Maternal health
Every year in Sierra Leone, thousands of pregnant women lose their lives while giving birth. An overwhelming number of these maternal deaths in Sierra Leone are due to preventable factors. At the heart of our work, UNFPA aims to end preventable maternal deaths by supporting the Government in strengthening its skilled workforce, improving health facilities, monitoring data on maternal deaths, and addressing maternal morbidity.
Reproductive, maternal, newborn, child and adolescent health is a priority for the Government of Sierra Leone. Over the years, with generous funding from UK aid, UNFPA has been supporting the Ministry of Health and Sanitation (MoHS) in strengthening Emergency Obstetric and Newborn Care (EmONC) to save the lives of mothers and newborns
Every maternal death, regardless of the cause and place of death, is unacceptable to the family and to society at large. Despite a reduction of almost 40 per cent in the maternal mortality ratio (MMR) from 1,165 per 100,000 live births in 2013 to 717 per 100,000 live births in 2019, Sierra Leone still remains one of the countries with the highest MMR in the world. A report published in 2019, analysing maternal mortality trends from 2000 to 2017, ranks Sierra Leone as one of the three countries with the highest MMR out of 186 countries reported globally.
Most maternal deaths are preventable if life-saving preventive and therapeutic interventions are provided in a timely manner. Even when pregnancy-related complications do not result in death, some women are left with lifelong debilitating conditions such as obstetric fistula. In 2020, UNFPA provided technical and financial support to the MoHS and non-governmental organizations (NGOs) such as Doctors with Africa (CUAMM), Aberdeen Women’s Centre, Haikal, and CapaCare to implement interventions to prevent maternal deaths, manage childbirth complications and ensure accountability for every death that occurred, whilst implementing corrective measures to prevent recurrence through the Maternal and Perinatal Death Surveillance and Response Framework.
Strengthening EmONC services
Strengthening the quality of obstetric services is key to addressing maternal mortality. Data from the 2017, 2018, and 2019 Maternal Death Surveillance and Response reports show that more than 80 per cent of maternal deaths occur at health facilities, of which 75 per cent occur at government hospitals. To improve availability of quality specialized emergency obstetrics and newborn care services (EmONC), UNFPA with funding from UK aid provided technical and financial support to three referral hospitals – Princess Christian Maternity Hospital (PCMH), Bo Government Hospital, and Makeni Government Hospital – to meet the internationally accepted minimum standards measured by the nine signal functions. The three hospitals are among five hospitals which contribute to the highest number of maternal deaths, with PCMH being the highest. To achieve this, 218 health care providers had competency-based training in various aspects of EmONC which included Uterine Balloon Tamponade for management of postpartum haemorrhage triaging of obstetric emergencies, correct use of the partograph, basic ultrasound scanning, aseptic techniques, assisted vaginal delivery and other aspects of quality of care. Additional support included the establishment of high dependency units at two of the hospitals to care for critically ill pregnant and postpartum women, equipping the facilities with emergency care equipment such as cardiac monitors, oxygen concentrators, foetal scopes, maintenance of infrastructure and equipment, and secondment of obstetricians and midwives to provide specialized services.
Sustaining quality sexual and reproductive health services
To improve quality of care, UNFPA with funding from UK aid, collaborated with the Quality Management Programme (QMP) of the MoHS and the Institute for Healthcare Improvement to strengthen the quality of care in maternal, newborn and child health in Sierra Leone. To achieve this, 30 directors and managers from the MoHS were trained in management of large-scale Quality Improvement (QI) programmes; 40 staff from the QMP and learning districts were trained in leading and facilitating QI to be certified as QI coaches; and 110 service providers from selected health facilities were trained in QI in maternal, newborn and child health. Participants were provided with knowledge and skills on QI tools and methodologies and supported to initiate QI projects to improve Reproductive, Maternal, Newborn, Child and Adolescent Health (RMNCAH) service delivery in the various facilities. Quality improvement mini-projects were initiated by health care providers at three aforementioned referral hospitals on targeted topics such as the correct use of the partograph, monitoring critically ill patients, management of hypertension in pregnancy, prevention of wound infection and other key topics.
