By Bonnie Allen
MONROVIA, Sep 22 2010 (IPS)

Mercy Freeman sits on a small hospital cot in one of Liberia’s emergency hospitals, looking down at her frail son, whose dark eye sockets have sunk into his bony face.

Nearly forty percent of Liberian children under five are malnourished. Credit: Bonnie Allen/IPS

She has been feeding her 18-month-old son, Mark, bowl after bowl of plain rice without realising that he had become severely malnourished despite being regularly fed. After two weeks in hospital, Mark is still too weak to sit up, his skin dropping in large folds off his scrawny legs. He weighs only half of what he should be for his age and height.

“Most of these mothers are too young [when they start bearing children],” says Dr. Taban Dada, medical director at Redemption Hospital in Liberia’s capital Monrovia, one of the country’s largest public hospitals. “Many of them are having a lot of children before they are adequately prepared. At the end of the day, they’re not able to take care of these children properly.”

Adequate preparation, argues Dada, includes a high school education, maturity, financial resources to support a child and a basic understanding of nutrition and childcare, such hygiene and proper feeding.

Teenage mothers

A third of Liberian mothers give birth to their first child before the age of 19, according to 2007 national Ministry of Health statistics, making Liberia one of the countries with the highest rates of teenage pregnancy in the world.

Dada claims it is these young mothers who are to blame for the country’s alarming malnourishment rates, saying they are based on women’s ignorance about what makes up a healthy diet, not lack of food. Almost 40 percent of children under the age of five suffer chronic malnutrition, according to the country’s 2008 national nutrition policy report.

The authors of the report also found that the major developmental disruption caused by malnutrition takes place in the womb, mostly due to iron, iodine and vitamin A deficiency in the mother, as well as in the first two years of a child’s life. This often leads to stunting and irreversible brain damage.

“The children’s IQ will be reduced. They will not cope well in school,” worries Dada.

He says the Ministry of Health needs to follow through on its policy recommendations to introduce nutrition education into the school curriculum and train pregnant mothers about balanced diets during hospital visits.

Lack of parenting skills

In north central Liberia, amidst small rice fields and cassava crops, Ruth Zansi, the manager of a feeding programme for 900 children at the Hope for the Nations Children Recovery Centre in Ganta, agrees that lack of parenting skills and education are often to blame for malnutrition. But that’s not necessarily the mothers’ fault.

“During war time, people were scattered, people could not go to health centres or get an education,” explains Zansi, referring to 14 years of civil crisis that left an estimated 250,000 people dead, hundreds of thousands displaced and communities destroyed.

A 2008 government report reveals that 44 percent of teenage girls have never gone to school, and 62 percent of women are illiterate, mainly as a result of the civil war.

“Mothers do not understand that [their children] are malnourished. They think someone has [be]witched the child. They only come [to the feeding programme] because they are pushed, but they would rather go to a witch doctor,” explains Zansi who herself is a mother of eight.

Zansi’s staff patiently teach teenage mothers about the benefits of breastfeeding and how to supplement meals with affordable proteins, such as beans and nuts.

Food insecurity

While she cuddles a small boy with a swollen belly, she argues that poverty and food insecurity are also critical factors causing malnutrition. Liberia remains one of the poorest countries in the world, according to the 2008 United Nations Development Programme Human Development Index, and rampant unemployment means many families are too poor to diversify their diets with vegetables, meats and other high-nutrient foods.

Since the civil war ended in 2003, Liberia has imported more than half of its food and struggled to introduce large-scale farming of rice, cassava and corn.

Teenage mothers do not intentionally harm their children, agrees Save the Children child protection programme manager Geoffrey Oyat: “They do love their babies. They try to do their best. But within the context they’re operating in, they do not have the resources to look after their child.”

Oyat says with poverty and high unemployment comes a high rate of teenage and unplanned pregnancies: “[The girls] are providing for themselves, exposing themselves, trying to sell in the streets and getting boyfriends.”

Poverty

Back at the paediatric ward at Redemption Hospital, malnourished children with swollen bellies are fed rice mixed with green vegetables and a protein-rich milk blend. Like Mark, most of the toddlers are stunted and severely underweight. Because of their weak immune systems, they are also more vulnerable to diarrhoeal diseases, malaria and pneumonia than other children.

