The maternal mortality Millennium Development Goal (MDG) Sierra Leone needed to achieve by 2015 was 450 maternal deaths per 100,000 live births, however, the estimated maternal mortality ratio (MMR) for 2015 was 1,360 deaths per 100,00 live births (WHO, 2015). If the ideal state for maternal mortality is supposed to be 450 maternal deaths per 100,00 live births as set by the UN (2000) then the need is to reduce the MMR by 910 deaths per 100,000 live births. I chose to use the MDG for maternal mortality as the target state because the 189 UN member states created the MDGs, specifically MDG 5, to improve maternal health worldwide. Two targets were set: target 5A - reduce the MMR by three quarters between 1990 and 2015, and target 5B - achieve universal access to reproductive health by 2015 (UN, 2000). In 2013, an estimated 289,000 women died worldwide during pregnancy and childbirth, this was a 45% decrease from the levels that were recorded in 1990 (WHO, 2015). This proves that the targets set by the UN in 2000 are achievable and one way to reduce the MMR is by providing women with better access to family planning options. Over 10% of all women, worldwide, do not have access to or are not using effective methods of birth control (WHO, 2015). However, there are many more reasons why women and girls in Sierra Leone die as a result of treatable complications of pregnancy and childbirth.
In 2009, the Amnesty International (AM) documented the three delays that are linked to maternal deaths in women and girls in Sierra Leone. The first is the delay in seeking medical care potentially due to their belief in using only traditional medicines or based on past bad experiences with the health-care system or because male decision-makers in the household/cultural barriers do not prioritize the woman’s health. The second delay is accessibility, reaching the health facility to get the care they need can be difficult due to geographical isolation and/or poor road infrastructure (MDSR, 2016). The civil war (1991-2002) destroyed the economy and health infrastructure, which caused an increase in unattended birth deliveries and unavailable emergency obstetric care (Figueroa et al., 2017). Many families also cannot afford transportation to a health care facility and sometimes there are very few ambulances available even if cost is not the issue (AM, 2009). The third delay is due to the quality of care, many facilities do not have skilled doctors, nurses or midwives; there is a lack of availability of essential medications, blood for transfusion, electricity or clean water; there is a limited capacity to perform emergency caesareans and hysterectomies, and poor staff attitude towards patients all contribute to an increase in maternal deaths (AM, 2009; MDSR, 2016).
The root cause I will address is the lack of available and accessible maternal health services. Women in Sierra Leone do not have the same rights as their male counterparts and therefore the importance of women getting quality maternal health care is not recognized as a priority on the national agenda. By improving the availability and accessibility of maternal health services we can begin to tackle the delays that cause maternal deaths. Women may not choose to delay seeking medical care if they are informed on the need for urgent treatment of pregnancy-related complications, available and accessible maternal health services would educate women and their families to recognize these symptoms and seek help. Improving the availability and accessibility of maternal health services means that health facilities, services and information on health will be within easy reach and affordable to everyone (AM, 2009). As well as, improving the availability and accessibility of maternal health services will require all health facilities, goods, services and information to be medically and scientifically appropriate and ‘of good quality’ (AM, 2009). For example, all hospitals and clinics will employ doctors, nurses and midwives that are skilled in their field of work. The inadequate reduction of the MMR is a result of the three interconnected delays that can be addressed by making maternal health services more accessible and available for all women and girls in Sierra Leone.
However, to make maternal health services more accessible and available for women in Sierra Leone there are many barriers that need to be addressed. These barriers include: the inequitable distribution of health services such as emergency obstetric services; insufficient medication and medical equipment in hospitals and clinics; lack of proper medical training for doctors, nurses and/or midwives; the lack of transport to health facilities and the cost of health care (AM, 2009; MDSR, 2016; WHO, 2015). Medical personnel, particularly medical personnel working in remote health centers, do not always get paid on time or if they do receive payment, it is a very small amount (Treacy et al., 2018). Therefore, many health care personnel rely on payment from patients (before a health care service is provided) in order to provide for themselves and their families (Treacy et al., 2018). This requirement of an upfront payment to receive care that is a basic human right is one of the reasons why women in Sierra Leone delay seeking treatment.
However, in 2010, the President of Sierra Leone introduce the Free Health Care Initiative (FHCI), which abolished health user fees for pregnant women, lactating mothers and children under five years of age; after the end of the civil war the government and development partners recognized that for free healthcare to become a reality the entire health system needed to be reinforced (Witter et al., 2018). Evidence shows that the FHCI contributed to increased awareness of danger signs by the community as well as on a smaller scale greater accountability from health services (Witter et al., 2018). The FHCI has also contributed to an increase in postnatal care (PNC) appointments, between 2010 and 2014 the number of first PNC appointments rose by 50% (Witter et al., 2018). Along with the FHCI, the government in Sierra Leone developed the Reproductive, Maternal, Newborn, Child & Adolescent Health Strategy (RMNCAH) for 2017 to 2021, which aims to address many of the barriers to maternal health care.
Thus, the current health system in Sierra Leone does not fully recognize a woman’s right to health, specifically a woman’s right to maternal, sexual and reproductive health; without this acknowledgement improving access and availability of maternal health services will be difficult which may impact the ability of Sierra Leone to reach its target state of 450 maternal deaths per 100,000 live births.