Running head: GLOBAL HEALTH PROJECT 1

Maternal Mortality in Sierra Leone

Sarah Berry, Vanesa Hernandez, Raul Palma, Chelsea Ruthrauff, and Katelyn Sult

California State University, Stanislaus

GLOBAL HEALTH PROJECT 2

Maternal Mortality in Sierra Leone

Executive Summary

Motherhood is one of the most important occupations in this world. In Sierra Leone, the

transition into motherhood becomes a time of great risk, and these risks should be addressed in a

priority-like manner. In 2010, approximately forty percent of the population in Sierra Leone had

access to health care (CARE, 2010). There are nearly two million people living in Sierra Leone,

and with fewer than 180 government health workers who can assist with maternal delivery,

maternal risks have increased dramatically (CARE, 2010). Sierra Leone has one doctor for every

33,000 people (CARE, 2010). In comparison, within the United States, there are approximately

730 people to one doctor (CARE, 2010). These statistics need to be changed in order to help the

women of Sierra Leone.

Through our proposed project, based off the learnings of evidence-based practice

literature reviews, we aim to reduce the maternal mortality rate in Sierra Leone from 1,360

deaths out of 100,000 live births to seventy out of 100,000 live births by the year 2030 (Mason,

2016). In order to achieve this goal, parenting classes will be provided in order to educate

traditional birth assistants (TBAs) by utilizing formal midwifery training. Funding for this

proposal will come from grants, donations, and fundraising efforts. The initial team will be

comprised mainly of medical volunteers, who are obtained by volunteer advertisement in local

hospitals, informational meetings, and religious affiliates. The group of medical professionals

will consist of a multidisciplinary team comprised of nurses, physicians, medical students, and

nursing students, all who have been formally trained before departure. Upon arrival to Sierra

Leone, contact will be made with the gatekeeper, person of contact, in order to appropriately

communicate with the community. The gatekeeper, elders, TBAs, current health care
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professionals, and all other members of society will have the opportunity to be involved in the

educational opportunities presented. Using personal and working relationships, autonomy and

confidence will be instilled in the TBAs so improved, quality health care is provided to all

patients experiencing childbirth. Progress will be evaluated by qualitative, personal, semi-

structured interviews with open-ended questions, quantitative surveys, and quantitative

observations. Limitations are further detailed in the section labeled monitoring and evaluation.

Maternal mortality rates are a growing concern in Sierra Leone. As an aim to help this

vulnerable population, a proposal has been created with efforts from volunteers, various methods

of funding, and a growing opportunity for educational enhancement. Throughout this paper,

discussion of the problems at hand, a literature review and analysis, a logic model, project goals

and objectives, the technical approach and work plan, and monitoring and evaluation methods

will be discussed.

Background

The transition into motherhood should be filled with joy, love, and happiness. But for the

women living in Sierra Leone, childbirth equates to death. Why is this? This is because many

areas within Sierra Leone are absent of obstetric, antenatal, and postnatal services. This means

that multiple complications have the capability to arise without professional assistance. Antenatal

care is typically never received; resulting in nearly 1,360 maternal deaths per 100,000 live births

in Sierra Leone (Mason, 2016). The United Nations International Children’s Emergency Fund

(UNICEF), estimates that in “2015, 1 in 17 mothers [in Sierra Leone] have a lifetime risk of

death associated with childbirth.” (Mason, 2016). Currently, there is a shortage in skilled health

care workers in Sierra Leone because of the Ebola outbreak; this has negatively affected the

provision of health care in this location (Mason, 2016).

