Imagine if a pregnant woman comes to a hospital to give birth and is turned away because she doesn't have a bag of supplies that includes diapers, a baby hat and bleach.
That's the reality in Liberia, a country where nearly half the population lives below the international poverty line and the annual per capita income is $673.
The bag of supplies, which also must include menstrual pads, a onesie and a baby carrier, costs about $100.
Even as Liberia encourages hospital deliveries to lower the nation's newborn and maternal death rates, the policy has the opposite impact.
Liberia has one of the highest rates of deaths for newborns in the world: , according to UNICEF: 58 in 1,000 births. And the maternal mortality rate from the last country health survey was 742 per 100,000 births — more than 50 times the rate in the United States.
The problem isn't just the rule about supplies. By the end of the civil war in 2003, many of the spaces to give birth safely were destroyed — only 51 of the nation's 293 health facilities remained — and, by the end of the Ebola outbreak in 2015, 8% of the country's doctors, nurses, and midwives had died.
But the supply rule is definitely a factor.
"Many women don't have the money to buy this stuff," says Viola Makor, the resident midwife at the Links Maternal Waiting Home and the reproductive health supervisor for the Suakoko district in Bong County. "When they don't have those materials, they don't come to the hospital."
Why they have to bring their own supplies
The reason for the supply requirement is simple: Public hospitals are strapped.
"It's been like that since I was a kid," says Yassah Lavelah, a nurse from Monrovia who is now 36. She says it is impossible to pin down exactly when hospitals began asking for the supplies. "This is a standard of operation for [public] hospitals in Liberia," she says, even though in theory they are free of charge.
But now Lavelah has come up with a small-scale solution. In May 2021, she created the Comfort Closet in the Links Home – a place where women from remote parts of the country can come and stay as their delivery date approaches so they are close to a hospital or clinic.
Lavelah buys in bulk to get a discount. She estimates that she only has to spend about $160 to fill 25 bags of supplies – that's how many she'll typically give away in a month.
She pays for the supplies with her own money and donations that friends and supporters collect with fundraisers on Facebook, like picking a charity for donations in honor of their birthday.
She says that so far more than 300 women have been able to give birth in a skilled facility because of the Comfort Closet, whose supplies are intended for women staying at the maternal waiting home — mainly those who come from faraway rural areas.
"It is extremely valuable," says Jody Lori, a professor and associate dean of global affairs at the University of Michigan School of Nursing who has studied waiting homes in Liberia. "[The policy] keeps some women from having a facility birth because they believe they must bring these supplies or they are just ashamed that they don't have them."
Making it possible for more women to give birth in a health facility is critical, says Dr. Trokon Washington, the county health officer of the River Gee County health system in Liberia. When girls and women deliver at home, Washington says, they might be attended by a traditional midwife who does not have the training or resources to help someone experiencing complications.
A commitment made in childhood
Lavelah has known since she was a child growing up in Monrovia of the potential dangers of home delivery. Her mother, a certified midwife, would help women give birth in Lavelah's room because it was the only space available.
There was no nearby health center, and Lavelah's mother was willing to help for free because the women and girls had no money. When there were complications, there was no ambulance, so the family had to use a wheelbarrow to push the woman to the nearest clinic, about an hour away.
When Lavelah became aware of the requiring of supplies for hospital admission, she says: "I told myself I was going to do something about that."
Her idea was to provide free bags of supplies to a maternal waiting home.
The Links Maternal Waiting Home near the Phebe Hospital gave a room to Lavelah and her team from the Mavee Maternal Empowerment Initiative, a small nonprofit Lavelah started and named after her mother. They renovated and painted the room and it became the "Comfort Closet."
Makor, as the resident midwife, ensures that every woman who stays at the home gets a bag.
Why doesn't the government pick up the tab for the supplies?
Liberia, one of the world's most impoverished countries, spent only 8.5% of its GDP on health care in 2019 — the most recent data. "Most standards say to keep at least 10% toward health," explains Dr. Ann Marie Beddoe, a gynecologic oncologist who led a World Bank Health Workforce Program in surgery and obstetrics in Liberia. "The government is the main supplier of these public hospitals, gloves, medical equipment, medicine, everything. They don't have the money."
Because the maternal waiting homes do not provide the supplies needed for hospital admission when the time comes, women may question why they should use the maternal waiting home at all. "Even though it was open to the public, women were not coming," Makor says. "What was the reason to go to the waiting home if nothing is there?"
Currently a master's student in social work at Temple University in Philadelphia, Lavelah is stocking up on supplies to bring home – and in November plans to open a second Comfort Closet in the Gbartala Clinic in Bong county. "My hope is that every hospital, clinic and maternal waiting home in Liberia can have one," she says.
Jason Silverstein is a lecturer of global health and social medicine at Harvard Medical School and co-director of the Media, Medicine, and Health program.