Barriers and Promising Interventions for Improving Maternal and Newborn Health in Sierra Leone by Plan Nederland

Barriers and Promising Interventions for Improving Maternal and Newborn Health in Sierra Leone

Kathy Herschderfer, Korrie de Koning, Elizabeth Mâ&#x20AC;&#x2122;balu Sam, Patrick Walker, Heidi Jalloh-Vos, Symone Detmar

Part of the knowledge strengthening component of the MDG5 Meshwork Public Private Partnerships Programme for the improvement of Maternal Health in Sierra Leone

Rapid Assessment of Interventions for Improving Maternal and Newborn Health, in Sierra Leone

Affiliation and role of the authors Kathy Herschderfer and Korrie de Koning: Royal Tropical Institute, KIT, Amsterdam, The Netherlands. Kathy was the researcher responsible for data collection, data analysis, writing the report, and contributed to the tool development and training. Korrie was responsible for the design of the research, training, tool development and data analysis, and she contributed to the report. Elizabeth Mâ&#x20AC;&#x2122;balu Sam* and Patrick Walker: University of Sierra Leone, Freetown, Sierra Leone. Patrick was the field supervisor and contributed significantly to the data analysis and the report. Elizabeth was instrumental in the data analysis phase and in report writing. Heidi Jalloh-Vos: Medical Research Centre, Freetown Sierra Leone. Heidi contributed to the development of the design, data collection process and feedback on the report. Symone Detmar: TNO, Quality of Life, Leiden, The Netherlands. Symone assisted in data analysis and provided support for the qualitative analysis programme.

This report is in memoriam of Elizabeth Mâ&#x20AC;&#x2122;balu Sam who sadly passed away just before this report went to print.

Reference:

Herschderfer K. Sam E. Walker P. Jalloh-Vos H. Detmar S. Koning K. de, 2011, Barriers, and Promising Interventions for Improving Maternal and Newborn Health in Sierra Leone, Medical Research Centre, Freetown, Sierra Leone

ISBN/EAN: 978-90-818323-0-4 Contact information Royal Tropical Institute (KIT) Development, Policy and Practice Mauritskade 63

Medical Research Centre (MRC) Dr Heidi Jalloh-Vos Health Programme Manager 5 Frazer Davies Drive

Rapid Assessment of Interventions for Improving Maternal and Newborn Health, in Sierra Leone

1092 AD Amsterdam The Netherlands www.kit.nl Tel: + 31 20 5688494

Freetown Sierra Leone Email: hjallohvos@hotmail.com; Tel: + 232 76684337

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Acknowledgement First of all the authors would like to thank the research assistants involved in the full process of data collection and data analysis. They were Foday R. Musa, Patricia A. Williams, Kaditatu S. Kamara, Joseph L.M. Goakai, Zainab Kamara, Joseph B. Fobay, Isatu P. Kamara, Ambrose Rogers and Alikali Turey. In addition, we would like to thank Mr Samual J. Braima at the University of Sierra Leone for his input in the instrument development workshop and the initial phases of data collection. In particular, we would like to thank Mr Foday R. Musa for entering the coded qualitative data into the computer software. We are also grateful to Dr. Memunatu Pratt for her involvement in the first analysis workshop. The authors would like to thank the leaders and families in the research communities who generously opened their homes to accommodate the research team during their stays in the communities. We would also like to express our appreciation to the non-governmental organisations (NGOs) in the research districts of Koinadugu, Kenema, Bo, Bombali and Tonkolili. They helped with the logistics of data collection and assisted us with details of the interventions implemented by them. We would like to give a special thanks to all the stakeholders and NGO field officers who took time from their busy schedules to help validate the findings and discuss the implications of the findings. We especially thank the Ministry of Health and Sanitation in Sierra Leone for their insights and collaboration, in particular Dr. Kisito S. Dao, Chief Medical Officer MoHS; Dr Samual A. S. Kargbo, Director Reproductive Health Programme, MoHS; and Dr. Sarian Kamara, programme Officer of the Reproductive health Department of the Ministry of Health and Sanitation. We also thank Cordaid Memisa in the Netherlands for the overall management of the MDG5 Public Private Partnership Programme in Sierra Leone.

Rapid Assessment of Interventions for Improving Maternal and Newborn Health, in Sierra Leone

List of abbreviations ANC

Antenatal Care

BEmONC

Basic Emergency Obstetric and Neonatal Care

CEmONC

Comprehensive Emergency Obstetric and Neonatal Care

CHC

Community Health Centre

CHO

Community Health Officer

CHA

Community Health Assistant

CHP

Community Health Post

CHW

Community Health Worker

EmONC

Emergency Obstetric and Neonatal Care

FGD

Focus Group Discussion

FHCI

Free Health Care Initiative

GBV

Gender-Based Violence

IDI

In-Depth Interview

KIT

Royal Tropical Institute

MCH Aide

Maternal and Child Health Aide

MCHP

Maternal and Child Health Post

MNH

Maternal and Newborn Health

MNCH

Maternal, Newborn and Child Health

MoHS

Ministry of Health and Sanitation

MRC

Medical Research Centre

NGO

Non-Governmental Organisation

PBF

Performance-Based Financing

PHU

Peripheral Health Unit

PPP

Public private Partnership

RBF

Result-Based Finance

RCH

Reproductive and Child Health

SRHR

Sexual and Reproductive Health and Rights

SSI

Semi-Structured Interview

TBA

Traditional Birth Attendant

TNO

TNO Quality of Life

United Nations

USL

University of Sierra Leone

Rapid Assessment of Interventions for Improving Maternal and Newborn Health, in Sierra Leone

1 Executive Summary 1.1 Introduction Sierra Leone is a country with one of the highest maternal mortality rates in the world. The Ministry of Health and Sanitation (MoHS) of Sierra Leone recognises this problem and has developed, in collaboration with partners, the National Reproductive and Child Health Strategic Plan 2008-2010 in order to reduce maternal, neonatal and child mortality in Sierra Leone. One of the programmes supporting the improvement of maternal and newborn health (MNH) is the Public private Partnership (PPP) programme, funded by several bodies including the Dutch Ministry of Development Cooperation and Cordaid. The PPP project is led by Cordaid; KIT is responsible for the research for the PPP project. The overall objective of the PPP programme is to contribute to the successful implementation of the National Reproductive and Child Health Plan 2008-2010 (and the follow-up after this period), in order to reduce maternal, neonatal and child mortality in Sierra Leone. The Royal Tropical Institute (KIT), in collaboration with the Medical Research Centre (MRC), the University of Sierra Leone and TNO Quality of Life, has undertaken a research programme aimed at identifying promising practices that can be scaled up as a comprehensive package to be implemented in each district, through a rapid assessment. 1.2 Methodology The objective of the study was to:  assess the effect of the interventions currently being implemented in Sierra Leone as perceived by the users and providers of care;  contribute to the development of effective strategies for MNH improvements;  contribute to strengthening research capacity in the country. This rapid assessment was mainly qualitative. Its aim was to study the effect of interventions, currently being implemented by NGOs in Sierra Leone, as perceived by the users and providers of care. The study looked at access, availability, quality and other factors influencing utilisation of government health facilities across the study communities – whether or not supported by NGOs. It explored and identified traditional beliefs and practices and identified interventions for improving MNH. It has also provided qualitative baseline data for future programmes and interventions in MNH. An important element of the research involved collaboration with researchers and research assistants from the University of Sierra Leone. Various training workshops were held to strengthen their skills in data collection and analysis, and on-the-job support was provided for carrying out field data collection and analysis. The knowledge, experience and skills of the people involved provided a valuable sharing of insights as well as capacity building for everyone engaged in this process. Various stakeholder meetings were held in order to:  validate the mapping of various interventions implemented by NGOs for the improvement of maternal health;  discuss the criteria for the selection of study districts and communities;  validate the preliminary findings;  discuss the findings and draw implications for policy and practice. The criteria for the selection of study districts that emerged from extensive stakeholder consultation were:

Rapid Assessment of Interventions for Improving Maternal and Newborn Health, in Sierra Leone

 

implementation of prioritised interventions such as community education, referral system and loan scheme, and strengthening facility interventions; geographical distribution.

The study took place in March and April 2010 – before the implementation of free health care – in the districts of Koinadugu, Bombali, Kenema, Bo and Tonkolili. The following criteria determined the selection of research communities: variations in types of promising practices being implemented by various NGOs geographical distribution of communities, and communities with and without health facilities. In total, fourteen villages fulfilling the criteria were visited. Data were collected by ten data collectors. Data were collected from the following sources: 17 focus group discussions (FGDs) with women, men or mixed groups of young people; 29 semi-structured interviews (SSIs) with key informants and 27 in-depth interviews (IDIs) with women who had delivered at least two babies. Visualisation techniques including 30 Venn diagrams were used during the IDIs to map the importance of individuals influencing decision-making about labour and delivery. Forty-two birth timelines were made during these IDIs to look at actions during pregnancy and delivery over time. Five health facility assessments and six provider skill assessments with health facility staff were also conducted. Further information was obtained through observations, field notes and informal contacts. Analysis Qualitative data analysis was carried out using Atlas-ti v.6. This took place at two analysis workshops involving most data collectors, three additional social scientists from the University of Sierra Leone, and two international facilitators experienced in qualitative analysis. The coding framework was developed by the analysis group in two phases. It was based on the conceptual framework, the continuum of care model and issues emerging from the initial data. Two validation workshops were held (one with NGO field officers and one with all stakeholders) to present the data summaries from the preliminary analysis to validate the outcomes. Analysis matrix sheets were used to analyse data across the various sites and, where relevant, data from various respondent groups and various techniques was triangulated. 1.3 Main findings 1.3.1 Decision-making Women in Sierra Leone generally expressed a lack of autonomy in health care decision-making. Women rank their husbands mostly as the primary important decision-makers. The norm is that husbands control the resources and, as such, play a very influential role in giving permission to seek and finance care. However, decisions about what is needed during labour and delivery itself is women’s business. In places with a community health centre (CHC) maternal and child health aides (MCH Aides) are often perceived as more influential than traditional birth attendants (TBAs), and they are ranked higher. In places with a maternal and child health post (MCHP) there is no difference found and in places with no primary health unit (PHU), TBAs are mentioned slightly more often than MCH Aides. The capacity of women to take their own decisions emerges most clearly in their practices around family planning. Generally speaking men claim control over

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fertility and family planning. Women go against these decisions but in secret, as is illustrated by some of the quotes. Family planning organisations have open access to the villages and chiefs. Men and women alike allow them in and appreciate their work. However, they do not reach all communities and some respondents stated that they would prefer to access family planning at the clinics to ensure continuity of services. Uptake is still low. The reasons given are that many children still die and that men resist family planning. It appears that the uptake is slowly increasing; in a few interviews, the women said that they made the decision to use family planning together with their husbands. 1.3.2 Knowledge and beliefs In almost all areas, various NGOs, health providers and media campaigns provided some education on birth preparedness and danger signs. The respondents in all the communities mentioned the most important danger signs in pregnancy, delivery and newborn care. The main maternal concerns were swelling of the feet and face, bleeding, anaemia, fever, delay in the delivery of the placenta, convulsions, and abnormal presentations. The main neonatal concerns are the newborn convulsing, not breathing or not crying. However, no matter what action is taken, the belief system in all communities is traditional. Communities believed that problems such as the death of the baby, miscarriage, prolonged labour, retention of the placenta and the refusal of the child to breast feed are due to the motherâ&#x20AC;&#x2122;s infidelity. Sometimes, different interpretations lead to different actions. For example, the motherâ&#x20AC;&#x2122;s feet swelling up may be interpreted as meaning that she is carrying a boy; other times it is seen as a danger sign and either traditional or medical help is sought. Convulsions (eclampsia) are seen as a sign that treatment by the traditional healer is required. However, women will go to both the health centre and to the traditional healer. 1.3.3 Perceptions of access The data show that distance is a huge barrier to accessibility to a health facility, especially for communities without health centres. The distance factor is usually further complicated by lack of vehicles, bad roads and high transport fares. A hammock or a motorbike may be used to carry the woman in labour to the PHU. As the Presidentâ&#x20AC;&#x2122;s Free Health Care Initiative had not yet been initiated in Sierra Leone, cost was a major concern in all the study communities. Payment for services and drugs at the health centre are barriers to accessing care. In most communities, cost is a major barrier for referrals from the facility to the district hospital. In some communities the ambulance service is free, but people still have to spend extra money on blood, drugs and so on at the district hospital. This dissuades people from agreeing to referral. When complications occur, women need ambulance services or other transport to be referred to district-level care. We have seen that barriers to these services include seasonal factors, poor roads in general, poor means of communication and administrative boundaries. The costs associated with ambulance referral services is still an issue except where they are provided free of charge by NGOs. 1.3.4 Perceptions of quality The study shows that quality-related issues that people are concerned about include shortage of drugs and supplies, the unavailability of health providers, incompetence and/or inexperience of the health facility staff, and poor staff attitude. Respondents also strongly believe that motivating health facility staff in

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Rapid Assessment of Interventions for Improving Maternal and Newborn Health, in Sierra Leone

cash or kind can improve the quality of care. Many considered the health centre as the best place to seek care. Availability of staff and drugs is generally better in the facilities supported by NGOs. Staff availability is a problem in facilities with only one staff member. In some of the facilities in the study communities, availability of staff and drugs was inconsistent. Staff were generally seen as friendly and encouraging, except in two facilities. TBAs are regarded as having vast experience but are not always appreciated because they are sometimes seen as being impatient and insensitive. 1.4 Practices in pregnancy and childbirth 1.4.1 Uptake of facility birth  Quality and distance strongly influence the uptake of facility births.  In all the study communities, irrespective of what type of facility is available, women go to TBAs as the first point of call.  In areas with a CHC, women go to the TBA as a first port of call and are then often taken to the health centre. In areas with no facility present, women deliver in almost all cases with the assistance of a TBA. 1.4.2 TBA practices  There are trained and untrained TBAs, and TBAs mentored and supervised by staff in facilities. There appears to be a shift from TBAs working in isolation to TBAs working together with facility staff. Because of their influential roles in women’s society, TBAs may have the potential to be influential in changing beliefs and practices in communities.  The various community education interventions are good at increasing knowledge about danger signs and the need for facility birth. However, this knowledge is strongly influenced by traditional beliefs and practices amongst TBAs, especially in relation to eclampsia, prolonged labour and retained placenta. Practices around eclampsia, prolonged labour and retained placenta are often inadequate. Traditional beliefs relating to complications during delivery and childbirth – particularly prolonged labour or retained placenta lead to delays in timely referral. Individual interviews with TBAs and with women with least two children show that TBAs let women wait till the baby or placenta comes, even if it takes 3 to 7 days. This practice is also seen when TBAs deliver women in some of the maternal and child health posts (MCHPs). In facilities where TBAs are well-supervised this practice was not observed. 1.5 Knowledge and skills of maternal and newborn health providers The skills and knowledge of CHOs are very good. Skills assessments of the MCH Aides show that they know well what to do in most situations, but they have much less insight into why they have to do it. The current situation is that only the CHOs are capable of practicing Basic Emergency Obstetric and Neonatal Care (BEmONC) at the PHU level but lack of experience means it is not always taking place. 1.5.1 Community interventions The study showed the existence of ‘bylaws’ aimed at increasing facility birth. This measure is enforced by chiefs fining husbands, women and/or TBAs if they do not go to a health facility for delivery. In some cases, when the woman cannot reach the facility because the birth happens too fast or at night, the bylaw decrees that the child should be brought to the health facility the next day. These bylaws seem to be effective, especially when women live close to a facility. Informal data as well as information from respondents indicate that women who arrive with a

Rapid Assessment of Interventions for Improving Maternal and Newborn Health, in Sierra Leone

delivered baby at the facility are sometimes registered as a facility birth. Government data does not confirm this. In areas without health facilities, women tend to deliver primarily with the assistance of TBAs. At the moment, there is a shortage of skilled MNH workers. Consolidation of services into larger bed capacities is justifiable if people can reach them before labour has started. For example, the establishment of waiting homes by various NGOs in Sierra Leone could stimulate facility birth, although our data shows that implementation of these homes is still challenging. 1.6 Implications  Serious conditions such as eclampsia, prolonged labour and retained placenta are not always referred in a timely manner and the prevention and treatment at the health facility level needs to be reviewed.  Given the important role the TBA plays, the policy direction taken years ago to exclude the TBA from the health care system should be reviewed.  Creating birth waiting homes is a promising intervention but needs further development and research.  The functioning of bylaws need to be investigated.  The number of health workers posted in facilities needs to be reconsidered to ensure availability of staff at facilities and outreach posts.  Community education needs to focus on important decision-makers such as women’s societies and husbands in order to influence beliefs and practices.  Distance, cost and administrative boundaries hinder effective referral. Better coordination of ambulance services and referral need to be put in place and effective boundaries for catchment areas established. 1.7 Recommendations for a comprehensive package of maternal and newborn health interventions 1.7.1 Improving the decision to seek timely and appropriate care  Continuation of community education and development – although the latter needs to focus more on women’s societies and husbands, and include more reflection on community beliefs.  Community education needs to focus on important decision-makers such as women’s societies and husbands in order to influence beliefs and practices.  Increasing community knowledge on signs of impending birth to foster timely arrival at facility for birth.  Development of clear roles and tasks for TBAs and training to prepare them for their tasks in advising women within the continuum of care.  More understanding is needed about the effectiveness (short- and long-term) of bylaws aimed at increasing utilisation of facility birth and newborn care. 1.7.2 Improving the ability to reach PHU and treatment facility  Look into innovative ideas to ensure better transportation of pregnant women and newborns from the community to the health facility.  Develop Birth Waiting Home model for the Sierra Leon context.  Learn from existing NGO practices what factors influence the quality of ambulance services and develop a model for overcoming barriers and scaling up services into all districts.  Improve organisation and coordination of referral services for obstetric and neonatal emergencies. 1.7.3 Improving adequate treatment and care  Reconsider number of staff in facilities to ensure availability of staff at facilities and outreach posts.  Support and improvement of health facilities by supplying drugs, and improvement of staff competencies and motivation.

Rapid Assessment of Interventions for Improving Maternal and Newborn Health, in Sierra Leone

    

Integrate the TBA within the health facilities and supportive supervision of her practices. Develop alternative and innovative initiatives involving m-Health technology to connect women and health services. Review practices in providing post-partum care and follow-up, and in prevention and treatment of eclampsia. Develop interventions aimed at reducing the use of unnecessary and inappropriate drugs in MNH – on demand side as well as supply side. Increase health worker motivation and retention.

1.8 Next steps The results of this study were presented to a stakeholders’ meeting on 2 December 2010 in Freetown. It was attended by more than 60 representatives from the MoHS, NGOs, the United Nations (UN), donor organisations and other interested parties. Following this, a working group consisting of experts from the MoHS and representatives from NGOs in Sierra Leone working in the area of sexual and reproductive health met periodically in the first half of 2011 to develop a comprehensive package of ‘promising interventions’ based on the findings from this study and intended to complement existing structures and ongoing projects. Before the end of 2011, implementation of a community-based adult-learning intervention will start in a number of chiefdoms in the districts where the implementing NGOs work and where a referral system and Basic Emergency Obstetric and Neonatal Care (BEmONC) services are in place.

Rapid Assessment of Interventions for Improving Maternal and Newborn Health, in Sierra Leone

Table of Contents ACKNOWLEDGEMENT ...................................................................................... IV LIST OF ABBREVIATIONS ................................................................................. V 1

EXECUTIVE SUMMARY ...................................................................... VI 1.1 1.2 1.3

INTRODUCTION ................................................................................... VI METHODOLOGY ................................................................................... VI MAIN FINDINGS ................................................................................. VII

1.3.1 1.3.2 1.3.3 1.3.4 1.4

PRACTICES IN PREGNANCY AND CHILDBIRTH .................................................. IX

1.4.1 1.4.2 1.5

Decision-making ............................................................................................... vii Knowledge and beliefs ..................................................................................... viii Perceptions of access....................................................................................... viii Perceptions of quality ...................................................................................... viii Uptake of facility birth ....................................................................................... ix TBA practices .................................................................................................... ix

KNOWLEDGE AND SKILLS OF MATERNAL AND NEWBORN HEALTH PROVIDERS ............... IX

1.5.1

Community interventions ................................................................................... ix

1.6 1.7

IMPLICATIONS ..................................................................................... X RECOMMENDATIONS FOR A COMPREHENSIVE PACKAGE OF MATERNAL AND NEWBORN HEALTH INTERVENTIONS .................................................................................. X

1.7.1 1.7.2 1.7.3 1.8 2

NEXT STEPS....................................................................................... XI

INTRODUCTION ................................................................................. 1 2.1 2.2 2.3

BACKGROUND TO THE STUDY .................................................................... 1 POLICIES AND NGO INTERVENTIONS IN SIERRA LEONE ...................................... 1 EVIDENCE ON EFFECTIVE INTERVENTIONS ...................................................... 3

2.3.1 2.3.2 2.3.3 2.3.4 2.4 3

MAPPING OF INTERVENTIONS BY NGOS IN SIERRA LEONE ................................... 8

CONCEPTUAL FRAMEWORK ....................................................................... 9

METHODOLOGY ................................................................................ 11 4.1 4.2

SELECTION OF STUDY SITES ................................................................... 11 DATA COLLECTION TECHNIQUES AND RESPONDENTS ........................................ 11

4.2.1 4.2.2 4.2.3 4.3 4.4 4.5

4.6

xii

Semi-structured interviews ............................................................................... 11 In-depth interviews ........................................................................................... 12 Focus group discussions and other participatory methods .............................. 12

DATA COLLECTION PROCESS AND MANAGEMENT ............................................. 13 DATA ANALYSIS ................................................................................. 13 QUALITY ASSURANCE ........................................................................... 13

4.5.1 4.5.2 5

Interventions addressing barriers to seeking care in the community ................. 4 Interventions addressing perceptions of quality of care ..................................... 6 Role of Traditional Birth Attendants .................................................................. 6 Other interventions that may affect Maternal and Newborn Health .................. 7

PURPOSE AND OBJECTIVES ............................................................... 9 3.1

Improving the decision to seek timely and appropriate care .............................. x Improving the ability to reach PHU and treatment facility ................................ x Improving adequate treatment and care ............................................................. x

Capacity strengthening and stakeholder involvement ...................................... 14 Ethical considerations ...................................................................................... 14

STUDY LIMITATIONS ............................................................................ 14

RESULTS .......................................................................................... 16

Rapid Assessment of Interventions for Improving Maternal and Newborn Health, in Sierra Leone

5.1

DECISION-MAKING ABOUT CARE BEFORE AND DURING DELIVERY .......................... 16

5.1.1 5.1.2 5.1.3 5.1.4 5.2

KNOWLEDGE BELIEFS AND ACTIONS ........................................................... 20

5.2.1 5.2.2 5.2.3 5.2.4 5.2.5 5.2.6 5.2.7 5.3

Community-based/oriented interventions ......................................................... 45 Referral service interventions ........................................................................... 45 Facility and quality of care interventions ......................................................... 45

UTILISATION OF FACILITY SERVICES .......................................................... 45

DISCUSSION AND CONCLUSIONS .................................................... 47 6.1 6.2 6.3 6.4 6.5 6.6 6.7

Profile ............................................................................................................... 41 Integration of TBAs with health facilities ......................................................... 42 Areas of work .................................................................................................... 43 TBAs as first port of call during labour and delivery ....................................... 43 Quality of TBA care .......................................................................................... 44

PERCEPTIONS OF PROMISING INTERVENTIONS IN MNH HEALTH ........................... 45

5.6.1 5.6.2 5.6.3 5.7

Staff attitudes .................................................................................................... 35 Availability of drugs and supplies .................................................................... 36 Staff Availability ............................................................................................... 36 Expertise ........................................................................................................... 37 Diagnosis and Treatment.................................................................................. 37 Care for the newborn ........................................................................................ 38 Other considerations ........................................................................................ 38 Measures of technical quality ........................................................................... 38

ROLE OF THE TBA AND THEIR PRACTICES .................................................... 41

5.5.1 5.5.2 5.5.3 5.5.4 5.5.5 5.6

Access from home to the health facility ............................................................ 27 Distance ............................................................................................................ 27 Costs ................................................................................................................. 28 Other barriers to accessing the facility from home .......................................... 29 Access from health facility to referral hospital................................................. 29 Seasonal factors and poor infrastructure ......................................................... 30 Community actions to increase access to health facilities ................................ 31 Community actions to increase access to referral facilities ............................. 33

QUALITY OF CARE ............................................................................... 34

5.4.1 5.4.2 5.4.3 5.4.4 5.4.5 5.4.6 5.4.7 5.4.8 5.5

Normal signs and actions during pregnancy .................................................... 20 Normal signs and actions during delivery ........................................................ 22 Danger signs and actions during pregnancy .................................................... 23 Danger signs and actions during delivery and post-partum............................. 25 Danger signs and actions during the neonatal period ...................................... 25 Traditional beliefs and practices ...................................................................... 25 Religious beliefs ................................................................................................ 27

ACCESS AND REFERRAL ......................................................................... 27

5.3.1 5.3.2 5.3.3 5.3.4 5.3.5 5.3.6 5.3.7 5.3.8 5.4

The role of the husband .................................................................................... 17 Other decision-makers regarding childbirth .................................................... 18 Decision-making about family planning ........................................................... 19 Decision-making about neonatal care .............................................................. 20

DECISION MAKING .............................................................................. 47 KNOWLEDGE, BELIEFS AND PRACTICES ....................................................... 48 ACCESS .......................................................................................... 50 QUALITY.......................................................................................... 52 ROLE OF TBAS .................................................................................. 53 SUMMARY OF BARRIERS TO IMPROVING MATERNAL AND NEWBORN HEALTH ............... 54 SPHERES OF INFLUENCE ON LABOUR AND DELIVERY ......................................... 54

PROMISING INTERVENTIONS, AND RECOMMENDATIONS ................ 57 7.1 7.2 7.3 7.4

SUMMARY OF PROMISING PRACTICES.......................................................... 57 IMPROVING THE DECISION TO SEEK APPROPRIATE CARE IN TIME ........................... 57 IMPROVING THE ABILITY TO REACH PRIMARY HEALTH UNIT AND TREATMENT FACILITY .... 58 IMPROVING ADEQUATE TREATMENT AND CARE ................................................ 58

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7.5

FURTHER RESEARCH NEEDED ................................................................... 58

NEXT STEPS ..................................................................................... 59

REFERENCES .................................................................................... 61

ANNEX 1 OVERVIEW OF NGO INTERVENTIONS FROM MAPPING STUDY ......... 66 ANNEX 2 OVERVIEW OF STUDY DISTRICTS, CHIEFDOMS AND COMMUNITIES 72 ANNEX 3 RESEARCH TABLE ............................................................................. 73 ANNEX 4 EXAMPLE OF BIRTH TIMELINE ......................................................... 76 ANNEX 5 OVERVIEW SOURCES OF DATA ......................................................... 77 ANNEX 6 INTERVENTIONS IN STUDY COMMUNITIES..................................... 78 ANNEX 7 OVERVIEW VENN DIAGRAMMES ...................................................... 81

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Rapid Assessment of Interventions for Improving Maternal and Newborn Health, in Sierra Leone

Figure Figures Figure Figure Figure Box 1: Box 2:

1: 2a 3: 4: 5:

Conceptual framework……………………………………………………………………...........10 and 2b: Examples of Venn Diagrammes ............................................. 16 Knowledge, beliefs and actions ......................................................... 49 Spheres of influence ........................................................................ 55 Conceptual framework of promising interventions ............................... 60

Time needed for outreach activities: ..................................................... 36 Examples of special support for TBAs .................................................... 42

Rapid Assessment of Interventions for Improving Maternal and Newborn Health, in Sierra Leone

Introduction This report includes the justification, methodology, results, implications and recommendations of a rapid assessment of factors influencing health seeking behaviour for maternal and newborn health care. Interventions and promising practices implemented by the Ministry of Health and Sanitation – with or without non-governmental organisation (NGO) support – and by local authorities have been described and assessed based on the perceptions of the users and providers of maternal and newborn health (MNH) care.

