Have Songs

Why Midwives?

Why Midwives?

At the Canadian Association of Midwives (CAM), we believe that reproductive and sexual health is not only a right in and of itself but is fundamental in gaining broader equality around the world. Without access to quality reproductive health care, women, girls and pregnant people risk illnesses and infections, pregnancy complications, and even death, which prevent them from going to school, establishing a career, and participating fully in society. Without access to family planning, or the ability to make decisions about their own bodies, they lose their right to self-determination and lack control over the course of their future. And, without access to the right information, people are kept in the dark about facts, options, and services that can drastically improve the quality of their lives.

So, why midwives? Because midwives play an essential role in promoting health, reproductive rights, and in reducing maternal and infant morbidity and mortality. Midwives believe in respectful and dignified care, informed choice, and evidence-based practices. Midwives not only work with clients but with entire families and communities. Midwives help to empower others.

Since 2008, CAM has been working in partnership with midwifery associations and partner organizations in the Global South to support the availability and quality of reproductive, maternal, and newborn health care. Our work has focused on increasing the recognition of midwives, improving the ability of midwives to provide quality reproductive and sexual health care, and strengthening the capacity of local midwifery associations to manage projects and engage in advocacy work. Our approach is rooted in collaborative partnerships and mutual learning, based on relationships of trust, transparency, and shared values. In line with Canada’s Feminist International Development Policy, we believe in a feminist approach that works to raise the participation and decision-making of girls and women and in supporting local women’s organizations that advance sexual and reproductive rights.

Through Midwives Always Have Songs, CAM wants to share with you the valuable work that midwives, both Canadian and South Sudanese, have accomplished together in South Sudan. We hope to show you the positive change that can come from investing in midwives, to create a world where everyone and their newborn will have access to quality health care. Just like songs, midwives have the ability to move, inspire, and uplift.

South Sudan is a relatively small country—geographically smaller than the state of Texas, with a population of about 11 million.Central Intelligence Agency (10 September 2020). The World Factbook: South Sudan, available at: https://bit.ly/39fDWgh

But it is an incredibly diverse country with a rich, complex history. It is home to over 60 different indigenous ethnic groups, each with their own language or dialect.UNDP South Sudan (n.d.). About South Su­dan, available at: https://bit.ly/36ZTrWN Long before it became its own country, during pre-colonial and colonial times, the area of southern Sudan was used by the northern region as a recruiting ground for slaves. Decades of differential policies and exclusionary practices between the north and the south resulted in a southern Sudan that was far less developed. These problems were both rooted in—and exacerbated by—ethnic, cultural, and religious differences—a predominantly Arab and Muslim North, versus a largely African and Christian South.Deng, F. (1995). War of Visions: Conflict of Identities in the Sudan. Brookings Institution Press: Washington D.C.

For years, the South fought for its right to self-determination and autonomy. In 2011, Dreams became reality and the Republic of South Sudan became an independent country. As the world’s newest country though, South Sudan faces numerous challenges. Years of war have impacted the country’s infrastructure and health and education systems. There is a severe shortage of trained professionals, a lack of policies and regulatory frameworks, and many people’s basic needs remain unmet.Downie, R. (November 2012). The State of Public Health in South Sudan, Report for the CSIS Global Health Policy Center. As a result, South Sudan has some of the worst maternal and neonatal health indicators in the world.World Health Organization (May 2018). Country Cooperation Strategy at a Glance – South Sudan, available at: https://bit.ly/3q5x2jE It is estimated that one in seven South Sudanese women will die in pregnancy or childbirth, often because of infections, haemorrhaging, or obstructed births.Small Arms Survey (2012). Sudan Human Security Baseline Assessment, available at: https://bit.ly/3nMAuh5 The majority of these deaths could be prevented if women were to deliver in a health facility with a skilled birth attendant. However, according to UNICEF, only 12% of births take place in a health facilityUNICEF (n.d.) South Sudan – Key Demographic Indicators, available at : https://bit.ly/3kWFEoP and only 19% of births attended by a skilled birth attendantWorld Health Organization (May 2018). Country Cooperation Strategy at a Glance – South Sudan, available at: https://bit.ly/3q5x2jE

Since 2016, the Canadian Association of Midwives (CAM) has been proud to be involved in the Strengthening Midwifery Services in South Sudan Phase II Project (SMS-II) as an implementing partner of the United Nations Population Fund (UNFPA) and South Sudan’s Ministry of Health. This project is a continuation of the first phase of Strengthening Midwifery Services in South Sudan Project (March 2012 to December 2015) funded by Global Affairs Canada. Some highlights of Phase I included support to 242 students (59 nurses and 183 midwives) in completing their education, scholarships to 13 doctors and 20 clinical officers for further education in different specialisations including obstetrics and gynaecology, equipping four Health Sciences Institutes with upgraded laboratories and libraries, and the establishment of a national nursing and midwifery association with 10 State Chapters. 

