It's one of the most dangerous places in the world to have a baby, where maternal and infant mortality are rife. DEIRDRE VELDONvisits Sierra Leone.

MARIATU BANGURA (35) is married with five daughters. The three sons she bore died in infancy. She seems weary and a bit angry. She lives in a tiny village, 200km from the capital and spends her days looking after her daughters and farming subsistence crops. There are times, she admits, when desperation pushes her to the limits.

“Sometimes you feel like throwing the baby away. You know these women who don’t have anything – she feels like killing the baby, because she doesn’t have anything.” Her diet is rice and staple crop cassava, even when she is pregnant or breastfeeding. On rare occasions she gets meat, which she gives to her husband to “keep him happy”.

She has no money and doesn’t want any more babies. “The men like us to have lots of children, but they are not responsible for them,” she says.

Family planning is available free of charge here, but Bangura says there are other issues with getting contraception.

“Some of the men will never agree to family planning.” The government has tried to staunch depressing rates of maternal and infant deaths by insisting all births happen in clinics or hospitals.

Bangura lives just five kilometres from the nearest clinic, but it may as well be on another continent if she’s in labour and has no transport.

This is Sierra Leone, one of the most dangerous places in the world to have a baby.

Women in this west African country have a one in 21 chance of dying in childbirth. By contrast, delivering a baby in Ireland is so routine, it’s almost humdrum. Just one in 17,800 women is expected to die giving birth. Almost all maternal deaths in Sierra Leone result from haemorrhage or infection at unassisted births.

This country of six million people has been eaten from the inside out by conflict. Its war might have ended a decade ago, but economic and social progress is as stunted as its children.

More than one in five children is stunted at birth because their mothers do not have enough to eat in pregnancy. One third of children die from poor nutrition, while malaria, diarrhoea and pneumonia kill children in large numbers.

Ireland is tipping the other end of the scales. Two in five women attending Dublin’s Holles Street hospital are overweight, according to the Master of the hospital, Dr Rhona Mahony. This has pushed up birth weights too, with one in five newborns weighing in at more than 4kg. Dr Mahony says we are kidding ourselves about our diet. “People will often lie about what they are eating, or they may have little self awareness.

“We did a study where we asked women to write down honestly what they ate. They were often very surprised. There were a lot of crisps, a lot of snacks.” We are also eating excessively large portions, she adds.

Breastfeeding is one area where the two countries share common ground. In Ireland, 38 per cent of women are still breastfeeding after one month. In Sierra Leone, just one third of women breastfeed exclusively.

Breastfeeding is hindered by the tradition of giving babies water instead of the nutritious colostrum produced in the first few days. After this, breastfeeding is difficult to re-introduce.

At Magburaka public health unit in Tonkolili district, northeast of Freetown, the under-five clinic is in full song. Nurses are teaching the waiting women a song advising against being pregnant and breastfeeding at the same time; the logic being they should have two years between pregnancies.

Of 26 children who have been weighed this morning, six are malnourished. Nine-month-old James Kuyaleh weighs 4.9kgs and is severely malnourished, says district nutritionist, Salamatu Koroma. He will be given Plumpy’nut, a fortified peanut paste in widespread use.

Child malnutrition is just one of the challenges facing Concern’s 1,000 Days campaign here. The programme aims to ensure women and babies get the best possible food and healthcare from conception to a child’s second birthday. For most women, getting enough food is one thing, getting the right kind of nutritious food is quite another.

In April 2010, the government introduced free mother and baby healthcare. Many women had given birth at home until then, attended by the local traditional birth assistant (TBA). In declaring that all women should give birth in a clinical setting with trained personnel, the government put many TBAs out of a job. Now, it is illegal to pay them.

Government policy assumes conditions for delivery in clinics are better than those in women’s homes. Often they are, but some, like the health clinic in Mabella, one of Freetown’s biggest slums, offer the most rudimentary of services. One of the clinic’s midwives, Eugenia Bodkin, shows the delivery room in which two women can, implausibly, give birth on side-by-side tables. Heel marks break the leather surface. Bodkin pulls out the delivery “equipment”, consisting of a kidney dish with a few rusty scissors inside. In August, Bodkin delivered 40 babies here.

