A Clinical Perspective of Maternal and Child Health Care in Sierra Leone: Princess Christian Maternity Hospital and Ola During Children’s Hospital Haroun Habib, MPH

Learning Objectives List the specific barriers to quality maternal and child health care in low-resource countries. Identify global best practices in providing maternal and child health care in low- resource countries. Formulate possible solutions in providing better clinical care to pregnant women and children under five in low-resource settings. Give examples of what the "ideal" clinical care for pregnant women and children under five would look like in a low-resource setting.

Inequities in the Health Care System

SL: Key Health Indicators Source: WHO Sierra Leone Health Profile Infant mortality rate of 165 deaths per 1000 live births. Life expectancy of 41 years maternal deaths per live births. The lifetime risk of a woman dying from complications in pregnancy and childbirth is 1 in 8.

Other Relevant Stats Source: WHO Sierra Leone Health Profile

Barriers to Quality Maternal and Child Health Care The greatest barrier is cost due to “cost- recovery” health care system. – User fees and cost of medications Critical shortage of doctors, nurses and midwives The use of traditional birth attendants vs. coming to the hospital to have babies delivered. Bad roads and the lack of ambulances

Princess Christian Maternity Hospital

1. Poor quality at high cost Quality Health Care 1. Poor quality at high cost In 2008 only one-quarter of all births took place in a health facility in Sierra Leone, according to a Demographic and Health Survey, and just 42 percent of births were delivered by a skilled provider. Historically, Sierra Leoneans have on average visited health facilities less than once a year – because of the cost.

2. Limited Financial Resources 2. Limited Financial Resources

3. Understaffed Quality Health Care 3. Understaffed

4. Underpaid Staff Quality Health Care 4. Underpaid Staff Salary: Doctors: 450,000 Le = ~$150 Nurses: 250,000 Le = < $100 CHN: 180,000 Le = ~$70

Ola During Children’s Hospital – “Cottage”

Cottage Hospital

3 rd Pediatric referral center for whole country Princess Christian Maternity Hospital --Only 2 teaching hospitals 3 wards, 90 beds, therapeutic feeding unit 600 children died (2006) = 15% inpatient MR

Health Facility

Case Study: Mohammed 1 yr, 7 months; rapid HR; pallor  chronic anemia due to Malaria

Treatment Cost 5000 Le (for container) Le (to sign and test blood)  25,000 Le

Ideal Outcome Given the proper treatment and care, Mohammed is able to recover and be a healthy baby.

Global Best Practices in Maternal and Child Health Care Delivery Ukraine’s Mother and Infant Health Project: emphasizes the presence of the mother’s partner during delivery, and avoiding unnecessary cesareans and other surgical interventions. China’s Safe Motherhood Program increased hospital births and increased visits to expectant mothers by healthcare professionals significantly reduce maternal mortality Ethiopia’s Health Services extension program –found that while women are more likely to visit health facilities earlier during pregnancy, very little effect is detected on the use of other antenatal and post-natal services.

Improving Maternal and Child Health Providing prenatal care and monitoring o Example: Eclampsia is a major cause of death in pregnancy and still births but it is easily treated if diagnosed early Proper antenatal care and education; women need to be educated on importance of attending information sessions throughout their pregnancy Need to train more qualified midwives, especially in the rural areas.

Other Noteworthy Initiatives The Averting Maternal Death and Disability (AMDD) Program operates on the assumption that all pregnant women are at risk for serious complications and thus focuses on improving access, utilization and quality of emergency obstetric care. – Regional Prevention of Maternal Mortality (RPMM) Network: teams and projects in 19 sub-Saharan African countries. Pay for performance (P4P) in Pakistan consists of supply-side payments to providers and demand-side vouchers that subsidize the costs of a package of reproductive health care services and transportation for poor women.

Steps to Improvement Upgrade the skills of existing Skilled Birth Attendants (SBAs) in managing both the mother and baby. Supply the necessary resources. Implement suitable community-based interventions to achieve the required behaviors in family members, health workers, and volunteers to improve newborn health. Develop national clinical practice guidelines to improve maternal and child health.

Recent Innovation: Free Healthcare Scheme In April 2010 Sierra Leone launched "Free Health Care Medical Insurance", a system of free healthcare for pregnant and breast-feeding women and children under five. Expected to save the lives of more than one million mothers and children, at an initial cost of $19m Main donors have been the UN and the UK, who between them have helped refurbish hospitals, supply drugs and pay health workers' wages.

Better Quality Care=Better Outcomes Note: Some pictures were obtained from a third party and/or internet sources. Permission was obtained to use all of the pictures in this PPT.