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Background: The number of maternal deaths in sub-Saharan Africa continues to be overwhelmingly high. In West Africa, Sierra Leone leads the list, with the highest maternal mortality ratio. In 2010, financial barriers were removed as an incentive for more women to use available antenatal, delivery and postnatal services. Few published studies have examined the quality of free antenatal services and access to emergency obstetric care in Sierra Leone. Methods: A cross-sectional survey was conducted in 2014 in all 97 peripheral health facilities and three hospitals in Bombali District, Northern Region. One hundred antenatal care providers were interviewed, 276 observations were made and 486 pregnant women were interviewed. We assessed the adequacy of antenatal and delivery services provided using national standards. The distance was calculated between each facility providing delivery services and the nearest comprehensive emergency obstetric care (CEOC) facility, and the proportion of facilities in a chiefdom within 15 km of each CEOC facility was also calculated. A thematic map was developed to show inequities. Results: The quality of services was poor. Based on national standards, only 27% of women were examined, 2% were screened on their first antenatal visit and 47% received interventions as recommended. Although 94% of facilities provided delivery services, a minority had delivery rooms (40%), delivery kits (42%) or portable water (46%). Skilled attendants supervised 35% of deliveries, and in only 35% of these were processes adequately documented. None of the five basic emergency obstetric care facilities were fully compliant with national standards, and the central and northernmost parts of the district had the least access to comprehensive emergency obstetric care. Conclusion: The health sector needs to monitor the quality of antenatal interventions in addition to measuring coverage. The quality of delivery services is compromised by poor infrastructure, inadequate skilled staff, stock-outs of consumables, non-functional basic emergency obstetric care facilities, and geographic inequities in access to CEOC facilities. These findings suggest that the health sector needs to urgently investigate continuing inequities adversely influencing the uptake of these services, and explore more sustainable funding mechanisms. Without this, the country is unlikely to achieve its goal of reducing maternal deaths.
The cross-sectional health facility survey was conducted from March to April 2014 in Bombali District, one of five districts in the Northern Region of Sierra Leone. The survey included all public and missionary health facilities in the district. In total, 100 health facilities were surveyed, consisting of three district hospitals, 94 public peripheral health units and three not-for-profit health facilities. The survey team interviewed the officers-in-charge on the day of the survey and observed two or three antenatal providers at work within each of the 97 peripheral health units. Face-to-face interviews were conducted with 486 pregnant women who accessed antenatal services in the surveyed health facilities on the day of the study. They were interviewed immediately after they received antenatal services. We adapted and field tested the WHO safe motherhood questionnaires and the antenatal care observation checklist developed by the USAID Maternal and Child Health Integrated programme [17, 18]. We collected data on the numbers of beds assigned to pregnant women in facilities; the infrastructure, equipment, drugs and supplies of the clinic; antenatal and delivery services; complications that occurred; laboratory services; emergency obstetric services and referrals; and family planning and educational materials in the clinic. We observed and assessed current practice in antenatal clinics using the antenatal checklist. In the antenatal client exit interview, women were asked about their age, how they got to the clinic, the cost of using the services, their maternity and delivery history, the services and counselling they received in the clinic, and their knowledge of pregnancy-related danger signs. Several records, including antenatal cards, delivery register, normal delivery and complicated delivery records, were reviewed retrospectively. Data were collected on maternal and newborn outcomes, including mode of delivery, live births, Apgar scores, birth weight, fresh stillbirths, macerated stillbirths, immediate neonatal deaths, maternal outcome and referrals. Quantitative data were analysed using SPSS. The summary measures were proportions calculated for quantitative variables. Confidence intervals were calculated for proportions. National standards [19] for antenatal interventions in peripheral health units during antenatal clinics were adapted and used to assess the adequacy of antenatal services offered to women in three domains. A woman who was examined for the recommended six physical signs on her first antenatal visit was rated as having received an adequate examination. If fewer signs were examined for, she was rated as having been inadequately examined. Women who were observed to receive the four recommended basic tests on their first antenatal visit were adequately screened and fewer tests were rated as inadequately screened. If three interventions were offered to women in their third trimester, women were considered to have received adequate interventions. Fewer interventions were considered an inadequate level of care. The distance was calculated between each facility providing delivery services and the nearest comprehensive emergency obstetric care (CEOC) facility. Then, the proportion of facilities in a chiefdom within 15 km of each CEOC facility was calculated. A thematic map was developed to show inequities in CEOC facility service provision. The study was approved by the National Ethics and Scientific Review Committee of the Ministry of Health and Sanitation. Pregnant women who participated gave individual informed consent. The outbreak of Ebola in May 2014 made it difficult to collect qualitative data. Focus group discussions were not convened as planned because of the Health Emergency Regulation limiting the movement of people. The study did not collect data on the structural and intermediary determinants of heath inequities that affect maternal outcomes.
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