Sierra Leone is an African country that is part of the developing nations of the world. It is made up of twenty ethnic groups. Among them are the Creole (Krio) group of which 10% are descendants of freed Jamaican slaves, (Quindex mundi Profile, 2010). In their July 2009 estimates a population of more than five million, with a death rate as 22.22 deaths /1,000. In terms of gender specific maternal mortality rate it is estimated to be 1 in 9 births, (UNICEF), prompting Amnesty International to dub it "a human rights emergency." This means that for every nine mothers who give birth in Sierra Leone, one is expected to die, defining its Maternal mortality rate as staggering compared to the rest of the world and even some other developing countries, (UNICEF). The ICD 2007 of the World Health Organisation (WHO) defines maternal death is any death of a mother during pregnancy and up to 42 days after birth. This state of affairs in Sierra Leone is of particular importance when examined against the Millennium Development Goals of improving maternal health by 2015.
Like every nation of the world, Sierra Leone has been concern with attaining the stipulated goals of the Millennium by 2015, but seems not to be able to achieve it. This has primarily to do with the fact that they are a developing country and as such are plagued with the same kind of challenges that the rest of the developing countries faces. The fifth MDG calls for the reduction of maternal mortality by 75% 2015. It is thought, that critical to attaining this goal is optimum management of pregnant women during labour, (Ronsmans ,Elahi Chowdhury, Koblinskyc & Ahmedb, 2010). They further advised that this can only be achieved by utilising skilled medical providers, especially during the labour process and for the first 24 hours thereafter.
WHO estimates, that in excess of 528,000 women die yearly due to complications surrounding child bearing and pregnancy. A number of obstetric conditions have been named as the common causes. They include; sepsis, obstructed labour, haemorrhage, eclampsia, complications of abortion and ruptured uterus. They go on to report that cumulatively, haemorrhage is the cause of more than half the maternal deaths in sub-Saharan Africa accounting for more than one-third obstetric deaths worldwide. In Sierra Leone, haemorrhage was indeed a major cause, the primary predisposing factor being the culturally inescapable practice of genital mutilation, where it was reported that 90% of the women in Sierral Leone have some form of Female Genital Mutilation (FGM), (Bitong 2005). The resulting scar, especially from the more invasive form of FGM, infibulation, significantly compromises the birth canal, often producing tears in the walls of the vagina and also increasing the use of episiotomy, surgical incision into the walls of the vagina, in order to facilitate birth. Both processes predisposes to post-partum haemorrhage and death, especially in the absence of trained medical personnel, as is most often the case in Sierra Leone.
In 1980s, a main goal of primary care in Sierra Leone was to achieve the reduction of maternal mortality to 30% of the present statistic, (Konteh World Health Forum, 1998). They hoped to have accomplished this by the close of the century. Konteh notes that the target was not reached and gives a number of reasons for its failure. One of the reasons, he postulates was that intervention techniques employed, were not specific for the population. The "Human Services Practitioner" Systemic code (2008), stipulates that any intervention aimed at a population must be done with thorough knowledge of the population to be served and technics specially to meet the need of that population. The absence of that cultural specificity has been identified as the reason why many of the pregnant women refrained from using the services that were made available. Even so, when some of the women attempted to use the clinics, they were met with very aggressive and unfriendly nurses and other health care personnel, (Konteh, 1998). He also noted that there was a very poor antenatal history since most of the women refused to attend the antenatal clinics let alone the postnatal ones. For this reason a mother's child birth history was largely unknown and as such health care professionals were unable to do risk stratification plans to effectively deal with any imminent complications. Notwithstanding, many deliveries happened in homes. In 1996, "about 69.5% of deliveries in the prior 24 months occurred at home, 21.5% were performed at a health centre, and about 9% occurred in the hospital,"( Konteh, 1997). He cites that this was due mainly to the fact that remote areas were usually not reached by maternal health aides. Those areas were predominantly served by, traditional midwives called "traditional birthing assistants". Further to that, Konteh notes, these birth assistants were not well perceived among the health providers because their supplies, instruments and tools were unsterile and frequently the cause of infection often with fatal outcomes.
