August 05, 2010

By encouraging women to come to clinics sooner, MSF is helping more women in Sierra Leone deliver children safely.



Sierra Leone 2010 © Annika Schaefer/MSF

Kenyan midwife Rhoda Chemati examines an expecting mother in the Waiting House of Jimmi Bagbo Community Health Clinic.

For some women, services such as antenatal care, obstetrics, and postnatal care are expected as a matter of course. Women in Sierra Leone, one of the world’s poorest countries, can barely imagine such things. They live in a place with perpetual shortages of midwives, gynecologists, and drugs. Very few have the opportunity to give birth in a clinic, much less a hospital. The consequences of this can be lethal. More women and their children die during pregnancy or birth in Sierra Leone than almost anywhere else on earth.

Doctors Without Borders/Médecins Sans Frontières (MSF) provides care for pregnant women in two districts, care that often saves lives. At one MSF facility, the Jimmi Bagbo clinic, located around 45 kilometers (28 miles) south of the city of Bo, Florence Lahai, an MSF midwife from Sierra Leone, describes a 19-year-old woman who is about to give birth: “She has come to us on her own," Lahai says. "She has been in labor for five hours. It’s her first pregnancy but she’s being really brave.”


Sierra Leone 2010 © Annika Schaefer/MSF

Sierra Leonean midwife Florence Lahai at a meeting with traditional birth attendants (TBAs) at Jimmi Bagbo.

It’s hot inside the clinic. Lahai mops the young woman's brow with a damp cloth, checks her pulse and her contractions, and feels her belly to determine how the baby is situated. Then everything happens quickly, and the young woman is soon the mother of a healthy baby daughter. Community health officer Elisabeth Hawa Abdulai takes the girl, makes sure her airways are clear and clamps and cuts the umbilical cord. Abdulai rubs palm oil into the baby's skin to keep her warm and administers a vitamin K injection to prevent hemorrhaging.

Just a few feet away, in the clinic's yard, more than a dozen women are assembled under a large straw roof. These are traditional birth attendants who have come to Jimmi Bagbo from the surrounding villages. They are in high spirits, singing, dancing, and drumming. Lahai and her colleagues are trying to encourage the birth attendants to help more women deliver their babies safely. “We need your help if we are to do anything about the numbers of mothers in our country who die in pregnancy and childbirth," they tell the attendants. “The pregnant women from the villages come to you when they need help.”

It makes sense, after all. This past April, Sierra Leone implemented a system of free healthcare for pregnant women, breastfeeding mothers, and children under five, but there are still precious few resources in rural areas for expecting mothers. A long, arduous journey is often required to reach the nearest clinics. There are no ambulances, and many women are too poor to afford a bus ticket, meaning they must walk for hours in the tropical heat. For women already in labor this is practically impossible, and thus, not surprisingly, home births are the norm.

But the risks are great. Many of the attendants have only limited training. Few have rubber gloves or sterile instruments, which leaves mothers and their babies open to exposure to lethal infections. They are not able to respond to complications that might arise, either. In such cases, the mothers can spend days in labor at home in their villages rather than getting the medicines, blood transfusions, or caesarean sections they urgently need. Even if they do somehow get to a clinic, it could be too late.

Jimmi Bagbo is also in a rural area. The road leading to it is a bumpy, sandy track. Some patients travel up to ten hours to reach the clinic. It is not, at present, possible to reduce their travel time. But it is possible to encourage women to make their way to the clinic sooner, to make it clear that they have a place to go where they will be looked after in the time leading up to childbirth.

To that end, MSF built a waiting house on the grounds—a large room with several beds and a cooking area outside—so women can spend the last few days or weeks of their pregnancy here as opposed to waiting for the onset of labor before trying to make the journey. “Please tell the women in your villages about our clinic and our waiting house,” Lahai exhorts the birth attendants. “Bring them to us! We can help them and we are happy to see each woman who comes to us.”

The outreach to the attendants has had some success, it seems, as a growing number of them are working with MSF and accompanying pregnant women to the clinic to give birth. The birth attendants even waive part of their fee in order to allow their charges to receive the best possible care.

On this day, seven women sit in the shade in front of the waiting house. Among them is Aminata Baimba. She arrived six days ago from her home village of Bomu Kaku. The 28-year-old is going to deliver her sixth child and expects contractions to begin at any moment. She is calm, however, even when she says that only two of her five children are still alive. “One of my children died a week after the birth,” she recounts “I had given birth at home.” The umbilical cord was not clamped and cut in sterile conditions and the newborn baby became infected with tetanus.

She is determined to avoid a similar fate this time, she says. “I heard about the clinic in my village, so I left the children with my mother-in-law and set off. The birth looks likely to be difficult because the baby is lying in the breech position, but I’m being well looked after here." She seems confident that this time, her child's life will have a healthy beginning.

Obstetric Care Saves Lives

In Sierra Leone the mortality rate among women giving birth was 2,100 per 100,000 in 2005—more than 70 times higher than it was in Europe. The rate of infant mortality is also one of the highest in the world. MSF teams work in five clinics with employees from the Ministry of Health to help thousands of pregnant women before, during and after birth. In cases of high-risk birth and emergencies involving severe acute hemorrhaging, stalled labor, and other complications, patients are treated in the Gondama Referral Centre (GRC). If they have already lost an excessive amount of blood or are in shock when they reach the hospital, then the options are limited. However, emergency operations carried out by MSF have saved many lives, and in 2009, over 96 percent of MSF’s patients survived giving birth.

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