Blackouts causing loss of lives at Princess Christian Maternity Hospital in Freetown

Where pregnancy is a deadly gamble
Sierra Leone is one of the riskiest places to have a baby. One
teen fears repeating her mother’s story of dying in childbirth.

By Danielle Paquette
Photos by Melina Mara
Videos by Michaella Sallu and Alexa Juliana Ard
May 6, 2022

KONO DISTRICT, Sierra Leone — The doctor asked Susan Lebbie to find two units of blood before her due date, but she trudged into the maternity ward with only a pillow, an overnight bag and a cracked phone.

The 17-year-old had called everyone she knew for a donation: her aunt (had a toothache), her uncle (too old), her cousins (too young) and her friends (out of town or also pregnant). Now the deadline was here, though the contractions hadn’t started, just more kicking, and Susan was trailing a nurse past a poster that read: “Every 90 seconds, a pregnant woman dies.”

“Susan,” the nurse said. “Do you have your blood yet?”

One in 20 women in Sierra Leone die as a result of pregnancy or childbirth, according to the latest United Nations estimate, most often from losing blood. The West African country consistently ranks as one of the deadliest places on Earth to have a baby. Only South Sudan and Chad count higher mortality rates.

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Susan was orphaned when she lost her mother. She lives with her aunt and uncle.
Susan was orphaned when she lost her mother. She lives with her aunt and uncle.
Practically every death is preventable, but a decade of civil war destroyed much of the health system before the deadliest Ebola epidemic on record killed 7 percent of medical workers. Almost a third of the health budget comes from foreign aid, and the top donor plans to halt funding for a program that doctors say is critical to saving lives.

Chronic blood shortages add to the plight. Before the coronavirus era, countries across Africa collected just half of what they needed for urgent transfusions, the World Health Organization said. Then donations plummeted by 17 percent.

To be pregnant in Sierra Leone is to be at the mercy of resource-strapped institutions and the global trends shaping them. Survival is too often up to luck. Luck that a nurse or physician is nearby. Luck that the government is paying them. Luck that personnel aren’t charging for care that should be free. Luck that medicine is stocked. Luck that the blood bank has reserves.

Susan had bad luck from the start, so she vowed to control what little she could. She checked in early at Koidu Government Hospital, where two obstetrician-gynecologists, both aid workers, served 250,000 girls and women in the district.

Her intake form said “high-risk,” something she’d feared before a doctor scrawled the label. Susan was anemic. She hadn’t thought she could get pregnant because of some bad information. And since childhood, she’d seen creating life as a mortal gamble.

On the day she was born, her own mother died from losing too much blood.

Did she have her blood? The nurse waited for an answer. “No,” the teenager whispered, turning the corner toward Ward 3.

A motherless child
Susan was born into the scars of war. By the end of the 1991 to 2002 conflict, nearly three-fourths of the country’s health centers had been wiped out. The rest tended to lack adequate staff and equipment. By 2010, a study found that public hospitals were no more prepared for surgery than Union Army facilities during the U.S. Civil War.

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Even if Susan’s mother had wanted to go to what was left of the hospital, she didn’t have money to pay for care. She bled in labor, far more than normal. Women usually recover from that complication, but without a medical professional there to replace fluids and stitch ruptures, someone healthy can go into shock and die within hours.

Susan has never seen a photo of her mother. Relatives told her they look alike. The teenager only knows that her name was Satta. She was 20. People said she had a kind heart. And her absence has loomed over everything that has happened to Susan since.

Her father disappeared after she was born, so Susan’s grandmother adopted her as a baby and sold enough corn from a backyard patch to keep her in school. They memorized Bible verses together. Susan’s favorite was Psalm 27:3: “My heart shall not fear.”

Susan explains that she wants to give birth to a boy because a boy cannot become pregnant. (The Washington Post)
“[I would like to have]
a boy … because a boy
cannot get pregnant.”
Her grandmother died when she was 9, setting off the chain of events Susan said brought her to the maternity ward: Her only other family in Kono, her aunt and uncle, refused to take her in because they already had five kids and no money, so Susan appealed to a woman selling soap in the neighborhood, who gave her work and shelter.

When Susan was 16, a cyst burst on one of her ovaries. She wound up in the hospital where, she recalls, a nurse told her she would never be able to have babies. Later, the woman selling soap moved to Guinea, and Susan was homeless again until a man in his 60s who’d seen her on the job proclaimed himself an admirer.

He offered to pay her school fees if she stayed with him. Susan envisioned returning to class, graduating and finally taking care of herself. Months later, the man died of hypertension, leaving the teenager with nothing but a surprise pregnancy.

