sierra leone rapid emergency obstetric and …...8.1 availability of emergency services 24/7 8.2...
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Government of Sierra Leone
Sierra Leone Rapid Emergency Obstetric and Newborn Care (EmONC) Assessment2017
Government of Sierra Leone
Editor: Anita Palathingal
Design and Layout: Stephanie Tailleux
Front cover @Olivia Acland
CONTENTS
FOREWORD
ACKNOWLEDGEMENTS
LIST OF TABLES
LIST OF FIGURES
ABBREVIATIONS
EXECUTIVE SUMMARY
CHAPTER 1: INTRODUCTION
1.1 Country profile
1.2 Maternal and newborn health profile
1.3 EmONC signal functions and indicators
1.4 Objectives of the assessment
CHAPTER 2: METHODOLOGY
2.1 Overview of the assessment
2.2 Study design
2.3 Data collection instruments and pre-testing
2.4 Recruitment, training and deployment of data collectors, team leaders and coordinators
2.5 Data collection (fieldwork)
2.6 Data entry, cleaning, and analysis
2.7 Weighting procedures for data analysis
2.8 Quality assurance
2.9 Response rates
2.10 Research ethics
2.11 Limitations of the survey
2.12 Organization of the report
CHAPTER 3: EMERGENCY OBSTETRIC AND NEWBORN CARE INDICATORS
3.1 Indicator 1: Availability of EmONC services
3.2 Indicator 2: Geographic distribution (national and subnational) of EmONC facilities
3.3 Indicator 3: Proportion of all births in EmONC facilities
3.4 Indicator 4: Met need for EmONC services
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CONTENTS
3.5 Indicator 5: Caesarean deliveries as a proportion of all births
3.6 Indicator 6: Direct obstetric case fatality rate
3.7 Indicator 7: Intrapartum and very early neonatal death rate
3.8 Indicator 8: Proportion of maternal deaths due to indirect causes
3.9 Comparison of EmONC indicators
CHAPTER 4: PERFORMANCE OF OTHER MATERNAL AND NEWBORN HEALTH SERVICES
4.1 Availability of routine services and performance of other maternal and newborn health services
4.2 Performance of other maternal and newborn health services or routine signal functions in a three-month reference period
CHAPTER 5: FACILITY INFRASTRUCTURE AND COMMUNICATION
5.1 Ratio of beds to deliveries
5.2 Availability of separate rooms or designated spaces for Maternal and Newborn Health services
5.3 Availability of electricity
5.4 Availability of water
5.5 Infrastructure in maternity ward
5.6 Availability of modes of communication
CHAPTER 6: AVAILABILITY OF HUMAN RESOURCES
6.1 Staffing target and patterns
6.2 Availability of health workers 24/7
6.3 Regulatory policies and practices in performance of EmONC signal functions and other maternal and newborn health services
6.4 Ratio of midwives to 1,000 institutional deliveries and 10,000 population
CHAPTER 7: AVAILABILITY OF DRUGS, EQUIPMENT AND SUPPLIES
7.1 Management and stock-out of drugs
7.2 Availability of essential drugs
7.3 Availability of materials, equipment, supplies and guidelines in labour and delivery, and maternity wards
7.4 Availability of operating theatre equipment
7.5 Availability of laboratory equipment and supplies for blood transfusion
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CONTENTS
CHAPTER 8: REFERRAL SYSTEM
8.1 Availability of emergency services 24/7
8.2 Distance and time to the nearest facilities with surgical services
8.3 Availability of means of transport
8.4 Maintenance and management of vehicles
8.5 Referrals out due to obstetric and newborn indications
CHAPTER 9: CONCLUSION AND RECOMMENDATIONS
9.1 Conclusions
9.2 Recommendations
APPENDICES
Appendix A: Tables
Appendix B: Minimum required drugs, equipment, and supplies for determining readiness to perform EmONC signal functions
Appendix C: List of Technical Working Group TWG members and data collectors
Appendix D: List of facilities surveyed
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LIST OF TABLES
Table 2.2.1: The Sierra Leone Rapid EmONC Assessment 2017 timeline
Table 2.2.2: Number of health facilities surveyed by facility type and district, Sierra Leone Rapid EmONC Assessment 2017
Table 3.1.1: Availability of EmONC facilities (weighted), by district (EmONC Indicator 1), Sierra Leone Rapid EmONC Assessment 2017
Table 3.1.2: Percentage of facilities that performed each EmONC signal function in the last 3 months, by district, facility type and operating agency, Sierra Leone Rapid EmONC Assessment 2017
Table 3.1.3: Percentage distribution of facilities that administered parenteral uterotonics in the last 3 months, by type of oxytocic and district, Sierra Leone Rapid EmONC Assessment 2017
Table 3.1.4: Percentage distribution of facilities that administered parenteral anticonvulsants in the last 3 months, by type of medication and district, Sierra Leone Rapid EmONC Assessment 2017
Table 3.1.5: Percentage of facilities that removed retained products of conception in the last 3 months, by method and district, Sierra Leone Rapid EmONC Assessment 2017
Table 3.1.6: Percentage distribution of facilities that performed assisted vaginal delivery in the last 3 months, by method and district, Sierra Leone Rapid EmONC Assessment 2017
Table 3.1.7: Percentage of facilities that performed each signal function in the last 3 months and reasons for non-performance, by signal function, Sierra Leone Rapid EmONC Assessment 2017
Table 3.3.1: Percentage of expected births attended in all facilities and EmONC facilities, by District (EmONC Indicator 3), Sierra Leone Rapid EmONC Assessment 2017
Table 3.6.1: Direct obstetric case fatality rate (DOCFR) in all facilities and EmONC facilities, by district (EmONC Indicator 6), Sierra Leone Rapid EmONC Assessment 2017
Table 3.6.2: Percentage distribution of all maternal deaths, by cause of death, type of facility and operating agency, Sierra Leone Rapid EmONC Assessment 2017
Table 3.8.1: Percentage of facilities that use registers, by type of facility and operating agency, Sierra Leone Rapid EmONC Assessment 2017
Table 3.9.1: Comparison of EmONC indicators in 2008 and 2017, Sierra Leone Rapid EmONC Assessment 2017
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LIST OF TABLES
Table 4.1.1: Percentage of facilities providing selected services by district, facility type, operating agency and location, Sierra Leone Rapid EmONC Assessment 2017
Table 4.2.1: Percentage of facilities that provided other MNH services/signal functions in the last 3 months, by district, facility type, operating agency, and location, Sierra Leone Rapid EmONC Assessment 2017
Table 5.1.1: Ratio of maternity beds and couches to 1,000 deliveries, by facility type, operating agency and district, Sierra Leone Rapid EmONC Assessment 2017
Table 5.3.1: Percentage distribution of facilities according to source of electricity and, among those with electricity, percentage with functioning electricity at time of interview, by district, facility type, operating agency, and location, Sierra Leone Rapid EmONC Assessment 2017
Table 5.4.1: Percentage distribution of facilities according to their primary source of water, by district and facility type, operating agency and location, Sierra Leone Rapid EmONC Assessment 2017
Table 5.5.1: Percentage of facilities that have the indicated infrastructure in the maternity ward1, by facility type, Sierra Leone Rapid EmONC Assessment 2017
Table 5.6.1: Percentage of facilities with a functional mode of communication, by district, facility type, operating agency and location, Sierra Leone Rapid EmONC Assessment 2017
Table 6.1.1: Total number of health workers currently working, who left and who were posted in the last 12 months, by type of facility and cadre of health worker, Sierra Leone Rapid EmONC Assessment 2017
Table 6.2.1: Staff coverage during a typical week, percentage of hospitals and CHCs/clinics with health workers present on-site and on call at certain times, by health worker cadre, Sierra Leone Rapid EmONC Assessment 2017
Table 6.3.1: Percentage of facilities that provide EmONC signal functions, by health worker cadre, Sierra Leone Rapid EmONC Assessment 2017
Table 6.4.1: Number of midwives per 1,000 institutional deliveries and per 10,000 population and number of physicians, midwives and nurses per 10,000 population by district, Sierra Leone Rapid EmONC Assessment 2017
Table 7.1.1: Percentage of facilities with a pharmacy or supply of medicines that reported on pharmacy-related items, by facility type, Sierra Leone Rapid EmONC Assessment 2017
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LIST OF TABLES
Table 7.2.1: Percentage of facilities with a pharmacy or supply of medicines that had contraceptives and other drugs, by type of facility, Sierra Leone Rapid EmONC Assessment 2017
Table 7.3.1: Percentage of facilities that have the indicated materials for infection prevention in the maternity area1, by type of facility, Sierra Leone Rapid EmONC Assessment 2017
Table 7.3.2: Percentage of facilities with items for cervical/perineal repair pack and equipment for other procedures in the maternity area, by type of facility, Sierra Leone Rapid EmONC Assessment 2017
Table 7.3.3: Percentage of facilities with delivery and dressing instrument items, and gynaecological equipment in the maternity area, by type of facility, Sierra Leone Rapid EmONC Assessment 2017
Table 7.3.4: Percentage of facilities with selected furnishings and amenities in the maternity area, by type of facility, Sierra Leone Rapid EmONC Assessment 2017
Table 7.4.1: Percentage of hospitals with an OT that had selected equipment and supplies, Sierra Leone Rapid EmONC Assessment 2017
Table 7.4.2: Percentage of hospitals with an OT and with anaesthesia equipment and supplies, Sierra Leone Rapid EmONC Assessment 2017
Table 8.3.1: Percentage of facilities with a functional mode of transport, by district, facility type, operating agency and location, Sierra Leone Rapid EmONC Assessment 2017
Table 8.5.1: Number and percentage distribution of referrals-out due to obstetric and newborn indications by district, facility type and operating agency, Sierra Leone Rapid EmONC Assessment 2017
