RUNNING HEAD: MATERNAL MORTALITY IN SIERRA LEONE 1

Maternal Mortality in Sierra Leone

Charissa Zhu

FMSC110S

November 15, 2018

Maternal Mortality in Sierra Leone 2

Introduction

Maternal mortality is an important global health issue to address, but it is an extremely

complex issue with several determinants that influence a woman’s health while she is pregnant

or delivering. While this can still be a concern in highly developed countries, maternal mortality

is one of the leading causes of female death in the developing world (Mayor, 2004). It is

influenced by many factors, including the woman’s community status, classified as a distant

determinant, as well as her health and access to healthcare, classified as intermediate

determinants (McCarthy & Maine, 1992). In developing countries, a woman’s status in her

community is directly tied with her education and occupation; however, oftentimes traditionally

negative views on women lead to a lack of education within developing nations (McCarthy &

Maine., 1992). This lack of education also aggravates maternal mortality rates because the

woman’s limited knowledge inhibits her awareness of possible life-threatening complications

and therefore lessens the chance that she will seek professional help (Ahmed et al., 2010).

Maternal mortality is specifically a pressing issue in the West African country of Sierra Leone as

it hosts the highest maternal mortality rate in the world, with 1,360 women dying per every

100,000 live births (Jambai & MacCormack, 1996; World Health Organization, n.d.).

Background

Maternal mortality generally occurs due to obstructed labor, hemorrhage, sepsis, or

eclampsia, among other complications (Samai & Sengeh, 1997). This issue is extremely

pervasive in Sierra Leonean society, with with 1,360 maternal deaths per every 100,000 live

births in 2015; however, the maternal mortality rate is improving (World Health Organization,

n.d.). In 1990, there were 2,630 deaths per every 100,000 live births (World Health Organization,

n.d.). Delays in reaching medical care, such as poor road networks or high transportation costs,
Maternal Mortality in Sierra Leone 3

result in higher risk and rates of maternal mortality (Samai & Sengeh, 1997). Women who are of

lower socioeconomic statuses living in poorer areas are at higher risk for maternal mortality

because transportation to and from remote villages to medical facilities can be difficult,

especially during obstetric emergencies, which are extremely time sensitive concerns.

Additionally, the facilities are not evenly spread throughout populations, meaning that some

districts have a patient-to-facility ratio of 5900:1 (Samai & Sengeh, 1997). Aside from the

difficulties in obtaining emergency obstetric care, women are already set up for delivery

problems through the prevalence of child marriage. In Sierra Leone, 13% of girls are married by

age fifteen, and 39% by eighteen (UNICEF, n.d.). When children are delivering children, a

multitude of problems have the potential to arise. Obstructed labor occurs when the mother’s

pelvis is too small to deliver a fetus and its shoulders are unable to pass through her pelvic bones

(UNICEF, n.d.). Without a medical provider to administer a cesarean section, the baby will

surely die and the mother will likely not survive (UNICEF, n.d.). Young girls giving birth also

introduces the potential for obstetric fistulas, a condition that occurs when the pressure of the

baby’s head on the vaginal wall causes tissue damage and incontinence (UNICEF, n.d.). Girls

aged ten through fifteen have an 88% risk for developing fistulas during childbirth (UNICEF,

n.d.). Evidently, maternal mortality is an extremely dangerous and pervasive issue in Sierra

Leonean society.

Significance (4 paragraphs)

In 2015, the United Nations set forth 17 Sustainable Development Goals to be completed

by 2030 that will create a more equal, inclusive, and sustainable world for future generations

(United Nations Development Programme, n.d.). The third goal aims to promote proper health

and general well-being, which includes reducing the maternal mortality rate to less than 70
Maternal Mortality in Sierra Leone 4

maternal deaths per every 100,000 live births (United Nations Development Programme, n.d.).