Funded by Global Affairs Ca­nada and the Government of Sweden, SMS-II builds off the successes from Phase I by continuing to improve health services and reduce maternal and neonatal mortality within South Sudan. The SMS-II project takes a holistic approach by addressing three distinct key areas: 1) nursing and midwifery education, by ensuring nursing and midwifery students receive quality, evidence-based education; 2) maternal, neonatal and child health services, by strengthening the knowledge and skills of practicing midwives, nurses, clinical officers, and doctors; and 3) creating an enabling environment by facilitating gender-sensitive midwifery and obstetrics practices in South Sudan. SMS-II is a $50 million effort that has spanned five years and involved the hard work and commitment of countless individuals from UNFPA, South Sudan’s Ministry of Health, South Sudan’s health workforce, AMREF, International Medical Corps (IMC), the South Sudan Nurses and Midwives Association, the Society of Obstetrics and Gynecology of Canada, and CAM. Although CAM’s role in the project is small, we are humbled to be able to share our expertise in midwifery and association strengthening and to work in collaboration with some of the biggest stakeholders within international development and global health. 

In less than ten years, South Sudan has made enormous strides in taking care of its women and children. At independence, its maternal mortality was the worst in the world at an estimated 2,054 deaths per 100,000 live births, and there were only 8 qualified midwives for the entire country. Today, its maternal mortality is down to an estimated 789 per 100,000 and there are over 800 qualified midwives working throughout the 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/33c63sD As a young country, both in terms of when it was founded and the age of its population (median age is about 19 yearsCentral Intelligence Agency (10 September 2020). The World Factbook: South Sudan, available at: https://bit.ly/39fDWgh), South Sudan has shown that it is capable of harnessing its energy and hope for a transformative future. 

Voice Choice Change: The Lives of Midwives

Education in South Sudan

The Need for Quality Health Education

“This was the best gift for the South Sudanese. We want our future generation to ­embrace teaching as a rewarding career.”

Education in South Sudan

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.

The Need for Quality Health Education

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.”

“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.

It’s ten months later. The students have completed their coursework and are writing their final research reports. Galario now knows that the song he came up with, about active management of childbirth, is actually an example of a mnemonic device, an effective memory technique he can teach his future students. The energy is a bit different from that first day – they have had to adapt to numerous struggles, including COVID-19. Dr. O’Brien has had to fly back home to Canada, the College is closed, and some aspects of the research course have moved online. This is no small feat, considering most students don’t have electricity or Wi-Fi at home, let alone their own personal laptop. Still, they remain committed and motivated, finding ways to remain enrolled. Galario uses his smartphone to type out his research report and to e-mail his instructors with questions about his data analysis. He decided to do his research on young girls’ attitudes towards early marriage and pregnancy, an issue he holds close to his heart after watching his own sisters and cousins married off, sometimes as young as 13 years. Other students have chosen to focus on issues such as: medical students’ perceptions of abortion; the challenges to waste management within healthcare facilities; and understanding why nurses choose to leave the profession early. Dr. O’Brien explains how “The students are all aware that they have one of the worst, the highest, rates of maternal mortality in the world. They understand that. And they want to do something about it […] I could give them the tools to develop that knowledge, but I couldn’t tell them what it was that they needed to research. They had to tell me what was important.”

In just a few weeks, Galario will be part of the first cohort to graduate from the Diploma in Health Personnel Education. He and his peers will graduate with the skills and knowledge needed to train the next generation of health workers in South Sudan, with the hope that every person will one day be able to access the health care that they need.  Dr. O’Brien admits it wasn’t always smooth sailing. Working in South Sudan poses many challenges, but she’s very proud of her students; “They all had such compelling research questions, or problems, that they wanted to solve.” She hopes they’ve walked away with a newfound appreciation for research and that they can use their skills to overcome some of South Sudan’s most pressing health issues; “With one study, you can tackle one little piece of this, with another study you can tackle another piece […] The more people that are working on a problem, the more likely you are to make progress. You don’t have to find THE answer, but you can contribute to the answer.”

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    1. Conflict

    Years of conflict have affected the education system in South Sudan—schools closed down or destroyedAbol Kuyok, K. (2017). Higher Education in South Sudan: Living with Challenges, International Higher Education, 89: 16-18.—universities had their campuses located in Khartoum, in Sudan, during the war—now need to re-establish higher education within South Sudan.Moyo, N. (2019). Strengthening Midwifery Services in South Sudan Phase II: Learning Needs Assessment, Research Report for Canadian Association of Midwives submitted 17 September 2019.

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    2. Poverty

    80% of population lives
    under 1$ a day.Global Health Workforce Alliance (2020). South Sudan—Health Workforce Density, available at: https://bit.ly/2IYG7cR

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    3. Geography

    83% of population lives
    in rural areas.Global Health Workforce Alliance (2020). South Sudan—Health Workforce Density, available at: https://bit.ly/2IYG7cR

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    4. Gender

    Females significantly less likely to go to school than males, especially as they get older—gender norms require they stay at home, take care of children, cook & clean.UNESCO (2014). Education for All review report 2015: Republic of South Sudan, available at: https://bit.ly/2UQBTXw52% of girls married off before they reach 18 years of age.Abol Kuyok, K. (28 August 2017). How South Sudan’s universities have survived civil war and independence, The Conversation, available at: https://bit.ly/3pWvVT1


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    5. Shortage in EducationUNDP South Sudan (n.d.). About South Sudan, available at: https://bit.ly/3nSBtMS

    There are only about 20,000 students enrolled in higher education within South Sudan. At independence, South Sudan lost much of its academic staff who were from northern Sudan. Less than 1% of academic staff in South Sudan hold a PhD.

