The road to the College of Physicians and Surgeons, part of the University of Juba, is strewn with puddles and trenches, the result of recent heavy rains. As ­Galario navigates these obstacles, he sings to himself a song he made up during his Diploma in Midwifery, to help him remember active management of childbirth. He completed his midwifery studies in English, even though this is his third language. Coming up with songs helped him to remember English terminology and phonetics he was less familiar with. He passes by a row of street stalls where students and faculty can grab a quick bite to eat—the outdoor, local equivalent of a food court. Stall owners, almost in perfect unison, dab the sweat off their faces with handkerchiefs. Eggs sizzle and splutter on their grills as they prepare Rolexes—fried omelette wrapped in chapati bread. The smell makes Galario’s stomach growl but he continues on, not wanting to be late.

He enters the bustling courtyard of the College, giving a respectful nod as he passes his former supervisor from the clinic he used to work at. Walking by a line of beige buildings with orange-tiled roofs, he approaches the classroom number he wrote down weeks ago, when he first registered.

It’s the very first day of class for Galario and his peers enrolled in a new diploma program offered at the College; a Diploma in Health Personnel Education. There is an energy rippling through the classroom, an energy characteristic of all first days of school, from grade school to university. Nervousness, excitement, friends and colleagues catching up. The chatter continues despite the power outage, a frequent occurrence even in the most urban areas of South Sudan. The College does have a generator but, when there’s no fuel available, it doesn’t do much good. Without any fans or air conditioning, the heat covers the classroom like a blanket.

Despite this setback, one of the lead instructors; Dr. Beverly O’Brien, calls the class to order. Dr. O’Brien holds a doctorate degree in nursing and is an expert in maternal health issues, particularly maternal health disparities within global settings. After retiring from the University of Alberta, she is now offering up her skills as a contributor to the SMS-II project. She is one among several experts that CAM has provided to support the implementation of this course. She explains how this course; “Research Proposal Development,” will equip them with a deeper understanding of research, from its purpose to quantitative and qualitative research designs to data collection instruments. Having these skills will allow them to undertake their own research project in the next semester, where they can explore and critically analyze some of the main issues affecting health care within South Sudan. As Dr. O’Brien explains; “For me, research is generating evidence to provide the best care that you can provide to the people who need the health care. You need evidence to do that. [And] no amount of good evidence is useful if it’s not appropriate for the culture you’re serving.” 

The course is part of the Diploma Program in Health Personnel Education, led by South Sudan’s Ministry of Health, where the goal is to train established health professionals in South Sudan on how to teach others to become qualified health professionals. Lucia Buyanza, a nurse-midwife by training and the Head of Programme at the College of Physicians and Surgeons, says: “Education is the cornerstone for socio-economic progress. […] The training of health professionals to be teachers is a very big milestone. This dream come true started from far.” She vividly remembers discussions in 2014 around the future of Health Training Institutes. Even then, it was understood that there was a critical need to have properly trained teachers. She was reassured when, three years later, South Sudan’s Ministry of Health passed a decree, announcing the need for a South Sudanese educational curriculum focused on training teachers within the health sciences; “This was the best gift for the South Sudanese. We want our future generation to embrace teaching as a rewarding career.”

Future is a new concept for many South Sudanese. After decades of war, education in South Sudan faces numerous challenges. Schools were attacked or destroyed; students abducted. Poverty and forced displacement have prevented millions from attaining any form of higher education.UNESCO (2014). Education for All review report 2015: Republic of South Sudan, available at: https://bit.ly/2UTu3fB Global Partnership for Education & UNICEF (2018). Global Initiative on Out of School Children: South Sudan Country Study, available at: https://bit.ly/39h4MEq There is currently a severe shortage of health professionals, with an estimated one physician available per 65,574 people and one midwife per 39,088 people.Global Health Workforce Alliance (2020). South Sudan – Health Workforce Density, available at: https://bit.ly/3l6Twx3 Maternal and neonatal mortality rates are one of the highest in the world, with only 19% of births attended by a skilled professional.World Health Organization (May 2018). Country Cooperation Strategy at a Glance – South Sudan, available at:  https://bit.ly/3m19Q3r There is a dire need to increase the number of physicians, nurses, and midwives in this country. The number and the quality of them. But a strong, competent health workforce depends on the quality of their training and education. Students in medicine, nursing, and midwifery will do best when they’re taught by teachers who are not only experts in clinical practice but in pedagogy, curriculum development, teaching methods, and learning styles.

