Mamie Gibila travelled across choppy waters for almost four hours last week to reach a hospital. She was midway through labour with twins. The first baby was born at home, but she was unable to deliver the second and urgently needed medical attention.
Gibila lives in the town of Mina in the district of Bonthe, which comprises several islands off Sierra Leone, and the closest hospital is 105 nautical miles away. The journey, she says, was foul. When she arrived, it was too late to save her second baby.
This was her third pregnancy and her new baby boy, not yet named, is her second living child. She says she is 26 years old, but the doctor is sceptical. “From the looks of her she is less than 19 years,” says Dr Samuel Massaquoi, the district medical officer in Bonthe.
The district – where nine doctors serve 200,000 people spread across several islands that are not easily reached – illustrates the extreme challenges facing maternal health in Sierra Leone. The country has one of the world’s highest teenage pregnancy and maternal mortality rates. A third of girls aged 15-19 have children, and less than half (44%) of all births are attended by a nurse or midwife. Poor access to medical facilities and a lack of trained midwives mean that for every 100,000 births, 1,165 mothers die. Half of them are teenagers.
Just over a year since the country was declared free of Ebola, the government has pledged to prioritise fixing the dire state of maternal and sexual health services. One of its aims is to increase the proportion of women using contraceptives, from 23% to 33.7% by 2022.
“The targets are ambitious but they’re only ambitious because of where we are [as a country],” says Dr Kim Eva Dickson, the UN population fund (UNFPA) country representative. “Are they ambitious compared with where the country should be globally? Not really,” she says.
Still, the country faces an uphill battle. When the Ebola epidemic began in 2014, social services collapsed and schools were closed for almost an entire academic year. As health teams focused their efforts on disease control, family planning services ground to a halt. In a year, 18,000 teenage girls became pregnant – a “huge spike”, says Dickson. To make matters worse, global commodity prices plummeted, further battering the country’s fragile economy.
As aid money was redirected towards Ebola, and humanitarian crises elsewhere, funding for family planning fell sharply. Over the past three years, the amount allocated to the UNFPA for family planning in Sierra Leone has fallen by more than half from $3,503,000 in 2014 to $1,358,260 this year. Last week, at a global family planning summit in London, Melinda Gates, the American philanthropist, said she was “deeply troubled” by Donald Trump’s decision to stop US funding for international family planning.
The US has also cut support for the UNFPA, which faces a $700m shortfall until 2020. “For this year we’re OK, but we don’t know where we’ll be in November,” says Dickson, adding that the agency pays for 95% of contraceptives in the country. “We’re looking to the Nordics, Sweden, Norway. We were hoping for the UK but we don’t know – with a change of government, Brexit, it is a big problem.”
Already, important services are being scrapped. Clinics that are unsafe and in need of renovation have been left untouched, while activities aimed at raising awareness and creating a demand for family planning have been slashed. In Bonthe, a boat service that offered family planning stopped running in December 2016. Before, a team used the boat to provide contraceptives to communities on the remote islands, and take people to hospital. Now, family planning services are sparse and it’s even harder for patients to get help.
“In these island communities people don’t come to the hospital until they are deeply sick,” says Amara Lebbie, who is in charge of outreach at Marie Stopes Sierra Leone. The boat, which cost $35,000, didn’t just save lives, it built trust. “You cannot provide family planning to people who feel frustrated, people who feel they have lost their mother or daughter because somebody didn’t respond to take them to the hospital,” he says.
Building relationships is essential in places where myths about contraception are still common. Mary Magdalene Koroma, 18, who lives on Sherbro island, and who has had a contraceptive implant since she was 16, says few of her peers use family planning. “My friends said that if you start taking the pills you won’t be able to have children even in the future. And they don’t want to be faced with that,” she says.
Koroma’s mother, Alice, encouraged her daughter to use contraception because she wants to ensure that nothing jeopardises her education. Many of Koroma’s friends are now pregnant, which means they are excluded from school until after they have given birth. Even then, many will not have the money to continue studying. Not all parents think like Koroma’s mother. Standing outside a packed community hall in the capital Freetown, where a family planning outreach session is being held, Gladys Goba, programme coordinator at the Planned Parenthood Association, says some young people will use contraception without their parents’ knowledge, especially if they are from very religious families. “Some say I want the captain band [an implant in the arm] because they will not see me taking the pill every day, they will not see me having an injection every three months. It’s easy and the parents don’t see the arms of their child,” she says.
“That’s why the young people are coming [now],” adds Humama Kagbo, mommy queen, a woman leader, in the Dwarzak community. She points to the trickle of young people coming through the door: “They don’t want to get caught.” Earlier in the day it was mostly older people waiting in queues; now teenagers are arriving for contraception and reggae music has started pumping from the hall.
Young volunteers at the PPA are using WhatsApp and Facebook, as well as visits to communities, to spread the word. Health workers are also asking local priests and imams to raise awareness, with mixed results. There are still some taboos, says Goba. “There’s a perception that when a female gives a male a condom she’s a prostitute.” But attitudes are changing. When the outreach visits first started three years ago, some women would hide visits from their husbands – now men are more involved.
The Rev Songaye George-Buanne, director of Fambul Initiative Network for Equality, which campaigns for women’s rights by educating boys and husbands, says more projects should reach out to men. He started running husband schools and boys’ clubs in 2011 after witnessing men’s frustration that, during the advocacy work after the civil war, men were often left out.
“The whole human rights thing just focused on women and that sprang up some antagonism in men. [There was a feeling that] all the advocacy here is for women, what about us? Have men not been violated as well?”
Trying to tackle domestic violence without targeting men, or trying to improve women’s access to healthcare, without educating the man who is head of the household, did not make sense. “Traditionally the men make a decision as to whether the woman gets health services, where she gets health services, the quality of health services she gets access to,” says George-Buanne.
Men’s sexual health needs must also be addressed, he says. Since 2010, pregnant women, new mothers and children under five have been entitled to free healthcare, but there is not much point giving a woman free treatment for sexually transmitted infections if her husband is not getting the same attention.
Campaigners say free healthcare for new mothers has been a step forward, but services are often hampered by stock shortages or an acute lack of trained health workers, especially in rural areas. In Bonthe, which lacks basic facilities such as a bank, some outreach staff leave after a few months, says Lebbie.
The UNFPA is constantly weighing up whether to spend more on funding free treatments or whether to invest in raising awareness. “If you really want to reach people [in remote communities] then you have to go out to them,” says Dickson. “It’s only when people begin to see the benefits for themselves that they will make the effort.”
So far, it is the latter that’s been hardest hit, especially in areas such as Bonthe. In the hospital there, Gibila and her son are the only patients lying in the ward. “After [Gibila] is stabilised we’d be very much pleased to offer her family planning services,” says Massaquoi. He hopes that, if she receives pills or an implant, he won’t see her in his maternity ward again in the near future. But there are many others in her home town of Mina that his team cannot reach.