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    6. Implications for Health Ed.Bul Ajak, B.E. (2019) The factors contributing to low school enrollment of females in South Sudan, Archives Community Medicine & Public Health, 5(1): 29-34.

    A survey of Health Training Institutes found that 40% are teaching without any formal education in teaching, and all of those with teaching qualifications are located within the capital city; Juba.Over half of all educators and tutors surveyed indicated they had a lack of knowledge and skills in curriculum development and implementation, education administration, and policy development.

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    7. Impacts on Health Services

    Only 1 physician per 65,574 individuals and 1 midwife per 39,088 individuals.Girls Not Brides (n.d.) South Sudan Child Marriage Rates, available at: https://bit.ly/2J8Zbp2


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    8. Health Training Institutes

    Four Health Training Institutes supported through this program to strengthen their education programs. Creation of Tutor Manual, to standardize and guide educators and tutors training the next generation of midwives.

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    9. Diploma Programs

    Creation of 2 diploma programs:
    Diploma in Midwifery and Diploma in Health Personnel Education

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    10. Program Support

    4 Canadian education and midwifery consultants supported the development and implementation of these diploma programs

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    11. Tuitions

    Both diploma programs are free, costs covered through the project.


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    12. Enrollment

    Tutor manual distributed to approximately 100 educators and tutors. 265 students have graduated and 169 are currently enrolled in Diploma in Midwifery. 21 students enrolled in Diploma in Health Personnel Education.

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    13. In the Classroom

    Students have taken courses on subjects such as: Teaching and Learning Principles, Curriculum Development, Teaching and Learning Resources, Research Proposal and Data Analysis. Through the program, they have conducted research on these important health and social issues within South Sudan: Challenges to manage waste management within healthcare facilities, Medical students’ perceptions of abortion, Why nurses leave their profession early, Young girls’ attitudes toward early marriage and pregnancy.

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    14. Next Generation

    Next year, they will be qualified to train the next generation of health workers, including physicians, nurses, and midwives.

A smooth
of music and
hope rises
The midwives
always have a
Excerpt from “We are the headline. The front line. The last line of defense.” by Karline Wilson-Mitchell, RM

The Clinical Procedures Manual

CAM, in collaboration with UNFPA and SSNAMA, developed a Clinical Procedures Manual for all health facilities offering maternity care services in South Sudan. The goal of this manual is to ensure and standardize the quality of maternal health care offered across the country. Accompanying the manual are visually engaging clinic job aids, in both English and Juba Arabic, that can be posted within health facilities for easy access and consultation, to guide health care providers during non-emergency and emergency situations. Some of the topics covered in the manual and job aids include breech births, neonatal resuscitation, pre-eclampsia and eclampsia, respectful maternity care, and family planning. These tools are one further step in helping to reduce maternal and neonatal mortality in South Sudan.

In 2019, 111 Nurses and midwives graduated with diplomas in nursing and midwifery (34% already employed) and 221 students 221 (36 nurses and 185 midwives) remain in training. This brings to 572 (443 midwives and129 nurses) graduated under direct support from UNFPA since 2012. At independence, in 2011, South Sudan had only 8 qualified midwives.

Peer to Peer program

“The fundamentals of midwifery are the same—empowering women, supporting reproductive justice, facilitating safe birth and newborn care, and advocating for gender equity.”

An innovative approach to mentorship

“The South Sudanese midwives are dealing with cases daily that I may see only once or twice in my career in Canada.”

Peer to Peer program

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.

“The fundamentals of midwifery are the same—empowering women, supporting reproductive justice, facilitating safe birth and newborn care, and advocating for gender equity.”

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.

An innovative approach to mentorship

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.”

“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. 


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    1. Infrastructure to rebuild

    Years of conflict have devastated both the country’s health and education infrastructure, with clinics, health facilities, and schools being forced to close.UNESCO (2014). Education for All review report 2015: Republic of South Sudan, available at: https://bit.ly/3m1erTf Downie, R. (November 2012). The State of Public Health in South Sudan, Report for the CSIS Global Health Policy Center.

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    2. Fear

    Fear of undignified, disrespectful care has been found to be a major factor influencing women’s decision to not seek out maternal health care.Kane, S., et al. (2018). Too afraid to go: fears of dignity violations as reasons for non-use of maternal health services in South Sudan, BMC Reproductive Health, 15(51): 11 pages.


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    3. Childbirth

    789 mothers per 100,000 die in childbirth.World Health Organization (May 2018). Country Cooperation Strategy at a Glance – South Sudan, available at: https://bit.ly/2USlOQS

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    4. Access to health services

    60 out of 87 counties have inadequate or no health services at allWorld Health Organization (May 2018). Country Cooperation Strategy at a Glance – South Sudan, available at: https://bit.ly/2USlOQS. Only 25% of the population in South Sudan has regular access to health services.Alsheikh, M. (2015). South Sudan National Strategic Plan for Human Resources for Health 2011-2015, The Republic of South Sudan Ministry of Health.

