FOCUS ON SIERRA LEONE

MATERNAL HEALTHHow can we ensure that all women have access to

quality maternal health care?

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?MATERNAL HEALTH Why is maternal health an issue?

CHECK IT OUTTo find out more about fistula and other women’s issues, read/watch “Half the Sky”: http://www.halftheskymovement.org/Learn more about the causes of maternal mortality: http://www.who.int/mediacentre/factsheets/fs348/en/index.html

Between 1990 and 2015, the maternal mortality rate has decreased by about 44 percent globally. Despite this progress in improving maternal health, the leading cause of death and disability among women of reproductive age (ages 15–49) in the developing world continues to be from complications during pregnancy and childbirth. Nearly 300,000 women die of complications during pregnancy or

childbirth every year, and 99 percent of these deaths occur in the developing world. Though maternal mortality has decreased over the last 20 years, this number is still unacceptably high because almost all of these deaths could have been prevented, even in the least developed countries. Women also suffer from disabilities due to complications, such as fistula, which can occur during childbirth.

IMPACTS OF MATERNAL MORTALITY

Maternal mortality occurs when there are complications during pregnancy or during or after childbirth. Most maternal deaths occur on the day of delivery, which is why having a skilled birth attendant present at the birth is very important. Approximately 75 percent of all maternal deaths are from the following major complications:

■■ Severe bleeding or hemorrhage (during or after childbirth)

■■ Infections such as sepsis (mostly after childbirth)

■■ High blood pressure or hypertension (during pregnancy)

■■ Unsafe abortion

The remaining 25 percent are caused by complications from diseases such as HIV and AIDS or malaria.

CAUSES OF MATERNAL MORTALITY

WHAT IS MATERNAL HEALTH?Maternal health refers to the health of women during pregnancy, childbirth, and the postpartum period (World Health Organization).

Hemorrhage27%

Indirect28%

Other direct10%

Hypertension14%

Sepsis11%

Unsafe abortion 8%Embolism 3%

Definitions

Maternal Mortality (Death) Maternal mortality occurs when a mother dies while pregnant, within six weeks of giving birth, or during the termination of a pregnancy, even if the cause of death is not directly related to her pregnancy.

Neonatal Mortality Neonatal mortality rates are based on the number of infant deaths that take place during the first month of life.

Antenatal Care The medical care given to women during pregnancy. It includes monitoring the health of the mother as well as the fetus (the unborn child) and giving the mother preventative care during her pregnancy such as the tetanus vaccine, iron supplements, and preventative treatment for malaria. It is recommended that women have at least four antenatal care visits during their pregnancy.

Postnatal Care The medical care given to the mother and newborn child after birth and during the first six weeks of life after birth.

Obstetrics The branch of medicine and surgery concerned with childbirth and maternal care after birth.

Source: UNICEF, 2015

Global Estimates of the Causes of Maternal Deaths

FISTULAFistula is an incredibly painful childbirth injury, which mainly occurs in poor countries where women give birth without any medical help or give birth at a very young age. During labor, the baby’s head is constantly pushing against the mother’s pelvic bone. This pushing can create a hole, or fistula, between the birth passage and other organs, meaning women who suffer from it cannot hold bodily fluids or waste. This, along with the fact that it often makes women unable to have additional children, causes many sufferers to be treated as social outcasts. Thankfully, this condition is treatable with a surgery that costs about $450. However, many women who suffer from it cannot afford the procedure.

?MATERNAL HEALTH AROUND THE WORLD Where is maternal mortality a serious problem?

DID YOU KNOW?■■ Every day, about 830 women die due to complications of pregnancy and child birth.

■■ More than half these deaths occur in sub-Saharan Africa and almost one third occur in South Asia.

■■ Complications in pregnancy and childbirth is a leading cause of death among adolescent girls in developing countries.

■■ Improving maternal health also drastically improves child survival rate.

Source: WHO, 2015

In the year 2015, world leaders gathered at the United Nations Sustainable Development Summit to set goals addressing 17 of the world’s most pressing issues, following the Millennium Development Goals developed in 2000. Sustainable Development Goal (SDG) three focuses on health and well-being for all with a specific target to reduce the global maternal mortality ratio to less than 70 per 100,000 live births by 2030.

