Acceptability of community-based maternal and newborn care in South Sudan: A qualitative study using the Theoretical Framework of Acceptability

South Sudan faces among the highest maternal and newborn mortality rates globally, with approximately 87% of deliveries occurring at home without skilled birth attendance. In 2024, the International Rescue Committee launched a Community-Based Maternal and Newborn Care (CBMNC) program in Aweil East County, Northern Bahr El Ghazal, deploying trained Boma Health Workers (BHWs) to deliver essential maternal and newborn health services at the household level. This study explored the acceptability of the CBMNC model among diverse stakeholders. This qualitative descriptive study was grounded in the Theoretical Framework of Acceptability (TFA). Data were collected between May and July 2025 through 17 focus group discussions (FGDs), 14 in-depth interviews (IDIs), and 10 key informant interviews (KIIs) with 185 participants, including program recipients, male partners, mothers and mothers-in-law, Boma and Hospital Health Committee (BHC/HHC) members, BHWs, supervisors, and health system stakeholders at state and national levels. Framework analysis combining deductive coding based on the seven TFA constructs with inductive thematic analysis was used. CBMNC was well accepted by recipients and their families, despite provider and health system concerns about sustainability. Trust in community-selected BHWs made home-based care valuable, especially given limited facility access. Intervention coherence relied on pictorial aids, repeated visits, and peer learning to address low literacy. Participants perceived commodity interventions like misoprostol and chlorhexidine as impactful, while behavioral counseling was less recognized. Clients faced minimal burden, but providers experienced significant challenges and inadequate compensation. Health stakeholders were cautiously optimistic but questioned lay provider capacity and long-term viability in a fragile environment. CBMNC can achieve high community acceptability when delivered through trusted, community-selected health workers using contextually appropriate strategies. However, community acceptability alone is insufficient for sustainable scale-up. Addressing provider compensation, workload, and structural integration into national health systems is essential to ensure that gains in acceptability translate into sustained service delivery.