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LIST OF FIGURES
Figure 3.1.1: Current EmONC status of facilities and UN targets, Sierra Leone Rapid EmONC Assessment 2017
Figure 3.1.2: Percentage of grading of facilities based on their EmONC status by facility type, Sierra Leone Rapid EmONC Assessment 2017
Figure 3.1.3: Percentage of facilities that performed each EmONC signal function in the last 3 months prior to the survey, Sierra Leone Rapid EmONC Assessment 2017
Figure 3.1.4: Percentage of facilities that are ready to provide and currently providing each EmONC signal function, by facility type, Sierra Leone Rapid EmONC Assessment 2017
Figure 3.2.1: Percentage of EmONC facilities compared with the UN recommended ratio, by district, Sierra Leone Rapid EmONC Assessment 2017
Figure 3.3.1: Distribution of institutional deliveries according to EmONC status by type of facility, Sierra Leone Rapid EmONC Assessment 2017
Figure 3.3.2: Percentage distribution of institutional delivery by mode of delivery and district, Sierra Leone Rapid EmONC Assessment 2017
Figure 3.4.1: Percentage of women with expected major direct obstetric complications treated in EmONC and all facilities, by district, Sierra Leone Rapid EmONC Assessment 2017
Figure 3.4.2: Percentage distribution of expected births and expected major direct obstetric complications according to locations by EmONC grading, Sierra Leone Rapid1
Figure 3.5.1: Percentage of expected births delivered by caesarean section in all facilities and EmONC facilities, by district, Sierra Leone Rapid EmONC Assessment 2017
Figure 3.5.2: Institutional caesarean delivery rate among all facilities and facilities that provide caesarean delivery by operating agency, Sierra Leone Rapid EmONC Assessment 2017
Figure 3.6.1: Distribution of institutional maternal deaths due to direct obstetric causes
Figure 3.6.2: Cause-specific DOCFR in all facilities, Sierra Leone Rapid EmONC Assessment 2017
Figure 3.7.1: Intrapartum and very early neonatal death rate in all facilities, by district, Sierra Leone Rapid EmONC Assessment 2017
Figure 3.8.1: Percentage of maternal deaths due to indirect causes in all facilities, by district, Sierra Leone Rapid EmONC Assessment 2017
Figure 3.8.2: Post-abortion care women discharged with FP by district, Sierra Leone Rapid EmONC Assessment 2017
Figure 3.8.3: Percentage of facilities with a labour and delivery register that was complete and up-to-date, by facility type, Sierra Leone Rapid EmONC Assessment 2017
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LIST OF FIGURES
Figure 5.2.1: Percentage of facilities with separate room or space for selected maternal and newborn services, by facility type, Sierra Leone Rapid EmONC Assessment 2017
Figure 5.4.1: Percentage distribution of primary source of water (from those that had a source of water), Sierra Leone Rapid EmONC Assessment 2017
Figure 5.4.2: Percentage distribution of facilities that had shortages of water for days (from those that had a source of water), Sierra Leone Rapid EmONC Assessment 2017
Figure 6.1.1: Number of health workers required and number available for nurses, MCHAides, CHOs, Midwives, and lab technicians, Sierra Leone Rapid EmONC Assessment 2017
Figure 6.1.2: Number of health workers required and number available for MDs, nurse anaesthetist, emergency surgical officers, obstetrician/gynaecologists, general surgeons, paediatricians, anaesthesiologists and neonatologists, Sierra Leone Rapid EmONC Assessment 2017
Figure 6.3.1: Percentage of facilities with at least one health worker cadre to provide each of the EmONC signal functions by facility type, Sierra Leone Rapid EmONC Assessment 2017
Figure 6.4.1: Ratio of midwives per 1,000 deliveries and a physicians, midwives, and nurses combined per 10,000 population, by district, Sierra Leone Rapid EmONC Assessment 2017
Figure 7.1.1: Percentage of facilities with a pharmacy/supply of medicines, with a drug inventory register, and whose drug inventory register was up-to-date by facility type, Sierra Leone Rapid EmONC Assessment 2017
Figure 7.1.2: Percentage distribution of facilities with a pharmacy or supply of medicines that reported most common causes of delays in delivery of medicines and supplies by facility type and operating agency, Sierra Leone Rapid EmONC Assessment 2017
Figure 7.1.3: Percentage of facilities with a pharmacy or supply of medicines that reported stock-out of some essential drugs in the last 12 months, Sierra Leone Rapid EmONC Assessment 2017
Figure 7.2.1: Percentage of facilities that had drugs related to the signal functions and emergencies, and anaesthetics and other drugs, Sierra Leone Rapid EmONC Assessment 2017
Figure 7.3.1: Percentage of facilities that had indicated MNH guidelines, Sierra Leone Rapid EmONC Assessment 2017
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LIST OF FIGURES
Figure 7.3.2: Percentage of facilities with selected newborn resuscitation pack, Sierra Leone Rapid EmONC Assessment 2017
Figure 7.4.1: Percentage of facilities with an OT for obstetric patients and of those with an OT, percentage with a separate OT room, Sierra Leone Rapid EmONC Assessment 2017
Figure 8.1.1: Percentage of facilities with obstetric and neonatal care 24/7 by district, Sierra Leone Rapid EmONC Assessment 2017
Figure 8.2.1: Percentage distribution of CHCs/clinics according to distance to the nearest facilities with surgical services by district, Sierra Leone rapid EmONC Assessment 2017
Figure 8.2.2: Percentage distribution of CHCs/clinics according to time to the nearest facilities with surgical services by district, Sierra Leone rapid EmONC Assessment 2017
Figure 8.4.1: Number of facilities with at least one mode of motorized transport and available tools/spare parts, funds, and fuel for maintenance and transporting clients, by district, Sierra Leone Rapid EmONC Assessment 2017
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FOREWORDThe Government of Sierra Leone in collaboration with its partners has worked over the years to ensure the provision of quality sexual and reproductive health services as well as maternal and newborn health care services to its population. However, available evidence reveals that, while some progress has been made, more needs to be done to greatly improve the health of mothers, adolescents and children. It should be noted that the country’s maternal mortality ratio remains one of the highest in the world despite the improvements in the use of maternal health services. This points to the low quality of health care provided to women during pregnancy, childbirth and the postnatal period and the urgent need to further strengthen care to significantly reduce the high level of preventable deaths.
Recognizing that improving access to Comprehensive Emergency Obstetric and Newborn Care (CEmONC) and Basic Emergency Obstetric and Newborn Care (BEmONC) are critical to meeting these goals, the Ministry of Health and Sanitation conducted an EmONC assessment in 2017. The survey was carried out with support from the United Nations Population Fund under the UKaid-funded Saving Lives Project (SLP 1). The objective of this assessment was to provide information to policy makers, managers, service providers, donors, partners and other stakeholders on the state of readiness of referral health facilities for emergency obstetric and newborn care.
This 2017 EmONC needs assessment was a cross-sectional population-based survey of health facilities in Sierra Leone covering a total of 173 hospitals, family health centres and private clinics that provided delivery or other maternity services at the time of the survey. The findings provide information on services from all levels of care in each district in the country. This assessment report comes at an opportune time, as the Ministry of Health and Sanitation moves in the ‘New Direction’ outlined by the Government. We believe the findings, conclusions and recommendations related to the gaps in access to care in the districts will be very important in prioritizing key services in the health sector.
I would like to acknowledge UNFPA for coordinating this incredible effort and UKaid for its funding support. I also applaud the Ministry of Health and Sanitation team and the technical working group members, whose tremendous work and support has resulted in the successful implementation of the 2017 EmONC needs assessment and the production of this report.
Dr. Amara JambaiActing Chief Medical OfficerMinistry of Health and Sanitation
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ACKNOWLEDGEMENTS
Sierra Leone’s country core team is very grateful to the Ministry of Health and Sanitation (MoHS) for its leadership and coordination for the successful completion of this assessment.
The core team also extends its appreciation to UNFPA for overall coordination and technical support, in particular; Mr. Wasihun Andualem UNFPA consultant, for his technical assistance throughout the process, Dr Sylvia Fasuluku for coordinating the survey process, Dr. Mohammed Elhassein, Ms Margaret Mannah- MacCarthy for coordination support and Dr. Kim Eva Dickson for overall guidance and oversight.
The team acknowledges the technical and financial support of many agencies, including UNICEF, WHO and UKAID, that were committed to the successful completion of this assessment.
Appreciation goes to the data collectors and supervisors for their professional undertaking in the data collection and supervision, as well as all the health facility managers and health care workers who contributed to the data collection. Without them, this assessment would not have been successful.
The core team also acknowledges the unreserved support and dedication of its members and the Technical Working Group that coordinated and facilitated this assessment.
