Having children is a deadly business

A pregnant woman is more likely to die giving birth in Sierra Leone than in any other country in the world.

Health experts blame a shortage of medical staff equipped to deal with complications that can occur during labour, as well as the financial and logistical impracticalities of getting from home to a hospital.

In this West African country struggling to emerge from a decade-long civil war, mothers die in 1,800 of every 100,000 live births, according to the 2005 global report from the United Nations Children's Fund (UNICEF). That's roughly two women out of every 100 that have a baby.

Sierra Leone's children fare even worse. Some 17 percent of all children die before they reach their first birthday and a quarter die before they reach the age of five.

Samuel Pratt, who works as a UNICEF health officer in the capital Freetown, attributes Sierra Leone's high maternal mortality rate to the fact that many pregnant women turn to traditional birth attendants. These attendants are usually women from the community, who have received no formal education.

“80 percent of all deliveries are done by traditional birth attendants but they are not trained to take care of complications,” he told IRIN from his office nestled on one of the steep hillsides that surround the capital.

If there are no skilled people around to stop a woman from bleeding or to remove her placenta, deadly complications can arise before, during or after delivery, he said.

Other international aid workers in Sierra Leone describe the maternal mortality rate as "shocking."

And some traditional birth attendants openly admit they run into problems.

“Sometimes, if the mother is a teenager, the birth is difficult. Or if they are old and have had too many children, it is difficult," said Rebecca Elli, who helps deliver babies in the village of Ngaya in eastern Sierra Leone.

"Some women have died in my hands," the attendant told IRIN, adding that she did try to refer difficult cases to the nearest community health centre, a few miles down the road.

But a referral is not without obstacles, as Catherina Coppens, the head of Medecins Sans Frontieres Holland in Sierra Leone, pointed out.

Her group runs several safe houses where women about to give birth can stay to ensure they are close to a hospital but transport is tricky.

"When you have to leave the village to go to the clinic, how do you reach it?” she said.

Sierra Leone is one of the world's poorest countries and money is tight to splash out on transport.

In eastern Sierra Leone, which suffered heavy destruction during the 1991-2001 civil war, the roads are in poor shape anyway.

For Issatu Mansaray in Kono, a diamond-mining district in southeastern Sierra Leone, there was only way to get the prenatal care she needed. She had to walk.

Pregnant with her first child, the skinny 17-year-old decked out in a yellow wrap-around skirt, explained in a whisper how she struggled to reach the newly-rehabilitated community health centre in the small town of Najaiama Sewafe.

“I was feeling dizzy all the time, vomiting, not feeling well, so I walked nine miles to come and see the doctor,” the single motherto-be said.

The health centre, which attracts patients from around the region, does not charge for consultations. However, because of funding difficulties, the clinic is often forced to make patients pay for any medicine they are prescribed.

Esther Swaray, one of the health workers at the clinic, explained that many destitute patients simply do not have the means to pay for these drugs, which are also in short supply anyway.

“We have difficulties with drug supplies. At first World Vision gave us the drugs, but now the Health Ministry has taken over. Depending on supply, the patients may have to pay for the drugs,” Swaray said, shrugging her shoulders.

Poverty and unemployment remain high in Sierra Leone, which is still ranked by the United Nations Development Programme (UNDP) as the world's poorest country.

Coppens, the head of MSF in Sierra Leone, reckons that a government drive to recover costs by charging a nominal fee for health services has created a situation where fewer than half the country's five million people can obtain the care they need.

But even if a pregrant woman persuades her partner to let her attend a clinic and raises the money needed to pay for the bus fare and the consultation fee, she is not gauranteed to receive proper healthcare. There are simply not enough doctors and nurses available to meet Sierra Leone's needs.

Pratt at UNICEF estimated that around 80 percent of the country's health facilities were destroyed during the civil war. The conflict also prompted many of the people that used to staff rural health centres to flee to the towns for safety or or to neighbouring Guinea and Liberia as refugees.

There are only 284 community health officers available to serve Sierra Leone’s five million inhabitants, half the number required to staff all the country's community health centres, according to UNICEF.

These paramedics receive three and a half years training and can carry out life-saving medical interventions, including some basic surgery.

Nationwide there is a doctor or community health officer for every 31,300 inhabitants. However, coverage varies considerably.

It is best in the capital Freetown, where there is one doctor or community health officer for every 20,500 inhabitants. But it worst in Koinadugu district in the north of the country, there is only one qualified medic for 226,100 inhabitants.

Sierra Leone has yet to resurrect a proper referral system to ensure that the most difficult medical cases are passed on to regional hospitals equipped to offer more sophisticated care.

“There should be a continuum of efforts in communities. Qualified staff should be able to refer cases and register births, and hospitals should be able to offer specialized care," Pratt said.

UNICEF has been working with Sierra Leone's government and local and international aid groups to address the poor healthcare for mothers and children. It has been training district health staff, supplying vitamins to mothers and babies, and helping prevent common diseases.

Pratt said there reasons to be optimistic that the situation would improve.

“It is encouraging to see that a large number of facilities are being reconstructed in some districts as pools of donors have facilitated reconstruction,” he said.