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.

Death and Life in Sierra Leone

Photographer Anna Kari, http://www.documentography.com/ and Time Magazine reporter Vivienne Walt document maternal mortality in Sierra Leone in this masterfully done photo/audio essay:
http://www.time.com/time/photoessays/2008/sierra_leone_mothers/

I met with Anna and Vivienne for lunch as they were trying to organize themselves for a trip to a rural village for the story. Anna told me that she was confronted in Freetown by angy people who heard that Time was looking for dead women to photgraph. Dealing with this extremely sensitive issue was not easy, but Anna and Vivienne did a wonderful job detailing the injustice of the preventable death of a woman at the start of her child's life.

No drug charges in cocaine case?

By Mohamed Massaquoi and Kevin Hill

The case of The Inspector General of Police vs. Harvey Steven Perez & Others, known around Sierra Leone as the cocaine case, represents the biggest drug bust in the country’s history and the biggest challenge so far to President Ernest Bai Koroma’s government.

But in the haste to bring to justice those responsible for trafficking an estimated 700 kilograms of cocaine into the country, a scandal that has seen a minister sacked and 19 people charged with crimes, is the government about to bring about an injustice instead?

According to Vandie Nabie, Director of Complaints, Investigation and Legal Services at the Human Rights Commission of Sierra Leone, if the new Dangerous Drugs law is used to charge the accused with drug offenses it may contravene the Sierra Leone Constitution of 1991 and the Universal Declaration of Human Rights.

“To contemplate legislation (of a new law) while holding the accused, it could be considered retroactive – that is the gray area. The charges must be prospective, not retroactive”, said Mr. Nabie.

The case of Inspector General of Police vs. Harvey Steven Perez & Others commenced on August 1^st, 2008 before Principal Magistrate Deen Tarawallie. The accused are charged with a range of offenses including unlawful possession of small arms, unlawful entry, malicious damage to the perimeter fence valued at Le20 million, unlawful landing, conspiracy for unlawful landing, conspiracy to pervert the cause of justice and conspiracy to aid the escape of fugitive offenders with the aim of perverting justice.

The defendants are in court on what Mr. Nabie called “holding charges”, or lesser charges meant to hold the accused in police custody until further charges can be brought against them. The indictments are based on the existing law when the crimes were committed.

At the time of the commission of the crimes, there was no law in Sierra Leone that covered the specific offense of possession or trafficking of cocaine. To retroactively charge the accused with the new law might violate their rights guaranteed under national and international law.

Article 23, subsection 7 of the Constitution states “No person shall be held to be guilty of a criminal offense on account of any act or omission which did not, at the time it took place, constitute such an offense”.

Article 11 of the UDHR states that “No one shall be held guilty of any penal offence on account of any act or omission which did not constitute a penal offense, under national or international law, at the time when it was committed”.

“There are limits to human rights which are outlined in the constitution. In cases where public safety or public morality is in danger, the government can intervene. But is this exception outdated?” Mr. Nabie asked.

According to him, if the government retroactively charges these defendants it would be “inconsistent with good governance”.

The new Dangerous Drugs law was drafted in 2006 to strengthen existing law, but was not tabled in parliament until after the plane containing the cocaine was intercepted and the accused arrested under a certificate of emergency by the President.

For a law to be brought in under a certificate of emergency the situation or issue at hand must lead to public emergency or imminent danger, only then can a certificate be issued.

According to Mr. Nabie filing charges retroactively under the new law is “not conducive to rights protection. At the moment charges are laid, (the defense will) file an indictment to the Supreme Court.” If the someone claims that their human rights are being violated in Sierra Leone, they must appeal to the Supreme Court to have their case heard.

Defense lawyer and President of the Sierra Leone Bar Association, C.F. Edwards, said that if charges are laid under the new Dangerous Drugs law, “we intend taking it up to the Supreme Court. They may (file charges), according to the wording of the law, but according to good sense and international conventions, you don’t.”

