Before the Beginning

02 December 2015

“She arrived septic and in a bad condition”.

I’m sitting in the morning meeting of the hospital that MSF is starting to support, it’s only 8am and already the heat and humidity is building up.

Sierra Leone remains the most dangerous country in the world to be a pregnant woman, and over the last years it has gotten worse.

We are here looking at ways to improve maternity services, but we are also reaching beyond the hospital gates to try and better understand the full picture of what it means to be a pregnant woman in the country.

In 2011 maternal death accounted for 36% of all deaths in women aged between 15 - 49. It is almost certain that it is higher now.

Since Ebola, the World Bank has estimated that maternal mortality will rise by a further 74% from the pre-epidemic levels.

Quite simply, for women there is a silent public health emergency on an epic scale burning in the hills around us.

This is my third mission in Sierra Leone.

I clearly remember my first shifts in a hospital here, women arriving horrendously late and with multiple complications. The fate of their baby often sealed before they reached the hospital doors, and occasionally their own lives too.

This time I’m the one listening, hearing the doctor tell me of his night and the challenging cases that were brought to him.

An 18-year-old girl in her second pregnancy, arrived after several days of obstructed labour. The baby’s head visible from outside, but not coming. Contractions completely stopped and the bladder largely distended.

Unsurprisingly she showed signs of a severe infection, as did her unborn baby whose heart rate was running alarmingly high.

He decided to take her to theatre where he encountered a difficult and traumatic caesarean section.

The baby dying minutes after delivery and the girl losing litres of blood. A long and infected labour, with a caesarean section in the late stages of labour has many risks.

In this case the uterus tore down to the cervix and through major arteries. Luckily, for now, she remains alive and stabilising. Many tuts, many heads shaking, why did she come so late?

In the following days I took a journey out of the town to see where our patients are beginning their journeys from, and what care is available in the community.

I took the girl’s story with me and this is what I found.

Like many women she had begun her labour at home. Officially home birth is illegal in Sierra Leone, but it still accounts for roughly 50% of all births.

She lived in an agricultural village, her mother giving her “native herbs” to induce the labour, the contractions begun but she did not deliver quickly and walked the several miles to the nearest health post.

At the health post she was assessed and found to be in early labour, over the course of that day and night she progressed slowly through the labour.

As she opened completely and was ready to birth her child, the contractions stopped. The health worker checked her and found that she had a large bladder, which can sometimes stop the baby’s head from passing through the birth canal.

She wanted to help the woman to empty her bladder, she knew how to do it, but the simple equipment she needed had run-out and not been replaced.

The health worker knew that an ambulance would take too long to get down the thin mud roads, so put the woman on the back of a motorbike and sent her to another, larger, health centre.

The girl arrived just before sun rise. The baby’s head was very low and could be seen. The midwife in the centre had had training on how to use a vacuum extractor, which can be used to help deliver a baby in the late stage of labour, the centre had a working machine too.

But she had never used it on a real patient and had no-one to supervise her.

On examination, she found the bladder to be full too. The clinic had a urine catheter which was supposed to be single use only, but was being repeatedly used as it was the only one in the centre.

Unable to pass the soft, rubber catheter she called an ambulance and began antibiotics. Then they waited, and waited.

Around 11 hours later the ambulance arrived, the girl’s condition deteriorating. The head sitting at the exit to the world, and the bladder full.

The ambulance then took the bumpy journey down the pot-holed road to the main hospital, around other three / four hours.

And so she arrived, and a new story began.

What is left for her?

Quite possibly an obstetric fistula, like the other teenage girl on the ward who has been disowned by her family.

Around 15-30 women in Sierra Leone have a long-term complication, such as fistula, for every one that dies.

She will also have a scar on her uterus that leaves her at risk of other life threatening complications in her future pregnancies, such as uterine rupture.

To be pregnant in Sierra Leone today, especially if a teenager, is a walk along the tight-rope.

It does not need to be that way, at every step of her journey, just like the many who took it before her, were moments when a simple intervention would have changed her (and her child’s) personal history.

  • Access to safe delivery at the village.
  • Equipment and training in the various health units.
  • The ability to get to a place of safety in a timely manner.
  • The knowledge and skills to avoid unnecessary and high risk caesarean sections, and prevent obstetric fistula formation.

Stories like this are a daily occurrence. Despite highly motivated healthcare workers, barriers still remain to safe deliveries - making pregnancy a life threatening condition in Sierra Leone.

That is why we are here and we will respond like we do in any humanitarian medical emergency.

Trying to see the wider picture, not just what arrives in the hospital, but the story behind the mess.

Not replacing, but supporting our colleagues to provide the care which any woman and her unborn child, anywhere in the world deserve.