Sierra Leone: One of the most dangerous countries in the world in which to give birth

In Sierra Leone, doctors emphasise, there are no epidurals for women in labour. Without anything to dull the pain, wards are full of praying, screaming, and – eventually – the sound of crying babies. That noise is a good thing. It’s the sound of survival.

The small West African coastal country, of roughly 8.4 million people, has been free from war for more than two decades. It has overcome the West Africa Ebola outbreak, and its population is not suffering from major drought or displacement. But Sierra Leone remains one of the most dangerous countries in the world in which to give birth.

The UN says that about one in 20 Sierra Leonean women will die as a result of pregnancy or childbirth. Those figures put it in the bottom three countries globally – only slightly ahead of Chad and South Sudan. It’s an improvement on 2015, when it was one in 17, giving Sierra Leone the highest maternal mortality rate in the world.

Dangerous experience

Last year, Unicef said that a woman in sub-Saharan Africa is about 130 times more likely to die from causes relating to pregnancy or childbirth than a woman in Europe or North America. The organisation also said there has been “staggering backsliding” across women and children’s health due to Covid-19, conflict and the climate crisis.

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Maternal deaths in sub-Saharan Africa are almost 50 times higher than any other region, according to a 2019 UN report. In 2020, about 70 per cent of all maternal deaths were in sub-Saharan Africa.

“While pregnancy should be a time of immense hope and a positive experience for all women, it is tragically still a shockingly dangerous experience for millions around the world who lack access to high quality, respectful healthcare,” said Dr Tedros Adhanom Ghebreyesus, director general of the World Health Organisation (WHO) this year, as UN estimates said a woman dies every two minutes globally as a result of pregnancy or childbirth. “These new statistics reveal the urgent need to ensure every woman and girl has access to critical health services before, during and after childbirth, and that they can fully exercise their reproductive rights.

“Severe bleeding, high blood pressure, pregnancy-related infections, complications from unsafe abortion, and underlying conditions that can be aggravated by pregnancy (such as HIV/Aids and malaria) are the leading causes of maternal deaths. These are all largely preventable and treatable with access to high-quality and respectful healthcare.”

The death toll among mothers does not tell the whole story either. In obstetrician Benjamin Black’s book Belly Woman, which documents the challenges medics faced providing maternal healthcare in Sierra Leone during the Ebola outbreak, he said that for each death about 30 women are permanently or severely disabled by pregnancy complications. And babies die too. In 2017, there were 1,120 deaths per 100,000 live births; compared with eight per 100,000 in Europe.

Sierra Leonean medical staff say the 2014-16 Ebola outbreak was a setback for maternity care, largely because of the number of healthcare professionals killed by the disease. The outbreak began four years after medical fees for pregnant women and children under the age of five had been lifted nationwide, in a move the New York Times said put the country at “the vanguard of a revolution”. The outbreak meant that the number of women who attended healthcare facilities during their pregnancies or when in labour fell significantly.

Street traders

Today, officials argue that the tide is turning for the better. At the King Harman Maternal and Child Hospital, in capital city Freetown, a senior manager said they are well aware of the challenges they are operating under. “It is not easy. Rome was not built in a day,” he said. He asked not to be named, deferring to spokespeople from the ministry of health, who led a tour of the hospital and were keen to emphasise that improvements are being made.

About 2,000 women die from childbirth-related complications annually nationwide, they said, but they claimed there has been a notable reduction over the past few years. The government hopes to reduce it to less than half that in the coming year, they said.

“We know it’s an emergency issue for our nation,” said John Jallieu, a communications officer for Sierra Leone’s ministry of health. “We have an energetic minister. We are recruiting additional midwives to tackle this situation.”

“It’s a priority issue. It’s on top of our list,” added his colleague James Kallay. Both men nodded when asked if they personally knew women who had died during childbirth, but Kallay said the government is tired of their country being associated with this. “We don’t want to focus on complaints, we want to focus on solutions. We can complain and it won’t solve any problems,” he said. “We just want to focus on the good we have.”

