Juba — Cut off from development by five decades of civil war, South Sudan has the highest maternal mortality rate in the world and high levels of infant mortality and morbidity. Large families struggle to get by in the war-ravaged new nation.
With the help of aid agencies providing family planning services to bolster a fledgling healthcare system, women and families are starting to choose life for the first time.
At Gurei clinic on the outskirts of the capital, Juba, women crowd into a makeshift shelter set up to give talks on birth spacing and limiting. Shushing babies and quieting older children, women who never knew there was a way to control when they arrived are engrossed as health workers explain methods from condoms and pills to inter-uterine devices and hormone implants.
"Some women are just lucky - they don't get their periods and so they stop reproducing for a few years... but not me, I suffer from very quick reproduction," said 21-year-old Jennifer Yeno.
A new concept
She had the first of her three children when she was 15, much like 5 percent of girls that are already mothers by that age; 16 percent are married off early. In South Sudan, a 15-year-old girl is also more likely to die in childbirth than complete her education.
Mother of five Lily Juwa Sisa says she had her first child at 13. She was married off early and had to drop out of school as her father died.
Worries that she will be again left destitute in a game where women are often treated as disposable pawns, she recently got a contraceptive implant.
"I lost my husband and so that's why I need this. I have a new husband and I am not sure whether he is ready to settle with me or not," she told IRIN. "He doesn't have enough money to have more children, but the little we have we can share," but only before her girls "have an education", so as not to be left dependent like her.
"Let me first see the future - that's why it's very important for me to choose," she added.
Sisa also worries that she could have complications after a difficult last birth of twins that required an emergency Cesarean section.
Yeno says she may want more children in the future, but for the next five years the hormonal implant in her arm will make sure her family can grow at a rate that she and her husband have the energy and money for.
"People who reproduce with the gaps between children, they are ever happy," she said. "When I go back to my place, whoever has the same system of reproducing quickly, I will tell her she is able to come here and get the same system I have."
The average woman in South Sudan has 6.7 children and the population is growing at 3 percent a year, with returnees also pouring in since a 2005 peace deal ended decades of civil war and a 2011 referendum secured independence.
Despite an abundance of aid to the new nation, hopes that improved education and health will bring down child and maternal mortality rates will take time to be realized.
Jude Omal, clinical officer for family planning NGO Marie Stopes International (MSI), which provides family planning services at clinics like Gurei, says a shortage of clinics and trained health professionals are major hindrances to women's access to family planning.
"There are some health facilities which don't provide the basic reproductive services like delivery," he said.
At Gurei clinic, pregnant women pack the benches and floor outside the three-room clinic while doctors jostle for space to examine and consult mothers-to-be. Many will need to be referred to Juba's only, and also poorly staffed, public hospital, where three of the country's eight registered midwives work.
Data from 2008 suggests that over 2000 women die for every 100,000 births, and that even these figures could have been understated due to the remoteness of South Sudan and lack of records.
"If you produce too much, you are more prone to birth-related complications because you will not get access to well-trained staff, so these family planning services are valuable to both communities and the government," said Omal.
MSI currently only runs three centres and does outreach work at clinics in South Sudan's three southern Equatoria states, where most of those returning from abroad, Khartoum and East Africa have settled. It hopes to expand its client base of roughly 3,000 northwards through word of mouth of satisfied customers.
In these more remote and conservative areas that rely almost wholly on subsistence farming and cattle keeping, harsher climates and lack of infrastructure have kept the outside world out. There, and in other rural parts of the Equatorias, the only methods communities are using are that men refrain from sex with their wives until a child is of walking age.
John Okech, a medical officer for NGO Adventist Development and Relief Agency (ADRA), says birth spacing is important for South Sudanese women to prevent anaemia, a condition many die of during labour or through past-partum haemorrhaging.
"Some mothers when they want to deliver they die because of obstructed or prolonged labour," says mother of three Milka John, who was aware that having babies in quick succession was dangerous but never knew how to stop. "Women keep producing as many of them are not informed."
Explaining family planning
Often it is out of their control, in a male-dominated society where women have few rights over their lives.
John says she did not get permission before opting for a five-year implant as her policeman husband's salary "can't take care of us at home".
"I didn't ask my husband, as he would refuse definitely. The husband would say, 'Let her just continue delivering'. But I want to have some rest so I can be a bit healthier," she explained. "It's important as it will enable me to take care of the children, make sure they go to school and get an education."
"I want to take care of these three first, and if they grow well and the interest comes then I will produce," she added.
"Typically in South Sudan, where food is scarce, breastfeeding is vital to a baby's nutrition," said ADRA's Okech. "Without spacing the birth, the children will be getting malnutrition, not good feeding, as... [they] should be getting breastfeeding up until at least two years."
But health risks aside, economic factors in South Sudan - one of the poorest countries in the world with no welfare system, high unemployment and high levels of insecurity - endanger the lives of women and children. South Sudan's economy has plummeted since the government decided in January to shut down oil production, cutting off 98 percent of its revenue.
Okech says many families are opting for birth control because they cannot afford to feed, clothe and educate more children.
"It helps the child and then it helps even the family - it helps them with the education and health of the children for economic reasons," he said. "The women complain mostly of their husbands, as the husbands actually don't allow for the women to take the family planning measures, so the women decide by themselves sometimes."
In a largely pastoralist country that prizes big families, men are slowly coming round to the idea that small families also have a value.
"Most mothers who prefer these methods, it is related to economics, because they realize that we are in a very challenging economic situation, where if you produce many children in this challenging environment you may not have the money to take care of the children, to feed them," said MSI's Omal. "And also some husbands, because they have challenges in terms of remuneration, the salary that they are getting... they want the right number of children that they can take care of."
Showdowns at outreach clinics between staff and angry husbands not consulted still occur, but health workers say that as awareness grows, they will fade.
"This service is voluntary. We don't force mothers, and we always encourage mothers who want to have this, to go and seek consent from their husbands," Omal added.
This report does not necessarily reflect the views of the United Nations.