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    5. Maternal and neonatal care

    Maternal and neonatal healthcare coverage is extremely low. On average, less than 20% of mothers with newborns receive adequate maternal and neonatal health care.Valadez, J. (2015). Finding the gap: revealing local disparities in coverage of maternal, newborn and child health services in South Sudan using lot quality assurance sampling, Tropical Medicine & International Health, 20(12): 1711-1721.

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    6. Antenatal services

    A survey of 156 health facilities in South Sudan found that 40% do not offer any antenatal services.Berendes, S., et al. (2014). Assessing the quality of care in a new nation: South Sudan’s first national health facility assessment, Tropical Medicine and International Health, 19(10): 1237-1248.


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    7. Skills

    Increase the skill set of physicians and surgeons with regards to maternal health care and emergency obstetrics.

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    8. Professional development

    Offer continued professional development opportunities to South Sudanese midwives, to increase their ability to provide quality maternal and neonatal care.

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    9. Support system

    Create a support system for in-service midwives, to increase their ability to provide quality maternal and neonatal care (the peer to peer program).

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    10. Increase the number of skilled trained midwives


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    11. Physician trainings

    25 medical instructors were trained on how to teach physician & surgical students on Emergency Surgical Skills for General Surgery and Obstetrics. 28 physician & surgical students trained on Emergency Surgical Skills for General Surgery and Obstetrics.

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    12. Peer-to-peer exchanges

    26 South Sudanese midwives reached through Peer to Peer. Over 1,060 exchanges between Canadian and South Sudanese midwives since 2017. Some of the topics covered: vasectomies, malaria treatment, Hepatitis B, HIV/AIDS, hypertension, retainted placenta, shoulder dystocia, breech deliveries, sexual violence, menstruation difficulties, preeclampsia, obstructed labour.

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    13. Number of midwives trained

    30 midwives were trained in Respectful Maternity Care (RMC) and 34 midwives in Infection Prevention & Control (IPAC).

Waves of rhythm
moving like
the Indian
Having families.
Loving our work.
We always have songs.
Excerpt from “The Midwives Always Have Songs” by Karline Wilson-Mitchell, RM

Respectful Maternity Care Training

Through the Peer-to-Peer program, South Sudanese nurses and midwives have expressed topics and issues they would like to receive Continuous Professional Development training on, including Respectful Maternity Care (RMC). To meet these demands, CAM organized and delivered a three-day workshop on RMC, attended by 30 nurses and midwives. RMC is rooted in the concept of human rights, with the belief that every girl and woman has the right to access respectful, dignified care. RMC encompasses the right to health, the right to privacy, the right to autonomous decision-making over one’s body and life, and the right to freedom from discrimination. CAM and its partners, including UNFPA and SSNAMA, believe that RMC is fundamental in reducing maternal and neonatal mortality. Many studies have shown that a ­barrier to seeking maternal health care, including delivering within a health facility, is fear of or past experiences of disrespectful, even abusive, care. Quality care should not only include clinical knowledge and skills but also respectful care that preserves the rights and dignity of girls and women.

Association Strengthening

South Sudan Nurses and Midwives Association

“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.”

Association Strengthening

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.”

South Sudan Nurses and Midwives Association

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.”

“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.”

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.


  1. Info3-EyeChart
    1. Visibility and resources

    Lack of visibility and respect of midwives in the eyes of the public. Lack of resources, including office space, materials, and financial resources to advocate for the profession of midwifery.

  2. Info3-piggybank
    2. Membership fees

    Due to high rates of poverty and many midwives not being paid, membership fees not a realistic source of income for a midwifery association in South Sudan.

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    3. Capacity

    In order for midwives to be able to effectively run associations, capacity-building is a necessity.

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    4. Low member engagement


  1. Info3-ChessPiece
    5. Strategize

    Develop strategies with SSNAMA in association strengthening, advocacy and promotion of excellence.

  2. Info3-Scissors
    6. Resources and workshops

    Develop learning resources and workshops for SSNAMA staff and board members in leadership & governance, advocacy, membership engagement, strategic planning, and resource mobilization.

  3. Info3-handshake
    7. Relationships

    Strengthen alliances and part­nerships with key stakeholders within the health sector.

  4. Info3-heartsupport
    8. Campaigns

    Increase visibility and awareness of midwives and their role within public health through campaigns, events, and promotional materials.


  1. Info3-Student
    9. Professional development

    Increase value of being an association member through continued professional development opportunities.

  2. Info3-Money
    10. Income

    Develop income-generating opportunities for SSNAMA, to increase financial sustainability of association.

  3. Info3-Group
    11. Student chapter

    Launch a Student Chapter for the association.


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    12. Resources

    Development of materials including the Labour Pains comic book series and animated short film, recruitment brochures, and association website, to explain and advocate for the profession of midwifery within South Sudan.
    Creation of a learning center with computers, TV, and a resource library at SSNAMA offices.

