The slow road to progress: why is Sierra Leone’s maternal mortality rate so high?

It is just before 6pm when the call comes in to Tom Swaray’s mobile phone. The sun in Moyamba District in Sierra Leone’s Southern Province is well on its way to setting. The information he receives is scant. An unnamed pregnant girl — 17, maybe 18 — has been in labour for 12 hours. She is in a town called Rotifunk. “Not too far,” Swaray says, and calls for one of his ambulances.

Forty-five minutes later the Toyota Land Cruiser pulls up next to the empty white tarpaulin tents that were originally pitched to treat Ebola patients and are now the district’s medical centre. The light is fading as the driver, Michael Elie, sets off over the ferrous dirt to find a nurse at Moyamba government hospital. He emerges with Jane Fatmata Kamara, pulled from her triage night shift, and the two set off into the dark.

The girl they are going in search of became pregnant in a place where death often follows birth. Sierra Leone is thought to have the highest rate of maternal deaths of any country in the world. Women here have an estimated one in 17 chance of dying from pregnancy or child birth-related causes. To place this figure in historical context, UK parish records show better odds for English mothers in the early 1700s.

The same maladies that killed those British women 300 years ago are killing women in Sierra Leone and across sub-Saharan Africa today: haemorrhage, sepsis, hypertensive disorders, illegal abortions, obstructed labour. All can be treated successfully with basic interventions, as long as what public health specialists call the “three delays” do not supervene: in seeking care, reaching care and receiving care.

That is why Elie and Kamara drive at breakneck speed along the narrow, perilously veined, cratered road to Rotifunk. On the map it is only 20 miles, but time and distance have an uncertain relationship in rural Sierra Leone. The unnamed girl and her unborn child wait, the risk to one or both of their lives rising every minute.

Sierra Leone’s dubious distinction is not just its supposedly record-breaking rate of maternal death. A World Bank line graph plotting the World Health Organisation’s estimated maternal mortality rates for low-income countries over the past 25 years shows war zones such as South Sudan and the Central African Republic closely bunched together. But Sierra Leone’s line, while decreasing gradually from a high during its own 1990s war, is extraordinary.

It floats high above the whole motley crew at 1,360 maternal deaths per 100,000 live births as of 2015. This estimated ratio is almost three times higher than the average for sub-Saharan Africa. If the figures are correct, around 3,100 women will have died maternal deaths last year alone; 3,956 men and women died in Sierra Leone during the Ebola outbreak of 2013-16. The statistics are a mark of continuing infamy for the country.

“We need to say something about those figures you are using,” says Dr Santigie Sesay at his office in Freetown, Sierra Leone’s capital. Dr Sesay is the government’s director of reproductive and child health, responsible for coordinating the state’s response to maternal death. “We’ve put in place a maternal death surveillance and response team, and developed a technical guideline. When a death is reported, they go and confirm.”

It sounds simple. From January to August this year, 432 maternal deaths were recorded by the ministry of health and sanitation. According to their figures, even allowing for some under-reporting, the collective wisdom of the WHO, Unicef, the UN Population Fund and the World Bank is exaggerating Sierra Leone’s problem by a factor of four. Either that, or about another 1,000 Sierra Leonean women died maternal deaths in the first half of this year, and Dr Sesay had no way of knowing about it.

Before the Ebola outbreak deaths were not habitually reported to the government in Sierra Leone. The business of death is a strictly family or community matter and the reports were of little value to the state. But when the outbreak came, data on who died, where and how, suddenly became vital to stem its spread.

Reporting every death was made mandatory. Initially, people were resistant, dreading the prospect of their loved ones being slung into the next life by a stranger in a hazardous materials suit. However, more resources were mobilised and surveillance increased at the community level. There was a surge in reporting across the nation. But as the epidemic abated, so too did the higher rates of death reporting. Now, according to the ministry of health’s own surveillance update for September 2016, only around a quarter of all deaths are being reported.

The ministry of health requires poorly paid community health workers to report maternal deaths to health facilities, which in turn must report to district-level medical teams. Possible weak links abound in this system, not least because those government employees doing the reporting are the same people under pressure to ensure that mothers do not die in their communities.

