Implementation outcomes of a community-based maternal and newborn care model in rural South Sudan: an implementation research study
This implementation research study demonstrates that while the International Rescue Committee's community-based maternal and newborn care model in rural South Sudan achieved high acceptability and adoption through trusted local health workers, its long-term sustainability and effectiveness are currently hindered by structural challenges including excessive worker workload, documentation difficulties for low-literate staff, and incomplete institutional ownership.
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In the vast, rural landscapes of South Sudan, where dirt roads turn to rivers during the rainy season and health clinics are often days away by foot, a mother's journey to give birth is fraught with peril. The country faces some of the highest rates of maternal and newborn death in the world, driven not just by a lack of medicine, but by the sheer difficulty of reaching the people who need it most. For decades, global health experts have known that bringing care directly to a family's doorstep can save lives, a concept known as community-based care. However, knowing that a model works in theory is different from understanding how it functions when the ground is muddy, the roads are flooded, and the people delivering the care are often volunteers with their own struggles. The question is not just whether these community health workers can deliver a package of life-saving tools, but whether the system built around them can survive the weight of the work, the gaps in funding, and the complex realities of a society where trust is earned daily and resources are scarce.
To answer these questions, a team of researchers and aid workers from the International Rescue Committee set out to test a specific plan in the Aweil East County of South Sudan. They implemented a program called the Community-Based Maternal and Newborn Care model, which relied on local volunteers known as Boma Health Workers. These workers, chosen by their own neighbors, were tasked with visiting pregnant women and new mothers in their homes up to nine times. During these visits, they provided counseling on nutrition and safety, and handed out essential medicines like iron tablets to prevent anemia, malaria treatments, and a specific drug called misoprostol to prevent dangerous bleeding after birth. The goal was to see if this approach could be trusted by the community, if the workers could actually do the job without burning out, and if the government could eventually take over the system to keep it running forever.
The study, which ran for eighteen months, revealed a story of remarkable human resilience mixed with deep structural cracks. On the side of success, the program found that the community embraced the workers with open arms. Because these health workers were selected by their own villages, they carried a moral authority that outsiders could not. Mothers trusted them, and the workers felt a deep sense of duty to serve, even when the work was exhausting. The model proved highly appropriate for the environment; bringing care to the home bypassed the impassable roads and the fear of traveling long distances with a newborn. The data showed that when women received these visits, they were far more likely to adopt life-saving practices, such as keeping their babies warm, cleaning the umbilical cord properly, and starting breastfeeding immediately. The workers, many of whom had limited ability to read or write, managed to deliver a complex set of instructions and medicines, proving that low literacy does not have to be a barrier to high-quality care.
However, the path to success was paved with significant challenges that threaten the program's future. The most pressing issue was the sheer workload placed on the health workers. They were expected to walk long distances to reach scattered families, often without reliable transport, and then spend hours filling out detailed paper records. While the researchers adapted these forms to be easier to read and fill out, the act of documentation remained the most time-consuming and difficult part of the job. The workers were paid a small extra incentive for this new work, but they and their families felt this was not enough to compensate for the time they spent away from their own farms and livelihoods. The researchers noted that while the workers stayed in the program because of their sense of duty, this reliance on moral obligation rather than fair financial support is a fragile foundation that could crumble over time.
Another layer of complexity emerged around the distribution of misoprostol, the drug used to stop bleeding. At the national level, some government officials were hesitant to give this medicine to community workers because of its association with abortion, a sensitive and legally restricted topic in South Sudan. This created a tension where the people closest to the mothers—the community workers and the families themselves—saw the drug as a life-saving tool, while distant policymakers viewed it with suspicion. Despite this friction, the community workers managed to distribute the drug safely, and the data showed that the fear of misuse was largely unfounded, with only one isolated instance of incorrect use recorded. This divergence in perspective highlights how political concerns can sometimes clash with the urgent, practical needs of a community.
The study also shed light on the difference between giving people a medicine and changing their daily habits. The workers found that handing out a pill was much easier than convincing a mother to change a long-held tradition, such as how she cares for her newborn's cord or how she feeds her baby. While the community quickly accepted the physical items, the behavioral changes took longer to take root and required constant reinforcement. Furthermore, the researchers found that the program was not fully integrated into the government's regular health system. While government officials attended meetings and helped design the plan, the money for medicines and the management of the supply chain still relied heavily on outside donors. When a national policy shift changed the number of workers supported per village, it caused confusion and feelings of unfairness among the workers, exposing how vulnerable the program is to decisions made far away from the villages it serves.
Ultimately, the research concludes that this model works and can save lives, but it is currently too fragile to last on its own. The community has shown it is ready and willing to accept this care, and the local workers have proven they are capable of delivering it. Yet, for the program to continue growing and to truly protect mothers and newborns in the long term, the system needs to address the heavy burden on the workers, find a way to fairly compensate them, and ensure that the government takes full ownership of the supply chain and the funding. Without these structural changes, the success of the past eighteen months risks fading away, leaving the most vulnerable families once again without a safety net in a landscape where the road to a hospital is often too long to walk.
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