By Kevin Sullivan
Washington Post Foreign Service
Sunday, October 12, 2008 9:28 PM
KABALA, Sierra Leone -- Saio Marah, nine months pregnant and two days into labor, lay on a hospital bed and groaned loudly with each contraction.
She had arrived at the rural hospital earlier on the back of a motorcycle, about the only public transport available in this muddy little town in the distant back-country bush of one of Africa's poorest nations.
Now, in a dark and hot labor ward with rain blowing in the open windows and puddling on the floor, Marah grimaced as James Konteh slapped on rubber gloves and examined her.
Konteh, an ophthalmologist by training, is one of only two doctors who serve 300,000 people in this remote district, so he has become a de-facto obstetrician.
He placed a plastic Pinard stethoscope -- a cheaper, funnel-shaped alternative to a standard stethoscope--to Marah's massive belly and listened.
"The fetal heart rate is very rapid," he said. "The labor is obstructed. The baby is in distress so we must operate right away."
Konteh pulled out his cellphone and began dialing his four surgical nurses. It was 6:30 p.m., and they had all gone home when their 10-hour shifts ended a half-hour earlier.
Marah had waited too long to come to the hospital, and now the baby, her first, was in trouble. The surgery was urgent, but it would take time to get the operating room team back.
"What can I do?" Konteh said. "There's nobody here."
The nurses hooked up an IV to increase Marah's fluids, hoisted her onto a gurney and rolled her into an empty waiting room. She lay there naked, covered loosely by a small cloth, and waited for her caesarian section.
"I haven't been able to sleep for three days," she said. "The pain is too much."
It was a Monday evening, and her husband, Mohamed Barrie, said she had gone into labor on Saturday. Both of them were worried about the expense of going to the hospital, he said, and were sure she could deliver easily enough without assistance from hospital doctors. So they had gone to a neighborhood clinic where a nurse examined her and sent her home.
Now she was three centimeters dilated, her water had broken and she had finally come to the only hospital in Koinadugu, a sprawling and rural expanse in the far northeastern corner of this West African nation.
"This is our problem -- all the delays," said Samuel Kargbo, the British-trained director of the hospital and the only other physician in the country's largest and poorest district.
The region's largely illiterate population lives in villages scattered over a mountainous area about the size of Connecticut. The few rutted roads are often washed-out and impassable.
Even Kabala, the largest town, has no electricity or running water. Outlying villages are little more than a few thatched-roof huts. Families grow rice and vegetables, but this month, in the height of the rainy season there is less to harvest, less to eat.
Kargbo said many women delay seeking medical care for their pregnancies. He said many don't fully understand the risks, and are daunted by the costs and distances they need to travel for care.
So they tend to rely on poorly trained local midwives. When problems develop, they end up walking, or being carried in makeshift hammocks, for hours or even days to reach the hospital.
Sierra Leone also has one of the highest fertility rates in the world, with each woman having an average of more than six children. Karbo said some women have even more, and every pregnancy is a "chance of dying."
Kargbo said a government program, assisted by UNICEF, CARE, Catholic Relief Services and other organizations, has established 54 small public health clinics around the district. Each is staffed with at least one well-trained nurse.
That has reduced the number of women dying, he said, but a woman in Sierra Leone still has a one in eight chance of dying in childbirth -- and rural Koinadugu has historically had the worst death rates in the country.
"There is no going back," Kargbo said. "We are at the back already. We need to move forward."
By 7:30 p.m., Marah had been waiting for an hour on her gurney, the remains of a large dead spider hanging from a web on the ceiling over her head.
"Ohhhh, help me out, help me out," she groaned to no one in particular. "My firstborn, help me."
Outside the open window, next to a filthy and unused sink in the corner, thunder rolled across the hills and the wind picked up into strong gusts. Between contractions, Marah sang a song to herself.
Her husband arrived with a catheter and a urine bag, which the nurses had sent him to out to a pharmacy to buy. He said he paid about $3.
Patients must pay for all the drugs and medical supplies used in the hospital, in addition to fees for delivery -- about $10 for a regular deliver, and $70 or more for a C-section. Some operations are delayed while husbands run out to buy rubber gloves for the surgeon.
"I'm worried about how I am going to pay this bill," said Barrie, 32, who said he earns less than $100 a month making jewelry in a local market.
Marah's pain was increasing, and the nurses rolled her onto her side.
"I am going to die," she groaned. "God help me."
At 8:15, Konteh walked into the waiting room wearing a pair of long denim shorts and reading glasses, with a little sticker still attached showing their strength (+2.50).
He pressed the plastic funnel against Marah's belly again, listening for the baby's heartbeat -- an hour and 45 minutes after he first checked. The door squeaked loudly as a nurse walked in. "Sssh," Konteh said, ordering the noisy ceiling fan turned off so he could hear better.
He changed ears, and pressed the funnel in different places across Marah's belly, while Marah stared off toward the ceiling. Konteh straightened up and looked at the head nurse.
He shook his head.
Marah's baby was dead.