Despite recent progress, we are still short of the annual decline needed to meet the goal. As of 2010, the global maternal mortality ratio declined by only 3.1 percent per year since 1990. This is still far less than the 7.5 percent annual decline required to achieve the SDG maternal health target.

What do you think world leaders should do in order to meet this goal?

SUBSTANTIAL GEOGRAPHIC DISPARITIES IN MATERNAL MORTALITY

CHECK IT OUTLearn more about maternal health: http://www.childinfo.org/maternal_mortality.htmlLearn more about Sustainable Development Goal Three: https://sustainabledevelopment.un.org/sdg3

THE RIGHT TO HEALTH

Essentially, the right to health means governments must create conditions in which all people in their country—men, women, and children—are able to be as healthy as possible. The right to health has been published in numerous international human rights declarations and treaties. Perhaps the most notable is the Universal Declaration of Human Rights (UDHR), which has been signed by every country in the world but three: the United States, Somalia, and South Sudan.

How can governments create better conditions for maternal health? They can encourage or provide reproductive and sexual health services such as family planning, antenatal and postnatal care, and emergency obstetric services; improve

human resources for health so there are more skilled birth attendants; and increase access to information on maternal health and nutrition.

What do you think are some of the barriers to governments in the developing world providing these services? Make a list, then check your answers on page 5.

As of 2015, the average maternal mortality ratio in developing countries was 239 per 100,000 live births, which is far more than the average 12 per 100,000 ratio in developed countries. The levels of maternal care have increased in many parts of the world during the past decade. However, only 51 percent of women in low-income countries have access to skilled care during childbirth, meaning millions of births are not assisted by a skilled caregiver such as a midwife, a doctor, or a nurse, resulting in a high number of deaths.

The enjoyment of the highest attainable standard of health is one of the fundamental rights of every human being without the distinction of race, religion, political belief, economic or social condition.

—World Health Organization Constitution

2030 GLOBAL GOALS

United States14/100,000

Death per 100,000 live births

Afghanistan496/100,000

India174 /100,000

Australia6/100,000

DRC693 /100,000

Sierra Leone1,360 /100,000

France8 /100,000

Map: WHO, 2015

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Sierra Leone Country InformationLOCATION: Western Africa

CAPITAL: Freetown

POPULATION: 6 million

SIZE: Slightly smaller than South Carolina

LANGUAGES: English, Mende, Temne, Krio

RELIGIONS: Muslim 60 percent, Indigenous beliefs 30 percent, Christian 10 percent

LIFE EXPECTANCY: 58 years

INFANT MORTALITY RATE: 70 deaths /1,000 live births

MATERNAL MORTALITY RATE: 1,360 deaths /100,000 live births

ACCESS TO CLEAN WATER: 63 percent

LITERACY RATE: 48 percent

POPULATION LIVING ON LESS THAN $1.25/ DAY: 60 percent

AT LEAST FOUR ANTENATAL CARE VISITS: 76 percent

INSTITUTIONAL DELIVERY (AT HOSPITAL OR CLINIC): 54 percent

SKILLED ATTENDANT AT BIRTH: 60 percent

LIFETIME RISK OF MATERNAL DEATH: 1 in 17

Sources: UNICEF & CIA World Factbook, 2016

In the 1780s, Sierra Leone became the home of a campaign by British philanthropist Granville Sharp, who suggested it serve as the site for a new home for hundreds of freed slaves. These freed slaves, from Nova Scotia, lived in a settlement known as a Freetown, now the capital of Sierra Leone. The British took responsibility for the country and adopted it as its base during its campaign against the slave trade. Over the next fifty years, approximately 50,000 slaves were recaptured by the British navy, freed, and brought back to Sierra Leone. Sierra Leone was under British control until it achieved independence in 1961.

In 1991, civil war broke out in the country after a rebel group, the Revolutionary United Front (RUF), began to attack villages on the eastern Liberian border. A military coup in 1992, which began as a result of unchecked corruption and bad governance, was partially affected by a similar war that was occurring at that same time in neighboring Liberia.

SIERRA LEONEHow do poverty and political instability affect maternal health?

