Nigel Deen

Harvard College ‘12

Department of Health Policy and Management, Harvard School of Public Health

Abstract

The purpose of this study is to evaluate the quantity and quality of care that pregnant mothers receive from health institutions in Sierra Leone, as well as explore the social determinants that prove especially important in reducing maternal mortality rates. I sought to determine: (1) the current state of the maternal health care infrastructure in Sierra Leone, (2) the patterns of care-seeking by pregnant Sierra Leonean women, and (3) the barriers to the delivery of maternal care. By interviewing pregnant women and collecting data on government hospitals, I assessed the level and quality of available maternal care. I was able to distinguish physical, cultural and resource barriers that impact maternal health outcomes.

Introduction

In response to the high maternal and infant mortality rate, in April 2010 the Government of Sierra Leone declared that all healthcare services for pregnant and lactating women and young children would be rendered free of charge. The government of Sierra Leone launched the Health Sector Strategic Plan 2010-2015 to achieve this. The purpose of this plan was to ensure successful implementation of the Basic Package of Essential Health Services (BPEHS) to improve health service delivery. According to the government, this package ensures the provision of minimal essential quality of care for all and includes services that have the greatest impact on the major health problems (especially that of maternal and child health) [1]. This new strategy aims at cost-effective interventions that focus on preventative care such as family planning as well as interventions to improve the availability of essential and emergency obstetric care.

This project attempts to evaluate the quantity and quality of care that pregnant mothers receive from health institutions in Sierra Leone and will explore social determinants that prove especially important in reducing maternal mortality rates. I collected data from secondary sources through a targeted scan of locally produced reports and from primary sources through a survey of health care facilities in the capital city, Freetown, and two rural villages, Bo and Kenema. The purpose of this study is to determine: (1) the current state of the maternal health care infrastructure, (2) the patterns of care-seeking by pregnant Sierra Leonean women, and (3) the barriers to the delivery of maternal care. My research will focus on two issues that are especially important in reducing maternal mortality rates. The first concerns the availability of maternal health resources in hospitals. The second is to evaluate the effectiveness of the Health Sector Strategic Plan in transitioning deliveries from Traditional Birth Attendants (TBAs) and relatives to hospitals and maternal clinics.

Methods

I conducted data surveys in six hospitals: four in the capital of Freetown and two in the surrounding rural villages where, often times, the most experienced maternal health officials are community trained midwives. I identified 68 women who were either pregnant or had recently given birth. It is important to note that this patient survey does not represent all Sierra Leonean women in general, only self-selected Sierra Leonean women who were able to find themselves in a hospital. The survey included questions concerning reproductive history: number of previous pregnancies, pregnancy outcomes, dates of deliveries, location of delivery, type of birth attendant, and experience of complications during or shortly after delivery. The survey also included questions regarding women’s decision-making when choosing delivery locations (deliver at home, at a Peripheral Health Unit (PHU), or in a hospital) and delivery assistance: doctor/midwife/nurse, traditional birth attendants, or others. I also recorded the travel distance between the women’s home and local health facilities as well as costs incurred during pregnancy and delivery; these include transportation and medical costs. Since the government has recommitted to providing free health services to pregnant women, the women were also asked about their experience regarding their knowledge of the free healthcare policy and whether it influenced their decision-making. At each facility, I conducted interviews with at least three healthcare officials/health workers to quantify the clinical resources available for maternal care and to determine the challenges that exist in providing health service to pregnant and antenatal women.

To quantify socioeconomic status, I used the Progress Out of Poverty Index (PPI) [2]. The PPI is an objective client poverty assessment tool. It estimates the likelihood that a participant has income below the Food Poverty Line, National Poverty Line, 75% of the National Poverty Line, 100% of the National Poverty Line, 150% of the National Poverty Line, USAID “Extreme” Poverty Line, $1.25/Day/2005 PPP (purchasing power parity) line, and $2.50/Day/2005 PPP line [3]. I also used a linear regression model to predict the relationship between prior pregnancies and socioeconomic status and between incidence of maternal complications and labor duration.

Results

Sixty-eight women were interviewed with an average age of 25 years. Of the 68, approximately 82% identified themselves as being married. The largest proportion of women (41%) lived in the capital of Freetown. The next largest lived in the rural town of Bo (24%), followed by Kenema (9%). The remainder of the women traveled from different rural regions of Sierra Leone in order to receive care.

Pregnant women in Sierra Leone must overcome many barriers in order to receive antenatal care (ANC). Based on my research, these barriers can be divided into three categories: physical access, community barriers, and a lack of adequate resources. Each of these barriers contains compounding effects and does not exclusively affect a woman’s chance of survival; in essence, they each play an integral role in determining the quality of healthcare that a pregnant woman receives in Sierra Leone.