Freeman, who dropped out of school in Grade 8, struggles to understand the doctor’s explanations, but Dada is confident that she will be able to nourish Mark back to health with some support from the hospital. He has given Mercy a schedule to access dry rations of enriched porridge at a nearby clinic to provide her son with the nutrients he needs to grow.

*This article was produced by Bonnie Allen and New Narratives Fellow Clara K. Mallah, of FrontPage Africa. New Narratives is a project supporting women journalists in Liberia.

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By Bonnie Allen
ZWEDRU, Liberia, Jul 14 2010 (IPS)

Henry Teh gently slides down a blue hospital sheet to expose the bare belly of a pregnant woman. As he pokes around to feel the position of the foetus, the midwife-in-training knows he is breaking tradition and changing the face of obstetric care in Liberia.

Many Liberian women are uncomfortable with being attended by male midwives. Can this resistance be overcome? What are the alternatives? Credit: Bonnie Allen/IPS

In 2009, Teh became one of the first men to be admitted to a midwifery training program in Liberia’s southeast. The rural midwifery school, closed for 20 years due to war, was reopened by the British medical aid agency Merlin and Liberia’s Ministry of Health and Social Welfare.

Shortage of qualified trainees

School officials quickly discovered that there was a shortage of qualified female candidates in the remote region. Few young women in Liberia graduated from high school in the past few decades because parents preferred to send their sons to school.

The decision to recruit men seemed to make sense, said midwifery trainer Sawah Shaffa. “[Liberia] has got male doctors. They got male nurses. So, midwifery should not be limited to only women.”

At the Martha Tubman teaching hospital in Zwedru, Teh invites another pregnant woman to lie down on the exam table. The young man explains how he jumped at the opportunity to become a midwife because of a personal tragedy – his 19-year old sister died giving birth while stranded in the bush.

“She was trying to walk from the nearby town to Kanweaken, where we have the clinic. She started bleeding severely and there was no car available.”

Villagers loaded the pregnant woman into a hammock to carry her to the next town, but she died on the road before an ambulance could arrive.

A 2009 report by the United Nations Children’s Fund (UNICEF) indicates Liberian women have a 1 in 12 lifetime risk of dying from pregnancy or childbirth complications, usually due to obstructed labor, haemorrhage, or infection, resulting in the eighth highest maternal mortality rate in the world.

UNICEF concludes that 80 percent of maternal deaths could be prevented by access to trained health workers.

Liberia has roughly 3.8 million people but just 400 trained midwives. Health officials say another 1,200 midwives are needed.

But whether the male midwife experiment will be successful is still in question.

Overcoming cultural obstacles

In the packed hospital waiting room in Zwedru, a young pregnant woman winces in pain and clutches her belly. Aletha Cherley, 22, is nervous because it’s her first pregnancy but, although she’s feeling cramps and back pain, she is reluctant to let Henry Teh examine her.

“For me, if a different man who is not my boyfriend sees my private parts, I can be too ashamed. …It’s very shameful to me. That’s why they have ladies here to do that,” says Cherley.

“You know, midwife means somebody to stay with a woman for long. And most women will not feel comfortable for another man to be with them until they deliver,” agrees Kenyan midwife Zeena Abdalla Ramadhan, Merlin’s training coordinator.

“Midwifery is something private… it’s woman to woman.”

Fifty-six-year Abdalla, known by all as “Mama Zeena,” has spent nearly half her life training midwives in Sudan, Chad and Kenya’s Kakuma refugee camp. She knows there are cultural barriers to introducing men into the traditional field of midwifery.

“In South Sudan, they can only call a man when the woman has failed. Then the man will come with a spear to remove a baby, a stuck baby. Still, woman has to be around.”

Can trained men fill gap?

Mama Zeena trained as a midwife after losing her own full-term baby in 1987. Today, she has become a vocal advocate for training more skilled birth attendants in poor, post-war states.

She warns that the Millennium Development Goal of reducing the world’s maternal mortality rate by three quarters by 2015 and providing universal access to reproductive health cannot be met without greater investment.

In Liberia, she has wrangled with the question of whether training a male midwife is of any use if gender issues prevent pregnant women from seeking their expertise. The decision is made more difficult because male applicants score highest on the entrance exam.

