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Sierra Leone: How a dysfunctional blood transfusion system fuels maternal mortality

By Kemo Cham

Blood transfusion is critical to healthcare, yet in Sierra Leone accessing this life saving service is a nightmarish experience.

Infrastructural challenges aside, fear, fueled by myths and misconceptions, has made it hard to come across people willing to donate blood, even when loved ones are in deathbed. Nowhere is this situation more impacting than in Maternal and infant healthcare.

Sierra Leone has the highest Maternal Mortality Rates (MMR) worldwide - 1, 165/100, 000 and is also ranked in the top 10 countries with the highest Infant Mortality Rates (IMR) – 114/1000. 

According to a UNFPA report, postpertum heamorrhage is the leading cause of maternal deaths in the country, accounting for 46 percent of the deaths, pointing to a need to strengthen the blood system.

The National Safe Blood Services (NSBS), a program of the Ministry of Health and Sanitation (MoHS), is struggling to deal with demand, amidst increasingly understaffed and ill-equipped facilities across the country. 

In the southern Bo District, Lab Technician Juliette B. Murray is struggling to cope with demand for blood, amidst recurrent power outage and lack of essential equipment needed to process and store blood.

Power had just gone when a team from the NGO Focus 1000 arrived on an assessment mission at the blood bank. Four hours later, power was still not restored.

The Bo Government Hospital is the third largest in the country after Freetown and Makeni. On average 15 units of blood a day is issued out from the bank, according to officials.

Like the other regional banks, the Bo facility was established and equipped under a tripartite partnership involving the Health ministry, the Sierra Leone Red Cross Society (SLRCS) and the German Red Cross. This was towards the end of the civil war. Since the Germans left, all the regional banks have withered down due to lack of funding.

The NSBS, which operates from the main referral Connaught Hospital in Freetown, is supposed to receive subvention from the MoHS but funding is irregular and officials say when it comes sometimes for a whole year only one or two disbursements are made. Consequently, the banks are left to struggle to meet basic demands.

The program caters for 30 health facilities nationwide - 17 government and 13 private hospitals. All of these are supplied from three regional banks in Bo, Makeni and Kenema.

Thanks to support from the Global Fund and the World Health Organisation (WHO), the building housing the Bo facility, consisting of a lab and a phlebotomy room, was rehabilitated in recent years. But its staff of eight has been struggling to put their expertise into full use.

“As you can see, it (building) is small and not conducive,” said Ms Murray.

“Water is our number one problem,” she added. 

They wash their test tubes with foam soap, instead of the standard liquid solution. The danger with this is that soap can react with blood and causes contamination, making the possibility for cross infection high. It can also make the test tube cloudy, thereby prevent accurate reading.

There is also no incubator or centrifuge, because of which, coupled with the effect of recurrent power outage, the bank cannot conduct cross-matching, an essential element in the blood transfusion process.

Erratic power supply also means blood samples are constantly at risk of going bad, as they can only last for within 24 hours outside the controlled environment.

Osman Kargbo, Senior Technician with the NSBS, said in such a working environment, group specificity is the fallback. But this, he noted, doesn’t combat they look for in blood samples. He explained that some antibodies that cause reaction can only be identified through cross matching.

Technicians also test for a host of diseases in donated blood samples, like HIV and Hepatites.

Kargbo, who is attached to the NSBS headquarters at Connaught, said because of power outage, cross matching is rarely done outside Freetown.

Another crucial deficiency at the Bo blood bank is the absence of a phlebotomist. These are the only people, after doctors, licensed and authorized to collect specimens from the body for clinical or medical purposes. Essentially, every blood transfusion center is supposed to have at least one. Nationwide there are nine trained phlebotomists – Five in Freetown, two in Makeni and three in Magburaka.

In 2014, several nurses were trained as phlebotomists under a flagship program of the Office of the Sierra Leone President. The problem with that arrangement, observed Kargbo, is that the trainees were already in the health system as nurses. He said lack of incentives, coupled with staff shortage in the wards and outpatient sections, makes it impossible to retain blood banks staff.

In the absence of a phlebotomist a technician or nurse can do the job. But this, Kargbo said, increases the burden on the technician.

The Bo blood bank serves as coordination point for the four districts in the southern region. Francis Rogers, its Voluntary Blood Donor Recruitment Officer, said the 12 voluntary donor clubs in the region are virtually dead for lack of funding to sustain their activities. He doesn’t remember the last time they engaged in a blood donation drive.

The only line of survival for the bank is the occasional support from aid agencies like the Italian NGO CUCAM, which provides refreshment and transport refunds for volunteer blood donors. 

Rogers and his team of three recruitment officers have themselves not received any form of remuneration for the last four years. Salaries stopped when donors withdrew. 

“But every morning we are coming. Every morning we pay our transport to come to work,” said Rogers.

WHO says providing safe an adequate blood should be an integral part of every country’s national health care policy and infrastructure. It also recommends that all activities related to blood collection, testing, processing, storage and distribution be coordinated at the national level through effective organization and integrated blood supply networks. 

Sierra Leone has had a national blood policy since 2006. But, evidently, it is yet to be fully implemented. A National Blood Advisory Committee was created in line with this policy, but its members, appointed mainly from the MoHS and the Sierra Leone Red Cross (SLRC), rarely meets.

Little wonder, therefore, that all these years the country has depended almost entirely for blood on the family replacement system. This means that when someone is sick and needs blood transfusion, family members will be required to donate an equivalent amount of the blood they need.

Sometimes even among close families it is hard to convince people to donate. But even when there are willing donors, getting the right type of blood is another daunting challenge. Amid the ensuing chaos, there are endless complaints of blood bank officials monetizing the blood system.

Blood is needed for a variety of services, including the treatment of severe anaemia in children. Anaemia is listed among the leading indirect factors of maternal mortality in the country.

Blood is also needed for accident victims, cancer patients, blood disorder patients, and Sickle Cell patients. All of these are illnesses and conditions plaguing Sierra Leone’s health sector. 

Constant replenishment of the blood banks is therefore crucial because even with reliable power supply, blood can last for only 35 days before it goes bad.

According to a WHO categorization, Sierra Leone falls under Low-Income countries with 5 donations of blood per 1000 people, the smallest in the world. NSBS figures show that family replacement donation accounts for about 80 percent of total blood transfused annually nationwide in 2015. 

Dr Riad Mahmoud, a health specialist at the UNFPA Country office in Freetown, said with just 1 percent of its seven million population donating, there will be enough blood to save the lives of the many people at risk of dying for lack of blood.

And there have been renewed efforts recently towards realizing this goal. The visit to the Bo Blood Bank was part of that effort.

Through community engagements, Focus 1000, under a partnership with strategic grassroots organisations dubbed ‘Kombra Network, is raising awareness on the importance of voluntary blood donation. It’s all part of its campaign against maternal and infant mortality.

Mohamed Bailoh Jalloh, Chief Executive Officer of Focus 1000, said rate at which women and children were dying required a rethink of the current approach to the situation. 

“Far too many women die unnecessarily every year in Sierra Leone because they cannot access blood if required during pregnancy. It is our moral and civic responsibility to donate blood for free to help save the lives of mothers and children,” he said.

(c) 2018 Politico Online