Q&A: Reimagining What’s Possible For Maternal Health Care in Sierra Leone

Sierra Leone has one of the highest maternal mortality rates in the world, making it one of the most dangerous places for women to give birth. The country sees 1,120 maternal deaths for every 100,000 live births—a number that far outpaces the global average of 211. But it doesn’t have to be this way.

Since 2014, PIH has focused on improving maternal health care in Sierra Leone, where it originally began working in response to the Ebola outbreak in West Africa. PIH has not only provided care to patients but has sought to strengthen the country’s health system in partnership with the Ministry of Health, laying the groundwork for accessible, quality care for future generations. In November, PIH announced plans to build, staff, and resource a Maternal Center of Excellence in Kono District in the eastern part of the country.

Bestselling author John Green recently sat down for a virtual conversation with PIH leaders to reflect on the past, present, and future of PIH’s maternal health work in Sierra Leone. These leaders included Dr. Joia Mukherjee, PIH’s chief medical officer; Isata Dumbuya, a nurse midwife who leads the reproductive, maternal, and child health program at PIH Sierra Leone; Jourdan McGinn, deputy executive director of PIH Sierra Leone; and Armah Quist, program officer with PIH Sierra Leone at Lakka Government Hospital.

Below are highlights from the conversation, edited and condensed for clarity.

Green: When I first started learning from you and your colleagues about the work that was being done in Sierra Leone around maternal mortality, what was explained to me is that it's not an issue with ambulances or blood pressure cuffs or medications or running water –the issue is that if the system does not get stronger, then there is no way to make lasting change. And I think that is really powerful.

Mukherjee: None of these problems started today and they're not going to be solved today. But if we really look at the history and invest in the places that were so historically impoverished—that's why you use the term impoverished instead of poor, because it's an extraction—nowhere is that more clear than in Kono District in Sierra Leone, where the very hospital is literally in the shadow of a diamond mine, where resources are being just sucked out of the community, as Paul explains in his new book (Fevers, Feuds, and Diamonds).

As we started to look at Ebola, it wasn't a question only about a virus. I'm an infectious disease doctor. I went in the Ebola treatment unit, many of our great colleagues were in their PPE in the unit, but we weren't the ones getting Ebola . It was the people who were living 10, 12 people in a house, the people who didn't have the opportunity, the privilege to isolate and quarantine. The things that we're hearing now with COVID that drives the inequality so high. These things are what make people very susceptible. And then when you go to get care, there's no care for you.

So we started to treat Ebola. But we rapidly understood that Ebola was just one piece of the overall suffering of people we saw. One of the district directors said, ‘I'm glad you're here helping us do Ebola. But if a kid falls out of a mango tree and breaks his arm, what am I gonna do?’ Regan Marsh, who was our chief medical officer in Sierra Leone for a number of years, wrote about how, in the middle of the Ebola crisis, a pregnant woman who came seeking care was bounced, hither and yon, because no facility had adequate supplies to take care of her. And she ended up dying. And that wasn't because of Ebola directly, but it was indirectly because of the impact of this terrible disease on a health system that was absolutely unprepared.

So we saw during our Ebola work that Sierra Leone had the highest maternal mortality in the world and that really became our focus—if we could focus on maternal mortality, that would prepare the system for Ebola, that would prepare the system to fix that broken arm of that kid. And so really we look at our maternal health work as a battle horse that will bring attention to this human rights issue and feminist issue but at the very same time elevate the standard of care.

Green: We're also joined by Isata Dumbuya, a nurse midwife who has been leading the maternity ward at Wellbody Clinic and also at Koidu Government Hospital in Kono District since 2018. Isata, I wonder if you could first tell us what inspired you personally to work in Sierra Leone? And when you first came to Koidu Government Hospital, what was the situation there as compared to, say, the United Kingdom?

Dumbuya: I was born in Kono District and I grew up between Sierra Leone and the U.K. So I spent quite a number of years in Sierra Leone, including going to secondary school. In the U.K., I trained to be a nurse and then a midwife. I finished my midwifery training in 1999.

When I came to Sierra Leone to work with PIH, it was very different from the United Kingdom. In the first week of my arrival, two women died. This was a shock—a real eye-opener—because where I came from in the U.K., women did not die as a result of pregnancy, they did not die as a result of wanting to give birth. In Sierra Leone, you see these young women come in and, in front of your eyes, they die, from preventable things.

Over the years, it's taken us time to try and change this picture. And it is changing, because we now have systems and services in place that do make a difference. We have a working blood bank. We've got pharmacies and labs. We've got drugs that we can be able to give them to improve their conditions and improve their chances of survival. And we have well-motivated and trained staff. We've got a high dependency unit which is set up now to make sure that when sick women come in, we're able to treat them. The same for their babies because we have a special care baby unit now where small, premature babies, sick babies can get care.