“If we had just gone only with the grades, we could have ended up having only men… But [community members] raised the concern. We cannot train people who will not be useful. So, we decided, let’s not consider more men.”

The school reduced the number of male midwifery students accepted in 2010 to just two. Mama Zeena does not know what will happen next year.

Back in Henry Teh’s exam room, the young man places his ear against a fetal scope shaped like a horn, and presses it against the pregnant woman’s belly to listen to the foetal heartbeat. Teh, who was charging cellphones to earn money in his small village last year, beams with pride as he describes how much he loves training to become a midwife.

Unlike school officials, he’s confident pregnant women will overcome their shyness and cultural taboos to seek medical care from him in the village.

“I love this field so much… and you just have to approach women in a manner that you think she will be comfortable.”

The first class of 32 midwives, who will graduate in December 2010, have signed contracts with the Ministry of Health that guarantee them a full-time job for three years, to be served across six rural counties in southeastern Liberia.

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In a small office tucked behind the stairwell in Liberia’s Ministry of Education, the once-proud staff of the Girls’ Education Unit appear defeated.

Berniece Johnson, now 19, says poverty led to sex with an older man to pay for fees and a uniform. Pregnancy forced her to quit school altogether. Credit: Bonnie Allen/IPS

The workers in this fourth floor office, entrusted with charting a new course for the education of the country’s girls and women, have no salaries, no budget, and few projects under way.

“We attend meetings. We attend workshops. But when we put a project proposal together, it is not supported,” sighs the Unit’s director, Lorpu G. Mannah.

Despite the 2005 election of Ellen Johnson-Sirleaf, Africa’s first female president, and the introduction of free and compulsory primary education, many young girls in this post-conflict West African nation continue to drop out of school to cook and clean for their family, or earn a meagre living selling food or fresh water on the streets.

They face discrimination, sexual violence, family pressures, early pregnancy, forced marriage, and harmful traditional practices. Three out of five Liberian women can’t read.

Promises

When Johnson-Sirleaf came to power four years ago, the Harvard-trained economist inspired dreams of a better future for the country’s women. With much fanfare, she launched a National Policy on Girls’ Education in April 2006, and hailed girls’ education as the “cornerstone” of development in Liberia. The Girls’ Education Unit was opened shortly after to implement the policy.

Beyond universal primary education and rebuilding destroyed schools, the national policy promises to cut girls’ secondary school fees in half, train more female teachers, punish teachers who sexually exploit students, and provide counseling.

It also stipulates that “a separate budget line should be established in the education budget specifically for this purpose…”

Four years later, the Ministry of Education (MOE) has still not earmarked a budget to implement the policy.

Reality

Liberian families continue to struggle with rising secondary school fees. Only one out of 10 grade school teachers are women. Counseling, life skills and health services are almost non-existent. Girls are forced to trade sex for grades with teachers, or barter sex on the streets for financial support.

Statistically, the gender gap in Liberia’s elementary schools has narrowed. The most recent school census revealed that girls accounted for 47 percent of students registered at Liberia’s public primary schools, but only 31 percent at public high schools in 2007-2008.

Mannah credits free tuition, feeding programs by the World Food Program, and piecemeal scholarships by international donors for uniforms and writing materials.

Those numbers are misleading though. The census only measures enrolment at the beginning of the school year and does not consider the high drop out among girls several months later due to family obligations, teenage pregnancy, or poverty.

UNICEF maintains that statistics reveal lower enrolment and retention of girls after Grade Three. UNICEF Education Specialist, John Sumo, blames the Liberian Government for abandoning its girls’ education policy.

“As far as we know, there has not been any commitment from the Ministry to Education to see what can be done in the implementation of the national policy,” said Sumo.

This prompted UNICEF to stop financing girls’ education projects through the Liberian Government in January 2009, instead choosing to funnel money to international NGOs. UNICEF also decided to revoke its funding of the Girls’ Education Unit’s salaries and operational costs as of January 2010.

“We have a work plan but it has not been sponsored by donors or government,” insists Mannah, who confesses deep frustration that the education ministry is ignoring the Girls’ Unit.

