Illustration by Punnava Alam
Article by Amy Qiao
As Isata Dumbuya, the director of reproductive, maternal, neonatal, and child health at Partners in Health in Sierra Leone, states, “Every time we cannot give a pregnant woman what she needs, it’s a tragedy.” However, it is an unfortunately common tragedy in Sierra Leone, the third deadliest place in the world to give birth. While most of these deaths are fully preventable, an under-equipped healthcare system leaves many in peril.1 Maternal mortality has long been an issue in Sierra Leone, but that is not to say it is unsolvable. By transforming the maternal healthcare system and reducing teenage pregnancy rates, Sierra Leone can address this long-standing, dangerous public health issue.
Before we can explore solutions to maternal mortality in Sierra Leone, we must first understand the severity and leading causes of the issue. In 2017, the modeled estimate of maternal mortality ratio (MMR) in Sierra Leone was 1,120 per 100,000 live births. For perspective, the global modeled estimate was 211, and the modeled estimate in the United States was 19.2 Maternal mortality is caused by the “three delays”: a delay in deciding to seek care, identifying and reaching a medical facility, and receiving appropriate care. These delays are exacerbated by several causes, most notably a lack of access to high-quality maternal healthcare and high teenage pregnancy rates, both of which are significantly prevalent in Sierra Leone.2 Tackling these three delays at their root causes is the key to addressing maternal mortality.
At the root of the three delays is a lack of access to high-quality maternal healthcare. The aftermath of the Sierra Leone Civil War (1991-2002) left three-fourths of the nation’s health centers in ruins and many without any healthcare access, worsening the prevailing maternal mortality problem.1 The problem is even worse for pregnant people in rural areas where hospitals are harder to get to and transportation is less prevalent. The issue is not limited to a lack of healthcare facilities but also a lack of resources within those facilities. The leading cause of maternal mortality in Sierra Leone is postpartum hemorrhage, which can be treated by a blood transfusion.4 However, many hospitals are not equipped with blood banks. Some physicians advise pregnant people to prepare their own emergency supply of blood during the third trimester, but this is an unrealistic expectation for many.1 In addition, healthcare facilities in Sierra Leone often lack critical resources such as electricity, running water, and delivery beds.3 A lack of healthcare facilities coupled with a shortage of resources is a significant contributor to the three delays.
Beyond inadequate access to maternal healthcare, maternal mortality is aggravated by high rates of teenage pregnancy fueled by child marriage. In 2020, Sierra Leone had an adolescent fertility rate of 107 per 1,000 live births, more than double the global rate and over six times the US rate.2 Child marriage is a significant issue in Sierra Leone, with recent data estimating that nearly 40% of girls in Sierra Leone get married before the age of 18.5 Child brides are much more likely to experience teenage pregnancy, leading to a higher risk of pregnancy and labor-related complications. Child marriage also prevents young girls from continuing their education, which can be a valuable foundation for empowering futures, promote family planning, and ultimately reducing teenage pregnancy and maternal mortality.5
While the problems that contribute to maternal mortality seem incredibly daunting, there are several solutions Sierra Leone can turn to. Regarding health sector solutions, Sierra Leone must expand the number of healthcare facilities available to pregnant people as well as improve the quality of maternal healthcare within those hospitals. Sierra Leone has made tremendous strides in healthcare accessibility with the introduction of the Free Health Care Initiative (FHCI) in 2010, which made healthcare free for children under five and pregnant/breastfeeding people. This was a crucial step in increasing access to maternal healthcare, with the proportion of women giving birth in a hospital growing from 25% in 2008 to 83% in 2019.1 However, many pregnant people in rural areas never make it to a hospital and instead receive services from Traditional Birth Attendants who are not trained to treat certain medical complications.6 To effectively reduce MMR, UNICEF recommends Sierra Leone establish at least five Basic Emergency Obstetrical and Neonatal Care centers and one Comprehensive Emergency Obstetric and Neonatal Care center in each of its sixteen districts.6 Ensuring that each district is adequately equipped to care for its pregnant population is essential to dismantling the three delays.
The quality of care in these hospitals is equally if not more important. The Wellbody Clinic in Sierra Leone, established by Partners in Health, prioritizes the mentorship of maternity staff and provides maternal waiting homes where pregnant people can be monitored 24 hours before their due date.7 Although it is only one of two healthcare facilities in the Kono district, it has paved the way for high-quality maternal healthcare. In the past four years, the clinic has had no maternal mortality.7 Using the Wellbody Clinic as a blueprint, Sierra Leone must continue to establish comparable high-quality maternal healthcare facilities throughout the nation.
Along with health sector solutions, Sierra Leone must prioritize non-health sector solutions to address the high rates of teenage pregnancy, specifically through delaying child marriage. Child marriage is a major obstacle to reducing maternal mortality and is rooted in firmly established gender norms. However, Sierra Leone can take multiple measures to address these obstacles. From 2016-2019, the country implemented Phase I of the UNFPA–UNICEF Global Program to End Child Marriage which promoted girls’ empowerment and engagement, created vital discussion surrounding gender equity and child marriage, and coordinated studies on child marriage to better inform policy development. These measures were taken in accordance with the National Strategy for Reduction of Adolescent Pregnancy and Child Marriage, which recognizes the connection between child marriage and teenage pregnancy. Altogether, the program led to significant results: over 57,000 young girls aged 10-19 in Sierra Leone participating in at least one intervention to equip them with skills and information to prevent child marriage, and almost 9,000 were able to enroll and continue with their education.8 For Phase II of the program, Sierra Leone must build upon important lessons learned in Phase I, incorporating important lessons learned. This involves increasing the reach of the program to young girls throughout Sierra Leone, ensuring schools provide comprehensive sexual education, and promoting positive social norms throughout communities while eliminating harmful gender norms.8
Maternal mortality is a daunting public health challenge, but prioritizing these solutions will ensure every pregnant person receives the care they need. Some of these solutions require funding and others a cultural shift, but a need they share in common is a global commitment to improving healthcare and gender equality in low- and middle-income countries. With the proper global support, Sierra Leone can embrace the solutions needed to tackle one of the biggest public health challenges in the world.
- Danielle P. Where pregnancy is a deadly gamble. Washington Post. Accessed November 8, 2022. https://www.washingtonpost.com/world/interactive/2022/sierra-leone-maternal-mortality
- World Bank open data | data. Accessed November 8, 2022. https://data.worldbank.org/
- Harriet M. In Sierra Leone, new hospital facilities save mother’s lives. Published April 5, 2017. Accessed March 18, 2023. https://www.unicef.org/stories/sierra-leone-new-hospital-facilities-help-save-mothers-lives
- Maternal, neonatal and child health. Accessed November 8, 2022. https://www.unicef.org/sierraleone/maternal-neonatal-and-child-health
- Harriet M. Ending child marriage and teenage pregnancy in Sierra Leone. Published September 19, 2017. Accessed November 8, 2022. https://www.unicef.org/stories/ending-child-marriage-and-teenage-pregnancy-sierra-leone
- Harriet M. Making strides to improve maternal health in Sierra Leone. Published May 26, 2016. Accessed November 8, 2022. https://www.unicef.org/stories/making-strides-maternal-health-worst-place-to-be-mothe
- Sierra Leone. Partners In Health. Accessed November 8, 2022. https://www.pih.org/country/sierra-leone
- UNICEF. Sierra Leone Country Profile.; 2020. Accessed November 8, 2022. https://www.unicef.org/media/88841/file/Child-marriage-Sierra-Leone-profile-2019.pdf