In Sierra Leone, Pregnant and Praying for Success

By Lane Hartill

Hawa Bokarie took off her pink flip-flops, the ones with the butterflies on them that her husband bought her, and steered her belly—heavy in her eighth month of pregnancy—5 miles down a mud path to the health clinic.

Before her hike, she ate a few wild bush yams. That's what she and her husband, Bokarie, have been living on since they ran out of rice a few weeks ago. The lack of food means she's all baby. Her collarbones show like curtain rods; her shoulder blades look sharp as machetes.

Hawa doesn't know how old she is, but she knows she's had nine children. Seven have died. She's not about to lose this one.

That's why she's willing to hike barefoot, before the sun comes up, through the forest to the government health post that Catholic Relief Services helped build in Gbahama, a tiny village in Kailahun district in eastern Sierra Leone.

Being pregnant in Sierra Leone is dangerous. Nobody knows for sure what the maternal mortality rate is. United Nations statistics say that 1,800 women die in childbirth for every 100,000 births. But those numbers are likely higher in some districts and lower in others. By comparison, in Denmark, which has one of the best ratios in the world, 3 women die per 100,000 births.

Statistics don't mean much to Hawa. She knows that this will be her first delivery in a clinic. And thanks to the advice of CRS' Sylvester Amara, a health field agent who drives the back roads of the district on his motorcycle, educating women on the finer points of feeding themselves, Hawa knows that she needs to eat fruit and fish and peanuts. But that's easier said than done when she and Bokarie are broke.

Still, she loves Sylvester's advice; nobody has given her any before. She now knows what protein is, something she'd never heard of before. She knows that when the baby comes, she needs to exclusively breastfeed for six months.

On a recent day, in the back room of the clinic, Ansu, a nurse-in-training, suddenly recognizes Hawa. Ansu was a little girl when she fled to the jungle after the war came to Kailahun. She, Hawa and scores of other families hid together. Now she's lifting Hawa's dress over her stomach, revealing a delta of stretch marks. Ansu takes a Pinnard stethoscope—which looks like a plastic vase—and listens for the fetal heartbeat. It sounds healthy.

Hawa is lucky Ansu is there, even though she's not the most qualified medic. Sierra Leone's Ministry of Health says eight obstetrician-gynecologists serve a country of 5.7 million people. That means there is one ob-gyn for every 416,666 women.

Keys to Success

Dr. Samuel Kargbo, the district medical officer for northern Koinadugu district, believes there are fewer than five ob-gyns in the country. Regardless, maternal mortality can be reduced, he says, if the mindset of Sierra Leoneans shifts. "You don't have to have high economic development to lower the maternal mortality rate," Dr. Kargbo says. "It's the willingness of the people to change."

Suzanne Van Hulle, CRS' health program manager in Sierra Leone, says that a range of factors contribute to the high maternal mortality rate:

• Women delay in going to the clinic. This is made worse by the delay in treatment when they arrive.
• The country has few qualified doctors. Those that do practice don't want to live in isolated areas and work for low pay.
• There aren't enough drugs and medical equipment at hospitals and clinics.

"So many women live in rural areas that are often a four-hour walk, one way, to the closest health care center, which obviously is the last thing a pregnant woman at term would like to do," says Van Hulle.

Women often rely on traditional birth attendants in the communities because they know them and they charge less than a hospital to deliver a baby. The danger is that they are often poorly trained, and when complications arise, they are not able to handle them.

That's why CRS—in conjunction with Dr. Kargbo and local communities—is constructing birth waiting homes in four chiefdoms in Koinadugu district.

"Since most women die within 24 hours of delivery, it is crucial that women access a health care center prior to going into labor, and also remain under medical supervision for one to two days after giving birth," says Van Hulle. "The birth waiting homes tackle these two issues."

Dr. Kargbo also thinks men need to play a more active role: "More husbands need to be involved," he says.

Don't tell that to Bokarie, Hawa's husband.

A Love Story

He made her go to the health clinic, even though every time she leaves, he's lost without her. "She's the only woman I hope to have," he says. He's just finished planting his swamp with rice, and is physically drained, but gushes about his wife. "That woman standing over there is my mother and is my father," he says, adding that his own parents have died. "Even yesterday when she left us, we became so discouraged." He was forced to go to a neighbor and ask for a plate of rice for dinner.

He loves her now just as much as the day he met her, all those years ago at a village dance. Prince Nico, the Nigerian-Cameroonian singer, was singing "Sweet Mother" on the record player when Bokarie approached her. She was pretty, he says. Hawa remembers his charm and dance moves. They hit it off.

Life for the newlyweds was sweet. Bokarie worked as an apprentice carpenter, building chairs and tables. Hawa sold cakes in the market. But the afterglow didn't last long. One day, Hawa saw people rushing by with bundles on their heads. Retreating army soldiers followed close behind them. Knowing that wasn't a good sign, she hurried home and collected some clothes, pots and pans, and some dry rice in a bundle and joined them. She threw Iye—her 5-year-old daughter—on her back, held onto the hand of Saffa—her 10-year-old son—and hotfooted it for the forest, hoping to outrun the rebels.

"It was terrible," she says. "What came to mind was just to stay alive."

Life in the forest was miserable. Hundreds of people lived in the damp jungle, hiding from the war. Hawa, Bokarie and the kids went through the rice in two months and were then forced to live on wild yams, cassava and bananas. They set bush traps for porcupines and large rodents called cutting grass or cane rats. They used soap made from crushed cocoa pods. They lost all sense of normalcy. But worst of all, they lost Iye. She fell sick and died; Hawa still doesn't know why.

They had only been at the camp for a few months when the sound of gunfire erupted nearby. This time, they ran to neighboring Guinea. For 11 years they lived in a refugee camp. Hawa gave birth four times. Two babies were stillborn and two died as toddlers from unknown ailments.

When they moved back to their village in 2002, it was gone. Every house had been razed and the jungle had swallowed the rest. Once again, they started over. Bokarie rebuilt their house. Hawa helped him plant the rice fields. They made money from the cocoa they harvested from the trees Bokarie's father had planted years before.

"[Life is] difficult," says Hawa. "But you have to live. Nobody is going to do it for you. If you relax, who will do [the work] for you?"

On a recent day, Hawa spent her afternoon shuttling back and forth between her outdoor kitchen and her house. Bokarie and the rest of the men just watch her. She picks eggplants from the garden she keeps behind her house. She hikes up her skirt and squats down, squinting through a smoking fire to make a spicy sauce that she pours over a bed of rice. She gives a big bowl to Bokarie, who shares it with several hungry villagers. Most of the meat—river crab the size of silver dollars—goes to Bokarie. Hawa eats alone, allotting herself one tiny crab.

Bokarie washes the dishes after the meal.

Hawa's exhausted at the end of the day. She can barely keep her eyes open. She may be thinking about what Bokarie told some visitors earlier that day, that he wants four children. Hawa was within earshot and said nothing. She's ready to stop after this one. Giving birth 10 times is enough. But that's a conversation for another time.

Lane Hartill is the West Africa regional information officer for Catholic Relief Services. He is based in Dakar, Senegal.