Marley Rashad
Maternal Health in Sierra Leone
From: Secretary of Health, Sierra Leone
To: Minister of Finance, Sierra Leone
Introduction
The maternal mortality ratio in Sierra Leone is currently approximately 1,300 deaths per
100,000 live births. The burden of this staggeringly high mortality ratio is borne primarily by
poor, rural, and uneducated women who have difficulty accessing and affording emergency
obstetric care, and are often unable to assess that emergency care is even needed. Because nearly
one in seven Sierra Leonean women is expected to die in childbirth in her lifetime, the
repercussions are both social (familial instability) and economic (millions of dollars lost in
female labor). An effective intervention system must focus on providing basic emergency
obstetric care to a wide watch of women and provide a way to get more women to deliver in a
hospital.
Nature and Magnitude of the Problem
The maternal mortality ratio (MMR) in Sierra Leone is among the highest in the world.
Although estimates range from as low as 857 deaths per 100,000 live births (country-reported
statistics) to as high as 1,800 per 100,000i live births, the actual ratio is most often reported at
around 1,300 deaths per 100,000 live births.ii This is down from around 2,000 deaths in the year
2000iii. Although there is a long list of maternal health problems that affect Sierra Leonean
women, MMR is one of the strongest indicators of maternal health as a whole, and the dismal
MMR of Sierra Leone stands out among other maternal health issues.
Women in Sierra Leone who die in childbirth are most likely to die of hemorrhaging,
infection, obstructed labor, hypertensive disorders in pregnancy, and complications of unsafe
abortion.iv Among these, all but complications of unsafe abortion are related to lack of
emergency obstetric care (EmOC) during childbirth. According to the latest WHO estimates, 87%
of Sierra Leonean women receive at least one antenatal care visit during pregnancy, but only 45%
continue with consistent care and have at least four visits.v Beyond this, only 42% of births are
attended by skilled health personnelvi and only approximately 10% of expected births were seen
in health facilities.vii
Affected Populations
Poor, rural, and uneducated women bear the heaviest burden of Sierra Leone’s high
MMR.viii With only 5.2% of the population of Sierra Leone living in urban areas and 76.1 % of
the population living on less than two US dollars per day, a vast majority of Sierra Leoneans fall
into this category. According to a Lancet article, MMR among the poorest quintile is consistently
more than twice as high as that of the wealthiest quintile.ix MMR and lack of EmOC is also the
highest in the Eastern Province and Southern Province of Sierra Leone. Six districts (Bonthe,
Kailahun, Kono, Moyamba, Pujehun, and Tonkolili) had no EmOC services, and other districts
such as Bombali and Port Loko had comprehensive emergency obstetric care x (CEmOC)
coverage of 3.5 and 2.1 per 500,000 population, respectively.xi No facilities in any of the
provinces in Sierra Leone qualify as basic emergency obstetric care facilities (BEmOC).xii
Risk Factors
Poor, rural and uneducated women are most heavily affected because they are least likely
to give birth with a skilled attendant present or at a hospital, have the most trouble accessing care
and determining when they need to access EmOC because of failure to diagnose complications
accurately and in a timely manner, and have the most trouble affording the care. Out-of-pocket
expenditure as a percentage of private expenditure on health is reported at 89.5%, which is a
staggeringly high proportion for the typical Sierra Leonean woman.xiii Additionally, although
national policy states that MCH services are free, a variety of fees were paid for pregnant
women's and sick children's attendance at health facilities. Fees varied widely between facilities
and were so unpredictable or arbitrary that patients and their families could not anticipate their
out-of-pocket expenditure.xiv The density of nursing and midwifery personnel density is 1.7 per
10,000 population, with the majority of those personnel being located in urban areas.xv Although
the UN recommends 5 EmOC facilities per 500,000 population with at least one of which being
a CEmOC facility, the EmOC coverage for Sierra Leone was 1.2 facilities per 500,000
population in 2009, well below recommendations, and the majority of these where concentrated
in the Northern Province, leaving the Southern and Eastern rural areas disproportionately
underrepresented.xvi
Economic and Social Consequences
The MMR in Sierra Leone is among the worst in the world, and reflects and perpetuates
the low status of women in that society. The total fertility rate per woman in Sierra Leone is 5.2,
which makes their likelihood of dying in childbirth in their lifetime about 1 in 7 to 1 in 9.xvii This
is even worse than the rate for women in all of Sub-Saharan Africa, the worst region globally,
who suffer a 1 in 16 chance of dying in childbirth. Not only is the high instance of maternal
mortality a human rights issue, but it contributes to instability among families in a society where
women are usually the primary caregivers for children and maintain the order of daily life. The
cycle of under-education, poverty, and high mortality is self-perpetuating, and according to
numbers from the Women Deliver conference, the annual global economic impact of maternal
and newborn mortality is a $15 billion US loss in potential production each year. It is estimated
that the total value of women’s unpaid house and farm work is equal to one third a country’s
Gross National Product, which for Sierra Leone could represent something like $100-150 million
USD.xviii
Priority Action Steps
Interventions should be targeted at the Southern and Eastern Provinces and should
include redistribution of EmOC services at already existing facilities, a standardization and
subsidizing of health care costs, and an incentive program to motivate more women to give birth
in hospitals. Ideally, the majority of EmOC facilities should be BEmOC, with fewer of the
EmOC facilities needing to be CEmOC, because a lack of BEmOC facilities can lead to
excessive use of CEmOC facilities and, consequently, to poor quality of services rendered.xix
Additionally, the BEmOC facilities should be the ones more easily accessible by a majority of
women (in rural areas, in other words). The health workers and facilities that do exist are poorly
utilized because such a low percentage of women give birth in a hospital, so a per-birth incentive
of even $50 might convince women to make the effort to give birth in a hospital as well as
subsidize their travel expenses.
