Sierra Leone: the most dangerous place in the world to become a mother

The toll women dying in childbirth in Sierra Leone takes can be seen outside a small house in Mattru in the rural Bonthe District. A traditional "baffa" shelter has been built from cane and palm leaf thatch. It's erected between the third and seventh days after a family member dies, and demolished on the 40th day, so that mourners can have shade when they gather.

Mamie Moriba, 30, died in late January. Her sister-in-law, Matilda Conteh, tells her story. When she was nine months pregnant, Moriba was admitted to a local hospital with typhoid. She was discharged three days later but got sicker. When she went back in, the hospital didn't have medication to treat her pain. Conteh ran to a pharmacy to buy Tramadol. As Moriba struggled, she knew she wouldn't be able to deliver her baby.

“She asked for the doctor to come down and do a C-section,” Conteh says. “I asked the nurse to get the doctor on the phone, but the nurses had no credit on the phone so they couldn’t call the doctor.”

When a nurse eventually got through to the doctor, his phone went dead. Moriba lay on a mattress on the ground in pain as a nurse used a stethoscope to determine if her baby was still alive in utero. It was. Then they checked her pulse. It was weak. Moriba said her sight was fading.

“The nurse said she was dying. That’s how she passed away, that’s how she died. We collected the body later.” Tears gather in Conteh’s eyes. “We tried to call the doctor. We wanted him. The medical facilities don’t have enough drugs, essential drugs, they don’t have enough equipment. If they had drugs, they wouldn’t have asked me to go and buy it.”

Moriba already had two small children, now living with their father. “Mamie was a very active lady. When she came to the house she took over the entire cooking. She was that kind of person.”

Sierra Leone has been on the brink since gaining independence from Britain in 1961. There has been a succession of military coups, an era of a single-party state which culminated in the execution of a vice-president, and a vicious civil war that lasted for more than a decade and ended in 2002, leaving tens of thousands dead and hundreds of thousands displaced. It’s a country that has lurched from crisis to crisis. On top of that, there’s the so-called “resource curse”.

Sierra Leone should be a very rich country. It is one of the largest producers of diamonds in the world, best known for the blood diamonds that fuelled the purchase of weapons during the civil war. A sizeable chunk of its diamond trade is still smuggled. It has gold, and is one of the world's biggest producers of rutile, a titanium ore. The aluminium ore bauxite is mined here too. It has the biggest iron ore deposit in Africa, the third largest in the world. Recently, oil has been discovered. And with the capital Freetown (almost a straight line 7,000km south of Ireland – there's no time difference) sitting on one of the largest natural harbours in the world, it's perfectly suited for transporting exports.

But issues of corruption and exploitation collude to mean very few benefits of living in such a blessedly fertile land are seen by its people. Sierra Leone is poor, one of the poorest countries in the world.

Ebola was another kick in the shins. The Sierra Leonean economy contracted by 21.5 per cent in 2015. Out of over 14,000 reported cases, Ebola killed 3,955 people in Sierra Leone between May 2014 and February of this year. The outbreak shut down the education system, impacted on mining, scuppered economic growth, and placed an already creaking health system under incredible pressure, creating a knock-on effect on health in general, not just people infected with Ebola.

It also has another big problem. Sierra Leone is one of the most dangerous places in the world to be pregnant and to give birth. It has the highest maternal death rate in the world and one of the worst infant mortality rates. It’s hard to put such a desperate scenario in context, but if we compare it to Ireland, the latest statistics show we have nine maternal deaths per 100,000. A 2013 report put Sierra Leone’s maternal death rate at 1,100 per 100,000, 122 times worse than Ireland. The infant mortality rate in Ireland was three deaths per 1,000 births in 2014. In Sierra Leone in the same year, it was 90 deaths per 1,000 live births.

Ebola made a bad situation worse. The work that was being done by the organisation World Vision and others to report pregnancies, and get women to give birth in clinics as opposed to at home, unravelled during the Ebola crisis. With traditional birth attendants banned, there has been progress made to train them in modern health practices. Community health workers visit villages and try to ensure women give birth in clinics. But when Ebola hit, the fear that spread about this strange disease impacted mothers and babies. People were too scared to go to clinics. There were rumours that nurses were injecting people with Ebola. When an ambulance or health workers came to a village, people would run away.

Now, with Ebola gone, health workers and organisations try to pick up the pieces. In Lungi airport, health workers in white coats greet disembarking passengers with hand sanitiser and call for vaccine booklets for a record of a yellow fever injection. A short minivan journey in the dark to a beach precedes a 45-minute boat journey on the pitch-black sea to Freetown, where beyond a wooden boardwalk, cars wait at an almost vertical incline.