  2. 13. Stable funding sources

    In partnership with the Vocational Skills Development Organization of South Sudan, establishing 7 income-generating activities for SSNAMA across the country, including pharmacies and restaurants. Submission of 5 funding proposals by SSNAMA to increase their programming reach and financial stability.

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    14. Advocacy

    Production of the documentary “Voice, Choice, Change” to showcase the lives and roles of two South Sudanese and two Canadian midwives, seen by approximately 10,000 people.

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    15. Next generation

    1,368 qualified nurses and midwives joined the association between 2016–2020. 9 continued professional development workshops organized by SSNAMA staff for its members, covering topics such as: clinical communication skills, adolescent sexual and reproductive health and rights, COVID-19 infection prevention and control, and respectful maternity care.

I became a
midwife to
people and
give them
a chance to be heard
at this time of
their life.
Jenn Nguyen, RM Canada

Peace on earth begins with birth

“This project changed my life. On a tour of Juba Hospital the midwives shared with me the harrowing story of how they provided care during the conflict in 2016 whilst bullets flew through the hospital. I asked them what motivated them to keep providing care under such dangerous conditions, and they told me that they hoped they children they caught would bring peace to South Sudan. There is a Jeannine Parvati Baker Quote: ‘Peace on earth begins with birth.’ It wasn’t until I was in Juba that I really understood the full potential of that saying, and what a midwife’s role in achieving it truly is. …I learned about the complex history of South Sudan, from repetitive colonization through the war for independence and the subsequent civil wars.

“I learned about the benefits to society as a whole that come from professional associations, as civil society actors, supporting and sustaining rapid increases in human resources for health, particularly in fragile contexts I learned about the unique challenges in working in fragile and conflict zones where it becomes apparent how artificial the northern aid distinction between humanitarian and development projects are and particularly, about the lived realities of health professional associations in fragile states.”

Alixandra Bacon, RM, CAM President 20–22

Labour Pains Animated Film

Based on the comic book series of the same name, the animated film valorizes the experiences of a young midwife who must save the life of a young mother in an overwhelmed medical clinic. The characters are voiced by South Sudanese supermodel and activist Mari Malek and South Sudanese activist/actor Elizabeth Arjok.

Dr. Ronald Lett, Founder & Director of Curriculum Development, Canadian Network for International Surgery

“Midwifery is crucial to vaginal delivery and that midwifery skills are available to women in South Sudan. However, also crucial is having a surgical dimension as back up.”

Nester Moyo, RNM/MCH and Consultant for SMS-II

“Educators are the custodians of any profession. Midwifery is one of the critical means by which any government is going to achieve Universal Health Coverage. Because of the undeniable need for well-educated midwives and nurses in South Sudan, given the high maternal and newborn mortality rates, having strong tutors and educators in the Health Science Institutes of South Sudan is paramount. It is one of the key means with which maternal and newborn mortality and morbidity can be reduced.”

Lucia Buyanza, RNM, Head of Department for the Health Personnel Education Diploma, Juba College of Nursing and Midwifery

“Education is the cornerstone for socio-economic progress. To be trained by a qualified teacher is a life long engagement and leaves a lasting impression. To set up the school was a challenging journey with very complex scenarios. However I remained optimistic that the program will be there also for others to learn… my dream always was that of seeing the students graduate and teach others.”

Tutor Manual

CAM, in consultation with UNFPA, South Sudanese tutors, and Canadian consultants in midwifery education and curriculum development, has developed a tutor manual to guide all midwifery tutors in South Sudan on how and what to teach students. Esther Willms, a Canadian midwife who helped work on the manual, explains: “The goal is to provide a standard approach in midwifery education, based on evidence-based principles of teaching and learning, to ensure that all midwifery students across South Sudan receive the same curriculum and quality of education. Tutors are supported in delivering a wide variety of courses including anatomy and physiology, gynecology, life saving skills, psychology, nutrition, and sexual and reproductive rights and health.

Emergency Obstetric and Newborn Care Training

CAM has also partnered with the Canadian Network for International Surgery (CNIS) to develop and implement a 6-month training on emergency obstetrics and surgery for medical instructors, physicians, and associate clinicians. This training covers topics including pregnancy, intrapartum and postpartum complications; neonatal conditions; family planning; and traumatic and non-traumatic emergency surgeries. Since the start of the SMS-II project, 53 people have completed this training and are now equipped with life-saving skills for both mothers and newborns.

Akat Gabriel, MD, Surgical resident Juba Teaching Hospital

“A woman came to us with a ruptured uterus. She travelled a very, very long way to Juba. Very difficult and very dangerous. If we had had the resources and trained people in the facility, we could have saved her baby. Thankfully, we were able to save her.”

Basak Ardalani, RM

Basak was one of the original members of the SMS-II team. She was the driving force behind the Clinical Procedures Manual. Her desire to see a uniform curriculum to maternal health care was realized in 2019. Basak sadly passed away suddenly in 2017. We greatly miss her wisdom and remarkable energy. Her work lives on in the pages of the manual, and many lives will be saved because of her efforts.