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AIDS Acquired Immunodeficiency SyndromeAMDD Averting Maternal Death and DisabilityAMTSL Active Management of Third Stage of LabourANC Antenatal careARV AntiretroviralAVD Assisted Vaginal DeliveryBEmONC Basic Emergency Obstetric and Newborn CareCEmONC Comprehensive Emergency Obstetric and Newborn CareCHC Community Health Centre CHO Community Health OfficerCS Caesarean SectionD&C Dilation and CurettageD&E Dilation and EvacuationDOCFR Direct Obstetric Case Fatality RateEmONC Emergency Obstetric and Newborn CareFANC Focused Antenatal CareFP Family PlanningGP General PractitionerHIV Human Immunodeficiency VirusHR Human ResourcesIUD Intra Uterine DeviceIV IntravenousKMC Kangaroo Mother CareMCHAide Maternal and Child Health AideMD Medical DoctorMDSR Maternal Death Surveillance and ResponseMMR Maternal Mortality RatioMNH Maternal and Newborn HealthMoHS Ministry of Health and SanitationMVA Manual Vacuum AspirationNGO Non-Governmental OrganizationNICU Neonatal Intensive Care UnitOT Operating TheatrePAC Post-Abortion Care PHU Primary Healthcare Unit PMTCT Prevention of Mother-to-Child TransmissionPNC Postnatal CareSACHO Surgical Assistant Community Health OfficerSSL Statistics Sierra LeoneTWG Technical Working Group
ABBREVIATIONS
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EXECUTIVE SUMMARY
Sierra Leone’s 2017 Emergency Obstetric and Newborn Care (EmONC) Assessment was the second such assessment since the first one conducted in 2008. The 2017 EmONC covered all hospitals and a sample of Community Health Centres (CHCs) and clinics that provided delivery or maternity services at the time of the survey.
The survey used abridged versions of the Averting Maternal Death and Disabilities Program’s recent EmONC assessment tools (Modules 1 to 5): infrastructure, communication, transportation, human resources and service statistics over a 12-month period (deliveries, newborn outcomes, direct and indirect obstetric complications, maternal and neonatal deaths, and referrals).1 The provision of EmONC signal functions and other maternal and newborn health services were also covered in this assessment.
All public and private hospitals and a 50 per cent sample of CHCs and private clinics were selected for this assessment. Accordingly, a total of 181 hospitals, CHCs and clinics (public and private) were visited and 173 that provided delivery services in the last 12 months prior to the survey were included in this analysis. Sixty-eight health personnel with a minimum health background qualification of a diploma (with two years of college education) served as data collectors and supervisors. Data collection was conducted between August and September 2017.
The data analysis for this report used a weighting procedure to represent and generalize at the national and district levels due to a mix of methods (census of hospitals and sample of CHCs/clinics) used for data collection. Unless specified in each of the specific texts or tables, absolute values (n’s) are presented unweighted and all proportions, percentages and rates are presented weighted.
Key findings from each chapter are summarized below.
EmONC indicators and readiness
-Based on the UN handbook of EmONC signal functions , a facility qualifies as Basic if it performs all the seven basic signal functions (parenteral antibiotics, anticonvulsants and uterotonics (all by injection), manual removal of placenta, removal of retained products of conception, assisted
vaginal delivery (AVD) with vacuum extractor or forceps, and neonatal resuscitation with bag and mask) and it qualifies as Comprehensive if it performs all the Basic plus caesarean delivery and blood transfusion in the last three months prior to the survey.2 Accordingly, UN recommends a minimum of five EmONC facilities for every 500,000 population, of which, at least one of the five EmONC facilities should be comprehensive.
• In 2017, Sierra Leone was required to have 73 EmONC facilities – 58 Basic Emergency Obstetric and Newborn Care (BEmONC) and 15 Comprehensive Emergency Obstetric and Newborn Care (CEmONC) – and 62 were fully functioning as EmONC (85 per cent of the recommended number; 41 BEmONC and 21 CEmONC), leaving a gap of 11 EmONC facilities.
• Out of the total 73 required EmONC facilities, 15 comprehensive EmoNC facilities were required. Sierra Leone exceeded this recommendation by having 21 functioning comprehensive EmONC facilities (148 per cent).
• Coverage of EmONC facilities by district was also observed as a gap of one to five EmONC facilities in nine out of the 14 districts (Kono, Bombali, Kambia, Port Loko, Tonkolili, Bo, Moyamba, and Western Rural and Urban). In terms of CEmONC facilities, only Moyamba and Western Rural had a gap of one CEmONC each.
• When we look at the facilities that are partially functioning as EmONC, 41 per cent of the total facilities were missing only one or two basic EmONC signal functions. These facilities were distributed across all districts with the highest in Bo (10 facilities), followed by Western Urban (nine facilities), and Kenema, Port Loko, and Moyamba (seven facilities each), and Kailahun and Bonthe (five each) to the lowest in Kambia and Koinadugu (two each).
1. The Averting Maternal Death and Disability Program (AMDD) is part of the Department of Population and Family Health in the Mailman School of Public Health at Columbia University in New York City. Tools are accessible at AMDD’s website: https://www.mailman.columbia.edu/research/averting-maternal-death-and-disability-amdd/toolkit#toolkit.
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-Facility readiness to provide EmONC signal function is a composite indicator that helps to measure a facility’s preparedness to provide EmONC services. Readiness is defined as the availability of at least one health worker cadre on staff who can provide the signal function and the availability of a minimum package of drugs, supplies and equipment.2,3
• Overall, hospitals and CHCs/clinics were better staffed than equipped, and had supplies in readiness to provide EmONC signal functions. This meant that facilities were not fully prepared to provide EmONC signal functions primarily due to lack of the required drugs, equipment and supplies than lack of health personnel.
• Of the seven basic EmONC signal functions, facilities were the least ready to provide removal of retained products of conception (26 per cent) services and AVD (42 per cent).
• Fifty-four per cent of the facilities did not provide AVD and 68 per cent did not perform removal of retained products of conception. The most pertinent problem for the non-performance of AVD was lack of equipment and supplies; and for removal of retained products, no indication, (no pregnant woman presented that required these procedures) lack of equipment/supplies and training were cited as the main reasons.
• Hospitals were the least ready to provide caesarean section (CS) deliveries and blood transfusions among all signal functions. Although hospitals were better staffed, they lacked supplies and equipment. In addition, actual performance of these signal functions was higher than their readiness to provide caesarean delivery and blood transfusion, indicating that hospitals might be providing these services under suboptimal conditions.
• Eighteen and 15 per cent of hospitals did not provide caesarean delivery and blood transfusion, respectively. Lack of training or skilled health workers, and a lack of supplies and equipment and weak management were some of the bottlenecks.
- The institutional delivery rate rose from 10 per cent in 2008 to 28 per cent in 2016. This indicates that 72 per cent of the expected births took place either at homes or at lower level of health facilities (health posts) or never been reported in hospitals and CHC/clinics. Koinadugu, Kono and Tonkolili had the lowest proportions of expected births that took place in hospitals and CHCs/clinics.
- From the 28 per cent of expected births that took place in hospitals and CHCs/clinics, over 80 per cent were in facilities that were not able to provide one or more signal functions.
- Met need for EmONC4 in 2017 (15 per cent) was twice as high as in 2008 (7 per cent). Although progress had been made, the achievement was far below the UN standard of 100 per cent. Ten of the 14 districts (Moyamba, Bombe, Kailahun, Port Loko, Tonkolili, Kono, Kambia, Bombali, Koinadugu and Bo) were even below the national average (15 per cent).
-A huge reduction of direct obstetric case fatality rate (DOCFR)5 was found, from 7 per cent in 2008 to 3 per cent in 2017. Yet, the DOCFR rate remains higher than the international standard (<1 per cent).• Of the 475 weighted total maternal deaths,
PPH/retained placenta (16 per cent), severe pre-eclampsia/eclampsia (16 per cent), and obstructed/prolonged labour (11 per cent) were the top three leading causes of maternal deaths over all other direct and indirect obstetric causes.
• When we looked at the cause-specific case fatality rates, PPH/retained placenta (24 per cent), severe pre-eclampsia/eclampsia (24 per cent), and obstructed/prolonged labour (17 per cent) were again the top three cause-specific case fatalities for mothers.
- Intrapartum and very early neonatal death rate in EmONC facilities in 2017 was 34 per 1,000 deliveries, which is twice as high as in 2008 (17 per 1,000 deliveries).
- Almost all facilities are using different register books for recording maternal and newborn care services. Despite facilities using a labour and delivery register (one of the many registers used to collect data on delivery, complications and maternal and newborn outcomes), only 63 per cent of hospitals and 74 per cent of CHCs/clinics had the registers complete and up-to-date.
2. WHO, UNFPA, UNICEF, AMDD. 2009. Monitoring emergency obstetric care: a handbook. Geneva: World Health Organization.3. The minimum package of drugs, equipment and supplies is determined based on a country’s national standards or basic packages.4.According to the UN estimate, 15 per cent of expected births are expected to develop major direct obstetric complications. Met need for EmONC is, therefore, defined as the proportion of women with major direct obstetric complications who were treated in the health facilities divided by the expected complications.5. DOCFR is the proportion of women with direct obstetric complications who deliver in facilities and die before discharge.