To support the delivery of quality integrated sexual and reproductive health (SRH) services, UNFPA, with funding from the Government of China, supported the MoHS in establishing Reproductive Health Centres in five health facilities (King Harman Maternal and Child Hospital, Makeni Government Hospital, Murray Town Community Health Centre, Laka Ogoo Community Health Centre and Regent Community Health Centre). These centres will serve as comprehensive units to provide SRH services including family planning, cervical cancer screening and treatment, sexual gender-based violence (GBV) management, sexually transmitted infections management and HIV counselling and testing. The MoHS was supported by UNFPA in developing guidelines for the establishment of the Reproductive Health Centres to enable more such centres to be established by other partners.
Human resources for health
To deliver quality EmONC services, a skilled health workforce is critical. UNFPA supports the training of midwives at three midwifery schools (National School of Midwifery, Freetown; School of Midwifery Makeni; School of Midwifery, Bo) to improve the availability of skilled birth attendants in the country. To improve the availability of emergency surgery, UNFPA, with funding from UK aid, and in collaboration with the NGO Capacare, supported the task-shifting of emergency surgery to community health assistants who receive training as surgical assistants. Additionally, UNFPA supports the Government’s efforts to increase the availability of anaesthetic services by training nurses and community health assistants.
In 2020, 158 midwives graduated from three midwifery schools, bringing the total of midwives produced since 2010 to 1,145 (an increase of 16 per cent from the 2019 total of 987 midwives). Thirty nurse anaesthetists and anaesthetic technicians graduated from the anaesthetic training programme, bringing their combined total to 234 since the programme’s inception in 2003. Twelve surgical assistants graduated from the three-year training programmme and were deployed to various hospitals for housemanship.
Strengthening the quality of clinical practice for midwifery students
To improve the quality of clinical practice during midwifery training, a preceptorship policy and implementation guidelines were finalized and launched with funding from UK aid. Seventy-eight preceptors and faculty members from the three midwifery schools were oriented to the guidelines. This was followed by an assessment of 45 preceptorship sites to document their suitability for midwifery students’ clinical practice and to identify gaps to be addressed, to inform future programming. In addition, five midwifery tutors were supported in receiving bachelor’s and master’s degrees, to raise the standard of their teaching.
Continuity of sexual and reproductive health services during the COVID-19 pandemic
In responding to the COVID-19 pandemic, UNFPA drew lessons from various studies from the Ebola epidemic in 2015. The studies revealed increased maternal mortality and morbidity, increased cases of GBV and increased unplanned pregnancies among young people resulting from reduced utilization of maternal health and family services. These issues occurred as a result of the closure of some health facilities due to the overwhelmed health system, and reduced utilization of services by women for fear of contracting Ebola from the health workers. During the COVID-19 pandemic in 2020, UNFPA facilitated the continuity of sexual and reproductive health services by providing targeted support to selected health facilities and modifying the mode of programme delivery. With funding from UK aid, and through the NGO CUAMM, COVID-19 isolation facilities were created at UNFPA-supported hospitals and equipped to facilitate screening for COVID-19. Personal protective equipment and infection prevention supplies were provided to targeted hospitals, community health centres and implementing partners. Doctors, midwives and other selected health care workers were trained in infection prevention and control (IPC) practices.
In the wake of the COVID-19 pandemic, UNFPA supported a rapid assessment to determine the continuity of reproductive health services in selected health facilities. Following this, five facilities (King Harman Maternal and Child Health Hospital, Aberdeen Women’s Centre, Regent Community Health Centre, Ross Road Community Health Centre and Waterloo Community Health Centre) were supported in carrying out IPC and MNCH quality improvement activities as part of the recommendations from the assessment.
Whilst complying with the Government’s COVID-19 management guidelines on inter-district movements and large gatherings, UNFPA and implementing partners embarked on innovative approaches to programme implementation. Fistula surgeries were suspended from April to September and only resumed in October with ramped up days of surgery. Virtual lessons for midwifery students led to the completion of midwifery training during the year. COVID-19 messages were integrated into community sensitization activities for fistula which led to the achievement of planned community sensitization activities despite the cancellation of community gatherings during the pandemic. Implementation of on-the-job training for health workers, as opposed to classroom/ hotel-based trainings, led to more workers reached with targeted skills trainings than planned. With funding from the Government of Iceland, three thousand mama and baby packs were distributed to women who delivered in health facilities to encourage institutional deliveries. With technical leadership from UNFPA, and in collaboration with the MoHS and other United Nations agencies, and with funding from UK aid, a 13-bed specialized COVID-19 treatment centre was established and handed over to the Government on 28 May 2020.
