Womanslaughter: Sierra Leone’s mothers are bleeding to death

Women are dying for the sake of the cost of a first-class postage stamp.

The shrieking cries of newborn babies echo down the dilapidated corridors of Freetown’s largest maternity hospital. Midwives and doctors move hastily around the swamped wards, attending to the constant influx of women in labour. Mothers cradle their fragile babies, perching on the edge of crowded hospital beds.

“We don’t want our mothers and babies to die,” Ruby Williams the head nurse of the hospital tells me, “we are greatly concerned.”

The cry of a newborn is not the sound of relief we welcome so joyfully here in the UK. Although it may symbolise the safe delivery of a baby and the start of a new life, for women in Sierra Leone, the natural process of giving birth can be catastrophic.

Sierra Leone is the most dangerous country in the world for a pregnant woman. With the highest maternal mortality ratio on the planet, mothers across the country are forced to recognise how fatal bringing new life into the world can be devastatingly ironic.

Princess Christian Maternity Hospital is the referral hospital for many medical clinics across Sierra Leone, including the medical centres in both slum and rural communities, meaning that if there are complications during labour, mothers are sent here; it is a hospital which is constantly running at capacity.

While 99% of maternal deaths occur in the developing world, it’s thought 99% of these are also preventable. The leading cause of death in childbirth is catastrophic bleeding, known as Postpartum Haemorrhage (PPH).

In the UK, after a mother gives birth, she is given an injection of Oxytocin, which prompts the uterus to contract, eliminating the risk of catastrophic bleeding. Oxytocin is a drug which must be refrigerated to work effectively.

Electricity is a luxury in Sierra Leone, hospitals that are fortunate enough to have it, experience frequent power cuts, which can be disastrous to stocks of medication. Therefore using Oxytocin post-childbirth is unrealistic for the majority of health care facilities in Sierra Leone, and this leaves women at high risk of catastrophic bleeding.

In 2015, the medical community welcomed the news that the World Health Organisation (WHO) had approved a drug for use to treat and prevent postpartum haemorrhage, a drug initially used to treat stomach ulcers could now save thousands of mothers bleeding to death across the world.

This drug is called Misoprostol, which can be used as an alternative to Oxytocin. It is temperature stable and can be easily administered, just three tablets of Misoprostol given under the tongue or rectally can save a haemorrhaging woman’s life. Each dose costs less than a first-class postage stamp.

But women across Sierra Leone are being denied access to this life-saving drug, meaning thousands of mothers are still dying during childbirth.

The Sierra Leone government does not supply Misoprostol to hospitals across the country, the only supplier of the medication is a small NGO, based in the United Kingdom.

Life For African Mothers was founded by Angela Gorman in 2005, Gorman is a retired NHS neonatal nurse, in November 2005 she watched a BBC Panorama documentary which showed devastating scenes inside the maternity hospitals of Chad, Africa.

Angela and three others were so moved by the documentary that they contacted the BBC and took action. Gorman visited Chad and later founded her organisation. For the last 14 years, Angela has worked tirelessly to save thousands of women’s lives across west Africa through donations of lifesaving medication and the training of midwives. Her organisation is the sole provider of Misoprostol to Sierra Leone.

Why would the government deny Sierra Leone’s women access to the life-saving drug? “I think it might be the risk of the medication falling into the wrong hands,” Angela tells us. Misoprostol can also be used to facilitate abortions. In a country where abortions are illegal, are women being denied life-saving medication in the fear that it could be used for the wrong reasons?

Morlai Kamara, who lives in Kroo Bay, Freetown, has volunteered with Life For African Mothers for over seven years as their Sierra Leone distributor. He works tirelessly to distribute the medication by hand to each healthcare facility, ensuring the medication gets to the right person, a huge administrative role which bears a lot of responsibility.

I was fortunate enough to join him on the distribution of thousands of tablets in September 2018. When asked why he thought the Government was not supplying Misoprostol to its hospitals, he told me: “Misoprostol is very expensive for the free health care in Sierra Leone, presently the ministry fo health is working on [a] rapid posting of doctors, matrons and nurses.”

The lack of resources Morlai refers to is instantly apparent as I sit in the delivery ward of Princess Christian Maternity Hospital (PCMH), I am in awe of the midwives working in such strenuous conditions, I felt helpless as an onlooker and wished I was qualified or capable enough to share their workload. But all I could do was watch, having been in the delivery room of a UK hospital just months before, after the delivery of my beautiful niece, a new level of gratitude for the country I was born in to washed over me.

Contrary to the statement claiming that Misoprostol is too expensive for Sierra Leone’s healthcare programme, Angela tells me about the costs of losing a mother through childbirth, these include the massive loss of productivity, caring for orphans and the aid to affected countries. “It costs the world £15 billion to lose 550,000 women a year, the number of women dying in childbirth when we first started, it’s now 300,000,”

“To save the women would have only cost £5 billion, so if we don’t do this on humanitarian grounds, we should do it on economic grounds,” she continues, “but how can we even quantify the emotional costs?”

So why are so many women dying?

Postpartum haemorrhage is not a direct result of childbirth. However, for mothers who have experienced prolonged labour, the risk is increased. Mothers in Sierra Leone are at risk of experiencing prolonged labour for a number of reasons.

Education plays a key role in women accessing medical care at the right time. Sat in the ‘delivery room’ of a small slum health clinic in Freetown, I ask the midwives working about the challenges they face. Princess, an energetic midwife tells me of the risks of home births: “We face challenges within the community,” she says. 

“Most of the women here choose to deliver in their community with a traditional birth attendant,” she tells me about their local slum community, claiming that pregnant women are choosing to stay and give birth at home with unskilled birth attendants who have befriended them.