A few days after my meeting with Dr Sesay, a baby girl called Naasu Koi arrives into the world at the Tikonko community health facility in neighbouring Bo District. Her mother, Hawa Koi, has attended prenatal classes at the clinic throughout her pregnancy and made the two-mile journey from her village to deliver her fourth baby into the familiar arms of nurse Irene Moseray. It is a textbook birth.

Koi’s mother-in-law, Miatta Momoh, who is older than she can remember, sits on a hard wooden bench outside, waiting to see her latest granddaughter. The blue wall behind her has layers of faded posters from UN and non-governmental organisations — adverts for a different life. They tell her to consider an intrauterine device, to “use Mr Condom” and to get checked for Aids. Childbirth was a different experience for her, conducted at home with the help of senior women from the community — known as traditional birth attendants (TBAs). Sometimes mothers died, but no one was blamed. “It was the will of God. And if there was a delay in delivery, they would ask that woman. ‘What have you done? Please tell us. Have you done something wrong to your husband?’” Momoh laughs. “But these things used to work to get the woman to deliver!”

The government concluded TBAs were a dangerous anachronism and tried to ban them from assisting births. In 2010, it launched a free healthcare initiative for pregnant women, lactating mothers and children under five. Bylaws proscribing home births and imposing severe fines for mothers and those facilitating were also brought in. But TBAs are a fundamental part of the traditional structures that govern most people’s lives and, unlike government health clinics, are present in every village. While facility deliveries did increase, by 2013, the last time the country’s demographic and health survey was conducted, half of births in rural areas were still taking place at home.

Just that week, a horror story was doing the rounds at the ministry of health. It concerned a pregnant 13-year-old who had died recently in Bombali, in the north of the country. A TBA had locked her in a house during labour and by the time the community health worker broke down the door, it was too late. The image of the government representative, an outsider, trying to kick down a door locked by the trusted TBA seemed emblematic. While health workers may have access to the medicine, it is often the TBAs who have patients’ trust.

The image of a government representative trying to kick down a door seemed emblematic

Pragmatic solutions are needed. At Naasu Koi’s birth in Tikonko, two former TBAs watched as the nurse delivered. Since 2014, as part of a project piloted in Bo District by Concern Worldwide, an international NGO, 200 former TBAs have been trained and rebranded as MNHPs (maternal and newborn health promoters). Instead of delivering babies in isolation, they visit, encourage, check for danger signs and refer pregnant mothers to healthcare facilities. The small amount of money and social status they previously attained through deliveries is now made through selling essential items to the mothers they visit. Rather than women being locked away from government healthcare, the TBAs’ familiarity and influence in communities is being harnessed to help mothers access it.

According to the nurses at Tikonko, backed up by the town chief responsible for enforcing the community bylaws, Naasu Koi’s birth was typical. No women in the area has given birth at home in the past two years, they say, and no one could remember a maternal death. At three more remote rural clinics, in Bo and then Moyamba district, I am told the same story: maternal death doesn’t happen, not in this community, not any more. Death is elsewhere.

The next day I meet Massa Amadu, a 32-year-old nurse from Freetown sent to work in Moyamba City. Children fill every space in her small house. She has adopted six, three of whom have lost their mothers in the past two years in pregnancy or birth-related deaths. She thrusts the youngest, five-week-old Hassan, into my hands. “His mother needed blood and there was none. She had already borne 10 children,” she says.

She has one son of her own, back in Freetown. “But I should have two,” she says, showing a blurred picture on her phone. It is of a dead baby, Foray, wrapped in a white swaddle. He was the product of a relationship with a man who, unknown to Amadu, was already married. When his wife found out, problems began. “She took me to the herbalist — she wanted me to die.” Foray died in his sleep soon afterwards and Amadu ended up with severe elephantiasis. She believes both misfortunes were punishments — products of the jilted wife’s curse.

When the medicine her hospital gave her didn’t work, Amadu began to visit a herbalist in a distant village. The elephantiasis reduced. It was from the same village that she adopted Hassan. Around his neck is a tiny amulet on a string. She puts my finger on his head gently, locating a small hole. “It’s the traditional remedy for this,” she says. The hollow is Hassan’s anterior fontanelle, which can be felt in almost all babies. When it eventually closes, as it does in all children, Amadu will conclude that the charm played its role. “I take it off when I take him to my hospital though,” she laughs. “We tell the patients not to use traditional medicine”.