According to Principal Magistrate Deen Tarawallie, “it is up to the prosecutors to file charges, but it is my understanding that you cannot charge someone retroactively. I was made to understand that a bill must be passed into law that would make provision to be able to charge retroactively.”

It would be up to the attorney general to approve the use of the law in this case, and the inspector general of police to levy the charges.

According to a high ranking official involved in reforming Sierra Leone’s legal system, who requested anonymity for this story, the new law was drafted in 2006 during the reign of Ahmed Tejan Kabbah and the SLPP. That government, heeding warnings on the increasing use of West Africa by international drug cartels as a transit point for drug trafficking, held consultative meetings nation-wide to better understand what cocaine could do to the country.

The Dangerous Drugs Act was then drafted to help change the image of the country as a player in the international drug trade and to act to save the Sierra Leone’s youth from the dangers involved in using and trafficking narcotics.

The act was subsequently presented to the SLPP government, but no action was taken. The act was also presented to the current APC government, but it was not tabled in Parliament until after the largest narcotics bust in the country’s history.

Cocaine trial defence may apply for new magistrate

By Ben Samuel Turay and Kevin Hill

Lead defence attorney and President of the Sierra Leone Bar Association, C.F. Edwards, has stated that unless Principal Magistrate Tarwallie Deen allows for a transfer of two ill accused to a medical facility he will apply for a transfer to a new magistrate court.

The defence filed a motion appealing for the bail and transfer of two defendants to a secure medical facility after both began suffering from serious medical ailments. Principal Magistrate Tarwallie Deen rejected the application outright.

“The ruling given was out of place with our application. We applied that following the doctor’s evidence the defendants should be taken out for medical treatment. We will apply for a transfer to another magistrate court”, said Mr. Edwards.

Last Wednesday the defence held a walk-out protest in reaction to the rejection of the motion. The protest may continue as the defence team seeks to bring further attention to the plight of two of the accused who are suffering from poor health.

According to lead defence attorney, C.F. Edwards, who is also President of the Sierra Leone Bar Association the walk-out was staged to bring attention to a situation they say is a violation of their clients’ rights.

The conditions in which the accused are held should not violate international standards. Rule 60(1) of the Standard Minimum Rules states that “The regime of the institution should seek to minimize any differences between prison life and life at liberty which tend to lessen the responsibility of the prisoners or the respect due to their dignity as human beings”.

By not providing the two accused proper medical treatment the state may be in violation of sec. 20(1) of the Constitution of Sierra Leone 1991, which states “No person shall be subject to any form of torture or any punishment or other treatment which is inhuman or degrading”.

According to Prinicipal Magistrate Tarwallie Deen the protests of the defence are unfounded. “They decided to walk out because, according to them were applying for bail and I refused bail; (granting or refusing) bail is at the discretion of the court.”

When asked how the court will proceed if the defence continues their walk-out protest, he said, “We will proceed or we will give them one adjournment date to get new legal representation.”

Plan and MTV Spotlight Strong Salone Woman

By Mohamed Massaquoi and Kevin Hill

In an effort to show the strength of young women, to protect their rights and to have their voices heard across the world, Plan International in partnership with MTV Netherlands has created a television show that focuses on an up and coming young woman in Sierra Leone.

19 year old Harriet Tucker, creator of youth radio show called Child’s Rights Watch in Moyamba and student at Fouray Bay College’s Mass Communications Department, is the subject of the show that will air on MTV in the Netherlands.

Child’s Rights Watch is a radio program that talks about issues important to young people and has developed a network of young co-hosts who create the forum for discussion.

“I started the radio program in Moyamba in 2005 where I came in touch with Plan International. I have gone to Kenema, Bo, Makeni to get children who I can work with because there is an increase of child rights violations (across the country). I know that with the radio program it will reduce”, Harriet said.

