When a river and several hours of dirt roads stand between you & the nearest hospital, giving birth can be deadly. One nurse is hoping to change that.
It's 8am and already the air hanging over Bonthe Island off Sierra Leone's southern coast is humid and sticky. Wearing jeans and rubber slippers, nurse Flaviour Nhawu arrives at the pier breathless, in an ambulance that is the only four-wheel-drive vehicle on the island.
A few minutes before, she had received a call from a remote village called Bendu, where a 35-year-old woman named Kadi had just gone into labour. Now, she and another nurse are preparing to board a white motorboat for the choppy 20-minute ride across the Sherbro River. On the other side, they will walk another quarter of an hour along a dirt path, between tall palm trees and villages of sparse huts, to reach Bendu's small clinic.
This is what it's like to give birth in the world's most dangerous country for mothers. (Valeria Scrilatti/ Zona)
There, Kadi, who is frail and malnourished, is writhing in pain.
Nhawu knows this will be a difficult birth, so she calls for a motorcycle to carry Kadi back to the boat. As it speeds across the river, the woman stares at the water, her eyes clouding over.
Once they reach the opposite bank, it's straight into the waiting ambulance.
A few hours later, in the Bonthe district hospital, Kadi gives birth by C-section to a healthy baby girl. And then, on the maternity ward's pink sheets, she falls at last into a deep, untroubled sleep.
Sierra Leone is the most dangerous country in the world to become a mother, 2015 World Health Organisation (WHO) data shows. For every 100 000 live births, more than 1 300 mothers lose their lives, 2015 WHO figures reveal. According to the country's latest Demographic Health Survey conducted in 2013, a third of women between the ages of 15 and 49 who die in the country die before, during or shortly after childbirth.
By the time that Sierra Leone's decade-long civil war ended in 2002, the conflict had decimated the national health system. Clinics and hospitals lay in ruin and some healthcare workers were either dead or gone - fleeing the country to take refuge abroad.
Almost 10 years later, less than half of the hospitals surveyed were able to provide expecting mothers-in-distress with life-saving care such as caesarean sections or blood transfusions in the case of complicated births. Postpartum haemorrhages (heavy bleeding after birth) are the leading cause of maternal deaths and responsible for one out of three such deaths, a 2016 government report shows.
None of the clinics in nine of the country's 13 districts, 2011 research published in the journal PLOS found, could provide basic emergency obstetric care or the type of treatment needed to resuscitate newborns or prevent post-birth infections.
When the Ebola virus hit in 2014, the situation went from bad to worse. The world's largest Ebola outbreak would last three years, sweeping through Guinea, Sierra Leone and Liberia. Safe deliveries and C-sections fell by more than 20% during the peak and even as new cases began to dwindle in 2015, a 2016 study featured in PLOS reveals.
In the year the outbreak started, the C-section rate fell to one-fourth of what would have been needed to prevent excessive maternal deaths.
Even for Sierra Leone, however, Bonthe is badly off. The intense and melancholic beauty of its lagoon landscape obscures extreme poverty. Comprised of a series of islands and a section of the mainland, the district ranked as one of the country's poorest even before the outbreak, according to the country's most recent demographic health survey.
Most people here live on pure subsistence farming, growing beans, cassava and potatoes.
Government-provided electricity has not yet arrived in the district, and there are no paved roads, only a few dirt trails that are difficult to access. People and goods move only along the tangle of rivers that flow into the Gulf of Guinea. For pregnant women in distress, it can be a long journey to reach the main hospital on Bonthe Island.
If a pregnant woman has a complicated labour, haemorrhages or experiences a sudden, dangerous increase in blood pressure, she may wait hours before being brought to the hospital, says Nhawu, a public health expert who co-ordinates maternal health programmes on Bonthe Island for the Italian NGO Doctors with Africa. The organisation, which is the main partner of the district health authority, is also known by the Italian acronym Cuamm.
Sierra Leone's Bonthe island may have sunny beaches and rolling waves but its picturesque beauty hides a deadly secret. (Valeria Scrilatti/Zona)
"Both her own and her child's life are at risk," the Zimbabwean nurse explains.
Nhawu first came to Sierra Leone during the Ebola outbreak and today has an unusual connection with her patients: she's pregnant too.