Bibliography
i
"Country Statistics." Global Health Observatory Data Repository. World Health Organization, 2010. Web. 17 Nov
2011.
ii
Kizito Daoh, et al. "Averting Maternal Death And Disability: The Status Of Maternal And Newborn Care Services
In Sierra Leone 8Years After Ceasefire." International Journal Of Gynecology And Obstetrics 114.(2011): 168-173.
ScienceDirect. Web. 15 Nov. 2011.
iii
Carla Zhar et. all. Maternal Mortality in 2000: estimates developed by WHO, UNICEF and UNFPA. France:
World Health Organization, 2004. Print.
iv
"Improve Maternal Health." Millenium Development Goals. UNICEF, 2010. Web. 17 Nov 2011.
v
"Country Statistics." Global Health Observatory Data Repository. World Health Organization, 2010. Web. 17 Nov
2011.
vi
"Country Statistics." Global Health Observatory Data Repository. World Health Organization, 2010. Web. 17 Nov
2011.
vii
Kizito Daoh, et al. "Averting Maternal Death And Disability: The Status Of Maternal And Newborn Care
Services In Sierra Leone 8Years After Ceasefire." International Journal Of Gynecology And Obstetrics 114.(2011):
168-173. ScienceDirect. Web. 15 Nov. 2011.
viii
Khan, Irene. "Maternal Death Rate in Sierra Leone is a "Human Rights Emergency"." Amnesty International.
UNICEF, 21 sep 2009. Web. 15 Nov 2011.
ix
Margaret C Hogan et all. “Maternal mortality for 181 countries, 1980–2008: a systematic analysis of progress
towards Millennium Development Goal 5.” The Lancet, Volume 375, Issue 9726, 8-14 May 2010, Pages 1609-1623,
ISSN 0140-6736.
x
According to the Daoh article “Averting Maternal Death And Disability: The Status Of Maternal And Newborn
Care Services In Sierra Leone 8Years After Ceasefire,” the signal functions are (1) administration of parenteral
antibiotics, (2) oxytocics, and (3) anticonvulsants; (4) manual removal of the placenta (MRP); (5) removal of
retained products; (6) assisted vaginal delivery (AVD); (7) blood transfusion; and (8) obstetric surgery. Health
facilities providing the first 6 signal functions are classified as basic EmOC (BEmOC) facilities and those providing
all 8 signal functions are classified as comprehensive EmOC (CEmOC) facilities.
xi
Kizito Daoh, et al. "Averting Maternal Death And Disability: The Status Of Maternal And Newborn Care Services
In Sierra Leone 8Years After Ceasefire." International Journal Of Gynecology And Obstetrics 114.(2011): 168-173.
ScienceDirect. Web. 15 Nov. 2011.
xii
Kizito Daoh, et al. "Averting Maternal Death And Disability: The Status Of Maternal And Newborn Care
Services In Sierra Leone 8Years After Ceasefire." International Journal Of Gynecology And Obstetrics 114.(2011):
168-173. ScienceDirect. Web. 15 Nov. 2011.
xiii
"Country Statistics." Global Health Observatory Data Repository. World Health Organization, 2010. Web. 17
Nov 2011.
xiv
Kizito Daoh, et al. "Averting Maternal Death And Disability: The Status Of Maternal And Newborn Care
Services In Sierra Leone 8Years After Ceasefire." International Journal Of Gynecology And Obstetrics 114.(2011):
168-173. ScienceDirect. Web. 15 Nov. 2011.
xv
"Country Statistics." Global Health Observatory Data Repository. World Health Organization, 2010. Web. 17 Nov
2011.
xvi
Kizito Daoh, et al. "Averting Maternal Death And Disability: The Status Of Maternal And Newborn Care
Services In Sierra Leone 8Years After Ceasefire." International Journal Of Gynecology And Obstetrics 114.(2011):
168-173. ScienceDirect. Web. 15 Nov. 2011.
xvii
"Country Statistics." Global Health Observatory Data Repository. World Health Organization, 2010. Web. 17
Nov 2011.
xviii
Carine Ronsmans, Wendy J Graham. “Maternal mortality: who, when, where, and why.” The Lancet, Volume
368, Issue 9542, 30 September-6 October 2006, Pages 1189-1200
xix
Kizito Daoh, et al. "Averting Maternal Death And Disability: The Status Of Maternal And Newborn Care
Services In Sierra Leone 8Years After Ceasefire." International Journal Of Gynecology And Obstetrics 114.(2011):
168-173. ScienceDirect. Web. 15 Nov. 2011.