Rural midwives on front line of Sierra Leone maternity crisis

It is final exams season at Masuba midwifery school in rural Sierra Leone, and 70 more students are about to begin working life at the sharp end of the country's maternal health crisis.

Established in 2010, the school is only the second dedicated midwife training unit for a country of seven million people, located at the end of a bone-shaking series of dirt tracks several hours from the capital by car.

Keeping women and babies alive is an extreme challenge in the remote communities the graduates will serve, where suspicion of medical professionals is entrenched and family planning near non-existent.

"My first placement where I was sent in Kabala (a northern town)... people don't believe in the hospital facility," said Aminata Kanu, sitting in her classroom with dozens of others in identical blue uniforms and white hats.

Ebola severely strained the already limited resources of a crumbling health system when the 2014 epidemic erupted, and many women are reticent to seek professional medical care.

"We counsel them, tell them the importance of being in the hospital," 23-year old Kanu said, expressing frustration that some women "still refuse" to give birth outside the home in the presence of a traditional birth attendant.

The trainees will work exclusively in the villages and small towns that represent the greatest challenges for reversing Sierra Leone's sad distinction of holding the world's worst maternal mortality rate -- 1,360 deaths per 100,000 live births.

School places are oversubscribed even though training salaries are low by local standards -- 590,000 leones ($150) a month plus a 200,000 leone monthly grant from the United Nations Population Fund (UNFPA) -- and hours long. Jobs in this area are scarce.

- Feathers and string -
The Masuba school in central Sierra Leone emphasises culturally sensitive training and works to shift what tutor Cecelia Lausana said was a sometimes unconstructive attitude to communication with patients.

Gesturing towards a board of examples of traditional birth control used in rural communities, such as feathers worn in the hair and plaited cotton bracelets, Lausana said women would not be persuaded to abandon such methods. 

"If we don't support the traditional methods we can't get them to use the modern one. We encourage them to use the traditional methods as a 'back-up'," she said, smiling.

Senior instructor Halima Shyllon said a cultural gaffe involving just one woman could alienate entire villages. 

"I went to do supervision (in) a Muslim-dominated community. And they have sent a male midwife! He has to work with the traditional birth attendant so he is standing at the door and giving instructions."

Getting the traditional attendants in rural areas on board was key, the midwives agreed. Some jealously guarded their privileged role, they said, even if more women died as a result. 

One town under her supervision "has a beautiful facility but ... only a few people come," said Shyllon.

"Students were sent on outreach... They discovered that it was this traditional birth attendant that was conducting all the deliveries at home."

- FGM complications -
Some communities are taking firm action. The village of Makali north of Masuba has passed a punitive by-law on any women delivering at home: a 50,000 leone fine per child, and double for twins.

Another practice complicates the lives of the midwives: female genital mutilation (FGM). 

Nine in 10 women have undergone FGM in Sierra Leone, according to a report released this year by UNICEF, and nearly 70 percent of women support its continuation.

Women who are "cut" experience increased complications during caesarian sections, greater risk of haemorrhage and prolonged labour, according to the World Health Organization.

Showing off a life-size pregnant model donated by the Netherlands and named Jessica -- after the school's principal -- students were shown how the whole vaginal area became extremely tight during birth for FGM-affected patients, usually requiring an extra surgical cut to aid delivery.

Jessica arrived four years ago and replaced the previous training tool: a pair of leggings through which a soft toy was pushed at an opening in the front of the garment. Models and props remain in short supply.

There are other threats to the school's work: support for equipment had increased in the last couple of years, according to the tutors, but the full funding of tuition by UNFPA was at risk for next year's intake due to budget cuts at the UN agency.

Transportation was another serious problem, both for students and patients, Shyllon said.

"There are some districts where the population is so sparse that you meet one community and you have to go a very far distance before you can meet another," often taking huge chunks from small salaries.

The ambulance system in this country still has a "long way" to go, Shyllon added.

For fellow tutor Lausana, the key was to train many more rural midwives, as 40 percent currently work in Freetown, the capital serving just 15 percent of the population.

"I believe if they train more midwives, and midwives are attending to every birth in this country, it will help greatly," she said.

Source: AFP