Tackling Sierra Leone's appalling maternal death rate

There was no nurse in this village, Nyandehun Besiema, in Pujehun district in the Southern Province of Sierra Leone, and no traditional birth assistant (TBA). That, then, meant a journey during labour to a nearby town across a river. First, she was rowed in a canoe and then men from the village carried her in a hammock through jungle.

On the other side, in bushland, the men realised her pain was the result of labour and so left her to cope alone.

"I gave birth by myself," Amie, who does not know her own age, says. "Nobody was there to help me.

"After [the birth] the [placenta] stayed within me and I was struggling. The men came again, and they had to carry me again. And when we reached the health centre, the baby had died on the way.

"I was so helpless."

Amie was able to stay in the health centre for a week while she recovered from her ordeal. Healthcare in Sierra Leone is free for pregnant women and lactating mothers, an initiative introduced in 2010 by the president, Ernest Bai Koroma. However, healthcare, as is clear from Amie's story and stories of other village women like her, is rarely readily accessible in a country that has the highest rate of maternal death in childbirth in the world. For every 100,000 live births in Sierra Leone, 1360 mothers die, compared to nine in the UK.

In Sierra Leone, Amie's trauma is commonplace.

There is one nurse or midwife per 10,000 people and in Pujehun district there are just three ambulances per 375,000 people. The district is vast and the terrain not easily passable with unsurfaced, potholed roads meaning the ambulance can take eight hours to arrive.

Women in villages without health centres often have no choice but to walk for hours to reach help with no guarantee they will make it without they or the baby dying on route.

Nyandehun Besiema now has a health centre but it is a far, far cry from adequate. Like the rest of the structures in the village, it is made of mud with wooden supports and, as with the rest of the village, there is no running water and no electricity.

In two small, dark and stiflingly hot rooms, nurses Kadiatu Sama One and Veronica Konneh, wearing their striking bubblegum pink uniforms, work with next to nothing to bring new life into the world. There is barely enough space in the delivery room for a second person to hold up a torch or swat away mosquitos. There is one bed so if two women are labouring at once, one must lie on the floor.

Seven months ago Kadiatu (there is another Kadiatu Sama in the district but she is the eldest) left her husband and four children, who she sees once a month, to come and work in Nyandehun Besiema, a placement it has taken her some time to adjust to.

"What caused my distress, when I saw the community was the place was small. The [health centre] was not up to standard: the delivery room is small, no toilet facilities, the accommodation was not conducive…so, when I saw these things, I was not happy, I was stressed," she says

"I adapted because of the job, I’ve got myself committed. That whatever the condition I see, I have to work with because that is what I signed for.

"That gave me courage to stay, even though it is strenuous, we are managing."

When women go into labour away from the village, the nurses will travel to them on foot, crossing rivers.

Without electricity, medicine such as vaccines cannot be stored so the nurses must travel to fetch it from another village, returning it at the end of the day. For those who can afford it, transport between villages involves chartering a motorbike - a Honda - and the nurses do this when there are vaccinations to be given.

Although she qualified eight years ago, Kadiatu, 34, was only placed on the payroll in 2016. Many nurses, as Veronica is now, are expected to work as volunteers.

Veronica, 28, was sent to Nyandehun Besiema after finishing training 22 miles away in Pujehun town where her husband still lives. The nurses work across eight towns with a population of 1694, employed seven days a week and working through the night, if needed. The most common ailments they see are malaria and diarrhoea, as well as sexually transmitted diseases.

Veronica goes on to speak of Bondo Society, the secret society where girls are "trained" to become wives and are subjected to Female Genital Mutilation (FGM). Although FGM was banned for girls under 18, it is carried out in the country from the age of 10.

"The sign when women marry and begin to have children in this village is the development of breasts," Veronica says.

"They have to go through the traditional set up, the Bondo society. They train them how to cook, how to take care of their husband. They train them how to give birth - what you have to do, how to prepare for a baby - when you have given birth, you have to breastfeed. After the Bondo Society you are qualified as an adult.

"Female circumcision is a part of this - always. All - most - of the women in the village will have had it and gone to the bush." The death of a 10-year-old girl in Sierra Leone in December sparked renewed calls for an end to the practice, which is an entrenched part of the culture carried out by respected women known as soweis.

NURSE Kannie Kamara, slight and quiet, her head bowed as she speaks, cradles her daughter Betty Tucker. Not yet one month old, Betty suckles on her mother as she waits to be seen at the health centre by Veronica or Kadiatu.

Nurse Kannie - this is her name, not her occupation - has walked four miles from her village of Gbomukor where there are no health facilities. The teenager says she is 17 but she could easily be 13, she looks so young.

Nurse Kannie's boyfriend, whose age she says she does not know, bolted when her parents found out she was pregnant.