CHECK IT OUTLearn more about Sierra Leone: http://www.sierra-leone.org/Learn more about Concern’s response to the Ebola crisis: www.concernusa.org/our-approach/what-we-do/emergency-response/ebola

In January 2002, the President declared the civil war officially over. However, during this eleven-year period, tens of thousands of people died and more than two million people (about one-third of the population) were displaced. As a result, poverty became even more widespread, the majority of schools were closed, and hospitals and clinics were shut down, looted, or left understaffed. Health services were very limited and costly, leaving few people who could afford healthcare even if they had access to it.

Since the end of the war, Sierra Leone has been slowing trying to reestablish democracy. Sierra Leone has also achieved significant economic growth, but it still has a long way to go. In 2012, the country held its first democratic elections. The new government lists its priorities as furthering development, creating jobs, and ending corruption. Sierra Leone’s progress was interrupted in 2014 by the Ebola epidemic which spread throughout the country.

HISTORY

SIERRA LEONE

DID YOU KNOW?■■ The country’s name comes from “Serra Leoa,” which means “Lion Mountain Range” in Portuguese.

■■ Sierra Leone is home to many natural resources including diamonds, titanium, bauxite, iron, and gold.

■■ The world’s third largest diamond was found in Sierra Leone in 1972. It is called the “Star of Sierra Leone” and worth $3 million.

Above: Freetown, Sierra Leone

?In 2010, the Government of Sierra Leone launched a new initiative to provide free health care for all pregnant women, breastfeeding mothers, and children under fi ve years old. Concern is a member of the group of health sector actors who advocated for and are currently supporting this policy. The implementation of free health care has been instrumental in the effort to expand access to essential services, as cost of treatment is one of the major barriers to improving maternal health.

Concern works with the Ministry of Health and Sanitation to increase the quality of

MATERNAL HEALTH IN SIERRA LEONEHow can we improve maternal health in Sierra Leone?

maternal and newborn health services provided at health facilities through intensive technical training and on-the-job supervision. Concern also works with the government and other partners to advocate for improved systems to ensure that all health facilities have the medical supplies and equipment they need to deliver high quality care. In addition, Concern trains Community Health Workers to refer women to the health facility for antenatal care and delivery, to teach women about healthy practices during pregnancy, and to instruct them in proper newborn care.

FREE HEALTH CARE INITIATIVE

CHECK IT OUTLearn more about the Free Healthcare Initiative: http://www.healthpovertyaction.org/wp-content/uploads/downloads/2012/07/SierraLeoneFHIbriefi ngweb12.pdfRead about Sierra Leone’s high maternal mortality rate: www.concernusa.org/press/the-slow-road-to-progress-why-is-sierra-leones-maternal-mortality-rate-so-high/

In 2010, Concern supported over 300 women in weekly Pregnant Women’s Club sessions held at Concern-supported clinics. During these meetings, women are guided through topics such as what to expect during different stages of labor, common problems and dangers during pregnancy, how to minimize transmission of sexually transmitted diseases to children, the benefi ts of breastfeeding, and the importance of immunizations.

PREGNANT WOMEN’S CLUBS

Mariama’s Story

Mariama Dumbuya is a twenty-year-old mother to her daughter, Adama. Mariama attended the Pregnant Women’s Club for pregnant women and new mothers in Portee-Rukupa, an urban slum area in Freetown. Prior to attending the Pregnant Women’s Club, Mariama, like many mothers in Sierra Leone, initially only fed her newborn baby water, believing it was the best for her child. She now thinks the most important lesson she took away from the weekly club meetings was the importance of exclusive breastfeeding. As a result of learning about the nutritional benefits of breast milk, she has since switched to breastfeeding.

1,000 DAYS The fi rst 1,000 days of a child’s life is the window of time where proper nutrition is fundamental in terms of a child’s physical growth, ability to learn, and health. These 1,000 days start at conception and last until the child is two years old, meaning a mother’s nutrition during pregnancy and the child’s nutritional status until the age of two plays an incredibly important role in the health of the child. Proper nutrition during this stage helps prevent irreversible defi ciencies, increases the child’s ability to be a productive member of society, and helps break the cycle of poverty. The 1,000 Days campaign is an advocacy group that promotes global action and investment to improve nutrition for mothers and children during this critical 1,000 fi rst days. Concern Worldwide is currently participating in the 1,000 Days campaign with several partner organizations, including Save the Children, Care, and the U.S. Department of State.

Above: Former U.S. Secretary of State Hillary Clinton with Concern Worldwide’s former CEO, Tom Arnold. Photo: Concern Worldwide.

