This is a personal From the Field story by Direct Relief Staff, Lindsey Pollaczek.

Sierra Leone has one of the highest reported maternal death rates in the world. In 2005, the maternal mortality ratio was 2,100 deaths per 100,000 live births and a woman’s lifetime risk of dying due to complications in pregnancy and childbirth was 1 in 8. Long distances to health facilities, the cost of health services, shortages of health workers and essential drugs, supplies, and equipment, and the low status of women are familiar challenges in sub-Saharan Africa – and chronic issues in Sierra Leone.

But it’s not all bleak. In fact, the documented maternal mortality figures have slightly improved, and after spending the last few days traveling through Sierra Leone I have seen some encouraging interventions which improve quality of and access to maternal health services. These, along with the government’s introduction of Free Health Care Initiative for pregnant and lactating mothers and children under five in April 2010, are working to break down the barriers which limit a woman’s access to care in pregnancy, delivery, and the post-partum period. At Direct Relief, we focus on three key interventions which improve maternal health services and quality of life. In Sierra Leone, I uncovered each of these important interventions during my journey.

One of the most important interventions to reduce maternal death and disability is for women to deliver with a skilled birth attendant. The skilled attendant is able to manage normal deliveries and can recognize signs of life-threatening complications that require referral to a higher-level of care.

The School of Midwifery in Makeni, Bombali District, is the largest midwifery school in the country and is currently training 138 midwives. The new school is unique as it trains a lower level of nurse that previously was not allowed to enter midwife training. Only the higher level of nurse was able to train as a midwife, but they often elected to work in more attractive settings following their graduation: hospitals in larger cities or in management positions with the Ministry of Health. Therefore, most deliveries in primary health centers at present time are attended by maternal-child health aides and traditional birth attendants, neither of which qualifies for the title of “Skilled Birth Attendant,” according to the World Health Organization’s definition. The new generation of the midwives at Makeni will help change the current situation.

Bright and early Monday morning, the school was full of eager students working hard to gain the honor of becoming the first graduating class of the Makeni School of Midwifery in January 2012. Most of the midwives trained at Makeni will work in remote clinics in rural areas, where the needs are often greatest. I spoke with a few students who had been nominated by their peers to represent the class. They shared with me their appreciation for the training and their motivation for taking up the course. “There are certain things I used to do, maybe not the right way,” said student Ramatu Kano, “but now that I am in the program I have seen my mistakes and already corrected them. I am very happy to be part of this course.”

This is the first time that midwifery training has been open to qualified males, and several have enrolled in the program. Midwife-in-training Steven Ngaujah lost his sister when she died giving birth to twins without a skilled birth attendant present. “So many other women in Sierra Leone are in this position, so I was moved to be part of this work to see that maternal mortality is reduced in this country,” he explained. He recognized that his position as a male midwife in Sierra Leone was rare but he was willing to break down that barrier to see that women receive better care in pregnancy.

Once the midwives graduate from Makeni and are posted in rural areas, they must have the right equipment and supplies to use their new skills fully. Imagine spending two years in training only to be placed at a health facility that lacks the tools you need to do your job. This is a common scenario in Sierra Leone that is demoralizing for the health provider and potentially life-threatening for the women who need care. Direct Relief is working with the School of Midwifery in Makeni to ensure that when the midwives graduate they have the supplies they need.

“Now in the community and in the health facilities there are midwives working barely without equipment,” said Francess Fornah, the head of the school. “If we can equip the midwives with the midwifery kits and delivery sets then I think we have gone a long way.”

The midwife students agreed. “These [midwife kits] are very difficult to get here,” Ramatu Kano said. “This would help me to work in the community, and I would appreciate this very much.” When Francess introduced me to the first class of 72 students during the tour of the school and she announced that Direct Relief was equipping all of the graduating midwives, the students erupted in great applause.