Community health officer Adama Gondor insists it is possible to get an ambulance through the muddy mile of teeming market in time to transfer to hospital in cases with complications. Transport is a recurring theme. Simply getting to the local clinic can become a life or death issue.

Back at Magburaka clinic, Sister Kadiatu Kamara relates flatly how, on September 1st, a pregnant patient bled to death at home, because there was no ambulance available. The district’s two ambulances are broken down and there is no hope of having them repaired. To nobody in particular, Kamara says: “You see the problem of free healthcare? When you have all of these other problems?”

Concern’s primary health care co-ordinator in Tonkolili, Rosalind McCallum, says: “Road access is a very big challenge for women here. There are many instances of delayed care-seeking because of road access or because of a lack of understanding of the seriousness of the condition.” Two hours offroad at Mayossoh clinic, the local committee has hit upon a solution. With a flourish, they unfurl the hammock they use to ferry labouring women around. The fabric still bears the lettering of its previous life as a food sack, but it is well made and, carried by four or six men, incredibly, the best means of getting a woman to the clinic.

One of the biggest barriers to seeing women and babies thrive in Sierra Leone is the culture, says Dr Mahony, who visited the country earlier this month with Concern. She says this culture fuels early pregnancy, frequent pregnancy, rape and lack of access to healthcare or education. “I found that most upsetting really, that these women are just not important within their society.”

International aid agencies such as Concern are prioritising community involvement in health and education projects, often through the local chiefs. At Kunturloh health clinic in Freetown, the chief is trying to account for the high rate of teen pregnancy there. In Ireland, teenage pregnancies have hovered at around five per cent for almost half a century. In Sierra Leone, 40 per cent of maternal mortality happens in women under the age of 20. The chief says girls are targeted and raped when they are sent to fetch water for their families in the evenings in a practice known as “Water for Water”.

With a smirk, he adds: “Some of the problem lies with the girls themselves, because they go chasing the boys.”

At an ante natal clinic in Freetown, Husanatu Jalloh is one of 100 expectant mothers waiting in the baking outbuilding. She looks so fragile; it is hard to believe she is even 18. She is 32 weeks pregnant with her second child. Her first baby died at 17 months from pneumonia, she says, deadpan. She left school at 16 for her first pregnancy. “They don’t allow them to go to school when they are pregnant; it’s a bad example,” says one of the nurses.

Dr Mahony says she was appalled to hear about the secret societies, which most girls join before marriage. Female genital mutilation is carried out as part of the initiation process.

Violence is part of life here. “I was horrified by the level of rape and violence and women’s descriptions of being hit by their husbands. And if husbands weren’t happy, then it was acceptable for them to hurt their wives and that’s a very frightening attitude,” says Mahony.

At Freetown’s Princess Christian Maternity Hospital, Dr Philip Koroma is agitated. Maybe it’s because he is jumping up and down to fling open the window every time the power goes off, which is five times in half an hour. Koroma says being the main national referral centre has its drawbacks.

“One woman yesterday delivered at home and experienced postpartum haemorrhage. She went to a hospital nearby, who referred to us, rather than deal with the haemorrhage. That is so the death is not recorded as being theirs. . . ” “The workload is too tight,” he says, head in his hands. Five obstetric consultants are working there, but four are retired and have returned on short-term contracts. “I am now responsible for the whole country,” he adds.

In general, the lack of skilled workers and professionals is crushing. In 90-odd health clinics in the Tonkolili district, not one doctor is involved, even on an advisory basis.

The new clinic at Kunturloh has been open for three months and local official Mohammed K Turay is concerned. He worries that the wall around the clinic will collapse because of a build-up of water from the adjoining hill. We look at the wall, and arms outstretched, he says: “There is nowhere for the water to go. This building is open three months and it would be a shame to see all this work undone.”

Deirdre Veldon and Brenda Fitzsimons travelled to Sierra Leone with Concern. For more on Concern's 1,000 DAYS campaign see: concern.net