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According to a study done by Amara (2012), many expecting mothers have turned to

TBAs, to assist during the birthing process. The quality of care provided by a health care facility

is significantly better than that of TBA usage (Amara, 2012). TBAs are not trained to care for

postpartum hemorrhage, which is a major cause of maternal deaths, especially in the rural

locations in Sierra Leone (Mason, 2016). TBAs and other medical staff should be properly

trained by medical professionals of traditional medicine to be able to help decrease maternal

mortality rates within Sierra Leone. On average, antenatal care received throughout Sierra Leone

was 86 percent, but not timely due to distance, transportation methods, and social norms to delay

care-seeking until pregnancy is visible (Sharkey et al., 2016). These barriers were present

especially within the poorer areas of Sierra Leone (Sharkey et al., 2016). Approximately only

53.6 percent of women and newborns, delivered at home, had postnatal checks. In contrast, if

delivery was done within a health care facility, 94.1 percent of women and newborns received

postnatal care (Sharkey et al., 2016). Clean cord care, delaying first baths, and immediate

breastfeeding were inadequate across all districts (Sharkey et al., 2016). “Efforts should be made

to improve geographic access to facility-based care in these settings, and traditional and

community-based providers should be engaged as key partners in improving maternal and

newborn health as the country works to strengthen and even rebuild its fragile health system”

(Sharkey et al., 2016).

Literature Review

Article One

The purpose of the study was to discuss the many interacting vulnerabilities that

influence their healthcare-seeking decisions during pregnancy and childbirth (Bolkan,

Sagbakken, & Treacy, 2018). The research design method was a qualitative study that collected
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data through seven focus group discussions and twenty-two in-depth interviews with women

who had been pregnant within the last year, older women who had been involved in a delivery or

had a close family member in the village who had been pregnant within the last year, and men

who had a close family member in the village who had been pregnant within the last year. The

results of this study showed that pregnant women in rural Sierra Leone face many intersecting

vulnerabilities including poverty, gender inequality, and the unequal distribution of money,

power, and resources. Males were deemed to be the childbirth decision makers. Essentially,

childbirth decisions are greatly influenced by the constraints of poverty and other social

determinants (Bolkan et al., 2018).

Article Two

The purpose of this study was to examine the quality of free antenatal services and access

to emergency obstetric care in Sierra Leone (Bangura, et al., 2017). A cross-sectional survey was

done in ninety-seven peripheral health facilities and three hospitals. One hundred antenatal care

providers were interviewed, and 276 observations were made and 486 pregnant women were

interviewed. A few assessments were completed: the adequacy of antenatal and delivery services

were assessed, the distance between each facility providing delivery services and the nearest

comprehensive emergency obstetric care (CEOC) facility was calculated, and the proportion of

facilities in a chiefdom within fifteen kilometers of each CEOC facility was calculated. The

results of this study showed that the quality of services was poor. Only twenty-seven percent of

women were examined, two percent were screened on their first prenatal visit, and forty-seven

percent got interventions as recommended. Ninety-four percent of the facilities provided delivery

services, a mere forty percent had delivery rooms, forty-two percent had delivery kits, and only

forty-six percent had portable water. Thirty-five percent of deliveries were supervised by skilled
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attendants and only thirty-five percent of those were adequately documented. In regard to

national standards, none of the five basic emergency obstetric care facilities were completely

compliant. The central and northernmost parts of the district had the least access to

comprehensive emergency obstetric care (Bangura et al., 2017).

Article Three

This study’s purpose was to identify why women use services provided by TBAs as

compared to health facilities, and to suggest strategies to improve utilization of health facilities

for maternity and newborn care services (Amara et al., 2012). Qualitative data were collected

through focus group discussions conducted in urban and rural areas of Sierra Leone. There were

four sites with five focus groups consisting of young women, young men, adult women, and

adult men. There were eight participants in each focus group. Additional inclusion criteria

consisted of presence in the vicinity of a hospital and previous personal use of the hospital by

oneself or a family member. The results of this study are that the quality of care in relation to the

survival of pregnant women and their newborns in health facilities are only marginally better

than the services provided by TBAs. The cost in time, dignity and money associated with using

health facilities outweigh the benefits and serve as barriers to health facility utilization while

encouraging TBAs services. The comprehensive care of a quality perceived to be significantly

better than TBA care, free of financial considerations at the point of need and with appropriate

infrastructure that will begin to go away from TBAs and make the idea of universal skilled

attendance at delivery a reality (Amara et al., 2012).

