Marla Marek, a veteran maternity nurse, was introduced to Sierra Leone when one of her students went there for a different kind of health care career.
The assistant professor of nursing at California State University, Stanislaus, has since taken two trips to the west African nation to work in a hospital for women who are seriously injured during childbirth.
A higher percentage of women die from childbirth in Sierra Leone than in almost every other country in the world.
At a government hospital in the capital city of Freetown, a major port on the Atlantic Ocean, mothers die in about 18 of the 200 births per month. In the United States, it happens 13 times in 100,000 births.
"Having spent my career working with child-bearing women, it's sad to watch women die every day in Sierra Leone," said Marek, who was a full-time nurse at Memorial Medical Center for 17 years. "It gets under your skin. You feel you have to do something."
Her former student, Joanie Alderson, felt the same calling.
She is a ward supervisor at Aberdeen West Africa Fistula Centre, which offers surgery for women who survive a leading cause of maternal death -- obstructed labor.
In a country with few medical facilities, women in remote villages may be in labor for up to six days if the baby doesn't make headway into the birth canal.
The baby usually is stillborn and the women suffer damage to their urinary systems, leaving them incontinent and the subject of ridicule in their home villages.
Danger isn't recognized
Few medical personnel are in the rural areas and many villages have only traditional birth attendants who rely on folk medicine.
"If a woman is in labor for 24 hours, they don't recognize it as a danger sign," Marek said. "There is a failure to seek appropriate care. Many of them need approval from the chief to get transportation to leave the village."
Women who survive obstructed labor often have a fistula or hole between the bladder and vagina, or a damaged rectum. They can suffer nerve damage, making it difficult to walk.
Foreign health workers hear horror stories about traditional attendants who injure mothers by pushing on the belly, or rolling a log down it, to get the baby out. Women are harmed when untrained health workers give them too much pitocin, a synthetic hormone that increases the frequency and strength of contractions.
Prolonged labor may be seen as a sign of transgression, so the attendant may ask the woman to confess adultery, Marek said.
It's believed women might be prone to prolonged labor because of poor nutrition or a high incidence of teenage pregnancies. Women also carry heavy loads on their heads, which may change the structure of their pelvic bones.
Marek, who was in Sierra Leone for two months in the summer and five weeks in December and January, went on trips with hospital staff into the country's interior to find victims of obstructed labor. The three-day trips in Land Cruisers took them over unpaved roads; some villages were accessible only by canoe.
In villages with huts made of mud bricks and thatched roofs, they asked chiefs to direct them to women who needed medical attention. The women often were hidden away, Marek said.
"These women get ostracized," she said. "They are wet all the time. They smell. They weren't able to produce a child in a country where women are valued for their ability to have children."
Every Thursday, the Land Cruisers return with six to 10 incontinent women. A specially trained surgeon is needed to repair the fistulas. The center has a full-time urologist and surgeons from other countries volunteer their time.
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