A six–hour drive brings us to the Bonthe district of Sierra Leone in the south-west. This is one of the most inaccessible areas in the country, with terrible terrain and under- resourced health services. On the main roads, police checkpoints are accompanied by health workers screening for Ebola, checking temperatures with infrared guns. On the rural roads, it’s almost impossible to get above 30k/h as cars ease in and out of craters and jostle passengers like stones in a washing machine. Terracotta-coloured dust spins off the dirt tracks and coats everything. It’s hot, the type of stifling, muggy heat that feels like it should break any minute but never does. Malaria is widespread, the most common cause of illness and death in the country. There are frequently nearly two million cases of malaria a year, infecting a third of the population.

At World Vision's base in Mattru in Bonthe, the base manager, Omaru Sesay, speaks about the knock-on effect of Ebola. Many children died during the crisis, not from the disease, but because of ongoing illnesses, acute respiratory infections, and malaria that wasn't being treated because they were scared to go to clinics. He sums up the situation as "fear, just fear. When the outbreak occurred, remember, Ebola was reported in this part of the world for the first time. People had their doubts, they couldn't understand the disease, or that when people died you couldn't touch them. People said, 'What kind of disease is this?' People thought it was something that didn't exist. We had to teach people: Ebola is here and it's killing people."

Trinity College’s Centre for Global Health partnered with the Ministry of Health and Sanitation in Sierra Leone and World Vision Ireland and UK in mHealth, or mobile health, and Sesay refers to an innovation where community health workers (CHWs) register pregnancies and communicate with nearby health facilities with mobile phones.

At the Bonthe District Health office, the management team comprises district medical officer Kargbu Labour and district health sisters Zainab "Mama" Bangure and Susan Tucker. Labour has a habit of repeating "Can you imagine?" after every sentence. "In the district, the biggest issue that causes maternal death is delays . . . it's a hard-to-reach area. Transportation is a big issue . . . The hospital is another problem. We are grossly understaffed. A single doctor. Twenty-two per cent of students training in the medical school [in Freetown] are now working in the UK. They are all gone. The same again with nurses. We have a nursing school in the district, but because of the hard-to-reach parts of the district, they prefer to go to another district. We have 55 peripheral health units – 29 of them are single staff. One nurse. Can you imagine?"

During the Ebola crisis, teen pregnancies spiked when schools were shut down. “We have a lot of teenage pregnancies,” Labour said. “Teen pregnancies because of early marriage. Some get pregnant without a husband. We are talking to them about family planning, but if you think of the hard-to-reach areas, we don’t have the logistics. At times, contraception is hard to access. If they go to the health facilities, it’s a long distance . . . Some of them we get to by using boats, but it uses a lot of fuel.”

Bangure, a no-nonsense nurse, says there were three maternal deaths in January. “When we talk about teenage pregnancies,” she says, “we talk about [girls aged] 11, 12, to 14. Even yesterday we took a case aged 14 years. The baby was delivered.”

For girls so young, rape has to be a factor, “Yes, you must expect that. These are school-going children. They get pregnant from their peer groups. Most of the fathers are almost the same age.” Tucker interrupts, “Last week, we had a 12-year-old. Her husband is 16.”

Tucker also says in some cases young women hide contraception from their partners. “The men don’t agree with it,” Bangure says. “Because of the terrain, not all NGOs are working here. World Vision cannot do everything. At times, there are some bylaws – that if a woman is pregnant you have to go to a health clinic – but if a woman is pregnant, and they have to travel eight, nine miles, sometimes they are carried by hammocks. So we have a lot of challenges.”

Readying herself to go back to work, there’s was a sense of urgency and irritation about Bangure. “But with all these questions, are you people going to do anything in terms of assistance? It’s such a pity. We have just one doctor . . . If you people can do something and not just talking, talking, talking about it. We want to know what people are going to do in terms of help. We need at least two or three doctors here. We need personnel. We need them. There is no midwife in the hospital . . . We only have one ambulance and it’s not enough. Think about this: if three people ask for an ambulance, we just have one. Please see what you can do. Please think of us.” She stands up, “Okay, I have to go work now.”

At the Red Cross clinic in the Timbo area of Mattru, women sing a song about hand washing. Sample lyric: "If you wash your hands with soap before you feed your children, it's for the best." A small concrete structure with a corrugated roof, the triage area is a booth in the open made from blue plastic sheeting. One of the women attending, Mary Sesay, 21, with her five-month-old baby David, got a laugh from the crowd when she speaks about how ragged the equipment is, miming a baby falling out of the torn harness they use to weigh infants. The adult weighing scales is broken so they can't check the mothers' weights anymore.

