A day in the life of a midwife in South Sudan
Annette Bennett describes her everyday life as a midwife in Africa and what it's like delivering babies and upskilling locals in midwifery care in a country with basic medical resources.
Content warning: This article discusses child mortality and may be disturbing for some readers. If it has raised concerns for you, help is available via the UTS Counselling Service (for UTS staff and students) on 02 9514 1177 or contact Lifeline on 13 11 14.
Nestled between Ethiopia, Uganda and the Democratic Republic of the Congo lies the landlocked country South Sudan. Born from civil war (with its northern neighbour Sudan) just eight years ago, the country is home to 12 million people, with a baby being born every 70 seconds.
For over 20 years, Annette Bennett has worked as a midwife in Africa. For the past 18 months, she’s worked in South Sudan teaching and mentoring the next generation of midwives and tending to pregnant and birthing women.
Rising early so I can work with the night staff, I walk from the ‘base’ to the hospital. I’m accompanied by one of the night guards (for security and because it’s still dark) and aided by the light of a torch.
We walk along a muddy path as its rainy season, weaving our way through the tukals – traditional mud homes with thatched roofs – and the makeshift fences surrounding them.
Greeting the hospital night guard in Arabic while he opens the gate, I enquire after his health and that of his family, as is the custom.
Our base is in Maban (a village in the far north-east). I split my time between here and the capital Juba (in the south). I enjoy the mornings and evenings here because, sleeping in a canvas tent, I go to bed and wake up listening to the sounds of the surrounding village – families talking, babies crying, livestock, street dogs and eager roosters.
As I arrive at the maternity ward, I’m met by the soft moans of a young mother in labour. The maternity section of the hospital is small for all that’s achieved within it.
The first five-by-six-metre room has four hospital beds and two birthing beds, all of which are occupied. In one, a woman who has given birth an hour earlier, lays on her side, eyes closed, resting with her newborn vigorously sucking away at her breast.
Next to another bed, is the woman I could hear as I entered, leaning against the wall, moaning softly, hands rubbing up and down her thighs. She wants to push but is being urged to wait until her cervix is fully dilated – it’s common for traditional birth attendants and family to encourage women here to push before they are fully dilated – thinking it will speed up the process – however it causes swelling, obstruction and trauma.
In the corner, two pregnant women have been newly diagnosed with malaria. They lay on the two narrow ‘delivery’ beds separated only by a burgundy synthetic curtain offering very little privacy. The two remaining beds are occupied by women recovering from malaria.
Through a wide doorway is a second room of similar size. It contains seven postnatal beds, occupied by women who gave birth over the previous three days, and a table for the midwife station.
Most of the floors are covered with woven mats where female family members – mothers, sisters and grandmothers – are curled up asleep.
The sleeping family members slowly wake and roll the mats away; most moving outside to make tea and porridge on small open fires. The cleaner nudges the last of them awake, forcing them outside so she can sweep and mop the floor.
After greeting the midwife on duty, Miriam* and the traditional birth attendant (who assists the midwife) Howa*, I ask what they’d like me to do.
Howa is from the local Mabanese community; most of the professional midwives are from Juba and can’t speak the local language. So, while Howa’s not literate and can’t give out medications or document vital signs, she can translate and provide insight into cultural preferences and practices. This arrangement mostly works well; however, sadly, there are times when there are differences in management opinions on issues like early pushing and infection prevention techniques between the professional midwife and the traditional birth attendants.
Documentation is also a constant challenge, particularly on busy days when traditional birth attendants are unable to record any interventions they conduct. This is slowly improving as we train staff and local people to become professional midwives.
Miriam explains there are three women recovering from emergency caesarian sections and four women post ‘normal birth’ that she has not had a chance to asses since late the night before. Following Miriam’s direction, I begin my patient rounds – taking vital signs and conducting postnatal checks while she distributes the morning medications.
As a referral hospital for a population of more than 200,000, the maternity unit is usually busy caring for women recovering from difficult births and caesarians.
I ask Miriam about the progress of Khadija* who is on ‘day one’ following emergency surgery. Khadija* lives in Sudan and crossed over the border near Maban. After being in labour for three days, Khadija’s family decided to seek medical help. It’s the rainy season and without a hospital in their region, Khaidja and her family had to travel through dangerous floodwaters and shin-deep mud to reach Maban.
