countries in the
developing world (WHO, 2013).
• Most of the deaths are associated with emergency
and humanitarian conditions; inadequate
infrastructure and personnel; and cost of services.
• Despite spirited effort and huge milestones, MDG 4
and 5 goals remain unmet

4. Introduction-South Sudan
• Maternal and neonatal outcomes are worse in South
Sudan as decades of political unrest has left few sites
with infrastructure and other resources for training
of HCWs and for providing maternal care services.
• The youngest country in the world, South sudan got
independence in July 2011, 6 years after
comprehensive peace agreement (CPA) with Sudan in
January 2005 following decades of fighting.
• According to HMIS report 2012, only 11% of
deliveries occur in the facility, the rest 89% occur at
home/community.

5. Introduction Cont.
• Of the facility deliveries, 26%(or 2.5% of the total
deliveries) are conducted by skilled birth attendants
(HMIS Report 2012).
• Most facility ANC and deliveries are manned by
MCHW and TBAs, (HMIS 2012).
• At 2,054 per 100,000 live births (SSHHS-2010), MMR
in South Sudan is the highest in the world.
• Local causes of maternal deaths are bleeding,
obstructed labor, post-abortal/partum sepsis, and
other pregnancy conditions in that order.

6. The Safe Motherhood Project
• In January 2013, CMMB with support from AMHF, a
private US donor initiated a two-year emergency Safe
Motherhood Project in Ezo County.
• Ezo County has the highest MMR in South Sudan at
2,327 per 100,000 live births.
• One of the ten counties of Western Equitoria State,
South Sudan, it borders Central African Republic and
Democratic Republic of Congo.
• The population of Ezo is estimated at 310,000, and
includes refugees and IDPs from Lords Resistance
Army (LRA) attacks from 2008 to date.

7. Project Objectives
The project has four objectives:
 Renovating and outfitting Ezo PHCC to offer EmONC
services on 24-7 basis.
 Improving knowledge base and skill set for HCWs,
TBAs and the community leaders on SM.
 Creating linkage, networking and referral systems
between community, TBAs, PHCC/CU and Ezo PHCC.
 providing communication and transport in
pregnancy , delivery and neonatal emergencies.

8. Objectives cont.
• These objectives aim at addressing 3-delays that
result in poor maternal and neonatal outcomes.
• The three delays are;
 Delay in decision making at the households.
 Delay in accessing health care facilities.
 Delay in access to and provision of appropriate
quality treatment at the facilities.
• The project is modeled on RESCUER- Rural Extended
Services for Ultimate Emergency Relief in Northern
Uganda that used TBA referral and linkage.

9. Design and Implementation
• Project started with hiring of expatriates to provide
project leadership (1 Doctor and 2 midwives).
• At Ezo PHCC, a new labor suite was built, a room
renovated to become maternity ward, and
equipments and other supplies were procured.
• The activities were cascaded and now operates in 20
facilities (2PHCC and 18 PHCU), and with 40 TBAs,
selected by facility health committees.
• TBAs, CHWs, CHPs and community leaders have been
trained on Safe Motherhood.

10. Design and Implem. cont.
• Facility based mentorship HCWs on quality service
provision is conducted on quarterly basis.
• Two Rickshaw ambulances operate and transport
patients in emergency.
• The TBAs map and link the pregnant women for ANC,
and conduct home visits in pregnancy and to post-
partum mothers/infants.
• They also assist CHWs in providing ANC services at
the facilities.
• Standard medicines- TT, IPPT, LLITNs, folic/ferrous,
and de-wormers are provided during ANC.

11. TBA Supplies and Roles
Supplies
• Safe delivery kit with disposable
single use items modeled on
UNFPA/maama kit.
• Solar charged mobile phones
• Solar lighting source
• Gumboots, aprons
• Bicycles
• Medicines- Paracetamol and
misoprostolol
Roles
• Mapping and linking Pregnant
mothers to PHCC/CU for ANC
• home visits for pregnant and
postnatal mothers
• Assisting with ANC at PHCC/CU
• Referring high risk pregnancies
• Conducting simple uncomplicated
deliveries
• Calling for emergency transport

12. Design and Activities cont.
• High risk mothers are identified using agreed criteria
by TBAs and referred to Ezo PHCC.
• 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.
• The project has made use of technology in
transportation, solar-lighting, solar phone charging,
and in mobile communication.
• SMP has been in operation for 18 months, and is set
to end in 6-months.

