Access to Essential Medications and Equipment for Obstetric and Neonatal Primary Care in Bombali District, Sierra Leone

• DOI: http://doi.org/10.1002/wmh3.295
• Published date: 01 March 2019
• Date: 01 March 2019

Access to Essential Medications and Equipment for

Obstetric and Neonatal Primary Care in Bombali

District, Sierra Leone

Manso Mohamed Koroma, Mohamed Amadu Kamara, Namoudou Keita,

Virgil K. Lokossou, Abu James Sundufu, and Kathryn H. Jacobsen

The increased demand for basic emergency obstetric and neonatal care (BEmONC) services in Sierra

Leone since the launch of the nationwide free maternity care initiative in 2010 has strained the

capacity of the system to provide high-quality care. In 2014, members of our research team visited all

97 functioning primary health-care facilities in Bombali district in the Northern Province of Sierra

Leone to evaluate gaps in access to BEmONC. Although most facilities had the equipment necessary

for maternal and neonatal care, these were often not in satisfactory condition . Most of the

facilities did not stock all of the es sential medicines for BEmONC, and less than 10 per cent of

the facilities had suff‌ici ent stocks of unexpired and properly st ored medications. Stronger supply

chains will be necessary to imp rove health system performance in Sierra L eone, reduce maternal

mortality, increase neon atal survival, and achieve targets as sociated with the Sustainable

Development Goals (SDGs) .

KEY WORDS: maternal health, essential medicines, neonatal health

Introduction

In Sierra Leone, all pregnant women are eligible to receive free maternity care

at peripheral health units (PHUs) as part of the national free health-care initiative

launched in April 2010 (Donnelly, 2011; Witter et al., 2018). The use of health-care

facilities when giving birth increased signif‌icantly after the implementation of

the free health-care program (Jacobsen et al., 2012; Maxmen, 2013). In the national

2008 Demographic and Health Survey (DHS), 24.6 percent of the births in the

previous f‌ive years were reported to have occurred at a health facility (SSL, 2009).

Five years later, in the 2013 DHS, this percentage had increased to 54.4 percent

(SSL, 2014). The increased demands on the health system generated by higher

rates of use require additional personnel and supplies. When these demands are

not met, resource limitations may restrict the quality of maternal and child

health-care services (Maxmen, 2013).

World Medical & Health Policy, Vol. 11, No. 1, 2019

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doi: 10.1002/wmh3.295

#2019 Policy Studies Organization

All PHUs in Sierra Leone are expected to provide basic emergency obstetric

and neonatal care (BEmONC) services. BEmONC requires pregnant women and

newborns to have reliable access to: (i) parenteral antibiotics, (ii) oxytocics or other

uterotonic drugs, (iii) anticonvulsants such as magnesium sulfate for preeclampsia

and eclampsia, (iv) manual removal of the placenta or removal of a retained

placenta with vacuum extraction or other techniques, when required to stop

hemorrhage, (v) assisted vaginal delivery such as vacuum extraction or forceps

delivery, and (vi) neonatal resuscitation with a bag and mask (WHO, UNFPA,

UNICEP, & AMDD, 2009) (comprehensive emergency obstetric and neonatal care,

or CEmONC, adds two additional items to the list: access to caesarean sections and

blood transfusions. Those additional CEmONC services are not typically available

at PHUs.) Health resources in Sierra Leone were stretched thin even before the

launch of the free maternity care initiative. A 2008 survey found that almost no

PHUs were able to provide all of the core BEmONC functions, and concluded that

severe shortages in staff‌ing, equipment, and supplies were hampering the ability of

clinicians to provide high-quality obstetric care (Oyerinde et al., 2011).

As part of monitoring progress toward improving access to BEmONC, Sierra

Leone’s Ministry of Health and Sanitation (MoHS) has conducted quarterly or

semi-annual reviews of BEmONC coverage across the country since 2010. These

facility improvement team (FIT) assessments examine the status of facilities,

staff‌ing, medication, and equipment at community health centres (CHCs), the

PHUs that offer the most advanced primary health services (MOHS, 2014). A FIT

score of 100 would indicate that all sampled CHCs were fully prepared to offer

all types of BEmONC services. Scores are derived from an evaluation of seven

facility performance enablers: water and sanitation, electricity, referrals, equip-

ment, blood and laboratory services, staff‌ing, and drugs (Yilla, Nam, Adeyemo, &

Kargbo, 2014). The average FIT score for sampled CHCs in Sierra Leone increased

from 47 points in late 2010 to 73 points by June 2015 (MOHS, 2015). This indicates

that good progress has been made in some aspects of access to maternity care,

but FIT scores vary considerably by site. Sierra Leone has three provinces plus

the capital city area. Each province is divided into several districts (14 total across

Sierra Leone) which are composed of chiefdoms (149 total across the country).

Each district has a district health management team (DHMT) that oversees

approximately 50 PHUs that are staffed by a total of about 100 clinicians. FIT

scores by district in June 2015 ranged from a high of 83.6 points to a low of just

55.7 points (MOHS, 2015).

Bombali district is located in the Northern Province of Sierra Leone along the

border with Guinea. The capital of Bombali district is the city of Makeni, which is

the third most populous city in the country and the largest city in the Northern

Province. However, there are many rural areas within the district that are diff‌icult

to reach due to underdeveloped and poorly maintained road networks. Residents

of these rural areas often have diff‌iculty accessing health-care services and

medications. The Northern region has a lower rate of use of maternal health

services than the country’s other regions (SSL, 2009, 2014; SSL/UNICEF, 2011).

The percentage of babies in the North who were born at a health facility increased

Koroma et al.: BEmONC Supplies in Sierra Leone 9