1,000 DAYS 1,000 DAYS

?Cost of Health Care

Many developing countries do not have free health care for mothers and children under five. This is a huge barrier to mothers in these countries, as over 700 million people live in abject poverty, meaning they live on $1.90 a day or less. For them, even small health care fees are often impossible to pay, making it less likely that they will seek care at a clinic or hospital.

Location of Clinics and Lack of Transportation

More than 60 percent of people living in impoverished countries live more than five miles from a health facility. This distance drastically increases for those living in rural areas. For example, in Zambia it takes an average of 11 hours for a woman in labor to reach a health care facility that is equipped to meet her needs. Even if a mother lives relatively close to a health care facility, she often has no transportation or has to travel over really bad roads, making the journey much longer and much more difficult. Traveling long distances is also difficult because it takes women away from their responsibilities at home, such as taking care of their other children and household needs.

Number of Trained Health Care Workers

There is an overall lack of trained doctors, nurses, midwives, and other health care workers in most developing countries. Africa suffers from a deficit of 2.4 million doctors and nurses. They currently only have about two trained health care workers for every 1,000 people. In the Americas, however, there are approximately 25 health care workers per 1,000 people.

WHAT ARE THE OBSTACLES TO IMPROVING MATERNAL HEALTH?

BARRIERS TO IMPROVING MATERNAL HEALTH

“The health of a mother and child is a more telling measure of a nation’s state than economic indicators.”

—Harjit Gill, Former CEO of

Philips ASEAN and Pacific

“What we have learned today complements our own experiences from outside this session . . . Building on this, myself and some of the other men plan to form an outreach committee to share our learning with other men in our community and mobilize them to better support their wives during pregnancy.”

—Gibril Carew, participant in the Concern Men’s Orientation

session in Kroo Bay slum, Freetown

Cultural Barriers

Some cultures prefer using more traditional birth attendants and birth practices. This can be problematic if the birth attendants are not properly trained to recognize the warning signs of a troubled pregnancy or if they do not have access to medicine and equipment needed to tend to sick mothers and children. In some countries, certain cultural traditions lead men to feel that it is not necessary for them to accompany their wives or partners to a health care facility, which makes it even more difficult for a woman to get access to a trained health care provider.

CHECK IT OUTLearn about how Concern re-trained traditional birth attendants: www.concernusa.org/feature_story/first-banned-then-reborn/Read about other solutions to maternal mortality: http://www.unicef.org/health/index_maternalhealth.html

“It is my aspiration that health finally will be seen not as a blessing to be wished for, but as a human right to be fought for.”

—Former United Nations Secretary-General Kofi Annan

?In order to meet the third SDG, people around the world are coming together to implement innovative solutions in order to increase women’s access to maternal health services and thereby decrease maternal mortality rates. Below are some ideas that are being used by various governments, local communities, and NGOs to improve maternal health.

Which ones do you think will be most effective? Can you think of other ideas?

Educating Women

Teaching women the importance of good hygiene before and after childbirth can help prevent infections. Educating girls and women about the importance of antenatal care and family planning, encouraging girls to delay their first pregnancy, and helping women understand the importance of delivering with a skilled birth attendant also help decrease the maternal mortality rate. Providing women and girls with a traditional education, such as numeracy and literacy skills, is also incredibly important because better-educated women tend to marry later and have fewer children.

Look at the graph below. What are other ways you think education level affects maternal mortality rates?

POSSIBLE SOLUTIONS

How can all countries ensure that

MOTHERS RECEIVE QUALITY HEALTH CARE?

Community Health Workers

Instead of focusing solely on more traditional approaches to women’s health such as directly implementing programs in health clinics, Concern brings basic health care to people’s doorsteps. This saves mothers time and improves access to healthcare for the poorest populations. This approach is unique because it puts women at the forefront in the fight against preventable diseases. How does Concern do this? Concern works with all locally available resources and stakeholders–such as health providers, volunteers, neighborhood health committees, community-based organizations, social and religious leaders, government officials, and traditional health providers—and facilitates communication between the groups about important issues related to health services. Concern then invests in training and educating women volunteers, who are well respected in their communities, to treat basic medical needs and encourage community members to seek further treatment at a clinic or hospital when necessary. These volunteers are called Community Health Workers. This program not only allows greater access to healthcare for some of the poorest populations, but it also empowers women by giving them a voice and an important role in their communities.