“You born a child, you need to nurture the child. But if you born a child and you don’t do nothing, the child is starving.”

New minister, new dawn?

There has been little accountability for the past four years at the Education Ministry. The Minister during that time, Joseph Korto, was removed from his post in May 2010, shortly after he was named in an audit for alleged misappropriation of huge sums of money.

Audits to track development loans and aid, as part of the requirements for debt forgiveness, revealed dubious scholarship schemes and false claims for new schools that were abandoned or left incomplete.

At his swearing-in ceremony, the new education minister, Othello Gongar, stated, “I have not come to MOE to criticise the works of my predecessors, but to rather start from where they stopped in order to make the system viable.”

Gongar pledged to lobby the national legislature to increase Education’s overall budget from roughly 8 percent to 25 percent of the $347 million dollar national budget.

In the budgetary cash contest, Liberian girls and women are competing with war-destroyed roads, electricity grid, limited running water and sewage systems, a dysfunctional justice system, and other institutional and infrastructural problems.

“What about the human resource?” demands Miatta Fahnbulleh, a leading advocate for girls’ education in Liberia. “Yes, I want roads. Yes, I want 24-hour electricity. But I also want to live in a country where 9 out of 10 people aren’t ignorant… We need to develop minds,” she emphasises, pointing her finger to her temple.

Back at the Ministry of Education, Lorpu Mannah shows up each morning at the Girls’ Education Unit. Though she’s no longer paid, she still writes proposals to international NGOs requesting money to sponsor night schools for teenage mothers, counseling centres in high schools, or scholarships for women who want to become teachers.

“To be frank, I do it out of sympathy for the young girls.”

By Bonnie Allen
SANNIQUELLIE, Liberia, Jan 13 2010 (IPS)

Just a few metres outside the front door of a large white-washed courthouse in north central Liberia, Tete Garwo sells small plastic bags of cold water and passes time by pleading her case to thirsty customers. The 40-year old woman describes how she was forced out of her house by an abusive husband, then deprived of her half of the property.

“The man started cursing me, cursing me,” says Garwo, as she slams the lid of her orange plastic cooler. “The man says he doesn’t want me. He started threatening. I was afraid, so I left.”

Seated on a tree stump outside the courthouse, Garwo describes with a bitter laugh how she sold cabbage and peppers from her garden for years to build a house with her husband of 22 years.

“I give him a good idea that we buy the land and build the house… but my name not on the paper.”

Garwo says she and her estranged husband took their property dispute to a community leader for a traditional settlement and the so-called judge ordered her husband to give her 140 U.S. dollars.

“He’s refusing. He won’t pay,” sighs Tete.

Garwo is well aware that she is entitled to a half of the property – the Inheritance Law passed in 2003 entitles women to own property, or assume property upon divorce or widowhood, regardless of customary or statutory marriage – she has never taken a few steps inside the Circuit Court she spends her days in front of to claim her share of the house and the land it stands on.

“I was not having a lawyer. No money,” Garwo says.

Inside Sanniquellie Circuit Court, the staccato clatter of an old typewriter echoes as the court clerk, Arthur Gaye, flips through a dusty stack of files.

“No cases,” he confirms. “Since (the property law) was amended, no one has actually come to claim on it.”

The 2003 law was widely celebrated by women’s rights advocates, but six years later it is rarely applied in court.

“It’s depressing,” declares Anna Stone, who specialises in gender-based violence issues and women’s rights for the Norwegian Refugee Council in Liberia’s capital, Monrovia.

“I don’t think it’s that (women) don’t want to (go to court),” Stone says. “They’ve resigned themselves that it’s just too hard. It’s too expensive to pay lawyer fees. It’s too time-consuming. And, as it drags on, the husband’s family is getting angry and putting pressure on her. Bullying her, basically to drop the case.”

Stone explains that women are also reluctant to exercise their legal rights under the reformed Rape Law of 2005. The number of cases successfully prosecuted in the justice system is very low, even in Monrovia where women are more likely to have been exposed to public awareness campaigns, and have easier access to police, courts, and legal aid services.

In August 2009, the Liberian government reported to the United Nations committee overseeing the Convention on the Elimination of All Forms of Discrimination Against Women (CEDAW).

