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JUBA, Jul 10 2008 (IPS) - A vast pregnancy has swollen the tiny woman walking South Sudan's shining new maternity ward clutching two pieces of paper stapled together. She looks no more than 16, wide-eyed with recent pain.
"She has already had a caesarean," Maclean said, shaking her head. "She is in labor but waited until now to come to the hospital."
Juba, the capital, now has a proper maternity ward, delivery chairs and even two incubators, still festooned with opening day ribbons. In its first five days, it dealt with 46 normal births and six caesarean sections. Unlike in the rest of the South, there are plenty of drugs in the new storeroom. Government officials estimate only 25 percent of the population has access to even the most basic medical care – the new ward offers women from Juba and its surrounds the best care available in South Sudan.
One in fifty births results in the mother's death
According to the United Nations Population Fund (UNFPA), Africa has the worst rates of maternal mortality in the world at 820 deaths per 100,000 births. After more than 50 years of on-off war, South Sudan has the world's worst rates of maternal death: 2,054 per 100,000.
Two years ago a visit to Juba's maternity ward was a trip into desperation. Dark rooms with dirty, peeling walls smelled of blood. The weighing scales and stirrups looked like relics from the 1960s, the obstetric instruments medieval.
Originally the plan was simply to refurbish the rooms along with the rest of the hospital, using some of the millions of dollars in aid that has flowed in after a 2005 peace deal.
But UNFPA, which promotes the right to health and equal opportunity for all by assisting with collection of data and designing policy, lobbied for a new, bigger ward with its own operating theatre. "It is a model of how other hospitals should be renovated," Alexander Dimiti, also from UNFPA, told IPS.
The three-year-old Government of Southern Sudan has a special work plan to reduce maternal mortality, although one official said there was so much to do – human resources, awareness building, medical supplies – that it has been hard to make a start. Practically, health workers' time is spent firefighting yearly disasters including outbreaks of cholera, meningitis and measles.
"Reproductive health is relegated to the background. There are a lot of competing needs," explained Dragudi Buwa, UNFPA's head in the South.
While effective methods for dealing with emergencies in cooperation with U.N. agencies, systems for the sustained supply of reproductive health drugs and equipment that Dimiti calls the "pillar" in a health system that could really impact the MMR have not been developed.
Very weak communication links between different levels of the emergent government are partly to blame, Dimiti said. The vast and region also has few roads linking scattered rural communities and many areas are cut off during the rainy season.
Transport is often expensive or very difficult, and as Dimiti pointed out, Southern women are often not the decision-makers about their own pregnancy or health. And even if women can reach a hospital, too often they are made to wait in long queues by poorly-trained staff.
Skills badly needed
Festo Juma, Juba Teaching Hospital's chief administrator as well as its only obstetrician, looks exhausted as he describes some of the emergency caesarean cases he faces; women brought in on trucks after traveling hundreds of kilometres over bad roads in agonizing obstructed labor and already having lost a lot of blood.
One aspect of the hospital’s maternal care unit has not been given a fresh start – the midwife centre where dozens of traditional birth attendants were trained is no longer operating.
"They (traditional birth attendants) had no real impact," Maclean says. "With a small level of education they just stuck to what they knew before."
The birth attendant would palpitate a pregnant stomach, as is the practice by usually elderly women who traditionally assist labour in this region – but their training did not equip them to draw important conclusions. The only result, Maclean suspects, was a general lessening of respect for trained midwives.
But women had little choice: a survey after the war found only eight trained midwives – a government official said the number was in fact only six – in the South, which UNFPA estimates has a population of around 10 million.
Thirty-six new community midwives have recently graduated from a new 18-month-course specially designed to suit the needs of the South by the government and UNFPA. But the U.N. agency estimates that at this rate it will take 60 years to get to international maternal health standards. A U.N.-government survey found only seven percent of births are attended by a midwife or nurse and only 13.6 percent of births took place in a health institution.
"In the rural areas the situation is very much worse… The main cause (of the high number of deaths) is the complete absence of obstetric services in three quarters of the South," Juma says, between operations in his white Wellington boots, green scrubs and a face mask around his neck.
"Most of our people died because of war. We want to replace them, to develop," says maternity nurse Susan Poni. Women are encouraged – including by top politicians – to have many children, and many start young. In one state, 47 percent of girls are married before they are 15.
The government has not yet finalized its Reproductive Health Policy but it will call for "spaced births, no matter how many children are wanted," health ministry official Pamela Lomoro said. But 92 percent of women in South Sudan are illiterate and the war has meant that the messages about a woman's right to choose when to be pregnant have not reached many even the capital, let alone rural areas.
"Of every 1,000 pregnancies, 200 are adolescents," Armah warns. "The young are dying."
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