CHECK IT OUTSee how girls’ education improves maternal health: http://unesdoc.unesco.org/images/0022/002259/225945e.pdfRead about how satellites were used to map community health workers: unicefstories.org/2016/10/31/mapping-community-health-workers-with-satellites-in-sierra-leone/

Providing Medications

Over 25 percent of women who die following childbirth die because of severe bleeding. Injecting a medicine called oxytocin immediately after childbirth can effectively reduce the risk of bleeding. Pre-eclampsia, or high blood pressure during pregnancy, is also major cause of maternal mortality. Yet, administering drugs such as magnesium sulfate can reduce a woman’s risk of developing pre-eclampsia. However, many clinics and hospitals in developing countries do not have access to lifesaving medicines such as these. Providing clinics with these medicines could potentially save thousands of lives.

Educating Men on Maternal Health Issues

While educating women on issues relating to maternal and child health is incredibly beneficial, it is not enough to ensure sustained behavior change. Therefore, men also need to be engaged and made aware of how they can actively support their wives and partners. Concern instituted three-hour Men’s Orientation sessions so that participants could share their own experiences and to mobilize them for behavior change. Since implementing the program, there is strong evidence that the interest and involvement of men in the community has improved and the number of husbands accompanying their wives to clinics during pregnancy has increased.

SPEAK OUT !Which of the solutions provided best address each barrier to maternal health?

PROBLEMS SOLUTIONS

Health Care Costs Educating Women

Location and Lack Community of Transportation Health Workers

Lack of Providing Trained Workers Medications

Cultural Educating Men on Barriers Maternal Health IssuesSource: UNESCO, 2011

UNESCO International Standard Classification of Education

Noeducation

Primaryeducation

Lowersecondaryeducation

Uppersecondaryeducation

Postsecondaryeducation

0.4

0.35

0.3

0.25

0.2

0.15

0.1

0.05

0Dis

tribu

tion

of m

ater

nal d

eath

s (%

)

MATERNAL HEALTHGlobalHealth.govhttp://www.globalhealth.gov/global-health-topics/maternal-and-child-health/Maternal Health Task Forcehttp://maternalhealthtaskforce.org/discover/global-maternal-health-newsWomen Deliverhttp://www.womendeliver.org/knowledge-center/facts-figures/maternal-health/ Center for Disease Controlhttp://www.cdc.gov/reproductivehealth/maternalinfanthealth/index.htm

ORGANIZATIONSEvery Mother Countshttp://www.everymothercounts.org/ Global Organization for Maternal and Child Health www.go-mch.org

REFERENCES AND RESOURCES

The Fistula Foundationwww.fistulafoundation.orgEngender Healthhttps://www.engenderhealth.org The World Health Organizationwww.who.int

SIERRA LEONEThe Guardianwww.guardian.co.uk/world/sierraleoneHuman Rights Watchhttp://www.hrw.org/africa/sierra-leoneThe New York Timeshttps://www.nytimes.com/topic/destination/sierra-leone The World Health Organizationhttp://www.who.int/countries/sle/en/ UNICEFhttps://www.unicef.org/infobycountry/sierraleone_55584.html

CAMPAIGNSCARMMAhttp://www.carmma.orgThe Half the Sky Movementwww.halftheskymovement.org The Thousand Days Campaignwww.thousanddays.org

CONCERN WORLDWIDE US, INCwww.concernusa.org

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332 S Michigan Ave., 9th Fl.Chicago, IL 60604312-431-8400

This publication is intended to inform readers about the issue of maternal health and does not necessarily reflect the views of Concern Worldwide U.S., Inc. or Concern Worldwide on this issue. Concern Worldwide does not officially recommend or endorse any of these organizations.Concern Worldwide U.S., Inc. is a New York not-for-profit corporation exempt from Federal income taxation under section 501(c)(3). Concern Worldwide U.S., Inc. supports projects carried out in the field by Concern Worldwide, registered in Ireland.This publication was written and produced in 2013 and updated in 2017.Photo credits: front and back cover, Kieran McConville; page 2 top, Brenda Fitzsimons; page 2 bottom, page 5 bottom, page 6, Megan Christensen; page 4, Robert Mulhall. All photos except where indicated: Sierra Leone, Concern Worldwide.

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