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

AuthorNamoudou Keita,Manso Mohamed Koroma,Abu James Sundufu,Kathryn H. Jacobsen,Mohamed Amadu Kamara,Virgil K. Lokossou
Published date01 March 2019
Date01 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
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
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

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