2.1 Background to the study Sierra Leone is a country with one of the highest maternal and newborn mortality rates in the world (Hogan, 2010; Rajaratnam, 2010). The Ministry of Health and Sanitation of Sierra Leone recognised the problem (MoHS, 2009) and developed, in collaboration with partners, the National Reproductive and Child Health Strategic Plan 2008-2010 in order to reduce maternal, neonatal and child mortality in Sierra Leone. One of the programmes supporting the improvement of maternal and newborn health is the Public private Partnership (PPP) programme, funded by a number of bodies including the Dutch Ministry of Development Cooperation and Cordaid. The PPP project is led by Cordaid, and the Royal Tropical Institute (KIT) is responsible for the research for the PPP project. The overall objective of the PPP programme is to contribute to the successful implementation of the National Reproductive and Child Health Plan 2008-2010 (and the follow-up after this period), in order to reduce maternal, neonatal and child mortality in Sierra Leone. Within the Public private Partnership (PPP) in Sierra Leone – one of the five projects that form part of the MDG5 Meshwork – partners joined forces to support the improvement of MNH and the National Reproductive and Child Health Strategy Plan 2008-2010, as drafted by Sierra Leone’s MoHS. As part of this programme KIT, in collaboration with the Medical Research Centre (MRC), the University of Sierra Leone (USL) and TNO Quality of Life (TNO), undertook a rapid assessment aimed at identifying factors influencing health seeking behaviour for MNH and promising practices aimed to address these factors. 2.2 Policies and NGO interventions in Sierra Leone Sierra Leone’s National Health Sector Strategic Plan (2010-2015) aims to strengthen six key pillars of the health system: (1) leadership and governance, (2) service delivery, (3) human resources for health, (4) medical products and technologies, (5) health care financing, and (6) health information systems. The strategies in the plan focus especially on the needs of mothers, children and the poor. In general, the policy environment is supportive of addressing maternal and newborn health. The MoHS developed a Reproductive and Child Health (RCH) programme with the goal of making a significant contribution to reducing maternal and child mortality and morbidity, through efficient and responsive service delivery by all stakeholders. Two relevant policies exist to help the programme achieve this goal: the Reproductive Health Policy 2007-2015 and the Child Health Policy 2007-2015. The Reproductive and Child Health Strategic Plan 2008-2010 was developed in accordance with these two policies, and implemented by the government in partnership with development partners. The goal of this plan is to reduce the maternal mortality ratio and under-5 and infant mortality rates by 30% within three years by providing comprehensive, highquality reproductive and child health services and strengthening the health system Ministry of Health and Sanitation Sierra Leone, 2008. Some key points related to maternal and newborn health, as mentioned in the National Child Health Policy, are the provision of high-quality obstetric care to all pregnancies

Rapid Assessment of Interventions for Improving Maternal and Newborn Health, in Sierra Leone

and the promotion of breastfeeding practices (Ministry of Health and Sanitation Sierra Leone, 2007b). A joint appraisal of the RCH programme and implementation found that, ‘The public health system capacity to deliver RCH services and to rapidly scale up interventions is insufficient. The flow and alignment between strategies, objectives, activities and indicators in the implementation plan needs to be improved, and immediate short term objectives defined.’ (MoHS Reproductive and Child Health Programme, 2008a). The policies aimed at improving maternal and child health outcomes are complemented with other policies, such as the President’s Free Health Care Initiative (FHCI), that took effect on 27 April 2010 and abolished all charges to pregnant women, lactating mothers and children under 5 years of age. The National Human Resource Policy (2006a) addresses the production and utilisation of human resources within Sierra Leone’s MoHS, responding to the contemporary challenges and developments, including a poor skills mix, a demotivated workforce, the exodus of human resources, and advancements in technology. As part of the FHCI the payroll was updated, extra staff hired and salaries increased. The fatality rate from malaria in pregnancy motivated the MoHS to adopt a policy of Intermittent Preventive Treatment (IPT) of malaria during pregnancy in Sierra Leone. All pregnant women should receive IPT during antenatal care (ANC). Others include the use of insecticide-treated nets, tetanus toxoid, effective and prompt malaria treatment, alongside prevention of anaemia through sound nutritional guidance and de-worming. In 2007 it was estimated that at least 75% of all blood transfusions were for women and children. The National Blood Transfusion Policy (2006b) focuses on screening of blood for HIV/AIDS, syphilis, hepatitis B&C, strengthening both government and private blood transfusion centre, and ensuring quality services by monitoring and supervising the blood services programme. In an effort to scale up essential health care services, primarily for pregnant women and children, a basic package of essential services was developed by the MoHS in partnership with other stakeholders. The Basic Package of Essential Health Services (BPEHS) for Sierra Leone, (Ministry of Health and Sanitation Sierra Leone, 2010) consists of six distinct elements. 1.

2. 3.

4. 5.

It identifies the services that the MoHS guarantees will be available to the population, including utilisation of treated bed nets and promotion of early and exclusive breastfeeding; family planning to address problems of teenage pregnancy and child marriage; essential and emergency obstetric care, including prenatal, delivery and post natal services; integrated management of neonatal and childhood illnesses; preventive services, including immunisation and school health; and promotion of hygiene practices. It implies that a minimum set of health staff with appropriate skills will be present at each of the facility levels to provide the services. It gives guidance for the content of training programmes by defining the technical and management competences required at different levels of the health system. It gives guidance to what will constitute an essential drugs list for each level of the health system. It is presented in such a way that costs can be estimated to give an idea of the financial resources that will be required for service provision.

Rapid Assessment of Interventions for Improving Maternal and Newborn Health, in Sierra Leone

It provides a basis to prepare operational plans and to design monitoring and evaluation tools.

It also provides a comprehensive list of services to be offered at five standard levels of health care within the Sierra Leone health system.  Community level – TBAs and community health workers (CHWs)  Maternal and child health post (MCHP) level – maternal and child health aides (MCH Aides)  Community health post (CHP) level – community health assistant (CHA)  Community health centre (CHC) level – community health officer (CHO)  District hospital – doctors, nurses, laboratory technicians This basic package was established in 2010, and is currently in the process of being implemented. Generally there is complementarity between the various health policies that address issues affecting maternal and child health within the health sector. However, it is not clear from the policies and strategies how they will complement strategies from other sectors such as the gender programmes at the Ministry of Social Welfare, Gender and Children’s Affairs, which have specifically noted gender issues as one of the key factors driving the high maternal mortality rates. According to the Gender Strategic Plan 2010-2013, (Ministry of Health and Sanitation Sierra Leone, 2009b), some of the activities aimed at reducing maternal morbidity and mortality will be, ’promoting [...] women’s sexual and reproductive health and rights (SRHR) by forming SRHR committees at all levels; establishing response mechanisms for gender-based violence (GBV) survivors (e.g., free medical treatment and legal services); strengthening partnerships to reduce women’s vulnerability to HIV; capacitating TBAs on SRHR and referral procedures; advocating for accessible health services in rural areas; lobbying for the inclusion of family planning in school curriculum; and advocating for the passage of Sexual Offences Act into law.’ Teenage pregnancy has been noted as one of the reasons for high drop-out rates from schools in Sierra Leone UNICEF Sierra Leone, 2010), yet the RCH strategies have not covered strategies to address gender-related drivers of maternal mortality, nor have they covered adolescent sexual reproductive health comprehensively. Overall, 28 per cent of married women in Sierra Leone have an unmet need for family planning, with a higher proportion with an unmet need for spacing births than with an unmet need for limiting births. Only 8 per cent of Sierra Leone’s women’s need for family planning is met. If all currently married women who say they want to space or limit their children were to use a modern family planning method, the contraceptive prevalence rate would increase to 36 per cent (Statistics Sierra Leone, 2008). Almost four in ten Sierra Leonean women gave birth before age 18, while over half (56 per cent) gave birth by age 20 (Statistics Sierra Leone & ICF Macro, (2009). 2.3 Evidence on effective interventions This section summarises the results of a literature study carried out prior to this rapid assessment (Herschderfer et al., 2010a). The Thaddeus and Maine delay model helps to identify community and health service factors contributing to maternal deaths (Thaddeus & Maine, 1994). Continuum of care approaches promote the integration of programmes for MNH, rather than single interventions. Comprehensive MNH care packages can significantly reduce maternal and neonatal deaths, maximise the efficient allocation of scarce resources (including human resources) and increase efficiency when scaling up effective interventions (Kerber et al. 2007; Campbell & Graham 2006; Bhutta et al. 2008). Some of these packages have been suggested, but

Rapid Assessment of Interventions for Improving Maternal and Newborn Health, in Sierra Leone

there is a lack of systematic reviews of the effectiveness of these interventions (Kerber et al., 2007; Bhutta et al., 2008). Delays in adequate care at health facilities, as well as part of the delays in reaching facilities, can be addressed by interventions that produce effective health services, or what Ensor and Cooper (2004) refer to as supply-side determinants. These authors suggest that relatively little attention is paid to demand-side barriers, causes delays in deciding to seek care and in reaching health facilities. Demand-side barriers include lack of education and information (which would allow a person to assess whether care is needed); consumer cost barriers such as transport and community and household barriers such as cultural norms that influence decision-making. Interventions that operate through engagement of communities can reduce demand-side delays (Bhutta et al., 2008; Rosato et al., 2008). Community health worker and community support groups may form the necessary links between community uptake of interventions and primary health care services. Several studies suggest that community-based strategies to promote healthy household behaviours, community support and the use of facility services can be effective for promoting participation and community empowerment, and make a difference to MNCH outcomes. Community-based approaches, involving a cadre of CHWs who work together with both public and private facility-based health staff, may be the most effective way to provide services where the health system is not well developed. However, community donor emphasis on performance targets does not match the ’unhurried process‘ needed for community engagement. Moreover, community mobilisation seemed more difficult and expensive to replicate widely. Nevertheless, Ensor and Cooper (2008) suggest that even though many demand-side barriers exist, there is a lack of robust evidence on ways to reduce them. The effectiveness of existing interventions is an under-researched area; most evaluations of interventions focus on increased utilisation, not on outcome. 2.3.1 Interventions addressing barriers to seeking care in the community Several interventions can be implemented in communities to reduce barriers in receiving care. M’Jamtu-Sie (1996) makes a case for effective community health information provision in Sierra Leone. Community health information services encourage people to take care of their own health, enable them to make informed decisions concerning their health, and help them treat minor complaints at home when medical staff is unavailable or unnecessary. Health information is also focused specifically on women and TBAs. Portela and Santarelli (2003) argue for empowerment to be the aim of community health information provision. Research in other health areas suggests that empowering interventions, rather than increasing knowledge, can lead to greater satisfaction on the part of the woman, along with increased understanding and compliance. In an intervention in Sierra Leone in the 1990s, community motivators worked to increase awareness and change behaviour in the community regarding obstetric complications, providing education on danger signs and the need for prompt referral, as well as facilitating referral for obstetric emergencies (Kandeh et al., 1997). The contribution of the community motivators within a set of interventions implemented in this project seemed positive, but outcomes are marginal and unclear. Bhutta et al. (2009) note that, even though there is a paucity of evidence on community health workers’ (CHO) impact on stillbirth outcomes, there is some evidence of the benefit of utilising community health workers to improve neonatal outcomes. Another community-based intervention targeting the delay of access to health facilities is the implementation of community loan or saving schemes. Costs for transport, treatment and drugs, as well as food and accommodation for relatives, have been found to present significant barriers to accessing quality health services. Loan schemes offer women with obstetric emergencies financial support to seek care. Loan scheme interventions can offer financial compensation for

Rapid Assessment of Interventions for Improving Maternal and Newborn Health, in Sierra Leone

transport only, or a variety of costs. Community loan funds are often managed by the community themselves, and financial input can come from communities themselves or partly from implementing organisations. An established loan fund in Bo, Sierra Leone, seemed to have increased womenâ&#x20AC;&#x2122;s utilisation of the referral hospital, but no conclusions can be drawn since data was not available on the operation of the loan fund itself (Fofana et al., 1997). The authors attribute the apparent success to the existence of strong leaders in the project chiefdoms. An established loan fund in Nigeria also does not provide concluding evidence of effectiveness, with improved access and reduced delay being assumed, rather than properly studied (Chiwuzie et al., 1997). The potential of emergency loan/insurance funds for emergency situations seems promising, but the studies done so far do not provide sufficient evidence for actual maternal and infant mortality (Bhutta et al., 2009). A similar intervention, community-based health insurance, also lacks empirical evidence on its effectiveness. However, Smith and Sulzbach (2008) suggest that CBHI may be a useful medium for increasing demand for maternal health services, particularly where the use of these services is low and for expensive delivery-related care. Similarly, the effectiveness, cost, scalability and sustainability of conditional cash transfers (that provide money to women on the condition that they use specific health services) or voucher schemes, whereby women are given vouchers that they redeem for specified services at participating health services, are unknown (Bhutta et al., 2009). Poor transportation and communication between health facilities and the referral health facilities where ambulances are stationed further delays access to maternal health care. One intervention that addresses this need for transport is the implementation of a functioning referral system. A project in Sierra Leone included the provision of a referral vehicle and a radio communication system (Samai & Sengbeh, 1997). Utilisation of the hospital by women with obstetric complications from the project area increased significantly, and the obstetric fatality rate decreased. However, there is no conclusive evidence that these improvements were attributable to the improvements of the referral system. The improvement of the referral system in a project in Nigeria, combined with the establishment of a community loan fund, also lacked evidence on effectiveness (Essien et al., 1997). Access to transport and funds â&#x20AC;&#x2122;may haveâ&#x20AC;&#x2DC; helped women make prompt decisions to seek and reach appropriate care. How many women would have received this care without the intervention is unknown. Another intervention targeting timely access to maternal or obstetric care is the maternity or birth waiting home. These homes have been used to address geographical barriers to accessing maternal health care and to address transportrelated problems faced by pregnant women in rural and remote areas. Maternity or birth waiting homes are often residential facilities located near a qualified medical facility to enable women to travel closer to services before they go into labour and wait there until it is time for delivery. Birth waiting homes can be selfcatering or completely catered for. Antenatal care is often easily accessible for women staying in a birth waiting home. Building costs of the facility can be covered by communities themselves, the ministry of health, or NGOs; running costs can be partly covered by user fees of fundraising projects coordinated by women in the facility. Several studies (in Cuba, Malawi, Nigeria, Papua New Guinea and Zimbabwe) have shown the effect of birth waiting homes on increasing facility births, decreasing maternal deaths and stillbirth rates, and reducing emergency referrals and complications during delivery. Other studies in Zimbabwe showed no significant difference in risk status, or perinatal and maternal outcome between women who stayed in a birth waiting home and those who did not and went to a hospital to deliver. The authors of a Cochrane Collaboration review on this subject note that studies mentioned above are limited in evaluating the effect of using birth waiting homes on maternal and

Rapid Assessment of Interventions for Improving Maternal and Newborn Health, in Sierra Leone

neonatal outcomes. The studies have significant potential for bias and should be interpreted with caution. For example, outcomes for the women who stayed at home are not known (Lonkhuijzen, Stekelenburg & van Roosmalen, 2009). 2.3.2 Interventions addressing perceptions of quality of care Receiving quality care when needed depends in large part on the health facility’s quality of service provision – when women reach it in time. Quality of care, the cause of the third delay in the delay model, is influenced by the quality of service delivered by the health staff (discussed below) as well as sufficient drug supply and proper health facilities with the necessary equipment. A project in Sierra Leone included the instalment of better qualified medical officers; sensitisation workshops for all staff and trainings on recognition and management of obstetric complications for hospital and PHU midwives and nurses; upgrading of the maternity operating theatre; drug and supply provision for the hospital and project area PHUs; and monthly incentives paid to all maternity ward staff (Leigh et al., 1997). Maternal admissions increased significantly, which the authors attribute to the improved reputation of hospital services in the community. Secondly, the number of women with complications dropped, as did the case fatality rate. The authors indicate that the largest increase in utilisation occurred as a result of improvement of medical personnel, rather than material upgrading of the hospital – even though the latter did lead to increased utilisation and decreased case fatality rate. A number of studies (Bhutta et al. 2009) indicate that in settings where doctors are unavailable, task-shifting to other cadres of heath workers to perform caesarean sections and neonatal resuscitation may be effective for reducing stillbirth rates. However, limited data is available on maternal, stillbirth and neonatal outcomes. 2.3.3 Role of Traditional Birth Attendants Attitudes, beliefs and practices increase risks for mother and newborn. An innate resistance to Western health services results in low attendance of antenatal and postnatal clinics and hampers facility births, which can be addressed by including TBAs in the maternal health care system (Konteh, 1997). Jambai and MacCormack (1996) argue for the collaboration between biomedical health care and traditional health care to reduce maternal mortality in Sierra Leone. TBAs have often assisted in more deliveries than MCH aides, while government-trained MCH Aides have knowledge about pharmaceuticals and other health techniques. Personal loyalty, familiarity and trust of women in the community positions TBAs to have better access to women, enabling them to mobilise women to support the MCH Aide. The potential of TBA training is promising, claim Bhutta et al. (2009), even though controversies exist concerning the best training methods. Between 1970 and the early 1990s the World Health Organization (WHO) promoted the training of TBAs to advance maternal and newborn health. Lack of evidence demonstrating that trained TBAs can reduce maternal mortality eventually led to controversy over their training in relation to safe motherhood and a policy shift to skilled birth attendance (Maine, 1993; Starrs, 1998; Bergstrom et al, 2001). In 1992, the WHO emphasised that, if TBAs were going to contribute to safe motherhood, they must be ‘integrated’ into the modern health system through training, supervision, and technical support. By 1997, the WHO and many safe motherhood advocates turned from TBA training to the promotion of skilled birth attendance for all, and called for a new and expanded role for TBAs, where TBAs act as ‘link workers’ to skilled birth attendants rather than as primary care providers (Tarnpol, 2005). Although there are many supporters of TBA training as a means of improving maternal and newborn health, the most recent Cochrane Review addressing this states that, ’After more than three decades of experience, the evidence to

Rapid Assessment of Interventions for Improving Maternal and Newborn Health, in Sierra Leone

support TBA training has been limited and conflicting.â&#x20AC;&#x2122; It further suggests (based on the results of a single study) that TBA training could possibly improve maternal health, but that this needs to be further explored. An important point brought up by the authors is that besides assisting during deliveries, TBAs can also fulfil an important support role for women during pregnancy and childbirth. This new role for TBAs still needs to be studied. 2.3.4 Other interventions that may affect Maternal and Newborn Health Interventions using performance-based financing (PBF) aim to improve the quality of health service delivery by providing financial incentives to individual health staff. Health staff dissatisfaction with salaries, poor housing conditions, poor water access and sanitation at the health facility, as well as poor staff access to the health facility and lack of professional training are all disincentives to good performance by health care providers. The current literature presents encouraging evidence for the effect of performance-based incentives in lowresource contexts to motivate health staff to improve service delivery performance. Nevertheless, to date there are few experiences with performance incentives in the Sierra Leone health sector. Canavan and Coolen reported a number of improvements in maternal health outcomes in Sierra Leone attributed to use of PBF, which contributed to increased deliveries at health facilities and to the reduction of caesarean section rates due to timely referrals. Moreover, PBF has proven to be a catalyst for improved coordination, transparency and accountability between different stakeholders, since PBF stresses the need to link the investment to results whereby health workers will become more accountable for performance at all levels. (Canavan, 2010) Particularly in settings where most maternal deaths occur at home, without opportunities for medical diagnoses, maternal death reviews or verbal autopsies can be used as a tool to identify the cause of death. This data can in turn help plan and evaluate health interventions. HĂ¸j, Stensballe & Aaby (1999) assess the effectiveness of verbal autopsies on maternal deaths that occurred in communities in Guinea-Bissau. The best procedure seems to be to interview the head of the family, while allowing him to consult with a group of women from the household. The interview should be held in the household where the women gave birth, rather than where she lived. Aggarwal et al. (2010) conducted a study to assess the validity of a verbal autopsy tool developed by the WHO for ascertaining major causes of stillbirths. Despite an overall diagnostic accuracy of 64 per cent, distribution of specific causes of stillbirth determined by hospital records are similar to those determined by verbal autopsy methods. This suggests that the WHO verbal autopsy tool can be confidently used in settings with similar stillbirth rates to the study area when planning plan public heath interventions. Both HĂ¸j et al. (1999) and Ronsmans, Etard and Walraven (2004) note that there is a scarcity of research on verbal autopsies in rural settings. Findings from hospital-based studies on validating the causes of death from verbal autopsies, such as those described by Aggarwal et al. (2010), cannot be easily extrapolated to stillbirths at home. Ronsmans et al. (2004) stress that while verbal autopsy was initially seen as a method to assess the magnitude and medical causes of maternal death, it is now used more widely to provide information on medical and nonmedical causes of maternal death. Due to the lack of reliability in the verbal autopsy method, its use for precise quantitative comparisons should not be overestimated. Promotion of family planning in countries with high birth rates has the potential to avert 32% of all maternal deaths, claim Cleland et al. (2006). Family planning services can be offered at health facilities and at commercial outlets, and advertised through social marketing or through outreach and community-based provision. Outreach and community-based family planning services have proved

Rapid Assessment of Interventions for Improving Maternal and Newborn Health, in Sierra Leone

to be most useful in rural communities where access to other services is limited, where demand is fragile and when womenâ&#x20AC;&#x2122;s mobility is constrained. Key lessons from African experiences are that multipurpose workers are more effective and accepted than providers focused on family planning only. Community involvement in the design of projects and worker selection is essential, and payment is necessary to sustain effectiveness. More research is needed on the effectiveness of issues such as extended counselling about method choice or probable side effects, as well as follow-up visits in communities. 2.4 Mapping of interventions by NGOs in Sierra Leone Prior to carrying out this study, an extensive mapping of interventions implemented by NGOs in Sierra Leone and relating to maternal and newborn health took place (Herschderfer et al., 2010b). The preliminary results were presented at a stakeholdersâ&#x20AC;&#x2122; workshop in February 2010 for validation and a prioritisation exercise. The discussion that took place during this workshop helped inform the design on this rapid assessment. Annex 1 shows the overview of interventions mapped in themes according to district where they are being implemented.