Sierra Leone’s maternal mortality rate is currently at 1,360 deaths per 100,000 live births, but by

improving conditions for female reproductive health, progress within developing countries will

be accelerated because of the impact women have on society (World Health Organization, n.d.;

Bhutta, 2013).

Maternal mortality is a problem that, in and of itself, is related to family health. With the

death of a woman in childbirth or delivery, the entire family dynamic is affected. In some cases,

both the mother and the fetus die, which will have even greater impact on the social and

behavioral dynamic of the family. Women can also contribute to their family’s income, in which

case half of the household income is reduced, greatly affecting the financial and economic status

of families. In reducing maternal mortality, the health of the fetus is also improved (McCarthy &

Maine, 1992).

Bronfenbrenner’s ecological systems theory examines the relationship between an

individual and the environment around them; it can be applied to analyze factors that influence

maternal mortality in Sierra Leone (Psychology Notes, n.d.). In particular, societal traditions and

culture play a large role in customs of Sierra Leone and they might hinder a woman in delivery

from seeking medical attention (Bhopal et al., 2012). In this manner, societal views and cultural

values, part of the macrosystem, can negatively affect maternal mortality (Psychology Notes,

n.d.).

Addressing maternal mortality is extremely important for several reasons. Women

contribute greatly to society, thus improving conditions for female reproductive and general

health will accelerate progress within developing countries (Bhutta et al., 2013). Researchers

have also found that improving upon the factors that influence maternal mortality directly
Maternal Mortality in Sierra Leone 5

translates to better health conditions for her children (McCarthy & Maine, 1992). To specifically

address maternal mortality within Sierra Leone, researchers designed an intervention program.

Current effort

As Sierra Leone still holds the world’s highest maternal mortality rate, intervention

programs are being implemented with the goal of improving the health outcomes of women

throughout the country, as well as others affected by maternal mortality. An intervention

designed to improve delivery conditions for pregnant and delivering women in Sierra Leone was

started in 2006 and evaluated in 2009 by Bhopal et al (2012). The local population of

communities from the Kambian region of Sierra Leone participated in the program (Bhopal et

al., 2012). Women in Sierra Leone are at higher risk for death during delivery due to the poor

transportation infrastructure in Sierra Leone, most notably in the rural regions (Bhopal et al.,

2012). The roads are usually not paved and can sometimes cross over rivers, leading to major

setbacks in accessing medical care for the women in obstetric emergencies (Bhopal et al., 2012).

The study lists three specific phases of delay: the first is a delay in deciding to seek medical

attention, the second is a delay in accessing the medical facility, and the third is a delay in

receiving the medical attention (Bhopal et al., 2012). These roadblocks, both literal and

figurative, lead to extremely high maternal mortality rates (Bhopal et al., 2012).

In this intervention program, six eRanger motorbike ambulances were provided to

communities in the Kambia region (Bhopal et al., 2012). Kambia is a northern district with the

population of approximately 276,989 throughout 69 villages (Bhopal et al., 2012). These

motorbike ambulances were specifically designed for usage in areas without proper roads and

transportation systems (Bhopal et al., 2012). Though the aim of the project was to improve

conditions and outcomes for delivering mothers, the motorbike ambulances were also used for
Maternal Mortality in Sierra Leone 6

other non-obstetric emergencies, partly to foster acceptance in the local community (Bhopal et

al., 2012). In the Kambia district, there are 52 peripheral health units (PHUs) that provide

medical services to anywhere from ten to forty villages (Bhopal et al., 2012). The motorbike

ambulances were stationed at six different PHUs, spread throughout the region (Bhopal et al.,

2012). If, in a village, the traditional birth attendant, individual, family, or elders decide to send

for the ambulance, someone is sent by foot or bike to notify the peripheral health unit, who sends

the driver of the ambulance to pick up the patient and transport them to the nearest PHU (Bhopal

et al., 2012). Part of this intervention project also included a community education program

(Bhopal et al., 2012). Traditional birth attendants play a large role in local communities and the

delivery process, so they received training on identifying when it was necessary to summon the

ambulance and send the woman to the peripheral health unit for further medical attention

(Bhopal et al., 2012). Throughout four months, villagers were also shown a film called Call Di

Lifesaver, narrated by a popular local icon at town hall meetings where participants were also

able to ask questions (Bhopal et al., 2012). The aim of these video meetings was to familiarize

the community with the ambulance system and address any concerns they might have (Bhopal et

al., 2012).