Away from the jovial and boisterous singing and chatting, a tiny, lonely-looking figure sits in a corner. With one question, tears fall rapidly down her cheeks and she wipes them away quickly. Rashidatu Sesay is 15 but looks younger. Unlike the other women, she doesn’t have a baby with her. Pregnant at 14, her baby died two weeks previously shortly after she delivered.

“I’m sad,” she says. At full term, she went into labour at night. She came to the clinic where worn-out nurses argued about treating her. “Nobody was ready to take responsibility. The two people were arguing with each other. They didn’t want to treat me, they didn’t want to wake up.”

Beside Sesay, her mother, Nafisatu Salakoley, adds that the nurse said patients don’t appreciate them when they visit the clinic during the daytime and then turn up at night “bothering them”.

Sesay finishes the story, “I gave birth to the baby alive, but it was not healthy.” That was it. The baby died there and then. She went home. A group of men absentmindedly listen to our conversation, and I ask Sesay if she would like to have another child. She nods silently. What would be a good age to have a child? “Eighteen,” she says. “I want to wait until I am 18.” The men around her start spluttering with laughter. On the back of her T-shirt there was a mangled translation of “girl power never dies”.

To find out what young people actually think about the situation, we go to a local school. At Centennial School, a boy kneels outside a classroom in the midday sun with his hands behind his back as punishment. In a classroom of 17 to 20-year-olds, they give their opinions on pregnancy and contraception. Why are there so many teen pregnancies? A young woman puts her hand up.

“Because of poverty. For example, if my parents are poor, my parents don’t send me to school, they will use me as a source of money . . . If a boy wanted to have sex with me I can refuse. But you have poverty in homes, they use the girl as a source of money, so if she wants money and he comes to her, she offers [sex] for money.”

And what about contraception? A young man raises his hand, “some of our sisters do not agree to use condoms because they say the condom goes into their stomach. Some even don’t want to use condom because it will reduce sensation during intercourse.”

They conclude that 18 to 20 was the right age to have children. By that rationale, they should be having children now. There is laughter and a resounding “no!” Why? “We want to be educated.”

At the crossing of the river Jong, a passage of canoes and crocodiles, a wooden platform ships vehicles across, two at a time, pulled by a metal coil. Across the river at a clinic in Gbaninga, traditional birth attendants have been retrained as community health workers. They discuss what they didn’t know before and what they know now. What did they use for deliveries before? “A knife,” one says.

Working without pay, they’re proud of what they’re doing but hindered by a lack of resources and equipment. “We are doing it to help our community,” Iseta Farma says. “We save the lives of mothers and babies.”

It's tough going. During Ebola, new problems surfaced with girls, "because they were not going to school during Ebola, they were sitting at home or going into other communities. Most of them got pregnant," says Mariama Jusu. Mabinty Amara concurrs: "When they leave this village and go to big towns, their parents have nothing. They get married to an elder of another village. Even to get their school uniform is a problem. So they get married to the chief or someone. The chief would have two or three wives. Some teens, their children have not started walking and they're pregnant again."

For these women, their main request was a bicycle so they can cover bigger distances. “We were given a mobile phone by World Vision to register pregnant women, but the coverage here is very bad,” Jusu says, “We need bicycles. We need rain gear. During the rains we want to cover long distances and we can’t.”

One of the biggest logistical challenges in getting pregnant and breastfeeding women to health services is presented by water. The Sherbro Islands off the coast of the Bonthe district are beautiful and tropical and inaccessible. Here, the rivers give way to the sea. The vast majority of men are fishermen, paddling dugout canoes throughout the night, catching bonga, snapper, crab, and tarpon.

Korpoila island lies 8km away from another island with a clinic, Yoni. On the shore of Korpoila, calf-deep mud fringes a clearing where women and children descend in a traditional welcome, their faces covered in grey and white paint. The chief of the village, Kapaka Mboko, emerges suddenly, covered head to toe in flowing black palm grass, dancing with bells ringing underneath his skirt, his head topped off by a dark mask helmet carved with a child’s features.

A walk through the bush leads to a clearing surrounded by coconut and cotton trees. Women gather siting in the shade, and the devastation that’s befallen this village comea into focus. Five days previously, a fire swept through this clearing, burning down 11 houses, which left dozens of families homeless. With no shelter, they sleep outside on the ground. Inside what’s left of some of the mud-brick huts, the walls are scorched, the palm thatch gone. Chickens peck at coconut husks and babies cry.