Institutional delivery rate 2008 10%
2016 28%
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Performance of other maternal and newborn health services
- Based on self-reported data, facilities in all districts except Bo (72 per cent) and Bonthe (77 per cent) provided obstetric and neonatal care services 24/7 and only 57 per cent of private for-profits provided obstetric services 24/7. - Obstetric surgery, general and spinal anaesthesia services were provided in only 87, 82 and 80 per cent of hospitals, respectively.- All facilities provided the Active Management of Third Stage of Labour (AMTSL) and used the partograph for labour monitoring. The provision of family planning (FP) methods for post-abortion care cases, however, was reported only in 67 per cent of facilities. - Kangaroo Mother Care (KMC) was provided in 60 per cent of the facilities. Western Rural and Urban, Bonthe, Bombali, Kambia, and Koinadugu had the lowest proportion of facilities providing KMC. However, this assessment did not assess the provider’s real understanding of what KMC is. It is often misunderstood and interchangeably used as skin-to-skin care.- Provision of corticosteroids for pre-term and low birth weight babies among districts ranged from none in Western Rural to 87 per cent in Pujehun and 75 per cent in Kailahun.- Coverage of essential newborn care for premature and/or low birth weight babies was also very low as only 45 per cent of facilities were providing it.- Repair and treatment of obstetric fistula was provided in only 8 per cent (n=39) of hospitals. These few facilities were distributed only in Tonkolilii, Bo and Western Urban and all were private not-for-profit.
Facility infrastructure and communication
- Availability of beds in the health facilities was assessed and the ratio of maternity beds (obstetric/gynaecology + labour and delivery) to 1,000 deliveries met the international standard of 30–32 beds. However, Western Rural and Urban, Bo, Pujehun and Kambia fell short of the minimum number of beds.- Ninety per cent of hospitals had operating theatres (OTs). Despite the fact that CHCs and clinics were not expected to have OTs, 2 per cent of them reported that they had an OT. These were private clinics that had the infrastructure set-up and required staffing to provide surgical services. - Most facilities had corners for newborn care; but only 13 per cent of hospitals and none of the CHCs/clinics had Neonatal Intensive Care Units (NICUs). None of the facilities in Kailahun, Kono, Kambia, Koinadugu, Port Loko, Bonthe, Moyamba, Pujehun or Western Urban had a separate room for NICUs.
- Despite a large proportion of facilities (89 per cent) having a source of electricity, districts like Bonthe and Kenema had large gaps, as only 46 per cent and 69 per cent of their facilities had a source of electricity. Even in districts with greater coverage of electricity, interruptions for a day or more was common. - Availability of water was quite encouraging at the national level as 94 per cent of the total facilities had a source of water. However, severe shortages of water were observed in 41 per cent of the facilities in Western Rural district. - Functioning toilets existed in most facilities across the country except in Western Rural, where only 59 per cent of the facilities had them. - On-site communication mechanisms existed in almost every facility, but the main challenge was that facility communication was highly dependent on individual cell phones but there was no clear or even existing policy regarding the reimbursement of staff for use of their cell phones.
Human resources
- This assessment shows severe shortages in availability of all categories of health workers, except obstetrician/gynaecologists and general surgeons. The shortage affected all government health facilities, except the national/maternity hospital which had some gaps only with regard to nurses and lab technicians. - A huge gap was observed among nurses (needed 1,112), Community Health Officers (CHOs) (needed 509), maternal and child health aides (MCHAides) (needed 494), and midwives (needed 239). Lab technicians, nurse anaesthetists and medical doctors (MD) were also among the deficits. - Availability of health worker cadres 24/7 was a challenge in most sites. The assessment shows staff were more likely to be on site during the day, Monday through Friday, than at night or during weekends and holidays. The difference was greatest among obstetrician/gynaecologists, paediatricians, surgeons, and MDs in hospitals and lab technicians in the CHCs/clinics.- In hospitals, provision of basic EmONC signal functions were highly dependent on obstetrician/gynaecologists, MDs, Surgical Assistant Community Health Officers (SACHOs), CHOs, midwives and nurses; while caesarean deliveries were dependent on obstetricians/gynaecologists, general surgeons and SACHOs. Blood transfusions depended on the above-mentioned health workers plus midwives. Provision of regional/spinal/epidural anaesthesia was also dependent on anaesthesiologists (MD)/anaesthetists.- In CHCs/clinics, CHOs and midwives were the key staff that provided most of the EmONC services and nurses for the provision of parenteral drugs.
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- Comparing availability of the health workforce against the international standards6,7 Sierra Leone did not meet the standard stock of the health workforce – a target of seven midwives per 1,000 deliveries and 23 combined health worker cadres (physicians, midwives, and nurses) per 10,000 population. The findings stood at five midwives per 1,000 deliveries and four physicians, midwives and nurses per 10,000 population. Only four districts (Western Urban, Koinadugu, Kono and Bombali) met the standard for the number of midwives; and none of the districts met the health worker to population ratio.
Essential drugs, equipment, and supplies
- All facilities reported having a pharmacy/drug store or supply of medicines.- For most facilities the government was the major source of medicines and supplies.- Availability of essential drugs in Sierra Leone was also a huge bottleneck as parenteral antibiotics were not available in 37 per cent of facilities, atropine in a quarter of facilities (25 per cent), magnesium sulphate (injection) in over a fifth of facilities ( per cent please), and ketamine and oxytocin in 19 per cent and 17 per cent of the facilities, respectively. Two (name them here please, they are only 2) of the three regional hospitals had stock-outs of magnesium sulphate and oxytocin. - The most common cause of delays in the supply of medicines among hospitals cited was stock-outs at the central medical stores (45 per cent); while among CHCs/clinics, lack of transport (45 per cent) and stock-out at the central store (40 per cent) were the major problems. - All hospitals had one or more antibiotics, anticonvulsants, oxytocics/ prostaglandins and drugs used in emergencies, while most (79 to 90 per cent) of CHCs/clinics had one or more of these drugs.- Overall, 92 per cent of health facilities had one or more intravenous fluids and antimalarials.- Antiretrovirals, analgesics and anaesthetics were found in 84, 83 and 82 per cent of the facilities, respectively. Nationally, almost all facilities had one or more contraceptive methods; but only 66 per cent had emergency contraception.- Vitamin K for newborns was available in almost all (95 per cent) hospitals and 25 per cent to 38 per cent of CHCs and clinics.- Chlorhexidine was available in 91 per cent of facilities. - The most common available newborn resuscitation equipment was the mucus extractor (96 per cent), ambu bag (96 per cent) and infant facemask (90 per cent).- The most widely available guidelines (91 to 93 per cent of facilities) were FP, focused antenatal care,
Human Immunodeficiency Virus (HIV) Prevention of Mother-to-Child Transmission, immediate newborn care and infection prevention for HIV.- Gloves (98 per cent) and decontamination containers (91 per cent) were the most common available basic items.- Stethoscopes (96 per cent) and blood pressure cuffs (85 per cent) were the most commonly available basic equipment in the maternity units. Ultrasound was available in 53 per cent of district and 83 per cent of other hospitals. A functioning autoclave with temperature and pressure gauge was found in 52 per cent of facilities. Almost all of the facilities had at least one complete delivery set. The average number of delivery sets available was three per facility.- Eighty-two per cent of district hospitals and 94 per cent of other hospitals had OTs. Among hospitals that had an OT (n=35), only 54 per cent and 60 per cent of them had anaesthesia apparatus and oxygen cylinders, respectively.- Laboratories were available only in 46 per cent of CHCs and 21 per cent of clinics. Refrigerators were found in 59 per cent of district hospitals, 65 per cent of other hospitals and only 2 per cent of clinics with a laboratory.
Referral system
- Nationally, only 21 per cent of the facilities had a functioning motor vehicle ambulance; while 23 per cent of facilities had at least one mode of transportation, required for transporting referrals. Kambia, Kenema, Tonkolili, Kono, Bombali, Bo and Bonthe had the lowest proportion of facilities (6 per cent to 18 per cent) having at least one mode of transportation. - Six of the seven hospitals that did not provide surgical services were within the recommended 25-kilometre radius from the nearest hospital that had surgical services, to facilitate referral services. Forty-six per cent of CHCs/clinics were within the 25-kilometre radius, while over a third of them were over the 25-kilometre radius. Seven out of 14 districts had facilities within this distance.
Recommendations
Recommendations to meet the needs and gaps identified are organized into the thematic areas: coverage and readiness; other MNH services; data quality of EmONC services; infrastructure; HR; drugs/equipment/supplies; and referral systems.
6. United Nations Population Fund. 2011. The State of the World’s Midwifery 2011. New York: United Nations Population Fund.7. World Health Organization. 2010. Monitoring the building blocks of health systems: a handbook of indicators and their measurement strategies. Geneva: WHO.