By the time Khadija arrived in our hospital her uterus had ruptured. In surgery, Khadija’s dead baby – her sixth and the second to die – was removed and her uterus repaired. Khadija had a brief moment to see and hold her son before he was given to family members to take home to bury. Though Khadija is recovering well from her surgery,
I also ask Miriam about the progress of Aisha*, the woman leaning against the wall labouring. I’m told Aisha’s cervix has dilated five centimetres and the fetal heartbeat is ‘good’, but I’m encouraging the midwives to be more specific with their handovers. I watch Aisha’s family members now sitting on the bed with her, feeding her sips of thin porridge, clucking and whispering in acknowledgement of the pain their ‘daughter’ is experiencing.
Firstly, I check the women who were post-caesarian section.
Joanna* had a caesarian after a prolonged obstructed labour. The surgery saved her life, that of her baby and prevented her from developing an obstetric fistula (an internal injury that leaves women incontinent, humiliated and often cut off from her community).
Grace* in the next bed also had surgery for a prolonged obstructed labour but sadly her baby, which had been severely distressed when arriving at the hospital died soon after the caesarian. I am humbled by the strength of these women in the face of such loss and having to share a room with other women and their newborns.
In the next bed, Rebecca* is sleeping with her baby nestled against her breast. Rebecca is a refugee from Sudan, living in a large camp just outside Bunj town ... the main town in Maban county. There are approximately 150,000 refugees living in four camps surrounding Bunj.
When Rebecca’s labour had not progressed as she expected (it was prolonged compared to her previous births) she made her way to a primary health centre in the camp and was referred to our hospital.
On arrival, the day before, we found Rebecca’s baby had a healthy heartbeat and was managing well. Although the baby was breech, the position was still favourable for a vaginal birth.
One of my roles in Maban is to encourage staff to consider caesarian sections only when it’s absolutely needed. In the past, when an ambulance arrived referring a woman with an obstetric emergency our maternity staff would automatically prepare the woman for a caesarian. But over the last 18 months, by employing and mentoring more qualified midwives, building their skills to assess, support and manage women in labour, we have been able to lower the caesarian section rate and improve health care.
Medically, it’s recommended that women stop having babies after three or four caesarians. But many women here ignore this recommendation for cultural reasons. In the last year, we have seen several women arrive with a uterine rupture, who have previously had a caesarian and then tried to birth back in their village. With transient populations such as refugees and nomadic people we are unable to guarantee that a woman will have the level of care required for her next birth and so it is important not to leave her with a scarred uterus from a clinically unnecessary caesarian.
Right now though, as is our tradition every morning, I slowly walk into one of the waiting areas and gather with the rest of the hospital staff. Together we say prayers, read passages from the Bible and sing songs in Arabic and Mabanese. Once we’re done, I quickly return to the maternity unit.
Midwives Suzy* and Joyce* come in for the day shift. They receive a handover from Miriam. Suzy and Joyce will work with two traditional birth attendants and will be managing inpatients, birthing, pregnant women coming in as outpatients and antenatal checks.
It doesn’t take long before a LandCruiser arrives from one of the refugee camps. A traditional birth attendant carries in two small bundles of wet, blood-soaked cloth. Unwrapping them, we find premature twins – one boy and one girl, each weighing less than a kilogram. Their tired mother, Sara*, is brought in and helped onto the bed.
Placing the twins under an overhead warmer, we begin to assess and resuscitate them. Only one oxygen concentrator is working, so we quickly apply it to the stronger of the twins. Using an ‘ambu’ bag we gently try to resuscitate the other.
Sadly, today, both babies are very cold and not getting enough oxygen. I hold little hope for the smaller, male twin. I place him on his mother’s chest and explain his condition to her. There is nothing more we can do; but Sara can keep him warm and comfortable. The little boy lives for only another 15 minutes and is then taken away by family members.
In the meantime, the little girl is starting to breathe a little better, but her chance of survival is still poor. I place the baby girl on Sara’s chest with the oxygen still connected and explain that we’re trying to create a similar environment to that inside her uterus – one where her baby is warm, can listen to her breathing and heartbeat, and smell and taste her too.
When I have a moment, I ask Miriam how Aisha is doing (the woman who was in labour when I arrived). Part of my role is to encourage the midwives to regularly monitor the women and their unborn babies while they progress through labour and birth. It’s a foundation of midwifery care and enables us to make more informed decisions throughout the birthing process and pick up issues as they arise instead of working in a state of crisis management.
Suzy one of the traditional birth attendants and I juggle inpatients, outpatients, restocking and cleaning the maternity’s main working areas. We also accompany a doctor doing a morning round, reviewing the inpatients and seeing any outpatients the midwives have referred for a second opinion Joyce and the second traditional birth attendant have moved to another room to commence the antenatal clinic.
