Understanding barriers to increasing skilled birth attendance (SBA) in south Sudan

Background: In South Sudan, 87% of women deliver at home without a skilled birth attendant present. South Sudan has the highest maternal mortality reported in the world at 2054/100,000 live births and skilled birth attendance is essential to reducing these rates. Methodology: The USAID-funded Sudan Health Transformation Project, phase II (SHTP II), worked to raise the the percentage of skilled birth attendance over three years but met with limited success. To identify the barriers facing women, SHTP II held focus group discussions with mothers, pregnant women and TBAs in 13 counties across all 10 states of South Sudan. Results: Cultural barriers such as family traditions not allowed in facilities (not bathing newborns, not allowing the mother to walk around), preference for a squatting position, male and family pressures to deliver at home, distrust of facilities, and familaiarity with TBAs all contibuted to low use of SBAs. Distance and logistical barriers were the main constraints. Conclusions: Factors that affect SBA at deliveries can be addressed through community education, improved facilities, peer educators and transport to facilities. Using the Leadership Development Progam at local facitilies, we supported mother's groups and facility staff to overcome these barriers. Selected facilities showed upwards of a seven fold increase in the use of SBAs in a 6 month period by addressing the challenges identified. While increasing the use of SBAs remains a significant challenge in South Sudan, the SHTP II study results and successful application of the challenge model shows that progress can be made.