Sierra Leone has some of the highest rates of teenage pregnancy and child marriage in the world with one in eight women marrying before the age of 15 and nearly 40 per cent before the age of 18. Some 28 per cent of girls will give birth between the ages of 15 and 19 and, as visibly pregnant girls are banned from going to school or sitting exams, this severely impacts their education and life chances.

Teenage pregnancies are also particularly high risk. During her labour, which she describes as a "hot burning fire", Nurse Kannie walked to Nyandehun Besiema only to be told both nurses were away. A TBA in another village supported her to give birth, along with her mother.

The teenager says she has not yet been through Bondo Society but there were plans for her to be initiated in April. She doesn't, however, want to be married straight away.

"I want to be part of [Bondo Society]. My friends have been through it," she says. "But I don’t have any thought of getting married now.

"I look at [Betty's father] to be somebody with a curse. He doesn’t want to be responsible.

"Now my desire for my child is for my baby to leave Africa for the White Man’s Land."

Nurse Kannie was supported by a TBA but the traditional practice is being phased out by the government, which has banned TBAs from working alone but does allow them to support the nurses.

In Nyandehun Besiema Amie Kpaka, who looks far more senior than her 55 years, lives with her 11-year-old grandson Musa Fawaudu. Her daughter, her only child, died at the side of the road while walking to a health centre.

"When the girls are up to 13 years of age, we give them to men to marry them," Amie says. "My daughter was just 15 when she was given to marriage. She spent a year in her married home and then she became pregnant."

Her daughter, Musu, began bleeding so she and Amie started the long walk to the medical centre to deliver her second child. Musu was exhausted so men were sent for to bring a hammock to carry her.

Amie, still clearly weighted with grief, says: "Before the men came with the hammock, she delivered. When she gave birth and she breathed, that was the end.

"When my daughter died, I was crying among the people. But before we reached another town, the baby also died. She gave up. I was helpless. Look at our situation. My daughter died. The baby died. My mother wasn’t alive, my father wasn’t alive. I asked myself, ‘how am I going to live, my daughter has died. The baby has died’."

Musu's husband also died and so Amie chose to raise her grandson, who is a great comfort to her. She also decided to train as a TBA to help other women as she could not help her daughter.

The realisation came after she was present at the labour of her sister's daughter.

Amie was given a sharp knife to cut the umbilical cord. "I thought if I cut it will the baby not die? The TBA said, ‘no’. She held my hand and she told me to cut and I did a cut.

"That was the first day that I started working as a TBA."

Amie has delivered more than 200 babies but when the nurses came to the village, she stepped aside for them. Now, they work closely together and there is clear mutual respect. Women of the village will still come first to Amie and she takes them to the health centre.

Across the village, Tenneh Gasumu, the wife of the chief, has given birth to seven children, only one of whom has survived.

Tenneh came from another village following the civil war, which, running from 1991 to 2002, devastated the country. The villagers had left to enter a refugee camp and the village is still recovering. "No form of development has reached this village," she says.

She leads the women's group in the village and says they have no access to money and rely on the men to provide for them.

THE earth is yellow and the sky bowing to meet it, a pure, clear blue. Against this backdrop of primary colour, a rainbow of brightly dressed women bursts forth, unstoppable.

Joanna Tom-Kargbo, Senior Programme Manager for Health Legacy with Christian Aid, is smiling at the sight of dozens of mothers holding two metal boxes above their heads while singing with joy and welcome.

This is Bumbeh Pejeh village, one of 22 communities in Pejehun district - there are 867 in total - that Christian Aid with its partners RADA (Rehabilitation And Development Agency) and BAN (Budget Advocacy Network) works in.

These metal boxes are changing lives for women in these communities. The premise is straightforward: women join the box scheme, paying in a certain amount of money each week. This gives a source of finance to families in need of loans, which must be paid back with interest. Three women are custodians of each box, needing all three to open it and dispense money.

Loans are given for children's education and for healthcare, among other necessary items.

While introducing the box scheme, the NGOs take the villages through a two-day empowerment project that is very much led by villagers themselves. They also use a scheme called Gender Model Family to widen rigid gender roles.

Improvement in sanitation from the NGOs' involvement has also lead to a dip in the number of malaria and diarrhoea cases.

"I think for me, the response from the community in driving their own change is something I’m very much proud of," Joanna says.

"You can see when you go to the community, you talk with the community and things that you witness, in just 18 months, it’s amazing.

"You see the women are so confident. They are vocal.

"They are coming together, they are doing their businesses, they are contributing resources even to health service delivery within their communities."

While we visit there is a scandal in the village. A young girl of 16 is pregnant and a young boy of 17 is the father but the boy has run off, believed to have gone to Bo, a large city, to escape responsibilities and recriminations.

