Armed with a huge box of condoms and pills, Nurse Aminata Fullah leads me through the maze of muddy alleyways that make up Susan's Bay, in Freetown, Sierra Leone. In the city famous for blood diamonds there are no shortage of slums, but Susan's Bay is unique. Situated beside the city dump where garbage burns all day and night, it is difficult to tell where the dump ends and the shanty town begins.
"A lot of people in this area died during Ebola," Fullah tells me over the sound of a gigantic pig squealing from a trash-filled stream. By her estimate, the packed slum is home to around 8,000 people, their corrugated iron homes balancing precariously on a steep hill by the sea.
"This area was what we called an infection hotspot—hundreds of people were infected by Ebola, and more than a hundred of these people died," Fullah continues, expertly stepping past raw sewage as we head towards her makeshift clinic. Over the last three years, more than 14,000 people contracted Ebola in Sierra Leone, and the disease claimed 3,590 lives between the spring of 2014 and March 2016.
Fullah was among the thousands of local nurses who worked with international medics and volunteers to curtail and stop the spread of infection. At 25, she has been a nurse for only a few years, but is only being paid basic expenses for her work. "It's typical here for nurses like me—but I love my job. I prefer to be always busy and to be helping people." She marches me through Susan's Bay, her popularity obvious in the warm welcomes that greet us at every turn.
During Ebola, schools were closed down, and this put girls at greater risk of teenage pregnancy.
It was late May; the start of the rainy season when the city's waste flows down the mountain into the bay. The hot breezeless day did not help the stench and we had to avoid certain paths that were already flooded with sewage. By the time we arrived at the outreach clinic, several dozen young girls were already waiting in line, fanning themselves and each other by spinning scarfs of multi-coloured fabric around like a lasso.
Once inside, Fullah and her colleague Salamatu Kamara explained to the young women the various methods of contraception they had in their box, how to use them, and the importance of doing so.
Read more: The Broadly Guide to Pregnancy
August 8 marks two years since the World Health Organization declared the Ebola outbreak in West Africa a public health emergency. These days, Fullah and other nurses are on the frontlines of another health crisis: teenage pregnancy.
"We see about 80 people a day at times, depending on what [contraceptive] drugs we have," Fullah says. "Often we don't have drugs to give them. It is always very busy. The girls that come to use our services are all ages—but most of them are teenagers. Some are 13 or 14, some are older than that."
Healthcare workers say that girls in Sierra Leone can start having sex as young as 11. Teenage pregnancy has long been a problem, but the recent Ebola outbreak saw focus groups comprising of 1,193 children in total report a 47 percent jump in teen pregnancies, according to Save The Children, which trains nurses like Fullah to properly administer contraception and provide vital maternal healthcare services.
The actual reason for the increase in teen pregnancy is a source of contention among the government, NGOs, community leaders, and the girls themselves. But everyone agrees it is a bad thing indeed.
In Freetown, Save the Children health program officer Marget Tucker told Broadly, "During Ebola, schools were closed down, and this put girls at greater risk of teenage pregnancy." Though reliable data in Sierra Leone is difficult to obtain, Tucker estimates that around 20,000 teenage girls became mothers during the Ebola crisis, with poorer girls and those with lower levels of education being more vulnerable to becoming pregnant.
"Some of them had to etch out some means of survival and the only means of survival that they resorted to—most of them—was to have sex. Transactional sex, to be specific," she adds, "where the men pays them for having sex."
The government's own study, commissioned in response to the alarming findings by Save The Children and UNICEF, found that 74 percent of the teenage girls who became pregnant during the Ebola outbreak reported not having enough to eat at the time.
18-year-old Kumba* is among those girls became pregnant during the Ebola crisis. Her 25-year-old "boyfriend," who would give her money for school fees, food, and clothes, "didn't like to use condoms," she told me shyly.
Negotiating condom use is not an option for many of the younger women. Still, girls are punished for becoming pregnant by their families and by the government. Though Kumba is now back at home, her mother initially kicked her out for several months after discovering her pregnancy. Pregnant teenagers in Sierra Leone are commonly prevented from finishing their education, lest they be a corrupting influence on their peers. This means that becoming a mother can be catastrophic for their future prospects, though it does not negate the need to engage in risky sexual activity as a basic means of survival.
Back in the community health clinic built by Save the Children on the outskirts of Susan's Bay, Fullah explains: "Some girls, before they even have their period, they have already started having sex. This community is tough, so they have to start sex early to fend for themselves."
Ebola protection measures are still in place—I must have my temperature recorded and wash my hands to gain entry—and a notice for a missing woman who ran away from a nearby isolation unit remains on the wall.
Watch: The Abortion Pill
"During Ebola, we couldn't do outreach work [for contraception]," Fullah says. "I and other nurses were working with people with Ebola in the clinics, and many people didn't come to the clinics out of fear of catching it."
Longer-form methods of contraception such as implants or injections are the most popular, despite ongoing efforts to promote both condoms and femidoms. As well as contraception, the nurses at the center provide women's healthcare support and often have to refer young women on to specialist services run by Marie Stopes for the "mess" resulting from backstreet or self-administered abortions.
"Teenagers are doing these abortions a lot. We might not have the right injection for them, and they don't use condoms, so they have to have sex and then they get pregnant," Kamara tells me. "That is how it is. Then they go to a mixture of wacks and quacks—there are many ways."
Abortion is illegal in Sierra Leone, despite one of the main contributors to the country's staggering rate of maternal deaths. According to World Bank figures, 1,360 women out of 100,000 died in 2015 as a result of pregnancy, compared with 14 out of 100,000 in the US—one of the highest rates of maternal mortality in world. Teenagers are at higher risk of dying in childbirth than older mothers, and are thought to be responsible for around 60 percent of these deaths.
Marie Stopes International says that ten percent of those deaths in childbirth are believed to be directly related to unsafe abortions.The organization says this is a very conservative estimate. Ufuoma Festus Omo-Obi, the head of Marie Stopes in Sierra Leone, explains that there are chronic problems with underreporting due to the shame and stigma around abortion. Self-administered termination methods are popular—particularly with teenagers—and every year 10,000 women and girls seek help for post-abortion hospital care after obtaining an unsafe abortion.
"People use all sorts of things to procure abortions; traditional herbal remedies, or a mixture of alcoholic drinks and herbs, or chewing broken glass, or sand," Omo-Obi says. "Some of the younger girls use more extreme things like bicycle spokes, metal hangers or cassava leaves." In a method known as the "rocket propelled grenade" or RPG, raw cassava sticks are inserted into the vagina. This cheap and popular method is also one of the most deadly, and can lead to severe bleeding or perforation of the womb.
Sex education is not taught in schools, and the government's research into the increase in pregnancy during Ebola found that many teenagers do not understand the basics of conception or how to prevent pregnancy. As long as this continues, thousands more of them will die in childbirth or backstreet abortions every year. Nurse Fullah and her colleagues may have beaten Ebola, but their battle against Sierra Leone's teen pregnancy epidemic has only begun.
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