South Sudan

A ‘silent killer’, maternal and neonatal tetanus, is causing deaths of mothers and newborns across South Sudan

In the world’s 7th riskiest country for child birth, UNICEF and partners are trying to immunize all women of child-bearing age against tetanus, so that mothers and newborns don’t succumb to the vaccine-preventable, disease.

By Pavithra S Rangan

WAU, South Sudan, 8 March 2018 – Araw Ayom was her first child. His 21-year-old mother gave birth to him, a healthy boy of 2.75 kg, in the early hours of January 29. For three days, she gazed in awe as he slept, cried and suckled for milk. On the fourth day, however, everything changed: he stopped feeding, the muscles in his neck, abdomen, and slowly his entire body, grew stiff. He cried ceaselessly.

Anxious, Araw’s mother ran to the midwife in the village who said that something was wrong and that he had to be rushed to a hospital. The mother walked as fast as she could for hours, from the Roc Roc Dong village in Jur River county to a hospital in the Wau town, clutching the wailing baby in her arms. There, she discovered that Araw had contracted neonatal tetanus.

“She delivered him on the floor of her house littered with animal fecal matter,” says Dr. Marianna, the pediatrician at the St. Daniel Comboni Catholic Hospital’s neonatal ward. “She also said that the baby’s grandmother rubbed cow dung over his umbilical cord, a traditional practice, for it to dry up quickly. These are clear causes for neonatal tetanus, which kills nearly-all affected children, despite treatment.”

For three days, all of the hospital’s limited resources were rallied to stop Araw from slipping away into unconsciousness and ultimately death. However, at 5:30 am on February 4, the seven-day-old passed away. In January, three similar cases of neonatal tetanus have been reported from hospitals in Wau town alone and all three newborns died within days. “These are the few cases that get reported when families are able to travel long distances to the hospital. Many more, I believe, die each day in their homes without knowing the cause for death,” says Dr. Marianna.

In South Sudan, 91 per cent of all pregnant women deliver in their homes without access to a skilled birth attendant. As children and mothers often die without visiting a health facility, only 5 per cent of maternal and neonatal tetanus (MNT) cases are reported. “MNT is a silent killer because within days of a child’s birth in unsanitary conditions, with the use of contaminated instruments and dressing such as razor blades, cow dung or ash, even the healthiest newborns die,” says Paul Oyik Okot, a health officer at the Wau field office.

In South Sudan, which is among 34 countries in the world to be at a high risk of MNT, UNICEF and partners are working to cut its incidence to one in every 1,000 live births. “All efforts are underway to prevent the disease by ensuring that all women of child bearing age are immunized with five doses of the tetanus vaccine. This will protect both the newborn and the mother,” says Paul.

In the most recent campaign, in November 2017, 600 health care workers were divided into teams of three each comprising one vaccinator, one social mobilizer and one recorder. Massive public awareness and vaccination drives were seen taking place across the state.

“Initially, women blatantly refuse to be vaccinated. Myths are easily spread that the vaccine is for family planning and they feared coming to the posts,” says Monika Guido, a social mobilizer in the Hai Jalaba in Wau County. “However, after three rounds of rigorous campaigning and counselling, they are now able to see the benefits of the vaccine. Girls going to school readily took the vaccine and this further instilled confidence in other women.”

Along with the Ministry of Health, UNICEF has trained 201 vaccinators and employed them across Western Bahr El Ghazal, including in highly insecure areas such as Baggari. During the campaign, the vaccination was administered both at health facilities and temporary posts erected in populous locations such as markets and churches for the benefit of women.

After the first dose, the remaining four doses need to be taken with gaps ranging from one month to one year between them. Monika spends at least 45 minutes counselling each woman and her family about taking all five doses of the vaccine for full protection. Beginning at dawn, she works with community and religious leaders so they can help gather women for discussions to raise awareness. “Today, all women in over 200 households here have received at least one dose of the vaccine,” she says.

Besides training and supervising all healthcare workers, UNICEF analyses any adverse events following immunization and closely monitoring the progress. It also supports the installation of cold storage facilities in public health facilities across the state. “It would be very difficult for us to manage without the cold storage facility. Earlier, vaccines had to be brought from the central facility in Wau each day and we ran the risk of unavailability of vaccines in cases of emergency,” says Dr. Marianna.

Despite numerous challenges of access due to persisting insecurity, the third round of the MNT campaign in 2017 reached at least 54 per cent or 165,337 women in Western Bahr El Ghazal. As of 2017, campaigns by UNICEF and partners have ensured at least 48 per cent of all women in the child bearing age in the region have received at least the first dose of tetanus vaccine.

The comprehensive effort at eliminating MNT in South Sudan, including provision of vaccines, cold storage, training and employment of healthcare workers, social mobilizers and vaccinators, is provided by UNICEF Canada.