Article Four

According to the authors, the purpose of this study was to evaluate the implementation of

an emergency obstetric referral system in terms of its use, acceptability and accessibility
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(Bhopal, Halpin, & Gerein, 2012). It was a mixed-method study. Records were kept detailing

each use of the ambulance including: date, patient identifying details, start and end mileage, total

mileage, reason for referral, treatment, outcome, and staff member name. To get more

information regarding acceptability and value of the service, fourteen in-depth semi-structured

interviews were carried out with the lead members, staff members, ambulance drivers and

ambulance users. The result of this study showed that a motorbike ambulance provided at low

cost as part of the healthcare system in rural areas can help reduce a large barrier to receiving

care (Bhopal et al., 2012).

Article Five

The purpose of this study was to evaluate the effectiveness of healthcare provider training

in Emergency Obstetric and Newborn Care (EmOC&NC) which is a large component of

intervention programs with the goal of reducing maternal and newborn mortality (Ameh et al.,

2016). There was an evaluation of knowledge and skills of 5,939 healthcare providers before and

after three to five days of skills and drills in EmOC&NC in seven sub-Saharan African countries

and two Asian countries. Standardized assessments using multiple choice questions and objective

structured clinical examinations (OSCE) were used to measure change in knowledge and skills

and the improvement ratio by cadre and country. A linear regression was done to identify

variables associated with pre-training and improvement ratio. The results were that Ninety-nine

and seven tenths of healthcare providers improved their overall score. There were significant

improvements in knowledge and skills for each cadre of healthcare each individual provider and

each country. Essentially, the short in-service of EmOC&NC training was associated with an

improvement in knowledge and skills for all cadres of healthcare providers working in maternity

wards in both sub-Saharan Africa and Asia (Ameh et al., 2016).

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Article Six

This study’s purpose was to determine retention of knowledge and skills after

standardized “skills and drills” training in Emergency Obstetric Care (Ameh et al., 2018). This

was a longitudinal cohort study. There were 609 maternity care providers of whom 455 were

nurse/midwives in Ghana, Malawi, Nigeria, Kenya, Tanzania and Sierra Leone. Their knowledge

and skills were assessed before and after training at three, six, nine, and twelve months. An

analysis of variance to explore differences in scores by country and level of healthcare facility

for each cadre was done. Mixed effects regression analysis to account for potential explanatory

factors including: facility type, years of experience providing maternity care, months since

training and number of repeat assessments. The results of this study were that for up to one year

after training, both knowledge and skills were close to the levels obtained immediately after

training. Health care facility levels and experience were not determinants of retention. Overall,

after training, healthcare providers retain knowledge and skills for up to twelve months (Ameh et

al., 2018).

Logic Model Summary

To meet the program goal of decreasing maternal mortality, the following objectives have

been prioritized: increase the education regarding maternal mortality and prevention in the Sierra

Leone community within one month, increase accessibility to family planning services within a

twelve-month period, access to health-care will increase to 70 percent by 2030, and maternal

mortality will decrease within twelve-month. The inputs for the project include the use of

evidence-based practice literature to formulate community plans with awareness conferences and

educational programs. The input of funding will be through grants and fundraising, and staffing

will be provided by medical recruits, volunteers, and medical missionaries that will help run the
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programs provided. The outputs include activities involving midwifery programs, local

programs, and an awareness conference for the community. The participants in these activities

include midwives, medical staff, community members, and leaders. Short-term outcomes will

result in an increase in knowledge and awareness to staff and community members, regarding

maternal mortality and family planning methods. Knowledge regarding obstetric services and

access to these services is also expected to increase. The medium-term outcomes are expected to

result in medical staff practicing skills that decrease maternal mortality. Also, members of the

community will be accessing services early to prevent complications; health and well-being

reports from individuals are also expected to improve. Long-term outcomes involve an overall