Susan’s ultrasound in October 2021. (The Washington Post)
The peril of motherhood
Sierra Leone, a country of 8.3 million, remains at the extreme end of a regional trend. Sub-Saharan Africa accounts for 66 percent of all maternal deaths in the world. Researchers point to the fact that fewer women give birth in a health facility in West and Central Africa than anywhere else, at 60 percent, well below the global average of 83 percent.

Showing up doesn’t always mean getting help: Sierra Leone has reported a persistent dearth of health workers, and access to blood is widely unreliable. Abortion is illegal and frequently performed without medical supervision. Health officials estimate that unsafe abortions cause between three and four percent of the nation’s maternal deaths.

The number of women dying is “still too high,” said the health minister, Austin Demby. “It’s still unacceptably high.”

Calculating the risk of maternal death in Sierra Leone

The United Nations defines the “lifetime risk” of maternal mortality as the probability that a 15-year-old girl will die at some point from complications related to pregnancy or childbirth. Sierra Leone’s figure — one in 20 — is the third highest in the world.

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Sierra Leone has one of the highest maternal mortality rates in the world

Number of people who died in childbirth per 100,000 live births, 2017

Europe

8 deaths per

100,000 births

United States

19

Asia

75

Latin America

81

Northern Africa

105

Sub-Saharan Africa (46 countries including Sierra Leone)

452

Sierra Leone

1,120

Source: WHO, UNICEF, UNFPA, World Bank Group

MADISON DONG/THE WASHINGTON POST

Cost was one of the top obstacles deterring pregnant women from medical professionals. So in 2010, the country removed fees for their doctor visits and drugs under the Free Health Care Initiative.

The new program drove major progress. The share of women giving birth at a health facility in Sierra Leone jumped from 25 percent in 2008 to 54 percent in 2013 to 83 percent in 2019, national statistics show.

Then came the pandemic. Foreign aid worldwide shifted from old emergencies to new. Britain, the key backer of Free Health Care for years, told Sierra Leone’s Health Ministry the support had to end.

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Staffers at Koidu Government Hospital urge women to deliver their babies in a medical setting rather than at home.
(Melina Mara/The Washington Post) Staffers at Koidu Government Hospital urge women to deliver their babies in a medical setting rather than at home.
Extending the funds over the long term became unsustainable, said a British development official, speaking on the condition of anonymity to discuss sensitive matters.

The aid is now guaranteed only through September.

“It’s a life saver,” Demby said of Free Health Care. “The government is trying our very best to maintain it, but it’s getting a lot more difficult. The funding side of this is precarious. The value, and the need for it, is inordinate.”

As Susan entered the maternity ward in November, doctors across the country were already signaling trouble. “There are lucky weeks. There are lucky months,” said Frances Wurie-Sesay, an obstetrician at the King Harmon Maternity and Child Health Hospital in the capital, Freetown. “And there are times when the only free thing I can offer a patient is a consultation.”

Blood is a special challenge. Physicians in Sierra Leone advise women to find their own emergency supply during their third trimester. “There is never a guarantee,” Wurie-Sesay said, “that we will have the blood to save a life.”

Rebels destroyed much of Kono district during civil war in Sierra Leone.
Rebels destroyed much of Kono district during civil war in Sierra Leone.
Susan sought blood on her own while the hospital in Kono grappled with other shortages. Government trucks were delivering refills every 12 weeks or so, rather than every six weeks. Authorities blamed shipping delays and funding hits related to the coronavirus.

The maternity ward was out of a drug used to treat postpartum bleeding. Multivitamins were running low. So were antimalarial pills and painkillers. Partners In Health, the global nonprofit group that helps run the hospital, scrambled to fill the gaps.

“Every time we cannot give a pregnant woman what she needs, it’s a tragedy,” said Isata Dumbuya, director of reproductive, maternal, neonatal and child health at Partners in Health in Sierra Leone.

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Dumbuya, who was born in Kono, worked previously as a nurse midwife in London, where she witnessed one pregnant woman die over two decades.

Now she tracked deaths every month on a whiteboard: Six in May, the month Susan learned she was pregnant. Two in June. Two in July. Two in August. One in September. Three in October.

The power of a role model
The ceiling fan hung still in Ward 3. Sweat beaded on Susan’s forehead.

Five women, all days or hours away from childbirth, lay around her in cots. Body heat made the room muggier than outside. Morning light streamed through the floral-sheet curtains.

She’d slept maybe three hours, worrying about her lack of blood. Would she be okay without it? During the night, Susan had dreamed of a baby, her baby, with plump lips. “A big, big mouth,” she said, “like mine.”

She thought of her mother: Would Satta have been there to comfort her? Susan had been lonely for years, in and out of school, crashing on different floors, failing to connect with kids her age. Lately, she’d been living with her aunt and uncle, who, after everything, did not turn her away a second time.