In the birthing area, Aisha begins to push. The women in her family urging her on. Suzy asks her to stop – her cervix still isn’t fully dilated and if she continues she may end up with severe swelling and trauma.
Johar ‘signs’ the consent form with her fingerprint. (Like most women in her community, Johar hasn’t gone to school and is unable to sign her name.)
As I pull on a fresh pair of gloves, another car arrives from one of the outlying camps. Johar* is assisted to the birthing area and the young midwife from the health centre explains that she thinks the baby is in a breech position.
The baby’s heart rate is fast, and she wants to push. But when I examine Johar I discover her baby is not in a breech position. It’s in a position called a ‘face presentation’, with the neck of the baby is fully extended. It’s more common in women who’ve had many pregnancies and is the third one I have seen this year. I can clearly feel the baby’s nose, mouth and eye sockets.
It’s not possible to birth the baby normally and so we quickly prepare Johar for the operating theatre. Johar is reluctant to have a caesarian section since she’s always been able to birth ‘normally’ before. But she and her relatives finally agree and Johar ‘signs’ the consent form with her fingerprint. (Like most women in her community, Johar hasn’t gone to school and is unable to sign her name.)
Meanwhile, Aisha has birthed her baby – a daughter. Both grandmothers are hovering around, wanting to take the baby. In this culture, grandmothers take the new baby away from the mother, mostly out of concern for the mother’s health and her need to rest. But it can make initiating breastfeeding difficult. Helping families understand the importance of ‘skin-to-skin’ contact is a work in progress. Suzy explains why it’s important for the baby to stay on Aisha’s chest and asks the grandmother to not take the baby but to support Aisha by holding her new baby on her chest.
I leave the maternity unit in the late afternoon to join some staff (from Samaritan’s Purse, the humanitarian organisation I work for) who are meeting with other non-government organisations who run primary health centres in the area. We gather in the administration office of the hospital – a basic brick building with a large table and thankfully two wall fans. We are reviewing the referral system from the primary health centres to the hospital, particularly for obstetric emergencies, and discussing how we might improve it.
Since I only travel to Maban from Juba once or twice a month, I want to make the most of my time here. I try to spread my time across the staff working the day and night shifts. As is the case today, I often don’t stop for a break until the evening when I make my way back to the base, once again accompanied by a guard from the hospital.
When I do walk back before dark I enjoy meeting the children playing along the way and greeting groups of women returning to their homes usually carrying 50-litre jerry cans of water and bundles of firewood on their heads – often with a baby wrapped and tied to their back.
Dinner has been brought out in big pots and set out in the dining room. It’s one of only a few brick buildings in the compound and was built as a ‘strong room’ – it is the place that the staff run to when there is a security incident and need to take shelter and go into ‘lockdown’.
Today it’s a place to relax and talk about the day – some of the staff talk about the food distribution they conducted in one of the refugee camps; others talk about who is the latest to come down with malaria, while others are glued to the latest Nigerian soap on the TV.
Dinner is a mixture of traditional Southern Sudanese and East African dishes. The meals comprise of stews made of chopped leafy greens often flavoured with locally made peanut butter, stews with chunks of beef or lamb, beans and a few choices of carbohydrates such as fried banana, ugali (a glue-like starch made from Cassava flour), bread or kissera – which is a thin savoury pancake.
I take my time as I check on each of the women and newborns I met during the day. There is a lovely comradery among the women. They are from different countries and communities, and they have so little, yet they help each other with what they have.
Following dinner, I walk back to the hospital to provide cover while the midwife on duty has her dinner. I take my time as I check on each of the women and newborns I met during the day. There is a lovely comradery among the women. They are from different countries and communities, and they have so little, yet they help each other with what they have. There are a couple of grandmothers gently massaging flaxseed oil over their newborn grandchildren as is the custom, while another has brought in a stick of incense. I inhale the sweet scent of sandalwood, a favourite fragrance in this part of the world, as I make my rounds.
After the midwife returns from her dinner, I go back to the compound. The shower block does not have a roof and so I take a shower under the stars. Back in my tent, I quickly hop under my mosquito net. If the mobile phone service is good at this time I talk or message one of our four children and talk to my husband Mark who is based in Juba. After writing a few emails and reading, I enjoy drifting off to sleep to the sounds of the village and the rains falling on my tent.
*Names changed for confidentiality
Annette Bennett graduated from UTS in 2015 with a Master of Midwifery (Honours). She is currently the Maternal Advisor to Samaritan’s Purse – a humanitarian non-governmental organisation working in South Sudan.
Annette is also the winner of the 2019 UTS Alumni Award for Excellence - Faculty of Health, learn more about 2019 Alumni Awards.