The ping of her cell phone wakes Andrea up. She groggily rolls over, picks up her phone. 4am. Squinting her eyes from the glare of the screen, she sees it’s a text message from Jemilia, a midwife in South Sudan. 10am Jemilia’s time.”Birth this morning in maternity ward. Newborn anomaly. Can anyone help recognize this defect?” Andrea scrolls further down, to an image of the newborn; so tiny, wrapped in a kitenge (a colorfully patterned local fabric). Right below the baby’s face, protruding from the right neck and jaw area, is a circular mass, almost the size of the baby’s head.

Mostly awake now, Andrea scans her memories from when she did her BSc in midwifery at Laurentian University. Though she has been working as a midwife in Halifax for three years now, birth anomalies are few and far between. Cystic hygroma, maybe? She writes a reply, explaining how cystic hygromas are fluid-filled sacs, caused by a blockage in the lymphatic system. They’re usually found in the neck and head area. She’s hoping some of the other midwives on the text message chain will soon chime in, either to confirm her guess or offer another possibility.

Almost immediately, she receives a response: “Can it be drained? Or operated on?” She replies with an honest answer, even though she knows it’s probably not what her friend in South Sudan wants to hear; “I’m not sure how to treat it. Baby would need to be seen by a specialist.” The conversation continues, as they brainstorm how to find a relevant specialist in South Sudan, where there is already a shortage of doctors. Another South Sudanese midwife, from the capital of Juba, chimes in—she knows a doctor, not a specialist, but who trained in London. Maybe they have connections they could seek advice from?

The conversation shifts focus on how to best emotionally support the parents. In a country where 60 out of 87 counties have inadequate health services,World Health Organization (May 2018). Country Cooperation Strategy at a Glance—South Sudan, available at: https://bit.ly/35V01P1having a newborn with unusual complications is particularly stressful and overwhelming. In 2011, at the time of independence, there were only eight skilled midwives in the whole country.ReliefWeb (11 June 2019). From 8 to 700 midwives in 8 years, South Sudan is making huge strides in saving mothers’ lives, with UNFPA support, available at: https://bit.ly/3767RoaPost-­independence, after years of conflict, there is a need to strengthen the skills and capacity of South Sudan’s health workforce, including midwives.

This is where the Peer to Peer program comes in—an innovative approach to mentorship, the Peer to Peer program for SMS-II provides the opportunity for peer mentorship between Canadian and South Sudanese midwives. These midwives communicate via Facebook, WhatsApp, Skype and e-mail, offering each other mutually beneficial learning and support. Shannon Kaupp, a midwife and the coordinator of the Peer to Peer program, explains; “The Peer to Peer program is based on the idea of sharing knowledge. As midwives we share clinical information, cases, evidence, and research. We share experiences both good and bad. With international programs it is easy to focus on the differences between the two regions, but I feel that the Peer to Peer program highlights the similarities of midwifery in different parts of the world.” She elaborates: “The fundamentals of midwifery are the same—empowering women, supporting reproductive justice, facilitating safe birth and newborn care, and advocating for gender equity.” Just like Andrea’s story shows, “It is the local challenges that are different and one of the biggest ones is access to resources, including human resources. It is too often assumed that health care workers who practice in high resource countries have greater skills than those in lower resource areas. The Peer to Peer program has highlighted that this is not the case. The South Sudanese midwives are dealing with cases daily that I may see only once or twice in my career in Canada.”

