Reducing Maternal Mortality in Sierra Leone

By Rachel Horner and Kevin Hill

In Sierra Leonean 1 in 8 women will die giving birth. This horrifying statistic from the UN places the country among the worst places in the world for women to get pregnant and give birth.

There are many reasons for the conditions that have led to this situation, including a brain-drain that sees the best and brightest skilled healthcare workers leave the country for better salaries; the low economic status of women in the country that disallows them from making decisions on their own healthcare; and problems with simply getting from villages to health care centres that can provide the care required for complicated births.

The task of rebuilding and reforming a broken system has begun and there are things that we can do now to eliminate some of the senseless deaths that are taking our mothers, daughters and sisters from us.

According to UNICEF the key to avoiding maternal mortality is better healthcare during pregnancy, delivery and in the post-partum period. Healthcare interventions including antenatal care, HIV testing, skilled attendance at birth, emergency obstetric care and post-partum care.
"When offered across a continuum of care that integrates home, community, outreach and facility-based services, these interventions can have multiple benefits for mothers, children and the communities in which they live."

Cottage Hospital

Sister Safula Mansaray, a nurse in charge of operations at the Princess Christian Maternity Hospital said delays in getting complicated pregnancies to the hospital mean that women will die.
"When there are complications they bring them here. They come in worse condition, but we still see them. Patients arrive from various clinics in the area. Women access them, their cases are mishandled. When they realize they can't handle it, they send them here. When they arrive they do not even have money to buy drugs. We are trying in our own way."

When asked how it feels to witness the condition of the women, she said, "It hurts. Sometimes you want to help, but you have nothing. We do what we can sometimes the woman dies."

Sister Mansaray estimates the hospital sees up to 8 or 9 caesarean section deliveries per day. "Most survive, depending on the condition they arrive in. Sometimes they don't have money to buy so they just lay there to die. Government supplies drugs, but not at the right time. Things that we need to intervene are not there. IV drips, gowns, even gauze."

Sister Mansaray points to the work of traditional birth attendants as one of the causes of delay reaching medical help for complications during birth. "When they want to deliver they go to traditional birth attendants (TBAs), but they refer complicated cases too late."

According to Sister Taylor Young, a nurse Anaesthetist, there are many unqualified people who sell their services to the detriment of pregnant women. "Everyone is a midwife. Everyone is a doctor. People don't know where to go. Finally everyone fails. Some do have money, but they do not want to pay. They say the husband is in the provinces, the family disappears and the women are left on their own," she said.

A small amount of preparation, once it is known that a woman has become pregnant, can be the difference between life and death.

Sister Taylor Young advises, "If you know you are pregnant you can plan for this. If abnormalities are found early, lives will be saved. We should plan. Put small small money aside. If you can plan for Ashobi society and marriage, you can plan for this."

Turn Around

According to Dr. Ibrahim D. Thorlie, Consultant Obstetrician and Gynaecologist and head of Princess Christian Maternity Hospital, Sierra Leone can turn around the situation and begin providing proper medical care for pregnant women.

"The procedures for ante-natal care are the same here as in the rest of the world. The patient is registered in the out-patient department where she is screened by a midwife. If she needs a higher level of care she is referred to a specialized team. When the medical officer sees the patient he may refer the patient to a specialist or consultant. If the patient continues to come up to (the point of) delivery we will determine the type of delivery needed," he said.

Complications to pregnancy can be discovered early, if trained medical practitioner is able to examine the woman. Simple problems like high blood pressure or anaemia can cause a complication during childbirth. Caesarean sections, when planned in advance, can be performed as a safe, early intervention.

According to Dr. Thorlie, 50-60% of the complications are due to blood loss or chronic anaemia. Poor nutrition can cause anaemia. "If they are already anaemic in labour they are prone to losing more blood."

Delays in Care

Dr. Thorlie explained the main reasons for deaths that occur during childbirth. "The reason we have a high rate of maternal mortality is because of three types of delays in accessing care. First, in the villages, for traditional and economic reasons, when she feels that she is ill, if her husband is well off, she can seek medical care (at a hospital). If not, the family takes a decision, causing delays, and then sends her to the first (local) health provider centre.

Next, if there is no transportation from the first village to the next village there are more delays. Finally, when the patient gets to the health centre, if they have no skilled person - those who know what to do and can do it - or no drugs or supplies, they are finally referred to the hospital."
According to Dr. Thorlie there are many people who are exploiting the situation for their own financial benefit. "After the failure of the gold and diamond fields, the medical field is the next way to make money. People are getting the wrong advice, they start to treat them, or extort families. If the patient doesn't get what they need they surely will die."

Life Blood

"It is difficult to do free blood donation in this country. People are not assured their next meal. (The blood collected) is too small to reach demand. We ask relatives to donate blood. We have to convince people that donating blood will not mean they will die. We then screen the blood. Sometimes when they come with the blood it is too late: late referral, late arrival and no supplies at hospital. I am not a politician. I am a doctor. I cannot hide the truth", said Dr. Thorlie.

Philip Kamara, Laboratory Technician, said that blood needed to treat post-partum haemorrhages must be provided by the woman's family. Whenever a patient needs blood they have to provide a donor or two. The blood bank works on replacement donation. The bank has pre-screened blood available, but it must be replaced by new donations before it is allowed to be used.

"We bleed them, do the necessary screening, cross match for a service fee of Le5000 (US$1.50) per unit of blood. Sometimes we can do it for free. We had a patient yesterday who needed 10 units of blood, but the patient later died."

