The continuum of care approach for MNCH includes integrated service delivery for mothers and children from pre-pregnancy to delivery, the immediate postnatal period, and childhood to reduce maternal, neonatal and child deaths and improve health . Gogrial West had significant institutional and social barriers to MNCH based on this approach.
Brief summary of findings
Barriers to MNCH were more than lack of access to focused ANC. Women in Gogrial West had minimal education and little desire for contraception which impact maternal health and mortality [11, 12]. ANC was largely non-existent and consisted of sick visits instead of focused ANC and clinical facilities with a dearth of appropriate skilled healthcare workers to administer ANC. Mosquito net use, although high for the area, still represented only a small proportion of households putting women and children at risk, and especially pregnant women at risk for malaria. Immunization status of both women and children was low. Exclusive breastfeeding rates of 5% put a significant number of newborns and infants at risk for diarrhea and death [13, 14]. The overall lack of knowledge of danger signs, low use of skilled attendance at birth and the preferred use of largely untrained TBAs put women and newborns at significant risk in Gogrial West and represented barriers to MNCH that given the current situation will be difficult to change [13, 14]. In addition, a dearth of facilities that meet basic or emergency obstetric (EmOC) care criteria, lack of transportation and access, especially during rainy season, for obstetric emergencies leave women at the hands of untrained birth attendants and delivery at home. The time and distance needed to fetch clean water, especially while pregnant and the overall lack of clean water will continue to hamper MNCH. Finally, the presence of systematic and accepted violence in the community, largely addressed to women and children due to negative social norms will continue to add to barriers to health for women, newborns and children.
Context of findings
Contraception as an effective primary prevention strategy decreases maternal mortality 44% and satisfying the unmet need for contraception another 29% . Nationally, 8% of overall women use contraception. Less than 1% (0.3%) of women in Warrap State use any method of contraception and less than 3% of men and women in our study used contraception [1, 3]. Barriers to the use of contraception included long held social norms,women’s inability to discuss these issues, and men’s control of contraception among their wives. The difficulty for women to access contraception will hamper improvements in MNCH .
Danger sign recognition
Nationally, only 4% of women could recognize newborn and obstetric danger signs  compared with our study population where 45.8% of women and 42.9% of men were able to recognize newborn danger signs and 49.6% of women and 53.4% of men were able to recognize obstetric danger signs. Given the use of community health workers in previous programs and the need for communities to care for themselves because of the lack of clinical facilities, it is likely the recognition of danger signs was, in part, due to education from CHWs. In addition, the strong need for parents to care for their children in a setting where health care facilities could not meet their needs may have played a part in awareness despite available care.
Focused ANC is essential to decrease newborn mortality [13, 14]. ANC (at least four visits) in Gogrial West was six percentage points lower than the national average (20.5 vs. 26%) . Skilled birth assistance was found to be more than 5 percentage points lower than the national average (4.6% vs. 10%) and 3 percentage points higher than Warrap State [1, 3], whereas globally, at least 61% of women receive at least four ANC visits . Within Sub-Saharan Africa, 50% of women have skilled attendants at delivery, 4.6% in this study, 8.5% for Warrap and 19% nationally [1, 3, 14]. Although non-use of ANC has been linked to the poor recognition of pregnancy danger signs in South Sudan , our study found close to half of women and men knew >3 pregnancy danger signs, which suggests in Gogrial West knowledge of these danger signs was not related to care-seeking. In Gogrial West, access and or use of ANC is not feasible given fees charged at the clinic level and the distance to clinics. The overall lack of roads, limited access to clinical facilities for a large portion of the year, no ANC at the clinic level, no skilled providers and no EmOC facilities will continue to hamper the use of ANC for women in Gogrial West and continue to put MNCH at risk.
Eight percent of newborns received postnatal care at any time, which is 5 percentage points higher, but still severely lacking than the average for Warrap State . Postnatal care data is not available for South Sudan; however, from qualitative interviews it was clear barriers to post-natal care was an overwhelming misunderstanding of its importance to health, inability to leave the care of children to others to seek care, distance and time to clinical services, especially during the rainy season.
The prevalence of early breastfeeding (within one hour) in this study was 98.2% percent, which is nearly double the African prevalence of 50% . Data, other than our study, from South Sudan on early initiation of breastfeeding is unavailable. It is estimated that 16% of neonatal deaths could be averted if all infants were breastfed exclusively from the day of their birth and 22% averted if breastfeeding started within the first hour [13, 15, 16]. In Gogrial West, only 5.1% of infants are exclusively breastfed compared to 20% of infants in Warrap State and 28% of infants nationally [1, 3]. The common belief that water and cow’s milk can be administered to babies under 6 months in addition to the belief that sex cannot happen if a woman is breastfeeding will continue to shorten the exclusive breastfeeding period and put newborns and infants at risk.
Only a quarter of children had verifiable immunization for DPT3 in Gogrial West and were fully immunized. This was however, higher than the national average of 13% and 21 percentage points and higher than state averages of 3.2% [1, 3]. Previous vaccination campaigns and CHWs may have helped to ensure children in Gogrial West were vaccinated. Three-quarters of children not having full vaccination will continue to create a barrier to healthy mothers and children and will require vaccination campaigns to decrease the risk of neonatal, infant and child deaths from preventable diseases. Given the unhygienic practices used by TBAs and the risk for tetanus for mothers and neonates, this will be especially important.
