Sabrina Charles and Billy Mawindo (Guest writers)
Editor’s note: For long, Traditional birth attendants (TBAs) have played and continue to play a key role in maternal healthcare. In this article, Partners in Health–Sierra Leone share how the organisation is building the capacity of TBAs and integrating them into the formal healthcare system to reduce the maternal mortality rate in Sierra Leone.
Sierra Leone ranks as one of the countries with the highest maternal mortality rates in the world. The maternal mortality rate is driven by high-risk pregnancies, and obstetric complications like postpartum haemorrhage, hypertension, obstructed labour, and sepsis. While there is only an estimate of maternal deaths happening outside healthcare facilities, evidence shows that home deliveries are associated with high risk of maternal neonatal deaths. According to the World Health Organization (WHO), major complications that account for nearly 75% of all maternal deaths are mainly due to severe bleeding mostly after childbirth, infections usually after childbirth, high blood pressure during pregnancy, preeclampsia and eclampsia, complications from delivery, and unsafe abortion. However, healthcare providers can only identify, address, and record these complications if pregnant women have access to, and utilise, healthcare services.
The 2019 Sierra Leone Demographic and Health Survey (DHS) indicates that 83% of women in Sierra Leone deliver at health facilities and only 16% deliver at home. In Kono District, where Partners In Health–Sierra Leone has a large presence and closely collaborates with the district health management teams (DMHTs), there are one of the highest maternal mortality rates in the country at 8.9% according to the WHOs 2016 Government of Sierra Leone Health Sector Performance Report. The combination of Kono’s rugged landscape, lack of fundamental resources, and varying levels of distrust in local healthcare facilities has contributed largely to the devastatingly poor maternal and newborn health outcomes. We believe that a key strategy in improving maternal and child health outcomes is to increase the levels of trust between community members and local healthcare facilities and improve care seeking behaviours.
Many women across Sierra Leone maintain a strong sense of trust and comfort with Traditional Birth Attendants (TBAs) for care and home deliveries. TBAs are well regarded and experienced women in communities who assist mothers during childbirth and initially acquired skills by delivering babies serving as the first point of contact for support related to pregnancy and childbirth. However, as TBAs are not clinically trained and practice far from clinical settings inclusive of commodities and medications, the risk of fatal outcomes for their patients tends to be greater.
To increase levels of trust throughout communities in Kono and reduce the number of unsafe home births investments must be made in trust-based and system-wide solutions, specifically designed in partnership with TBAs. Mabel, a woman from Kono, shared that “some women still feel insecure and shy, there’s a lot of fear with women in the community” surrounding facility-based care, and potential lack of support, which corresponds with low rates of facility usage.
Some women have also expressed deep-seated fear about seeking care without someone to accompany them due to their perceptions of healthcare failures at the facilities leading to death. Additionally, women from Kono have highlighted the need for deepened, in-person community engagement and education about the free, high-quality care available for pregnant women as a key vulnerable population. PIH Sierra Leone’s approach to addressing this critical gap in the health system was to establish the Wellbody Coalition.
A coalition for maternal health progress
The Wellbody Coalition is comprised of PIH–Sierra Leone, the National Emergency Medical Services (NEMS), Lifebank, Janitri, and the Sickle Cell Carers Awareness Network (SCCAN). We work alongside NEMS to serve the greater population of Kono District to ensure timely and safe ambulance transport. Lifebank is a company offering their expertise in establishing blood banks and on-demand delivery of blood services in low resource settings. Janitri is enabling an innovative maternal health technology by equipping health facility staff with a cost-effective monitoring tool to identify high-risk pregnancies. SCCAN, is a Kono based organisation striving to raise awareness about sickle cell disease, prevention, and treatment options, which is a great need throughout the district. Moreover, our coalition’s expertise and engagement are supported by the Ministry of Health (MoH) and District Health Management Teams (DHMTs), who are jointly responsible for public health facility operations in Kono by supporting all levels of care delivery and ensuring integrated referral systems throughout the care continuum.
PIH–Sierra Leone’s hub-and-spoke model
To advance high-quality, safe, and respectful maternal care, the coalition also works across multiple ministries and directorates within the Government of Sierra Leone (GoSL). Together, the coalition is leveraging our expertise and working to ensure high quality maternal and newborn health care that is accessible at all levels of the community through PIH–Sierra Leone’s hub-and-spoke model.
