A baby was born, took one breath, then left the world again. No amount of the midwife pumping his legs up to his ribcage and back, or poking a finger hard and fast at his chest, would bring him back.
His 17-year-old mother lay in pain on the delivery table as her son was wrapped up in a yellow cloth. There was no time even for her to hold him, as another woman was about to give birth. The midwives quickly changed their bloodied robes and gloves. Because there was no other table, the second woman gave birth lying on the floor.
This time, the baby yelled as soon as she came out. She was healthy. While the midwives moved on to the next urgent case, their small delivery room filling up, she spent her first few minutes screaming on the concrete slab.
Welcome to life in Guinea, baby Katherine.
The situation for newborn babies and their mothers in this west African country is dire. Of every 1,000 babies born in Guinea, 123 die before their fifth birthday. For every 100,000 live births, 724 women die. Guinea has the world’s second-highest rate of female genital mutilation (FGM), after Somalia – 97% of women between 15 and 49 have been cut. Women who have had FGM are twice as likely to haemorrhage during childbirth, and haemorrhage is the leading cause of mothers dying in Africa.
Medicine is in short supply, and health workers’ salaries rely on selling enough of it. This leads to staff shortages; most health centres have one or two health workers when they should have eight.
The Ebola outbreak, which killed more than 2,500 people in Guinea, revealed how little access to medical care rural Guineans had. The health situation has improved slightly post-Ebola, but without donor money, the system would grind to a halt.
“The needs are identified, but the money is just not coming from the government,” says Guy Yogo, Unicef’s deputy representative in Guinea. After Ebola, the government increased its contribution to health from 2.66% to 4.66% of GDP, and has committed to 7% for next year. According to Yogo, however: “The minimum is 11-15% if you really want to have an impact.”
Katherine is one of nearly 5,000 babies officially born each year at Doko health centre in the Kankan region of north-eastern Guinea, but about 2,000 more are born to unregistered mothers who come to the area to search for gold in artisanal mines.
Births take place in one small room, with its single delivery table presided over by two midwives.
“Lots of women come, and there’s nowhere to put them all. They often have their babies on the floor. Better there than next to sick people – at least it’s clean,” says Bernadette Mansaré, a midwife.
When there is a moment between deliveries, she lectures the dozen pregnant women waiting outside on the importance of coming in for checkups.
Doko’s midwives have not had any training in 20 years. If they had, they might have known how to give the baby who died mouth to mouth resuscitation or proper compressions. Thousands of babies die from preventable causes each year.
One of the things that the response to Ebola brought was medical supplies, the like of which had not been seen in a generation.
Kondiadou health centre is near Kissidougou, one of the towns to which the UN started regular flights during Ebola. Before, reaching south-east Guinea from the capital involved a bumpy car journey lasting several days. Now, because of the flights, it is easier to get supplies and staff in, although the UN is expected to cancel the flight as soon as the threat of Ebola is completely over.
“It’s the first time we’ve got equipment like this since the centre was built in 1990,” says Therese Soropogui, a community health worker at Kondiadou, as she pulls out standard latex gloves and yellow washing-up ones and explains the difference.
A small camping stove, some sterilising kit, bandages and a few hundred pairs of gloves have been donated by the Spanish government and Unicef. And a red plastic bucket. It does not take much to save lives in remote Guinea.
“Before, we burned tools in the fire, and that took too long,” Soropogui says. “And if you had two women giving birth at the same time, you had to use our one set of tools for both women, one after the other. That was very difficult. Now we have three or four sets of tools and, at the end, you can sterilise them.”
Not all of the equipment seems to have been used, however, showing up what many see as an endemic problem with the UN’s approach.
“They give out supplies like sweets,” says Yolande Hyjazi, the country director of Jhpiego, an international health organisation. “The UN system is: what the government asks for, they buy, and that’s it. We’ve seen a lot of vacuum extraction equipment, but if you ask the staff about it they say: ‘I don’t know [what it is], the UNFPA [UN population fund] sent it.’ They give equipment without training.”
Even when staff do know how to use it, obstetric equipment does not solve a problem many women have – getting to a clinic.
Harriet Somadouno, a 20-year-old farmer in her third trimester, walked 17km to Kondiadou for a checkup, carrying 10kg of peanuts on her head to sell at the market en route.
“I walked with my friends, but I carried the peanuts myself,” she says. “It took me six hours. I’m going home tonight but I think it’ll be a quicker journey as I sold all the peanuts – perhaps four hours.”
Somadouno, exhausted after her walk, barely seemed to take in the information given by the nurse.
One scheme to help women involves what looks like a giant old-fashioned pram, which is attached as a sidecar to a motorbike. Spain has given 15 of them to health centres in Guinea.
Mamady Berete doubles up as Doko health centre’s broken bones specialist and the moto-ambulance driver. Dressed in high-vis from head to toe, he bumps up and down bush tracks and through enormous puddles, picking up pregnant women, strapping them in his sidecar and taking them to Doko.
The giant pram turns heads, but brings fresh problems, such as how to pay for petrol or maintenance.
“We have someone here who can fix it but, if a tyre breaks, we have to send to Conakry for a new one. It’s a bit difficult,” Berete says.
On his trips to the villages, Berete spreads the word about the health centre and encourages more people to use it.
Trust in Guinea’s health system was in short supply during Ebola, when clinics closed their doors, doctors and nurses died, and infected people seemed to disappear into hospitals never to return.
“People were afraid of our health centre – they said if you came here you’d catch Ebola. So people avoided coming,” says Berete. Because nobody came, salaries could not be paid, so the clinic had to shut, leading to even less trust in the service.
According to Yogo, the lack of working health systems meant the death toll from “collateral” diseases and health complications outpaced that of Ebola.
“More people died from malaria, diarrhoea and in childbirth than of Ebola,” he says. “The country did not have enough ambulances. They were all used for Ebola patients – nobody else.”
Now, people are trying to take advantage of the supplies and attention that Ebola brought, and keep people coming through the doors so staff can afford to keep those doors open.
Berete and his colleagues are succeeding: several health centres, including Doko, are recording pregnant women coming in greater numbers than before Ebola.
Somadouno, who left school aged nine and had her first child at 16, plans to repeat her gruelling 17km journey to give birth.
“I gave birth to my first child here and, because it went well, I’m coming back for this one,” she says. “My mother-in-law will come with me, but we’ll be on foot then too. My plan is to try to catch it early.”
Giving birth in Guinea: a life or death lottery bereft of midwives and medicine | Ruth Maclean