Rapid Assessment of Interventions for Improving Maternal and Newborn Health, in Sierra Leone

3 Purpose and objectives The purpose of this study is to contribute to the development of a package of interventions that will assist the MoHS to optimise the design and implementation of strategies to improve maternal and newborn health. The specific objectives of the study are to:  describe the factors influencing health seeking behaviour and practices related to accessing and utilising maternal and newborn health care;  identify selected innovative and promising practices and the effects as perceived by the community and the providers of care;  develop and present recommendations for an action research that will implement and test the effectiveness of interventions, using existing promising practices, to improve maternal and newborn health care that is context-specific to Sierra Leone;  disseminate the results nationally and internationally;  help build research capacity and collaboration with local stakeholders in Sierra Leone. 3.1 Conceptual framework Increasing emphasis is being placed on an approach to maternal and newborn health which looks at the care that needs to be provided along the entire reproductive life cycle. Kerber et al. (2007), among others, expand on the importance of the continuum of care as a model behind maternal, newborn and child health interventions. The continuum can be defined over the dimension of time (from before pregnancy, through pregnancy and childbirth, to post-natal and child care), and over the dimension of place or level of care (family and community care, outpatient and outreach services, and health facilities). Synergistic connections between these three delivery approaches are essential, since none of them are sufficient on their own (Kerber et al. 2007). The ‘three delays’ model is one such comprehensive approach to MNH. It is one of the most widely implemented models in maternal health programmes. As summarised by Canavan (2008), this model developed by Thaddeus and Maine in the 1990s revolves around three major factors that contribute to maternal mortality: 1. 2. 3.

Delay in recognising complications and deciding to seek care; Delay in reaching a treatment facility; Delay in receiving adequate care and treatment at the facility.

The research has adopted the continuum of care approach to explore factors influencing health seeking behaviour and delays in seeking care within pregnancy, labour and delivery, post-partum care and neonatal care. For the purpose of this framework, we have added family in the context of decisionmaking. An adapted version of the three delay model was the main conceptual model that informed the development of the instruments and the framework for analysis. See Figure 1 below for the adapted framework.

Rapid Assessment of Interventions for Improving Maternal and Newborn Health, in Sierra Leone

Figure 1: Conceptual framework Conceptual Framework for assessing promising interventions What interventions are Socio-economic factors influencing the decision to seek Cultural factors care? Perceived accessibility Perceived quality of care Have the interventions influenced the decision to seek care? What interventions address accessing the facility? Have the interventions influenced the actual accessibility? What interventions address receiving adequate treatment? How effective are they?

Actual accessibility

Actual quality of care

Illness related factors Socio-legal factors Gender relations Distance, transportation, costs Reputation or previous experience Satisfaction with outcomes, treatments and prescribed remedies Satisfaction with service Distribution and location of health facilities Distance, transportation, costs

Poorly staffed facilities Competence of personnel Poorly equipped facilities Inadequate management

Rapid Assessment of Interventions for Improving Maternal and Newborn Health, in Sierra Leone

4 Methodology This study used an exploratory, analytical qualitative research design to allow for in-depth exploration of factors influencing health seeking behaviour for maternal and newborn health and the effect, as perceived by the users and providers of care, of interventions implemented by the MoHS or NGOs, or a combination of both, in Sierra Leone. The study looked at access, availability, quality and other factors influencing utilisation of government health facilities across the study communities, whether NGO-supported or not. It explored traditional beliefs and practices and identified interventions for improving MNH. 4.1 Selection of study sites The research sites were purposely selected to ensure that they reflected the criteria for selection which were identified by the stakeholders during the mapping and prioritisation workshop mentioned in the preceding section. The criteria that determined the selection of research communities were: ď&#x201A;ˇ variations in types of promising practices being implemented by different NGOs;1 ď&#x201A;ˇ geographical distribution of communities; ď&#x201A;ˇ communities with and without health facilities. The chiefdoms and villages with and without facilities were selected based on information provided by government and NGO staff who were well-informed about where interventions were or were not being implemented. For an overview of the selected districts, chiefdoms and villages selected, see Annex 2. 4.2 Data collection techniques and respondents For an overview of issues to be explored, data collection techniques and respondents see research table in Annex 3. Each data collection technique, including issues explored, type of respondents and the recruitment process, is presented under the heading of the technique used. The selection forms a purposely selected sample to ensure that the respondents are knowledgeable about the issues and represent the various characteristics that are relevant to cover variety of opinions, perceptions and practices. 4.2.1 Semi-structured interviews Managers at district level, those in charge of facilities, chiefs, mammy queens, health management committees, health care providers including TBAs, community elders and other key and knowledgeable informants were interviewed to identify the factors that influenced the development and implementation of promising MNH activities. The objective was to gather information on the context of services provided and to provide insights into factors influencing health seeking behaviour and practices. Selection and recruitment for semi-structured interviews Stakeholders who participated in the mapping and the selection and prioritisation of interventions identified key stakeholders at the district level who were subsequently recruited by letter and/or personal contact by the researchers. Community member key informants were recruited by knowledgeable persons in the community during the data collection. 1

The variation in type of interventions was based on the conceptual framework adapted from the three delay model presented above.

Rapid Assessment of Interventions for Improving Maternal and Newborn Health, in Sierra Leone

4.2.2 In-depth interviews In-depth interviews (IDIs) were conducted to explore decision-making about care during labour and delivery, actions and care received during the continuum of care for maternal and newborn health, and reasons for these actions. A Venn diagram was used to visualise the relative importance of decision-makers. A timeline was used to visualise what happened during the following phases: pregnancy, delivery, post-partum care, neonatal care and post-delivery family planning. See pages 18 and 19 for examples of a Venn diagrams and Annex 4 for an example of a birth timeline Recruitment and selection for in-depth interview Women who had given birth to at least two babies and with an interval of at least two years between the last two babies were selected for IDIs. At the end of the focus group discussions (FGDs) with women, the researchers asked women who were willing to participate in the IDIs and who fulfilled the criteria to form a group. The researchers then selected from this group the people who would participate in the IDIs. They selected women from different parts of the village, women with variation in clothing, and some women who spoke more and some who spoke less during the FGDs. To ensure the inclusion of women who delivered outside the health facility, the researchers, who stayed for a few days in the village, asked informally about women who delivered at home and approached them to consent to the IDI. To ensure the inclusion of women with complicated deliveries, the health providers and TBAs were asked to identify women who had had complications during delivery. 4.2.3 Focus group discussions and other participatory methods FGDs were conducted with younger and older men and women from the community to get insight into agreements and disagreements about factors influencing health seeking behaviour and practices. A diagram was made during the discussion that summarised the various actors and criteria mentioned during the discussions. Recruitment and selection for focus group discussions When possible, knowledgeable persons helped with the selection of FGD participants. These knowledgeable persons were women and men who knew the community well and were respected within it. In order to avoid coercion into taking part in the interview, the knowledgeable persons were not in a position of authority. Selected FGD participants had to be one of the following: 1) pregnant women and mothers 2) men who were fathers 3) youth between 18 and 35. Each group included people from different societal groups in the community. FGDs were held for men and women separately, while the youth groups were mixed. Assessing services A questionnaire was used to assess services/staff competencies; a checklist was used to assess the supplies and equipment in stock. During the training of

Rapid Assessment of Interventions for Improving Maternal and Newborn Health, in Sierra Leone

researchers, the instruments were adapted from the existing WHO package for the assessment of maternal and newborn care services. 4.3 Data collection process and management The research team consisted of four researchers (one female and two male university lecturers from Foray Bay college, University of Sierra Leone, and one female international researcher from KIT), and four male and two female research assistants (selected from ten participants in the methodology training and the first field visit). The research team stayed for two to three days and nights in each chiefdom, in order to familiarise themselves with the village’s infrastructure and facilities, to have informal conversations with community members, and to place the collected data in context. In each village a summary of the first rough analysis was presented and discussed with the community. The data were collected just before the rainy season in March, April and May 2010 All data included in the analysis were transcribed and translated into English by the data collectors. Eight randomly selected transcripts were checked for consistency by translators at the Linguistics department at Fourah Bay College, University of Sierra Leone. They also re-translated incomplete transcripts. All transcripts were coded by two researchers and entered by one research assistant into Atlas-ti computer software for qualitative analysis. 4.4 Data analysis Data analysis took place in two analysis workshops involving most data collectors, three additional social scientists from the University of Sierra Leone, and two international facilitators experienced in qualitative analysis. The coding framework was developed in two phases. First, all data collectors read their own transcripts and presented the most important issues emerging from them. Secondly, all transcripts were read in small groups. A coding scheme was developed in plenary that was based on the conceptual framework, the continuum of care and the issues emerging from the first reading. A second workshop was held with summaries from the preliminary Subsequently, analysis matrix sheets various sites, and relevant data from techniques was triangulated.

all stakeholders to present the data analysis to validate the outcomes. were used to analyse data across the various respondent groups and various

4.5 Quality assurance The investigators were selected based on their ability to facilitate group discussions and conduct individual interviews as well as their ability to speak a local language in addition to English. They received a five-day training consisting of introduction to the protocols and the techniques, including role plays to simulate the various settings they would find themselves in, and a field trial. The data collectors were supervised in the field by three tutors from the University of Sierra Leone and the KIT researcher. The validity of the data was assured by feedback sessions to the community at the end of the research, using triangulation and ‘member checking’ (validation by stakeholders). The latter took place during a stakeholders’ workshop aimed at informing and disseminating the study’s preliminary findings.

Rapid Assessment of Interventions for Improving Maternal and Newborn Health, in Sierra Leone

Care was taken during reporting that individual respondents or, if relevant, geographical areas could not be identified. For this reason, quotation identifiers do not always provide geographical details. 4.5.1 Capacity strengthening and stakeholder involvement An important component of the research was the collaboration with researchers and research assistants from the University of Sierra Leone. Various training workshops were held to share expertise and develop skills in data collection and analysis, and on-the-job support was provided in order to carry out the field data collection and analysis. The knowledge, experience and skills of the individuals concerned provided valuable insight sharing and capacity building for everyone involved. Three training workshops were held to:  develop the instruments and train data collectors;  carry out preliminary analysis, including the introduction of the Atlas-ti analysis software;  finalise data analysis. The following stakeholder workshops and meetings were held.  Introduction of stakeholders to the research study.  Validation of the mapping of interventions implemented by NGOs for the improvement of maternal health.  Development of the criteria for selection of study districts and communities.  Validation of the preliminary findings by NGO field officers and stakeholders.  Dissemination and discussion of the final results and their implications. 4.5.2 Ethical considerations Ethical approval was obtained from the KIT Research Ethics Committee and the Sierra Leone Ethics and Scientific Review Committee on 12 January 2010 and 12 February 2010 respectively. In all cases, the data collection started after information about the study was provided. A standardised consent form was used to obtain permission/consent from the respondent. No personal identifiers of respondents were recorded and all data were kept in a locked cupboard or on the computer that could only be accessed by the lead researchers. The researchers arranged with the local health workers to refer respondents who needed more information and/or counselling after the interviews. In a few cases, health information activities took place after the data collection in response to questions from the respondents. In one case, a respondent was referred to the health facility for treatment. 4.6 Study limitations Limitations inherent in the study design The study design is specific to this particular project and is tailor-made for a rapid assessment. The study as planned was able to capture in-depth information that is representative for the variety of perceptions and practices. Given the use of a qualitative research design, and the sampling that is appropriate for such a design, the results cannot be generalised as proportions representative of the study population. Limitations of study

Rapid Assessment of Interventions for Improving Maternal and Newborn Health, in Sierra Leone

In general, respondents were willing to invest their time and spoke openly during the interviews. There were, however, a number a number of times that topics were considered ‘not open for conversation’ and this was respected by the researchers. Speaking about delivery is regarded a ‘secret’ issue and, especially details of traditional practices during delivery was not always openly spoken about. The male researchers were aware that this constraint may be exacerbated by their sex. In most cases, they were accompanied by a female researcher – not all of whom could speak the language fluently. In most cases the interviewers were able to establish a trusting relationship. Although in some interviews this was not the case, we are confident that the information obtained from the interviews reflects reality. We were unable to carry out IDIs with elders from the women’s society due to non-consent or refusal to fully answer the questions. This means that detailed information on traditional education about pregnancy and delivery is limited. Two important themes that emerged from the data were the issues of adolescent pregnancy and gender-based violence. As these issues were not systematically studied we cannot report on the results, but feel that they should be included in future studies. Systematic assessment of skills and facilities did not take place in all facilities. For this reason, the results are not representative for the facilities included in the study. They do, however, provide an insight into some practices. One of the aims of this study was to analyse facility coverage data in order to see if differences in facility uptake could be related to factors such as NGO support, type of facility, types of interventions, etc. This was unfortunately not possible due to missing and unreliable data.

Rapid Assessment of Interventions for Improving Maternal and Newborn Health, in Sierra Leone

5 Results A total of 5 districts (Koinadugu, Tonkolili, Bo, Kenema and Bombali), and 14 villages were identified based on the criteria. Data was collected and analysed from the following sources: 17 FGDs with women, men or mixed groups of youth, 29 SSIs with key informants, 27 IDIs with women, 34 Venn diagrams to map out decision-making authority and relationships, and 42 birth timelines. Furthermore, 5 health facility assessments and 6 provider skill assessments were conducted with health facility staff. For an overview of the number of techniques used and the types of respondents in each district see Annex 5. Response frequency is generally not reported because they could be interpreted as proportions despite the qualitative design and the purposeful selection not supporting this in any meaningful way. However, we will indicate how common or rare perceptions were where relevant. The analysis will also use terms such as ‘a few’ or ‘some’ for less than half, and ‘many’ or ‘a majority’ for more than half, and ‘all or almost all’ to indicate how common a response is. For a few crosscutting analysis results, numbers of responses will be used illustratively. Quotes are reported along with the type of technique used, type of respondent and the district recorded between brackets. Other specific identifiers have not been reported in order to ensure the anonymity of the respondents, especially when the subject of the quote is of sensitive nature. For example, statements about family planning or abortion could have repercussions for women in the area concerned. An overview of the NGO-supported interventions identified in the study communities by type of health facility can be found in Annex 6. 5.1 Decision-making about care before and during delivery Data regarding decision-making about delivery were obtained through Venn diagrams (see Figure 2, below) made by the woman during IDIs. The circles made in the Venn diagrams were translated into a rank and are presented in Annex 7. In addition, information about what decisions were made by whom and in which topic areas was obtained through IDIs, SSIs and FGDs Figures 2a and 2b: Examples of Venn diagrams

Rapid Assessment of Interventions for Improving Maternal and Newborn Health, in Sierra Leone

5.1.1 The role of the husband The results are reported in relation to decision-making regarding pregnancy in general, childbirth and family planning. In most cases, women ranked the husband as primary decision-maker; some ranked the husband as second or third most important decision-maker. The importance of the husband is often linked to either the in-law family or the woman’s family, and sometimes to both. In Koinudogu, Kenema, Bo and Yele, when labour pains start the pregnant woman calls on the women closest to her, such as her mother, friends, mates (co-wives), and sisters-in-law. In Bombali and Yeben the in-law family emerges as more important. This was also confirmed by the FGDs and the SSIs, as is illustrated by the following quote: ‘The man has the power to decide because he provides the money.’ [SSI, male community leader, Koinadugu] In most cases the woman in labour ranked herself as less important than others. In a few cases she did not rank herself at all. A woman gains some decision-making power about where to go for a delivery if she has her own income or savings but the husband still has the power to overrule such a decision, as is illustrated by the following quotes. ’The husband decides. If he doesn’t have money, the woman can take from her savings and go to the hospital or the grannies.’ [SSI, male community leader, Bombali]; ‘The women may decide for herself if the husband is not around.’ [SSI, TBA, Bo]; ‘The woman may decide for herself but if the man thinks she has made a wrong decision, he is at liberty to change it.’ [SSI, male community leader, Tonkolili] A clear exception to the husband being named as the most important decisionmaker was noted during FGDs and IDIs with women in Kenema. Although TBAs and other key informants saw men as decision-makers, the women generally viewed men as the ones who need to be informed and who pay, but not necessarily as decision-makers. Women’s agency is clearly expressed in the following quotes. In answer to the question who decides: ‘I decide for myself.’ [FGD women, Kenema] And in response to the question of what the woman would do if her husband suggested that she go to the TBA rather than the health facility: ‘I won’t do it. I will go where I deem it is safe for me. [...] Men normally leave this decision to the women.’ [FGD, women, Kenema] The Venn diagrams show that in places with a CHC, nurses are mentioned

Rapid Assessment of Interventions for Improving Maternal and Newborn Health, in Sierra Leone

more often than TBAs as decision-makers and are ranked higher. Especially in Kenema, nurses are ranked high. In places with a MCHP no difference is found, and in places without a PHU, TBAs are mentioned more often than MCH Aides. See Annex 7for an overview). The outcomes of the Venn diagrams are confirmed by the data obtained from IDIs, FGDs and SSIs. With a few exceptions, the husbands are reported as the most important decision-makers in all areas. The most important role of the husband is to finance care. The following quote illustrates not only the relationship between decision-making and control over resources, but it also reflects men’s strong feelings about ownership of women. In answer to the question about who makes decisions about delivery and care the following answer was obtained: ‘It is the head of the home, which is the man because he owns the woman and he is the one who spends his money.’ [FGD, men, Tonkolili] The power relationship and exchange between men and women shows the vulnerable position of some women and the power wielded by the husband through resource controlling. The following quotes from a youth FGD show the perceived importance of the work provided by pregnant women in return for the payment for care: ‘While we are pregnant our husbands expose us to difficult and hard work. [...] They threaten not to do anything for us if we have a financial matter to settle.’ [FGD, youth, Bo]. Another woman in the same group added: ‘What I think is this. If I have a husband and [...] I get pregnant. At this time, if I ask him for anything, he will not give it to me. He will insist that if I do not do the work he has set aside for me he will not solve any problem.’ [FGD youth, Bo] 5.1.2 Other decision-makers regarding childbirth The elderly women and the TBAs in the village decide what the husband pays for and when he pays it. Labour and delivery is women’s business and most men follow their advice. The men generally feel that they are not knowledgeable in this area. The following quote illustrates common responses from both men and women: ‘It is not for the husband to know such things. […] My sisters were more important and they would communicate the decisions to my husband. Also, my husband normally accepts decisions made by my mother-in-law, the [TBA], my aunt....’ [IDI, woman, Bombali] The importance of elderly women that emerged from all IDIs, FGDs and SSIs is illustrated by the following quote: ‘It is an elderly person in the family – the one who has experience in child birth. The men hardly make such decisions. They rest with the women.’ [SSI, man, Bo] The following quote from a youth FGD illustrates how young men learn to cope with the contradiction of having to be in charge whilst not having the knowledge and insights on which to base decisions: ‘When suspicious things are happening in the home, you will observe the way the women cluster and behave, you will make the decision. If you see the women making anxious movements together with the [TBAs] you will ask them to proceed to the hospital.’ [FGD, youth, Bo] TBA, on decision-making during delivery: ‘She decides for herself. Nobody tells her where to go. She goes off to the [TBAs] and if they can’t see her through, they will tell the man that there is no option but to refer her to Kamakwie hospital.’ [SSI, TBA, Bombali] However, refusal on the part of the husband to give permission may happen

Rapid Assessment of Interventions for Improving Maternal and Newborn Health, in Sierra Leone

and can lead to serious delays and harm to the woman: ‘If the man as the decision-maker and money-provider refuses permission, this leads to serious problems. The man could withdraw support and responsibility [...] the quarrel could lead to suffering, delay and perhaps the death of the woman.’ [SSI, female community leader, Bo] ‘Those who refuse to reveal the pregnancy to their husband or relations may end up having problems: they won’t be able to attend clinics, because the providers of finance are not aware of the problem. By the time they become aware, things might have gone wrong with the women that may result in a serious problem during delivery.’ [FGD, youth, Tonkolili] Men are increasingly pushed by health staff to enable their wives to visit ANC and deliver in a facility. ‘There are some women who will never go to the clinic [...] simply due to money and neglect by the husband. The [TBA] will then make a move and report the matter to the [CHO] who invites the husband and asks him why he shouldn’t provide money for his wife’s treatment in a clinic. They threaten the husband that they will take him to the police if he fails to provide funds for his wife to go to the clinic.’ [SSI, TBA, Koinadugu] In a few interviews, women described the support they received from their husband. One woman indicated her husband as the person she confides in and who supports her: ‘Even the day I experienced labour pain for the twins, he was with me in our room. He encouraged me to be patient until the time of delivery came.’ [IDI, woman, Koinadugu] 5.1.3 Decision-making about family planning Decision-making among women is most clear in their practices around family planning. Generally speaking men claim the control over fertility and family planning. Many women in all villages strongly indicated that they secretly go against the decisions of husbands not to use family planning. In many interviews and in all areas, husbands base their decision on fear of infidelity, or else they justify their refusal to take family planning on a mixture of religious grounds and what they see as their right, as is illustrated by the following quotes. ‘Women are not allowed to use family planning methods because the husbands say it is a free ticket to practice infidelity, and since the husbands do not agree they do it in secrecy.’ [IDI, woman, Kenema] ‘Most people are using family planning now. Earlier, our grandmothers used to have many children but that has changed now. Even I used to take the injection, but my husband didn’t like it so I used to hide to take it.’ [IDI, woman, Kenema] ‘I do not like family planning. As long as God gives me children, I will produce them, whatever their number. Tomorrow they will replace me, when I am dead.’ [FGD, man, Koinadugu] In a few interviews the women said that they made the decision to use family planning together with their husbands. In one instance the advice of the doctor was seen as very important. However, it did not last as long as the woman wanted, as is illustrated in the following quote: ‘He is aware [of my use of family planning] and he agreed because after the miscarriage the doctor advised me to join family planning for a while. But it only lasted two months. Now we have started having conflicts about it because he wants me to give him another child.’ [IDI, woman, Bombali]

Rapid Assessment of Interventions for Improving Maternal and Newborn Health, in Sierra Leone

The pressure on women to produce more children than they want leads to agony and to abortions that are carried out in various ways, as is illustrated by the following quotes from an FGD with women in another community in Bombali: ’If I get pregnant unexpectedly, I would have no another option but to give birth to the child.’ Another woman responded with: ‘I would use native herbs to get rid of a pregnancy.’ Other members of the group agreed that most men treat women badly when they are pregnant and that this is the reason they choose abortion: ‘I do not intend to have another pregnancy yet. But if I do, I will get rid of it.’ 5.1.4 Decision-making about neonatal care Decision-making about neonatal care and childcare was not explored in the same depth as the above issues. However, men often mentioned spontaneously how they observed the child and made sure it went to the clinic if the child was not well. In the interviews the statements showed not only their concern about the child but also the idea that they had to control their wives in this regard: ‘I will make sure that [my wife] goes with the baby every week for treatment and always observe the baby’s health throughout the three months after delivery.’ [FGD, men, Tonkolili] The rest of the FGD agreed with this statement. ‘[The mother] feared that she was going to spend a lot of money,’ but she was eventually, ‘forced by her husband to take the child to the clinic.’ [SSI, health management committee member, Tonkolili] 5.2 Knowledge beliefs and actions The data collection on knowledge beliefs and actions concentrated on normal signs and danger signs during the continuum of care, the beliefs that were associated with these signs and the actions that were taken to address the danger signs. Almost all detailed information about normal signs comes from IDIs and FGDs with women. At men’s FGDs, the participants were able to come up with general signs they noticed based on their experiences and observations. Often they referred to the pregnancy and delivery as ‘women’s business’ but still had lively conversations about what they knew about the issue. Throughout the study areas, normal signs of during pregnancy, labour and delivery were mentioned without probing. Danger signs during pregnancy, delivery, directly post partum and related to the newborn baby are generally well-recognised by the women and the TBAs in all areas. Male key informants and some men in the FGDs were well-informed. Men repeat what they have heard and have gathered from observations. When women are around, men tend to defer to the woman present, as was the case during some of the key informant interviews. 5.2.1 Normal signs and actions during pregnancy In general, throughout the study areas and amongst women, men and youths, there is sufficient knowledge about the normal signs of pregnancy. The signs most frequently mentioned were missing a menstrual period, loss of appetite/change in appetite, weakness/tiredness, and vomiting. Fever/rise in temperature is mentioned by many women and some men as a sign of pregnancy. An increased desire to have sex was mentioned by some men. Women who already have given birth before, see the following signs as confirmation of their pregnancy.