Through the Peer to Peer program, midwives in South Sudan have increased access to that precious human capital and midwives in Canada can learn about and be better prepared for cases that are much rarer in the Canadian context. The peers choose topics that are of interest and relevance to them, posting in group chats. Canadian and South Sudanese midwives are also “paired,” so that they can have more in-depth one on one conversations with each other. Newsletters are also sent out regularly to all peers, summarizing some of the discussions and providing additional resources. These midwives have shared details not just about their clinical work but also about their career goals and personal lives, discussing a range of topics from pre-­eclampsia, family planning and contraception use, prolonged labour, uterine rupture, gestational diabetes to supporting clients who have experienced sexual assault, leadership opportunities for midwives, and how to balance work with family life.

Andrea gets out of bed, unable to go back to sleep. As she puts a pot of coffee on, she starts humming a song she learned from her South Sudanese peers. She doesn’t know the words, but she remembers the melody. Last year, she traveled to South Sudan to help establish a national mentorship program within the country, sharing her experiences and lessons from the Peer to Peer program. Every morning, they would start the workshop in prayer and song. It honestly energized her and woke her up more than any caffeinated beverage could. She thinks that was the point—­midwives in South Sudan face numerous challenges every day, from low pay to disrespect. Even when they have the right knowledge and skills, they sometimes lack the needed equipment and technology to perform their jobs. Something to boost their spirits at the start of each day and to keep them going is important. Exchanges like the one from this morning make her wish she was back in South Sudan, so she could give Jemilia an understanding hug. Instead, she pours herself a coffee and sits down in front of her computer, sending out e-mails to some of the specialists in Canada that she knows through her work. Andrea hopes one of them may be able to provide advice on how to best proceed. She knows that both of her Canadian and South Sudanese peers are doing the same, exploring every option and resource that they have. As she goes through her day, she continues to hum the song, each note reinforcing the bond she shares with her South Sudanese peers, even though they are miles apart. 

I heard the midwives singing. 

That morning, as the roosters crowed, as the boda-bodas bleated, as the dust covered everyone weaving their way through Juba, I heard the sound of singing drift through the air. It was from the street, or a nearby church, or part of my dreaming. The sound was so faint, I almost didn’t believe it was real. The wind carries the songs in waves. Sometimes louder, sometimes softer, like the gentle music of low tide. One voice was joined by others in beautiful harmony. A single voice amplified by the strength of others. I heard the midwives singing, and it was inspiring.

It’s May 2019. We are waiting outside of the offices of the South Sudan Nurses and Midwives Association (SSNAMA) for Doris Lamunu, Project Coordinator of SSNAMA. Lamunu walks purposefully towards us, with two midwives, warmly saying hello to a group of students heading to class. Her face lights up as she greets us and welcomes back Canadian midwife Bev Langlois, who was last here in 2018. Langlois, a Canadian midwife and consultant for the SMS-II project, is helping to prepare trainings in Continuing Professional Development for SSNAMA and its members. Langlois marvels at the SSNAMA offices.”It was not like this when I was here the first time” she smiles.”This was just an empty space before.”

In 2010, a professional association to represent midwives and advocate for midwifery in South Sudan was little more than a hope, an ambition. Ten years later, SSNAMA is an established and functional association, complete with an office space, WiFi, and paid staff. Lamunu proudly gives us a tour. There is a main office, a board room, and a learning center / discussion room with computers and a projector where meetings, webinars, and trainings take place. The conference table is so long and large, it boggles the mind as to how the pieces managed to get through such a narrow door.

As she shows us around, she is answering text messages on one phone and a call on another. Lamunu is busy. She is always busy, seemingly everywhere at once. Lamunu has always had a passion for public health and, like many in South Sudan, a desire to support her community. After working as a clinical officer in a government institution and a health trainer at a Health Science Institution, she is now devoting her time to growing SSNAMA from its humble beginnings.  

