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How do you tackle maternal mortality in Sierra Leone? Try asking a midwife

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Osman was born in Freetown's Susan's Bay slum district in 2007. Like many women in Sierra Leone, his mother died in childbirth. Photograph: David Levene for the GuardianHow do you tackle maternal mortality in Sierra Leone? Try asking a midwife

26 October 2012

The post-2015 development framework must be shaped by people with first-hand knowledge of the challenges that lie ahead

Posted by Francess Fornah, Friday 2 November 2012

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My worry, as the high-level panel on post-2015 development goals meets this week, is that my voice – and those of many others working at the sharp end of development – won't ultimately have much influence.

Every day, thousands of community health workers, voluntary groups, teachers, entrepreneurs and civil servants engage in development activities in their own communities. They're hands on, responding to the needs of their communities – sometimes with the assistance of NGOs and donors, sometimes not. They know what works, because they're out there doing it; and they know what doesn't work, because they've seen it fail.

There's a real danger that the post-2015 process – though inspired by the same noble aims as the millennium development goals (MDGs) – will also share their failings. That is to say, they'll be a set of goals and targets created by distant elites, and they'll treat people as passive recipients of aid and development. Yet people are tired of being told what they need.

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I'm not saying the MDGs have brought no benefits. They have focused attention and funding on important areas. Working in midwifery in Sierra Leone, where one in eight women still dies during pregnancy or childbirth (pdf) and thousands more bleed to death after giving birth, I'm all too aware of the focus on reducing maternal mortality and the impact MDG five has had. Yet every day I work with nurses training to be midwives, and they don't know what the MDGs mean for their work. To them the goals are distant targets, far removed from the daily realities faced by a midwife in a developing country.

My midwifery school in Makeni trains community health nurses to become midwives, responding to the appalling lack of trained birth attendants in Sierra Leone. Previously, only state registered nurses could train to be midwives. Many would undertake further training and enter other fields, leaving us still short of practising midwives. Our aim is to train new midwives who remain in their communities – particularly in rural areas – helping women to give birth safely. This year, another 69 students graduated and are doing just that.

Sierra Leone has a shortage of midwives in rural areas. The problem is compounded by a lack of support for the childbirth assistants who do serve rural communities, who often have to leave their families behind in towns and cities to work in areas hard to access by road. Thus isolated, they have difficulty caring for, educating and – because they are based in distant villages with no mobile reception – even communicating with their own children. They often struggle to find somewhere to live, and have to manage without regular electricity and running water. It's little wonder some leave the profession or try to get work closer to home, once more leaving the community they served without a midwife.

Birth assistants working in maternity wards and communities don't need another system that replaces MDG five, creates a whole new layer of bureaucracy, and forces donors and governments to rethink their priorities. Particularly not one based on a document that comes out of London or New York. We need a framework that recognises the good work that's already happening in our poorest communities, and focuses on supporting and enhancing it.

We also need to be empowered to hold governments to account on these targets. When it comes to maternal health, leaders should be accountable to the women who are risking their lives just by having a baby. Poor and marginalised communities must have a say in measuring whether poverty-reduction measures are working. And we need specific goals and targets to tackle the inequality faced by women, who are excluded from so many of the decision-making processes that affect their lives.

In my country it is, slowly, getting safer for women to give birth. As I watched new midwives graduate this year, I could see the progress we are making. The MDGs have certainly played a part, and whatever comes after them has the potential to achieve much, much more. But to avoid squandering that potential, the panel must remember three things.

First, they must listen to people actively engaged in development in their own communities, ensuring those people are genuinely able to influence the post-2015 development framework, so that it supports the work they're doing.

Second, they must build on what has already been achieved. Don't tear up the MDGs and start again, and don't create new international commitments where they already exist. Instead, strengthen and implement what we already have.

Third, we need to find better ways to ensure governments are accountable to people living in poverty, and to the people actively working in poor and marginalised communities.

It's these points that I will make when I address the panel on Friday. If they are serious about tackling poverty, and I hope they are, they will need to listen to the thousands of people already actively engaged in development, and work together with them.

Francess Fornah is based at King's Health Partners in London as part of a three-month commonwealth fellowship placement organised by VSO. She is head of the school of midwifery in Makeni, Sierra Leone. On 2 November she will address the high-level panel as part of the civil society roundtable dialogues

Source: The Guardian UK



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