A pregnant woman arrived at the Kuajok Hospital in South Sudan in desperate need of a cesarean section. Joseph Deng, a midwife on duty that night, says he knew the situation was urgent: Without the procedure, neither she nor the twins she carried would survive.
Yet, the woman's husband refused to visit the hospital and sign off on the surgical delivery of the babies, saying his wife had delivered the two previous babies naturally and shouldn't have a problem. The doctor refused to operate, Mr. Deng said, because South Sudan's policy makes it mandatory for women to have the consent of their closest relative before undergoing any major treatment or care.
The woman asked Mr. Deng to send her home because she didn't want to die in the hospital. Instead, Mr. Deng says he pleaded with the doctor to operate and allow the woman to consent on her own. When he finally agreed, the woman had two healthy babies.
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This woman is one of the many patients that Mr. Deng has advocated and cared for in South Sudan, which has one of the highest maternal, newborn and child mortality rates in the world. According to the United Nations Population Fund, the country had 789 maternal deaths per 100,000 live births in 2015. In 2010, the number was 876. The maternal death rate is higher only in Sierra Leone, Central African Republic, Chad and Nigeria. According to the State of the World's Midwifery, a report from the UN Population Fund, less than 10 per cent of women receive the services they need to give birth safely. These numbers pushed Mr. Deng, he said, to become a midwife and ensure women get better access and care.
South Sudan had only eight midwives in 2011, when the country gained independence. Through the UN Population Fund's midwifery training project, the number of midwives increased to more than 400 in 2016 – Mr. Deng was one of the graduates in 2014. The project's largest donor is Canada, which has provided $86-million since 2012 and a $50-million multiyear grant that started in 2015.
Mr. Deng spoke to The Globe and Mail at the Metro Convention Centre in Toronto, where he attended the International Confederation of Midwives conference on behalf of the UN Population Fund.
What does a typical day look like for you?
It's usually very busy, to the extent that you will be getting extremely tired but must persist regardless of time. Sometimes you can be caring for more than 50 patients a day. Sometimes, I work alone in my ward and when there is an emergency, I have to handle it on my own while caring for many patients at once. A lot of the time, there are more patients than expected and less staff. For instance, sometimes in a ward with 12 beds, you will have only one person caring for them all – normally there should be at least three to four health professionals there.
It's very difficult seeing someone in a critical condition and not being able to help, either because there are no resources or because the family is not co-operating – you end up feeling really bad. But we must empathize with our patients, clients and our communities because if we don't, then who will? We have to bear the situation and have hope that more people will be trained and join us in this field, working to do the best for our communities.
What kind of impact do you find you're having on your community?
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Just the simple fact that a mother and a newborn could go back home in a safe and healthy condition is a remarkable impact. Counselling women about prenatal health care and having a successful pregnancy, as well as providing postpartum support also helps lighten the economic burden on families. If a mother can successfully breastfeed her baby, she feels free because breast milk has no cost. I remember one family visited the hospital after the mother delivered the baby at home. They were having trouble breastfeeding and were seeking the help of a midwife. When the baby finally was able to, we saw the mother was so happy and she went home feeling so much lighter.
How is your experience as a male midwife different from that of your female colleagues?
Being a male midwife in our society some years back was not easy because many people couldn't accept it. Before modern midwifery in South Sudan, there were traditional birth attendants – usually an older female family member – who would conduct deliveries at home. It was never something a male would be doing. But currently there are not any challenges I have encountered.
If you have communicated well with a patient, then there are no challenges. It's always important to remember that a client must be treated with respect, dignity and privacy. When you remember this, the patient becomes more at ease.
When you meet a new patient, what are their first impressions of you as a male midwife?
Sometimes patients come to the hospital only during times when they know who is working there. Some midwives are known in the community so patients will come to see them. But some people come in not knowing who will provide them with care and you can see they come with doubt, but depending on your approach they can quickly be at ease.
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Do you see more men becoming midwives and why do you think that is or isn't the case?
I see a lot of men becoming midwives in South Sudan. To be a midwife, it all depends on your commitment because you can be a female midwife and you may not be committed but a male midwife might be so passionate about his work – devoting his time to give holistic care to the patients. I became a midwife after I realized the skills I had as a nurse were not enough for midwifery practice and there was such a need in our hospital. It was very difficult when a mother would come bleeding and you wouldn't have the skills to help her.
What role does the international community (including Canada) have to play in the current maternal health situation in South Sudan?
We still really require the support of Canada, Sweden and other willing bodies because reproductive health is not in the minds of our people. People see birth as something that is a normal process and fail to understand that there are chances of complications and mothers need to be cared for immediately. We need more professional midwives to care for our country's reproductive health needs. We are calling for the international community to intervene by training personnel, by providing supplies and establishing facilities, as well as contributing to the improvement of the country's infrastructure – such as roads, which are vital for people trying to access health facilities. There are many areas in the country where people don't have access to midwives or a nearby health facility. Some mothers travel long distances to get to the nearest facility and upon arriving, there may not be enough health professionals to care for them.
What are your hopes for maternal health in South Sudan?
Most of our colleagues and most of our citizens have lost hope but I have a hope that South Sudan will realize its potential and will find stability and peace. As some health science colleges close down because of insecurity, many people are feeling discouraged, but we are still holding on to hope.
This interview has been edited and condensed.