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Elston JWT, Danis K, Gray N, West K, Lokuge K, Black B, Stringer B, Jimmisa AS, Biankoe A, Sanko MO, Kazungu DS, Sang S, Loof A, Stephan C, Caleo G. Maternal health after Ebola: unmet needs and barriers to healthcare in rural Sierra Leone. Health Policy Plan 2020; 35:78-90. [PMID: 31697378 DOI: 10.1093/heapol/czz102] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/03/2019] [Indexed: 11/13/2022] Open
Abstract
Sierra Leone has the world's highest estimated maternal mortality. Following the 2014-16 Ebola outbreak, we described health outcomes and health-seeking behaviour amongst pregnant women to inform health policy. In October 2016-January 2017, we conducted a sequential mixed-methods study in urban and rural areas of Tonkolili District comprising: household survey targeting women who had given birth since onset of the Ebola outbreak; structured interviews at rural sites investigating maternal deaths and reporting; and in-depth interviews (IDIs) targeting mothers, community leaders and health workers. We selected 30 clusters in each area: by random GPS points (urban) and by random village selection stratified by population size (rural). We collected data on health-seeking behaviours, barriers to healthcare, childbirth and outcomes using structured questionnaires. IDIs exploring topics identified through the survey were conducted with a purposive sample and analysed thematically. We surveyed 608 women and conducted 29 structured and 72 IDIs. Barriers, including costs of healthcare and physical inaccessibility of healthcare facilities, delayed or prevented 90% [95% confidence interval (CI): 80-95] (rural) vs 59% (95% CI: 48-68) (urban) pregnant women from receiving healthcare. Despite a general preference for biomedical care, 48% of rural and 31% of urban women gave birth outside of a health facility; of those, just 4% and 34%, respectively received skilled assistance. Women expressed mistrust of healthcare workers (HCWs) primarily due to payment demanded for 'free' healthcare. HCWs described lack of pay and poor conditions precluding provision of quality care. Twenty percent of women reported labour complications. Twenty-eight percent of villages had materials to record maternal deaths. Pregnant women faced important barriers to care, particularly in rural areas, leading to high preventable mortality and morbidity. Women wanted to access healthcare, but services available were often costly, unreachable and poor quality. We recommend urgent interventions, including health promotion, free healthcare access and strengthening rural services to address barriers to maternal healthcare.
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Affiliation(s)
- James W T Elston
- UK Field Epidemiology Training Programme, Public Health England, Blenheim House, West One, Duncombe Street Leeds, LS1 4PL, UK
| | - Kostas Danis
- Santé Publique France, the French national public health agency (SP France), 12 rue du Val d'Osne 94415 Saint-Maurice Cedex, France.,European Centre for Disease Prevention and Control (ECDC), European Programme for Interventional Epidemiology Training (EPIET), Tomtebodavägen 11A, 171 65 Solna, Sweden
| | - Nell Gray
- Manson Unit, Médecins Sans Frontières (MSF), Lower Ground Floor, Chancery Exchange, 10 Furnival Street, London EC4A 1AB, UK
| | - Kim West
- Manson Unit, Médecins Sans Frontières (MSF), Lower Ground Floor, Chancery Exchange, 10 Furnival Street, London EC4A 1AB, UK
| | - Kamalini Lokuge
- National Centre for Epidemiology and Population Health, Research School of Population Health, Australian National University, Building 62, Mills Road, Canberra, ACT 2601, Australia
| | - Benjamin Black
- The Whittington Hospital, Magdala Ave, London, N19 5NF, UK
| | - Beverley Stringer
- Manson Unit, Médecins Sans Frontières (MSF), Lower Ground Floor, Chancery Exchange, 10 Furnival Street, London EC4A 1AB, UK
| | - Augustine S Jimmisa
- District Health Management Team, Ministry of Health and Sanitation, Magburaka, Tonkolili, Sierra Leone
| | - Aiah Biankoe
- District Health Management Team, Ministry of Health and Sanitation, Magburaka, Tonkolili, Sierra Leone
| | - Mohammed O Sanko
- District Health Management Team, Ministry of Health and Sanitation, Magburaka, Tonkolili, Sierra Leone