E-Resource Library

To compliment the Tutor Manual, CAM has also created a resource library for midwifery tutors and students. A major barrier to education in South Sudan is the lack of internet, or the lack of access to or funds to purchase books. CAM has put together USB keys containing dozens of open-source resources and materials, from articles to videos and infographics, for tutors and students to consult and enrich their learning.

Dr. Jan Christilaw, Director of Women’s Health, Canadian Network for International Surgery

“Those of us in medicine know that when you train midwives, you have to train back ups as needed. We developed over 12 structured courses in a curriculum for medical officers, to enhance surgical and obstetrical skills, and improving timely access to underserved regions of the country. They can do this. To come up with a curriculum that after 6 months of training, health practitioners could be proficient in both obstetrics and general surgery… It’s a very ambitious project.”

Esther Willms, Registered Midwife and Consultant for SMS-II

“Midwives educate in all their interactions with parents to be and their families. They can empower them to take seriously their health, to become community change agents and to work at systems that threaten the health and well being of the child’s health and the birthing parent. Every interaction is an opportunity to educate and empower and be and advocate.”

Dr. Kirsty Bourret, PhD, MSc

“[…] was really excited to come to Juba to do the research development capacity workshop because fundamentally it’s something I’m interested in, and I really believe that everyone should have equal access to the capacity to develop their own research. Collaborating with communities and really working to problem solve within the context that people are working in, is really the way we can understand the issues that care providers and families are facing within those contexts and how we can work to create programs and policies that are actually applicable to them.”

Emmanuel Trépanier, SMS II Gender Advisor

“… While clinical skills transfer and association strengthening are central to the advancement of sexual and reproductive health and rights, an understanding of gender dynamics in health facilities, educational institutions and government is also essential to promote gender equality and women’s empowerment. My role is to help Canadian midwives involved in SMS II to consider social dimensions in their work, whether they might be involved in developing educational material, trainings, advocacy support, etc. One aspect of our gender work I am particularly proud of is the numerous ways in which we have contributed to amplify the voice of South Sudanese midwives. In many ways, the Beatrice and Regina characters from the Labour Pains comic book series embody the power of midwives but also showcase their vulnerability, needs and interests. Their stories come from South Sudanese midwives themselves.”

Scovia Naluma, National United Nations Volunteer (NUNV) Midwife, South Sudan featured in the film Voice Choice Change

“My life as a midwife in South Sudan is challenging. But because of training and education, I can save the lives of mothers and babies. The technology in Canada and South Sudan is different, but the knowledge is the same. We use our senses. Our minds, to analyze. I had finished a labour with a young mother. She developed a PPH and bled a lot. I saw her young daughter, and the new baby… and I said this mother should not die. She will not die. I stopped the bleeding. But she was still not good. There was no blood for transfusion. I donated my blood to save her. She sees me in the community. She is healthy. She is alive.”

Dr. Illona Hale, MD, Clinical Assistant Professor, University of British Columbia and co-creator of Emergency Skills Training Manual

“We created a curriculum to train medical officers who are already in practice so they can deal with some of the emergencies when they are out in the field. They are already good teachers. I have full confidence they will take this training and run with it.”

Dr. Michael Madding, Director General Training and Professional development

“Lessons from the success of the UNFPA project are helping in expansion of midwifery training to 16 other Health Sciences Institutions.”

Shannon Kaupp, Registered Midwife and Co-Coordinator for SMS-II Peer to Peer Project

“I learned that the fundamentals of midwifery are the same everywhere – empowering women, supporting reproductive justice, facilitating safe birth and newborn care, and advocating for gender equity. 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… Hearing the story of a South Sudanese midwife threatened at gunpoint because of a stillbirth is something that I am unlikely to experience in Canada. The professionalism and quick thinking he showed saved his own life and the lives of his colleagues.”

Sarilyn Zimmerman, RM

“My time in South Sudan confirmed once again the shared heart and soul of midwifery. As midwives we know the joys and sorrows, the frustrations and struggles, the close calls, the hard times and good times and the miraculous moment of birth. The common strength of midwives also exists in the need and desire to learn and improve not only our clinical skills but human relationships, to treat each other, the community, other health professionals, people, women and families with dignity and respect. “There are disheartening disparities but midwives can together change and support each other and move maternal and newborn health forward to a safer and healthier place through our shared work, our humanity and our care.”

IPAC Training

Another request for Continuous Professional Development that emerged through the Peer-to-Peer program was training on Infection Prevention and Control (IPAC). CAM delivered three-day workshops on IPAC, which outlines the importance, steps and actions to be taken by midwives, nurses and other healthcare providers to reduce the risk of infection among patients in the world’s newest country. Over 30 midwives, nurses, and administrators from all over South Sudan attended. “If I have the chance to attend several trainings like this and would have the ability to meet different people, with different ideas of how to influence others, it will bring a big change… and that’s what we hope for,” Julius Ladius said.

Bev Langlois, Registered Midwife & Technical Expert for SMS-II

“The Respectful Maternity Care workshop impacted me greatly. This was a workshop that brought out a lot of emotion. One exercise was to have everyone anonymously write on a piece of paper what is preventing them from implementing changes at their place of work and pass the papers to the front of the room. The responses were read aloud, included fear of being hurt, beaten or killed. It gave me an even deeper appreciation for the work the nurses and midwives are doing in South Sudan.”