In the last year, SSNAMA has advocated for better wages and working conditions, created reusable menstrual kits to ensure girls don’t have to miss school due to their periods and, in the wake of COVID-19, has launched information campaigns on the radio and in public spaces. They are also making over 3,000 face masks to distribute.”All of this is a great achievement towards sustainability and a nurse- and midwife-run enterprise” says Lamunu proudly. Repent Khamis, the chairperson of SSNAMA, agrees: “I am really proud to work with SSNAMA because, during my time, we were able to be accepted as a full member into the [International Confederation of Midwives]. CAM has supported the training of our members in leadership and has helped push midwifery to gain recognition in South Sudan.”

Since the start of the project, CAM, under the leadership of UNFPA and South Sudan’s Ministry of Health, has been supporting SSNAMA in strengthening their association. Association Strengthening is one of the main pillars (the other two being education and regulation) of not only the Canadian Association of Midwives, but the International Confederation of Midwives.”Having a strong midwifery association is paramount to the success of the profession in any given state, province or country,” explains CAM Executive Director Tonia Occhionero. “Associations are best placed to advocate to elected policy and decision makers, to advocate for midwives and their clients, and to promote the credibility and value of the profession to the general public.” She continues, “They can also advocate for better working conditions and pay. Midwifery is still, with a few exceptions internationally, a female dominated profession. Even though more men are midwives now […] the profession has been historically marginalized as a result the gender inequity that exists across cultures.”

Creating a strong midwifery association capable of advocating for its members in South Sudan was particularly challenging. In midwifery, like in music, relationships are everything. Between midwife and client. Midwife to midwife. Midwife to their association. And midwives to other health professionals, whether its nurses, doctors, or administrators. A country’s health system is an orchestra, a choir, with all members needing to be in sync, in harmony. But, due to years of conflict, the health system in South Sudan has become fragmented.

This is where CAM members like Bev Langlois and president Alix Bacon come in. Langlois and Bacon have spent the past few years traveling to Juba to help with capacity building for SSNAMA. They have given workshops in leadership and governance, membership engagement, strategic planning, and team building, as well as helped SSNAMA liaise with other key stakeholders including South Sudan’s Ministry of Health, UNFPA, and AMREF. Langlois reflects on a particularly impactful workshop: “The workshop covered written and verbal clinical communication. When we are reviewing a particular topic—we always try to use real examples—we were discussing what to do when you are faced with a situation where you are looking for a certain end result and you can’t get the person you need to help you. We discussed general strategies and then I asked the group if they had an example we could use. A woman in the front row raised her arm to share her story. She had a difficult case and needed the assistance of the doctor. She couldn’t get the doctor to do what she wanted and was frustrated. Arms popped up throughout the room when asked if anyone had ideas on how to handle a situation with interprofessional conflict. Great ideas were shared and support for the woman who shared was also given. My arms were filled with goosebumps.”

But the learning wasn’t one-sided. Bacon explains: “I learned a great deal about care provision in low resource settings. I also had lots of opportunity to reflect on the evolution of midwifery associations in Canada, the trajectory, and what we can learn from South Sudan when regulating new jurisdictions (P.E.I and Yukon, soon I hope), how we can engage members in rural remote settings, and how we ensure equitable opportunities for members to participate in and benefit from capacity building.” Langlois agrees; “South Sudanese people also know how to energize a meeting and have fun with governance work, and that’s definitely something I’d like to incorporate more of here […] The singing and clapping at the workshops—before the day starts, during breaks, at the end of the day—oh it made my heart sing!” 

With continued support to and reinforcement of midwifery and nursing in South Sudan, health care professionals will be able to save the lives of women and babies, earn decent wages, and have opportunities to further their studies or professional careers.”If we can do that… when we do that… it will change the country,” says Agnes Juan Silver, Secretary General of SSNAMA. And that would be music to everyone’s ears. Singing is nothing new. Midwives have always had songs. But if more people join in, together they can change the lives of mothers and babies around the world.