The girl's father has come to see the chief to ask for advice about what to do next.

As I'm preparing to speak to the man about the situation, a murmur bubbles and spreads. The boy has returned to fetch his belongings and has been collared by two neighbours, who have brought him to the health centre where a crowd is gathering outside.

He is positioned on a chair to await his fate while the girl is summoned, along with both sets of parents. The boy has the good grace to look utterly shamefaced and what rotten luck for him, to sneak back on an afternoon where not only is the girl's father present, Joanna is on the scene and an international journalist and photographer are there to capture his inglorious moment.

The situation is complex: this is the second time the boy has impregnated the girl, who is sleeping, with her toddler son, on the floor of a relative's house. Her parents have disowned her. His parents, meanwhile, have married him off to another woman to remove him from the situation.

The teenagers sit silently while the adults scrap and wrangle around them. Joanna's wheesht cannot be haud. "Tell me," she calls to the crowd, "What is the slogan of our First Lady?" Responses are not forthcoming.

"Who can tell me?" No one can tell her, but before long Joanna has the crowd chanting "Hands off our girls" on repeat. She is a force and she overwhelms the group before her. She gives a lecture on underage age sex, use of condoms, education for girls and ends with the bald fact that, had this boy been in the city, he would have faced the penalty for rape of life imprisonment.

Joanna's determined energy is shared throughout the village. It is present in the calm and and resolute manner of the village nurse, Neimatu Songa, who speaks of her love for her "Godly job". Her health centre, with the input of the NGOs, has lavatories, space and equipment, albeit very basic equipment.

It is in the pride of box keyholders Massah Brewah and Adama Fabuleh who help decide who will benefit from loans.

WIDOWER Ibrahim Koroma says he is still traumatised by the death of his wife, Mamie, who died in childbirth along with the baby. He is raising his two children, Massah, 16, and Abdul, 12, alone. Ibrahim and Mamie had six children in total but four died.

It is obvious that maternal health also impacts men and there is an acknowledgement that men must be brought on board in order for women to advance. Women in the village say domestic abuse is common place. Joanna says in the main, men are supportive of their wives. The nurses in both villages now say men are coming to the health centres for condoms and are accepting of their wives having the contraceptive injection or Pill, a huge step.

Joanna says: "The men are very, very supportive. It is all around mindset shift. And it is all around their awareness. So, before this time, in Pujehun, it is Muslim-dominated district where women are not allowed to talk, it’s a sign of disrespect for the men.

"Now men are doing the laundry in some villages, husbands and wives are cooking together. And this is, in turn, assisting in maternal health by easing the domestic burden on heavily pregnant women."

"It is our dream to expand," Joanna adds. "The communities are yearning for this project.

"We hope that we get the resources, and we are really calling on supporters, we are calling on people out there, so they can come to the aid, because the situation here is not really good."

Fatamata Dugba, brought to Bumbeh Pejeh several years ago for an arranged marriage, has given birth to five children. Two have survived: her boy, 13, and daughter, 12, both live with relatives so that they might go to school. Fatamata sees them just once a year and only then if she is able to take them gifts such as a chicken or palm oil.

Her story shows the impact the box system can have.

Six months ago she was pregnant again, seven months along. After a healthy pregnancy, she had begun to feel pain and an ambulance was called. Fatamata was safe in the knowledge the box would provide for her medical expenses, a burden eased at a frightening time.

"I can’t remember how long the ambulance took because my condition was…[she trails off].

"They had to remove the womb. I wanted to keep it, but my husband gave the authority, he said because of the situation, they should get rid of the womb. The men gave the order, so I just decided to accept what he did for me to have lived."

Tiny chicks scratch around near Fatamata's feet as she speaks, while their mother hen tries to gather them up. While pregnant women's healthcare is free, blood is not covered.

"My children's father is a teacher, it's voluntary so he doesn't get paid. I lost some amount of blood," the 30-year-old adds.

"I loaned some money from the box. I would have died if there hadn’t been any box.

"Because of the existence of the box that is one factor of my existence."

•This Christian Aid Week, May 12-18 2019, stand together with mums in Sierra Leone.

A gift of £7 could help buy a bag of cement for a new health clinic and help provide the urgent care that mums need.

Visit caweek.org/donate or call 020 7523 2493 to make a donation.

Your gift will support communities such as those featured and where the need is greatest.

Christian Aid is also inviting supporters to join its campaign to drop Sierra Leone’s debt that was incurred during its fight against Ebola, in 2014 to 2016.

It was the worst outbreak of the disease in history, killing 10 per cent of the country’s healthcare workers.

Debt repayments are taking money away from improving healthcare services that is so desperately needed.

Sign the petition at www.christianaid.org.uk/christian-aid-week/campaign-petition-drop-sierra-leone-debt