| | - Donald S Kazungu
- Médecins Sans Frontières - Operational Centre Amsterdam, Naritaweg 10, 1043 BX Amsterdam, The Netherlands
| | - Sibylle Sang
- Médecins Sans Frontières - Operational Centre Amsterdam, Naritaweg 10, 1043 BX Amsterdam, The Netherlands
| | - Annemarie Loof
- Médecins Sans Frontières - Operational Centre Amsterdam, Naritaweg 10, 1043 BX Amsterdam, The Netherlands
| | - Claudia Stephan
- Médecins Sans Frontières - Operational Centre Amsterdam, Naritaweg 10, 1043 BX Amsterdam, The Netherlands
| | - Grazia Caleo
- Manson Unit, Médecins Sans Frontières (MSF), Lower Ground Floor, Chancery Exchange, 10 Furnival Street, London EC4A 1AB, UK
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Vallières F, Cassidy EL, McAuliffe E, Gilmore B, Bangura AS, Musa J. Can Sierra Leone maintain the equitable delivery of their Free Health Care Initiative? The case for more contextualised interventions: results of a cross-sectional survey. BMC Health Serv Res 2016; 16:258. [PMID: 27412299 PMCID: PMC4942899 DOI: 10.1186/s12913-016-1496-1] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2014] [Accepted: 06/28/2016] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND In 2010, the Ministry of Health and Sanitation in Sierra Leone launched their Free Health Care Initiative (FHCI) for pregnant and lactating mothers and children under-5. Despite an increase in the update of services, the inequitable distribution of health services and health facilities remain important factors underlying the poor performance of health systems to deliver effective services. This study identifies current gaps in service delivery across two rural locations served by the same District Health Management Team (DHMT). METHODS We employed a cross-sectional household survey using a two-stage probability sampling method to obtain a sample of the population across two rural locations in Bonthe District: the riverine and the mainland. Overall, a total of 393 households across 121 villages were surveyed in the riverine and 397 households across 130 villages were sampled on the mainland. Maternal health, child health and sanitation indicators in Bonthe District were compared using Pearson Chi-Squared test with Yates' Continuity Correction across the two areas. RESULTS Women across the two regions self-reported significantly different uptake of family planning services. Children on the mainland had significantly greater rates of health facility based deliveries; being born in the presence of a skilled birth attendant; completed immunisation schedules; and higher rates of being brought to the health centre within 24 h of developing a fever or a suspected acute respiratory infection. Households on the mainland also reported significantly greater use of treated water and unrestricted access to a latrine. CONCLUSIONS If the government of Sierra Leone is going to deliver on their promise to free health care for pregnant women and their children, and do so in a way that reduces inequalities, greater attention must be paid to the existing service delivery gaps within each District. This is particularly relevant to health policy post-Ebola, as it highlights the need for more contextualised service delivery to ensure equitable access for women and children.
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Affiliation(s)
- Frédérique Vallières
- />Centre for Global Health, Trinity College Dublin, University of Dublin, 7-9 Leinster Street South, Dublin 2, Ireland
- />School of Psychology, Trinity College Dublin, University of Dublin, 2 College Green, Dublin 2, Ireland
| | - Emma Louise Cassidy
- />Centre for Global Health, Trinity College Dublin, University of Dublin, 7-9 Leinster Street South, Dublin 2, Ireland
| | - Eilish McAuliffe
- />School of Nursing, Midwifery and Health Systems, College of Health Sciences, University College Dublin, Belfield, Dublin 4, Ireland
| | - Brynne Gilmore
- />Centre for Global Health, Trinity College Dublin, University of Dublin, 7-9 Leinster Street South, Dublin 2, Ireland
| | - Allieu S. Bangura
- />World Vision Sierra Leone, 35 Wilkinson Road, Freetown, Sierra Leone
| | - Joseph Musa
- />World Vision Sierra Leone, 35 Wilkinson Road, Freetown, Sierra Leone
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