Mothers of Sierra Leone: Improving Maternal Health through Storytelling

Abstract

Mothers of Sierra Leone leverages the power of filmic storytelling to improve maternal health outcomes in Sierra Leone, a country with one of the planet’s highest maternal mortality rates. Since 2019, we have operated as part of Lehigh University’s Global Social Impact program, working with a team of interdisciplinary students to amplify the voices of Sierra Leonean women rather than transmit Western medical expertise. Our project is based on two premises: (1) we will not solve the healthcare crisis in Sierra Leone through technology and (2) women experience better healthcare outcomes when they are confident and comfortable to advocate for themselves. Our focus group and survey data indicate that our filmic storytelling improves women’s confidence to advocate for themselves and increases their knowledge of available health services. Maternal mortality may be one of the most expansive health challenges facing our planet today because we struggle to comprehend or delimit its parameters, including structural and systemic racism, networks of capitalism, insufficient infrastructure, disparate access to medicine, and patriarchal violence. Our failures to tell public, accessible, and equitable stories about maternal mortality exacerbates and often exoticizes this crisis.

“It is the nature of global capital and inequality to make us structurally incompetent.” ¹

In Tressie McMillan Cottom’s poignant essay, “Dying to be Competent” (2019), she reminds us of “the nature of global capital and inequality” that makes women of color “structurally incompetent,” especially within healthcare settings. When we deem individuals incompetent, we rarely value their ideas or listen to their stories; when we cease to hear individual’s stories, they become mere subjects, components of a study, or, as Cotton herself painfully remembers, “when my daughter died, she and I became statistics.” ² As Claire L. Wendland eloquently described in Partial Stories: Maternal Death From Six Angles (2022), this devolution into statistics deletes stories: stories of the structural racism that denies Cottom and many other women proper care, stories of desperate requests for appropriate medical attention, and stories of women’s healthy pregnancies and childbirths. ³

Maternal health is a complex and global health issue that involves various medical, cultural, gender, and historical dynamics. The United States is a nation with highly advanced medical technologies but lags behind other industrialized nations in maternal and child health indicators due to its glaring disparities in access to and quality of healthcare, among other systemic factors. Black and Brown women continue to experience poor maternal health outcomes at a shockingly disproportionate rate due to pervasive structural racism in and out of the healthcare system. ⁴ The maternal health crisis in low-income countries such as Malawi, Chad, South Sudan, and Sierra Leone, however, is driven by different factors, including a dearth of medical supplies and trained experts, insufficient civic and healthcare infrastructures, and legacies of imperialism, slavery, and patriarchal oppression that impede women’s overall well-being. Because of this complexity, unilateral, single-minded, or technologically focused solutions to maternal health – sometimes deemed the magic-bullet approach to chronic global health issues – have routinely fallen short. ⁵ And yet, despite this diversity and complexity, one consistent truth may remain: when we value and listen to women’s stories and treat them as competent, we have an opportunity to improve maternal health outcomes. ⁶

Mothers of Sierra Leone is a Global Social Impact Fellowship based at Lehigh University that leverages the power of filmic storytelling to improve maternal health outcomes in Sierra Leone. Since 2019, we have been collaborating with local clinical, educational, and community partners in Makeni and Freetown, such as the Sierra Leonean Ministry of Health, World Hope International, Child Health and Mortality Prevention Surveillance (CHAMPS), the National School of Midwifery, and the Aberdeen Women’s Centre to create short documentary films that highlight innovative strategies for maternal care, recruit and train new healthcare workers, and, most importantly, document the stories and experiences of Sierra Leonean women. Our work is based on three premises: (1) in isolation, technology-focused solutions will not resolve any maternal health crisis, (2) consulting Sierra Leonean women about the effects and effectiveness of our films results in more authentic stories and more impactful results, and ultimately, (3) when women hear other women’s voices in healthcare settings, they become more confident to advocate for themselves. We design our films – topically and aesthetically – for clinical, educational, and community audiences in Sierra Leone, and we evaluate the efficacy of the language and style of our films through qualitative and quantitative research to ensure that they communicate culturally appropriate messages; our research, in turn, informs the planning for our future films (Figure 1). Unlike many filmmaking projects based in low-income countries, we have no interest in raising consciousness in the West or inspiring individual Western viewers to donate money or resources. Instead, we organize focus groups to share our films with mothers, their spouses, and healthcare workers in Sierra Leone, and we listen to their feedback; this method ensures that we frame Sierra Leoneans as experts in their health narratives. We incorporate their recommendations and voices – and not the recommendations and voices of Western experts – in future iterations of filmic stories. We do not extract the stories of Sierra Leone as resources to rouse the powers, sympathies, or guilts of the West; indeed, our films rarely reach Western viewers. Our priority is to share the stories and experiences of Sierra Leonean women with Sierra Leonean women – stories that demonstrate their realities, resilience, and competence.