Rapid Assessment of Interventions for Improving Maternal and Newborn Health, in Sierra Leone

‘First, I started to experience fever and I also lost my appetite. In addition to this, I lost my menses. All these signs led me to the conclusion that I am pregnant.’ [IDI, woman, Bombali) ‘Missing my period would make me realise if I’m pregnant, and when the symptoms start – feeling sick, vomiting, running a temperature, weakness – I don’t eat.’ [FGD, youth, Bo] ‘I didn’t have any appetite for good food; the only food I had an appetite for was liquid food with plenty of pepper. That’s how I realised I was pregnant.’ [IDI, woman, Koinadugu] Men generally named the same pregnancy signs as women but one early sign of pregnancy mentioned sometimes by women: a rise in body temperature and often described as fever, was mentioned by most of the male respondents. The following observations were shared by men in the FGD in response to the question of how they know their wives are pregnant: ‘My wife normally tells me when she is pregnant, she feels general body weakness [...] she misses her period.’ Another man in the same group continues, ‘We know from the rise in their body temperature, weakness, vomiting. Normally we have sex once in a while, but if my wife starts calling for more sex then I will know that she is pregnant.’ [FGD, men, Koinadugu] When asked how they notice pregnancy in women, TBAs generally mentioned the same signs, with the addition of some specific symptoms not mentioned by others: ‘As soon as women get pregnant the eyes become pale, the pulse under their throat beats faster, their faces become pale, and vomiting takes place. All these signs signify that a women is pregnant. Some lose their appetite and prefer to eat sour food. Also, their nipples become black.’ [SSI, TBA, Koinaugu] Confirmation of pregnancy Women who have given birth before are usually unconcerned by the signs that they are pregnant. A woman in Kamawonie put clearly into words the thoughts of many other women who see signs specific to pregnancy as something temporary and normal, and they do not take immediate action when these signs appear. Most women mentioned the absence of menses as a sure sign of pregnancy, along with various other signs: ‘I had a loss of appetite. I experienced weakness. I had to spit a lot and I ate a lot of kola nuts and black mint.’ When asked what she did after experiencing these signs she replied: ‘I didn’t go anywhere. I just manage with these signs till the pregnancy was three month old.’ [IDI, woman, Bomabali] Another woman said: ‘I wasn’t afraid because I knew that all these things were happening to me because of my pregnancy.’ [IDI, woman, Koinadugu] In the communities in close proximity to a PHU, women often sought confirmation of pregnancy from the staff at the medical facility. One woman summed up her signs of pregnancy: ‘Each time I have been pregnant I fell sick. I vomited and lost my appetite. So that is how I’ll know I am pregnant.’ And when asked what she did after noticing these signs, she responded, ‘I went to the clinic. [...] I was checked and the nurse told me I was pregnant and that the pregnancy was a month old.’ [IDI, woman, Tonkolili] Another woman, when describing the signs of her pregnancy said: ‘I was vomiting frequently so I rushed to the nurse at this health facility. I came and explained how I was feeling. [...] She checked me

Rapid Assessment of Interventions for Improving Maternal and Newborn Health, in Sierra Leone

and asked me to do a pregnancy test and confirmed I was pregnant, so she put me on medication to stop the weakness and vomiting.’ [IDI, woman, Kenema] In some communities women take a more traditional approach to confirming pregnancy. One women told that after experiencing signs of pregnancy, ‘I told my husband and he said we should go to the [elder women] so they could confirm if it was true.’ [IDI, woman, Bombali] In the same village, another woman consulted with her own mother to seek confirmation: ’The first symptom I observed was that I started to experience slight fever. I told my mum about it and she told me that it I might have conceived, but I didn’t believe her. This was followed by slight changes in my physical condition.’ [IDI, woman, Bombali] First-time mothers tend to feel more insecure than other mothers, and the confirmation of pregnancy becomes a series of events over a period of time as the pregnancy becomes visible, as demonstrated by the following story from a young first-time mother to be: ‘To start with it was my first pregnancy after becoming a mature woman, so I didn’t know. At first I felt like vomiting. Sometimes I had fever and I felt very hot at other times, too. So I told an elder woman and she told me to hold on for two months. And in the third month, we went to a TBA and she checked me to be sure, because I didn’t know. I had no idea of what was going on. The TBA told me that I was pregnant and that we should take care of it, and she gave me some herbs. I also told my mother and she said we should take care of it and so should my sisters. After some time, we went to the TBA again for a check-up. At four months, I told my husband that I was pregnant and he gave me some money to go to the clinic. So I went to the clinic and the nurse checked me and told me that I was pregnant.’ [IDI, woman, Bo] Sources of knowledge about pregnancy signs There are a number of sources of knowledge about pregnancy signs mentioned by all the types of respondents. These include information from family and community and information from providers of care, including TBAs. A change over time was signalled, as shown by the statement given by a man during a focus group discussion. He was asked how they knew about the pregnancy signs they had mentioned: ‘We were told by the nurses at the clinic. Before, when the [PHU] wasn’t here, we went to the [elder women] and told them and they gave herbs as a cure.’ [FGD, men, Koinadugu] 5.2.2 Normal signs and actions during delivery Signs indicating the beginning of labour were rarely mentioned by many of the respondent groups. However, the signs that indicate that delivery is near were mentioned in most of the interviews with women, including TBAs. These signs included severe waist and stomach pain, back pain, bloody show, loss of amniotic fluid, and shivering. At an FGD, women were asked what things had to happen for them to conclude that delivery was imminent. One woman responded: ‘When the pain starts, there comes a period we know here as, ”the pregnancy wounds you”.’ When asked to clarify this, she continued: ‘When the pain starts, there comes a time when you start to bleed and water flows out.’ [FGD, women, Kenema]

Rapid Assessment of Interventions for Improving Maternal and Newborn Health, in Sierra Leone

When asked how they knew that a woman had almost reached the delivery stage, one TBA responded: ‘When a small amount of blood shows in some women’s vaginas or when the [waters break] and also when they experience serious stomach pain and waist bone pain: all these are signs that the delivery time is approaching.’ Another TBA responded: ‘When a woman produces a voice like a goat, that means the child is closer to coming out.’ [FGD, TBAs, Tonkolili] 5.2.3 Danger signs and actions during pregnancy The term ‘danger sign’ is well-understood as relating to the danger to the health of a mother and baby. People in all communities had been exposed to information in one form or another, in a similar way as for the normal signs mentioned above. A common danger sign during labour mentioned by the women and men was the stopping of the movement of the baby: ‘Normally, a pregnant woman should experience foetal movements, but if there is no movement then there is cause for concern. And usually, this movement should happen between four and nine months.’ [SSI, male community leader, Koinadugu, supported by elderly woman] When asked what danger signs they were aware of pregnant women having displayed, respondents frequently mentioned anaemia, swollen feet and face, bleeding during pregnancy and vaginal discharge: ‘swollen feet and face [...] when you have whitish hands it shows lack of blood.’ [FGD, women, Tongo] ’Pregnant women should not bleed because if this happens the pregnancy will abort. [...] Some women expel bad water that is smelly.’ [FGD, women, Tonkolili] Men shared experiences they observed in their wives and others: ‘When my wife was about six months pregnant her private parts were itchy. I took her to the clinic [...] and he told the two of us to take treatment.’ [FGD, men, Tonkolili] Swollen feet and face are mentioned as danger signs and convulsions were mentioned as abnormal but the cause of convulsions is ascribed in all research areas to the devil rather than to high blood pressure. The following quotes illustrate this: ‘I was attacked by a devil.’ What do you mean you were attacked by the devil? ‘My body just went stiff.’ [FGD, women, Kenema] People seek assistance for convulsions both in the traditional way and at the clinic, as is illustrated by the following quote: ‘She had the fit attack in her village. They kept her the whole night because she looked like she was going to die. The next day they brought her [here, to the MCHP]. I told her that she was not due to give birth yet, but that because of her condition we should call an ambulance. [...] They did not give me clearance to do that. Instead, they went to see a native doctor… the woman died before the ambulance got here.’ [SSI, maternal and child health aide, Bombali] Another health care provider told of a young girl with eclampsia who was treated traditionally before coming to the facility: ‘On the day they brought her to me, her blood pressure was 150/100. I did my intervention. When the paramount chief sent for me, they snuck away with the girl [...] and later brought her back again. By the time I was able to intervene she had started vomiting. I did all I could but she died.’ [SSI, community health officer, Tonkolili]

Rapid Assessment of Interventions for Improving Maternal and Newborn Health, in Sierra Leone

Swollen feet are viewed differently from convulsions. For convulsions the traditional healer is called. However, swollen feet may be helped by giving herbs or not eating too much salt: ’Well, in this community, our people say it is bad water [signalled by swollen feet and face] and this water can be in the [womb] and this can lead to still birth. This water can cook the baby and cause the death of the baby. Our people know the herb called sawey. They prepare the sawey for the pregnant woman to drink so that all the bad water in her system will drain away. Swollen feet during pregnancy are called Mahoi–Manopi.’ [SSI, male community leader, Bombali] One key informant associated swollen feet with malnutrition and was concerned about the hard work women carry out whilst pregnant: ‘Swollen feet are caused by malnutrition – women in this village do not eat a balanced diet. The other problem is that during pregnancy they expose their bodies to cold environments, such as when they do weeding in the rain. They do strenuous work, carrying heavy loads on the farms when processing palm oil. And they walk up steep hills to their farms. This hard work may induce bleeding that may occur during month two or three of their pregnancy.’ [SSI, health management committee member, Tonkolili] Some respondents, both male and female, mentioned their concerns about the taking of native herbs during pregnancy and the belief that herbs may harm the pregnancy. The following illustrates this: ‘These are some of the dangerous things that our partners do: some pregnant women drink too much native herbs, and this sometimes destroys their pregnancy or even gives the pregnant woman a serious infection.’ [FGD, men Tonkolili] Causes of problems during pregnancy The TBAs in Tonkolili summarise the main problems of expectant mothers mentioned by respondents as: ‘persistent fever or malaria’, ‘the carrying of heavy loads and the potential threat of miscarriage’, ‘husbands beating up their pregnant women’, and ‘lack of good care during pregnancy’. Violence during pregnancy was not systematically explored but spontaneously mentioned by women during the FGDs in Bo, Bombali and Kenema and by some of the TBAs in other districts. Violence is often perceived as inevitable if the woman, ‘wrongs the man’. [FGD, women, Kenema] The following case report from a FGD in Bombali demonstrates how powerless a woman can feel. ‘My husband beat me while I was pregnant. I was slapped and kicked on my back and I had a stillbirth when I delivered, and I believe I had the stillbirth because of that merciless beating’. According to the interviewer, the woman was angry and emotionally charged when expressing this and the other women showed by their expressions that they did not approve of her describing this incident during the interview. The woman continued her story and told that after the beating ‘I went to the chief. [My husband] was fined and told to take care of me and we returned home. But even now I am not satisfied with that decision, but what can I do? He is my husband.’

Rapid Assessment of Interventions for Improving Maternal and Newborn Health, in Sierra Leone

5.2.4 Danger signs and actions during delivery and post-partum In all areas, bleeding, delay in the delivery of the placenta, abnormal presentations such as the baby coming out hand-first or feet-first were recognised as danger signs: ‘Some of us bleed profusely after delivery which can be very dangerous.’ Also, ‘Some women have problems after giving birth. Some get paralysed.’ [FGD, women, Mabayo] And, stated by men at an FGD in Sahn: ‘Some women can bleed profusely just after delivery, in fact this may lead to death,‘ and ‘Sometimes the afterbirth does not come out and because it does not come out delivery is not complete and when that happens some people need referral.’ [SSI, male community leader supported by elderly woman, Koinadugu] The TBAs were all able to describe danger signs, usually in more detail than the men and women: ‘The danger signs during and after delivery are when pregnant women still see their periods, have swollen feet and pale skin, there is offensive vaginal discharge and pus, profuse bleeding, delay in the delivery of the placenta, and abnormal presentation such as the baby coming out with the hand or feet first, and convulsions which may lead to the death of mother and unborn baby.’ [SSI, TBAs, Bombali] 5.2.5 Danger signs and actions during the neonatal period Generally, if the baby does not cry after birth, is not suckling sufficiently at the breast, is pale [anaemic], or has fever and/or convulsions, these signs are recognised as danger signs in the newborn. See quotations below about recognition of danger signs for newborn health in response to the question, ‘What signs in a pregnant woman or a newborn would cause you concern?’ ‘I know that babies are in danger when the baby doesn’t cry, when the baby is anaemic and pale, and when the baby has convulsions immediately after he is born.’ [SSI, male community leader, Bombali] Some of the problems are seen as danger but treated using herbs, as is illustrated by the following quote: ‘My baby had severe stomach ache and I nearly lost him. His body became pale and we took him to the herbalist and were able to save his life.’ [FGD, women, Koinadugu] Certain skin disorders are also recognised as not normal and needing treatment: ‘There is a certain type of scabies which some babies suffer from. It appears on the skin and even inside the mouth. They prevent the baby from eating.’ [FGD, women, Koinadugu] Women mentioned other signs that concerned them enough to take babies to the clinic for attention (if the herbal treatment does not work): ‘Some children are born healthy but within a week you notice the baby getting smaller and smaller. It is referred to as ‘chameleon’. They give the babies traditional medicines, but if the babies don’t get better, we take them to the clinic.’ [FGD, women, Koinadugu] 5.2.6 Traditional beliefs and practices There are two main issues emerging from the data that is common to all areas. The first is the belief that problems such as the death of the baby, miscarriage, prolonged labour, retention of the placenta and the refusal of the child to breastfeed are all due to the infidelity of the woman. The common explanation for this is that when the woman sleeps with men other than her husband his blood becomes mixed with that of the baby, as is illustrated by the following

Rapid Assessment of Interventions for Improving Maternal and Newborn Health, in Sierra Leone

quotes: ‘What can go wrong with pregnancy? [...] Maybe the other man cannot have the same blood with the pregnant woman’s husband. This is why the pregnancy can abort.‘ [SSI, male community leader, Tonkolili] One women explained how and why she was beaten on the back with her husband’s slipper when her afterbirth was taking too long to deliver: ‘When they use your husband’s shoes and beat you with it to help you deliver afterbirth and you did not deliver it, it means that he is not the one that impregnated you. But if you deliver it, it shows that he is the man who impregnated you.’ [IDI, woman, Koinadugu] In the IDIs, women often expressed their unhappiness about the link that was made between infidelity and problems during labour. One woman shared her concern as follows: ‘In this town, when you have a prolonged labour they will say that you have been unfaithful to your husband and they will ask you to name the other man you have been having an affair with. If you fail to do this, you will be left to suffer till you die with the pregnancy.’ [IDI, woman, Bombali] The other belief that hinders timely treatment is the belief, described earlier, that convulsions are sent by the devil. The belief in traditional medicine is great when it comes to dealing with this condition: ‘The grandmother usually says that [the convulsions prove] the girl has a demon, so she makes a lot of herbs and gives it to her.’ [SSI, health care provider, Tonkolili] The death of children may also be linked to witchcraft and lead to delays in bringing the baby to the clinic, as is observed by one of the community leaders in Yele: ‘Traditional beliefs are numerous. [...] When a man lost his baby, the neighbours held the view that he had been cursed and this was the reason he lost four babies. Last time [...] they asked consent to undertake traditional measures, which I approved. Even though I advise them to go to the clinic, sometimes they take the child to the clinic when the baby is nearly dead.’ [SSI, community leader, Tonkolili] Not all women feel comfortable when other people in the community know that they are pregnant or are nearing delivery. Fear of witchcraft makes women want to keep quiet about labour pain till they feel they are close to delivery. This also causes women to come late to the health facility. In response to the question, ‘When the pain started, what did you do?’ One woman responded by saying, ‘I was home because the issue is delicate. It must not be publicised. There are evil people who will step in and complicate things. [...] You do not tie anything onto the hem of your [cloth worn around the waist] when accompanying a woman to go to deliver. If you do, you will create a problem for the person who is in labour. [...] I kept quiet and waited for the usual signs before contacting my mother.’ [IDI, woman, Bombali]. A common reason to go and see sorcerers is, ‘to find out the cause of illnesses that they get.’ [SSI, community leader, Bombali] The reason to avoid a pregnancy when still breastfeeding the baby was explained clearly by this TBA in Kathanta: ‘All that I eat transfers to the baby and any sickness I have in my body will also transfer to the baby

Rapid Assessment of Interventions for Improving Maternal and Newborn Health, in Sierra Leone

through the breast. [...] If you have unprotected sex with your husband and then you mistakenly get pregnant, the breast will develop milk and the new breast milk will affect the baby.’ [SSI, TBA, Bombali] 5.2.7 Religious beliefs A number of women indicated that their decision-making regarding the place of birth was left to a higher power and influenced their health seeking behaviour. When asked how the woman during labour would manage until she reached the place where she would deliver, one respondent said, ‘God will safely lead you to a place where you will deliver.’ [FGD, women, Koinadugu] Another woman said, ‘If it is not worth going to the hospital then I will not go there, because God will help me sometimes.’ [IDI, woman Bomabali] Both men and women indicated that their religious beliefs influence their opinions about family planning. ‘I don’t do family planning because it’s God who gives children so I’m not bothered about reducing their numbers.’ [IDI, woman, Tonkolili] ’I am a Muslim, I studied the Qu’oran and it tells me that I should not give my wife any medicines to stop her from producing children. If I do and anything bad happens... well, the Almighty will have me responsible.’ [FGD, men, Koinadugu] 5.3 Access and referral 5.3.1 Access from home to the health facility Barriers to accessing health facilities from home were identified as distance, costs, means of transportation and poor road conditions. The actual distance to the health facility reported by the study communities varied from a few hundred feet to ‘27 miles up the mountain’. Many of the key informants agreed that distance is a greater barrier in the most remote catchment areas. The cost associated with facility care for MNH and especially the cost of drugs (medicines) were the greatest barriers reported by respondents. A number of women indicated that the importance of receiving facility care was enough to accept the ‘burden of the costs’. Lack of transportation and poor road conditions as barriers to accessing facility care were also reported in many study communities. 5.3.2 Distance Focus group respondents ranked perceived access from home to the health facility higher in communities where CHCs are located. This corresponds with the finding that more women deliver in CHCs than in other types of facilities. It is most likely that the women and men interviewed lived close to the facility but could also indicate that having a CHC in the catchment area is a greater incentive to travel the distance to access care. One MPCH Post was also ranked high, which can be explained by the position and easy access of the facility for the most populated part of the catchment area. In the three study communities without health facilities, almost all the respondents found the distance ‘too long’ and ‘difficult’ and frequently stated that their community should have its own facility. One woman from a community without a health facility captured the essence of the problem of distance during an IDI: ‘Most pregnant women do not have sufficient strength to walk for long distances and even though they might be strong enough, when they arrive at the clinic they beg for

Rapid Assessment of Interventions for Improving Maternal and Newborn Health, in Sierra Leone

water to throw over their heads so that they can be OK.’ [IDI, woman, Koinadugu] The perceived problem of distance leads in some communities to women seeking health care close to home. One woman adamantly stated: ‘The TBA lives close to my house. I will go to her when I am due, instead of going to the health centre which is far away.’ [IDI, woman, Tongo] Distance and traditional beliefs were sometimes observed as complimentary barriers to accessing health facilities and particularly for catchment communities. One chief in Tonkolili states during an SSI that: ‘Regardless of all the sensitisation, some pregnant women still don’t have the opportunity to go to the clinic. Moreover, because of distance and their traditional health beliefs, they usually go to the elderly women in their communities.’ [SSI, community leader, Tonkolili] The problem of accessing care is especially pressing during the rainy season in some of the study communities. Seasonal factors were also a barrier to accessing facility care in some study areas. A health care provider described this problem during an SSI in Tonkolili: ‘We have seasonal factors, most especially in this kind of community. We have a very big river here called Teiyae and during the rainy season it can flood so much that canoes and even the ferry cannot cross it. So that sometimes prevents people coming, and if they live far away and don’t come here, they don’t have a way of solving their problems, and I don’t have a way to go there with my motorbike, frequently resulting in complications that might lead to death.’ [SSI, health care provider, Tonkolili] 5.3.3 Costs At the time of this study, there was no Free Health Care Initiative (FCHI) in Sierra Leone and the costs for MNH services varied from facility to facility. Differences for actual costs were mentioned for intake, medicines, ANC, birth, referral services and family planning. In general, the cost of health care was mentioned as the greatest barrier to seeking care. During FGDs, respondents ranked the costs of MNH care at facilities offering free services higher than the others. Facilities with free referral services also scored better. In general, complicated births cost more than uncomplicated ones. When asked what would keep a women from accessing care at the PHU many of the respondents blamed the cost of health care as a reason for not seeking facility care: ‘Poverty and lack of money’ [SSI, community leader, Bombali] ‘The lack of money is why some women don’t come to join family planning’ [SSI, TBA, Bombali] and, ‘If you don’t have money, you will certainly die. [...] Like the lady who died last time, because of lack of money.’ [FDG, women, Koinadugu] In Kenema, where at that time of the interview, the health facilities provided free care for pregnant women, costs were not an issue at all. The respondents in Kenema spoke about free health care as an incentive for seeking facility care: ‘Initially the cost used to stop us from coming to the clinic but nowadays when we come here, we are treated with kindness and it is free,’ and, ‘But I don’t see what would stop a pregnant woman from coming to the clinic since it is free.’ [FGD, women, Kenema] One woman in Kenema indicated that although health care was free, she would gladly give the health worker a financial gratuity to ensure quality care for her child: ‘We stopped paying after the announcement of free medical care. But even then the medicine is not enough. So, although the government says it’s free I don’t mind giving some money to a nurse to ensure that my child gets well.’ [FGD, women, Tongo]

Rapid Assessment of Interventions for Improving Maternal and Newborn Health, in Sierra Leone

5.3.4 Other barriers to accessing the facility from home Poor road conditions in general were also cited as impeding access to facilities in most of the study communities. Respondents from the catchment areas indicated the lack of roads (only bush paths) as a serious barrier to access. One exception to this was in Koinadugu where one woman stated that even though the health facility in her catchment area was accessible by a good road, she would rather walk the same distance over a bush path to another health facility where she thought that the quality of treatment was better (informal data). It appears that women often give birth before they reach the clinic. Especially women who have given birth before (multiparous women) seem to wait longer, ignoring signs of the impending birth, as they are usually busy working at home or on the farm. ‘I was alone in the house when my stomach started to ache. In fact, I was preparing to go to the clinic when I delivered the child on my own. [...] The TBA was angry that I delivered at home but, you see, it wasn’t my fault because the contractions and expansions were simultaneous and occurred in rapid succession, and I was very busy that day.’ [IDI, woman, Bombali] When this happens, the women are either alone and call for the TBA who is either on time or too late, or in some cases, they give birth by the roadside on the way to the facility and the TBA often accompanies the woman to help if necessary. 5.3.5 Access from health facility to referral hospital Infrastructure (roads) and seasonal factors were frequently mentioned as barriers to timely referral services. In most of the study communities, it was reported that seasonal factors (rains, flooding, etc.) negatively influenced the availability of ambulance services. This was especially true in areas with poor road conditions to begin with, because the rainy season makes these roads muddy so they become extremely difficult and dangerous to drive on. In some areas it was noted that during the rains, rivers can overflow their banks making road travel almost impossible. These factors can considerably delay the services reaching women in a timely manner or prevent them from reaching the women at all. In one particular area, a delay of at least six hours was reported because the shortest route could not be taken due to horrendous road conditions. Ambulance and other referral services in study population At the time of the study, ten of the communities had ambulance referral services supported or provided by NGOs (Sahn, Yele, Yeben, Kamawonie, Kathanta, Kassikirie, Kamaporto, Tongo, Gegbweme and Baoma Koro). Three communities had an ambulance service provided by the district health service (Yiffin, Sumbaria and Mabayo). Bandakoro was the only community where ambulance services were not available. In general, the health care providers and in some cases, members of the Health Management Committees were responsible for calling the ambulance. In a few communities where TBAs worked in the health facilities they sometimes called the ambulance. In the two communities in Bombali where there were no health facilities, TBAs (sometimes in collaboration with a so-called ambulance organiser) could call for ambulance service to the district hospital in Kamakwie. NGOs provided free referral services in six communities. In five communities, the costs were mainly for fuel and maintenance and ranged from SLL 25,000–

Rapid Assessment of Interventions for Improving Maternal and Newborn Health, in Sierra Leone

50,000. Respondents in one community cited SLL 150,000–300,000 as the fee for ambulance service and in one community this information was not obtained. Costs and up-front payment Almost all respondents in the communities where referral services were free spoke very positively about this provision, suggesting in some cases that it has led to a decrease in maternal and newborn deaths as shown by the following statement by a women during a FGD in Kenema: ‘Mortality in women and children was high. Women died from bleeding, delayed afterbirth and other complications. Our children died too. The problems have reduced. with the institution of the ambulance service.’ Another woman in Kenema shared her own personal story during her IDI explaining why she was so profoundly grateful for the free ambulance service: ‘I like the IRC [International Rescue Committee]. They saved me. I quarrelled with my in-law. He beat me unconscious. They sent for the ambulance that took me to [the district headquarter town of] Kenema where they revived me.’ The issue of the costs associated with referral services was the most frequently mentioned obstacle in communities where these services were not provided for free. More specifically, the issue of having to pay ‘up front’ before being able to use the service was a cause of much dissatisfaction amongst the respondents. A woman in Bombali summed it up during an IDI as follows: ‘In emergencies, the doctor [CHO] calls for the ambulance and when the ambulance comes we pay 30,000 Leones for the service, but if the money is not available, you will not be transported in the ambulance no matter what your condition is.’ [IDI, woman, Bombali] During an FGD, one woman in Koinadugu said: ‘If you do not have the money for the ambulance you will die.’ [FGD, women, Koinadugu] In all communities (including those where the ambulance service is free), the costs for treatment at the referral site were identified as a serious problem and an obstacle to accessing care at the referral level. According to one health care provider: ‘We do not pay for the ambulance service but the husband should be ready with some money that will be used to pay for things like blood.’ [SSI, health care provider, Tonkolili] In almost all the study areas, the cost of treatment at the referral level was cited as being an important barrier to accessing (referral) hospital care. During a FGD with the women in Bo, one of them explained why having an accessible referral service was both a blessing and a curse: ‘The referral issue has two prongs. On one hand we are happy that there is a final option if the health workers fail. But the means of executing the referral can be expensive for us here. Sometimes people loan or even give their children as security.’ [FGD, women, Bo] 5.3.6 Seasonal factors and poor infrastructure In a number of communities, seasonal factors and poor road conditions were cited as delays to timely referral services. One health care provider stated: ‘We normally call the ambulance, the only problem is that if it rains heavily the road gets muddy and sometimes the ambulance gets stuck and it can take some time to get the ambulance back on the road, so all that causes a delay in referral.’ [SSI, health care provider, Bo] In Koinadugu, most of the respondents spoke about the poor road conditions and especially that of the major route from Kabala to the Nieni Chiefdom.