Minister of Gender and Development Varbah Gayflor touted the country’s recently established Law Reform Commission, mandated to supervise the revision of Liberia’s discriminatory laws. She also pledged commitment to improving access to justice and providing public education and advocacy to encourage women to engage with the formal justice system.

The CEDAW committee urged the Liberian government to pass legislation condemning domestic violence and female genital mutilation.

But the Sanniquellie court’s records raise the question of whether the formalisation of women’s rights in Liberia is actually empowering women.

During a recent visit to Sanniquellie, Minister Gayflor told reporters that reversing decades of marginalisation can be a slow process.

“There are some (women) who know how to begin sitting, while others can start by running, some can crawl, and some can hold stick to walk.”

Attorney Deweh Gray agrees, “We can’t expect changes overnight.”

As president of the Association of the Female Lawyers of Liberia (AFELL), Gray helped push through the inheritance legislation and is now tackling a domestic violence bill.

Gray says it’s unfair to measure the success of recent law reform only by counting the number of cases on the docket.

“We are encouraging them to go for court, but for decades, Liberian woman have taken their disputes to traditional leaders for community reconciliation,” explains Gray.

These informal hearings by town, clan and paramount chiefs often involve rituals or decisions that discriminate against women, but Gray argues such incidents are becoming less frequent as Liberians become sensitised to new laws that protect women’s rights.

The prominent female lawyer concedes that court cases trigger more tension than a traditional hearing, which makes people nervous in a country torn apart by two decades of sporadic civil crisis.

“It’s true,” acknowledges human rights monitor Jesco Davis, who oversees a Rule of Law project for the Catholic Justice and Peace Commission in Nimba County.

Davis investigates cases in this rural region of Liberia, where more than half the women living in small villages, scattered throughout the dense rainforest, have never gone to school and can’t read nor write.

Initially, Davis predicted that illiteracy and lack of awareness would be the major barriers to implementing legal changes. Now, he blames a culture of fear.

“In our country, when you take somebody to court, you make that person your lifetime enemy. Your greatest enemy,” explains Davis. “That’s why… sometimes we have to go and get some of these cases, and sit down, and fix it at home.”

A few streets away, at the Ganta Concerned Women Centre, a small circle of women huddle around a wooden table to discuss an upcoming workshop. At the centre sits Musu Kardamie, the group’s feisty chairperson revered by every impoverished, downtrodden woman in the area.

“Women will resist (going to court) because why? We have no supporters. We have no backing to go to court,” says Kardamie, as the women around her nod their heads in agreement. “We don’t have the physical cash to fight our cases.”

Kardamie has a list of hardships faced by the Centre’s more than 500 members: widows banished from their house or forced to marry the brother of their deceased husband, abandoned women left homeless because of lack of dowry, or scared women who are deprived of inheritance by brothers who insist women cannot own property.

Kardamie says these women are aware of their rights, but have no resources to register a case, travel long distances to court, hire a lawyer, or pay the inevitable illegal ‘fees’ demanded by court officials.

There is only one private lawyer who takes civil cases in Nimba County, and there are no legal aid services.

“Money. Money is the answer. If you have money, it can do everything easy for you,” says Kardamie emphatically.

Back in Sanniquellie, court clerk Arthur Gaye ambles over to Garwo’s orange cooler, purchases a bag of water for the equivalent of three cents, then turns and walks back into the courthouse. He knows the woman’s plight, but can only shrug his shoulders.

“(Women) have to come to court. The court doesn’t go to them.”

Excerpt:

By Bonnie Allen
BAILA, Liberia, Oct 1 2009 (IPS)

As heavy rain hammers the grass thatch roof of her mud hut, Goromah Borbor huddles inside and quietly describes how her daughter Annie died while giving birth.

For women like Queen Smith, it's a long trek from their forest homes in northern Liberia to health care at a hospital in the region's principal town, Ganta. Credit: Bonnie Allen/IPS

The Borbor family lives in Baila, a village in central Liberia with three thousand people but no clinic. In emergencies, villagers must travel an hour by car to the nearest hospital, a trip that becomes more difficult during rainy season when roads deteriorate and fewer cars attempt the journey. 

Like hundreds of other women in Liberia every year, Annie Borbor died at home due to complications arising from pregnancy and childbirth. Her infant daughter also died.