She earned her room by cooking dinner for the couple and their children, squatting above a small grill. Cash was scarce, and some days she ate only two bananas. Her uncle, frustrated by it all, muttered so Susan could hear: “Girls today sit around and do nothing but get pregnant.”

Susan, 17, moved in with her aunt and uncle after becoming pregnant. She cooks and cleans to earn her stay with them. (The Washington Post)
“They treat me like all I’m
there for is to cook and do work
just because I got pregnant.”
Her aunt had been frosty, too, until she had a dream about Satta. Satta asked her to take care of her daughter and the baby. Susan’s aunt became kinder, boiling sweet potato leaves for Susan, a good source of iron for an anemic girl. She’d learned that after almost dying in childbirth herself.

Susan had considered abortion — some women turned to black-market pills or concoctions from traditional healers — but after the doctor told her she could never have a child, the teenager worried this might be her only chance. She hoped for a boy. Girls suffered too much, she thought. She prayed, “I don’t want my mother’s story to become my own.”

Even in the maternity ward, the sight of women cradling babies roused the old melancholy. She’d wanted that kind of love for herself as a kid. She wanted it for her baby.

Here came a nurse, reaching for her arm. “Okay, Susan,” she said. “Let’s take your vitals.”

Her pelvis was too small for safe labor, the doctor said. Before Susan’s first contraction, he wanted to perform a Caesarean section. Without the surgery, he explained, she could die.

Susan might have said no. She might have fled the maternity ward like another woman had two months earlier. She might not have come here at all if it weren’t for Aminata Saidu.

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Susan pledged not to miss a doctor visit even when money for transportation was tight. The hospital tracks each maternal death on a whiteboard.
Susan pledged not to miss a doctor visit even when money for transportation was tight. The hospital tracks each maternal death on a whiteboard.
A neighbor had told her to find “Nurse Ami” on the day Susan’s cyst burst. The 43-year-old was a traditional birth attendant, someone who steers pregnant patients to hospitals at the first sign of trouble.

Ami had a reputation for helping the sick. They’d stayed in touch. Susan knocked on Ami’s door after her period stopped.

Like many in Kono, Susan had thought C-sections were dangerous. Hospitals had a bad reputation since the 2014 to 2016 Ebola outbreak killed more than 11,300 people in West Africa. Many who checked in never left.

Now another virus was surging in the country, and the president was on television telling people to stay home. Deliveries at health centers dropped by 12 percent.

“You have to go,” Ami told Susan in her no-nonsense tone.

Ami prodded new moms who’d undergone a C-section in Kono to show off their faint scars and chunky infants. Nothing to fear! She made everything seem less scary.

With Susan, the advocacy blurred to intimacy. Susan slept between Ami’s daughters when she wanted to get out of her uncle’s house. Ami bought a bed for Susan and persuaded her uncle to let them paint the teenager’s walls a fresh shade of white.

“You need a nice place for the baby,” Ami had told them.

Why did she care?

“I love babies,” Ami said, grinning. “I love, love, love babies.”

When Susan cried in pain from a urinary tract infection, Ami sent an ambulance to fetch her on the nearest paved road. The teenager walked a quarter mile and hopped on a motorbike to find it. Not even an SUV could reach her house in the hills.

Susan’s mom died giving birth to her in Sierra Leone, where the maternal mortality rate is among the highest in the world. (The Washington Post)
“All the things she does
for me it’s like a mother.”
It was Ami who nudged Susan to check into the hospital early. They weren’t sure, exactly, when the baby would arrive. The ultrasound machine in Kono had been broken during Susan’s first trimester, the time women receive the most accurate readings for dating their pregnancies. Being in medical hands when labor started, Ami said, would be crucial.

On the morning of Susan’s C-section, Ami wasn’t answering Susan’s calls.

She was probably busy with her four kids, Susan thought. Ami was pregnant with her fifth, so she couldn’t donate blood, either. Susan pictured them raising their newborns together. Observing Ami. Imitating Ami. Susan longed to hear her voice, her familiar questions in their native language of Krio: How di belleh? How di body?

Her body jolted with panic when a nurse asked, “You ready?”

Susan slid on her rubber Nike sandals. She changed into a blue medical gown. She padded down the corridor, past the husbands on benches, to a man in an aquamarine hairnet, the anesthesiologist, who placed a hand on Susan’s shoulder and guided her toward the operating room. She stepped into the fluorescent light.

Susan, 17, is guided back to the operating room for her C-section on Nov. 24, 2021. (The Washington Post)
The line between joy and tragedy
Outside the hospital, in the space of 18 hours, two figures emerged with news.