Finally, when looking at barriers to MNCH, sexual and gender based violence (SGBV) plays a significant role in health of mothers and newborns including increasing the risks of HIV, sexually transmitted diseases, unintended pregnancies, unsafe abortions, and the health of mothers and newborns [17–19]. Global prevalence figures suggest that 35% of women worldwide have experienced domestic or SGBV in their lifetime ; 20% reported among reproductive age women in South Sudan . In our sample, 20% of all women reported several forms of SGBV including forced intercourse and domestic violence. However, many women believe that their role is to provide sex even if they do not want it suggesting that SGBV including rape is normalized. SGBV has a profound effect on MNCH and pregnant women are at the greatest risk and associated immediate risks to the health of mothers and an unborn child [18, 19]. Children of abused women have a higher risk of death before reaching age five and violence during pregnancy is associated with low birth weight of babies . Women who reported pregnancy losses due to assault and domestic violence, and acceptance of beatings by husbands for failure to “do things right” (68.6% by women in Gogrial West versus 79% nationally) suggests normalized violence [1, 3]. The close to half of women married before age 18, constitutionally considered SGBV, with rates as high 47% in Gogrial West and within 45% in South Sudan, despite a ban in early marriage in the constitution [20, 21], will continue to be at risk and barrier for MNCH especially with regard to obstructed births . Furthermore, the association in our data between early marriage and danger sign recognition, whereby women married after 18 years were more likely to be aware of health danger signs than early married girls, will play a continued negative role for healthy women and girls.
Care for women and girls before pregnancy
With higher education, women tend to have fewer children and space births more widely, which reduces maternal and child mortality [11, 12, 23]. Education is lacking in Gogrial West and requires a concerted effort to ensure women and children are educated. Early grade reading programs in bomas and subsidized school fees will be necessary to address some of the barriers to education, but negative social norms regarding education for women and girls must be addressed in order to make any meaningful changes for the future. Improved literacy and education levels will also have a positive effect on family planning [11, 12]. Within the context of Gogrial West, effective contraception as a cost effective intervention to save lives and improve child health may be difficult to implement. The overall lack of education and literacy among women and girls, desire to use contraceptives, long held social norms whereby children are needed for defense of clans, work, as well as infamy for males, women’s inability to discuss these issues with husbands, and men’s control of contraception among their wives will impede programs to supply contraceptives. Barriers to both education and contraceptive use through negative social norms will require collaboration of traditional leaders and time to enact positive social norm behavior change.
Care during pregnancy
ANC was largely non-existent and consisted of sick visits instead of focused ANC. Other barriers to ANC included a belief that clinics did not have adequate staff or supplies. The cost of services and the distance to clinics (especially during the rainy season) for many was an impediment. Despite the MOH policy of free healthcare providers and facilities were charging “under the table” for services making ANC impossible for most. As a part of focused ANC, intermittent treatment for malaria in pregnancy (IPTp) and the distribution of ITN can reduce newborn deaths 37–71% . The procurement and use of bed nets was limited and needs to be increased. Interventions such as ITN distribution is more effective and cheaper than case management of malaria during pregnancy. However, understanding the danger signs of malaria and the skills to refer and treat women with uncomplicated and/or complicated malaria is also necessary whether the provider is a community-based provider or at the health facility level. Although iron and folic acid supplementation, tetanus toxoid immunization, syphilis testing and treatment and counseling of maternal and infant nutrition, and IPTp are best managed at a facility level, they can also be managed, with the exception of syphilis testing, at the community level with trained community health personnel . Given the low rates of TT2+ and untrained traditional birth attendants (TBAs) using sorghum stalks, TBA’s and Aret’s using unsterilized knives and spear heads and the lack of clean birth kits and/or Chlorhexidine, an intervention to cover this gap is likely to decrease a significant number of deaths among mothers and newborns [9, 13, 14].
Child birth and postnatal care
The Ministry of Gender and Child Social Welfare (MOGCSW) recognizes that there is no alternative to TBAs and recommends that TBAs be educated and equipped, in the short term to aid in safe deliveries until a cadre of skilled healthcare providers can be available [24, 25]. Infant mortality can be improved by 55–87% with breastfeeding, and 27% with community based pneumonia case management [9, 13, 14]. Although immediate breastfeeding rates are high, rates of exclusive breastfeeding, the lack of danger sign recognition and subsequent treatment, immunizations and knowing the essentials of newborn care suggests that education and a behavior change communication approach and community case management are imperative in Gogrial West. An improvement in the numbers of skilled birth attendants and well-supplied facilities will be difficult to acheive in the near term and will require significant funding and country buy-in.
Without access to water, sanitation and hygiene (WASH), women and girls are exposed to infections, suffer a lack of dignity, and have a higher risk of child and maternal mortality due to diarrheal diseases in addition to injuries from carrying water [9, 26, 27]. WASH programs for Gogrial West need to address gender roles for fetching water, especially when pregnant, safe drinking water, and education regarding danger signs for diarrhea. With regard to SGBV, the Ministry of Gender and Child Social Welfare (MOGCSW) recommends a national policy to address SGBV; however, funding, support and a will to address these issues may hinder such a goal [24, 25]. Addressing early marriage and the inability to negotiate sex, education, prevention and testing are important to decrease the 75% greater risk of HIV among girls who marry early . Children are, on paper, protected from early marriage however, enforcement of the laws are rare [20, 21]. Finally social norms and values influence how women and children are protected or harmed . With women’s acceptance of IPV as a norm, barriers to MNCH will continue until negative social norms are addressed .