I question why unskilled birth attendants would be encouraging this. Hawa, another midwife, interrupts and says: “Some of them are relatives,” she says, obviously frustrated that women are being urged to risk their lives by giving birth at home.

Questioning the risks, Princess answers quickly: “Postpartum haemorrhage, sepsis, they don’t have the instruments we use here, at times they even do the delivery barehanded,” she says abruptly.

A country scarred by civil war and extreme poverty, Sierra Leone’s infrastructure can also pose a huge challenge in accessing medical care. This is especially obvious in Freetown. The overpopulated city experiences traffic and congestion that results in turmoil. I have sat in the back of a tuctuc for hours while the driver painstakingly attempts to negotiate the congestion across Freetown to get me back to my accommodation safely before dark.

Women in labour can face many obstacles when trying to reach the hospital via road, resulting in prolonged labour. In turn, it increases the risk of catastrophic bleeding. Ruby Williams is the Matron at PCMH, Freetown’s maternity hospital, “due to the traffic flow within the city, as you can see the roads are jam-packed with people, vehicles, tuctuc, we’re facing a major constraint”, she says. “The patient could be coming on her way, and that patient could lose her life due to postpartum haemorrhage,” she tells me.

Ebola had a devastating effect on Sierra Leone’s already-strained healthcare workforce. Many providers lost their lives to the relentless disease. Marla Seacrist is co-director of Hawa’s Hope, a small American NGO working to reduce maternal mortality in Sierra Leone. “Just when I think Sierra Leone was beginning to recover from that post-war environment, the Ebola,” she says tearfully. “We had friends that died from Ebola because they were health care providers here, serving. It was so complicated and so difficult”.

Access to medication can be another obstacle. If the hospital does not have sufficient stock, patients simply can’t be treated effectively. Often patients are asked to pay for medication and then asked to pay the nurse to administer it, as the unfortunate chances are she’s not getting a wage herself. For the majority of women living in extreme poverty, there is just no option, and the likelihood is if they can’t pay, they die.

In 2005 the United Nations published their Eight Millennium Development Goals, which they define as “eight goals with measurable targets and clear deadlines for improving the lives of the world’s poorest people”. The fifth development goal was to reduce maternal mortality by three quarters by 2015. This target was not achieved.

The scary reality is that in recent years, maternal mortality in Sierra Leone has been on the rise.

In May 2017, Sierra Leone’s latest Maternal Death and Surveillance Report was released. “This latest report reveals an unacceptably high level of maternal deaths in Sierra Leone, which is a true tragedy for our nation,” said Dr Ernest Bai Koroma, President of the Republic of Sierra Leone. The study confirmed that Sierra Leone has a devastatingly high maternal mortality ratio (MMR) of 1,165 deaths per 100,000 live births.

Family Care International and The International Centre For Research On Women published a report on the cost of maternal mortality in 2014, titled “A price too high to bear.”

The study painted a picture of the wider effects of maternal deaths. It explored the high correlation between mothers dying and their babies survival rate, “of the 59 maternal deaths in the study, only 15 babies survived the first 60 days of life.”

It also looked into the effects on surviving children, and that in some cases they “were withdrawn from or forced to miss school because economic disruptions made it difficult to afford school fees. When children did continue their schooling, often their grief and new household responsibilities negatively affected their schoolwork.”

For a country suffering from the worst maternal mortality ratio in the world, reducing the number of mothers dying in childbirth in Sierra Leone could play a key role in breaking the cycle of extreme poverty.

Angela Gorman, a retired neonatal nurse from Cardiff, worked at the University Hospital of Wales for 30 years. One evening, after a long shift as the Sister in charge of the Neonatal Intensive Care Unit, she sat down to watch a BBC Panorama documentary, which revealed the devastating maternal mortality rate in Chad, Africa.

Angela was so shocked that she decided to contact the BBC directly, and she was not alone. Three other viewers also contacted the broadcaster. As a group they took the bold decision to journey to Chad and see where they could help, the BBC joined them and documented this, What Happened Next was aired in December 2005.

Moved by what she saw in Chad, Angela decided to set up an organisation, Life For African Mothers, when she got home. Fourteen years on, Angela has visited 13 countries across Africa 35 times. Life For African Mothers has saved thousands of lives through the supply of life-saving medication, such as Misoprostol, and the training of hundreds of midwives.

Angela, who has never taken a salary from the charity, now works tirelessly to sustain the supply of this lifesaving medication. She also works to recruit midwife volunteers from the UK, and facilitate their trips to Sierra Leone and Liberia where they conduct four day long workshops to midwives working in the two countries. This training is invaluable to a healthcare workforce that is under extreme pressure.

The charity is very small, with no full-time employees. Despite this, the work they do has a substantial tangible impact across West Africa, I have first-hand experience on how respected the work they do is, especially by the doctors and midwives working in such difficult conditions.

Sitting in a small office just off the delivery ward of PCMH, the deputy matron of the hospital tells me: “Two years ago when I joined. We were seeing maternal deaths in double figures per month. For the past two years with Misoprostol and the support from Life For African Mothers, the numbers have decreased to one figure, and sometimes we can go a month without a maternal death,”

“I hope they continue to support us with the Misoprostol. The past month we have struggled with supply, I really hope they continue to support PCMH,” she told us.

If Sierra Leone is to see a reduction of the high maternal mortality ratio in the near future, significant effort must be taken to improve access to quality healthcare. In the meantime, it’s apparent that efforts should be made to support and sustain the supply of lifesaving Misoprostol, so mothers across Sierra Leone are not bleeding to death at the cost of a postage stamp.

 

 

 

 

 

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Featured image by Eloise Reader