One was a traditional birth attendant, a colleague of Ami. She wove through the gravelly courtyard where families camped out on mats and sheets of cardboard, waiting for their loved ones.

Some had traveled hundreds of miles to get here. They chatted, played games on their phones and shared plastic containers of chicken with rice.

The birth attendant reached a middle-aged woman in the crowd. The woman fell to her knees and screamed. People turned and looked.

“My daughter,” the woman screamed. “My daughter.”

Two men lifted the woman and carried her away. People folded their hands in prayer.

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May Saqui, 22, stared after the commotion, tears streaking her cheeks. The screaming woman was her mother. They had all spent the night together: May, her mother and her 35-year-old sister, Rebecca.

Rebecca had gone into labor that morning and started bleeding profusely.

“We woke up in the same bed,” May said. “Now she is dead.”

Rebecca had done her best to prepare, May said. She’d gotten blood from their mother. But they hadn’t made it to the hospital in time.

The newborn survived. May waited for the girl or boy. She didn’t know the gender yet.

The other messenger cutting through the courtyard that day was Ami, who had shown up with baby clothes while Susan was in surgery. She talked her way into the recovery room and bee-lined to Susan’s aunt, who was perched on a stray cinder block as a friend bent behind her, brushing her hair.

She smiled when she saw Ami, who was beaming and holding up her phone screen. There was a picture of a baby. A boy. Susan’s baby boy.

“Oh!” whooped Susan’s aunt. “God is good. God is good!”

Susan’s aunt celebrates after hearing her niece made it out of surgery with a healthy baby boy. (The Washington Post)
A new birthday
What Susan didn’t know is that on the day of her C-section, the hospital blood bank had about four dozen units. Several held her blood type, O positive.

If Susan had hemorrhaged in surgery, she could have needed up to four units of blood. But the doctor said her C-section had gone “flawlessly.” No transfusion required.

The two obstetrician-gynecologists here, both Partners In Health employees from Uganda, were known for working more than they slept. Susan’s doctor had started his day at 5 a.m. and finished four C-sections before getting to her.

The number of women who gave birth at the hospital had risen every year since 2018, a victory of aggressive outreach, staffers said. And the number of maternal deaths had fallen from 31 to 29 to 25 by 2021.

Susan said she had been afraid to ask about the blood. She felt shy around men. Both of the obstetrician-gynecologists were men. Quietly, she decided to leave it to God.

Susan recovers in the hospital after giving birth to her son, Evan. (The Washington Post)
She woke up in a recovery room next to her eight-pound baby boy. She gave him a biblical name, Evan, which means “God is merciful.”

“Look at his mouth,” she said. “It’s big. Like mine.”

Susan wrapped Evan in a turquoise onesie from Ami. She tried to breastfeed, but nothing came. A nurse fed Susan black tea with a spoon. Her head throbbed.

“He cries,” she said weakly, “right when I forget the pain.”

“He’s beautiful,” the nurse replied.

Susan stayed in her medical cot for three days. The headache lasted a week. A nurse prodded her to get on birth control, but Susan refused, pledging to avoid men. Another nurse reminded her to clean her wound and listen to her body: “Small, small pain is normal. If the pain is severe, come back.”

Susan and her family hop on motorbikes with Susan’s newborn, Evan. (The Washington Post)
Her aunt and uncle waited in the courtyard until it was time to go. Her aunt took Evan on one motorbike, and Susan went with her uncle on another, wincing through the bumps.

She eased into the bed that Ami bought her for the room painted white. Evan snoozed by her side. Susan closed her eyes.

In the coming weeks, she would do what her mother never got the chance to: breastfeed her baby, rock him, wrap him in fuzzy pajamas, read him pages from the Bible she kept next to her bed.

This place — the birds chirping, the breeze — was more comfortable than the hospital. Her body relaxed, though her mind buzzed. Hope and grief mingled. She thought of her mother. “Every day,” she said. “Every day.”

Susan focused on a Bible verse. Psalm 27:3: My heart shall not fear.

One of the deadliest places on Earth to have a baby
Today on Post Reports, we go to Sierra Leone, where having a baby can mean risking your life.Susan’s next goal: Becoming a doctor who helps women.
Susan’s next goal: Becoming a doctor who helps women.
About this story
This story is based on interviews over several weeks spent with Susan, her family, Aminata Saidu and staffers at Koidu Government Hospital. It was primarily reported over three trips to Kono District, Sierra Leone throughout Susan’s pregnancy — in July, October and November 2021.

Story editing by Jennifer Amur and Jesse Mesner-Hage. Photo editing by Olivier Laurent. Video editing by Jayne Orenstein. Graphics editing by Kate Rabinowitz. Design and development by Garland Potts. Copy editing by Anjelica Tan.