One pregnant woman, Farimata Marrah, 20, details some issues. “We cannot get facilities, and can’t get supplies if we can’t get there. We need food to keep us well nourished. We don’t have food. We want medicine. We have a clinic every two weeks, outreach comes here but we want it weekly. We don’t have food for our children. We don’t have a good water supply.”

This is a place so remote that no Google search or Apple map can find it. On the shore, a World Vision boat, which spent part of its journey being frantically bailed out, waited to bring the women to the clinic on Yoni. Heavily pregnant women are transported using hammocks, they carried to shore by men from the village. Once inside the boat, they lie on a mattress.

On the white sand beach at Yoni, health workers in blue shirts stand on the shore and sing songs to greet the arriving boat. The women walk in procession from the beach through coconut trees and across a bridge built over a stream. A woman draws water from a well outside the clinic, brownish-yellow and dirty. To get clean water here, they must walk two miles.

Inside the clinic, women are in labour. A few boxes of drugs are scattered around: ibuprofen, gentamicin injections, needles and a large roll of dusty gauze. Awareness posters and health stats are stuck up on the walls.

Alice Nallo is the MCHA, the Maternal and Child Health Aid. "I have worked almost five years without salary. We have big constraints here. People come from far distances. Sometimes they cannot get the boats to come. That's a big problem. One boat cannot serve us all because you have people who are far away. Some pregnant women are malnourished . . . We don't have clean water here."

She says she is praying to be approved for a salary at some stage. “We are really, really suffering here. We have solar for lights but it’s not functioning. If we have a labour case, we use battery torches in the labour room. We need drugs. Drugs for lactating mothers, pregnant women and children. We need delivery kits. We only have one delivery bed. We have oxytocin for bleeding when the mother is delivering, but we have no pain medication.”

What about paracetamol? She shook her head.

At a Maternal and Child Health Post in Kahekay in Junctionla on the mainland, another clinic is in full swing, a packed room of breastfeeding women and their babies. Anita Karimu, a health worker, spoke about the progress this clinic has made teaching mothers about breastfeeding. Before, she says, mothers would mainly give their babies water and some breastmilk; now they're breastfeeding from birth until 11 months. Immunisation against measles has been successful, and they give anti-malarial drugs to pregnant women. Karimu hands me an A4 piece of paper of "things we need" written in pen. That list: a delivery bed, a fridge, a steriliser, delivery kits, transport, an adult weighing scales, an ambu bag (a bag valve mask to resuscitate children), a phone, staff quarters, an incinerator (they currently use a fire pit to dispose of items) and, finally, electricity. A tarpaulin outside is made from bags from Sierra Rutile Ltd, a UK-listed mining company that recorded revenue of $123.4 million in 2013 and is currently undergoing a $77-million expansion of its operations in Sierra Leone.

Back on Bonthe Island, a slave ship rusts on the beach, a cotton tree growing up through it. Nearing twilight, the town feels eerie. Old factories and businesses lay derelict. Houses have been repeatedly patched up and added to over the years, with higgledy-piggledy two- and three-storey buildings creating a filmset look, half-western, half- Shire. During the civil war, this place was a ghost town. It still feels like that, just with people in it now.

Walking down one street past a roofless church, overgrown with weeds, teacher and former mayor Michael Garrick approaches. He's taught at St Joseph's school in the town since 1983. Garrick walks around to the local Catholic church, called, rather unbelievably, St Patrick's, complete with a statue of the saint in the porch. "We were trying to move forward," Garrick says, "and Ebola dragged us back."

A canoe at a nearby inlet bares the name ‘God Knows’. A woman who is clearly mentally ill walks by and is described as being possessed by a demon. A young boy with shorts made up more of holes than material, runs down the street smiling. The perfectly round west African sun begins to set, glowing orange. If you squint, the place – the sea, the beach, the jungle – could seem like paradise, but with eyes open it’s a society and a system that’s anything but.

In rural Sierra Leone, the roads are terrible until you near a mining site. Then, the dirt tracks miraculously become flat. Trucks spray water on the roads so the dust doesn’t disrupt their transportation, a gross sort of endeavour when pumps in wells don’t work. Mining company jeeps whizz around these flat, watered roads when a few miles away, health workers can’t afford a bike to get to pregnant women in need. Sierra Leone’s people – and NGOs – are trying very hard. There’s gold and diamonds in the ground, and desperation in the air.