June 7, 2016
Sierra Leone Again Last in Maternal Mortality

Two years ago we reported on the 2013 WHO maternal mortality report then just released by the WHO, which placed Sierra Leone at the bottom of the world ranking. We also ran an interview with Sierra Leone's Chief Medical Officer in which he defended his ministry's record and asserted that improvements were being made. Sierra Leone's then Minister of Health, Miatta Kargbo, describing the findings as not a true indication of the effectiveness of the government's Free Health Care Initiative, FHCI, a costly government program targeted at pregnant women, lactating mothers and under-five children. Two years on, the WHO has released the 2015 edition of the maternal mortality report and Sierra Leone again finds itself at the bottom of the ranking. Indeed, Sierra Leone's Maternal Mortality Ratio, MMR, actually deteriorated in the two year period, from 1100 to 1360 maternal deaths per 100,000 live births. The gap between Sierra Leone and the rest of the world increased significantly: this time round the second-to-last country was the Central African Republic, with an MMR of 881. In 2013, this position was held by Chad, with an MMR of  980. Improving maternal health is one of the Millenium Development Goals adopted in 2000 by all UN member states.

In 2014 government officials including the Minister of Health and the Chief Medical Officer defended the performance of the Ministry of Health, whilst not disputing the WHO's figures. This time round the reaction has been more muted, and some sections of the government appear to be questioning the WHO's findings, even though the results are substantially based on figures provided by the self same government. The deputy Minister of Health, Madinatu Rahman in the regular Sierra Leone Broadcasting Corporation press conference of June 2 claimed that the figures were not accurate. The 2015 report takes pains to stress the efforts that have been made to ensure that its findings are accurate and internationally comparable:

"Given the challenges of obtaining accurate and standardized direct measures of maternal mortality, the Maternal Mortality Estimation Inter-Agency Group (MMEIG) – comprising the World Health Organization (WHO), the United Nations Children’s Fund (UNICEF), the United Nations Population Fund (UNFPA), World Bank Group and the United Nations Population Division (UNPD) – partnered with a team at the University of Massachusetts Amherst, United States of America (USA), the National University of Singapore, Singapore, and the University of California at Berkeley, USA, to generate internationally comparable MMR estimates with independent advice from a technical advisory group that includes scientists and academics with experience in measuring maternal mortality."

Amongst African countries, the report highlights Cape Verde and Rwanda for having achieved the relevant Millenium Development Goal of a 75% reduction in the MMR between 1990 and 2015. Rwanda, facing some criticism nowadays for a perceived undemocratic administration, is particularly noteworthy for having  reduced a very high MMR of 1300 in 1990  to just 290 in 2015.  Sierra Leone's neighbours, Guinea and Liberia, similarly affected by Ebola in 2014 and 2015, have recorded MMRs of 679 and 725, approximately half the Sierra Leonean rate. Gambia is recorded with a rate of 706, Nigeria 814 and Ghana 319. By contrast the best performing countries in the world, Poland, Iceland, Greece and Finland, have Maternal Mortality Rates of just 3 deaths per 100,000 live births.

The continuing failure to show significant improvement in the MMR figures is an acute embarrassment, not only to the Sierra Leone government but to the international community, which has poured many millions of dollars into the campaigh to improve health indicators and outcomes in Sierra Leone. The WHO, UNICEF, UNFPA, and DFID, amongst others, were all enthusiastic participants in the free healthcare programme, FHCI, which was launched with much fanfare by President Ernest Bai Koroma in 2010. In the early years of the program it was very often touted as one of the government's major successes. The specific goal was to bring about improvements in health outcomes for pregnant women, lactating mothers and new-born children by providing them with free medical care, including drugs. From the start the program was beset by problems, with frequent allegations that drugs, often purchased by international partners, ended up being sold in pharmacies even whilst the clinics providing the supposedly-free health care service were turning away patients in need of drugs. As far back as 2011, Amnesty International issued a report calling for the government to strengthen monitoring and accountability within the program so as to stop people who "exploit the system and plunder valuable medicines".

Quite apart from the issue of the availability of free drugs, the Maternal Mortality Rate is intricately linked with the MCH service in Sierra Leone. The government’s front line troops in the fight to combat maternal mortality around the country are its Maternal and Child Health (MCH) Aides. They enter the medical field at a lower level than regular nurses and are trained specifically for ante- and post-natal care (ANC, PNC). They man hundreds of MCH Posts all around the country that provide basic ANC and PNC for the great majority of rural communities. They are trained to refer patients to higher-level institutions at the first sign of serious complication. There are indications that all has not been well with the MCH program for a good number of years. We will explore this in our next health report.