 

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Table 1: Descriptive Statistics

Variable n Mean Std. Dev. Min Max
Age 68 25.82353 6.839179 18 42
Children in Houshold 68 1.794118 1.569854 0 6
Adults in Household 68 3.808824 2.326084 1 13
Travel Time (min) 68 58.23529 172.7926 5 1440
Number of Prior Pregnancies 68 2.044118 1.765624 0 7
Labor Duration (hrs) 129 14.86047 22.41189 1 120
Cost of Delivery Assistance (thousands Le) 103 25.82524 32.44979 0 150
Duration of Ammenrrhea (hrs) 38 8.605263 7.674244 0 24
Duration of Electricity (hrs/week) 68 9.301471 11.2177 0 24
Progress Out of Poverty Index Score 68 32.76471 13.90707 9 71

Table 2: Transportation options to the hospital

Travel Time Mode of Transport to Hospital
Ambulance Bus Motorcycle Car Taxi Walk Total
5 0 0 0 0 1 0 1
10 0 0 0 0 2 6 8
15 0 0 2 0 0 7 0
20 0 0 0 0 0 4 4
30 2 2 3 2 8 9 26
60 1 0 3 0 6 5 15
120 0 0 1 0 2 0 3
180 1 0 0 0 0 0 1
1440 0 0 0 0 1 0 1
Total 4 2 9 2 20 31 68

Table 3: Medications given to Pregnant women during ANC visits

Iron Supplements Folic Acid Anti-Malarial Antibiotics,Pain Medicine
1st Pregnancy 38 22 16 7
2nd Pregnancy 25 15 8 4
3rd Pregnancy 18 12 5 2
4th Pregnancy 12 8 3 3
5th Pregnancy 12 4 0 1
6th Pregnancy 1 1 0 0
Total 106 62 32 17
Percent (%) 76.3 44.6 23.0 12.2
Urban 66 33 16 9
Rural 40 29 16 8
Total 106 62 32 17

Physical Access

When interviewing women, I discovered that most did not own a personal car and because of this, had to pay for public transportation to and from the hospital. If women cannot afford a taxi, they are forced to either walk or pay for the cheaper, riskier option of an ocada (motorcycle taxi). Of the 68 women interviewed, 29.4% of the women took a taxi, 13.2% an ocada, while 45.6% of the women walked to the hospital. The remainder were either brought in by an ambulance (5.9%), paid for a bus (2.9%), or came by their own personal car (2.9%). In regard to transportation fees, 87.2% of the women paid 1000Le or more in order to get to the hospital. This cost can place financial strain on many of the women who were either unemployed or dependent on their husbands’ income. When asked what the main reason for missing an appointment would be, 24.1% of the women said that the hospital was too far, while 9.6% replied that they had no means of transportation. Thus, the cost of transportation is a barrier to accessing care. Consequently, the option to walk as opposed to paying the taxi fees was the most popular option.

Of the women that walked, 45.2% walked for 30 minutes or longer in order to get to the hospital. Based on the data, physical access to hospitals remains one of the biggest barriers women have to overcome in order to receive care in Sierra Leone.

Women unable to get to the hospitals for antenatal care do not get the medications that they need in order to have a healthy pregnancy. Furthermore, due to the high demand of medication, hospitals sometimes go for months without vital medicines in stock. As a result, the effectiveness of antenatal care is lowered, medication deficiencies have been exacerbated by inappropriate use due to shortages in pharmacy professionals [4]. Many of the hospitals in Sierra Leone routinely distribute iron supplements, folic acid, and anti-malarial medication, but if a woman cannot access the hospital, she is left vulnerable to a variety of illnesses, the most common of which is malaria. Contraction of malaria can lead to anemia that requires a blood transfusion if not treated. During 139 previous pregnancies, 32.4% of women contracted malaria while pregnant.

The table shows that as the number of pregnancies increase, the amount of ANC care decreases. This may provide insight on some behavioral tendencies of Sierra Leonean women in regard to ANC. Because many of the women have to travel long distances in order to receive ANC, it becomes harder and harder to receive ANC with each additional pregnancy. Additionally, access to ANC is clearly more feasible if you live in the city. Rural pregnant women receive less ANC medication in every category except anti-malarial pills, in which they receive the same amount as urban pregnant women.

For the women that live outside of city centers (upline), antenatal care visits are a rare occurrence. Consequently, women who live upline come to the hospitals only when they are about to give birth. However, women in Sierra Leone can be in labor for days before reporting to a hospital (24.3% of women reported being in labor for 24 hours or longer). Needless to say, when in labor for that length of time, the probability of complications increases and both the life of the woman and the newborn are at risk. Although the maternal mortality ratio has declined since the 2005 estimates, the neonatal mortality rate has only recently begun to display similar progress. Between 2000 and 2005, Sierra Leone’s neonatal mortality rate was the second highest in the world, reporting 133.3 deaths/ 1000 live births. Between 2005 and 2010, that number has dropped to 113.68 deaths/1000 live births [5]. In the data I collected, 12.7% of live births resulted in neonatal deaths. This is only slightly lower than the average for the last 15 years, when 13.4% of live births resulted in neonatal deaths. As suggested from this data, the physical barriers to hospitals impact neonatal as well as maternal health outcomes.

