Population-based survey of antenatal care, skilled birth attendance, and essential newborn care in rural Aweil East County, Northern Bahr El Ghazal, South Sudan

In the quiet, dust-choked villages of rural South Sudan, the first hours of a newborn's life are a fragile threshold between survival and tragedy. For decades, global health experts have known that three simple actions can tip the scales: a mother receiving regular checkups before birth, a skilled professional present when the baby arrives, and immediate, gentle care for the infant right after delivery. These are not complex medical miracles but fundamental steps—checking blood pressure, cutting the cord with a clean blade, keeping the baby warm against the mother's skin, and starting breastfeeding within an hour. Yet in places torn by conflict and poverty, these steps often remain out of reach. When families cannot reach a clinic, or when cultural habits clash with medical advice, the risk of death rises sharply. Understanding exactly where these gaps exist, and why families make the choices they do, is the only way to build a path toward safer births.

This is the story of a recent journey into Aweil East County, a rural stretch of Northern Bahr El Ghazal State in South Sudan. Researchers from the International Rescue Committee and their partners walked through four remote villages, speaking with 338 women who had given birth in the year before the survey. They were looking for the truth behind the numbers: how many mothers were actually getting the care they needed, and what was stopping them from getting more. The findings reveal a landscape of hope mixed with deep, stubborn barriers. While most mothers are eager to start their journey to a healthy birth, the road often ends before they reach the finish line.

The story begins with the pregnancy itself. When the researchers asked the women if they had visited a health facility to check on their baby, the answer was overwhelmingly positive. Nearly all of them, about 92 percent, had made at least one trip to a clinic. This is a sign of hope, suggesting that the desire for care is alive and well in these communities. However, the story changes when we look at how far that journey went. Only about 43 percent of these women completed the recommended four visits. Many started the path but stopped short, perhaps due to distance, cost, or the feeling that one visit was enough. The visits that did happen were often basic; while many women had their blood pressure checked, fewer received the full suite of tests, and many left without the iron supplements or malaria prevention medicines they needed.

The most critical moment, the birth itself, tells a starker story. Despite the fact that nearly two-thirds of the women said they planned to deliver in a health facility, the reality on the ground was very different. Only 17 percent of the babies were born inside a clinic. The vast majority, 83 percent, were born at home. In these home births, the person helping was almost always a traditional birth attendant, a respected community member who has learned the art of delivery through generations of practice, rather than a doctor or nurse. Skilled medical help was present for only 17 percent of all births. This gap between what women intend to do and what they actually do is the central challenge. The researchers found that when women had to walk for two hours or more to reach a clinic, they were far less likely to make the trip, even if they wanted to. The distance was a wall that intention could not climb.

Once the baby was born, the care practices varied widely. On a positive note, most mothers, about 72 percent, put their baby to the breast within the first hour of life. This early start is a powerful shield against infection and hunger. Yet, other vital practices were missing. Less than a quarter of the mothers held their newborn skin-to-skin immediately after birth, a technique that keeps the baby warm and calm. Similarly, only about 38 percent of the babies received what experts call "clean cord care," meaning the cord was cut with a new or boiled blade and nothing harmful was applied to the stump. In many cases, traditional substances like oil, ash, or even lizard waste were used, which can introduce dangerous infections. The timing of the baby's first bath also mattered; while many waited until the next day, nearly 28 percent bathed their newborns within hours of birth, washing away the protective layer of vernix and risking a drop in body temperature.

The researchers also looked at what made a difference in these choices. They found that money played a huge role. Women from wealthier households were much more likely to complete their prenatal visits and to delay bathing their babies, likely because they had better access to transport and supplies. Education mattered too; mothers who had attended school were more likely to practice skin-to-skin contact and to keep their babies warm. Perhaps most surprisingly, the researchers found that women who had previously used family planning methods were more likely to wrap their newborns warmly and start breastfeeding early. This suggests that once a woman has a positive experience with the health system, she is more likely to trust it with her newborn's care.

The picture that emerges is not one of failure, but of a system strained by distance and tradition. The women in these villages are not ignoring medical advice; they are navigating a world where the clinic is a day's walk away, where skilled staff are scarce, and where the wisdom of the village elder is the only guide available. The study shows that simply building more clinics is not enough if the roads to them are too long and the cost too high. Instead, the path forward lies in meeting families where they are. The researchers suggest that training local community health workers to bring care directly to the villages, engaging husbands in the decision-making process, and creating better ways to transport women to clinics in emergencies could bridge the gap. The data proves that when the barriers are lowered, the desire for safe, skilled care is already there, waiting to be reached.