For Amadu, as for many people in Sierra Leone, traditional and modern medicine are complementary rather than in opposition to one another. Decisions on which to use might be based on what is most easily available, what seems to work or where one feels most respected. In childbirth, this presents a challenge. Some mothers will exhaust traditional remedies before seeking medical help. In remote areas, this leads to death. How to change this behaviour is part of a broader international development conundrum about how traditional practices viewed as harmful can be changed.

At the Tikonko health facility attendees at the monthly 10am antenatal class file in after noon. Some have walked up to five miles from villages while pregnant, and their fatigue shows. Eventually nurse Moseray begins a nutrition class, describing pictures of the correct food for pregnant mothers. The women’s eyes glaze over, so she and TBA Susan Pormeh produce a gourd rattle. It brings the listless women to their feet, dancing, clapping and chanting enthusiastically in the local language, Mende, to an easily memorised song about good nutrition and hygiene.

This approach mimics one used in Sierra Leone’s traditional secret societies, where song and dance predominate as teaching and expressive forms. Paul Richards, an anthropologist who has worked in Sierra Leone for more than 40 years, has recently published a book about Ebola. In it, he describes a “people’s science” through which communities have changed their cultural norms around burial practice and traditional healing. In Richards’ view, belief is formed by social action, not vice versa. In Tikonko, the gourd rattle seems as important a tool as the stethoscope in promoting maternal health.

However high Sierra Leone’s true maternal mortality rate might be, no single intervention can fix it. Whether through access to family planning, medication, prenatal care, emergency obstetrics, training of health staff, an effective referral system — not to mention tackling longstanding structural violence against women — the tide must raise all these boats at once. Old culprits such as corruption and inefficiency still hinder progress and there is insufficient funding for the task.

The underlying challenge is the need to bridge divides and suspicions between the helpers and the helped. In Tikonko, Moseray and Pormeh’s method of interaction with the women is vital. The nurse is both an insider and outsider — a formal practitioner, but one who can speak the local language and does not patronise, embarrass or hector. In combination with the provision of good-quality services, this is why the women have turned up today, and why they will return to give birth. “The nurse is kind here,” as Hawa Koi says. Perceptions of the state, and the quality of healthcare it offers, are not always so positive in a country where some citizens, confronted by the Ebola outbreak, concluded that their own government was trying to kill them. The distance between the urban and rural worlds, the deficit between the government and the governed, is wide.

Back in Freetown, Dr Sesay, in casting doubt on the WHO estimates, also identified a dubious utility for some in Sierra Leone’s ignominious record of the worst maternal death rates in the world. “These people [NGOs] need very bad numbers to sell to their donors and make money,” he says. “So most of the time they give out the negative part of it.”

By email, Dr Lale Say, co-ordinator of the WHO’s department of reproductive health and research, reiterated that the estimates are not precise figures, and encouraged caution making comparisons between countries. “The lower and upper estimates should be considered in such assessments,” she wrote. However, even using the WHO report’s lower estimate, Sierra Leone, would still have the highest ration in the world. Sonnia-Magba Bu-Buakei Jabbi, senior statistician at Sierra Leone’s government-funded independent statistics body was clear: “Ministry of health and sanitation officials are just trying to paint a pretty picture.”

By the time Elie and his ambulance finally arrive back at the Moyamba government hospital carrying the unnamed girl from Rotifunk, a full five hours have passed since her call for help. Her baby has still not come; the mother — probably younger than 17 — is just too small and her pelvis not wide enough. It is not clear whether the baby is even alive.

Hospital superintendent Dr James Jongopei, a youthful 32-year-old, decides on a caesarean section. In the operating theatre the following morning, surrounded by 11 hospital staff, he cuts open her belly and pulls out a tiny pink body from the red: a boy, premature. The umbilical cord is cut and the motionless, soundless baby is placed on a bright African lappa cloth incongruous against the clinical white and blue of the medical staff smocks. A mucus aspirator is pushed into his nose and throat and pumped, fluid sucked out again and again. The midwives lift him naked by his feet, vigorously massaging his back, trying to inspire circulation.

His mother needs a transfusion, and she is lucky: her blood type is common and the hospital blood bank is not empty this time. As the doctors sew her back up, her son finally coughs his way into life. There is a murmur of laughter among the delivery team. They have saved a life — two lives.

Letter in response to this article:

New mothers need access to clean water / From Margaret Batty