Safe motherhood and childhood in Sierra Leone: key findings from mixed-methods health-seeking behaviour study
Authors: Lavilla KM , Teal J , Schausberger B , Sankoh M , Conteh AB , Kamara AY , Tholley AM , Kubal MM , Jalloh Y , Jabbie E , Falama AM , Farma MM , Velivela K , Sang S , Sabrie F , Sitali N , Daly M , Black B , Caleo GNC , Lokuge K 
Published: July 2024

INTRODUCTION
MSF and the MoHS implemented a partnership model of free and accessible maternal and child healthcare at primary and hospital-level health facilities in Tonkolili District, Sierra Leone, in order to reduce barriers to care and improve health outcomes. We conducted a health-seeking behaviour (HSB) study in 2021 to evaluate impact and change since a previous HSB study conducted in 2016/17. We also compared MSF-supported primary health unit (PHU) catchment areas with MSF-unsupported PHU’s. In addition, we explored adolescent reproductive health, family planning, and female genital mutilation (FGM).

METHODS
Study design was mixed-methods, similar to that used in 2016/17, including a quantitative household survey, structured interviews with key informants, and qualitative in-depth interviews (IDI’s). We randomly selected 60 clusters; 30 in MSF-supported areas, and 30 in unsupported areas. IDI’s explored topics identified through the survey, and were conducted with purposively-sampled participants, and analyzed thematically.

ETHICS
This study was approved by the Sierra Leone Ethical and Scientific Review Committee and by the MSF Ethics Review Board

RESULTS
Between February and August 2021, 1,164 women and 1,177 carers (of 1,559 children aged under 5) participated in the survey; 59 structured interviews and 42 IDI’s were conducted. Compared to the 2016/17 study, access to healthcare improved, with the proportion of women delivering in a health facility increasing from 52.0% (95% confidence intervals (CI) 42-64) to 90.9% (95% CI 89.2-92.5), and the proportion of mothers reporting at least one barrier to accessing care decreasing from 90.0% (95% CI 80-95) to 45.9% (95% CI 43.0-48.8). Outcomes of care also improved over this period, with under-5 mortality decreasing from 1.55 per 10,0000/day (95% CI 1.30-1.86) to 0.25 per 10,000/day (95% CI 0.17-0.36).When comparing unsupported PHU’s versus supported areas in 2021, complications during labour or delivery were higher in unsupported areas (10.9%; 95% CI 8.6-13.6) vs 7.2% (95% CI 5.3-9.7), as was stillbirth (4.5%; 95% CI 3.1-6.5) vs 1.4% (95% CI 0.6-2.8). Under-5 mortality was 0.44 per 10,000/day (95% CI 2.4-7.2) in unsupported areas and 0.17 per 10,000/day (95% CI 0.8-2.9) in supported areas. 42.9% (95% CI 34.7-51.4) of adolescents in unsupported areas and 39.7% (95% CI 31.3- 48.7) in supported areas reported unmet need for contraception. More than 90% (96.6%, 95% CI 95.3-97.5) of women reported FGM. Qualitative data suggests that communities recognized the importance of delivering in a health facility with trained assistance. Nevertheless, health staff and community members felt the current fine system for home births was applied inflexibly in circumstances when distance, transport, or cost restricted or delayed access.

CONCLUSION
Since 2016/17, access to healthcare and outcomes have improved in all areas, but improvement has been greatest in areas where, in addition to hospital care, MSF supported MoHS PHU’s. This provides evidence for ongoing implementation and scale-up of comprehensive models of care. Progress made must not overshadow areas requiring further attention, such as care for adolescents, access to contraception, and the need to reduce stillbirths.

CONFLICTS OF INTEREST
None declared.