Rapid Assessment of Interventions for Improving Maternal and Newborn Health, in Sierra Leone

Because this road is virtually inaccessible, the ambulance has to take an alternative route from Kabala. A community leader spoke passionately about this during an SSI: ‘At other times though, the nurse calls the ambulance but it doesn’t come on time. On some occasions, if the ambulance is called in the morning at say 9.00 am. it will arrive at about 5.00 pm,’ and added, ‘When the road was good, the ambulance used to come from Kabala but now that the road is bad, it goes through Makeni and the distance is so long. Most of the time, it gets here late. We are suffering here.’ [SSI, community leader, Koinadugu] Another chief in the same chiefdom in Koinadugu was outspoken and very proactive in ensuring that women in need of referral services in his community would seek the closest help: ‘I will call all the relatives of the woman needing referral and ask them to convey her to a nearby and better hospital such as Masingbi, Maburka, or Makeni, but not Kabala [our headquarter town] because of the distance and the rough roads.’ [SSI, community leader, Koinadugu] The same chief also mentioned another problem causing delays in referral. He indicated that the distances between communities were so large and the roads so poor that the only available ambulance was often underway and often in a completely different area and could not collect the women in need in his community when it was needed. 5.3.7 Community actions to increase access to health facilities Communities have taken various actions to improve MNH. These were often triggered by and/or supported by NGOs and government policies and strategies. The community actions emerging from the study are aimed at improving access to health facilities. Hammocks and other means of transportation Almost all the communities reported the use of hammocks and other means of transportation, such as motorbikes. Hammocks are generally used to transport women from the community to the health facility, in some cases when an obstetric complication has occurred. In Bombali, the TBAs reported the use of hammocks to transfer women in need of referral hospital services to the road where the ambulance could pick them up. One health care provider stated: ‘The women in labour normally come on foot if they are strong enough but those who already have labour pains and cannot walk are carried in a hammock.’ [SSI, health care provider, Bomabali] That this is not always the best solution is confirmed by the following statement: ‘We improvise by using a makeshift hammock to carry them to Kathanta [...] but sometimes they do deliver by the roadside and the men are asked to move away.’ [SSI, TBA, Bombali] One community leader explained that the hammock is also used when the ambulance fails to come and said: ‘We will carry her above our heads in a hammock rather than leaving her here to die. […] It is not an easy task.’ [SSI, community leader, Bombali] Birth waiting home Another necessary activity identified by the field is the establishment of birth waiting homes. These are structures built in the proximity of health facilities where pregnant women living far from the facility can come to during the late stage of pregnancy and wait for signs of impending birth. This allows them to

Rapid Assessment of Interventions for Improving Maternal and Newborn Health, in Sierra Leone

be close enough to the facility to easily access it during the birthing process. In some cases, women at risk of complications at birth (high blood pressure, etc.) can also reside in a birth waiting home to ensure that the health care worker checks her regularly and ensures that she enters the facility on time when the birth starts. Two of the study communities had functioning birth waiting homes (Yiffin and Sumbaria) that had been built by the community with support from NGOs for the building materials and furnishings for the structure. One community (Bo) was in the process of building a birth waiting home with NGO support. Informal information from NGO field officers showed that the concept of birth waiting homes was catching on and that more were being built or planned throughout the country. Although the concept is promising, information from respondents and informants indicated that the birth waiting homes are not always successful. In general, once they have been opened the responsibility for running the birth waiting home lies with the community and there is often no continuity in the day-to-day care for the residents. The families of the pregnant women are often far away and cannot regularly visit to bring food and supplies. In Yiffin (Koinadugu), one woman told how the men cared for women who were waiting in at the home: ‘In the village [of Fornuba] that I came from, the men contribute rice, palm oil, fowl, peanuts, etc. These come along with the pregnant women as food support. Each week the husband comes to check the woman’s welfare.’ This unique case shows that it is possible to arrange for women to be cared for during their stay at the waiting home. In the field, the birth waiting homes were often used as a postpartum ‘ward’ where women recuperate after birth, receiving periodic checkups from the health care providers before being sent home. In one community a man spoke about the commitment and involvement of men and the community towards improving the health of mothers and babies: ‘What the men have done in this community to help mothers and babies is make bricks and build the birth waiting home. First it was covered by thatch but we saw that this was not ideal. The community came together and contributed to buy corrugated iron sheets to roof it.’ [FGD, men, Koinadugu] A health care provider in Koinadugu summed up the workings of the birth waiting home as follows: ‘It is in the birth homes that we screen them; those whose pregnancy is close to nine months will stay there until they deliver. They will be observed and if we detect any complications before the birth that we cannot handle, we call the ambulance before it is too late.’ [SSI, health care provider, Koinadugu] Bylaws The study also identified the phenomenon known by the term ‘bylaws’ that was discussed by all the respondent groups in almost all of the study communities. These laws are put in place by local authorities (chiefs) as a means of stimulating facility care and especially facility birth. In general, they are local rules that decree that women are required to attend antenatal care and give birth in a health facility. If this is not followed, fines can be levied on the woman, her husband and sometimes the TBA who assisted her at birth. Of the fourteen study communities, all eleven with health facilities reported having bylaws in place. In the three communities without health facilities, bylaws relating to facility birth were not in place, although in one of these communities, there was a local bylaw that women should not give birth in the ‘bush’ but rather in the TBA house built by the chief.

Rapid Assessment of Interventions for Improving Maternal and Newborn Health, in Sierra Leone

In general, the chiefs and local authorities are convinced that an increase in facility care will reduce the number of maternal and newborn deaths in their communities and generally speak with great passion about ‘their’ bylaws. According to a chief: ‘Before the law existed, we used to experience maternal and infant deaths. But since the law has been in place, we thank God that these have reduced.’ [SSI, community leader, Koinadugu] Local laws are very important to communities and are to be followed at all costs, as explained by a youth: ‘What my sisters have said is true. Before now – even before the construction of the health centre – a lot of people delivered at home, There were a lot of problems with delivering at home, so it was because of this that the law was made stating that when you sense labour you must go or be taken to the clinic. It does not matter whether you deliver on the way but you must go to the clinic.’ [FGD, youth, Bo] A TBA is Kenema explained how the law in her community was instigated: ‘We had a meeting with the chief, the entire chiefdom and all the tribal authorities, Bondo women, men and all TBAs. They passed a law that every pregnant woman should attend a clinic and deliver at the health centre. Whoever fails to do that will be reported to the chiefs and will be fined.’ [SSI, TBA, Kenema] By-laws are enforced in varying degrees from community to community. In one community in Bombali, the chief authorised the TBAs to scout out the rural villages to find women about to give birth and remind them that they need to access the health facility. In Koinadugu, the chief installed a health committee that is charged with finding women who have had an out-of-facility birth and bringing them to the chief. In most of the communities with bylaws, mitigating circumstances leading to out-of-facility birth are recognised. In a large number of communities the chiefs and health-related authorities reported that there is a general dispensation for women that did not reach the facility because the birth happened too quickly or because it occurred during the night. In these cases, most of the bylaws decree that when a newborn is brought to the health facility the next day for vaccination, no fine will be levied. 5.3.8 Community actions to increase access to referral facilities Loan and saving schemes The results of this assessment strongly suggest that there is sufficient knowledge in communities about the risk of complications during pregnancy and childbirth, and of the subsequent costs associated with referral services and treatment at referral facilities. However, it appears this is often not anticipated, leaving families to raise money when the situation is pressing and the referral is imminent. In some communities there are formal and informal mechanisms for loaning money needed for obstetric emergencies (or other medical issues). NGOs have played a major role in initiating or facilitating some of these initiatives. The study identified six communities where NGO-initiated or -supported loan or savings schemes had been implemented, with varying degrees of success. In many communities, at the moment of referral and if the fees cannot be paid, community members will help solve the problem as demonstrated by the following quotations: ‘If a family can’t afford the ambulance fees, the community contributes and loans them the money.’ [FGD, women,

Rapid Assessment of Interventions for Improving Maternal and Newborn Health, in Sierra Leone

Bombali] Community leaders also feel responsible and assist their community members, enabling them to get the medical assistance needed. One chief in Koinadugu explained: ‘As chief, I do extend credit to those men who cannot afford to take their wives to the hospital.’ [SSI, community leader, Koinadugu] The youth in Bo explained how religious organisations in their community have developed a mechanism to assist their constituents with pressing medical costs: ‘In this town we have Muslim and Christian organisations. In the mosque we contribute money to assist anyone who must have an operation. If you have a problem and your husband has no money, the organisation will contribute to help pay for the operation, because if they cannot help you at the health centre they refer you to Bo [district hospital]. The money goes towards covering some of the expenses.’ [FGD, youth, Bo] An NGO-initiated project in Bombali (now ended) provided loans for obstetric emergencies with the expectation that the loans would be paid back in instalments. According to a representative from the NGO, the project was successful in some communities and not in others. The reason for this is not (yet) known. One chief appreciated the effort and said: ‘The NGO has been appreciated in this venture. Most often they even set aside funds to lend to those whose women who might have problems of that nature but who have no money at that moment. This loan will be reimbursed as and when the matter has been resolved.’ [SSI, community leader, Bomabali] An informal conversation in Bo with members of the community revealed that a community fund for medical costs had functioned only very briefly. The reason for this, according to this person, was that the families who had loaned from it never paid back the money. A chief in Bombali provided insights into the reasons why a community-initiated loan scheme failed by saying: ‘Because it has happened more than once, when the money is given to somebody for safe keeping, the money is never produced on request. […] If we had another organisation where we can keep money for emergencies, then the problem is who do we trust to look after the money?’ [SSI, community leader, Bombali] According to most NGOs (key informants and field officers), communityinitiated and community-held funds have a better chance of success, although this will depend on the commitment from the community and good governance in administrating the funds. It was also suggested that small-scale funds developed by small groups within the communities receiving technical and material support from an NGO (through a village savings and loan scheme) are proving successful. This study did not obtain any data about this and cannot confirm this information. 5.4 Quality of care Quality of care is one of the key components influencing health seeking behaviour. The results reported here are based on the analysis of transcripts relating to perceived quality of care, the matrix ranking carried out during the FGDs, SSIs with key informants, and IDIs with women who have delivered at least two babies. It is important to note that this research took place before the implementation of free health care, except for the facilities in Kenema that were visited after free health care was introduced. The situation as it is now might be different because of this initiative.

Rapid Assessment of Interventions for Improving Maternal and Newborn Health, in Sierra Leone

The results show that people are concerned about attitudes of health care providers, shortage of drugs and supplies, the availability or unavailability of health care providers, and the lack of health facility staff expertise. In some facilities the community also believe that motivating health facility staff with financial or other benefits can improve the quality of care. Many respondents considered the health centre as the best place to seek care. Overall, the quality of most NGO-supported facilities is perceived positively for all aspects of quality of care, with the exception of one facility where there was dissatisfaction with the health care provider. Communities are grateful for facilities that will help women during complications 5.4.1 Staff attitudes Staff attitudes in most facilities were seen as good. The evaluation of the attitude of the MCH Aides who assisted during delivery was mostly very positive. Negative attitudes were only made about a few staff members Perceptions of health care providers and TBAs depended very much on the individual behaviour of the providers at the time. Being encouraged and reassured during delivery, patience, and not being pressured to push during childbirth were very much appreciated: ‘We went to the TBA and she took us to the nurses while I was in pain; when we reached the [PHU], they talked to me, rubbed my body and told me that I was alright and nothing was going to happen and that I would deliver the baby safely. They did this continuously until I gave birth to the baby.’ [IDI, woman, Bo] The next quote underscores the importance of feeling safe and receiving sympathetic care. ‘As for the nurses, they don’t even talk nicely to you. Unlike the grannies who will sit by your side until you deliver safely, the nurses have no sympathy.’ [IDI, woman, Bomabali] Women respondents during the IDIs and the FGDs were relating their experiences during childbirth. Less than half the women stated that they were kept longer in the home of the TBA than they wanted and one woman stated that she was called a ‘coward’ and accused of being ‘weak’: ‘The [TBA] was urging me to give birth quickly and I was also passing faeces, urine and water. In fact, I urged them to take me to hospital but she insisted that I was lazy and weak. Eventually the child was born and died.’ [IDI, woman, Bombali] It is likely that the outcome of the childbirth influences the perceptions of the woman. In the above case the TBA may have seen cause to speed up the delivery especially because of referral being difficult due to distance and circumstances. However, women do refer negatively to being rushed or not being sent on time to the hospital when complications start to emerge and perceive this as an important quality issue. Another aspect very much appreciated is that the staff are kind and respectful, In only one facility, an MCHP, the attitude of the nurse was found lacking: ‘Some women don’t go to the facility because of the bad attitude of the MCH Aides who do not encourage them. Even when they are in pain nurses don’t attend to them, so most would say I won’t go to that clinic, I would rather give birth at home. […] If you shout at some of our people they become ashamed and would not want to see you even after a month. So if that happens to a woman she won’t go to the clinic, even if her husband gives her money to go.’ [FGD, women, Koinadugu]

Rapid Assessment of Interventions for Improving Maternal and Newborn Health, in Sierra Leone

Other responses indicate that clients are providing incentives to the staff so that they are well attended: ‘We will give the nurse money so she will try harder.’ [FGD, women, Koindadugo] In a few facilities, community members pay staff because they believe that they get better treatment that way. In one facility the nurse reportedly only provide treatment if she was paid: ‘The nurse asks them for money before she examines the pregnant women to check if there is a problem or not. And if there is a problem she will give them some medicine, but only after she has been given some money.’ [IDI, woman, Koindadugo] 5.4.2 Availability of drugs and supplies Availability of drugs and supplies are very important for the community: all the communities stress the importance of the availability of drugs. An ambulance that arrives quickly is highly appreciated: ‘If any problem arises before or after delivery, then the [MCH Aide] will call the ambulance as quickly as possible and they also have good medicines for the baby and the mother.’ [SSI, TBA, Kenema]. A TBA who works with a clinic that has integrated working with TBAs emphasises the importance of medication as follows: ‘The women come to the clinic because of the medicines they get there.’ [SSI, TBA, Bombali] The assessment of drug availability is not always consistent. For most facilities women report a lack of some drugs at certain times. However, some facilities are frequently criticised for not having the drugs in stock. The insistence on receiving medication is not always in line with the concept of rational drug use but it does give a clear picture of the importance attributed to medicine use. Although women were treated well, one woman shared a general complaint: ‘There are simply not enough drugs at the clinic. Even when I had this miscarriage and was taken to the clinic, I was only given aspirin.’ [IDI, woman, Bombali] FGD, SSI and IDI responses show that in all NGO-supported facilities there is a regular supply of drugs, although shortages are reported (especially at the end of the month). There is a drug availability problem in some of the unsupported clinics. However, health care providers solve the problem, at least as far as the community is concerned, by buying and selling drugs themselves. ‘I do not depend on the drugs from government and UNICEF supplies, so I use my own money to buy the necessary drugs and sell them to the people.’ [SSI, health care provider, Bombali] 5.4.3 Staff Availability In most facilities staff was available except for those with only one active member of staff. It was often mentioned by the health care providers that the time away from the clinic was justified by outreach activities and participating in refresher courses. The Box 1: Time needed for outreach activities: One MCH Aide who worked alone at an MCHP explained that her catchment area consisted of six clusters of villages for outreach activities. She visited each cluster once a month and including the time needed to reach the villages (by foot) she estimated that each outreach visit took at least two days. This means that she is out of the facility for at least twelve days a month, with no one to replace her at the facility.

Rapid Assessment of Interventions for Improving Maternal and Newborn Health, in Sierra Leone

Absence without informing the community affected the perception of quality as is illustrated by the following quote: ‘They can be here for some time and then they just go, leaving the centre vacant. The health care providers are not always at the health centre. Since this [PHU] opened, the health care provider posted here does not stay here permanently. We want somebody who could stay here permanently. ’The reason female nurses leave the centre is because they say they are going to see their families.’ [SSI, community leader, Tonkolili] 5.4.4 Expertise To elicit ideas about perceptions of quality in relation to reputation and expertise, respondents were asked where they would go and the reasons they prefer a particular place to go for pregnancy care and delivery. All the interviewees in Bo, Kenema and Tonkolili villages emphasised that the clinic is the best place to go to. In Koinadugu and Bombali most preferences were for the clinic but some also preferred the care of the TBA.

Training and special expertise The fact that all health care providers have received special training is seen as an important reason for visiting the clinics, as is illustrated by the following quote in response to the question of which place they preferred for the delivery: ‘As I told you earlier, it is the health centre […] because they know all about pregnancies and deliveries. They have been trained for this job.’ [SSI, community leader, Yeben] and, ‘We told the women to refer their cases to the [MCH Aide] because she is trained and qualified for the delivery procedure.’ [SSI, health management committee, Yeben] A community leader also based the importance of facility use on the ability to safe lives: ‘Pregnant women should talk to the people at the clinic so that they can safeguard their lives.’ [SSI, community leader, Tonkolili] The expertise of nurses was also seen as a reason by a group of women in Kenema: ‘We go to the health centre because this is where we receive the best service. […] The nurses, they are the experts. The TBAs are like apprentices to the nurse.’ [FGD, women, Kenema] Mostly, clinics are given preference, also in villages without a facility. However, this is not always the case, and TBAs are also referred to as experts and in some instances the collaboration between TBAs and the nurse is seen as part of the TBA expertise, as is illustrated by the following quote: ‘The TBAs work with the nurses and they also understand about pregnancy and delivery, and they have more understanding than other people who do not work at the health centre.’ [SSI, community leader, Tonkolili] 5.4.5 Diagnosis and Treatment Generally, diagnosis and treatment facilities are seen as a reason to prefer the clinic as is illustrated by a group of TBAs: ‘Going to the clinic is the most preferable choice because the clinic will know if you are pregnant and can also help in dispensing or providing treatment to pregnant women.’ [SSI, TBA, Tonkolili] One woman in the IDIs highlighted the importance of examination and the ability to deal with any problems, the latter point being shared by many respondents. ‘I chose the [PHU] first because when I went there they examined me properly and also because I am pregnant and if there is a problem during my delivery, they will take me to the hospital.’ [IDI, woman, Tonkolili]

Rapid Assessment of Interventions for Improving Maternal and Newborn Health, in Sierra Leone

5.4.6 Care for the newborn The care of the baby directly after delivery is also an important point: ‘The TBA did not take care of my child after she was born. She told me to go back home. There is good care in the clinic.’ [IDI, woman, Bandakoro] The need for facility care nearer to their homes – not only for deliveries but also for childcare – is reiterated by many in villages without health facilities, as is illustrated by the following quote: ‘The most important thing we need here is a [CHC] and a trained and qualified nurse.’ This respondent continued: ‘We need a good health centre and a trained nurse to take good care of our children because my children haven’t even been vaccinated yet. If there was a nurse here this would have been a simple thing for me and my babies.’ [ID, woman, Koinadugu] 5.4.7 Other considerations Less common is the emphasis on equipment, cleanliness and prevention as reasons to go to the clinic, as is illustrated by a Health Committee member. ‘The clinic is the best place. It has the right tools for safe delivery, unlike the traditional methods. The equipment in the clinic is sterilised and is tetanus free, which is why I consider it the best place to deliver.’ [SSI, health management committee, Bo] Cleanliness and the environment were also mentioned by one of the TBAs: ‘The [PHU] is clean and decent.’ [SSI, TBA, Bombali] The main reason to choose for TBA care, beside the reasons mentioned above, is the close proximity of the TBA. However, the need to be fast when complications emerge may be underestimated: ‘I prefer the [TBA] because she is within our reach and serious cases are always referred.’ [SSI, community leader, Koinadugu] 5.4.8 Measures of technical quality During the study, facility and skills assessments were carried out in order to have a systematic measure of quality from a technical perspective. It was intended to use these assessments to look deeper into the relationship between quality of services and the support provided by NGOs. Assessment checklists previously used in Sierra Leone were shortened and adapted for this rapid assessment. One of the researchers, an experienced midwife, conducted these assessments with one of the data collectors to build capacity within the team. Due to logistical issues, these assessments were carried out in only three of the five districts, Bo, Tonkolilii and Koinadugu. In total five facility assessments and six skills assessments were conducted (three CHOs and three MCH Aides). Results of the facility assessments In general, all the assessed facilities were comparable. They had basic equipment and materials for health care provision including water supply, soap, refrigerator(s), EPI cold box, an ambulance on call and radio equipment. A few had a toilet or latrine and at least a minimal light source of light for emergency use. The facilities were assessed on their ability to provide services in all areas of the continuum of care for childbearing. Most of the facilities provided the full coverage of MNH services: antenatal care, including general check ups, tetanus toxoid immunisation, treatment of existing conditions, nutrition counselling and iron/folate supplementation; care for normal deliveries; postnatal care, including care at the facility directly following birth and follow up clinic visits/outreach visits; and family planning, including the provision of birth control pills and insertions of IUDs. Reducing maternal and newborn deaths can be achieved when complications during pregnancy and childbirth can be treated in time. The collective name for

Rapid Assessment of Interventions for Improving Maternal and Newborn Health, in Sierra Leone

these services is known as Emergency Obstetric and Neonatal Care (EmONC). At the PHU level, it is expected that CHCs can provide BEmONC which consists of seven signal functions: administering parenteral antibiotics, uterotonics drugs (to stop blood loss), administering parenteral anticonvulsants (to stabilise eclampsia), performing manual removal of placenta, performing removal of retained products of pregnancy (manual vacuum aspiration, dilation and curettage) and placenta, performing assisted vaginal delivery (vacuum extraction, forceps delivery), and neonatal resuscitation. All three CHCs assessed had the equipment and supplies to perform BEmONC). All the CHCs carried out syndromic diagnosis and treatment of sexually transmitted diseases (STDs) and HIV testing and counselling. The drug inventory was also assessed. All six facilities had a selection of the most needed drugs in stock, including antibiotics, pain medication, antimalarial drugs and tetanus toxoid, and, especially needed for obstetric emergencies: antibiotics, uterotonics and anticonvulsants. Although drug shortages and stock-outs were reported by in-charges in all the facilities, NGOsupported facilities appeared to be better supplied. In this small sample, it also appeared that the CHCs were better stocked than MCHPs. Oxytocin, the preferred uterotonic (by WHO) used to prevent and/or treat bleeding after birth was in stock in all the facilities except for one MCHP. In all facilities it was only used for treatment and not for prevention of bleeding in the third stage of labour. 2 All facilities had one labour bed and could accommodate one birthing woman at a time; in general, the CHCs were larger and had additional (examination) beds for more women who required care. Results of the skills assessments of health facility staff The health care providers were ranked in two areas: knowledge and experience. The respondents were asked twenty questions about separate aspects of care provision or health conditions presenting at the clinic. The assessor ticked the answers given on a list of â&#x20AC;&#x2DC;standard responsesâ&#x20AC;&#x2122; to the questions. If all the standard answers to the questions were not spontaneously given, the assessor probed to see if the provider could be triggered to remember more answers. Both CHOs and MCH Aides displayed sufficient knowledge. Compared to the CHOs, MCH Aides needed more probing to answer the questions fully. The second part of the assessment was intended to establish if the health care providers were able to maintain their skills through experience. This was achieved by checking off what the provider had be trained to do on a standard list of skills, and then using the same list to determine which skills they had used in the past three months. The assessments for the three CHOs show that they were all trained with the same skills sets, as was also the case with the three MCH Aides who were assessed. In general, almost all the providers had sufficient clinical experience to assume that their skills were up to date. There was some indication of tasks shifting from the CHO to the MCH Aide but this was mainly in general health and not specific to MNH. In the case of skills relating to BEmONC, one CHO revealed that although he had gone through training to perform vacuum-assisted deliveries and manual vacuum aspirations, he had not been able to practice during the training and 2

The third stage of labour begins after the birth of the baby and ends after the placenta and membranes have been completely delivered.

Rapid Assessment of Interventions for Improving Maternal and Newborn Health, in Sierra Leone

although he had the necessary equipment and theoretical knowledge, he was not confident enough to perform these procedures. The BEmONC status of the CHCs is related to the fact the there are CHOs on staff who have the knowledge, skills, experience and supplies to perform the basic functions of emergency obstetric and neonatal care. If the CHO is not available, women need to be referred on time, as MCH Aides (and nurses) are not trained to perform all seven BEmONC procedures. In most cases, they can administer EmONC medicines and can resuscitate the newborn mouth-tomouth. Using the abovementioned assessment data, with the addition of information obtained from the interviews, during informal conversations and sporadic observations, and based on the researcher’s expertise, some general remarks about the quality of the service providers can be made: 



 



MCH Aides do not always have sufficient knowledge of the physiology of pregnancy and childbirth to thoroughly explain the cause of their complaints to women. The Aides sometimes incorporate traditional beliefs into their explanations. This does not necessarily imply that the care provided is of poor quality. MCH Aides seem to dispense medicines as a cure for all complaints and problems that they are confronted with. This reliance on medication is often inappropriate but most likely not harmful as the medication is often only vitamins and/or light pain relievers. In some cases, MCH Aides advised more traditional methods as solutions to complaints. MCH Aides are generally well trained in the technical skills relating to birth, although they may sometimes lack sufficient psycho-social skills to create a trusting and safe environment for the birthing woman, as was demonstrated in a number of stories by women and during observations. On the other hand, the capacity of Aides to be ‘with women’ is influenced by the individual and her life experience. In this study women also talked about the care, kindness and friendliness of MCH Aides. MCH Aides cannot be considered skilled birth attendants because they are not trained or equipped to perform BEmONC, but they are an important lynchpin in the referral process if complications arise during pregnancy and birth. They are often the person who determines the moment of referral from a lower-level facility to a higher-level one where a CHO is based, and in some cases they are responsible for sending obstetric problems and emergencies directly to the referral hospital. Good practice carried out by MCH Aides can help reduce delays in seeking referral services. CHOs have a solid knowledge base for practice. They treat appropriately and refer on time when possible. CHOs can be considered skilled birth attendants as they are trained and equipped to perform BEmONC but they may lack experience with some aspects of emergency obstetrics. CHOs have a good understanding of not only technical issues but also the emotional aspects of maternity care.