13. Where We Work
MAP OF SOUTH SUDAN

14. Facility Committee TBA Training Session
TBAs Outfitted TBA Issued with bicycles

15. Outcomes to Date
• The project has recorded marked improvement in
core target: ANC attendance, mother-infant pair
attended, and maternal and neonatal outcomes.
• ANC and birth records in facilities have improved.
• 300-500 monthly ANC attendance from under 50 is
now being recorded.
• 150-200 deliveries occur every month at home and
in the facilities.
• 40-60 referred to Ezo PHCC maternity unit every
month and the number is increasing.

16. Cadre Before Now
Doctors 0 1
Midwives 0 2(2)
MCHWs 10 10
CHWs 22 22
TBAs 40 40
Trained leaders 0 20
CHPs 0 20
• TCNs are responsible for
project supervision.
• PHCC has new labor suite,
renovated maternity,
supplies stocked, clean
piped water system.
• 2 Rickshaw ambulances are
operational.
• EmONC services are
available on 24-7 at no cost
to women.

17. Outcome cont.
• 5-10 TBA calls are made monthly for emergency
evacuation.
• Maternal mortality stands at 0 for over 3200
deliveries recorded.
• Facility deliveries range 40-50% compared national
rate of 11% and is set to increase.
• The project still birth rate is 12 per 1,000 births.
 Every still birth and neonatal death are reviewed
monthly to identify preventable causes.

18. Table-Outcomes
Oct –Dec 2013 Jan-March 2014
Follow up/linkage 804 782
ANC Attendance 356 919
Total Deliveries 590 503
Facility deliveries 247 199
Home deliveries 296 304
Referrals-Other 94 151
Emergency referrals 17 20
Emergency calls 25 19
Surgical Interventions 6 11
Maternal deaths 0 0
Still births 6 7

19. ANC Attendance Jan-Apr 2014
0
100
200
300
400
500
600
700
800
Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr
Ezo PHCC
Other PHCC
Total
F-ANC

20. Rickshaw Ambulance
TBA visit following a referral
Labor Suite
Kangaroo Care being demonstratedTBA visit following a referral

21. FP
EQUITY FOR WOMEN
EmONC Services
BEOMNC
Safe Motherhood-Normal Setting
Community
/communi
Emergency
Transport
Training
In
Midwifery
F-ANC

22. EmONC Services
Safe Motherhood-Resource limited setttingCommunity
Programs
Communicati
on
Emergency
Transport

23. Success Stories
Brief stories on these(Presentation, Management )
• Lady in coma
• Severe poly-hydramnios
• Abruption placenta
• Cord prolapse
• Prolonged labor, commonly cervical dystocia
• Others; Retained placentas, incomplete abortions etc
 We have recorded no surgical or theatre related
complications

24. Program Challenges
• Supply chain and logistical difficulties resulting in delays in
delivery of medicines inherent in such emergency situations.
• Cultural/traditional practices, beliefs and norms that
encourage home deliveries and keeping of newborn for 6
months in the homestead.
• Unreliability of mobile telephone network.
• Only about 25% mothers attend ANC four times or more, with
an average 2.2 sessions.
• Literacy levels of TBAs; can not fill cards &registers.
• Bad roads, and other essential elements of dignified
livelihood lacking.

25. Bad TBA Practices Noted
Delay in referral in prolonged labor
Over-examination (vaginal)
Over - Zealous massage
Use of herbs in pregnancy

26. Future Plans
• BCC and male involvement initiatives.
• Initiate mobile outreach services to improve quality of ANC.
• Open more sites for BEmONC services.
• Holding maternity units for sparse population, bad road, no
phone network – Bagidi.
• Train more of skilled birth attendants take in newly qualified
nurse/midwives for fellowship.
• Have the supplies built into the government supply chain.
• Utilize the android mobile phones GIS system to map and
document emergency calls.

