Source: Thompson Reuters Foundation
Rushing from one pregnant woman to another in the antenatal ward of Sierra Leone's main maternity hospital, Josephine Powells, a midwifery student, is all too aware of the danger facing the dozens of expecting mothers under her care.
These women are preparing to give birth in a country estimated to have the world's highest rate of maternal deaths. More than one in 100 women in the West African nation die during childbirth, according to the World Health Organization (WHO).
"My niece died during childbirth a few years ago," Powells, 34, said during a break at the Princess Christian Maternity Hospital (PCMH) in the capital of Freetown.
"I wasn't there to assist her, to save her," she said, sweat dripping down her faded lilac scrubs. "Pregnant women must come tohospitalregularly so that they can get the help they need."
Despite a chronic lack of doctors, nurses and midwives and a tradition of giving birth at home, maternal deaths were on the decline in Sierra Leone until 2013 - having halved since 1990.
Then Ebola struck. The world's worst outbreak of the virus ravaged the country's fragile health system, killed a tenth of its doctors and scared people away from health centres.
Maternal and child deaths spiked as a result, and the country's maternal mortality rate soared to 1,360 deaths per 100,000 births last year from 1,100 in 2013, U.N. data shows.
The government and the United Nations say they have learnt lessons from the Ebola epidemic, which sparked a fresh drive to improve the health system - on which less than 10 percent of the state budget is spent - and reduce maternal deaths.
"Ebola was a necessary evil," MargaretMannah-Macarthy, midwife adviser for the U.N. Population Fund (UNFPA) told the Thomson Reuters Foundation. "It was an eye-opener which showed the issues facing our health system. Now we must tackle them."
Those issues include training more midwives, coaxing doctors back from abroad, boosting blood donations and ensuring women give birth in health facilities, health experts say.
Sierra Leone's 1991-2002 civil war drove away many medical professionals, leaving some 130 doctors to care for a population of seven million people - one of the world's lowest doctor-to-patient ratios.
There were also fewer than 100 midwives as of 2010, because, unlike other African nations, Sierra Leone did not invest in midwifery in order to combat maternal mortality, the UNFPA said.
The introduction in 2010 of free healthcare for pregnant women was a major factor in driving down the maternal mortality rate, but it left midwives overwhelmed,Mannah-Macarthy said.
Yet during the Ebola epidemic, it was not a lack of midwives but mistrust of health workers that saw maternal deaths soar.
Maternal deaths rose by 30 percent between May 2014 and April 2015 compared with the previous year, as fewer women soughtpre-natalcare or gave birth at health centres, a study by the UK-based Liverpool School of Tropical Medicine showed.
"It is the husbands and relatives of pregnant women who often make the decisions about their health, which during Ebola meant delivering at home with a traditional healer," saidHusainatuKane, chief nursing officer at the health ministry.
"It is crucial that we regain trust in the health system, and the important role that midwives play inchild birth."
The state aims to boost the number of midwives to some 1,150 in 2020 from around 500, which Kane called a "Herculean task". A second midwifery school opened in 2010 in the central Makeni region, and plans are afoot for two more in the east and south.
Preparing for a class in a cluttered room full of training dummies and baby dolls in the PCMH's National School of Midwifery, principal Joan Shepard said it was important that midwives were not concentrated in Freetown.
"If you teach midwifery only in the capital, then students set up a life here, and may not want to work elsewhere," she said, sifting through a pile of latex gloves and stethoscopes.
BOOSTING BLOOD BANKS
Besides increasing the number of midwives, the government has considered other strategies to improve the odds of survival for pregnant women in a country where 3,000 are estimated to die each year during or just after giving birth.
An emergency fleet of ambulances andparamedics,improved recording of maternaldeaths,and offering health workers who have left the country financial incentives to return are all on the agenda, according to several health ministry officials.
Yet with four in 10 maternal deaths caused by bleeding, appealing for donations and boosting blood banks is crucial.
"We don't have enough blood in our banks, so you often have to search for a donor for each pregnant woman in need," said Santigie Sesay, director of reproductive and child health. "By the time you find one, the woman will most likely be dead."
Sierra Leone needs a nationwide campaign to raise awareness about donating blood, and should reach out to communities, schools and even the military, the health official said.
Despite these difficulties, pregnant women are steadily returning to health centres for prenatal care and to deliver.
In the postnatal ward of the PCMH, new mother GraceSellahsaid she was anxious about going into labour, having lost her firstborn during childbirth two years ago.
"I was quite nervous," the 27-year old said, as the days-old baby boy nestled in her arms stretched and yawned after waking.
"But the nurses and midwives looked after me so well ... it filled me with the courage to give birth here inhospital."
By Kieran Guilbert