Elizabeth Nyachiew was 16 when she watched her neighbor bleed to death during childbirth. She vowed to become a midwife to spare others from the same fate in South Sudan, a country with one of the world's highest maternal mortality rates.
"If I saw people dying, I wanted to know why," she said. "I kept thinking if I was educated, I'd know the cause and I could help."
Now 36, in her office at a hospital run by the aid group Doctors Without Borders in the city of Bentiu, Nyachiew said she has weathered civil war, hunger and displacement to make it this far.
She is one of some 3,000 midwives in South Sudan. The country's health ministry says that number is insufficient to serve the population of 11 million people.
And yet Nyachiew's journey shows the extraordinary effort needed to get here.
As a girl in Leer in northern Unity State, Nyachiew faced pressure from her family, who didn't think girls should attend school. She stayed home until age 9 helping cultivate beans, pumpkin and maize on their farm.
When she finally persuaded her father to let her study, more fighting had begun in the long conflict that eventually ended with South Sudan's independence from Sudan in 2011.
Her family fled into the bush. Women were raped and relatives were killed, including her pregnant sister-in-law. As fighting ebbed and flowed, Nyachiew did what she could to study, even traveling to Khartoum and learning Arabic.
At 18, Nyachiew was admitted to a midwifery course sponsored by aid groups and based in Leer. She struggled to understand medical terms and thought she'd never pass. During the second year, she became pregnant. The school had a policy of not allowing pregnant women to participate, worried they might be distracted.
But Nyachiew wouldn't drop out. She threatened suicide and begged her brother to intervene. The administration let her stay.
Nyachiew named her daughter Jephaenia Chigoa, reflecting the term for "something good" in the Nuer language.
Even after she became a midwife, Nyachiew lived the dangers that many pregnant women in South Sudan face.
Much of the country has no road network, meaning that pregnant women often walk for hours or days to the nearest clinic. Some are carried in wheelbarrows or stretchers with the help of relatives and friends.
Nyachiew made that journey herself. During one miscarriage, she walked for two hours to the closest clinic in Leer while screaming in pain as blood streamed down her legs.
It was 2011, the year of South Sudan's independence. A civil war began two years later, killing nearly 400,000 people and ending in 2018.
When the fighting began, Nyachiew was studying in the capital, Juba. She returned to Leer, and her family again hid in the bush for months as people — including four brothers-in-law — were killed around them. Soldiers beat her, seeking money.
But the most difficult part was still being unable to help pregnant women, watching them die for lack of proper equipment and care.
South Sudan has made a fragile recovery from civil war. Violence between some communities remains deadly, and the United Nations says 9 million people — 75% of the population — rely on humanitarian aid.
Nyachiew lives in a displacement camp along with 100,000 others, including 17 relatives who rely on her as their sole breadwinner. Like others in the camp, she is scared to move out, worried that conflict could resume.
South Sudan's health system continues to suffer. The government allocates less than 2% of the national budget to the health ministry, whose system is propped up by aid groups and the international community. Many health centers outside the capital still have a desperate, wartime feel.
"The changes have been slow and uneven," said Janet Michael, director general for nursing and midwifery at the health ministry.
Data collection is so poor that no one knows for sure how many women are dying in childbirth. The U.N. has estimated that 1,200 women die per 100,000 live births.
Some women who survive still lose their babies.
In June, Nyalith Mauit lost one of her twins while giving birth. Health workers at a clinic struggled to deliver the first twin, who came out feet first. She was transferred to the Doctors Without Borders-run hospital, where Nyachiew leads more than a dozen midwives. But they were unable to deliver the second twin in time.
Mauit cradled her surviving day-old son.
"I am grateful there is a hospital here. If there wasn't, yesterday might have been the end of my life," she said.
Nyachiew, slender and serious, holding a walkie-talkie as she did her hospital rounds, hopes to see more midwives emerge to help.
The United Nations Population Fund is working with South Sudan's health ministry to train them and create mobile clinics to reach remote areas. But schools lack textbooks and trained tutors, and there is never enough funding, the health ministry said.
Nyachiew, who was expecting her sixth child while speaking to The Associated Press, hopes such issues can be addressed by the next generation.
"My message to little girls is to tell that they have to go to school because school it is very important, because if you go to school, you should become a doctor, you should become a nurse, you should become a midwife," she said. "So that you can help the entire community."