Figure 1. Brooke Erickson (Lehigh, College of Arts and Sciences 2024) interviews Dr. Rebecca Esliker, Dean of of the Faculty of Nursing and Allied Health Sciences at the University of Makeni (left) and Tiffany Valencia (Lehigh University College of Health, 2025) and one of our research collaborators, Musa Santigie Kamara, interview a mother about her maternal experience (right).

Our filmmaking and research are rooted in a core principle of the Public Humanities: to uphold the cultural value of individual and communal narratives. We also draw on key tenets of the Digital Humanities to direct our video production and dissemination, and we make important contributions to ongoing scholarship in Maternal and Child Health, Medical and Health Humanities, and specifically Narrative Medicine. In its origin, Medical Humanities advocated for the importance of humanistic methods in the training of healthcare professionals, especially physicians. Scholars such as Sari Altschuler, Jay M. Baruch, and Alan Bleakley, among many others, demonstrated both the need for and effectiveness of implementing humanities-based curricula in medical schools and residency programs. ⁷ As J. Donald Boudreau and Abraham Fuks make clear, “The blossoming of the medical humanities as a self-identified field is in large part a response to perceived failings in the contemporary practice of medicine”; they note “widespread complaints that physicians treat patients as cases or bearers of diseases rather than as individuals who are ill.” ⁸ Rita Charon, Ann Hudson Jones, Ann Jurecic, and Sayantani DasGupta have been instrumental in the critical field of Narrative Medicine that seeks to address this shortcoming in medical practice. ⁹ In her Introduction to The Principles of Narrative Medicine (2016), Charon explains how “Narrative medicine began as a rigorous intellectual and clinical discipline to fortify healthcare with the capacity to skillfully receive the accounts persons give of themselves – to recognize, absorb, interpret, and be moved to action by the stories of others.” She continues: “It emerged to challenge a reductionist, fragmented medicine that holds little regard for the singular aspects of a patient’s life and to protest the social injustice of a global healthcare system that countenances tremendous health disparities and discriminatory policies and practices.” ¹⁰ The theorists and practitioners of Narrative Medicine have informed the filmmaking and research of the Mothers of Sierra Leone, especially our attempts to appreciate the value of patients’ and clinicians’ stories, but we have emphasized both a distinct methodology and an alternative telos. Mothers of Sierra Leone foregrounds the stories and voices of women in Sierra Leone not to amend the training of medical experts but to empower women in Sierra Leone to advocate for themselves in healthcare settings (Figure 2). Our methodology is not to instruct or merely educate but to amplify. While Narrative Medicine was designed to better equip healthcare professionals to understand individuals’ stories of illness by providing them access to a more comprehensive portrait of a patient, we invite women, nurses, midwives, and others to express and share accounts of health – accounts that audiences in the West may at times struggle to fully understand. We do not tell pregnant women which clinics to visit, prescribe specific treatments or medicines, or detail a particular diet; instead, we communicate the voices of women and healthcare experts who recount stories, share options and examples, and demonstrate techniques. And our research indicates the effectiveness of such stories.

Figure 2. Christina Enodien (Lehigh University, College of Arts and Sciences, 2024), Hannah Falatko (Lehigh University, College of Health, 2025), and Mr. Musa Santigie Kamara film interviews at Gladys Koroma hospital in Makeni.

In Fall 2022, following the COVID-19 travel restrictions, we began qualitative assessments of our films, and in August 2023, we initiated a twelve-month, mixed-methods study at twelve distinct clinical locations. We have collaborated with local research assistants, Mr. Musa Santigie Kamara (MSK) and Mr. Gibrilla Abass Kamara, who support our work by facilitating focus groups, administering surveys, and translating documents. They also use our battery-powered, portable cinema kit that allows us to bring the films directly to clinical and community settings (Figure 3). Our first series of focus groups, in which we evaluated the efficacy of two films, Antenatal Care in Sierra Leone (2019) and Makeni Midwifery School (2022), returned promising data. Two clear themes emerged in mothers’ responses about these films: health education and awareness and trust in healthcare systems. In particular, nearly half of the mothers indicated that they gained valuable insights about family planning after viewing the film, including pragmatic information about child spacing, contraceptives, and other viable preventative measures. Some mothers reported how the films offered important ideas about available, safe immunizations, and an additional subset of women noted a heightened awareness of the importance of healthy dietary habits during pregnancy. Finally, almost 30% of mothers expressed an increased recognition of the training, expertise, and roles of healthcare workers in maternal healthcare settings; this figure suggests a corollary effect on mothers’ heightened confidence in healthcare workers and facilities. This preliminary data points to the educational functions of our films: they provide information that mothers understand and appreciate, and this knowledge increases women’s confidence within clinical settings.