During the interviews some birth stories were told that reveal less than optimal care with poor outcomes. The following case illustrates the cascade of interventions that can occur when complications are not recognised or acted upon in time.

Rapid Assessment of Interventions for Improving Maternal and Newborn Health, in Sierra Leone

One woman related that during her previous pregnancy she had regular ANC visits at the health facility. In a following visit to the facility the woman was told by the MCH Aide that the baby was now positioned well. The woman’s sister [a TBA] did not confirm this, indicating that the baby was crossed [transverse], which explained the pain the woman was experiencing. When the woman returned to the MCH Aide, she received an injection for the pain she had in her belly, but was not informed about the position of the baby in her womb. When she went into labour, she went directly to the facility and was first sent back home by the MCH Aide. When the contractions intensified, the woman returned to the facility where the MCH Aide put her in a room and left her alone with her family. They called the MCH Aide when the woman started to push and the Aide arrived at the moment that the baby’s hand came out. The woman’s sister advised that the baby was not coming in the proper position and that the hand should be pushed back inside but the MCH Aide said that this was a complication and called an ambulance for referral to the district hospital. It was there that a Caesarean section was performed, but the baby was born dead. During her recovery, it was discovered that the woman had developed an obstetric fistula which she later received treatment for in Freetown. She is now pregnant again after almost two years.

The following story illustrates how despite adequate care, poor results can occur because of traditional beliefs and practices. The care provider talked about the latest maternal death he had encountered. He indicated that cases like this were the cause of frustration and de-motivation. ‘We had one maternal death. She was a teenager, and after she was impregnated by a schoolboy in Freetown, she was abandoned so I took responsibility for her, including drugs and other things. She went away to the village for a month. So I took the motorbike to look for her in the village. What I saw was her feet and face were swollen, her abdomen was so large that I told her mother to bring her to the clinic the following day. The grandmother claimed that the girl had a demon so she prepared a lot of herbs and gave them to her. On the day they brought her to me, her blood pressure was 150/100. I did my intervention. When the paramount chief sent for me, they sneaked away with the girl; they brought her back at around 5pm. But by the time I wanted to intervene again she had started vomiting. I did all I could but she died.’

5.5 Role of the TBA and their practices TBAs in Sierra Leone play a very important role in providing care and support during the childbearing process. Although at the time this study took place there was no official government policy on TBAs, most key informants noted that WHO guidelines that discourage the training of TBAs was the government’s unofficial policy. The government is currently reviewing the role of TBAs and is developing a new policy addressing the changing role of TBAs. The results of this study can be used in this process as they address current TBA practices, TBA integration into health services, and the users’ and other health care providers’ perceptions about the quality of TBA care provision. 5.5.1 Profile The profile of TBAs in Sierra Leone is varied. They are generally older and experienced women who are embedded in the women’s societies and communities. In this study, the average age of TBAs interviewed was 60 years

Rapid Assessment of Interventions for Improving Maternal and Newborn Health, in Sierra Leone

and above (range: 42–70). Women in the communities generally speak about them using the terms nurse, traditional nurse, Mende nurse and granny. They are untrained or have had some form of training either from the government in the past or more recently from NGOs or from staff at the health care facilities. In many of the study communities, TBAs worked together with staff and were present at the facilities. The TBAs from the catchment areas brought women to the facility and worked alongside the staff during delivery. In some cases, when staff was not present, the TBA would deliver the baby in the facility. None of them were salaried, but in some cases they did receive incentives or small reimbursements. 5.5.2 Integration of TBAs with health facilities In most of the study communities with a health facility, a certain degree of unofficial integration of the TBAs into the care system was seen. A measure of integration of TBAs was developed that consisted of five areas in which collaboration was reported.     

Influence of TBAs in the community to bring women to the health facility for care. Receiving supplies or training. Mentorship or supervision from MCH Aides to TBAs. Receiving incentives or financial support from health facility staff. Conducting births at the facility in the absence of staff.

Based on the abovementioned criteria, TBAs were the most integrated in Yele, Sahn and Mabayo, and the least integrated in Baoma Koya and Kathanta. A TBA in one of these communities firmly believed that, ‘there was no other place to deliver than the health centre.’ [SSI, TBA, Bo] Integration of TBAs does not necessarily mean that they do not deliver babies. When health staff are not available, the TBA conducts the delivery on her own as is illustrated by the following quote: ‘If the [MCH Aide] nurse is not around we can do the delivery ourselves. And even though the nurse is in town, I can also deliver babies if there are no complications before the delivery but if there are, I will take her to the nurse to deliver her.’ [SSI, TBA, Kenema] Box 2: Examples of special community support for TBAs

Two exceptional cases in regarding the role of TBAs were identified in Bombali. In these communities, TBAs are the designated primary caregivers during labour and delivery and are supported by the chiefs. In one community, the chief has built a TBA house where all the women in the village are expected to deliver. One TBA describes her role as follows: ‘Our work here is to deliver those who can deliver safely. If a pregnant woman comes here to deliver, we observe her to see if she can deliver safely. If she cannot deliver safely we refer her.’ In the other community, the chief has put a by-law into place that is different from the ones discussed previously. As explained by the chief: ‘It is known to all that we have TBA houses where everybody is expected to deliver. Whoever delivers in a home or in the bush will be fined, unless it occurs to a woman while she is working on the farm. Issues of this nature can be spared. If not, it is expected of all to report to the TBAs any time one of them experiences labour pains.’ In the same community in Bombali, the TBA is also responsible for initiating referral. One women described the TBA’s role when there is a complication at

Rapid Assessment of Interventions for Improving Maternal and Newborn Health, in Sierra Leone

birth: ‘The phone number of the ambulance is with the ambulance organiser so if there is a case that needs referral the TBA will inform the chief and the organiser that the women is unable to give birth so the ambulance will be called for.’ 5.5.3 Areas of work In general, TBAs in Sierra Leone work during the antenatal, labour and delivery and the postpartum periods. This is a summary of the major activities as described by the respondents: Antenatal care: confirming pregnancy, accompanying women to register for antenatal care at the health facility, health advice and information, antenatal check-ups (visual evaluation of the mother, estimation of gestational growth), referring women with complications to the health facility. Labour and Delivery: Confirming labour, involved in deciding about the place of birth, accompanying women to the place of birth, supporting women at the health facility, attending to women and managing the entire childbirth process (including birth of placenta and membranes and cutting the cord), either in the community, on the road, or in a health facility, referring cases with complications to the health facility. Postpartum: Visual assessment of the condition of the mother, checking for blood loss, washing mother and baby, wrapping the baby, initiating breastfeeding, visual assessment of mother and baby in the days following birth. Newborn care: Health information, advice by complications. Family planning: Most communities did not consult TBAs regarding formal family planning methods, although there were some references to TBAs advising the use of traditional methods and, in a few cases, to the TBAs carrying out abortions. It appears that the TBAs often have a strong caring role during the birthing process and that they are the main caregivers after delivery. In one case, a woman miscarried at four months at the facility, with the TBA being the primary caregiver and information-giver following the delivery. ‘I was given a drip and some medicines were injected into the drip. The pain died down five minutes later and then what I could see was the baby following. It was a small object I cannot clearly describe. The doctor then called the TBA to check me and change my clothes. She checked me and told me I had lost the baby.’ [IDI, woman, Bombali] 5.5.4 TBAs as first port of call during labour and delivery From the IDIs with women, and from their birth timelines, it was very clear that the most women go to the TBA before taking other action after labour starts. This was found in villages with health care facilities as well as in villages without them. In 40 of the 42 birth stories told by women, the TBA was the first port of call. 



‘One night, I started experiencing labour pains, so I called my mother and we went to the TBA, who checked me and took me to the clinic where my baby was delivered.’ [IDI, woman, Bo] ‘When my stomach began to ache, I went to the TBA.’ [IDI, woman, Bombali]

Rapid Assessment of Interventions for Improving Maternal and Newborn Health, in Sierra Leone

Some women stay at home for a long time during labour and might go to the TBA when danger signs emerge: According to the [FGD with] men in Bo, when they see danger signs in their pregnant women the best place to take them is to the Mende nurses (TBAs) who work at the health facility. ‘Yes, we take them there for check-up. They have herbs that they use to treat them if they discover any problems. We also consult the omens after seeing signs that may make us panic to look for those signs and see what might have caused the problems.’ 5.5.5 Quality of TBA care Perceptions of the quality of care by the community have been discussed previously in the section on quality. Some of these were specific to TBA care. To get a better sense of the actual quality of TBA care, we studied women’s stories of complicated births that were summarised in birth time lines and followed by the TBA’s actions that were taken to address the complications. TBAs have knowledge of danger signs in pregnancy that is sometimes reflected in their practices. In general, TBAs understand the danger of post-partum blood loss. They often treat this traditionally but will refer if there is persistent bleeding. ‘After the delivery of the afterbirth, I was bleeding. [...] Because she was a native nurse she didn’t do anything until the following morning when the nurse at the health facility was available. They took me there, and that was the only time they gave me an injection and treated the baby as well. Then the bleeding reduced.’ [IDI, woman, Bo] Especially when the complications involve prolonged labour or retained placenta, the actions by the TBAs do not reflect their knowledge, and a number of potentially dangerous practices were identified. If the afterbirth (or parts of it) remains behind in the woman’s uterus for too long after the delivery, it could lead to severe infection or blood loss, both life-threatening conditions. A woman in Koinadugu said the following about the delivery of her placenta: ‘I was just lying down. It look me a week to deliver the placenta. […] They just gave me the native medicine continuously.’ A woman in Bombali told how after her miscarriage and treatment in the health facility, she experienced pain and went to the TBA who had looked after her in the clinic. The TBA explained that the placenta ‘was still in her stomach’ and took no further action. A week later the woman received injections from the TBA and was told that the placenta would ‘get rotten and come out later’. After three days the women started bleeding heavily, passed out and had to be taken to the facility where the afterbirth finally came out. Another woman in Bombali described her birth at the TBA’s house that stagnated for hours: ‘I ran to my sister in-law and she took me to the TBA. I couldn’t deliver the baby; I was there for five hours and still the baby did not come, it was only after such a long time that the ambulance was called to take me to a bigger hospital in Kamakwie. When we went to the hospital the nurse gave me an injection and put me on a drip, and after the drip I was able to deliver the baby.’ In this case of prolonged labour, the TBA may have waited too long before referral, thereby endangering the women and her newborn baby. It was previously shown in section 4.2.6 that there are strong traditional beliefs pertaining to retained placenta and prolonged labour. It may be possible that these beliefs influence the TBA’s actions, causing delays in referral.

Rapid Assessment of Interventions for Improving Maternal and Newborn Health, in Sierra Leone

5.6 Perceptions of promising interventions in MNH health A summary of the interventions being carried out by NGOs in the study communities can be found in Annex 6. The aim of this rapid assessment was to find promising interventions for MNH that can be developed into a comprehensive package to be implemented in Sierra Leone. The respondents in this study have identified a number of interventions in their communities and in some cases have voiced an opinion about the impact or usefulness of the interventions. Below is a summary of the interventions as perceived by the respondents, grouped by community-based/oriented interventions, referral services and facility-based interventions. 5.6.1 Community-based/oriented interventions The value of community-based health information/education in reducing sickness and raising awareness was emphasised by a number of respondents. On a critical note, one respondent felt that there was not enough sensitisation taking place. Community women’s cooking clubs in Koinadugu were valued because, ‘Many women attend and they are very beneficial.’ [SSI, health care provider, Koinadugu] They bring pregnant women together to inform and teach about healthy cooking and getting more nutrition out of your food. At the same time, it is a ‘mothers group’, providing a forum for group health education, Newborn care and nutrition promotion and sensitisation were valued because they contribute to, ‘babies growing fast with no illnesses’. [SSI, community leader, Koinadugu] 5.6.2 Referral service interventions Ambulance services for obstetric and neonatal emergencies at low or no cost are highly appreciated by the respondents. One respondent said, ‘It fills a gap, as the government ambulance did not come in the past. […] People are getting used to it and using it more.’ [SSI, health care provider, Tonkolili] 5.6.3 Facility and quality of care interventions A large number of respondents mentioned the supply of drugs to the PHUs. One respondent was critical because, ‘the supply was not always sufficient and not always appropriate’. (SSI, health care provider, Bo] Another respondent noted that, ‘Drug supply to PHU stops the patients from going to quack drug peddlers.’ [FGD, youth, Bo] This study shows strong evidence about the perceptions of quality being linked to an available and affordable drug supply. 5.7 Utilisation of facility services The research team was unable to obtain data from the MoHS regarding the uptake of facility births at the PHU level. This was because 2009 was a transition year from various data forms to one package of standard forms that will ensure a better quality of standardised data in the central data system. Data on the places of birth were found in various other sources, but an analysis of this data showed inconsistencies with national and district data and was not reliable for further research.

Rapid Assessment of Interventions for Improving Maternal and Newborn Health, in Sierra Leone

An analysis of the data obtained from the 42 birth stories shared by women during the IDIs suggests that the proximity of a health facility can prompt women to seek facility care during childbirth. This data confirms the information obtained during the FGDs and SSIs that indicated that women are more likely to use a facility if it is near to their home. In places with a CHC/CHP, the delivery of almost all the women interviewed occurred in the health clinic. There is some indication that the percentage of facility births may be higher in higher-level facilities (CHCs and CHPs) compared to MCHPs. Of the fourteen women interviewed in communities without health facilities, only one had delivered in a health facility.

Rapid Assessment of Interventions for Improving Maternal and Newborn Health, in Sierra Leone

6 Discussion and conclusions 6.1 Decision making The husband emerges in all areas as the person who provides the money for care. He is regarded as the head of the household and, in most instances, is identified as the most important decision-maker. However, the husband does not make the real decisions when it comes to labour and delivery. Various factors influence this decision-making. First of all, labour and delivery are seen as women’s issue and especially elderly women are regarded as experts. The mother-in-law and her family, and/or the mother of the woman in labour or mates, friends and neighbours advise the woman. In fact, the men see themselves as lacking knowledge about delivery in particular and accept the women’s advice. Secondly, the introduction of bylaws that impose a fine on the husband if he does not ensure that his wife visits ANC services and goes for a facility delivery has put pressure on men to provide finances for maternal and child care. The health care providers and the chiefs of the villages/chiefdoms have started influencing traditional practices during pregnancy, childbirth and neonatal and childcare through the bylaws. In most areas the woman in labour presents her situation as dependent on the husband to get permission for any action that costs money. If she has savings or other income she can make her own decisions. In a few places, especially in Tongo and Kenema, the women clearly claimed agency to decide where they would go for delivery, even, if necessary, against the wishes of the husband. However, both men and women acknowledge that they are dependent on expert advice for what to do when delivery starts, be it traditional support from the TBA and elderly women or from the MCH Aides and the CHO. From discussions and own experience it is important to place the role of women in maternal health issues in context. Sierra Leone, as other West African countries, has a very active secret society that initiates girls into womanhood and makes them eligible for marriage and is an institution that continues to assist women throughout their adult life (Fanthorpe, 2007). As a rite of passage to womanhood, women are circumcised and educated about pregnancy and childbirth during the period of a secret society confinement in the bush. The word ‘secret’ is to be taken literally. Women are not supposed to speak about these practices unless they are among members of the society. (MacCormack, 1979) The patriarchal norms and values about women’s position are very strong, but especially elderly women play an important role in society and they are actually the decision-makers. Thirdly, power relations between husband and wives play a role in what happens during pregnancy and delivery. The exchange of women’s labour and financial support for health care was only reported in Bo but it seems reasonable to expect that food production, labour and sex in exchange for economic support are part of the relationship in other places. The tone of women when they speak of the power of their husbands is often quite sharp and sometimes expresses a feeling of powerlessness. This is not surprising considering the strong patriarchal society they live in. The struggle between men and women becomes especially clear when they are speaking about family planning. Most men in the FGDs spoke against family planning because they claim the right to produce children and are afraid of

Rapid Assessment of Interventions for Improving Maternal and Newborn Health, in Sierra Leone

infidelity. Religious grounds may be used to justify their decision. The women, however, are very aware that the high number of pregnancies puts them at risk. In some cases they also fear ill treatment from their husbands during pregnancy. Some women openly talked about reverting to abortion if they are unable to use contraceptive or if contraceptives fail. Women in all areas defy their husbands if they feel strong enough and secretly take contraceptives with support from the health care providers. Nevertheless, the position of men towards family planning is crucial to make a change in the high fertility rate in the country. Men are clearly very interested in the survival of their children and also feel more able to make decisions about neonatal and childcare. Implications Community education needs to focus on important decision-makers such as women societies and husbands (Portella & Santarelli, 2003), as well as on community and religious leaders in order to influence decision-making about pregnancy and delivery. The implementation of male community motivators has been documented in Sierra Leone (Kandeh, 1997), and although it was not seen in the study communities, some information was gathered during the validation workshops. There is no evidence to show effectiveness and the reasons why this intervention has been stopped in some areas are unknown. Male involvement in maternal health and family planning has proven to be effective in other settings. (Roth, 2001; Wegner, 1998; Helzner, 1996) However, to succeed more work is needed to change the mindset of male leaders and other men. If not, women who now cannot access maternal services or those who hide the use of contraceptives may continue to suffer. 6.2 Knowledge, beliefs and practices In almost all areas some education on birth preparedness and danger signs was provided by various NGOs, health care providers and media campaigns. The respondents in all the communities mentioned the most important normal and danger signs in pregnancy, delivery and newborn care. The main maternal concerns were swelling of the feet and face, bleeding, anaemia, fever, delay in the delivery of the placenta, convulsions and abnormal foetal presentations. Not breathing or crying and convulsions in the newborn are the primary neonatal concerns. Being able to recognise danger signs is a successful result of community information programmes. However, no matter what action is taken, the belief system in all places is traditional. Communities believed that problems such as the death of the baby, miscarriage, prolonged labour, retention of the placenta and a child refusing to breast feed are due to the womanâ&#x20AC;&#x2122;s infidelity. This suggests that the community education has been limited to increasing knowledge rather than changing practices. Research suggests that empowering interventions, rather than increasing knowledge, leads to greater satisfaction on the part of woman, increasing understanding (Portelo and Santorini, 2003). Sometimes interpretations lead to different actions. For example, â&#x20AC;&#x2DC;swollen feetâ&#x20AC;&#x2122; is sometimes a sign that the woman is carrying a boy but at other times is seen as a danger sign and either traditional or medical help is sought. Convulsions (eclampsia) are seen as a sign that needs to be treated by the traditional healer or the granny. However, women will go to the health centre and to the traditional healer. Eclampsia is a serious problem that is currently

Rapid Assessment of Interventions for Improving Maternal and Newborn Health, in Sierra Leone

insufficiently addressed in the communities and may not be identified at an early enough stage in the clinics. Belief in traditional medicine and healing, which is a culture shared by many West African countries, often occurs side by side with the seeking of biomedical care. In the more isolated areas, however, these beliefs result in unacceptable delays that lead to the death of mothers and babies. Figure 3 (below) shows an overview of the knowledge and beliefs related to the most common danger signs revealing that although danger signs are recognised the common practices are a mixture of traditional actions and seeking medical care. The more remote a community, the more such delays might lead to serious illness and death. Figure 3: Knowledge, beliefs and actions

Knowledge of danger signs

Belief

Seriously swollen feet and face / convulsions Mentioned as danger

Spiritual, possessed by devil, sorcery

Bleeding Mentioned as danger

Danger

Prolonged labour Mentioned as danger

Retained placenta Mentioned as danger Babies stool (green) in amniotic fluid Not mentioned

Actions Go to traditional healer causing delay and death TBA: not so serious, herbs and ORS, otherwise referral

Women has been unfaithful, sex with another mean leads to â&#x20AC;&#x153;mixed bloodâ&#x20AC;? causing delays in delivery, placenta retention, death of the baby and the mother. The woman is at fault

Long delays in referral 2-3 days

Not mentioned

No action taken

Long delays waiting till placenta comes. Sometimes infection sets in after a week

Implications Community education and development is needed to address the belief system underlying serious conditions such as eclampsia, prolonged labour and retained placenta in pregnant women. The assistance to women is made more difficult because the mother might be blamed for the complication. Dialogue is needed about conditions that affect the newborn baby and are associated with either the mother or with traditional beliefs. It is clearly insufficient to provide health information. Communities are very aware of danger signs and also very concerned, especially about babies and children. There is a kind of desperation in which families are looking for help in both the traditional and modern spheres. The type of community education that is required can be taken from experiences with empowering education (Stromquist N.P., 2002) and studies into the effectiveness of community-based interventions (Bhutta, 2010, Darmstadt, 2005). Possible activities include intensively working with womenâ&#x20AC;&#x2122;s

Rapid Assessment of Interventions for Improving Maternal and Newborn Health, in Sierra Leone

groups to reflect on the norms, values and beliefs that hinder suitable actions. The exchange and discussion between various belief systems and the evidence base for what works should be included. Various manuals and approaches are available and can be adapted to the Sierra Leonean situation. An implication of this is the identification of NGOs who are able to carry out such a more intensive approach to education and on-the-job training to develop the right skills and attitudes. Another important issue is to discuss with influential women the need for early check-ups in pregnancy and timely seeking of care during labour and delivery, especially in multiparous women. 6.3 Access Obstacles to accessing facility care can be actual and perceived. The actual issues – distance, costs, road conditions, and so on – are important but only partly influence the choice for facility care. Our rapid assessment has shown examples of women defying physical barriers to reach facilities. They may be influenced by their conviction that facility care is better than the care they would receive at home, or it could be fuelled by the fear of being fined for defying bylaws. There is the example of one woman who chose to seek care at a difficult to reach facility rather than the one associated with her catchment area because she prefers the care received there. However, it appears that although most women have sufficient knowledge about the risks associated with pregnancy and childbirth, a large number do not access facility care, often defying local bylaws. It is possible that the choice to seek facility care is strongly motivated by the community environment and the importance attached to traditional and societal norms and values, especially when it comes to pregnancy and childbirth. Taking all this into consideration, when distance is used to explain the fact that facility care is not being accessed, it needs to be considered that this is an ‘acceptable’ answer that may possible mask any other more sensitive issues involved in the decision-making process. However, it is clear that actual distance or accessibility of roads (especially in the rainy season) are very important barriers for women in remote communities and are important contributing factors to the under-utilisation of facility services. In addition to the access barrier, especially multiparous women tend to wait for a long time before they go to a facility or TBA for delivery. Although not explicitly studied in this assessment, based on the interviews with women, they tell very little about the period between the onset of contractions and the very strong contractions that occur in the last phase of the dilation period. They usually precede their birth story with a description of severe stomach or back pain that is followed by loss of water (amniotic fluid), after which they begin on the pushing phase of the birth. Multiparous women in rural villages tend to come later to the clinic compared to primigravidas. Many times this results in births by the roadside, at the farm, or at home. Transportation for pregnant women to the health facilities is an important issue that can be further looked into. The hammock has been serving communities for a long time, but based on personal experience in other countries, there may be some other innovative solutions available that can be locally developed as wheelbarrow transport and bicycle transport.