The crux of the matter is that Sierra Leone sees less than 50% of its birth done by medical personnel that are trained in labour, and even a smaller proportion of pregnant women ever attend antenatal clinics, (Wachuku, 1994). The inevitable rise in mortality rate has led to international organisations like the Marie Stopes International (MSI) to commence work in Sierra Leone in an attempt to mitigate the impact of the rising maternal mortality rate in that country. Through its local non-governmental partner, the "Marie Stopes Society, Sierra Leone" (MSSSL), this organisation in 1986 was involved in building five clinic across Sierra Leone. During their discourse what they found as another major cause of the dismal maternal mortality rate had to do with beliefs that were steeped in social and culture practices like genital mutilation, authenticating the earlier report by the WHO, that genital mutilation was having significant consequence for the health of the mother in childbirth. Those social and cultural issues were considered to be a major obstacle to the effective management of labour emergencies. One example is the belief that labour lasting for more than 48 hours are not considered a complication of pregnancy, (Wachuku, 1994). In western medicine this is termed prolonged labour and has inherent complications like obstructed labour, uterine rupture and haemorrhage, (Collins, Arulkumaran , Hayes, Jackson & Impey, 2008). This is confounded by the belief that when complication occurs, it is often defined as a natural cause and not considered to be of an obstetric/medical origin. The MSSSL further found that transportation and lack of resources in the centres impedes the delivery of emergency services when the need arises.
Konteh, (1997) writing in the community development journal, cites a number of socioeconomic identifiers together with some health variables impacting maternal mortality rates in twelve chiefdoms in Sierra Leone. He first indicates that early marriage was directly related to the high parity, and went on to report that more than forty percent (40%) of the married women did so by the time they were fifteen years old. He also recorded that in the age group of 45- 90, about 85% of them had six or more children. He found the highest parity of more than nine children among 55.1% of the women population, with even higher fertility in some localised areas. Then consequence of increased parity include placenta previa, placement of the placenta too close to the cervix, placenta abroptio, bleeding between the placenta and the uterus and precipitous labour, extremely fast labour, all of which increases the risk of post-partum haemorrhage , (Oxford Handbook of Obstetric and Gynaecology 2009). This is happening against the back drop that the majority of women have never received primary education, a vital determinant of health, (WHO, 2010). As far as occupation is concerned 80% -90% of the population in the areas studied by (Kendeh 1997), were subsistence farmers who are poor, another important determinant of health as defined by the WHO.
This is not so say that the government did not recognise and was not concerned with the rate at which maternal deaths were happening. (Kendeh, 1997) noted that the government recognised the need to put in place programs to mitigate the increasing mortality rate among pregnant and post-partum women. He found that the Government embarked upon training community motivators to be competent in community education and formation of village action groups, which was to facilitate emergent transport of women in labour who develop complications. In 1993 -1994 some improvement was seen but the numbers quickly dropped due to severe disruption in service caused by civil strife, (Kendeh et al. 1997). From 1991, there has been years of political instability in Sierra Leone from the "Revolutionary United Front" (RUT) who overthrew the Government and was only able to return to democratic rule till 1998, (Global security, 2005). This did not give the government enough time to see the plan that began improving the maternal death situation come to fruition.
Assimilating the foregoing information still begs some questions. What then is reason for the high maternal mortality rate in Sierra Leone, especially since the main cause of maternal mortality rate is not unique to Sierra Leone? What sets them apart from the other developing nations that practice FGM and have high incidence of post-partum haemorrhage? The answer lies in the understanding that firstly, not only does Sierra Leone practice FGM, but they practice the most radical form of it, infibulation. Infibulation, classified as type III, involves the total excision of the external genitalia and the partial stitching of the vagina, leaving only a small outlet for menstruation (Bitong, 2005). It is the most extreme form of FGM and ninety four percent 94% of women in Sierra Leone are subjected to this form of FGM. This is happening against the backdrop that this practice, while with a prevalence rate of 90%, prevalence is highest in the rural areas that have very little trained health care personnel or healthcare facilities, and where most of the births are still done by the traditional birth assistants. As a result, though haemorrhage is the common cause of maternal mortality, in Sierra Leone, it more likely than not, to result in death for the mother.
It is rather unfortunate that the dismal maternal mortality rate in Sierra Leone will not show significant improvement, 0.1% as stipulated by the WHO. One underlying reason for the lack of improvement is the difficulty that government faces to provide access to health service and equip facilities in remote areas. This is compounded by the problem of FGM, which is so culturally ingrained, that attempts to address it have been met with violent resistance. This means that to effectively manage this precarious position, a paradigm shift will have to occur as it relates to gender mutilation, parity, understanding of what constitutes an obstetric emergency, availability of trained health aid with culture sensitive attitudes and general improvements in access to health care. Obviously this will demand a multilateral approach by many stakeholders to stem the tide, as well as an injection of foreign aid to help meet the costs. This is the recurring dilemma in so many developing countries, so much to do with so little resources, a situation that is confounded by political instability. Public health professionals will have to continue to do what they have always done - research, enlighten, give direction and simply wait to see if the guidelines are heeded. Meanwhile, the poor and vulnerable die daily.