Figure 3. Our research collaborators, Mr. Musa Santigie Kamara and Mr. Gibrilla Abass Kamara, transport our portable cinema kit on the back of a motorbike (left) and use it to conduct focus groups with mothers (right).

We have recently completed quantitative work, in which we conducted pre- and post-surveys with men and women in non-clinical settings to evaluate the impact of two different films: Family Planning at Kunsho Clinic (2022) and Normalizing Mental Health in Sierra Leone (2023). Data among mothers revealed a 21% increase in the perceived importance of family planning and a 61% increase in the likelihood of visiting healthcare clinics after watching Family Planning; over 50% of fathers reported an increased willingness to become involved in their partners’ healthcare after watching the same film. After screening the Normalizing Mental Health film, 13% of mothers noted an increased understanding of the importance of mental health and 21% of mothers indicated an increase in the likelihood of managing their own mental health (Figure 4). These quantitative data suggest the effectiveness of our filmic stories both beyond medical facilities and with Sierra Leonean men, an audience often unaware of the complexities of maternal healthcare, including issues of mental health and family planning. The challenge to improve maternal health outcomes in low-income settings can appear overwhelming. Our research demonstrates the potentially critical impacts of our films within Sierra Leone on familiar issues such as antenatal care as well as culturally sensitive topics such as mental health and men’s roles within families. We hope that our films will ultimately play a role in improving maternal mortality rates by further encouraging women and families to utilize available maternal and child healthcare resources.

Figure 4. Mothers watch our films during a monthly focus group.

Since 2019, our films have addressed four main topics: (1) healthcare training, (2) antenatal care, (3) perinatal care, and (4) postnatal care. In August 2023, we were asked by colleagues from the University of Makeni Public Health program to develop an additional series of teaching films to demonstrate the integral relationship between maternal health and public health centered around West African concerns and foregrounding West African voices. Without a doubt, one of the severe limitations of our work has been the language of our films. While English is the official state language of Sierra Leone, Krio is the most widely spoken language, and numerous communities prefer Mende, Temne, or Limba. In Spring 2024, we released our first film featuring Krio-language terms, Exclusive Breastfeeding Guidelines in Sierra Leone (2024), reaching a broader audience of mothers who may benefit from messaging about breastfeeding. The film features a detailed explanation of the guidelines and benefits of exclusive breastfeeding in the first six months of infancy. Exclusive Breastfeeding, moreover, features the expert advice of healthcare workers at Makeni Regional Hospital, the epicenter for healthcare in the Bombali District, who provide both medical information and visual, culturally accessible demonstrations, quelling common anxieties often experienced by young, first-time mothers. The film illustrates the knowledge of healthcare personnel and makes such knowledge available in an unthreatening and easily digestible format. In August 2024, Dr. Joseph Bangura, the Bombali District Medical Officer, and Ms. Kadie Fofansh, Bombali’s Senior District Nutritionist, adopted this film as part of their community training for Global Breastfeeding Week. Based on the success of this film, we have completed Krio-audio recordings of the vast majority of our films in order to re-release dubbed versions.

In Summer 2024, we also released Confidence and Confidentiality in Maternal Health (2024), one of our first teaching module films designed for students in West Africa that features brief comments from Dr. Fathima Wakeel, a Maternal and Child Health scholar who directs all research components of the project. The film includes comments and testimonials from healthcare workers, emphasizing the importance of welcoming women to clinics, building confidence, and establishing rapport; this prenatal preparation helps women feel assured when they return to give birth. It also highlights the critical role of confidentiality in ensuring trust, securing consent, explaining procedures, and protecting information. This teaching module film educates viewers, including students, mothers, and healthcare workers, on the value of holistic, relationship-based care.

The great pending challenge for Mothers of Sierra Leone is to consider how best to sustain our work. When we started this project, we knew that the stories we were documenting were not our stories. These are the stories of the women and healthcare workers of Sierra Leone, and if this project is to continue, they need to shape and share these stories. As we look to the future of such filmmaking, our goal is to collaborate with our key clinical and community partners in Sierra Leone – and build new partnerships – to make certain that women are trained and empowered to create and disseminate their own filmic stories. We advanced this goal during our fieldwork trip in August 2024 when we extended partnerships with the University of Makeni, Apex Multimedia, a local film production company, and the Empowering Women Foundation that works to produce films about women’s experiences in Sierra Leone (Figure 5). The methods of Mothers of Sierra have proved effective, but to sustain efforts to improve maternal health in Sierra Leone, women will need resources and support to tell their own stories, expressing their own experiences, expertise, and most assuredly, their competence.

Figure 5. Lauren Lencovich (Lehigh University, College of Health, 2025) and Mr. Musa Santigie Kamara conduct a focus group with healthcare workers at Masuba clinc, Makeni.