Rapid Assessment of Interventions for Improving Maternal and Newborn Health, in Sierra Leone

There is no conclusive evidence about birth waiting homes (Van Lonkhuijzen, 2009) but they nevertheless appear to be a promising initiative in some settings. They are being used in the communities where they are present, and members of the community have demonstrated some sense of ownership and the belief that they work. From all the interventions identified in the study, the bylaw is the one that is most spoken about in all the respondent groups. It is not clear how these bylaws originated but they are found throughout the entire country. According to most of the respondents, the bylaws put into place by the traditional authorities can strongly influence the utilisation of facility care in MNH. However, it is not clear how effective they are in changing beliefs and behaviour and influencing sustainable change. In essence, the bylaw represents a medical and societal value decided by those in power, which is imposed on communities who fear sanctions if they disobey them. The bylaw is a good example of a public health discourse where the local authorities take action based on their conviction of a public health need rather than action decided by the men and women involved. This action works to some extend but is certainly in remote villages insufficient to overcome the barriers. Women tend to deliver with a TBA and go the clinic when the baby is born to avoid a fine. Although this study was conducted before the launch of the FCHI, the data on the costs of health care as a barrier to facility-based care are still valuable, especially when discussing the utilisation of referral services. When complications arise or very serious illnesses occur, women and newborns need to access hospital (referral) services that are capable of treating these problems. EmONC is a proven intervention that saves lives and generally implies a referral to a hospital (Paxton, 2005). A good functioning referral service is essential to receiving timely help. Timely referral is costly, as this involves an ambulance, trained personnel, good communication and equipment, and maintenance and coordination. In most of the study communities, cost was a major barrier to referrals from the facility level to the referral hospital level. The results suggest that a greater utilisation of referral services could be achieved with a good functioning and free referral system in place. Besides the costs, the referral system must be organised and coordinated to ensure that delays in reaching the referral sites are avoided as much as possible. This will involve coordination between districts so as to include border communities. Implications Health services are generally focused on getting more people into the facilities, but it may be just as important to focus on getting services to the communities (Ramchandani, 2010; PMNCH, 2011 online). An expansion of current outreach programmes is possible but other innovative solutions (seen in other countries) such as mobile clinics and m-Health related solutions should be implemented (Ratzan, 2010). A better understanding of the signs of impending birth including more knowledge about the physiology of birth could contribute to women being better equipped to judge the moment when they should start accessing care. Based on the interviews with TBAs this understanding and knowledge would also be valuable for them as they often are the decision-makers in this area. Motorcycle or bicycle ambulances may be a good solution (Hofman, 2008), depending on the kind of roads that need to be travelled. For some bush paths, a wheelbarrow ambulance may prove more feasible than a hammock where at

Rapid Assessment of Interventions for Improving Maternal and Newborn Health, in Sierra Leone

least â&#x20AC;&#x2DC;four strong menâ&#x20AC;&#x2122; are needed. As one youth leader noted informally that the youth will help but there is not always motivation. Based on the successful youth blood donation groups seen in Kenema, it might be possible to develop referral groups of community youths who receive incentives for successful referrals. More knowledge about the factors that lead to success of birth waiting homes is needed. It is also important that the factors relating specifically to successful implementation in Sierra Leone are considered. These could include the strategic location of birth waiting homes to ensure easy access to very hard to reach areas. There is no clear evidence on how effective the bylaws are in increasing facility care, and more knowledge is needed about how large a role they play in the decisions taken at the household level regarding the place of antenatal care and birth. Combining bylaws with more empowering educative approaches may negate the need for by-laws in a later phase and be more effective in addressing obstacles to facility utilisation. To improve access to referral facilities, more investment is needed in road improvement, services that cross geographical boundaries need better organisation, there should be uniformity in communication systems, and sufficient backup vehicles. Under the current FCHI, the issue of extra costs for treatment at the referral facility should not be an issue. However, as the FCHI launched in 2010 does not include costs for referral services, these costs may still be perceived as a barrier in those areas where referral services are not provided for free. 6.4 Quality The study shows that the issues people are most concerned about are the shortage of drugs, staff attitudes, the availability of health care providers, and the expertise of staff to diagnose, treat and refer in time. Other considerations are the availability of equipment, prevention activities and cleanliness. In some areas communities are convinced that motivating health facility staff in cash or kind can improve the quality of care. Since this study, this is being addressed within the FHCI with top-ups to salaries and rural allowances. RBF transforms health systems so that they can focus on outcomes, as well as create demand for services focused on womenâ&#x20AC;&#x2122;s wellbeing, and contributing to the creation of a market that caters to the poor (Dorkin, 2010). The MoHS in Sierra Leone is planning to implement an RBF strategy. In some of the facilities in the study communities, the availability of staff and drugs was inconsistent. This may change under influence of the free health care, but in the first period of the FHCI, the supply of drugs has remained an issue. Availability of drugs is generally better in facilities that are supported by NGOs. Staff availability is a problem in facilities with only one staff member. The perception of quality is strongly related to the expectations that users of services have about the care they are to receive. This was demonstrated by the huge demand for medicine, as the community perceives this as necessary to successful outcomes. This has evolved into an issue of demand and supply and it appears that the providers are dispensing medication to all patients. Often these are vitamins and aspirin but they are prescribed for a huge variety of

Rapid Assessment of Interventions for Improving Maternal and Newborn Health, in Sierra Leone

complaints. The use of inappropriate or ineffective drugs is a financial burden to a health system and also contributes to patient dependence on medicines. Staff were generally seen as friendly and encouraging, except in two facilities. The appreciation of facility staff and TBAs is highly dependent on the attitudes of the providers. Rudeness, harshness, being hurried and delays in referral are perceptions of quality by which individual health workers are judged. Availability of staff was an important issue for many communities, especially those in an area with a single-staff health facility. To carry out other duties, such as outreach and ongoing education, the single staff member cannot always be present, but it appears that this issue has not yet been addressed. Many respondents considered the health centre as the best place to seek care. Reasons for preferring the clinic were the availability of trained staff to diagnose and treat correctly and timely referral when complications arise. There is a strong emphasis on promoting facility births, which in itself is a proven intervention that benefits childbearing women and their newborns. However, this is only the case when the facility has skilled and competent staff available and sufficient supplies and drugs. Too strong an influence without the enabling environment will not guarantee the quality of care for women and newborns. Implications The implementation of rational drug use might contribute towards less drug dependency and could be cost effective for the health system in Sierra Leone. Interventions in this issue would need to address the demand as well as the supply side, as it is often driven by the expectations and demands of clients who believe that all ailments can be cured with pills and injections. More staffing is needed and should be guided by comprehensive human resources for maternal health planning to ensure skilled and continuous care to women and newborns 24 hours a day, seven days a week, even in more remote areas. 6.5 Role of TBAs TBAs are community members who live and work close to childbearing women. They are generally respected and appreciated for their experience and their dedication to serving the community. They are mentioned in almost all interviews with women as the first port of call when they are in labour or have complications during pregnancy. TBAs can identify danger signs in pregnancy and childbirth, but just as in the community, knowledge does not always lead to appropriate actions and this is sometimes reflected in their practices. They can cause delays in seeking appropriate care by not referring on time. Many facilities work together with TBAs and there is a certain degree of integration that involves support, mentorship and task shifting (deliveries). However, they are never integrated into the health system and their integration is highly dependent on staff attitudes and local circumstances. TBAsâ&#x20AC;&#x2122; proximity to health facilities influences their collaboration with health facility staff, as especially in remote areas they do not come frequently to the clinics. Besides deliveries, TBAs generally provide emotional support to women and actual care to women and newborns during the postnatal period. TBAs provide

Rapid Assessment of Interventions for Improving Maternal and Newborn Health, in Sierra Leone

traditional health advice, except in the areas where they work closely with health staff. Implications A more systematic integration of TBAs involving close collaboration, possible training and supervision by staff could result in more adequate and timely care for women and newborns, especially in cases where complications arise. As there is no conclusive evidence of the benefits of TBA practice on maternal outcomes (Sibley, 2008), this would need to be evaluated. 6.6 Summary of barriers to improving maternal and newborn health The main barrier to improving MNH is difficult geographical access to facilities; costs of travelling with the ambulance or other transport, perceptions of quality, and actual quality provided by especially MCH Aides and TBAs were also mentioned as obstacles. Although free health care may have removed the barrier for costs for treatment, the costs of referral have not been addressed, except in a few areas. Perceptions of quality centre on the availability of drugs, staff attitudes and availability, the experience of the staff, and the cleanliness and comfort of the facility. The importance of drugs – that mostly consist of vitamins, including vitamin B injections – are perhaps not harmful and to some extent useful for undernourished and anaemic women. However, it also unnecessarily increases the costs for drugs. Especially multiparous women tend to wait until the later stages of labour before seeking assistance. This increases the chance that the baby is delivered by the TBA, as the mother may not be able to reach the health facility in time for a facility birth. Prolonged labour and retained placenta are especially problematic procedures performed by the TBAs, which are referred only when the situation is desperate. Convulsions due to eclampsia in pregnant women and fever in infants are recognised as dangerous but the tendency to seek treatment from a traditional healer as well as from biomedical providers is causing delays and death. Prevention and adequate treatment of eclampsia needs urgent attention, as do the practices of TBAs. The potential dangers of the use of herbs are insufficiently investigated. The abovementioned practices are based on the strong influence of traditional beliefs and practices within the women’s society. Community development and educational approaches that allow for reflection and a change in beliefs and practices are important interventions that need further development. Postpartum care is hardly addressed and requires interventions that guarantee follow up. To allow follow up and ensure the availability of staff for deliveries, at least two people should be employed who are also motivated to be available at the workplace. The husband plays a minor role in the type of choices made for seeking facility care during labour and delivery, although he has a major responsibility in being willing to pay for care. The husband and community leaders play a major role in determining fertility and husbands prevent women from using contraceptives for spacing children and controlling fertility. Women have started to take contraceptives in secret. However, this is stressful and if they are found out it causes major problems for women. Men’s knowledge about delivery and their role in birth control must be improved. 6.7 Spheres of influence on labour and delivery The following framework (Figure 4) was developed taking some of the main findings of this study into consideration. It shows the two spheres that influence health seeking behaviour during labour and delivery. It could also be applied to antenatal and postnatal care as well.

Rapid Assessment of Interventions for Improving Maternal and Newborn Health, in Sierra Leone

Figure 4: Spheres of influence

Spheres of influence on labour and delivery Medical / Modern Health Care Sphere

Health providers

Traditional Sphere Quality Access/Costs Bylaws

Chiefs Health management committees

Practices

TBAs Strength of awareness of womenâ&#x20AC;&#x2122;s societies & community

Traditional healers Womenâ&#x20AC;&#x2122;s societies (mothers, sisters, neighbours, friends, mates) TBAs

In principle, evidence shows that a shift from the traditional to the medical sphere can lead to a reduction in maternal and newborn mortality and morbidity. Government policies in Sierra Leone lay the groundwork for this shift. The choice for the traditional or medical sphere is influenced by the various actors, as shown in the figure above. On one side, traditional knowledge and beliefs and being part of traditional communities influences health seeking behaviour. One the other side, modern (Western) medicine and bylaws are also powerful motivators for women to seek care at the health facility level. Government policies in Sierra Leone lay the groundwork for this shift. Until now, there have been investments from the health sector (national, district and private) to implement interventions to help influence this shift from traditional to biomedical. These investments have primarily been in improving quality and access to health care, and reducing the costs involved have most likely been responsible for the increase in facility services in the country. Another area of investment has been in community education to influence health seeking behaviour. This study shows that although educating the community disseminates a general knowledge of danger signs during pregnancy and childbirth, they do not affect traditional practices around childbirth that delay appropriate care. Despite the investments and results to date, more needs to be done to influence a more significant shift from the traditional sphere to the medical sphere.

Rapid Assessment of Interventions for Improving Maternal and Newborn Health, in Sierra Leone

Data from this study indicate that there is a still a strong sense of tradition in the communities in Sierra Leone and that women leaders, including TBAs, have a powerful influence on the health seeking behaviour of women during pregnancy and childbirth. In order to capitalise on this influence it will be necessary to engage them and convince them of the benefits to health for women and children that come with facility care. This will involve more than health care information and promotion, and will require adult educational activities that create awareness and change attitudes and behaviours. Influential women and men in the communities need to be targeted and engaged to achieve change.

Rapid Assessment of Interventions for Improving Maternal and Newborn Health, in Sierra Leone

7 Promising interventions, and recommendations 7.1 Summary of promising practices From the discussion it becomes clear that although programmes and initiatives providing communities with health care information are appreciated and have resulted in improved knowledge of normal signs and danger signs during pregnancy, delivery and neonatal care, there are also gaps that need to be addressed. Shared decision-making between men and women, and influencing traditional knowledge and beliefs are necessary to make a difference in the health seeking behaviour of communities. TBAs can play an important role in this, as can community education and development programmes that go beyond health information. To advance the quality of care, NGO support to facilities can be effective in improving drug availability, supplies and staff skills and competencies. Gaps that need to be addressed are in the approach to the follow up of postpartum care and the prevention and treatment of eclampsia. In addition, staff availability is an important aspect to be addressed to make outreach possible without endangering staff availability for deliveries. Integrating and supervising TBAs in facilities is a promising intervention to improve the knowledge, skills and motivation of TBAs to actively refer women to the facilities on time. However, the way TBAs are integrated needs to be further investigated and developed. Birth waiting homes seem to be advantageous in bringing women closer to the facilities around the time of birth, especially those who live far away or who could be more exposed to complications. Referral systems and loans-and-savings schemes are promising interventions that would improve the ability of women to reach the referral facility when complications arise that cannot be treated at the PHU. New evidence is emerging that mobile phones could assist in making saving schemes more effective, and improve the ways in which referral is coordinated and communities can be reached. Staff motivation is an important issue influencing productivity, quality of care and retention of health workers. A more effective supply chain of drugs and supplies could improve the motivation of health facility staff. Based on information obtained during this study, incentives may also be a strong motivating factor for health workers. Upgrading and refreshing technical skills with sufficient clinical practice should be ongoing as should attention to attitudes and delivering respectful care. Violence during pregnancy and teenage pregnancy were not the focus of this study. However, issues around these two themes emerged and further research and interventions are needed to address them. We recommend that a feasible package of interventions that include each dimension in which potential delays can be addressed (outline below) are developed further and implemented in one district to develop a model for a package of interventions that will help improve MNH in Sierra Leone. 7.2 Improving the decision to seek appropriate care in time  Continuation of community education and development, although the latter needs to focus more on women’s societies and husbands, and include more reflection on community beliefs;  To influence beliefs and practices community education needs to focus on important decision-makers such as women’s societies and husbands;

Rapid Assessment of Interventions for Improving Maternal and Newborn Health, in Sierra Leone

  

Increasing community knowledge about signs of impending birth plays an important role in the timely arrival at the birth facility; Development of clear roles and tasks for TBAs and training to prepare them for their tasks in advising women within the continuum of care; More understanding is needed about the effectiveness (short and long term) of bylaws aimed at increasing the utilisation of facility-based maternal and newborn care.

7.3 Improving the ability to reach primary health unit and treatment facility  Examine innovative ideas to ensure better transportation of pregnant women and newborns from the community to the health facility;  Birth waiting home model developed for the Sierra Leon context;  Examine which factors influence the quality of ambulance services and develop a new intervention to implement;  Better organisation and coordination of referral services for obstetric and neonatal emergencies. 7.4 Improving adequate treatment and care  Staff numbers in facilities needs to be reconsidered to ensure availability of staff at facilities and in outreach posts;  Support and improvement of health facilities by supplying drugs and improving the staff competencies and motivation;  Integration of the TBA within the health facilities and supportive supervision of her practices;  Develop alternative and innovative initiatives involving m-Health technology to connect women and health services;  Review practices in providing postpartum care and follow up, and prevention and treatment of eclampsia;  Develop interventions to reduce the use of unnecessary and inappropriate drugs in MNH on the demand as well as the supply side;  Increase health worker motivation and retention. 7.5 Further research needed  Anthropological study into the education, rules and practices of secret societies, the role of elderly and younger women and the entry points for change.  Exploratory research into ways (including youth participation) to improve transport from communities to facilities during labour.  Operational research on how to make birth waiting homes more effective in Sierra Leone.  Research the effect of bylaws on change in health seeking behaviour in the communities.

Rapid Assessment of Interventions for Improving Maternal and Newborn Health, in Sierra Leone

8 Next steps The results of this study were presented to a stakeholders meeting on 2 December 2010 in Freetown that was attended by more than 60 representatives from the Ministry, NGOs, the UN, donor organisations and other interested parties. During this meeting the first steps were taken that would lead to the next phase of this work. A lively discussion was held based on the following questions:  

Which promising interventions are essential to improve MNH care at the primary care level? What are the criteria for selecting the geographical area(s) for implementation of a comprehensive package of interventions in MNH care?

The discussion was facilitated by representatives from the MoHS and the MRC. The results of this discussion were documented to kick-start work on the scaling up phase of the project.

A working group consisting of experts from the MoHS and representatives from NGOs in Sierra Leone working in sexual and reproductive health care met periodically in the first half of 2011 to develop a comprehensive package of ‘promising’ interventions based on the findings in this study that is intended to complement existing structures and ongoing projects. A framework was developed that takes into account the continuum of care (see Figure 5, below). Before the end of 2011, implementation will start in a number the districts where the implementing NGOs work and where a and services for Basic Emergency Obstetric and Neonatal Care in place. The community-based adult learning component is those areas.

of chiefdoms in referral system (BeMONC) are filling a gap in

The action research component of the PPP Sierra Leone knowledgestrengthening programme will focus on documenting innovative adult learning education strategies to change traditional beliefs and practices and reduce teenage pregnancies; the lessons learned about what works in the implementations of these innovations; and the context-specific mechanisms and conditions that are crucial for scaling up.

Rapid Assessment of Interventions for Improving Maternal and Newborn Health, in Sierra Leone

Figure 5: Conceptual framework of promising interventions Conceptual Framework Context

Influencing factors

Problem

Gender, norms, values,

Early marriage

Teenage pregnancy

Health system Road system

Intervention

Community education: Lack of access - reflection on norms to sex education and values and - reflection on and contraceptives change of beliefs and practices (men's groups, women's groups, TBAs, CHWs, health management Traditional Delayed committees, through beliefs and presentation for adult learning practices assisted delivery approaches, strengthening capacity for adultlearning approaches)

Expected results Short term: Increased willingness of communities to provide access to sex education, contraceptives. Changed attitudes to early marriage and teenage pregnancy. Long term: Reduced teenage pregnancy Short term: earlier presentation for delivery Long term: reduced maternal deaths

Lack of access

Referral systems (as present in intervention area)

HR, Insufficient supplies/equipm skilled ent, enablers attendance (light, water, etc.) constraints

B/C-EmONC strategies See above including post/neonatal care (as present in intervention area)

Rapid Assessment of Interventions for Improving Maternal and Newborn Health, in Sierra Leone

9 References Aggarwal, A.K., Jain, V. & Kumar, R. (2011). Validity of verbal autopsy for ascertaining the causes of stillbirth. Bulletin of the World Health Organization, 89, 31-40. Agongo, E.E.A. (2006). Child Survival and Maternal Mortality Reduction in Sierra Leone: A Situational Analysis. Freetown, Sierra Leone: Ministry of Health and Sanitation. BergstrĂśm, S, Goodbum, E. (2001). The Role of Traditional Birth Attendants in the Reduction of Maternal Mortality. In V. De Brouwere & W. Van Lerberghe, (Eds.). Safe Motherhood Strategies: A Review of the Evidence (pp. 75-95). Antwerp: ITG Press. Bhutta, Z.A., Darmstadt, G.L., Hasan, B.S. & Haws, R.A. (2005) Communitybased interventions for improving perinatal and neonatal health outcomes in developing countries: A review of the evidence. Pediatrics, 115 (2), 519617. Bhutta, Z.A., Ali, S., Cousens, S., Ali, T.M., Haider, B.A., Rizvi, A., Okong, P., Bhutta, S.Z. & Black, R.E. (2008). Alma-Ata: Rebirth and Revision 6 Interventions to address maternal, newborn, and child survival: what difference can integrated primary health care strategies make? The Lancet, 372 (9642), 972-989. Bhutta, Z.A., Darmstadt, G.L.,Haws, R.A., Yakoob, M.Y. & Lawn, J.E. (2009). Delivering interventions to reduce the global burden of stillbirths: improving service supply and community demand. BMC Pregnancy and Childbirth 9 (Supplement.1), S7. Bhutta, Z.A., Chopra, M., Axelson, H., Berman, P., Boersma, T., Bryce, J., ... Wardlaw, T. (2010). Countdown to 2015 decade report (2000-10): taking stock of maternal, newborn, and child survival. The Lancet, 375 (9730), 2032 â&#x20AC;&#x201C; 2044. Brouwere, V. de, Richard, F. & Witter, S. (2010). Access to maternal and perinatal health services: lessons from successful and less successful examples of improving access to safe delivery and care of the newborn. Tropical Medicine and International Health, 15 (8), 901-909. Campbell, O. & Graham, W. (2006). Strategies for reducing maternal mortality: getting on with what works. The Lancet, 368 (9549), 1284-1299. Canavan, A. & Coolen, A. (2010). Assessment for a District Based Performance Incentives Approach for MRC in Sierra Leone. Amsterdam: Royal Tropical Institute (KIT). Canavan, A. (2008). Review of global literature on maternal health interventions and outcomes related to provision of skilled birth attendance. Amsterdam: Royal Tropical Institute (KIT). Chiwuzie, J., Okojie, O., Okolocha, C., Omorogbe, S., Oronsaye, A., Akpala, W., Ande, B., Onoguwe, B. & Oikeh, E. (1997). Emergency loan funds to improve access to obstetric care in Ekpoma, Nigeria. International Journal of Gynecology and Obstetrics, 59 (Supplement 2), S231-S136. Cleland, J., Bernstein, S., Ezeh, A., Faundes, A., Glasier, A., & Innis, J. (2006). Family planning: the unfinished agenda. The Lancet, 368 (9549), 18101827.

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Darmstadt, G.L., Bhutta Z., Cousens, S., Taghreed, A., Walker, N & de Bernis, L. (2005). Evidence-based cost-effective interventions: how many newborn babies can we save? The Lancet, 365 (9453), 977-988. Dorkin, D., Vergeer, P., Skolnik & Sturdy, J. (2010). Results-Based Financing (RBF) in Service Demand and Delivery. In Background Paper for the Global Strategy for Women’s and Children’s Health: Investing in Our Common future (pp. 11-14). Geneva: Partnership for Maternal and Newborn Health. Ensor, T. & Cooper, S. (2004). Overcoming barriers to health service access: influencing the demand side. Health policy and planning, 19 (2), 69-79. Essien, E., Ifenne, D., Sabitu, K., Musa, A., Alti-Mu’azu, M., Adidu, V., Golji, N. & Mukaddas, M. (1997). Community loan funds and transport services for obstetric emergencies I n northern Nigeria. International Journal of Gynecology and Obstetrics, 59 (Supplement 2), S237-S244. Fanthorpe, R. (2007). Sierra Leone: The influence of the Secret Societies, with special reference to Female Genital Mutilation. Geneva: United Nations High Commissioner for Refugees, Status Determination and Protection Information Section (DIPS). Fofana, P., Samai, O., Kebbie, A. & Sengeh, P. (1997). Promoting the use of obstetric services through community loan funds, Bo, Sierra Leone. International Journal of Gynecology and Obstetrics, 59 (Supplement 2), S225-S230. Helzner, J.F. (1996). Men’s Involvement in Family Planning. Reproductive Health Matters, 4 (7), 46-154. Herschderfer, K., Eggens, L., Mantinga, P. & De Koning, K. (2010a). Literature Study for Maternal and Newborn Health Interventions in reference to Sierra Leone. Amsterdam,: Royal Tropical Institute (KIT). Herschderfer, K., Eggens, L.,& de Koning, K. (2010b). Mapping of Interventions aimed to improve maternal and newborn health in Sierra Leone. Amsterdam: Royal Tropical Institute (KIT). Hofman, J.J, Dzimadzi, C., Lungu, K., Ratsma, E.Y. & Hussein, J. (2008). Motorcycle ambulances for referral of obstetric emergencies in rural Malawi: Do they reduce delay and what do they cost? International Journal of Gynecology and Obstetrics, 102 (2), 191-197. Hogan, M.C., Foreman, K.J., Naghavi, M. Ahn, S.Y., Wang, M., Makela, S.M….Murray, C.J.L. Maternal mortality for 181 countries, 1980-2008: a systematic analysis of progress towards Millennium Development Goal 5. (2010). The Lancet, published online, DOI: 10.1016/SO1406737(10)60518-1 Høj, L., Stensballe, J. & Aaby, P. (1999). Maternal mortality in Guinea-Bissau: the use of verbal autopsy in a multi-ethnic population. International Journal of Epidemiology, 28 (1), 70-76. Hugen, B.J. (2010). Health seeking behavior and decision making processes of people in a low-resource setting: Experiences with free, quality, healthcare in a rural hospital in Sierra Leone. (Unpublished Master’s thesis), Royal Tropical Institute (KIT), Amsterdam. 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.

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Kandeh, H.B.S., Leigh, B., Kanu, M.S., Kuteh, M., Bangura, J., Seisy, A.L. (1999). Community motivators promote use of emergency obstetric services in rural Sierra Leone. International Journal of Gynaecology and Obstetrics, 59 (Supplement. 2), S209-S218. Kerber, K.J., de Graft-Johnson, J.E., Bhutta, Z.A., Okong, P., Starrs, A. & Lawn, J.E. (2007). Continuum of care for maternal, newborn, and child health: from slogan to service delivery. The Lancet 370 (9595), 1358-1369. Konteh, R. (1997). Socio-Economic and other variables affecting maternal mortality in Sierra Leone. Community Development Journal 32 (1), 49-64. Leigh, B., Kandeh, H.B.S., Kanu, M.S., Kuteh, M., Palmer, I.S., Daoh, K.S. & Moseray, F. (1997). Improving emergency obstetric care at a district hospital, Makeni, Sierra Leone. International Journal of Gynecology and Obstetrics 59 (Supplement 2), S55-S65. MacCormack, C.P., and Sande. (1979). The Public Face of a Secret Society. In Jules-Rosette , B. (ed.), The New Religions of Africa. Norwood NJ: Ablex Publishing Corporation. Maine, D., (1993). Safe Motherhood Programmes: options and issues. Centre for Population and Family Health, School of Public Health, Columbia University, New York. Ministry of Health and Sanitation Sierra Leone. (2006a). Human Resources for Health Policy in Sierra Leone. Government of Sierra Leone, Freetown, Sierra Leone. Ministry of Health and Sanitation Sierra Leone. (2006b). National Blood Transfusion Policy. Government of Sierra Leone, Freetown, Sierra Leone. Ministry of Health and Sanitation Sierra Leone. (2008). Reproductive and Child Health Strategic Plan 2008-2010. Government of Sierra Leone. Freetown, Sierra Leone. Ministry of Health and Sanitation Sierra Leone, (2007a). Reproductive Health Policy. Government of Sierra Leone. Freetown, Sierra Leone. Ministry of Health and Sanitation Sierra Leone, (2007b). Child Health Policy. Government of Sierra Leone. Freetown, Sierra Leone. Ministry of Health and Sanitation Sierra Leone. (2009a). National Health Sector Strategic Plan 2010-2055. Ministry of Health and Sanitation Sierra Leone, (2009b). Gender Strategic Plan. Government of Sierra Leone, Freetown, Sierra Leone. Ministry of Health and Sanitation Sierra Leone. (2010). Basic Package of Essential Health Services for Sierra Leone. Government of Sierra Leone, Freetown, Sierra Leone. Ministry of Health and Sanitation Sierra Leone, Reproductive and Child Health Programme. (2008a). Appraisal of Programme Strategy and Implementation Plan by Development Partners: 5-16 May 2008, Joint Appraisal Report. Government of Sierra Leone, Freetown, Sierra Leone. Ministry of Health and Sanitation Sierra Leone, Reproductive and Child Health Programme. (2008b) Nationwide Needs Assessment for Emergency Obstetrics and Newborn Care Services in Sierra Leone. Government of Sierra Leone, Freetown, Sierra Leone.