decrease in maternal mortality, improvement in overall delivery of care, increase in health

education of the community, and a decrease in maternal complications. The effects of the project

are expected to yield 250 TBAs and midwives that will be knowledgeable on how to improve

obstetric services, 170 leaders of the Sierra Leone cities will bring awareness to their own

communities and villages regarding maternal mortality, and by the end of the local program, 500

locals will report an increase in knowledge regarding family planning and maternal health

services. It is assumed that there is a lack of access in services, lack of knowledge in maternal

health, and lack of adequate training for staff to prevent the incidence of maternal mortality. The

external factors present include policies affecting health care services, funding by government,

and supply availability. Finally, the success of the project will be evaluated by analyzing a

decrease in maternal mortality to 1,000 of 100,000 live births within a twelve-month period.

Problem Goals and Objectives

The goal of our project is derived from the United Nations Sustainable Development

goals for maternal mortality. The current maternal mortality rate of Sierra Leone is 1,360 out of
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100,000 live births (Mason, 2016). Our primary goal is to reduce the maternal mortality rate of

Sierra Leone to seventy out of 100,000 live births by the year 2030 (Mason, 2016). In order to

achieve this goal, our project consists of short, medium, and long-term objectives. These

objectives are all highly supported by the review of the literature. Currently, in Sierra Leone,

pregnant women have increased vulnerability to maternal mortality due to poverty and social

factors (Bangura, et al., 2018). These factors often influence decisions made in regard to

maternal health and childbirth (Bolkan et al., 2018). We have focused on providing parenting

classes to address these factors in addition to formal midwifery classes provided to TBAs. Most

women in Sierra Leone chose to utilize the assistance of a TBA instead of a care facility due to

comfort and accessibility (Daoh et al., 2012). These facilities also only offer limited services and

are noncompliant to the requirements for obstetric care facilities (Banguar et al., 2017). It has

also been proven that the use of EmOC&NC will enhance the skills and knowledge of those

receiving the training (Ameh at al., 2016). These trainings are standardized and have resulted in

the retention of knowledge for up to twelve months (Ameh et al., 2018). These trainings will be

incorporated into the midwifery course content in order to improve and enhance the skills of the

TBAs. The above stated literature supports the objectives of the project.

The first objective of the project is that education regarding maternal mortality and

prevention will increase in the Sierra Leone community within one month. Evidence of this will

be determined through the introduction of midwifery classes for TBA. Attendance and

demonstration of learning during the classes will provide evidence as to whether this objective is

met. The next objective is that women will have an increased access to family planning services

within a twelve-month period. This objective will be evaluated similarly to the previous

objective, but through the introduction of maternal health courses for women in all seventeen
GLOBAL HEALTH PROJECT 11

villages of Sierra Leone. Attendance of these classes will be the primary evidence of increased

access to family planning services. The next objective is that women’s access to health care will

increase by seventy percent by the year of 2030. Evaluation of this objective requires careful

record keeping of all maternal health care interactions. This includes prenatal, labor and delivery,

and postnatal care. The final objective is that maternal mortality rates will decrease within a

twelve-month period. While the goal is for the rate to decrease to at least 1,000 out of every

100,000 live births, any significant decrease in mortality rates would provide evidence that the

interventions are effective. These four primary objectives will help assist in meeting the goal of

the project.

Technical Approach and Work Plan

The initial step in the technical approach is to thoroughly research the topic. This

involves research on cultural practices of the people living in Sierra Leone, the primary cause of

high maternal mortality, and evidence-based solutions. The next step is to create a set of goals

and objectives and determine how the effectiveness of interventions will be assessed. The team

must then create a plan of action including the logistics of transportation, housing, and location

for volunteers and staff. This also includes coming in contact with a gatekeeper, which is

essentially a contact person living within the culture that can act as a guide for newcomers

(Social Research Glossary, 2019). Other factors in the plan of action consists of specific

interventions, review of education content, and determining who will participate in the

education. Once these factors have been determined, the team must then obtain funding to

complete the project. The primary source of funding will be grants which require detailed grant

proposals. Additional funding could also come from donations and fundraising efforts. The

initial team must then build a larger team composed of volunteer medical professionals.
GLOBAL HEALTH PROJECT 12

Advertisement in local hospitals and informational meetings can assist in obtaining volunteers.

