By Kemo Cham
When a room packed with activists was asked how many times pregnant women were expected to attend antenatal clinic, the responses were interesting and revealing.
“Two times…Three times…Four times…,” they guessed.
It was a community engagement organized by the NGO, Focus 1000 in Kenema. There were about 20 women among about 50 participants. Curiously, mostly the men were responding. No one came close to the correct answer and this, noted one of the facilitators, was telltale of a major factor fueling maternal mortality in Sierra Leone – ignorance.
Sierra Leone is estimated to have the world’s highest ratio of maternal mortality: 1, 165/100, 000, according to its last Demographic and Health Survey in 2013. This translates to 245 maternal deaths per month, or 2,941 deaths annually. It is also among the top 10 countries with the highest rates of infant mortality: 114/1000.
This has been the trend for the last two decades, following the end of the civil war which left every infrastructure in ruins.
Between 2010 and 2014, the health sector attracted huge investment. By 2015, towards the end of the Ebola epidemic, the sector was virtually on its knees again, with maternal and infant mortality still its biggest casualties.
In 2016, the government introduced the Maternal Death and Surveillance Response (MDSR), making it mandatory to report every death of women of child bearing age. Its maiden report identified bleeding as the leading cause of maternal deaths, followed by pregnancy induced hypertension, sepsis, among others.
Experts say a crucial way to reduce the health risks of mothers and children is by increasing institutional deliveries under supervision of trained healthcare providers.
But the experience seeking healthcare has rendered facilities across Sierra Leone less and less appealing, giving rise to community factors that cause delay in seeking care, leading to life threatening complications.
In Manotong, a settlement at the foot of Mount Aureole in Freetown, there is no shortage of apathy towards health facilities, which are viewed as places of extortion. Almamy Kanu is surprisingly proud that none of his kids was born in a hospital.
“All three of them were born here at home and I am thankful to God that all went fine,” he says.
Manotong is a microcosm of life in the Western Urban Area. Many of the mothers here are teenagers. The men are either jobless and can’t afford to support, or they simply decided to move out.
Mariama Koroma, 23, has three kids, each fathered by a different man, none of whom is around. She prefers buying medications from quack doctors whenever the children fall ill.
“At the hospital you spend more than it costs to buy the medicine here,” she says.
Tracking maternal deaths
It’s therefore hardly a coincidence that the region has the highest rate of maternal deaths among Sierra Leone’s 14 districts, according to the 2016 MDSR report. At Week 46 in 2017, it had recorded 77 deaths, ahead of the northern Port Loko District at second with 44 deaths, out of a total of 439 deaths so far nationwide.
The MDSR primarily seeks to track and review every maternal death, identify contributing factors and devise appropriate interventions. It was adopted from a system developed during the deadly Ebola epidemic when reporting deaths was first made mandatory.
The 2016 report, which was its maiden edition, shows that 706 maternal deaths were recorded the previous year, representing a 56% improvement in reporting. But it also warned that the number of deaths captured - representing only 24% - was far lower than the expected target of 3000 estimated deaths, mainly due to underreporting at community level.
Most of the reported deaths (80%) were from facilities, while 13.5% occurred in the community and 5.6% in transit to a health facility.
With the highest number of pregnancies in the year (43, 295), the Western Area Urban recorded the second lowest rate of institutional deliveries – 49.1% - just below the national average of 54% in the DHS.
The goal of Ministry of Health is therefore to increase institutional delivery by 100%.
The Focus 1000 community engagement in Kenema was part of that effort. The strategy entails targeting grassroots people with behavior change messages with the goal of promoting regular attendance of antenatal clinic, at least eight times, before delivery.
“Pregnant women and their families need to get the right information from the onset, which is crucial in ensuring safe delivery,” says Musa Sangaray, Program Manager of Focus 1000’s ‘Saving Lives’ project, a donor funded initiative implemented by as part of a consortium of local and international NGOs.
In addition to improving on data collection, it crucially seeks to get communities closely involved with healthcare delivery, especially in the area of maternal and infant healthcare, says Sangaray.
A leading cause of complications in pregnancy is failure to recognize danger signs and delay in seeking care. The idea therefore, explains Sangaray, is to get every member of the community trained to identify these danger signs and encourage pregnant woman to seek timely care.
But beyond behavior change, Sierra Leone must also address other factors facing communities in more challenging environments.
