Care Beyond Medicine: Promoting Women’s Health in Sierra Leone

Across Kono District, in the rural east of Sierra Leone, Partners In Health-supported health facilities are busier than ever.

It’s not that patient needs are increasing—it’s that the quality of health care available is, thanks to PIH and the Ministry of Health & Sanitation’s partnership. With clinicians trained, infrastructure improved, pharmacy shelves stocked, and health service costs reduced (if not eliminated entirely), families across Kono have a newfound trust in the public health system and are showing up for care in record numbers. At Sewafe Community Health Center, one of the small, rural health clinics PIH is supporting, the average number of patients each month has skyrocketed, from 524 to 2,319.

Still, hospital and clinic staff around Kono know they’re seeing a mere fraction of the patients they could, as barriers to accessing health care, all rooted in poverty, remain steep. The obstacles are particularly intense for women, who face a unique set of social and economic limitations in Sierra Leone and, relatedly, a 1 in 20 lifetime risk of dying in pregnancy or childbirth—one of the world’s highest rates.

That is why PIH staff in Kono are working to get even more patients in the door, particularly women. Below, read about three new initiatives that are making women’s health care more accessible and just.

Partnering with Traditional Birth Attendants

In Kono, where health care has historically been high-cost and low-quality, traditional birth attendants (TBAs) are some of the most respected people in their communities, offering aspects of care pregnant women never found previously at a hospital: comfort, encouragement, and respect, as well as an affordable cost and the ability to remain at home to give birth.

With higher-quality, free maternal health care now available, delivering at health facilities is increasingly popular. In the last year at Koidu Government Hospital (KGH), the only hospital in Kono, clinicians have seen a 10% increase in maternity ward admissions.

Still, many women favor giving birth at home with a TBA by their side—an understandable preference, but also a potentially dangerous one, as the resources a hospital offers are irreplaceable in cases of life-threatening obstetric emergencies.

PIH has long worked with TBAs as a way to bridge the gap between communities and health facilities and to help quell Sierra Leone’s longstanding maternal mortality epidemic. At PIH-operated Wellbody Clinic, TBAs are paid employees alongside nurses and midwives, offering familiar support to women while they deliver under the watchful eye of a trained clinician.

This year, PIH expanded its partnership with TBAs, establishing a program to provide them a monthly stipend for holding regular health education events and referring and accompanying families to facility-based maternal and child health care—similar to community health workers.

After introducing the idea to local leaders, health care workers, and TBAs across Kono and collecting their feedback, PIH enlisted 136 TBAs in four of Kono’s 14 chiefdoms. Staff then provided a series of comprehensive maternal health trainings—how to spot an obstetric emergency, what symptoms require referral to a clinic versus to the hospital—and charged TBAs with accompanying not only pregnant women, but also women in need of postnatal care or family planning and their children in need of primary care like immunizations.

According to Isata Dumbuya, PIH’s director of maternal health, these training sessions had to be conducted delicately while clinicians and TBAs worked to find common ground.

“There were a lot of TBAs saying, ‘You [clinicians] blame us for all of the things that go wrong. We don’t do things to kill women; we think we’re helping them. Because this is all we know, this is where we get our living, this is our status symbol, this is what we’ve done since forever. This is where women come,’” Dumbuya said. “They were crying. I felt like crying. It was really emotional. What we [PIH] said is, ‘We understand and respect this, and we do not want it to change. What we want to change is for you to use your position in society to accompany women to a health facility.’”

TBAs have already begun their referral and accompaniment work. PIH will begin formally evaluating their impact in January and, in June, will assess how to continue improving the program before implementing it in additional chiefdoms. Already, the program is making a visible difference; Dumbuya says clinicians at PIH-supported rural community health centers are reporting an uptick in women arriving for care after being referred by a TBA.

This uptick is a good problem to have—indicative of one more pathway to care for women, but also another challenge to resources.

“The downside is supplies,” said Dumbuya. “Your patient load goes up, your consumption of basic essentials—gloves, needles—goes up. We’re looking into how we can increase the amount of essential supplies for maternal and newborn care.”

Family Planning as “Most Successful Outcome of the Year”

According to Dumbuya, PIH Sierra Leone’s most successful maternal health outcome for 2021 was increasing the number of people with long-term family planning.

“We fixed [our family planning systems],” she said, “and we’re going to really start to impact our rate of maternal mortality.”

Before this year, family planning was hard to come by in Kono. Teenagers and women are commonly forbidden from pursuing family planning methods by authority figures like parents and husbands. If they did manage to make it to a health facility, they would often have to wait, for lack of clinicians trained to provide contraception. When Dumbuya joined PIH and began working at KGH, in 2018, she recalls seeing groups of women waiting around but never receiving birth control. There were a mere three clinicians at the hospital equipped to provide it—all midwives, whose first priority had to be remaining in the labor ward to deliver babies.

“Fifty minutes later, sitting outside the family planning office, she cannot continue to wait,” Dumbuya said. “Some people are housewives, they’ve snuck out, they have to go home to cook. They’re thinking, ‘This is my only time I can do this. And I’ve finally managed to escape and get this done, and there’s nobody here to attend to me. It might be in the next few days that I get pregnant, the very thing I was trying to avoid, and now I have to live with the consequences of that.’”

In response this year, PIH held a series of two-week trainings on how to deliver various family planning methods, including long-acting reversible contraception, for nurses, midwives, and other clinicians at KGH, Wellbody Clinic, and other PIH-supported health centers. Today, the total number of family planning-trained clinicians in Kono is up to 40—27 of them work at KGH, a nine-fold increase.

Accordingly, wait times have decreased to help support the most vulnerable patients. KGH’s maternity ward now maintains a policy that women should not wait more than 30 minutes for family planning—and seen dramatic results. In 2019, clinicians provided 1,182 family planning visits; this year, they provided 5,530.

Combating Sexual and Gender-Based Violence

Maternal mortality, stigma and secrecy around family planning, and other women’s health challenges are underpinned by pervasive gender inequity and are connected to another health and social injustice: sexual and gender-based violence (SGBV).

Tragically common in Kono, across Sierra Leone, and around the world, gender-based violence demands safety nets—something many Sierra Leoneans, in particular women, lack. Thanks to local nonprofit the Rainbo Initiative, however, survivors have access to free clinical, legal, and psychosocial support within five centers across the country. To promote the work of Rainbo and a shared mission to combat SGBV, this year PIH formalized a partnership with the nonprofit and began investing in their center in Kono, located behind the maternity ward at KGH.

Funding from PIH has enabled Rainbo to grow its staff and conduct more educational sessions in communities and schools, with the goal of raising awareness around SGBV and equipping people with knowledge to recognize it, know their rights, and access care.

With PIH’s support, the Rainbo team—made up of paralegals, nurses, midwives, and psychosocial counselors—has undergone a refresher training around SGBV care, trained 20 local police officers to better recognize and manage SGBV cases, and reached 1,696 Kono residents with SGBV education.

This education is crucial in the face of the silence that fuels continued violence.

“Do women out there know where they can go if they become a victim of violence? Not all of them do,” Dumbuya said. “And not all of them recognize that it is SGBV. It might be her life, her norm; it might be what she expects to happen to her. So I’m really pleased that Rainbo has the funding to be able to make themselves more visible and go out there and say, ‘Hey, this is not okay. And when you feel you cannot cope with it anymore, come to us and we will be able to help you.’”

From April to November, 168 cases of SGBV were managed at the center—a handful of them referred directly from clinicians at KGH, who also have benefited from Rainbo’s education sessions and are working to make the care they deliver more gender-sensitive.