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CHAPTER 1INTRODUCTION
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Sierra Leone is situated on the west coast of Africa. It is bordered by Guinea to the northeast, Liberia to the southeast, and the Atlantic Ocean to the southwest. Sierra Leone has an estimated total population of 7,499,486 (projected for 2017) with an estimated annual growth rate of 3.2 per cent.8 The country is subdivided into four administrative regions – the Northern, Eastern and Southern provinces, as well as the Western Area, where the capital city of Freetown is located. Roughly 21 per cent of Sierra Leoneans live in the geographically small Western Area, 35 per cent in the north, 23 per cent in the east and 20 per cent in the south. These regions are further subdivided into 14 districts. The districts are further subdivided into 152 chiefdoms. Each district in Sierra Leone has a health management team and an average of 50 peripheral health units (PHU) and over 100 technical staff. The management team is responsible for planning, organizing and monitoring health provision, training personnel, working with communities and supplying equipment and drugs. Health services in Sierra Leone are organized in keeping with the Primary Health Care approach. The PHUs are designed to be the delivery points for primary health care in the country. The country has roughly 15 different ethnic groups. The official language is English, and most individuals also speak Krio, the most common local language.9
1.1 Country profile
1.2 Maternal and newborn health profileGlobally, maternal mortality has fallen by 45 per cent since 1990.10 Despite substantial reduction of maternal mortality in the last two decades, 800 women die every day due to pregnancy or childbirth-related complications. In 2015 alone, over 300,000 women died worldwide and there were 2.7 million neonatal deaths and 2.6 million stillbirths.11,12 Of the total maternal deaths in 2015, sub-Saharan Africa (66 per cent) and South Asia (22 per cent) accounted for 88 per cent of the global burden.1
Haemorrhage, hypertension disorders and sepsis accounted for over 50 per cent of maternal deaths in developing regions. These clinical conditions can readily be diagnosed and treated by skilled health professionals; and in most cases, mothers and neonates die where resources and services are inequitably available or accessible.13, 14
In the era of sustainable development endeavours, ending preventable maternal mortality remains a critical challenge in low- and middle-income countries despite significant progress in the reduction of maternal and neonatal mortalities. Ninety-nine per cent of preventable maternal deaths occur in these regions. Within countries, the risk of death is highest among the most vulnerable segments of society.5
Women in developing countries have, on average, many more pregnancies, and a woman’s lifetime risk of maternal death – the probability that a 15-year-old girl will eventually die from a maternal cause – is 1 in 180 in developing countries. The risk of maternal mortality is highest for adolescent girls under 15 years of age, and complications in pregnancy and childbirth are a leading cause of death among adolescent girls in developing countries.5,15
8. Statistics Sierra Leone. October 2017. ‘Sierra Leone 2015 Population and Housing Census - Thematic Report on Population Projections’.9. Statistics Sierra Leone (SSL) and ICF International. 2014. Sierra Leone Demographic and Health Survey 2013. Freetown, Sierra Leone and Rockville, Maryland, USA: SSL and ICF International.10. World Health Organization, UNICEF, UNFPA, World Bank Group, United Nations Population Division. 2015. ‘Trends in Maternal Mortality: 1990 to 2015’. 11. H. Blencowe, S. Cousens, F.B. Jassir et al. “National, regional, and worldwide estimates of stillbirth rates in 2015, with trends from 2000: a systematic analysis,” Lancet Global Health 4(2):e98-e108. 12. UN Interagency Group for Child Mortality Estimation. ‘Levels and trends in child mortality: Report 2015’..13 L. Say, D.Chou, A. Gemmill et al. “Global causes of maternal death: a WHO systematic analysis,” The Lancet, 2(6): e323-e333, available at http://dx.doi.org/10.1016/S2214-109X(14)70227-X.14 L. Alkema, D. Chou, D. Hogan, et al. “Global, regional, and national levels and trends in maternal mortality between 1990 and 2015, with scenario-based projections to 2030: a systematic analysis by the UN Maternal Mortality Estimation Inter-Agency Group,” The Lancet 387 (10017): 462-74.15 World Health Organization. ‘Maternal mortality fact sheet’, updated November 2016, available at http://apps. who.int/iris/bitstream/10665/112318/1/WHO_RHR_14.06_eng.pdf, accessed 06 December 2017.
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2015Maternal mortality ratio
1,360 deaths per 100,000 live births
1 in 17 bear a lifetime risk of dying during pregnancy or childbirth
According to United Nations (UN) estimates, Sierra Leone has the highest maternal mortality ratio (MMR) of 1,360 deaths per 100,000 live births and a 1 in 17 bear a lifetime risk of dying during pregnancy or childbirth. Despite substantial declines in the MMR in the last two decades from 2,900 in 1995 to 1,900 in 2005 and to 1,360 in 2015, the MMR in 2015 remains the highest in the world. Similarly, Sierra Leone also has very high child, infant and neonatal mortality rates: 156, 92 and 39 per 1,000 live births, respectively.5 Apart from maternal and child mortalities, Sierra Leone had been tested through multiple trajectories of economic and health crises including the Ebola disease in the last decade.
Recent country reports show that a total of 218,818 live births were reported in the health facilities in Sierra Leone. Of these, 5,608 were stillbirths, which is a rate of 25.7 per 1,000 live births. Nearly half of the stillbirths were fresh stillbirths; signalling suboptimal intrapartum care. In 2016, a total of 706 maternal deaths were reported, Most of the reported maternal deaths were in facilities (80 per cent) with the leading causes of death being haemorrhage, hypertension disorders and sepsis.16
Despite the huge burdens of diseases and tragedies of avoidable maternal and child mortalities in the past decade, Sierra Leone has been striving to tackle multiple bottlenecks, thereby improving health, social and economic outcomes by developing key strategies in line with the Sustainable Development Goals. Sierra Leone’s well-designed and evidenced strategic documents that focus on reproductive, maternal, child and neonatal health took into account the Sustainable Development Goals targets and country priorities.17 Sierra Leone is committed to implementing about 20 strategic plans and guidelines developed on different health pillars that articulated based on the six WHO building blocks of atypical health systems.18 Reducing maternal mortality to below 140 per 100,000 live births by 2030 as stipulated in the Goals will be achievable as some of the country results are promising and shed light on the direction and commitment shown so far.
It is with this enthusiasm and dedication that the Government of Sierra Leone and its partners agreed to conduct a rapid Emergency Obstetric and Newborn Care (EmONC) assessment to better inform the country’s efforts to reduce maternal, child, infant and neonatal mortalities and morbidities.
1.3 EmONC signal functions and indicators
EmONC refers to the care of women and newborns during pregnancy, delivery and the time after delivery (postpartum period) if or when a woman or her newborn experiences serious complications. According to global evidences, it is estimated that up to 15 per cent of expected births develop life-threatening complications during pregnancy, delivery or the postpartum period. Providing emergency care is recognized as an essential and effective component of obstetric services.19 Moreover, as indicated in a recent WHO document on facility standards, having complete and up-to-date data on women and newborns is essential, and therefore periodic monitoring and evaluation of progress on the availability, accessibility, utilization and quality of routine and emergency care for mothers and children is critical. 20
16 Ministry of Health and Sanitation. Maternal Death Surveillance and Response, 2016 Annual Report. Sierra Leone, 2016.17 Ministry of Health and Sanitation. ‘National Health Sector Strategic Plan (NHSSP), 2017–2021’. September 2017. 18 World Health Organization. 2010. Monitoring the building blocks of health systems: a handbook of indicators and their measurement strategies. Geneva: World Health Organization.19 WHO. 2003. Managing newborn problems: a guide for doctors, nurses, and midwives. Geneva: World Health Organization.20 World Health Organization. 2016. ‘Standards for Improving Quality of Maternal and Newborn Care in Health Facilities’.
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The UN handbook on EmONC clearly stipulates that EmONC measurement has nine signal functions that illustrate life-saving procedures for women experiencing major direct obstetric complications. A facility is considered to be functioning as BEmONC if the seven basic signal functions have been performed in the three months prior to the assessment and are available 24 hours a day and 7 days a week. And a facility is functioning as comprehensive EmONC (CEmONC) if caesarean delivery (caesarean section, CS) and blood transfusion services are provided in addition to the seven basic signal functions in the three months prior to the assessment.21
Basic signal functions refer to the following:12
1. Parenteral (intravenous – [IV]), intramuscular antibiotics;2. Parenteral (IV, intramuscular) anticonvulsants;3. Parenteral (IV, intramuscular) oxytocics;4. Manual removal of placenta;5. Removal of retained products, e.g. m,anual vacuum aspiration (MVA);6. Assisted vaginal delivery (with vacuum extractor or forceps);7. Neonatal resuscitation with bag and mask.Comprehensive signal functions refer to the above seven basic signal functions, plus:12
8. Caesarean delivery;9. Blood transfusion.
In addition to the EmONC signal functions, UN agencies and the Averting Maternal Death and Disability Program (AMDD)22 had developed eight EmONC indicators to monitor and evaluate the process and progress towards reducing maternal mortality. These indicators are:
1. Availability of EmONC. Percentage of recommended number of Basic and Comprehensive EmONC facilities, based on a ratio of five EmONC facilities for every 500,000 population, where at least one of the facilities provides CEmONC;
2. Subnational geographic distribution of EmONC facilities;
3. Proportion of all births from expected births in EmONC facilities;
4. Met need for EmONC (as a proportion of the expected complications);
5. CS as a proportion of all births;
6. Direct obstetric case fatality rate (DOCFR;
7. Intrapartum and very early neonatal death rate;
8. Proportion of maternal deaths due to indirect obstetric causes.12
In addition to the EmONC signal functions, this rapid assessment captured very few newborn signal functions – the provision of antenatal corticosteroids and Kangaroo Mother Care (KMC) – though the international community suggested seven signal functions that align with the primary causes of newborn deaths.