By issuing free healthcare to pregnant and lactating women, the Sierra Leonean Ministry of Health hoped to reinstitute faith in the healthcare system and to encourage women to transition away from delivering with traditional birth attendants to delivering at government hospitals. Despite the physical barriers that prevent women from accessing hospital services regularly, the data show that the government’s free healthcare plan has successfully increased the number of women that give birth at hospitals and clinics. The graph shows place of delivery for pregnant women from 1984 to 2011. As seen in the graph, the gap between deliveries at home and hospital has widened tremendously since the implementation of free healthcare in 2010. As such, women are now more likely to give birth in a hospital or maternal clinic. This means that an increasing number of women have access to hospital staff and medicines and are more likely to survive complications before, during, and after labor. Figure 2 shows assistance during delivery from 1984 to 2011.

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According to the data, more babies are now delivered with the assistance of skilled birth attendants as opposed to traditional birth attendants (TBAs) or relatives. This may have an effect on both the birth outcome and the health outcome of the mother and infant. The graph shows a drastic increase in the amount of babies delivered by doctors around the year 2000.

According to the data, prior to 2000, 26.9% of women delivered with the assistance of a traditional birth attendant or relative. After 2000, this number was reduced to 11.3%.

It is important to note that because of the Sierra Leonean Civil War from 1990 to 2002, women would have been less likely to have access to hospitals and might have been forced to give birth at home. However, with the current restructuring of the country’s healthcare system, it is important that the government continue emphasizing delivery in hospitals and clinics in order to reduce the risk of death for mothers and infants from otherwise manageable complications. This might also explain the spike in the number of births delivered by skilled birth attendants after the year 2000.

Traditionally, Sierra Leone is an extremely patriarchal society. Recent developments in the government and community have placed greater importance on securing civil equality for women. Unfortunately, progress has been slow and limited to the urban areas. Women in Sierra Leone therefore have additional socioeconomic burdens that complicate pregnancies even further. Although the age of marriage in Sierra Leone is 18, many women have typically given birth at least once by their 15th birthday. As mentioned earlier, the total fertility rate in Sierra Leone has remained six children or more for almost a generation [6].

In this project, data collected on fertility was done in several ways. History of all prior pregnancies was recorded. The year of each pregnancy, the outcome and any events during the pregnancy were also recorded. According to the data, 27% of the women interviewed had given birth at least once before their 21st birthday1. Furthermore, of the women who were currently pregnant, 24.5% of them had been pregnant at least 4 times before. Such a high amount of pregnancies increases the probability of complications during childbirth, thus increasing a woman’s chance of dying. Additionally, due to the young age at which women in Sierra Leone become pregnant, their educational options are limited, thus reducing their ability to obtain employment opportunities. Of the sixty-eight women interviewed, only three finished primary school, five finished secondary school, and two went on to college. Thirty-four women received no education at all, while seventeen started either primary or secondary school but were forced to drop out. As expected, there is a strong correlation between unemployment rate and education level (Table 4).

Table 4: Correlation between education and occupational status.

Education Level of Mother Occupational Status
Employed Student Unemployed Total
College 0 0 2 2
Finished Primary 0 0 4 4
Finished Secondary 2 0 7 9
None 16 1 18 35
Some Primary 1 0 1 2
Some Secondary 3 2 10 15
Vocational Training 0 0 1 1
Total 22 3 43 68

Some women replied that they were employed, but after further questioning, it was found that many women were actually describing themselves to be employed in the informal work sector. That is to say, they cooked and sold food on the streets and traded merchandise (perfumes, shoes, clothes, etc.) in order to make a profit (Table 5).

Table 5: Employment responses.

Job Frequency Percent (%) Total
Caterer 1 9.09 9.09
Farmer 1 9.09 18.18
Vendor 1 9.09 27.27
Tailor 2 18.18 45.45
Trader 6 54.55 100
Total 11 100 X

Based on these results, 63% of the women interviewed were currently unemployed; of those employed, 44% were employed in the informal sector. Low socioeconomic status can only increase the risk of complications during pregnancy. The living conditions of these women also exacerbate the situation by exposing them to parasites (including bacteria, viruses, etc.), thus causing them to be more susceptible to disease.

To quantify socioeconomic status, I used the Progress Out of Poverty Index (PPI) [2]. The PPI is an objective poverty assessment tool that estimates the likelihood that a participant has income below various poverty lines. The PPI uses ten statistically relevant poverty indicators in order to link the national and international poverty lines for comparisons of client poverty distributions both within a country and globally. For example, a score of 25 states that the participant is 99.3% below the Sierra Leonean national poverty lines, and 62.3% below the USAID “Extreme” Poverty Line. An illustration of a worked example for Progress Out of Poverty Index for Mexico can be found in Bigger (2009).