“The midwives never told me anything about why the girl was sick,” says Borbor, staring at the rain pouring down.

For every 100,000 births, 994 women died, according to the Liberia 2007 Demographic and Health Survey. The vast majority of women delivered in the community, or in facilities without qualified health workers.

In January 2009, the United Nations Children’s Fund (UNICEF) released a report that indicates a Liberian woman has a 1 in 12 risk of dying due to pregnancy or childbirth complication in her lifetime.

In Baila, on the border of Bong County and Nimba County, pregnant women face many of the most dangerous risk factors for maternal mortality. There is no medical clinic and women must travel long distances on bad roads to receive health care, such as skilled birth attendants, emergency obstetrics, and postpartum care.

Liberia is still rebuilding a health and transportation infrastructure that was destroyed by war between 1989 and 2003. The reconstruction efforts are hindered during wet season, between May and November, when Liberia receives on average 4300 millimetres of rain. It’s one of the wettest countries in the world.

Travelling becomes especially difficult as torrential downpours create huge potholes and wash out roads entirely. Streams and creeks overflow their banks, making footpaths impassable.

Medical studies performed in Senegal, Gambia, and Mozambique have shown significant increases in maternal mortality during the rainy season. Overall, researchers conclude that several factors contribute to the seasonal spike, including a higher rate of malaria and reduced access to health services.

Each Tuesday, Gban Kollie navigates the muddy paths and heavy rains on her long trek to Baila to sell vegetables at market.  “I’m pregnant now, but I don’t know how many months,” explains Kollie, as she wraps a bright gold and burgundy cloth around her large belly. She appears to be eight months pregnant.

Kollie has never seen a doctor or nurse practitioner. She lives deep in the dense rainforest and travels as far as Baila to earn small money to support her family. Going to a hospital would take several more hours by foot, and cost too much money by car.

The tired-looking woman has given birth to ten babies. All of them out in the bush. Seven died.

In her dialect Kpelle, Kollie explains, “Sometimes, when I am delivering my child, I have come through difficulties. One time I delivered a dead child.”

Traditional midwife Tohn Kolleh has delivered babies for 20 years, but acknowledges that emergency cases must go to hospital. The elderly woman says finding a car with space is difficult and expensive. Kolleh knows pregnant women who have died while standing on the side of the road waiting for a ride to hospital. Sometimes, villagers will load the woman into a wheelbarrow or hammock and carry her the distance.

“Some villages are far from the main road. It can take 4 hours to walk,” explains Kolleh.

The Ganta United Methodist Hospital is normally a 45-minute drive from Baila, but it takes longer during rainy season. On the maternity ward, infants wail and new mothers swelter on hospital cots. Assistant supervisor Comfort Neufville loudly chastises pregnant women for not coming to hospital earlier, and consequently, arriving with life-threatening conditions.

Many Liberian women avoid hospital deliveries because they live on less than $1 a day and cannot afford an expensive bill. In Ganta, a hospital delivery costs between $8.50 and $11, plus $2 for each additional day of treatment. The financial strain is amplified during rainy season, also known as “hungry season,” when there are food shortages and price inflation.

“By keeping these women in villages until the end, when complication comes in, that’s the time they come to the hospital,” vents Neufville, practically shouting so the entire maternity ward can hear her lecture. “When you reach here with that complication, to serve the baby and mother, we have to do surgery.”

Haemorrhage, infection, eclampsia, and obstructed labour are the four major killers, according to the World Health Organization. Medical complications that midwives with limited training, in remote villages, are ill-equipped to handle.

UNICEF concludes that about 80 percent of maternal deaths could be prevented with access to healthcare. In Liberia, government reports indicate that sufficient access to healthcare will require more than just medical clinics and more doctors, nurses, and midwives. It will also require better roads and improved educated for girls and women.

Back in Baila, as the rain subsides and the market draws to a close, a pregnant Gban Kollie rejects the idea of staying in the village to deliver her baby. She slowly, and awkwardly, begins her long walk back to the farm, out in the forest, far from the midwife and the limited help that is available. As for Goromah Borbor, she will continue to wonder how the joy of birth turned to misery of death, and the loss of a daughter and granddaughter.

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