1.4 Objectives of the assessment
The overall objective of this rapid assessment is to generate evidence on the current availability, utilization and quality of EmONC and routine delivery services in Sierra Leone.
Specifically, the assessment aims to:
• measure the availability of infrastructure, equipment, essential drugs and supplies in health facilities;• determine the availability of human resources;• map EmONC services as part of service availability mapping;• determine the status of EmONC services and utilization of life-saving procedures;• assess the availability and use of records for EmONC services and the completeness of EmONC data; • compare the results of this assessment with that of 2008 to measure progress made.
21 WHO, UNFPA, UNICEF, AMDD. 2009. Monitoring emergency obstetric care: a handbook. Geneva: World Health Organization.22 The Averting Maternal Death and Disability Program (AMDD) is part of the Department of Population and Family Health in the Mailman School of Public Health at Columbia University in New York City.
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CHAPTER 2METHODOLOGY
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2.1 Overview of the assessment
The Government of Sierra Leone, through the Ministry of Health and Sanitation (MoHS), and along with UNFPA and partners, started the 2017 rapid EmONC assessment in November 2016 with advocacy and preparatory activities. The MoHS, with UNFPA support, established a Technical Working Group (TWG) to provide input and guidance in the overall assessment process. The TWG was composed of representatives from the Maternal and Child Health (MCH) Directorate of MoHS, UNFPA, UNICEF, WHO and Statistics Sierra Leone (SSL). The TWG has been meeting regularly to discuss progress and provide directions on the assessment. In addition, UNFPA Sierra Leone through funding from UKaid , covered the cost of this assessment including hiring an international consultant to support the coordination of the process technically and ensure that the assessment meets international standards.
2.2 Study design
The 2017 Sierra Leone rapid EmONC assessment is a national cross-sectional facility-based assessment that includes all public and private hospitals and a 50 per cent sample of all mid-level facilities (family health centres and private clinics) that provide maternity services. A total of 173 hospitals, family health centres and private clinics that had provided delivery/maternity services at the time of the survey were included in this assessment. The data collection was held between 20 August and 8 September 2017.
2017 2018
Apr Jun Jul Aug Sept Oct Nov Dec Jan Feb Mar Apr May Jun Jul
Planning and advocacy
Adaptation of modules, finalization &pre-testing
Development of data entry screens in Census and Survey Processing software
Recruitment of data collectors andsupervisors
Printing of data collection tools
Recruitment and training of data entryclerks
Data collector training
Data collection and field level supervision
Data entry (including review and cleaning(at questionnaire level
Data cleaning
Data analysis (table shells adaptation,(weighting, analysis
Report writing
Report validation workshop
Dissemination and action planning
Table 2.2.1: The Sierra Leone Rapid EmONC Assessment 2017 timeline
173 hospitals, family health centres and private clinics were included in this assessment.
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Facility selection
Based on the complete list of health facilities that the MoHS has, the TWG selected all eligible public and private (for-profit and not-for-profit) hospitals (referral, general, primary), and a 50 per cent random sample of family health centres and private (for-profit and not-for-profit) clinics. Eligibility was determined according to the Basic Package of Essential Health Services 2015–2020 document, using MoHS definitions and the facility tier levels. This included: (1) health facilities that must provide skilled deliveries; (2) facilities that reported having attended births in the last 12 months; and (3) facilities deemed functional and providing delivery services at the time of the assessment. In the assessment, the data collectors visited 187 health facilities and 173 facilities that had attended births in all the 14 districts.
The health facilities selected for this assessment were given district codes based on the existing district coding system by SSL. Survey teams also visited District Health and Sanitation Offices to verify the existence of the facilities on the list. Seven health facilities were removed due to non-provision of maternity services at the time of the assessment. Table 2.2.2 shows the number of facilities surveyed and included in the final database.
Facility type
National/ maternity hospital
Regional hospital
District hospital
Otherhospitals1
Community health centre Clinic Total
National 1 3 17 18 124 10 173
District
Kailahun 0 0 1 1 7 0 9
Kenema 0 1 0 1 15 0 17
Kono 0 0 1 0 10 0 11
Bombali 0 1 0 3 9 1 14
Kambia 0 0 1 0 7 0 8
Koinadugu 0 0 1 0 6 0 7
Port Loko 0 0 2 2 10 0 14
Tonkolilii 0 0 1 1 7 0 9
Bo 0 1 0 4 18 0 23
Bonthe 0 0 1 1 8 2 12
Moyamba 0 0 1 1 9 1 12
Pujehun 0 0 1 0 7 0 8
Western Rural 0 0 1 0 6 1 8
Western Urban 1 0 6 4 5 5 21
Table 2.2.2: Number of health facilities surveyed by facility type and district, Sierra Leone Rapid EmONC Assessment 2017
Note 1.Other hospitals include private-for-profit, NGO, and faith-based hospitals.
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Respondent selection
Since the unit of analysis for all modules in this assessment is a health facility or the data is about the health facility, selection of respondents was not an issue; those who provided facility data ranged from facility in-charges and medical directors to health service providers in the maternity, pharmacy, operating theatre (OT), laboratory and elsewhere in the facility.
2.3 Data collection instruments and pre-testing
The 2017 Sierra Leone EmONC TWG selected the core modules (Modules 1−5) from AMDD’s recent set of tools revised in 2014. The team adapted the tools to the local context in an abridged version. This rapid EmONC assessment, therefore, utilized five facility-based modules or data collection instruments and one national module that dealt with basic facts on population, human resource standards, medical and midwifery training institutions, training standards on emergency obstetric and newborn care and associated information at the national level.Specific modules used for this assessment are the following.
Module 0: National data collection tool designed to collect information at the national level. This tool helped the research team gather information such as national and district-level populations, lists of health facilities, national drug lists, scope of work for health workers, information about policies related to the level of staffing and availability of educational institutions for midwives, nurses and doctors.
Module 1: Identification of facility and infrastructure. This required interviewing a person of authority at the facility, and recording background information on the facility, including size or capacity, overall infrastructure, summary of services provided, communication mechanisms available, transportation systems that existed, types of ambulances, and the distance and time required to access a nearby facility with surgical services. SSL has provided data on GPS coordinates of the health facilities that was readily available and not collected as part of the rapid EmONC assessment.
Module 2: Human resources involved interviewing one or more persons with excellent knowledge of the staffing patterns of health care workers providing obstetric and newborn care at the facility and the signal functions and essential services the staff provide. It also covered the staffing situation 24 hours a day and seven days a week in that facility.
Module 3: Essential drugs, equipment, and supplies examined the availability of medications, equipment and supplies; laboratory services; and clinical management guidelines and protocols necessary
for the delivery of EmONC and routine maternal and newborn services. This module was conducted primarily by interview and observation.
Module 4: Facility case summary was used to collect the necessary data from facility registers and records to calculate the EmONC indicators. This data included the number of deliveries, obstetric complications, CS, maternal deaths, stillbirths and pre-discharge very early neonatal deaths recorded during the calendar year (January – December).
Module 5: EmONC and other essential services looked at how facilities actually function and whether they offer all, some, or none of the services necessary to treat and save newborns and women with obstetric complications. It also looked at why these services were not available. Performance information was determined through interview and validation from the registers. This module used a different reference period from Module 4. Instead of the 2016 calendar year, it referred to the three months prior to the survey visit. A rolling three-month period was used between August and September 2017. Thus, the two-time periods did not overlap.
Pretesting of the modules took place as part of the data collector’s training to detect problems in the flow of the questions, gauge the length of time required for interviews, and identify problems in the understanding of terms and concepts. After the pretesting, the technical team corrected inconsistencies and other issues identified.
2.4 Recruitment, training and deployment of data collectors, team leaders and coordinators
UNFPA Sierra Leone recruited individuals with mainly either a diploma or a higher degree in nursing or midwifery, or in other related health backgrounds, to serve as field staff. This included medical doctors (MDs), obstetricians, community health officers (CHOs), environmental and laboratory technical persons, midwives and nurses, and others. Some had prior experience as data collectors and had a Master’s degree in Public Health. The final assessment team included 12 central coordinators (from UNFPA and MoHS), 14 supervisors, and 32 data collectors. Recruitment criteria were developed and used for the recruitment of data collectors and supervisors (full list in Appendix D).
UNFPA’s international consultant, hired as a senior technical expert for this assessment, led the training of the data collectors and supervisors with support from UNFPA’s International Data Specialist.
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Some of the TWG members (mostly from UNFPA Sierra Leone, MoHS, SSL and other UN offices) were co-facilitators of the training. The data collector training took place in Freetown from 3 to 7 August 2017, attended by 32 data collectors, 14 supervisors and 8 data entry clerks, including a data manager.
The data collector training consisted of instruction on interviewing techniques and field procedures, a detailed review of the questionnaire content and instructions, mock interviews between participants in the classroom, and practice with the five modules. A daylong field activity at nearby health facilities in Freetown provided trainees with an opportunity to practice data collection in the field. In addition, survey coordinators and supervisors received additional instructions on data quality control procedures and fieldwork coordination.
