Review Article

Missed Opportunities in Maternal Care: Findings from Death Audits in South Sudan

Abstract

Maternal and perinatal mortality remain unacceptably high in South Sudan, with a maternal mortality ratio of 692 deaths per 100,000 live births, far exceeding the Sustainable Development Goal (SDG) target. In line with World Health Organization (WHO)  recommendations, Maternal and Perinatal Death Surveillance and Response (MPDSR) was introduced to strengthen quality of care, accountability, and learning within the health system. A retrospective descriptive review of maternal and perinatal deaths was conducted in 11 health facilities supported by the Momentum Integrated Health Resilience (MIHR) project in Bor, Budi, Juba, Jur River, Wau, and Yambio Counties between March 2023 and December 2024. Facility-based MPDSR committees reviewed deaths using standardized national tools and the WHO-recommended six-step MPDSR audit cycle. Data were extracted from facility records and analyzed descriptively. A total of 22 maternal deaths and 117 perinatal deaths were reviewed. Postpartum hemorrhage was the leading cause of maternal death (64%), followed by malaria in pregnancy (14%) and severe anemia (9%). Perinatal deaths were predominantly  intrapartum-related, with fresh stillbirths accounting for 59%, followed by macerated stillbirths (21%) and prematurity-related complications (10%). Major modifiable health system factors included shortages of essential medicines and supplies, insufficient availability of skilled health workers, delays in accessing care, weak intrapartum monitoring, unreliable electricity, and limited newborn resuscitation capacity. MPDSR supports identification of preventable deaths and health system gaps. Strengthened institutionalization of MPDSR and targeted investment in intrapartum, emergency obstetric, and newborn care are essential to reduce preventable maternal and perinatal mortality in South Sudan.