He said that there is ongoing investment in new equipment and supplies, while the ministry is trying to introduce an app on which health clinics can register and track pregnancies. Kallay said this will be a big help.

He led the way into an antenatal ward, where midwives sat together as a woman writhed in pain on a bed. Another could be heard screaming in the attached labour ward.

One midwife, Millicent Kpanabon, stepped forward seemingly ready to air complaints, before being warned by a hospital official not to say too much.

She explained that they see up to 75 deliveries each month, while nearly 1,000 pregnant women visit the hospital. Their biggest concern, she said, was that they only had one foetal Doppler, which midwives use to monitor the baby’s heartbeat. “They’re very expensive,” she said.

The Irish Times was not given access to the Princess Christian Maternity Hospital – a referral hospital that takes bad cases and is known to have a higher death rate than other places. On the street outside, traders sell goods including Dettol, nappies and baby products. A passing woman, who had recently given birth there through Caesarean section, said her brother paid the hospital for the delivery, but she didn’t know how much.

Another new mother, Isatu Conteh, carried a nine-month-old. The baby was born at a community centre in Wellington, east Freetown. She said her aunt had to pay the centre, as well as buying toiletries and other supplies.

‘The safest place’

The entrance to Aberdeen Women’s Centre is on a busy Freetown roundabout. It’s close to the upmarket Radisson Blu Mammy Yoko hotel, near Lumley Beach, where young people exercise or eat and drink in the bars and restaurants. The centre is a highly popular destination for pregnant women, attracted after hearing that there have been no maternal deaths there for the last two years.

Speaking outside the maternity ward, supervisor Kumba Koroma said they had performed 17 deliveries that day. “Every woman was okay,” she said. “This is the safest [place to give birth], everyone wants to come here and that’s the big problem we’re having ... We’re having so many patients. We need an extension of the maternity hospital and more staff.”

She said they turn away pregnant women who are not registered with them, though not if they arrive already in labour.

Unlike in other Sierra Leonean hospitals, where the families of women in need of blood have to scramble to donate in emergency situations, women due to give birth in Aberdeen are asked to come in when they are 36 weeks pregnant and give blood in advance. It is stored in case they need it during childbirth; if they don’t, it can be repurposed for other women. While all medication is supplied, they also have to bring toiletries and baby clothes. Women spend between one and three nights in the centre, depending on whether they have a Caesarean or not. Babies that need to be admitted to an intensive care unit are transferred to another hospital.

Mohamed B Jalloh, one of four doctors working there, said the situation in Aberdeen is much better than in other hospitals he has worked in, because they have enough medical supplies. In other places, the issue is “not about manpower but about drugs and equipment,” he said.

Free healthcare for pregnant women nationwide may be government policy but it is not the reality, Jalloh said. When women get to hospital, “there are no gloves, you are telling the patient to go buy it ... It’s just a lack of medical consumables: [it] could be equipment, could be drugs.” He said women can die as a result, while getting blood is also “really a challenge”; some hospitals and healthcare centres don’t have the capacity to store blood for long and the temporary blood banks can be empty.

Women who give birth in public hospitals or health clinics are often given lists of goods to bring with them, which can include multiple pairs of gloves, a bucket, pads, an old towel, material for wrapping the baby and disinfectant.

Jalloh worked as a pharmacist during the Ebola outbreak. At that time, people were afraid to go to hospitals, he said, “but that has passed ... Hospitals are available. You hardly see anyone giving birth at home, but sometimes it happens in the provinces.”

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But both then and now, he said, there were problems regarding co-ordination and discussion between aid agencies, the government and the healthcare workers. If real progress is to be made, he emphasised, medical staff need to be listened to. “The ministry and NGOs should sit down with the healthcare workers themselves, because we know the industry.”

This report was supported by the Simon Cumbers Media Fund.