But five months into the pregnancy, her expanding belly doesn't stop her from jumping in and out of speedboats headed to emergency deliveries, walking kilometres to reach the most remote healthcare facilities and holding the hands of other pregnant women awaiting C-sections.
"In 2016, together with the WHO, we recorded 28 women who died at childbirth in Bonthe," reports Samuel Massaquoi, the district medical officer.
"It's a high number for a population of only 200 000 people. But thanks to the innovations brought by Cuamm, in 2017 that number has been halved, according to our government statistics."
Nhawu is a big part of the reason for that change. She came up with the idea to create the chain of ambulances, speedboats and motorcycles that now get women from remote corners of the district to the hospital where they can more safely give birth.
She also wrangled the resources to make it happen, getting the district to provide the vehicles, although the service is reliant on funding from Cuamm for the fuel and upkeep of ambulances.
The organisation partnered with the United Nations Population Fund (UNFPA) to help train health workers at the Bonthe Government Hospital on emergency obstetric care. In 2017, UNFPA estimated that this work and similar projects in two other district hospitals in the country saved the lives of almost 7 000 women.
Sierra Leone is one of the most dangerous places in the world to give birth. (Valeria Scrilatti / Zona)
Bonthe's hospital, meanwhile, now has a doctor who specialises in obstetric emergencies, a blood bank and solar panels that provide electricity 24 hours a day. And Cuamm has also trained, by Nhawu's own count, hundreds of community healthcare workers who now know how to recognise labour complications and set into motion the chain of events needed to save the lives of mothers and babies.
At the district's main hospital, Francess Kenjah, 22, has just arrived. Malnourished and silent, she's about to give birth to her second child. She's just spent seven hours on a boat from her village at the opposite end of the district.
Without Cuamm subsidising her trip, it would have been impossible for Kenjah to afford the $220 (R3 120) boat ride here.
But even when mothers make it safely to the hospital, as Kenjah did, there are still many other challenges to giving birth here, Yellia Kargbo, a midwife at the hospital, explains. The demographic and health survey shows that about one in three Sierra Leonean teenage girls between the ages of 15 and 19 have fallen pregnant. In Bonthe, half the women will welcome their firstborn before the age of 20.
"We handle too many early pregnancies, even 12-year-old girls," Kargbo explains. "They usually do not go to school so they get married at a very young age. When they are pregnant they run serious risks, for themselves and their children."
Childbirth at an early age brings a host of problems for the women and their babies.
Adolescents who fall pregnant are less likely than adults to access the care they need before and after the baby comes, 2011 WHO guidelines on preventing early pregnancy say. Babies born to young mothers are also at an increased risk of dying before their first birthday.
In many low- and middle-income countries, pregnancy or childbirth complications are a leading cause of death for young women.
Women's and girls' problems don't end there. A 2013 survey reveals that one in four women here have also experienced domestic violence.
Edna Tuckev is the chief of a town called Mattru. Together with Nhawu, Tuckev created structures to train women on health and hygiene issues, as well as on their fundamental rights.
"Here, you can see women who are dried up," she explains. "The bones of their neck are protruding because many husbands leave them without food. So we try to sensitise people on women's rights and wellbeing for the wellbeing of the entire community."
Inside the hospital, meanwhile, another patient is waiting for an obstetric check.
The baby is in good health, but the nurses tell the mother that her legs are too swollen. She needs to rest more often.
The patient answers with a wide, bright smile.
"All right, girls. I promise you that I'll go to bed earlier," Nhawu says.
"Since I've been pregnant, I've got a completely new vision of my work," she tells Bhekisisa later.
"Now I can deeply understand how pregnant women feel and all the difficulties and the fears of a pregnancy," she explains.
"I'm more and more determined to push for them to receive quality health services so that they can go home happy and healthy to celebrate their newborns without any shadow of sickness or death." - Additional reporting by Laura Lopez Gonzalez
This story is a part of the multimedia project "Crossing the River" on maternal mortality in sub-Saharan Africa, by Emanuela Zuccalà and the photographer Valeria Scrilatti. Produced by Zona, it's been funded by the Innovation in Development Reporting Grant Programme of the European Journalism Centre.