After leaving the motorbike ambulances in the Kambia district in 2006, Bhopal et al

conducted an evaluation of the program in September of 2009 to assess their impact, their value,

and their acceptance within the community (2012). The evaluation consisted of an analysis of

ambulance data, over a dozen interviews, and one focus group discussion (Bhopal et al., 2012).

Each time the ambulance was used, the peripheral health unit recorded date, patient information,

total mileage, referral reason, treatment, outcome, and health care provider (Bhopal et al., 2012).

It was found that for 81% of cases brought to the PHUs, the patient was treated; however, 19%
Maternal Mortality in Sierra Leone 7

of the time, the patient was referred to a hospital to seek further professional medical attention

(Bhopal et al., 2012). Additionally, Bhopal et al. administered fourteen semi-structured

interviews with the directors of each PHU, the staff, the ambulance drivers, and the villagers who

used the service (2012). Villages who recorded using the ambulance system more than three

times were selected randomly, then within those villages past ambulance users were also selected

through a random process (Bhopal et al., 2012). One focus group was created with six pregnant

women chosen by the head of their local PHU; the goal of this group was to evaluate the

opinions of possible ambulance users (Bhopal et al., 2012).

Though the intention for the ambulance program was to reduce maternal mortality, the

motorbike ambulances were also used for other non-obstetric emergencies (Bhopal, 2012).

However, of the delivery- and labor-related emergencies, it is reasonable to infer that this service

reduced significant mortality rates within the participating villages in the Kambia region of

Sierra Leone (Bhopal, 2012). These findings have valuable implications for the future of

maternal and female health in Sierra Leone and other countries because it will guide future

efforts to address maternal mortality, as it demonstrates an effective model for reducing maternal

mortality rates, though the specifics will vary for each country due to the differing cultural,

political, and societal climates.

The program seems very feasible, though there are some obstacles that might cause

delays (Bhopal et al., 2012). Problems with the wheels of the ambulances were reported several

times and in some cases, parts had to be shipped from overseas (Bhopal et al., 2012). It was

difficult to keep records at the PHUs, especially with regards to the mileage figures (Bhopal et

al., 2012). It was also very likely that the associations between the interviewer and the donor

organization could have influenced the outcome of the interviews, introducing possible bias
Maternal Mortality in Sierra Leone 8

(Bhopal et al., 2012). Translations during the interviews might have also affected the results and

outcomes, as some meanings may be lost between interpretations. The next step for this program

will be to maintain the original project in Kambia and expand it to other regions of Sierra Leone,

as well as other countries that have high maternal mortality rates. Additionally, Bhopal et al. did

take into consideration the socio-ecological model when designing the intervention program. The

social environment and culture of the community, within the macrosystem, were addressed

through the informational video and town hall meeting that introduced this project to community

members and provided an opportunity to address any possible questions (Bhopal et al., 2012).