In the event of sufficient funding, volunteers may become paid staff depending on expertise and

involvement. Prior to traveling to Sierra Leone, the entire team must frequently meet to discuss

goals, objectives, and interventions, collaborate on education techniques, and complete logistical

tasks to ensure that details of travel and accommodation are adequately planned. Once the team

has traveled to Sierra Leone, the participants must establish a relationship with the people in the

area; specifically, traditional birth assistants working in Sierra Leone. Elders will be contacted in

nearby villages and the gatekeeper will act as a liaison between the two cultures. During the

establishment of the relationship, it is important to assess cultural perspective of the problem as

well as cultural values within childbirth practices. During this step, the team must create

awareness of the issue and encourage participation in future education. After establishing a

relationship, education must begin, initially starting with current traditional birth assistants. This

will include midwifery programs that focus on evidence-based techniques for labor and delivery,

infection prevention, and interventions for hemorrhage. Incorporated into these classes will be

EmOC&NC training which has proven to enhance the knowledge and skills of those receiving

the training (Ameh et al., 2016). Within these educational classes, assessment of learning will

occur through observation of skills and verbalized discussions. Education will then be expanded

through the use of family planning and maternal health classes for local women. We will

encourage the traditional birth assistants in the midwife classes to advertise these classes and

help to lead the education. This will produce autonomy and confidence within the future

midwives as well as assist to create trusting relationships between all participants. This classes

will also initially function to meet the six short-term objectives. The original team of healthcare

professionals will also accompany the new midwives to births and assist with the use of
GLOBAL HEALTH PROJECT 13

evidence-based techniques. Throughout this process, the team will record maternal mortality

statistics in order to assess the long-term outcome of the interventions. While some results, such

as outcome of education, can be observed immediately, long term effects may take a few years to

occur. As a result of the long timeframe, the volunteers may return to the United States

intermittently. The team will continue to obtain long-term funding through the use of grants and

continue to recruit new volunteers. After the interventions have proven long-term effectiveness,

the team can progress to new goals such as the establishment of long-term facilities and self-

sufficiency of the educational programs.

Monitoring and Evaluation

According to (Zief. Knab, & Cole, 2016), the primary goal of monitoring and evaluating

methodology is to help the research/study produce rigorous evidence of program effectiveness

that would meet the community and stakeholders’ standards. To achieve this goal, our team has

created a logical framework model for maternal morbidity that includes a situation and program

goal, outputs, outcomes, assumptions, and external factors to serve as stepping stones toward a

final evaluation.

Collecting data can be expensive and resource intensive. Utilizing resources such as

money, time, and overall dedication to the project, one must be able to propose a realistic and

efficient means for gathering data. What our team proposes for this project is a mixture of both

qualitative and quantitative data collection methods that will be beneficial to our project goal.

Qualitative data is to gain insight and understanding on underlying reasons and motivations for

an issue. Three means of qualitative data collection that we propose are providing face-to-face

personal interviews, a paper survey or questionnaire, and focus group interviews. According to

Anastasia (2017), face-to-face personal interviews are among the most common qualitative data
GLOBAL HEALTH PROJECT 14

collection methods. We propose a personal, semi-structured interview asking the same series of

open-ended questions to all respondents. This allows the interviewer to probe further by asking

follow-up questions and getting more information in the process; however, limitations to this

method can be language barriers, cultural differences, and geographical locations. A paper

survey or questionnaire is ideal for large populations, providing more detail will aid in the

analysis of data, but also make the analysis process more tedious and time-consuming. During a

focus group, an interview method will be done in a group discussion setting among three to ten

with something in common; most likely village midwives, nurses, and those who aid during the

childbearing process. Our focus group method can obtain highly detailed and descriptive data by

using the groupthink model.