For the actual data collection, the data collectors were divided into 14 teams of three, with one member per group serving as a supervisor. Teams were deployed in the third week of August 2017 for data collection. Initially, all the teams were deployed in Freetown (Western Urban and Western Rural districts) to closely monitor the work of the data collectors and provided necessary field support. After the data collection was completed in the Western area, the teams were deployed to the remaining 12 districts.
2.5 Data collection (fieldwork)
The MoHS issued a letter to all the District Health Offices requesting their support in the national rapid EmONC assessment. District Health Offices wrote supporting letters to the health facilities in their catchment area to ensure that the data collection ran smoothly.
UNFPA, with support from the MoHS, organized the fieldwork, including the hiring and payment of data collectors, logistics and transportation, planning of team itineraries and communication with the District Health Offices to ensure they were well-informed and prepared to help when needed. The team-level supervisors were engaged as data collectors as the same time, problem solving whenever the teams faced challenges at the facilities. In addition to the supervision of data collection at the team level, the TWG members provided field supervision and spot-checking in many of the districts, including the accuracy of data extraction. Several TWG meetings were held at the central level to update the TWG on the progress of data collection and to jointly solve problems (e.g., lack of accessibility in some areas). The fieldwork began on August 20 and ended on 8 September 2017. When one team concluded its work early and a neighbouring district had not yet finished, the former was deployed to help finish the larger districts.
2.6 Data entry, cleaning, and analysis
In addition to the training of data collectors and fieldwork, UNFPA also hired an experienced Data Manager and eight data entry clerks to manage data entry and cleaning, and to assist in the analysis. All of the data entry clerks and the Data Manager were trained on the data collection tools. UNFPA’s International Data Specialist also provided oversight for the data entry, cleaning and analysis.Before the actual data entry, UNFPA’s reproductive health team which was part of the assessment from the beginning, reviewed the filled questionnaires, consulting with data collectors and calling the health facilities when needed This was done at UNFPA’s office in Freetown. The data manager backed up data as frequently as possible and used password-protected computers to ensure maximum protection of data loss and to avoid file corruption. The data were secured and were not accessible to unauthorized persons.
Double data entry was done to ensure accuracy and completed by the end of September 2017 for all modules. Data cleaning included range checking, data structure and a set of checks for internal consistency. All errors detected during cleaning were corrected. Most of the inconsistencies were in Module 4 (case summaries), particularly in the number of deliveries, complications, and maternal and neonatal deaths. Health facilities with these inconsistencies were contacted and data were cleaned accordingly. This process took quite a long time (from November 2017 to March 2018) due to reasons of either accessibility of data or poor quality of data at the district and regional hospitals. Prior to analysis, further steps were taken to ensure unique identification numbers, validation of facility type and location, and the recoding of “other” responses.
All data management was done using Census and Survey Processing software 6.2 programming. The data were exported to Statistical Packages for Social Sciences version 22 for analysis. ArcGIS/ArcMap software was used to create maps. Prior to the completion of data collection, table shells were developed or adapted, and finalized by the TWG. The international consultant then populated the table shells and drafted a report, and these were reviewed by the TWG.
Stratification variables
Four common stratification variables are used throughout this report:
• District, consisting of the 14 administrative units established by the Government of Sierra Leone available for 2016 – 2017. • Facility type, collected originally in six categories:
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referral or specialized hospital, regional hospital, district hospital, community health centre (CHC), private clinic and “other.” The “other” group was examined closely and when appropriate a facility was recoded into one of the other seven categories, but most of the “others” were private clinics that were not tied into any health system tier level, other than functioning at the primary care level. For most of the analyses the first five categories, were maintained, but for some tables the six categories were collapsed into two: hospitals and CHCs/clinics.• Operating agency, defined initially by four categories: public/government, private-for-profit, private-mission or faith-based and “others”. The last category encompasses mostly non-governmental and not-for-profit facilities that can be categorized into three: (1) public or government, (2) private-for-profit and (3) private not-for-profit, including non-governmental organization (NGO) mission, or faith-based. • Urban or rural, based on the responses to Module 1 and not verified from any other sources.
2.7 Weighting procedures for data analysis
Since the survey utilized a mix of methodologies to cover all hospitals (both public and private) and a sample of CHCs and clinics, weighting and extrapolation were crucial to present data on UN indicators as well as overall facility-based information on infrastructure, HR, drugs, equipment, supplies, deliveries, complications and deaths, and signal functions. The weighting was based on the total number of sampled CHCs and clinics that conducted deliveries, which represented nearly 50 per cent of the total number of CHCs and clinics in the country. The weighting process considered district-level homogeneity in terms of service delivery. This meant that all CHCs in a certain district were given equal weight, keeping other considerations constant (unchanged). So, hospitals, as an example, were given a weight of one, since it was a census, while CHCs and clinics had district-specific weights that ranged from 1.50 to 3.86 depending on the sampled CHCs and clinics in each district.
2.8 Quality assurance
Quality assurance activities involved multiple steps along a continuum of training, data collection in the field, and data processing at the central level, especially during the first weeks of data collection. During data collection, a supervisor was assigned to each team. The role of the supervisor was to provide support to the data collection teams, provide logistical support where needed, review the modules for completeness and collect completed
modules for submission to national coordinator. Members of the TWG were involved in supportive supervision, spot-checking and validation of the data. When needed, these team members telephoned facilities for clarification and to ensure quality.
Quality assurance began with the recruitment of data collectors and supervisors with a health background. Data collectors and supervisors took pre- and post-tests to assess their learning and knowledge of the assessment guidelines and standards for data collection. Each data collector and supervisor was given a hard copy manual of the assessment guidelines as a reference.
Before the actual data entry, UNFPA’s reproductive health team, that was part of the assessment from the beginning, reviewed the filled questionnaires, consulting the data collectors and calling the health facilities when needed. This was done at UNFPA’s office in Freetown. During data entry, there was close supervision by the TWG members and in particular the data manager who was responsible for handling all queries from data entry clerks.
After the data entry, there was also a rigorous review of the dataset by the international consultant and UNFPA staff. Further inconsistencies were identified and corrected accordingly, through direct contact of the health facilities over the phone. As part of the review and cleaning of the data, the international consultant and UNFPA team visited five health facilities (three hospitals, a CHC and a private clinic) in Freetown for verification of the data. This was done in the second half of November 2017 to ensure the quality of the data. An in-depth review of the data found that several inconsistencies, particularly in the number of deliveries, newborn outcomes, direct and indirect obstetric complications, maternal and neonatal deaths. Such inconsistencies were thoroughly reviewed and facilities were called to correct the data. A few data collectors revisited the regional hospitals, due to the volume of deliveries and the need to be physically present to verify data. This process continued from November 2017 to March 2018.
After data entry, cleaning and quality assurance activities, all questionnaires were filed systematically by district for easy access and retrieval during the data validation and analysis stages.
28
2.9 Response rates
The response rate for this assessment was 96 per cent. Of the 187 health facilities selected for the survey, only seven failed to participate due to the unavailability of a health provider to respond to the assessment questionnaires or because a few facilities were closed at the time of the survey.
2.10 Research ethics
Trainers introduced data collectors to principles of confidentiality and ethics in data collection. No person’s name (except that of the interviewer) was recorded on any of the modules. Permission to enter each facility, to interview the different employees, and to review registers was requested from the facility in-charge at the beginning of each visit. The response from the medical director or facility in-charge, matron and all other respondents with whom the team had contacted, was always respected. The teams carried with them official letters of cooperation from the MoHS and its district-level offices. The MoHS had granted approval to conduct this assessment.
2.11. Limitations of the survey
Despite the fact that the EmONC assessment is a facility-based assessment that presents data mostly in aggregate forms, there were a number of data acquisition problems. Lack of a complete record of deliveries, complications, maternal and neonatal deaths and newborn outcomes was a huge problem across all districts that required caution in generalizing the data at national and district levels. Facility records were often incomplete. The misclassification of the cause of death can occur in several ways: the cause of death can be reported incorrectly as direct instead of indirect or vice versa. Maternal deaths due to indirect obstetric causes in EmONC assessments are known to be especially difficult to identify because they rarely occur in the maternity or gynaecology wards. For example, the pregnancy status of a woman who dies of hepatitis in a non-maternity ward may not be displayed in the labour and delivery logbook or register. Furthermore, the cause of death may remain unknown when autopsies are infrequent; and not infrequently such reports are omitted. The Sierra Leone EmONC data also exhibited inconsistencies in reporting direct and indirect causes of maternal death and unknown causes as well. The UNFPA team and the international consultant spent much time cleaning up these types of inconsistencies.
Complications are also frequently under-recorded and therefore ‘met need for EmONC’ may be underestimated. The under-recording of
complications (and deaths) will also impact the DOCFR. During this assessment, there had been a high number of malaria, severe anaemia, and other indirect causes. The number of pregnant women who developed these complications might be higher than the reported number, due to other vertical programmes implemented in the health facilities, which would lead to either a lower count of all pregnant women, or repeated counting whenever pregnant women accessed health facilities for treatment. This would impact the calculations for met need and DOCFR.
Observation of equipment, supplies, and drugs was encouraged but not mandatory, given their high number. The mandatory observations were few; for example, the type of drug inventory system, the refrigeration of oxytocin, and whether liquid spills or trash could be seen on the floor.
