Sierra Leone: Rebirth of a nation

In Sierra Leone, a training programme for midwives has done more than just save lives. Laura Smith reports

When Mary Kamara's husband was murdered by rebels during Sierra Leone's civil war, she was left alone with seven children to support. The only way she could earn money was by breaking stones to sell to her neighbours as they rebuilt their shattered homes. "I had no idea what to do," she says now. "It was a very, very hard time."

But everything changed for Mary when the charity ActionAid began to offer free training for birthing attendants in her neighbourhood. Since completing the course, she has overseen hundreds of births and now helps train women – and their partners – to look after their babies.

"This is something I've wanted to do since I was a little girl, so it made me very happy to learn," she says. "It also gave me a way of earning a living to keep my family."

Sierra Leone is one of the poorest country in the world. Ten years of civil war took a heavy toll and although the fighting ended in 2002, women and children are still paying the price. The West African nation has the highest maternal mortality rate in the world and the highest number of deaths of under-five-year-olds.

Until this decade, the Kola Tree community, a poor neighbourhood near the capital Freetown, where Mary lives, was no exception. Everybody, including Mary, knew somebody who had died in childbirth. The untrained local women who attended births with only traditional herbs to help could do little when women got into difficulty. Then, in 2000, as the war continued to rage, ActionAid began to offer training courses to traditional birth attendants. In the following months, 54 women were given six months of tuition in ante- and post-natal care, allowing them to deal effectively with births – and, crucially, to recognise when a problem was serious enough for a woman to be taken to hospital.

The programme has seen the numbers of women dying during childbirth drop considerably in the areas where birth attendants have been trained. For local women, having a specialist in their own community has given them peace of mind.

Jariatu Sesay, 22, who was attended by Mary when she gave birth to her third child, a daughter, says: "I was worried before in my pregnancy. It is very stressful and there aren't many resources. I could not have afforded hospital if something bad had happened. But Mary helped me out well and nothing went wrong. We are very grateful."

The government admits that these women are filling a huge gap in an under-resourced health service, only around 50 per cent of which is funded by the government. "Trained birth attendants are very, very useful to us," says Dr Amara Jambai, the government's principal medical officer for the western region. "They carry information straight to the heart of communities. They offer a path directly to people that we would never otherwise reach."

Freetown is a prime example. Over a million people live there, yet there are only 162 government health workers trained to deliver a baby – less than one for every 6,000 people. And this in a capital city that has the best resources in the country. "We have a big, big problem keeping trained staff in this country," says Dr Jambai. "We are losing them at an alarming rate. Only about six new doctors a year go into the state healthcare system and we also lose large amounts of nurses as they can get better money in other countries."

Even where facilities do exist, most women can't afford to attend them. Having a caesarean in a clinic or hospital costs the equivalent of £250, a simple delivery £30. And the journey to get there can also be difficult.

"If there are problems, we have to carry the woman all the way down the hill into Freetown," says Mary. "This would mean four people carrying her in a hammock for almost two miles to find a taxi, and another three miles in the car to reach the nearest hospital."

The Millennium Development Goals, to which more than 190 countries, including the UK, have signed up since 2000, include a target to improve maternal health, in particular to reduce by three-quarters the maternal mortality ratio by 2015. The presence of a skilled birth attendant is seen as essential to meeting that goal, as research has shown that their presence during labour reduces the likelihood of mothers dying during childbirth.

The ActionAid project shows how a little training can go a very long way to meet such goals. The initial six-month course was followed by refresher training in 2004 and now they pass on their knowledge to others in the community – whether through home visits to expectant mothers or at the four centres which have since been set up, where trained birth attendants work with state-registered nurses to weigh babies, offer health advice and give vaccinations.

Isatu Kargbo, who lives in Looking Town, another poor hillside community near Freetown, was already helping women give birth when she heard about the ActionAid training. "I was already a practising birth attendant but I had little experience so really I had no confidence," she explains. "Then I heard about the training and I knew straight away I wanted to do it. I am happy to help my community and my own income has increased, so thank God for that."

The 38-year-old has now delivered 79 babies since the training, and all the women have survived. Recalling her first delivery after the training – a woman with triplets – she says: "I was so happy I had already had my training that day, I can tell you. I was very calm and I knew what to do, but if it had been before... well, it might have been different."

Importantly, Isatu says another outcome of the project has been to improve how women are seen by men.

"It has definitely changed women's place in society," she says. "Men have a lot more respect for women now, they know they have knowledge and can look after their babies well. It has greatly improved my status in the community. All the way down the valley, people now think highly of me."

For Mary Kamara, who has now been using her skills to help women in Kola Tree for nearly seven years, the ActionAid training was a life-changing opportunity. "I was very concerned about the women dying when birth went wrong – it had always been on my mind and I knew this was a bad thing and that I could help," she says. "I now have the full respect of the community, and I definitely feel good about that. I am conscious that I myself have made a difference to the deaths of mothers in this community and I am very happy to be able to say I have done this."

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