Discussion

To tackle the problem of maternal mortality from a holistic standpoint, it is important to

recognize the factors that influence one’s health status. The social determinants of health, the

“personal factors and community conditions” that affect one’s ability to receive health care, is

one such method for categorizing these factors (Jacobsen, 2019). It includes place of residence,

race, ethnicity, occupation, gender, sex, religion, education, socioeconomic status, social capital,

and age, among others (Jacobsen, 2019). With regards to maternal mortality, many of the social

determinants interchangeably play important roles. One’s sex is a necessary precondition to be a

victim of maternal mortality, though place of residence also holds crucial influence. If a woman

is giving birth in a remote village, not only is she very far from a medical center, but transporting

her to the facility will be difficult, as Sierra Leone’s transportation infrastructure is very poor

(Bhopal et al., 2012). Of the seventeen United Nations Sustainable Development Goals,

decreasing maternal mortality rates in Sierra Leone would address both the third goal, promoting

good health, and fifth goal, promoting gender equality (United Nations Development

Programme, n.d.). Researchers have found that improving upon the factors that influence
Maternal Mortality in Sierra Leone 9

maternal mortality directly translates to better health conditions for her children (McCarthy &

Maine, 1992). Additionally, by creating developments within the female health sector, especially

including factors that would decrease maternal mortality, women are given more steady footing

to establish themselves within society, thereby moving towards a more equal society. Through

improving access to health care and raising awareness within communities, demonstrated

through the intervention project designed by Bhopal et al., rates of maternal mortality will

decrease (2012). Thus, it is clear that similar programs should be implemented throughout Sierra

Leone, as well as other countries that have high maternal mortality rates and poor transportation

infrastructure, to improve rates of maternal mortality.

Conclusion

Maternal mortality is an extremely pervasive and harmful issue throughout Sierra Leone.

Though there are intervention programs, like the ambulance system in Kambia, that have

effectively shown improvements can be made, maternal mortality rates are still high in Sierra

Leone so there is still much work to be done. Women play a large role in society and contribute

greatly to the lives of their families and communities; thus, improving the conditions for female

and maternal health will improve the conditions of a nation.

Maternal Mortality in Sierra Leone 10

References

Ahmed, S., Creanga, A. A., Gillespie, D. G., & Tsui, A. O. (2010). Economic Status, Education

and Empowerment: Implications for Maternal Health Service Utilization in Developing

Countries. PLOS One, 5(6), 1–6.

Bhutta, Z. A., Das, J. K., Rizvi, A., Gaffey, M. F., Walker, N., & Black, R. E. (2013). Evidence-

based interventions for improvement of maternal and child nutrition: what can be done

and at what cost? Maternal and Child Nutrition, 382(9890), 452–477.

Central Intelligence Agency. (n.d.) The World Factbook: Sierra Leone. Retrieved from

https://www.cia.gov/library/publications/the-world-factbook/geos/sl.html.

Jacobsen, K. (2019). Introduction to Global Health (Third). Burlington, MA: Jones & Bartlett.

Jambai, A., & MacCormack, C. (1996). Maternal Health, War, and Religious Tradition:

Authoritative Knowledge in Pujehun District, Sierra Leone. Medical Anthropology

Quarterly, 10(2), 270–286.

Mayor, S. (2004). Pregnancy and childbirth are leading causes of death in teenage girls in

developing countries. BMJ, 328(7449): 1152.

McCarthy, J., & Maine, D. (1992). A Framework for Analyzing the Determinants of Maternal

Mortality. Studies in Family Planning, 23(1), 22–33.

Psychology Notes. (n.d.). What is Bronfenbrenner’s Ecological Systems Theory? Retrieved from

https://www.psychologynoteshq.com/bronfenbrenner-ecological-theory/.

Samai, O., & Sengeh, P. (1997). Facilitating emergency obstetric care through transportation and

communication, Bo, Sierra Leone. International Journal of Gynecology & Obstetrics,

59(2), 157–164.
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UNICEF. (n.d.). Ending child marriage and teenage pregnancy in Sierra Leone. Retrieved from

https://www.unicef.org/infobycountry/sierraleone_100861.html.

United Nations Development Programme. (n.d.). Sustainable Development Goals. Retrieved

from http://www.undp.org/content/undp/en/home/sustainable-development-goals/.

World Health Organization. (n.d.). Global Health Observatory country views. Retrieved from

http://apps.who.int/gho/data/node.country.country-SLE?lang=en.