27. Discussion
• We know what works: infrastructure, equipments-
ambulance, and supplies; trained and motivated
health providers; affordable EmONC services.
• MDG 4 and 5 may not be achieved due inadequate
resources for these.
• What we don’t know is what to do in the absence or
scarcity of the resources.
• MoH policies don’t address resource gaps.
• Use of TBA is a centuries old practice that presents
mixed outcome in the literature review.

28. Discussion cont.
• Primary Surgery, popular book authored (1990) by
renown medical specialist advocates use of TBAs.
• TBAs interventions based on referral system have
been successful in Brazil and Guatemala.
• Yet, some countries banned in the 90’s and others
recently despite evidence numerous home deliveries.
• Malawi in 2010 banned TBAs, maternal deaths
increased, and the ban got lifted.
• In many countries there has been a change in
nomenclature-HHPs, CHWs, but TBA like activities
continue.

29. Discussion cont.
• Why did previous TBA interventions fail?
• Simple; means of communication, affordable means
of transport; and accessible EmONC was not part of
the package.
• The pre-technology ban in 80’s and 90’s may have
been acceptable, review needed in tech. era.
• Community misoprostol distribution strategy will
use among other cadres, TBAs and is being put to
scale. There is need to re-consider TBAs role in the
evolving scenario.

30. Discussion cont.
• There is need to tie African MOH policies to
resources and practice.
• 80% of maternal deaths occur in 20 countries
offering perfect opportunity to focus programs.
• Simple technology-tradition/community based
models could provide the much needed push for
MDG achievement.
• These are low-cost solutions with immediate
outcomes.
• They are scalable with potential for substantial
impact in resource poor settings.

31. Conclusion/Recommendation
• The huge resource gap in maternal care is a reality.
• MDG 4 and 5 remain unmet.
• Immediate/mid-term solutions need to be put to
scale to prevent maternal deaths.
• Combining technology with tradition/community is
as effective response to maternal mortality.
• The project further recommends operations research
around such technology-tradition based models.

32. References
1. South Sudan HMIS report, 2012
2. South Sudan Household Survey (SSHS) 2010
3. Reproductive Health Needs assessment report, 2012
4. Maurice King et al.; Primary Surgery 1,
5. http://maternalhealthinuganda.weebly.com/traditional-birth-attendants.html
6. http://www.theguardian.com/katine/katine-chronicles-blog/2010/mar/30/traditional-birth-attendants-ban
7. Traditional birth attendants are an effective resource; http://dx.doi.org/10.1136/bmj.e365 (Published 18 January 2012): BMJ
2012;344:e365 World Health Forum. 1995;16(4):409-13.
8. Matthews MK, Walley RL, Ward A, Akpaidem M, Williams P, Umoh A; Training traditional birth attendants in Nigeria--the
pictorial method.
9. http://www.ncbi.nlm.nih.gov/pubmed/8534350
10. Traditional birth attendants filling the blank space. Ngal E. M.
http://amplifyyourvoice.org/u/elngala/2012/12/11/traditional-birth-attendants-filling-the-blank-space-in-rural-cameroon
11. Ngozo C. Malawi: Uncertainty over role for traditional birth attendants. Global Issues March 2011.
www.globalissues.org/news/2011/03/15/8880.
12. Bisika T., The effectiveness of the TBA programme in reducing maternal mortality and morbidity in Malawi; East African
Journal of Public Heath; Issue 2008 5(2): 103-110
13. Marilza et al; The safe motherhood referral system to reduce cesarean sections and peri-natal mortality - a cross-sectional
study [1995-2006]: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3256099/
14. Marge et al; Issues of programming for Safe Motherhood: http://pdf.usaid.gov/pdf_docs/pnack513.pdf

33. Acknowledgements

34. Questions?

35. “Together, we can change the
fate of mothers at birth and
achieve MDG.”

36. Thank you