Sierra Leone has one of the highest maternal mortality rates in the world. In developed countries, on average there are fewer than 10 maternal deaths for every 100,000 live births. In Sierra Leone, the rate is nearly 200 times higher.

That statistic, from the United Nations children’s agency (UNICEF), is just one of several staggering indicators of the lethal nature of childbirth in one of the world’s poorest countries.

“The maternal mortality rate in Sierra Leone is very high and more and more women continue to die," said Dr Peter Sikana, a reproductive health specialist with the UN Population Fund (UNFPA) in Sierra Leone. "Most of those women die from labour, profuse bleeding and a good number of complications of pregnancy and infections after deliveries.”

The country, which is still recovering from a decade-long war that ended in 2001, ranks second to the last on the UN’s Human Development Index, just above Niger - a desert country with far fewer resources than diamond and gold-rich Sierra Leone.

And high rates of maternal and infant mortality - one in six babies dies at birth - are two of the worst symptoms of Sierra Leone’s ailing health system. “These figures… are driven by a fatal mix of poverty, ignorance and poor health provision,” said Médecins Sans Frontières (MSF) in its report ‘Lessons from pain - treating Sierra Leone’s endless health emergency’ released earlier this year.

Lack of training
In her lifetime a Sierra Leonean woman has a one in six chance of dying in childbirth, UNICEF says. One of the reasons is because many young mothers have narrow pelvises, which can lead to obstructed labour. Female genital excision, which is almost universal in the country, is another complicating factor. Scarring from the procedure can make labour problematic.

The use of traditional medicine can also be hazardous. One mixutre in particular stimulates contractions but also causes ruptured uteruses. Postpartum haemorrhage causes about a quarter of maternity deaths in Sierra Leone, according to MSF.

"We have a situation in Sierra Leone where the pregnant mothers would like to go to quack doctors and birth attendants during pregnancy and delivery, but when they experience medical complications that is when they come to the hospital,” said Dr Francis Smart from the Health Ministry’s reproductive health division. “Most times those mothers when they arrive are already at the point of death.”

The MSF report cited the experience of one woman who said she had four stillbirths at home before finally giving birth to a healthy baby once she was able to get to a hospital and have a caesarean section.
Midwifery is a way that some Sierra Leonean women find to make a living for their families in a nation where at least 65 percent of the population is unemployed. But many of the women lack the skills to run the delivery homes that they operate, said Dr Sikana.

"This issue of unskilled birth attendants is causing a serious problem in maternal deaths and needs to be regulated by the government,” he said.

Mamie Joseph, a 60-year-old midwife who runs a delivery home in Freetown, said traditional delivery is an age-old practice that Sierra Leonean mothers know well.

"I have been in this practice for over 35 years now and I have not experienced any death,” she said. “We the traditional midwives are helping the health programme in Sierra Leone. For example, when a woman is in serious pain at midnight and there is no hospital near she would definitely come to the traditional midwife.”

Poor resources
Medical professionals and Sierra Leonean women themselves say another reason they go to the midwives is because they lack the funds to pay for hospital care, and in many cases they don’t even have the transportation costs to bring them to a health centre. Click here to read a Hear our Voices about one pregnant rural woman’s plight.

Through a cost-sharing scheme at the government-run Princess Christian Maternity Hospital, Sierra Leone’s biggest maternity hospital, in Freetown, patients pay 40 percent of the cost of healthcare and medicine. Despite the reduced fees, many women still choose to visit midwives.

One recent afternoon, a dozen pregnant women lined up at Mamie Joseph's delivery home on a hilly and densely populated suburb that overlooks Freetown. One of the women, Afsatu Yasine, said she prefers the delivery home than the hospital because it is cheaper.

"My husband is not working and we cannot afford such a bill,” said the 31-year-old mother of three. “But at Mamie Joseph it is cheaper.”

Another problem with providing service to Sierra Leone’s pregnant women has been a lack of skilled medical personnel. The country’s poor economy drove many away and then the civil war forced out others. Those who remain struggle to earn a living.

“Because of the inadequate incentives most of the trained doctors and medical staff are not always present at hospitals and go elsewhere around town to do jobs where they can earn more money,” Dr Smart said.

In addition to poor salaries, staff members say a lack of basic supplies and services makes work difficult at the Princess Christian Maternity Hospital.
"The referral system is very weak,” Dr Smart said. “We do not have well-organised ambulance systems and one of the two ambulances assigned at the hospital is completely down at the moment. How can we get patients who need emergency care to come to the hospital?"

Dr Ibrahim Thorle, the medical director of the hospital, said although doctors performed caesarian sections, the full kit necessary to perform the life-saving operation is incomplete. In addition, there is a lack of medicine. Click here to read a Hear Our Voices with Dr Thorle.

"We are constrained sometimes to give prescriptions to patients to buy drugs outside of the hospital," he said. "This is just the case of Freetown, the capital city, and in the interior the case is worse.”

Way forward
Sierra Leone's minister of health, Abator Thomas, said maternal health was a “major concern” for the government. She said a new project called the Accelerated Childcare Support and Maternal Health Programme aimed to coordinate all of the health institutions and draw up a national plan aimed at curtailing maternal mortality.

"We expect to start this project soon, in at least about a year, depending on international donor support," she said.

MSF says it has invested in maternal “waiting houses” near the district hospitals in northwestern Kambia district and the central town of Magburaka. Pregnant women near birth or with complications wait in the houses to minimise the time between the onset of labour and contact with qualified medical help.

“They are open to any pregnant woman who wants to spend the last few weeks close to a hospital,” MSF said in its report. “The record of the relatively limited number of mothers passing through these houses in the last one and a half years suggests a substantial impact on mortality.”

One 30-bed structure costs about $2,000 to build and an additional $2,500 per year pays for three staff to run and guard it. The World Food Programme (WFP) supports the houses with food deliveries, MSF said.