At Koidu Government Hospital, more women are coming—we've seen a 38% increase in uptake in antenatal care. We've also seen that the delivery rate has increased by about 69%. Women are coming in and having babies. So we're doing a great job and we'll continue to do that, but we need to do more because there are still women out there dying. There are still women out there that do not access these services. There are still women out there that, for whatever reason, do not come to us and they still die. This hurts and breaks us, because we feel that every woman has a right to live; they shouldn't be dying just because they want to have a baby. This is not accepted in other parts of the world. And this is something that we all need to fight within Sierra Leone.

Green: When I talked to you recently, I asked you what you felt like was the next critical step and you immediately answered the Maternal Center of Excellence. I wonder if you can talk about why you see that as such an important next step in such a transformative moment for health care in Kono.

Dumbuya: The Maternal Center of Excellence will be a place where women are going to be able to access cervical cancer screening, family planning, a safe place for adolescents and youth friendly services. We've already started doing that. But the Maternal Center of Excellence will be able to provide this on a wider basis. We're going to have three surgical theaters. So anyone coming in for a Cesarean section won’t need to wait. And we have a special care baby unit now, but this will be upgraded to a neonatal intensive care unit. So we will be able to offer even higher level treatments for sick neonates and sick babies. And this is going to be a place where staff can come and be trained and receive all the sort of resources from experts.

This is going to be like the blueprint to show that in Sierra Leone, where for many years we've had the highest maternal mortality rate in the world, we can also have a state of hospital where people can come not just from within Sierra Leone but from neighboring countries to access this care. I believe this will just be the beginning and together we're going to change this picture because these women, they deserve this. Our staff, our clinicians, they deserve this. This is our dream.

Green: That's so inspiring. Thank you so much for sharing that. Every time I get to talk with you, it feels like my heart grows three sizes. I'm going to move now to Jourdan McGinn, the deputy executive director of PIH Sierra Leone. Since we've been talking about the Maternal Center of Excellence and how transformative this can be in Kono and beyond, I wonder if you can talk about the origins of the idea for the Maternal Center of Excellence, what the planning process has looked like so far, and what the initial inspiration was.

McGinn:  This Maternal Center of Excellence is really a product of the success that Isata spoke about. We wanted to think a little bit more radically to say, ‘In one of the countries with the highest maternal mortality rates in the world, how could we radically reduce this?’ Almost exactly three years ago today, a group of us sat in a small conference room and we asked ourselves, ‘What would it take to accelerate the reduction of preventing these women of dying from causes they don't have to? What if we didn't just accept incremental progress? What if we didn't just add a few more beds? What if we rethought what was possible?’

We re-imagined building really an entirely new ecosystem to address what, John, you said at the beginning really is a crisis of maternal death. And so the MCOE is exactly that—it's a re-imagining of what is possible for women in poor and under-resourced communities like Kono District. And it's far more than a building. It's a part of this ecosystem—about the community connecting to the clinics, connecting to the hospital.

We've partnered with Build Health International to design a 120-bed facility, which will triple the number of beds we have now on the existing campus of Koidu Government Hospital. And it's important that it's on this campus because this is a government hospital and this Maternal Center of Excellence will be a government facility. It will be managed by the government of Sierra Leone. We've designed it with them from the beginning. So really this is a collaboration.

Green: We're going to move now to Armah Quist, a program officer at Lakka Government Hospital, which is the only dedicated tuberculosis hospital in Sierra Leone. Armah is also an activist and organizer. When we spoke previously, Armah, you mentioned that, having put all of this work into building a feminist movement among young women in Sierra Leone, you had so many hopes for the Maternal Center of Excellence and that it was something that you so dearly wanted to see happen. I wonder if you could talk about what your hopes are for this center.

Quist: The Maternal Center of Excellence has a lot of potential to push women’s rights in Sierra Leone, especially Kono. This is exactly why the Maternal Center of Excellence needs to exist—because women and girls in Sierra Leone deserve better. They deserve a youth friendly space where they can go and ask questions about their bodies. The place I never had. And if they get pregnant, they deserve to go to a hospital that will treat them with dignity, whether they are married or unmarried, whether they are young or old, whether they are rich or poor. They deserve a place where they have a good chance of surviving childbirth.

This is what the Maternal Center of Excellence will create for all women and girls in Sierra Leone. It will create a place where the next generation of women can be empowered. The Maternal Center of Excellence is about far more than health care—it’s about feminism. It’s about women realizing their potential. And it’s about giving women the dignity and voice they deserve.