The refined version of a hub-and-spoke model allows us to deliver a comprehensive care cascade — from community-level care, to primary care (spokes), and to the district hospital (hub) — for specialists through strong a strong referral system. To complement this model, we engage deeply with key stakeholders in the government and community to build capacity and sustain trust in the local health care system. By working closely with the DHMTs, we have been able to engage and recruit various community leaders such as paramount chiefs, female community leaders, town speakers, marker leaders, youth leaders, and peripheral health unit (PHU) management. Moreover, we have been able to more deeply engage with, and generate buy-in from the TBAs. We plan to recruit and train 100 TBAs by June 2024, who will be responsible for providing education, generating demand, and linking to quality antenatal, labour and delivery, and postnatal care at the five “spokes”. To date, we have successfully recruited and trained 50 TBAs.
Shifting the mindset of TBAs
The current cadre of TBAs is already making great strides in helping us increase the referral rates. Before the implementation of the program, TBAs would bring a pregnant woman to a facility when the woman was in critical condition and would surrender responsibility at the hospital entrance as they would fear association with a dying pregnant woman. With support from MSD for Mothers, we have been able to invest time and resources in building relationships with cadres of TBAs throughout key communities in Kono District and provide context-specific trainings to empower them to provide referrals and improved services. Beforehand, there was no formalised referral system in place. Now, TBAs are more inclined to bring pregnant women to the clinic or hospital when they are in stable condition, proudly providing accompaniment and support, knowing that they are a more integrated aspect of the local health care system.
The coalition will also strive to increase community reach to 80%, establishing a system that will meet the needs of approximately 79,000 pregnant women in Kono each year, with hopes for scale-up. Throughout this shift, we keep the TBAs’ mantra of, “referral, referral, referral” top of mind.
However, this progress has not been without challenges. Despite the increased demand that we were able to generate at the health facilities, low levels of supplies — essential equipment, commodities, and medicines — remain an issue. These challenges are reflective of shortfalls that span the national health care system and will continue to serve as areas of improvement for health system strengthening by the MoH and implementation partners alike moving forward. By fostering a relationship that leverages the unique skillsets and cultural insights of TBAs, while leveraging the expertise of the Wellbody Coalition, we are ensuring access to high-quality, accessible, and affordable maternal health care.
As we embrace our collaborative and innovative approach, we will continue to support women throughout their pregnancy journeys, increase the rates of referrals for safe facility-based births, and ensure a healthier future for the mothers and newborns of Kono District. Ultimately, the integration of TBAs into formal health care systems given their deep community knowledge stands as a testament to our commitment to forging a more inclusive, safe, and effective future for maternal health care.
This program is supported by funding from MSD through Merck for Mothers, the company’s $650 million initiative to help create a world where no woman dies giving life. MSD for Mothers is an initiative of Merck & Co., Inc., Rahway, N.J., U.S.A.
About the Authors
Sabrina Charles, MPH
Sabrina Charles is the Communications Associate for Partners In Health Sierra Leone. In her role, Sabrina showcases the organisation’s unique mission, values and accomplishments through storytelling. Through the remarkable human stories she tells, she advocates for a preferential option for the poor in health care. She also manages communications, media relations and donor relations.
Prior to her current role, Sabrina worked with the Community Health Acceleration Partnership, as a Program Officer, she led the strategy behind grant-making initiatives for birth equity programs. Sabrina has also worked as a Project Manager for Partners In Health United States advocating for health equity and justice at the local, state, and federal level. Sabrina is a native of Detroit, MI and received her B.S. in Psychology from Howard University and her Masters of Public Health from the Drexel University Dornsife School of Public Health.
Billy Mawindo is a values-driven leader, an experienced healthcare professional and researcher currently working as the Reproductive, Maternal, Newborn, and Child Health (RMNCH) Program Manager at Partners In Health Sierra Leone where he plays a crucial role in designing and operationalising RMNCH programs. Born and raised in Blantyre, Malawi, Billy has always been committed to making a positive impact in his community and beyond. Through his visionary leadership and tireless dedication, Billy has made a profound impact on the lives of adolescents, youth, and survivors of gender-based violence in Kono District, Sierra Leone.