It was past midnight when Zelpha Sarah Sigin's labor pains began.
Wilma Thomas Ajiba, a community health volunteer in Mideh, South Sudan, arrived at the family hut just after Sigin gave birth to her daughter. "When the baby came, [Sigin] started bleeding," Ajiba says. "It just poured. I checked to see that there is no second baby, and I gave her the tablets."
The tablets stored in Sigin's hut were three white pills, the recommended dose of the drug misoprostol, a uterotonic that helps contract the uterus and prevent postpartum hemorrhage— the leading cause of maternal deaths. Unlike oxytocin, the drug most women receive after giving birth to prevent hemorrhage, misoprostol does not require refrigeration, making it a safe, low-cost, and effective alternative for use in village health centers that often lack electricity—or at home when a pregnant woman can't get to a facility. "The bleeding stopped. And the mother is well," Ajiba says, gesturing to the smiling Sigin, who had given birth seven days before.
In South Sudan, surviving childbirth is an achievement. The newest country on the planet, South Sudan has the highest maternal death rate in the world. This situation is attributed in large part to a 20-year civil war that degraded the health system, deteriorated health facilities, and depleted the ranks of midwives and other health workers. Late last year, violence among political rivals broke out again, endangering the country's most vulnerable citizens: its women and children. When health services are disrupted, women are left to give birth at home, often alone, perhaps with a traditional birth attendant—but rarely with a skilled health care provider who can help if complications arise.
Jhpiego, an international health organization and affiliate of Johns Hopkins, has been working on maternal health issues and expanding access to lifesaving care since its founding 40 years ago. Jhpiego-led studies conducted more than a decade ago in Indonesia first showed the potential of using community health workers to distribute misoprostol to women in the last trimester of pregnancy for self-administration to prevent postpartum hemorrhage at home births in the developing world.
In 2012, Jhpiego began working in South Sudan through the U.S. Agency for International Development to help the government provide basic health services in two of the country's 10 states. In collaboration with the Ministry of Health and other partners, Jhpiego decided that community distribution of misoprostol would bring lifesaving care to pregnant women who couldn't reach a health facility in time and therefore had to give birth at home. Today, 260 home health promoters (the term used for the volunteer community health workers) and 60 health care providers working in 33 health facilities have been trained on the use of misoprostol, which is distributed in the eighth month of pregnancy. More than 1,000 pregnant women have received this care without adverse complications.
Ajiba, a grandmother of 12 children, was chosen by her village to serve as part of a trained corps of volunteer home health promoters who identify pregnant women in their community and educate them on safe birth practices and connect them to health services. During a visit to South Sudan, photographer Kate Holt and I followed Ajiba and several other home health promoters on their daily routine, helping pregnant women make a birth plan, checking on new mothers and babies during home visits, and conferring with community midwives in their clinics.