In the eastern Kenema District, for instance, where most of the population lives in rural settings, people trek long, mostly unmotorable distances, to access health facilities. Many rely on makeshift modes of transportation, further compounding the problem for patients in delicate conditions.
Joseph Blah is still mourning his wife, Mary who died giving birth to their fifth child nine months ago.
“They said she lost a lot of blood and there was not enough blood to save her life,” the 45-year old widower explains, with baby Mary, named after her late mother, playing on his lap, clearly oblivious of the future.
Mary had gone into labor while been transported by commercial motor bike from Blama in the Small Bo Chiefdom to Kenema Town. She was delivered by the roadside, in the bush.
Community organizer Mohamed Sam says the poor nature of the roads in most parts of the district had led to many pregnant women going into labour en route hospitals. Sam, who chairs the Kenema District Council’s Health Committee, blames the situation on lack of prioritization of the health sector, citing delay in disbursement of funds to the Council, with the consequences of inability to procure relevant drugs and medical equipment.
The Kenema Government Hospital serves as the main referral center for the district’s 120 Peripheral Health Units (PHUs). For all this, says Sam, there is only one ambulance, which for the most part is faulty.
“In hard to reach terrains like Gorama Mende and the Tunkia axis, the roads are bad and rough. When someone is in labor people call for a whole day and the ambulance will be on repair. By the time they are ready, it requires over 50 to 60 miles to the health facility,” Sam says, noting that this has largely contributed to keeping people away from health facilities.
Kenema ranks third, with 60 deaths, in the MDSR report.
Only way out
Public Health expert and gynecologist, Dr Michael Bome, agrees on the need for adequate funding to the health sector to address maternal mortality. He emphasized on the need for trained personnel and mobility.
Dr Bome, the District Medical Officer of nearby Pujehun, has an extensive experience dealing with this problem serving in some of the most challenging parts of the country, including Kono and Kailahun. But he says the unique geographical nature of Pujehun stands it out among the rest.
A substantial part of Pujehun is separated from health facilities by rivers, amidst almost non-existent transport infrastructure, so that even as host to the best maternal health facility in the country, the district hasn’t been able to cut down maternal deaths to an appreciable level. It ranks below in the maternal mortality rate among the rest but this, note analysts, could well be attributed to underreporting.
“It is very expensive to operate in Pujehun. One district, three territories,” laments Dr Bome. “That’s why to date we have not been able to combat maternal mortality, to reduce it to the level at which as a District Medical Officer I will be proud.”
Globally maternal mortality remains a challenge, but Africa has the highest concentration of worst performing countries. Sierra Leone, alongside South Sudan, Chad, Somalia, CAR, Burundi, and Guinea Bissau, has for long been among the top 10 countries with the highest number of deaths. All these countries have one thing in common – a history of political instability – yet, with the exception of Sierra Leone, they have all made commendable progress.
In 2008, for instance, Sierra Leone recorded 890/100, 000 MMR, while South Sudan had 2, 054, according to a joint World Bank-UN ranking. Ten years later, South Sudan has reduced its MMR to the fifth highest with 789/100, 000, while Sierra Leone is ranked at the top with 1, 165/1000.
The UN Sustainable Development Goals  target reducing maternal mortality ratio to less than 70 per 100,000 live births by 2030.
Reproductive health specialist Dr Fatu Fornah, says institutional delivery is a big part in tackling Sierra Leone’s maternal mortality crisis.
Fornah, the Team Lead for Reproductive and Maternal Health at the WHO Country Office, says there are far better services available in facilities that can’t be provided at home.
WHO is involved with a number of interventions seeking to address maternal mortality in the country, notably an Emergency Obstetric and New Born Care Training scheme, through which health workers are trained on life saving techniques. Furnah explains that hemorrhage, which is the leading cause of maternal deaths, is often caused by the placenta getting stuck in the womb after delivery. She says skilled midwives and nurses can manually remove the placenta, which usually stops the bleeding.
“There might be challenges, and we recognize there are challenges in our health centers…but when women have complications in pregnancy, there is a couple of things that we can do in our hospitals and our clinics that we cannot do at home,” she says.
This story was written as part of a journalism fellowship with the U.S. Embassy in Freetown. All opinions expressed in this article are those of the journalist and do not reflect the views of the U.S. Embassy.
(c) 2018 Politico Online