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M’Sie, N. (1996). Health information for the grass roots. World Health Forum, 17 (3),277-282. Partnership for Maternal, Newborn and Child Health (PMNCH). Foster Innovations. Knowledge Summary (10), pp. 46-49. Retrieved from http://portal.pmnch.org/knowledge-summaries/ks10. Paxton, A., Maine, D., Freedman, L., Fry, D., Lobis, S. (2005). The Evidence for emergency obstetrics. International Journal of Gynecology and Obstetrics 88 (2), 181-193. Portella, A., Santarelli, C. (2003). Empowerment of women, men, families and communities: true partners for improving maternal and newborn health. British Medical Bulletin, 67, 59-72. Rajaratnam, J.K., Marcus, J.R., Flaxman, A.D., Wang, H. Levin-Rector, A., Dwyer, L….Murray, C.J.L. (2010). Neonatal, postnatal, childhood, and under-5 mortality for 187 countries, 1070-2010: a systematic analysis of progress towards Millennium Development Goal 4. The Lancet, 9730, 19882008. Ramchandani, R. Innovation in Service Delivery. (2010). In Background Paper for the Global Strategy for Women’s and Children’s Health: Investing in Our Common future (pp. 56-61). Geneva: Partnership for Maternal and Newborn Health. Ratzan, SC, Gilhholy, D. (2010). Innovative Use of Mobile Phones and Related Information and Communication Technologies In Background Paper for the Global Strategy for Women’s and Children’s Health: Investing in Our Common future (pp. 28-35). Geneva: Partnership for Maternal and Newborn Health. Ronsmans, C., Etard, J.F. & Walraven, G. (2004). Verbal autopsies: learning from reviewing deaths in the community. In Lewis, G. (Ed.), Beyond the Numbers: Reviewing maternal deaths and complications to make pregnancy safer (43-55). Geneva, WHO. Roth, D.M., Mbizvo, M.T. (2001). Promoting Safe Motherhood in the Community; The Case for Strategies that Include Men. African Journal of Reproductive Health, 5 (2), 10-21. Rosato, M., Laverack, G., Howard Grabman, L., Tripathy, P., Nair, N., Mwansambo, C., Azad, K., Morrison, J., Bhutta, Z.A, Perry, H., Rifkin, S. & Costello, A. (2008) Alma-Ata: Rebirth and Revision 5 Community participation: lessons for maternal, newborn, and child health. The Lancet, 372 (9642), 962-971. Samai, O. & Sengeh, P. (1997). Facilitating emergency obstetric care through transportation and communication, Bo, Sierra Leone. International Journal of Gynecology and Obstetrics, 59 (Supplement 2), S157-164. Sibley L.M., Sipe T.A. Brown, C.M., Diallo M.M., McNatt K. & Habarta N. (2007). Traditional birth attendant training for improving health behaviours and pregnancy outcomes. Cochrane Database of Systematic Reviews 2007, Issue 3. Art. No.: CD005460. DOI: 10.1002/14651858.CD005460.pub2 Smith, K.V. & Sulzbach, S. (2008). Community-based health insurance and access to maternal health services: Evidence from three West African countries. Social Science and Medicine, 66 (12), 2460-2473.

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Rapid Assessment of Interventions for Improving Maternal and Newborn Health, in Sierra Leone

Annex 1

Overview of NGO interventions from mapping study

THEME Community strengthening and training

Health education and promotion targeting communities

INTERVENTION

NGO

Support and training to Health Management /Village Development Committees (etc) Support to and capacity strengthening of civil society organizations (CSOs and CBOs) Training of (community) health volunteers Training of male community health volunteers TBA support and training

MRC CARE IRC Concern Save the Children Concern Health Unlimited Cause Canada Concern Medicos del Mundo CARE COOPI CARE MRC Concern Save the Children UMC

Health clubs and various other types of groups Adolescent sexual and reproductive health education

Breastfeeding education

â&#x20AC;&#x2DC;Generalâ&#x20AC;&#x2122; MNH education

CARE CRS World Vision ChildFund CRS Health Unlimited Marie Stopes

Rapid Assessment of Interventions for Improving Maternal and Newborn Health, in Sierra Leone

DISTRICT Tonkolili, Bombali, Bo Kenema Tonkolili, Western Area Kailahun, Pujehun Tonkolili, Western Area Bombali Moyamba Tonkolili, Western Area Koinadugu Koinadugu, Kono Koinadugu, Bombali, Tonkolili Tonkolili, Bombali, Bo Tonkolili, Western Area Kailahun Bombali, Kono, Moyamba, Western Area Koinadugu Kailahun, Koinadugu, Tonkolili Bo, Bonthe, Kono, Pujehun Bombali, Kailahun, Koinadugu, Port Loko, Tonkolili Koinadugu, (Kailahun, Tonkolili?) Bombali All except Pujehun (until august 2010)

THEME

INTERVENTION

Health education and promotion targeting communities (cont.)

MRC Plan Red Cross Save the Children UMC

Advocacy Obstetric Fistula Gender-based violence and traditional harmful practices Radio messaging Health information and promotion (targeting pregnant women)

Loan/savings schemes / community

NGO

(Pregnant) women support groups (including start up kits for womenâ&#x20AC;&#x2122;s groups)

Mother to mother support groups NGO initiated loan schemes

Rapid Assessment of Interventions for Improving Maternal and Newborn Health, in Sierra Leone

World Vision Health Unlimited CARE Concern MSF CARE IRC CARE Cause Canada ChildFund Concern Health Unlimited IRC Red Cross Save the Children World Vision CRS Health Unlimited MRC Save the Children Cause Canada

DISTRICT Tonkolili, Bombali, Bo Moyamba, Kailahun, Bombali All districts Kailahun, Pujehun Bombali, Kono, Moyamba, Western Area Bo, Bonthe, Kono, Pujehun Bombali Tonkolili, Koinadugu, Bombali Tonkolili, Western Area Bo, Pujehun Koinadugu, Bombali, Tonkolili Kenema Koinadugu, Bombali, Tonkolili Moyamba Bombali, Kailahun, Koinadugu, Port Loko, Tonkolili Tonkolili, Western Area Bombali Kenema All districts Kailahun Bo, Bonthe, Kono, Pujehun Kailahun, Koinadugu Bombali Tonkolili, Bo Kailahun, Pujehun Moyamba

THEME Referral services

INTERVENTION Ambulance services

NGO CARE Cause Canada ChildFund Concern COOPI IRC Health Unlimited Marie Stopes MSF MRC Save the Children UMC

Hammock Communication for referral services

Birth Waiting homes

Birth waiting homes/maternity homes

Red Cross CARE Concern COOPI IRC Medicos del Mundo MRC MSF CARE Cause Canada Concern MOMS MRC

Rapid Assessment of Interventions for Improving Maternal and Newborn Health, in Sierra Leone

DISTRICT Koinadugu, Bombali, Tonkolili Moyamba Bombali, Kailahun, Koinadugu, Port Loko, Tonkolili Tonkolili, Western Area Kono Kenema Bombali All except Pujehun (until august 2010) Bo, Pujehun Tonkolili, Bo Kailahun Bombali, Kono, Moyamba, Western Area All districts Koinadugu, Tonkolili?) Western Area Kono Kenema Koinadugu Tonkolili, Bo Bo, Pujehun Koinadugu Moyamba Tonkolili, Western Area Kailahun Bo, Tonkolili

THEME Capacity building (service providers and DHMT)

INTERVENTION Training for health personnel

ChildFund Concern COOPI CRS Health Unlimited IRC Marie Stopes

Training for DHMT in supervision and management

Supporting facilities

NGO

Drugs, equipment and logistics

Medicos del Mundo MRC MSF Save the Children World Vision CARE Cause Canada Plan CARE Concern IRC Plan Save the Children World Vision Cause Canada ChildFund Concern COOPI

Rapid Assessment of Interventions for Improving Maternal and Newborn Health, in Sierra Leone

DISTRICT Bombali, Kailahun, Koinadugu, Port Loko, Tonkolili Tonkolili, Western Area Kono Koinadugu, Tonkolili Bombali Kenema All except Pujehun (until august 2010) Koinadugu Tonkolili, Bo Bo, Pujehun Kailahun, Pujehun Bo, Bonthe, Kono, Pujehun Koinadugu, Bombali, Tonkolili Moyamba Moyamba, Kailahun Koinadugu, Bombali, Tonkolili Tonkolili, Western Area Kenema Moyamba, Kailahun, Bombali Kailahun, Pujehun Moyamba Moyamba Bombali, Kailahun, Koinadugu, Port Loko, Tonkolili Tonkolili, Western Area Kono

THEME

INTERVENTION

Supporting facilities (cont.)

NGO CRS IRC Marie Stopes

Facility (PHU) upgrading

Support hospital

Providing services

Facility health service provision

Community based health service provision

Medicos del Mundo MRC MSF Plan Save the Children World Vision Concern Health Unlimited IRC Medicos del Mundo MSF Plan COOPI Health Unlimited IRC IRC Marie Stopes MSF Save the Children CARE ChildFund

Rapid Assessment of Interventions for Improving Maternal and Newborn Health, in Sierra Leone

DISTRICT Koinadugu, Tonkolili Kailahun? Kenema All except Pujehun (until august 2010) Koinadugu Tonkolili, Bo Bo, Pujehun Moyamba, Kailahun, Bombali Kailahun, Pujehun Bo, Bonthe, Kono, Pujehun Tonkolili, Western Area Bombali Kenema Koinadugu Bo, Pujehun Bombali, Kailahun, Moyamba Kono Bombali Kenema Kenema Western Area Bo, Pujehun Kailahun Koinadugu, Bombali, (Tonkolili) Bombali, Kailahun, Koinadugu, Port Loko, Tonkolili

THEME

INTERVENTION

Providing services (cont.)

NGO CRS Marie Stopes Medicos del Mundo Plan UMC

Fistula repair

Provider motivation and incentives

Gender-based violence and traditional harmful practices Performance Based Incentives

Mercy Ships West Africa Fistula Foundation IRC ChildFund COOPI Health Unlimited IRC Marie Stopes MRC Plan Red Cross World Vision

Rapid Assessment of Interventions for Improving Maternal and Newborn Health, in Sierra Leone

DISTRICT Kailahun All except Pujehun (until august 2010) Koinadugu Moyamba Bombali, Kono, Moyamba, Western Area Western Area Bo Kenema, Kono, Freetown Bombali, Kailahun, Koinadugu, Port Loko, Tonkolili Kono Bombali Kenema All except Pujehun (until august 2010) Bo, Tonkolili Moyamba, Kailahun, Bombali All districts Bo, Bonthe, Kono, Pujehun

Annex 2

Overview of study districts, chiefdoms and communities

District

Chiefdom

Community

Niawa Lenga

Tonkolili

Gbonkolenken

Koinadugu

Nieni

Sahn Yele Yeben Yiffin Sumbaria Bandakoro Mabayo Kamawonie Kassikirie Kathanta Kamaporto Tongo Gegbwema Baoma Koya

Makari Gbanti Bombali

Kenema

Stella Limba Lower Bambara Tunkia Koya

Rapid Assessment of Interventions for Improving Maternal and Newborn Health, in Sierra Leone

Annex 3

Research Table

Main question

Technique

Instruments

Respondents

Objective

To identify the factors that influenced the development and implementation of activities

To identify the effectiveness of the intervention in addressing delays in deciding to seek care

Rationa Coordinatio Processes Stakeholders Practical considerations

Desk review, SSI

Desk Review Guide and Topic Guide for SSI development and implementation (see also topic guide step 2)

Community key stakeholders, DHMT members, NGOs, MoH Central Level, Clinic Staff, Community groups

Changes in perceptions of illness related factors? Changed abortion practices, post abortion care, sanctions on infidelity

Pile sorting excersise

Protocol for Pile Sorting

Women and Men

SSI key informants

Topic Guide for SSI with key informants on deciding to seek care

Key informants

FGD

Topic guide for FGD on deciding to seek care

Men women youth

Timeline

Protocol for timeline deciding to seek car

Men women youth

Desk review: collated data on severity of cases presenting Desk review: HMIS utilisation data, Qualitative reports; survey outcomes

Questionnaires and checklist

N/A

Questionnaires and checklist

N/A

Less severe cases arriving at the service centre? Increased utilisation of ANC and delivery care?

Rapid Assessment of Interventions for Improving Maternal and Newborn Health, in Sierra Leone

Objective

Main question

Changed decision making about seeking care in the community why and how, Changed gender relations and agency of women

To identify the effectiveness of the intervention in addressing delays in deciding to seek care (continued)

Changed perceived accessibility?

Changed perceived quality of Care

Objective

Main question

Technique

Instruments

Respondents

Venn Diagram/timeline

Protocol for the Venn Diagram on decision making (integrate questions on actual acccesibility)

Women who delivered, husbands, TBAs

SSI key informants

Topic Guide for SSI with key informants on deciding to seek care

Key informants

FGD

Topic guide for FGD on deciding to seek care

Men, women, youth

Mapping of MNH providers

Map

Men, women

SSI key informants

Topic Guide for SSI with key informants on deciding to seek care

Key informants

FGD

Topic guide for FGD on deciding to seek care

Men, women

SSI key informants

Topic Guide for SSI with key informants on deciding to seek care

Key informants

FGD Matrix Diagram

Topic guide for FGD on deciding to seek care

Men, women, youth

Technique

Rapid Assessment of Interventions for Improving Maternal and Newborn Health, in Sierra Leone

Instruments

Respondents

Have the interventions influenced the actual accessibility?

Have the interventions influenced adequate and appropriate treatment/ Q of C?

Increased ANC, FP, postpartum neonatal care Increased distribution and location health facilities Decreased death in transit, severe cases Increased access to transport? How? Reduction of out of pocket expenses Increased ability to pay Type of staff and number of staff Stocks, equipment

Competence personnel

Diagnosis and action

Desk review

Desk Review Guide and Instrument for data collection at District and PHU Level (Report HMIS, HMIS Utilisation Data) Topic Guide for SSI with key informants on deciding to seek care

N/A

SSI providers

Topic Guide for SSI with providers on accessibility and quality of care

Providers

FGD

Topic guide for FGD on deciding to seek care

Women and Men

SSI key informants

Key informants

HR reports Observation (Adapted WHO Health Facility Checklist) Adapted WHO questionnaire and knowledge test

Observation guide (Health facility checklist) questionnaire and invented case history for knowledge test

Health staff

Knowledge Test

invented case history with test questions

Health staff

Rapid Assessment of Interventions for Improving Maternal and Newborn Health, in Sierra Leone

Annex 4

Example of birth timeline

Increase in body temperature I told my mother and she told me I might be pregnant. Later I missed my period The pregnancy started to develop. I later told my husband who gave me money for clinic. I was given a card by the nurse who examined me. First visit at 4 months. The second I was given a vaccination.

ID- 29

One night I experienced continuous stomach pain. I told my mother in law who contacted the TBA. It took 4 days under pain before delivery. Water broke and the child came half way.. The TBA pressed my stomach. She could not fix this problem, an ambulance was called from Kamakwie. I was later told the problem was that the head of the child was too big. In Kamakwie I was told that I have no sufficient blood. Afterbirth came out ok.

They told me I almost died due to lack of blood and water. But since I was in the hospital I knew I would get back my life. A rubber tube was inserted into the nostrils of the baby and the breast to give her food. After 4 days I started breast feeding. When tubes were removed we were discharged. When child started crying it felt good. Service from TBA and ambulance very well.

I have never heard of FP. I did not know anything about it.

1st child Pregnancy & antenatal care

Labour & delivery

2nd child

Serious stomach pains (9 months). Reported to I know from friends that if you miss mother in law who informed TBA who refused to your period you are pregnant. When I give her assistance because she was having a noticed this I told my husband. problem with the community people. I never felt He gave me money to go to clinic. good and water broke. My mother together with few people from Kassikirie village assisted me. I delivered. After birth ok. Mother and child ok.

F 76

Rapid Assessment of Interventions for Improving Maternal and Newborn Health, in Sierra Leone

Postpartum

Family Planning

The child started sucking the next day after delivery. The child was washed, dressed and bandage the umbilical cord well. I was given great attention.

Annex 5

Overview sources of data

IDI

FGD

Venn Diagrammes

SSI

Birth narrative timelines

Health Facility Assessments

Provider Skills Assessments

Bo Sahn

Yele

Yeben Koinadug u

Tonkolili

Yiffin Sumabria

Bandakoro

Bombali Mobayo

Kamawonie

Kamaporto

Kathanta

Kassigirie

Gegbwema Baoma Koya

Tongo

Kenema

TOTAL

Rapid Assessment of Interventions for Improving Maternal and Newborn Health, in Sierra Leone

Annex 6

District Bo

Tonkilili

Koinadugu

Interventions in study communities

Chiefdom

Community

Type of PHU

Niawa Lenga

Sahn

CHC

Gbonkonlenken

Yele

CHC

Type of NGO support* RS/FS

RS/FS

Gbonkonlenken

Yeben

MCHP

RS/FS

Nieni

Yiffin

CHC

Sumbaria

MCHP

Bandakoro

Rapid Assessment of Interventions for Improving Maternal and Newborn Health, in Sierra Leone

Types of interventions Ambulance service and radio communication Support to facilities (drugs, supplies, Support to staff (training, mobility, incentives) Support to DHMT and VHC Birth Waiting Home (being built) Ambulance service and radio communication Support to facilities (drugs, supplies, Support to staff (training, mobility, incentives) Support to DHMT and VHC Ambulance service and radio communication Support to facilities (drugs, supplies, Support to staff (training, mobility, incentives) Support to DHMT and VHC Health Education (pregnancy groups and cooking groups, breastfeeding, GBV) Support to VHC Village loan scheme Health Education (pregnancy groups and cooking groups, breastfeeding, GBV) Support to VHC

*CB= Community Based, RS= Referral Services, FS= Facility Support

District

Chiefdom

Location

Type of PHU

Type of NGO support*

Bombali

Makari Gbanti

Mabayo

MCHP

Sella Limba

Kamawonie

CHP

CB/RS/FS

Kathanta Yimbor

CHC (without CHO)

CB/RS/FS

Drug supplies (incidental)

Kasikirie

CB/RS/FS

Kamaporto

CB/RS/FS

Rapid Assessment of Interventions for Improving Maternal and Newborn Health, in Sierra Leone

Types of interventions

Health Education (women’s groups, fistula advocacy, training of male health advocates) Ambulance Service Referral Hospital (PBF, training and supplies) Health Education (women’s groups, fistula advocacy, training of male health advocates) Emergency Obstetric Fund Ambulance Service Referral Hospital (PBF, training and supplies) Health Education (women’s groups, fistula advocacy, training of male health advocates) Emergency Obstetric Fund Ambulance Service Referral Hospital (PBF, training and supplies) Health Education (women’s groups, fistula advocacy, training of male health advocates) Emergency Obstetric Fund Ambulance Service Referral Hospital (PBF, training and supplies)

District

Chiefdom

Location

Type of PHU

Type of NGO support*

Kenema

Lower Bambara

Tongo

CHC

CB/RS/FS

Tunkia

Gegbewema

CHC

CB/RS/FS

Kandu Lepiema

Boama Koya

CHC

CB/RS/FS

Rapid Assessment of Interventions for Improving Maternal and Newborn Health, in Sierra Leone

Types of interventions

Health education (radio messaging, women’s groups, blood donor groups) Ambulance services and communication Training DHMT /joint supervision Support to facilities (drugs, supplies, Support to staff (training, incentives) Support referral hospital (training, supplies) Health education (radio messaging, women’s groups, blood donor groups) Ambulance services and communication Training DHMT /joint supervision Support to facilities (drugs, supplies, Support to staff (training, incentives) Support referral hospital (training, supplies) Health education (radio messaging, women’s groups, blood donor groups) Ambulance services and communication Training DHMT /joint supervision Support to facilities (drugs, supplies, Support to staff (training, incentives) Support referral hospital (training, supplies)

BO No 2 No 3 No 4 No 5 No 6

4 1 1 1 2

times identified ranked 1 ranked 2

5 3 1

1 1 0

2 5 3 4 4 0 1

6 3 2 5

5 5 4

4 0 1

1 0 0

1 0 1

2 3

4 5 3

3 0 0

Sahn 3 6 3 6 5 5 0 0

6 6

3 0 0

1 1 0

1 0 0

2 0 1

2 0 0

TONKOLILI No 7 No 8 No 9 No 11 No 12 no times identified ranked 1 ranked 2

1 1 1

2 2

4 3 1

2 0 2

1 1

3 2 1

3 0 0

2 0 1

4 0 0

Yele 5 3 4 Yeben

4 4

1 0 0

4 0 0

2 0 1

Rapid Assessment of Interventions for Improving Maternal and Newborn Health, in Sierra Leone

0 0 0 81

0 0 0

2 0 0

1 0 0

Father

Father in law

Stepmother

Grandmother

Aunty

Friends

Sisters

Chief Mateâ&#x20AC;&#x2122;s mother in law

Brother in law

TBA

Nurses/MCH Aides

Mates

Neighbours

Sisters in law

Childbearing woman

Mother in law Mother of childbearing woman

Overview Venn Diagrammes

Husband

Annex 7

Father

Father in law

Stepmother

Grandmother

Aunty

Sisters

Friends

Chief Mateâ&#x20AC;&#x2122;s mother in law

Brother in law

TBA

Nurses/MCH Aides

Mates

Neighbours

Sisters in law

Childbearing woman

Mother in law Mother of childbearing woman

Husband KOINADUGU No 13

No 14

No 16 No 17 No 18 no times identified ranked 1 ranked 2

2 1 3 5 2 1

3 6

4 4 0 0 0

2 0 1

2 0 0

1 1 0

2 0 0

Yiffin 5 4 Sumbaria 7 2 Bandakoro 1 3 3 5 2 1 0 0

3 1 0

5 0 2

5 4

5 2 1

0 0 0

1 0 0

1 0 1

1 1 0

2 4

1 0 0

KENEMA No 31 No 32 No 33 No 34 no times identified ranked 1 ranked 2

4 1

Gegbwema 1 3 Tongo 2 6 1 2

3 3

1 4 1 1 0

1 0 1

3 1 0

1 0 0

0 0 0

4 2 1

2 0 1

Rapid Assessment of Interventions for Improving Maternal and Newborn Health, in Sierra Leone

5 6 0 0 0

0 0 0

2 0 0

3 3

5 1 0 0

3 0 1

1 0 0

2 0 0

No 20

No 21 No 22

6 3

No 23 No 24 No 25 No 26

1 1 8 1

No 27 No 28

2 2

1 1

No 29 No 30 no times identified ranked 1 ranked 2

2 2

4 3 5 3

6 4

8 4 4

2 7 6

3 5

1 10 5 2

Mabayo 4 5 Kathanta 4 5 2 5 7 Kamawonie 5 6 4 5 1 4 5 Kassikirie

5 1 0

2 4

3 6

10 0 1

2 0 2

5 0 0

1 0 1

6 3 Kamaporto 4 5

8 1 0

2 0 0

Rapid Assessment of Interventions for Improving Maternal and Newborn Health, in Sierra Leone

8 0 0

2 0 1

1 0 0

0 0 0

1 0 0

Father

Father in law

Stepmother

Grandmother

Sisters 2

Aunty

Friends

Mateâ&#x20AC;&#x2122;s mother in law

Chief

Brother in law

TBA

Nurses/MCH Aides

Mates

Neighbours

Sisters in law

Childbearing woman

Mother of childbearing woman

Mother in law

Husband

BOMBALI

Rapid Assessment of Interventions for Improving Maternal and Newborn Health, in Sierra Leone

The following organisations are partners in the Knowledge-Strengthening component of the MDG5 Meshwork Public private Partnerships Programme for Improvement of Maternal Health in Sierra Leone, led by KIT.

Medical Research Centre

University of Sierra Leone

TNO Quality of Life (TNO)

The authors acknowledge the Ministry of Foreign Affairs of the Netherlands and Cordaid for their support.

Disclaimer The views expressed and the information contained herein are not necessarily those of or endorsed by the Dutch Ministry of Foreign Affairs or Cordaid Memisa, and are the sole responsibility of the authors.

Rapid Assessment of Interventions for Improving Maternal and Newborn Health, in Sierra Leone