The partnership between Plan and MTV Netherlands is designed to use the large audience of the youth culture and music channel to talk to young people in the Netherlands about the importance of upholding the rights of girls, especially those who are living in conflict and post-conflict areas.

According to Lydia Tiemens, Project Coordinator with Plan, the show seeks to “get Dutch youth involved in development issues and to stand up for the rights of their peers.”

Plan International believes that girls are facing double discrimination because of their gender and their age. This discrimination often leaves them without access to basic health services, education, and forces them to face extremely high levels of violence, abuse, and harassment. It is hoped that through international support for girls pressure can be placed on governments to protect the rights of the girl child. The program is part of Plan International’s ‘Because I Am a Girl’ campaign.

The MTV show pairs Harriet with Giovanca Ostiana, a popular singer from the Netherlands, and Ashley Nyland, a Dutch student and MTV co-host as they go to Moyamba, Kenema, Bo and Freetown to talk to girls about the challenges they face. The group also records a song which will be played on radio across Sierra Leone.

Being a part of the project has given Giovanca a chance to see many of the issues that Plan International is attempting to highlight. “This has been a big experience. We’ve learned more about the impact of war on children. They face the consequences.”

It is hoped that increased awareness amongst the youth in Netherlands of the violation of the rights of girls living in developing countries and conflict and post-conflict environments will lead to increased support for these issues at the national level in their country.

Tackling juvenile injustice in Makeni

By Mohamed Massaquoi and Kevin Hill

Coordinator for the Justice Sector Coordination Office Wednesday disclosed that there are major gaps in the criminal justice system when dealing with juvenile offenders in places outside of Freetown and Bo, where remand homes and approved schools exist. Makini, in the north of Sierra Leone, is one such place.

Sarah Lewis made the statement in an exclusive interview with Concord Times at the Justice Sector Coordination Office (JSCO) Guma building Freetown. She said that JSCO has conducted a survey on the juvenile justice system in the country and Makeni was identified as a place of concern. Many juvenile cases in the city are not properly handled as the township lacked the required facilities to provide proper justice for children who are in conflict with the law.

“There is lack of coordination between the police, prisons and the judiciary in dealing with juvenile justice system. We have decided to organize a seminar for these stakeholders so that juvenile justice can be treated with the seriousness it deserves. We shall be talking about the child rights act, institutional and capacity development among others. We want to bring everybody together because juvenile justice is our major concern”, she said.

In an effort to combat these challenges the JSCO has created a pilot project called Makeni Chain Linked, which will develop greater communication, coordination and cooperation between the police, prisons and the judiciary.

The JSCO have put a manual together to provide training for officers of the Family Support Units so that they will be able to handle cases properly, especially those that deal with juveniles. “One thing that came out clearly during our survey was that Makeni does not have remand home. Therefore, children who are in conflict with the law are put in the same cells with that of adults”, she said. This practice is against the law in Sierra Leone and violates the rights of the juveniles who are placed at greater risk when housed with adults.

The community policing partnership is one of the methods JSCO has embarked upon to ensure that there is a reduction of the crime rate in communities across the country. Lewis further noted that access to justice is another area her organization is working towards as there are still many people, especially in the rural areas, who do not have access to proper justice system. “Over 70 percent of the population relied on traditional justice system therefore, there are plans to review the Local Court Act to strengthen the rule of law” she said.

Makeni Chain Linked is just part of the greater reform of the justice system in Sierra Leone, which hopes to establish a public defender unit, legal aid, witness protection program and to create alternate sentencing to create a more just system while alleviating the burden on Pademba Road Prison. These actions must be taken to strengthen the rule of law in Sierra Leone, to better uphold the human rights of its citizens and to hold accountable those who would violate them.

Closer to home

The story of a woman who experienced first hand the horrors of civil war in Sierra Leone and lived to tell the tale - she now calls Toronto home.
http://www.thestar.com/living/article/488690