When she went into labor last November, 18-year-old Kema James climbed onto the back of a motorbike taxi in her village in eastern Sierra Leone and rode half an hour to the main government hospital in the nearby city of Kenema. When her baby was delivered, he was sickly yellow and stricken with sepsis, an ailment caused by bacteria in the blood, and he hung limply in the hands of the hospital staff. He died five days later before he could be named.
The same fate befell 17-year-old Christina Dasama, only her child was stillborn and she suffered excessive bleeding from a vaginal tear during birth. Another woman in the maternity ward bled to death during childbirth the same week.
Although these deaths might have been preventable, the country is still reeling from the effects of the Ebola outbreak, which has crippled its health care system. Monique Jaques, an American photographer who traveled to Sierra Leone late last year to photograph Ebola’s aftermath for a broader project on maternal health in West Africa, documented the plight of these three women.
“Everyone seemed to cover Ebola and the whole media scrum was there and then everyone kind of just left and that was like the end of it, even though for these countries it’s not over,” said Ms. Jaques, 30, whose work focuses on women and their places within societies and explores how communities rebuild and heal after trauma. “Maybe it’s not a global problem anymore, but in this region, it still is an issue that they’re fighting all the time.”
Sierra Leone and Liberia — two of the West African countries hardest hit by the virus — have long ranked among the world’s worst for maternal health, but before the outbreak they had been slowly improving after years of civil wars that reduced both nations to ruin.
Those meager gains have since been erased. Many health care workers, especially those in maternity wards, were exposed to Ebola through contact with bodily fluids and died, devastating the ranks of skilled hospital staff. Most of the country’s health facilities were forced to close during the epidemic, precipitating an institutional collapse.
“Ebola destroyed the whole health system in Sierra Leone, and I’m pretty sure it’s the same thing in Liberia and Guinea,” said Dr. Sarah Neusy, a humanitarian reproductive health adviser who worked on Ebola in Sierra Leone for Save the Children. “It’s like having lost 10 years in terms of health quality. Now you have to train new staff from a young age, you need to restart everything.”
Making matters worse, many health care workers who survived Ebola have been reluctant to return to work, while pregnant women often avoid the poorly equipped clinics and hospitals for fear of contracting the virus or other diseases.
“Women will die at home, they will die on the way to those first small clinics and they will die after a referral on the way to a bigger hospital and in the hospital they will also die of infection or hemorrhage or whatever depending on the structure or depending on the level of staff and their qualifications, or the medications,” Dr. Neusy said.
Ms. Jaques — who was commissioned by WaterAid, an international nonprofit agency that aims to improve access to safe water, sanitation and hygiene — spent a week at the Kenema hospital photographing life and death in the maternity ward. Her images reveal the stark conditions faced by health care workers and patients — a lack of running water, unreliable electricity and limited access to medication and sterile equipment.
In one photo, a health care worker in protective clothing uses a grimy rag to wipe down a mattress and a bloodstained gurney. In another, Ms. James stares despondently at her son on Day 3 of his short life. And then there is the burial of Ms. Dasama’s baby, encased in a brown cardboard box and put in an unmarked grave. The quiet resignation of such images is as disturbing as the shocking state of the sickly babies when they emerged limp and jaundiced from the womb.
“Rather than an epic event, this was more like just a day in a maternity ward, even though it was shot over a week,” Ms. Jaques said by phone from her home in Istanbul. “Kema and Christiana are so young to have experienced a loss, and for both women this was their first child. Yet this is the reality of the situation in a country torn by disease and civil war.”
As grim as the situation is, basic prenatal consultations can identify problems and advise expecting mothers and family members on how to improve maternal and infant health. But like many women fearful of Ebola, neither Ms. James nor Ms. Dasama sought prenatal care, and both suffered from anemia, often caused in poor countries by protein- and iron-deficient diets. Anemia causes fetal health problems and impedes blood clotting, increasing the risk of bleeding during childbirth. Pregnant women in impoverished countries like Sierra Leone are often given iron and vitamins to supplement poor diets.
One of the biggest problems in Sierra Leone, including at Kenema hospital, is poor hygiene caused by the lack of running water.
“Running water and hygiene and hand washing is basic, we’re not talking about highly sophisticated stuff, but this affects everything,” Dr. Neusy said.
Keeping the aftermath of Ebola in the spotlight was important for Ms. Jaques, but she also offers a sense of optimism by depicting the more uplifting moments when babies are born healthy and families bring food and gifts, showing how things should be.
“Most of these deaths are easily preventable; this is something that can be changed, and improved,” Ms. Jaques said. “It’s not hopeless.”
Finbarr O’Reilly is a writer in residence at the Carey Institute for Global Good, where he is working on a book, “Shooting Ghosts,” about the psychological costs of war, to be published in 2017 by the Viking imprint of Penguin/Random House. He was based in West Africa as a Reuters reporter and photographer between 2001 and 2014.
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