Deborah Bonser, Registered Midwife, Consultant & Co-Coordinator of SMS-II Peer to Peer Program

“SSNAMA identified a need and requested the IPAC workshop as one of the topics they would like to provide for continuing their professional development. Infection prevention (training) is, in fact, a worldwide need for healthcare providers. I would say it’s fantastic that SSNAMA managed to get midwives here from across the country. The group consisted of midwives doing maternal newborn care, nurses working in the operating theatre, and every other possible ward and situation.”

Research Capacity Building

The 10 day workshop led by Dr. Nsengimana Ferdinand and Dr. Beverly O’Brien was designed to explore some of the basics in research to support tutors who would share their knowledge with their institutions and places of work. The course objectives were to develop and acquire skills to put forth a research proposal; to help identify core problems and solutions to address the challenges facing the country; understanding and critiquing already published research, and methods of teaching research to undergraduate students.

Labour Pains Comic

A three-part comic book series designed as midwifery educational tools, public engagement pieces and midwifery recruitment materials. The comics valorize the real-life experiences of midwives, while offering both soft (conflict resolution) and hard skills (using a balloon tamponade procedure to stop a post-partum hemorrhage; neonatal resuscitation). Over 3000 comics are in circulation.

Dr. Alex Dimiti, Director General for Reproductive Health, MoH

“Quality of the trained Midwives has gone up from a historical position where midwives were certificate holders trained on the job. Training of nurses and midwives has provided for empowerment of this cadre of health workers and the image of the profession has greatly improved and became popular.”

Reusable Menstrual Kits

The South Sudan Nurses and Midwives Association (SSNAMA), with support from the Canadian Embassy’s Funding for Local Initiatives program have created a series of reusable menstrual kits to help keep girls from missing any school while they have their periods. Each kit contains three reusable/ washable pads, soap, and a washcloth. The kits are created in small sewing station at SSNAMA, with materials purchased from local suppliers. The kits are distributed to young women all over South Sudan.

Agnes Juan Silver, Secretary General SSNAMA

“There are many challenges. Even when we talk about basic hand-washing, sometimes there is not even adequate water, or even running water, let alone disinfectant or soap. We know that frequent hand-washing prevents infection, but the facilities do not provide adequate resources. Let alone PPE. Often we have to buy our own. So we (SSNAMA) must advocate for this.”

Karline Wilson-Mitchell, DNP, MSN, CNM, RM, RN & Consultant for SMS-II

“The courage of SSNAMA members blows me away! I’m reminded that many attendees had not been paid for months. Facilities, clinics, hospitals are government funded and the money that should be stocking medical supplies, salaries and medications keeps disappearing. They make do… and there are many ways to start an IV creatively… and they continue to be creative. The shifts can only be staffed sporadically, since these highly skilled professionals may need to supplement their income by selling in the market or providing a local catering service. But when they do come in to work, they give more than I ever thought it possible to give in service. Some have lost their lives on the walk home… ”

Continuous Professional Development

Continuous Professional Development (CPD) is central to ensuring that professionals remain competent and up-to-date on new evidence, procedures, and technology within their field. CAM has helped developed a series of CPD trainings and handbooks for nurses and midwives in South Sudan, to further their knowledge and skills. Topics include: Clinical Professional Development and Infection Prevention and Control (created by Deborah Bonser RM and Barbie Legett RN); Respectful Maternity Care (created by Barbie Legett RN, Bev Langlois, RM and Karline Wilson-Mitchell, PhD) and a handbook on Advocacy (created by Patrice Latka, RM).

Susanna Ku, Registered Midwife, featured in the film Voice Choice Change

“Every day we struggle to be recognized. We want to feel that the health system recognizes our work. We want to be respected for the work we do. But a lot of people misunderstand what a midwife does. A lot of people seem to think we are just in the bush, trying to make birth as natural as possible. And when people say as natural as possible, they mean that we are divorced from science and new technology. Midwifery has transformed. And it has transformed in a way to be part of the health system that really cares about not only a person as s number for statistical purposes, but as a person and their rights as a human being. A midwife is a health care provider who is a specialist in low risk pregnancy. We are experts in low risk pregnancies.”

Voice Choice Change—The Lives of Midwives

A 30 minute documentary about the ideas, motivations, challenges and successes of four midwives- two in South Sudan (Dora Kunda and Scovia Naluma) and two in Canada (Susanna Ku and Jen Nguyen). The film along with its accompanying 15 minute profiles of each midwife, has been seen by over 15k people in South Sudan and Canada, both in person and online. Based on the comic book series of the same name, the animated film valorizes the experiences of a young midwife who must save the life of a young mother in an overwhelmed medical clinic. The characters are voiced by South Sudanese supermodel and activist Mari Malek, as well as South Sudanese activist/actor Elizabeth Arjok.

Jen Nguyen, Registered Midwife, featured in the film Voice Choice Change

“People think we become midwives because we like cuddling babies… I became a midwife so I can support people and give them a chance to be heard at this time of their life.”

