Integrating Traditional Birth Attendants into the Formal Health System: A Qualitative Exploration of Strategies for Improving Perinatal Outcomes in South Sudan

This qualitative study addresses the critical challenge of persistently high maternal and neonatal mortality in South Sudan, where access to skilled birth attendance remains severely limited. It investigates the potential of formally integrating Traditional Birth Attendants (TBAs)—who deliver a substantial proportion of rural perinatal care—into the national health system as a pragmatic strategy to improve outcomes. Fieldwork was conducted between 2023 and 2024 in Central Equatoria and Warrap states, employing semi-structured interviews and focus group discussions with 42 purposively sampled participants, including TBAs, midwives, community health workers, and Ministry of Health officials. A rigorous thematic analysis of the data identified three interdependent prerequisites for successful integration: first, implementing a standardised, competency-based training curriculum for TBAs focused on danger-sign recognition and timely referral; second, creating formalised, respectful linkage mechanisms between TBAs and primary healthcare facilities; and third, addressing systemic barriers such as transportation and communication. Crucially, the findings underscore that any integration model must explicitly value TBAs' cultural legitimacy and pre-existing community trust, positioning them not as substitutes for skilled personnel but as vital connectors within the health ecosystem. The study concludes that a culturally sensitive, system-oriented integration framework is a feasible and necessary public health strategy for South Sudan. It provides evidence-based recommendations for policymakers to develop inclusive protocols that leverage community assets to bridge the healthcare access gap and accelerate progress towards national and continental health targets.