Quantitative data collection methods proposed are quantitative surveys, and quantitative

observations of the global health issue. By conducting quantitative surveys, our team will

provide a closed question survey with answers provided; this will be ideal for large populations

in gathering generalizations about our issue, but it will restrict some of the details, so we will

pair this method with our qualitative proposal of focus groups and interviewing. Lastly, we

propose a quantitative observation data collection method. This method of data collection is done

by systemic observation by being immersed into the issue. Our researchers will currently assess

services in a specific area, or number of services used in a vicinity through being involved in

teaching campaigns regarding maternal morbidity (Anastasia, 2017).

Whenever addressing an issue with a possible solution, it is important to have stakeholder

involvement from the beginning (CDC, 2007). By involving stakeholders in the beginning of the

evaluation process, our group will be more likely to: reduce stakeholders’ distrust and fear of

evaluation, increase the chances that stakeholders will support our evaluation efforts and
GLOBAL HEALTH PROJECT 15

advocate for the program, and increase the credibility of findings. We can first involve potential

stakeholders in the program evaluation process by inviting them to a meeting, or series of

meetings, to brief stakeholders on our program as well as the activity we want to evaluate; in our

case it would be the maternal morbidity rates in Sierra Leone. We should also obtain a clear

understanding of stakeholder interests, perceptions, and concerns related to our proposed

program and evaluation. Asking questions such as how available they are to participate in the

evaluation process, and how we can meet their evaluation and communication needs can help us

determine the amount of involvement stakeholders want to participate in. During the meeting

stakeholders should be asked that they clearly identify their roles and responsibilities related to

the evaluation process before it begins. We can better determine a sense of involvement by

having them reflect on their strengths and resources, and how much that they want to be

involved. Another way to involve stakeholders in key activities throughout the planning and

implementation of the evaluation can include identifying and prioritizing program activities that

need to be evaluated, overcoming resistance to evaluation and identifying benefits, and

determining and using evaluation findings for program improvement (CDC, 2007).

According to the Agency for Healthcare Research and Quality (AHRQ) (2014),

disseminating findings to stakeholders should follow a dissemination plan. This plan includes a

Why- Sierra Leone is a country that continues to have high maternal mortality rates, What-

maternal morbidity and a better quality of life can be accomplished through better healthcare

education and proper training in Sierra Leone, To whom- the stakeholders and global healthcare

professionals, How- research articles, and conference presentations, and a When- the ideal

timing of the project and agenda of the audience (AHRQ, 2014). Our team believes that findings

should be disseminated to stakeholders through the use of journal articles that agree to publish
GLOBAL HEALTH PROJECT 16

the findings, and through conference presentations to reach a larger audience who is more

focused on the situation at hand.

Conclusion

Sierra Leone, a country that has dealt with civil unrest, disease epidemics, and most

recently the global health issue of maternal mortality. Throughout this paper our team has

comprised a literature review showcasing the effects of education and the improvements made

towards decreasing maternal mortality rates in Sierra Leone. Established was the use of a logic

model and project goal that can provide guidance for our team to effectively look at the issue and

plan accordingly. Devising technical approaches and work plans that incorporate evidence-based

practices to discuss and approach the issue with a realistic approach. Determining monitoring

and evaluation methods to effectively gather data using a combination of qualitative and

quantitative techniques and coming up with a plan on how to disseminate findings to

stakeholders’ post-research. Childbirth should be received with joy and an acceptance of the task

of becoming a maternal figure. These feelings can be fleeting for the women of Sierra Leone due

to their high rates of maternal mortality and lack of prenatal care. Is it a lack of education?

Neglect? Or perhaps, is it a cultural point of view on how women are to bring life into the world?

Whichever way one looks at this issue, it is an issue of prominence and concern on a global

standard because women should not have to give their own lives to bear future generations.

Appendix

Logic Model
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