Ten minutes later, Marah climbed onto the metal table in the hospital's operating room. The surgical nurses, who work together as a team with Konteh, had arrived back to work. As they scrubbed themselves to create a sterile environment, a large roach crawled across the floor.
Konteh changed into his scrubs, then a sterile gown, which a nurse tied behind his back. Standing about 5-foot-3, he climbed up a small two-step stool next to the operating table in a pair of large rubber boots.
Marah lay on her back, with her arms spread out, making a T-shape. One nurse checked her blood pressure, another prepared to administer a general anesthesia through an IV in her wrist.
Marah lay still and quiet, except for the nervous twitching of her right big toe.
There was no oxygen, heart monitor or blood available. The air-conditioner remained off, despite the heat and humidity. An overhead light shone brightly on Marah's belly, which a nurse sterilized with an orange-colored wash.
At 8:39, the doctor and all the nurses stepped back, held out their hands with palms up, and prayed for a safe surgery.
"In the name of Christ our Lord, amen," they finished, in one voice, crossing themselves.
Konteh nodded at one of the nurses, who pushed a syringe full of anesthesia into Marah's veins, and she was out in seconds.
At 8:40, Konteh drew the scalpel down the center of Marah's belly. Four minutes later, a tiny head appeared in the incision. Konteh gently pulled the baby fully free. A nurse cut the umbilical cord and Konteh handed the infant , a girl, to Isatu Kamara, the mid-wife on duty.
Kamara hurried the silent baby over to a small examining table and pressed its chest with her forefinger.
"Nothing," she said. "No sign of life."
She turned the baby over.
"This is a fresh stillbirth," she said. "This baby has just died."
She put the body on a scale: 6.5 pounds.
A good size, otherwise apparently healthy and well developed.
"If she had come to the hospital earlier, this baby could have survived," Kamara said.
Kamara wrapped the baby in the colorful cloth that Marah had worn wrapped around herself as a dress. Then she placed the tiny body on a small rolling table and pushed it into the room where Marah had waited for her surgery. She left the baby there alone, under the harsh neon light, with the wind and rain still blowing in the window.
As Konteh stitched up Marah's belly, he said he had found the baby's head badly stuck in Marah's pelvis, with the umbilical cord wrapped around its neck.
His staff had been working since early morning, he noted, and had needed to go home to eat and rest. They came back as quickly as they could.
Konteh said the hospital doesn't have the money or the staff to have 24-hour coverage. Konteh lives in a house on the hospital grounds, and the surgical team works all day and is on 24-hour call for emergencies. Doing surgery without the full team could risk the patient's life.
Konteh stepped down from the table, pulled off his gown and tugged at his scrubs, which were soaked with sweat and sticking to him.
Two hours later Marah woke up in the hospital's post-surgical ward, where eight other women who had recently had C-sections were lying under anti-malarial mosquito nets with their babies.
The ward was dimly lit by a kerosene lamp.
Konteh was at her bedside, rubbing his patient's cheek to rouse her.
Still groggy and not quite lucid, she looked at Konteh.
"Thank you," she said.
"I didn't do this for you, God did it for you," he said.
Marah closed her eyes and opened them again.
"Where is my baby?" she said.
"Tomorrow I will tell you everything about your baby," he said.
"God Bless you," Marah said, and drifted back off to sleep.
Shortly after 6 the next morning, with a heavy mist hanging like a wooly blanket over hills so thick and lush they looked like heads of broccoli, Marah's dead baby girl still lay in the same empty room.
Marah lay in her bed, awake.
Her husband was at her side, with a bundle of clothes for her. All over the ward, babies were crying and mothers were nursing or changing diapers.
"I am not going to cry," Marah said, her eyes filling with tears.
"Thank God I came to the hospital," she said. "If I had stayed at home I would have died."
Relatives and friends stopped in to offer their condolences about the baby, but mainly they seemed happy that Marah was well.
She had still not seen her baby, and she said she didn't want to.
"There is no need," she said.
Her husband stood outside the ward with two nurses, discussing the bill. The total for the anesthesia and other medicines and supplies was about $50, and the operation fee was another $70.
He peeled off notes and paid about a third of what he owed; the rest he would pay in installments.
At around 10 a.m., several of Marah's female relatives picked up the baby girl's body, with its perfect little hands and feet and tufts of black hair, and brought it into a hospital bathroom. There, in a shallow basin, they washed it and wrapped it in a white cloth for burial.
They handed the baby to its father, who said a quick silent prayer with the baby in his arms. Then he handed the baby to the hospital's night watchman.
In this part of the world, the bodies of stillborn babies are often disposed of by the hospital. Stillbirth is such a common occurrence that the hospital has a small, unmarked graveyard set aside for them.
Sierra Leone has the highest rate of infant mortality in the world, with 16 percent of babies dying before their first birthday. Kargbo, the hospital director, said 26 babies were stillborn at this hospital last year.
The watchman carried the baby out the hospital's front door. He climbed up a hill into the long grass, behind a utility shed, where he had already dug a shallow grave.
It was set amid several small mounds overgrown with thick grass, the unmarked graves of other stillborns.
He placed the baby in the hole, and said a little prayer.