How Investigating Deaths Could Help Put an End to High Maternal Mortality in Sierra Leone
Sierra Leone has one of the highest maternal mortality rates in the world, with an estimated 1,165 deaths per 100,000 live births, according to the UN. This is more than triple the maternal mortality rate of neighbouring Ghana, which sees 319 deaths per 100,000 live births, and more than 160 times when compared to Canada’s rate of 7 deaths per 100,000 live births.
And according to a report by the government of Sierra Leone and UN partners such as UNICEF and UNFPA, 7 out of 10 maternal deaths go unreported, meaning the rate is likely much higher.
That is why the nation’s Maternal Death Surveillance and Response system (MDSR) was established in 2015.
National and district committees were established across the country to investigate maternal deaths — which include the death of any woman during a pregnancy or for six weeks following her delivery.
This system was established in an effort to curb maternal deaths in the country by tracking the deaths, identify the causes, making recommendations at a national level, and working with communities to reduce maternal mortality at a local level.
Sierra Leone’s MDSR program is supported by UNFPA Supplies, the UN program dedicated to increasing access to contraception worldwide with the goal of eliminating maternal deaths, increasing access to family planning, and ending gender-based violence and harmful practices.
UNFPA expects a funding gap of $222 billion when it comes to achieving these goals by its 2030 target, which is why world leaders like Canada are being called upon to increase funding to UNFPA Supplies.
To learn more about Sierra Leone's efforts to investigate maternal deaths, Global Citizen interviewed Isatu Sturay, a community health nurse, and Dr. Foday Sesay, a district medical officer, who are members of the district health management team in Makeni, in Bombali District, who carry out these investigations in northern Sierra Leone.
The following interview has been slightly condensed and edited for clarity.
How exactly do you investigate maternal deaths?
Sturay: When a maternal death occurs, we should be notified within 48 hours to conduct a verbal autopsy. We have a standard form we use for the investigations and find out the answers to these questions.
We will go to a community and meet with community elders to explain to them our purpose. At times, they think we are going to police them. We tell them we just want to prevent deaths of other women.
We do a social autopsy, too. We sit with people from the community and explain to them what happened once we know, so that they can understand, and we come up with recommendations. We tell them: ‘We are not here to give you problems, we just want to sit together and find solutions.’
What are some of the misconceptions people have about maternal health issues and the investigations your team conducts?
Sturay: There are many misconceptions, which is why we explain to people in the community the purpose of our visit. In our investigations, hemorrhaging is one of the major causes of maternal deaths, so people are scared of bleeding.
Sometimes when we seek blood donors, people will be afraid of donating and they will say, ‘I have to tend to my farmwork.’ They will also say they’re not healthy, but it’s just an excuse. So we sensitize them about this. People are also very afraid of cesarean sections and they think if they get a C-section, they will die.
Sesay: We see that between 80 to 85% deaths happen in facilities, not through home births. This also contributes to people from the villages being afraid of going to the hospital which is in a big town. They think, ‘If I go there, how will I manage? Will I be able to get food? Who will take care of me?’
What are some of the factors you see that may contribute to maternal mortality?
Sesay: There are barriers to providing medical treatment like a lack of delivery beds and other equipment that easily gets worn out. Other challenges include: ensuring clinics and hospitals have the right drugs and supplies, not having enough midwives and their skill level.
Transportation to hospitals was a big challenge, but this has improved significantly because of NEMS.
[Writer's note: NEMS is the National Emergency Medical Service — a fleet of nearly 100 ambulances that rolled out as part of a 2018 initiative to improve health outcomes by helping patients safely and quickly get medical care. However, sometimes these ambulances still take up to two hours to reach the nearest hospitals, putting patients at risk.]
Of course, electricity and water are problems that contribute, too. When we do our analysis, they act as contributing factors, not primary factors such as infections and hypertension, but they are in the background.
Sturay: There are also cultural factors that contribute. We try to involve the men in our work because sometimes when there is no power and a woman is giving birth, the woman looks to the man to decide whether she should seek care at a clinic. There are traditional beliefs, for example, that if a woman is having a seizure, it is a spiritual attack, when it is [actually] high blood pressure. So people keep her at home and contact a traditional healer, not knowing that they are delaying her from seeking urgent care. If a woman’s feet swell, people will think she is giving birth to a male child and just keep her at home, they don’t know she should seek medical attention.
What do you with the information gathered in investigations?
Sesay: We do an analysis of the data at a district and national level. When we find a weakness, we try to see if it’s because of a lack of capacity of skills and provide training where we can.
Two months ago, we decided we would visit hospitals once per month in our district to ensure people are following guidelines. We also visit community health facilities and provide training and mentoring where needed.
In Sierra Leone, deliveries by traditional birth attendants have been banned due to safety, but some women still prefer this method of delivery. Can you share with us what you do to discourage this?
Sesay: Traditional birth attendants are not supposed to do deliveries. Most of the time when a woman dies and a traditional birth attendant was involved, it is difficult for them to admit this, because they know they shouldn’t be doing this, so they cover what happened.
The law is grey in this area, so we don’t charge them legally, but medically, we tell them not to do deliveries. We communicate these messages through chiefs and other community stakeholders.