Doris Lamunu, Program Manager, SSNAMA

“One thing I’m proud of today in SSNAMA is the positive visibility among members, stakeholders and internationally… I would like to see more advanced midwifery practices, the current colleges offering bachelors and master’s program, CPD platform and quality leadership in midwifery. The directorate of nursing and midwifery having a director midwifery. Regulation fully functional to support the midwifery services in the country. Working with CAM has been exciting, and our well coordinated interactions despite such distance.”

Repent Khamis, Chairperson, SSNAMA

“The inspired, passion, knowledge and experience that CAM had in midwifery profession inspired me to value midwifery as a profession. CAM pushed midwifery to gain recognition in South Sudan. Hence more you people are seeking to join midwifery training. I am really proud to work with SSNAMA because during my time, we were able to be accepted as a full member in ICM and ICN is in progress.”

Alix Bacon, RM

“The governance load in a young association is incredibly heavy. Participation is voluntary, and it is a lot to ask of full time health care providers, who are also often parents and grandparents, who may not have been paid in months and have long commutes to work and often work side jobs to pay the bills, to volunteer their time.”

Kelly Chisholm

“What really struck a chord with this project was the support that it has through the UNFPA and Global Affairs Canada. This is a project that isn’t just going into a country and slapping a band-aid on a problem and walking away, this is something that has longevity, it has teeth and more importantly it has a level of sustainability which I’m hopeful will make a difference to the south Sudanese people.”

Dr. Bev O’Brien, PhD

The focus of O’Brien’s research program was to support and strengthen women who are experiencing challenges to their comfort, safety and well-being during pregnancy, birth and early motherhood. Dr. O’Brien’s past research includes coping with severe nausea and vomiting and other perinatal discomforts; more recent projects included an exploration of health disparities within global settings.

Dora Kunda, NUNV-Midwife, South Sudan featured in the film Voice Choice Change

“This is why I became a midwife. To save our dear mother’s lives.”

Dr. Janet Michael, Director for Nursing and Midwifery, Ministry of Health, South Sudan

“The numbers of trained midwives at health facilities have increased in line with the vision of ‘Scaling up of training—a midwife for every delivery.’”

Barbie Leggett, RM

It was a privilege to work with South Sudanese midwives and nurses. They were such committed professionals doing amazing work and it was humbling to hear their stories and everyday challenges. A memorable experience after the Respectful Maternity Care workshop, which was emotional and had a profound impact on all involved, was a visit to local hospitals and clinics and to see first hand the changes that had been implemented based on the recommendations from the workshop. It was such a rewarding experience as these changes would have a direct and positive impact on patient care and outcomes.

Kelly Chisholm

“The nurses and midwives of South Sudan are the guardians of the country’s future for generations to come. It was a privilege that I will be forever grateful for. The radical and extraordinary goals were the agenda and no amount of challenges could waver the faith of team.”

Ferdinand Nsengimana, PhD

I have been part of a team that educated nurses and midwives in South Sudan since 2012 up to 2019. While knowing that by mid 2019 there were close to 500 midwives who had qualified from different health sciences institutes in South Sudan compared to eight qualified midwives in 2012 was a reward to me, meeting some of the newly qualified midwives providing midwifery services in all 12 health facilities visited while collecting data for a research on the topic “Assessing the Quality of Integrated Reproductive and Maternal Health Services at the SMS II”  and hearing the men and women who benefited from these services expressing their happiness about the improvements they see was even more rewarding.

Cathy Ellis, RM

“…I was struck by the good work of the midwives in both types of facilities but especially at the Primary Health Care Centers. What I learned there was how they integrated the Community Midwives ( the Traditional birth Attendants) with the midwives on the maternity ward. They provided comfort, education and support. The trained midwives worked well with them and educated the families, took histories and managed complications. It was a very good partnership. I now share this model with my students in the global Maternal Infant Health Care course at UBC….a culturally safe way of caring for mothers in labour and birth and how traditional midwives are integrated into the health system.”

These midwives were brave. One night two men came into the clinic to rape them. They ran and hid in a small locked room and phoned for help. The manager of the health centre wanted to close it after 5 PM as it was not safe for the staff but the midwives did not agree. They felt the responsibility to care for the community during day and night for reproductive health needs. Instead, they enlisted police officers form the local police station to come at night and guard so that the maternity ward could stay open to care for the community birthing needs at night. That seemed to work well and the health care centre remained open at night.

The main objectives of the SMSII Project is to reinforce midwifery services in South Sudan through education, peer‑to‑peer training and association strengthening, in order to reduce maternal and infant mortality while providing support and resources to empower women in their reproductive rights and health.

SMS II is a United Nations Population Fund (UNFPA)‑led collaboration between: Canadian Association of Midwives (CAM), The South Sudanese Nurses and Midwives Association (SSNAMA) South Sudanese Ministry of Health (MOH) and other Health Science Institutions in South Sudan. It is funded by the governments of Canada and Sweden.

Pillar infographics © Bruno Feder; Dreamstime; Leo Reynolds/Flickr;
Creative Commons. Scrapbook photos courtesy of project staff. All others photos © Bruno Feder.

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