The blood bank currently has only 5 units of blood in stock. Each bag of blood lasts only between 21 and 35 days. The bank needs a steady supply of electricity to maintain its stocks. It has a backup generator.

"The major problem is getting blood bags, usually from medical stores from government. From March there has been no supply. Patients have to go to an outside pharmacy and buy them. Each bag is Le10000 (US$3.00)."

The bank also requires a steady supply of kits and reagents for screening the blood. The tests available at the bank for Hepatitis B and C, Syphilis and HIV take up to an hour to be completed. Rapid tests, which provide nearly instantaneous results, are available, but are not provided. In case of emergency these tests can save lives.

Additional Problems

Princess Christian Maternity Hospital faces many problems, including keeping qualified people on staff. According to Dr. Thorlie, the expectations of providing health care in such circumstances are difficult to meet. "Workers are not committed, remuneration is so low. A medical officer just out of medical school is paid under US$100 per month, a nurse with 20 years experience gets US$100 per month. We are expected to produce the best with little. We want to reduce maternal mortality, but we must have committed staff. Human resources cannot be retained because salaries are too low."

In addition to human resource management, supplies of basic necessities like electricity and water can also go out at any time. "The light goes off with the power cuts. It's better now under the current government, (but) he blood bank can be spoiled and we can have no light in the operating theatre."

"The provision of equipment, consumables and drugs is not regular. When we have enough, when they are around, maternal mortality rates are bound to fall", he said.

"We need to reorganize our health system. We who know do not have a voice. We are seen as being radical. If we can get real reforms to the system there is a chance, until then we cannot reduce maternal mortality. Our system is abnormal, those in power understand normal systems. What we say is greek to them. For all the workshops for TBAs maternal and infant mortality rates are the same. Health needs a permanent solution. They look to consultants from abroad. We need to go back to the drawing board and re-plan our system."

Government Strategy

In reaction to the need for a complete overhaul of the health care system in Sierra Leone, Dr. Soccoh Alex Kabia, Minister of Health and Sanitation, said that government is in the process of implementing their strategy for health care sector reform, with tangible results expected by the end of this year.

"The maternal and child mortality rate is very high, it has been high for a while now. We inherited a problem, the whole system is not functioning well at all.

Minister Kabia points to limited human resource capacity, institutional capacity and standards that are not up to par, a lack of medical supplies, energy and water as major issues facing the Sierra Leonean health care system.

Sierra Leone has only 64 government doctors, including 8 obstetrics and gynaecology, 5 paediatricians, 7 internists and one psychiatrist. PCMH is a major teaching hospital in the country, but it suffers from all of the problems that affect the rest of the system.

The government launched a strategic plan in February of 2008 that seeks to address these problems and answer the question, why do women and children die? "We believe once implemented in full it will turn the situation around. Government has not been able to offer good incentives. This plan addresses all the issues. After the analysis there will be follow through. By the end of the year, 5 districts and PCMH will be upgraded. We have a plan which will be implemented. We've done it the right way", said Minister Kabia.

"10-15% of all births have serious complications, including obstructed labour and infectious diseases not addressed prior to delivery. You need expert attention. Most people have difficulty in transportation causing delays. By the time they get to the major cities, it is too late. We often don't have the trained people to deal with the problem", he said.

With the cost of transportation from villages to medical centres often being too great for women to bear, the government is considering eliminating service fees for those most at risk.

"Currently the system works on a cost recovery system whereby patients are charged for services. We are aware that there are problems with the system - drugs that do not reach the people that need them. We are on the verge of deciding to allow free treatment for emergency services for vulnerable groups such as pregnant and lactating women, school aged children and the aged. HIV people already receive free treatment across the board", said Minister Kabia.

According to Minister Kabia, Sierra Leone is obligated to provide more support to the health care sector. The Abuja Declaration, adopted at the 24-27 April 2001 UN summit, and signed by Sierra Leone in the fight against HIV/AIDS and other related diseases demands that 15% of the GDP be earmarked for the health sector. According to Minister Kabia, Sierra Leone currently gives 9% of their GDP, or US$9 million. The health sector is supported mostly by donors.

International Assistance

Reproductive health technical advisor, Dr. Peter Sikana, for the United Nations Population Fund, said that UNFPA has worked in Sierra Leone for over 20 years helping to revitalize the health care system in the country. "We are focused on reducing maternal mortality. We want to ensure that every woman pregnant will deliver in a place where the nurses are skilled."

To accomplish this UNFPA is supporting PCMH through the preparation of a team of health workers to treat mothers who develop complications at the hospital. "In this regard we will provide drugs, equipment to put measures in place. We have spent US$1.2 million to reduce the maternal mortality rate in Sierra Leone. Drugs and equipment have just arrived, which will be distributed regularly and frequently to the hospitals, in order to save the lives of the mothers and the children of the country," he said.

Local Assistance

Abioseh Mansaray, Program Manager of the Sierra Leone Prevention of Maternal Mortality Association, said that the reason why women do not demand better health care treatment is that they are not in control of their financial destiny.

"What is disturbing women is the poor economic status of women in the country. Husbands hardly provide for women to seek antenatal care", he said.

His organization is in the process of providing a micro-finance project for women so that they can engage themselves in small business to afford these services. "We also want to sensitize men in reproductive health services, especially in the rural areas so that they will focus more attention on their pregnant wives."

Plan Ahead

With simple planning that begins when a woman becomes pregnant, including regular antenatal care and financial support from families, Sierra Leone can immediately save the lives of many women. With a forward looking strategy to tackle the problem, and promises of effective follow through from government and international agencies, putting the plan into action is the only thing that truly stands in the way of lowering rates of maternal mortality in the country.