Since a sample of community health centres and private clinics were included in the survey, when reporting at district levels, the extrapolated results (weighted data) may not reflect the true nature of the data at facility and district level.
2.12 Organization of the report
In the rest of this report, chapters 3 to 8 cover the results of the survey; they are organized, to a great degree, according to the different modules administered by the data collectors. Chapter 9 collects specific recommendations organized around the themes of coverage, infrastructure, HR, drugs/equipment/supplies, and referral. Because of the large number of tables in every chapter, many tables are placed at the end of the report in Appendix A. Tables are numbered sequentially where the first number (to the left of the decimal place) refers to the chapter number, the second number refers to the section number and the last number refers to the sequential number of that table within the specific section. Table numbers that end with the letter ‘A’ mean that they are in Appendix A. For example, Table 3.1.2 would be found in the body of the report (chapter 3, section 1, table 2) and Table 3.1.1A will be found in Appendix A.
CHCs and clinics are grouped together and labelled either as ‘CHCs/clinics’. Similarly, sometimes all hospitals are grouped since they are all expected to provide comprehensive emergency obstetric care.
29
CHAPTER 3EMERGENCY OBSTETRIC AND NEWBORN CARE INDICATORS
30
CHAPTER 3EMERGENCY OBSTETRIC AND NEWBORN CARE INDICATORS
23 The three-month reference period was chosen because it provides a snapshot of the functioning of a facility at the time of the visit and recall is more accurate over shorter periods. 24 WHO, UNFPA, UNICEF, AMDD. 2009. Monitoring emergency obstetric care: a handbook. Geneva: World Health Organization.
0
10
20
30
40
50
60
70
8073
62
EmONC (CEmONC + BEmONC)
58
41
Basic
1521
Comprehensive
UN targets Fully functioning
EmONC status
Sierra Leone’s 2017 EmONC assessment summarizes eight globally known EmONC indicators. The EmONC indicators as articulated in section 2 of chapter 1 measure availability, utilization and quality of care services for pregnant women and newborns. These indicators also assess the country’s health system strength in delivering life-saving interventions to both the mothers and their babies. The indicators will further be very helpful for evidence-based local action planning, and strengthening the responsiveness of the country’s health system at the national level. The eight indicators are:
1. Indicator 1: Availability of EmONC services;2. Indicator 2: Geographic distribution of EmONC facilities;3. Indicator 3: Proportion of all births in EmONC facilities;4. Indicator 4: Met need for EmONC;5. Indicator 5: Caesarian Sections as a proportion of all expected births;6. Indicator 6: Direct Obstetric Case Fatality Rate ;7. Indicator 7: Intrapartum and very early neonatal death rate;8. Indicator 8: Proportion of maternal deaths due to indirect obstetric causes in emergency obstetric care facilities.
Data for these indicators were extracted from different register books: labour and delivery, OT, discharge, referral, PMTCT, FP, malaria, and other registers over the 12 consecutive months of January to December 2016. As mentioned in the limitations section above, the data collectors were challenged with inherent problems of using routine service data: non-existent, incomplete and inconsistent data for deliveries, complications, newborn outcomes, maternal and newborn deaths at all levels of health facility and in all locations. Data collectors were trained to meticulously count entries in those registers without relying on the routine HMIS information.
The data used to determine whether a signal function was performed were based on the immediate three months prior to the facility visit.23
3.1 Indicator 1: Availability of EmONC services
Based on the international definition of EmONC signal functions (Chapter 1, section 2), a facility qualifies as Basic if it performs all the seven basic signal functions and it qualifies as Comprehensive if it performs all the Basic plus CS and blood transfusion in the last three months prior to the survey.24 Accordingly, UN recommends a minimum of five EmONC facilities for every 500,000 population, of which at least one should be comprehensive.
In 2017, Sierra Leone was required to have 73 EmONC facilities, and 62 were fully functioning as EmONC (85 per cent of the recommended number), leaving a gap of 11 EmONC facilities (Table 3.1.1A in Appendix A, Table 3.1.1 and Figure 3.1.1). In addition, of the total 73 required EmONC facilities, it was required to have 15 comprehensive EmoNC facilities. Sierra Leone exceeded this recommendation by having 21 fully functioning comprehensive EmONC facilities (148 per cent).
Figure 3.1.1: Current EmONC status of facilities and UN targets, Sierra Leone Rapid EmONC Assessment 2017
31
Coverage of EmONC facilities by district was also shown in Table 3.1.1. Overall, a gap of one to five EmONC facilities was observed in nine out of the 14 districts. These are Kono, Bombali, Kambia, Port Loko, Tonkolili, Bo, Moyamba, and Western Rural and Urban. In terms of CEmONC facilities, only Moyamba and Western Rural had a gap of one CEmONC each.
Table 3.1.1: Availability of EmONC facilities (weighted), by district (EmONC Indicator 1), Sierra Leone Rapid EmONC 2017
Basic and Comprehensive EmONC facilities Comprehensive EmONC facilities
Percentage of actual to
recommended
Popu
latio
n1,2
Reco
mm
ende
d2
Actu
al
(wei
ghte
d)3
Actu
alre
com
men
ded
Gap
[ex
ceed
s [m
inim
um
Reco
mm
ende
d2
Actu
al (w
eigh
ted)
3
Act
ual
reco
mm
ende
d
Gap
[ex
ceed
s [m
inim
um
Basi
c an
d Co
mpr
ehen
sive
Targ
et >
5
Com
preh
ensi
veTa
rget
> 1
n n % n n n % n
National 7,296,402 73 62 85 11 15 21 144 (6) 4 1
District
Kailahun 541,202 5 5 92 0 1 1 92 0 5 1
Kenema 629,457 6 9 143 (3) 1 2 159 (1) 7 2
Kono 522,301 5 1 19 4 1 1 96 0 1 1
Bombali 624,084 6 1 16 5 1 1 80 0 1 1
Kambia 355,469 4 3 84 1 1 1 141 (0) 4 1
Koinadugu 421,212 4 7 166 (3) 1 1 119 (0) 8 1
Port Loko 633,166 6 3 47 3 1 3 237 (2) 2 2
Tonkolilii 546,812 5 4 73 1 1 2 183 (1) 4 2
Bo 593,160 6 4 67 2 1 2 169 (1) 3 2
Bonthe 204,349 2 3 147 (1) 0 1 245 (1) 7 2
Moyamba 328,373 3 0 0 3 1 0 0 1 0 0
Pujehun 357,105 4 10 280 (6) 1 1 140 (0) 14 1
Western Rural 450,755 5 4 89 1 1 0 0 1 4 0
Western Urban 1,088,957 11 8 7 3 2 5 230 (3) 4 2
Note: 1. Sierra Leone population in 2016 was taken to match the service statistics. Source of Population Estimates: Statistics Sierra Leone, October 2017; ‘Sierra Leone 2015 Population and Housing Census - Thematic Report on Population Projections’, Freetown, Sierra Leone.2. WHO, UNFPA and UNICEF recommend as a minimum a ratio of five EmONC facilities per 500,000 where at least one is Comprehensive (Monitoring Emergency Obstetric Care: A Handbook, 2009). 3. Weighted number of EmONC facilities.
EmONC grading
One of the key uses of this EmONC assessment is to inform local level planning to be evidence-based. In this regard, apart from classifying facilities as fully functioning CEmONC and BEmONC, they are also categorized by the number of signal functions missing in the three-month reference period. Accordingly, EmONC grading is defined as CEmONC – that performs all the nine signal functions, BEmONC – performs all the seven basic signal functions, “Almost there” – missing one or two of the seven basic signal functions, “On the way” – missing three or four of the seven basic signal functions, “Barely functioning” – providing only one or two signal functions, and “Non-EmONC” – facilities that did not provide any of the signal functions. In this definition, we do not know which of the signal functions is missing.
32
Table 3.1.2A (Appendix A) and Figure 3.1.2 show this classification by district, facility type, operating agency and location. Of the total facilities, only 7 per cent were CEmONC and 13 per cent BEmONC. However, quite a large proportion of the facilities (41 per cent) were “Almost there” that can easily be upgraded to make them function as BEmONC. A little over a third of them were “On the way” that misses three or four signal functions. The remaining facilities (5 per cent) were barely functioning as EmONC.
Figure 3.1.2: Percentage of grading of facilities based on their EmONC status by facility type, Sierra Leone Rapid EmONC Assessment 2017
Performance of EmONC signal functions
Performance of the signal functions was based on the three-month reference period prior to the survey. In addition, data on performance and non-performance of these signal functions was substantiated from self--reports of facilities or their in-charges in the maternity sections, and verifications were made from register books. This was done after the interviews were completed and when the data collectors started extracting service statistics data from registers.
As Figure 3.1.3 and Table 3.1.2 show, almost all of the health facilities that provide delivery services had provided parenteral antibiotics, followed by provision of parenteral oxytocics (98 per cent) and newborn resuscitation with bag and mask (90 per cent). The least performed signal functions in the specified refe-rence period were AVD (32 per cent), removal of retained products of conception (46 per cent), and manual removal of placenta (61 per cent).
CHCs/clinics are not expected to provide CS and blood transfusion due to the requirement of the facilities in terms of infrastructure set-up, availability of required human resource, equipment, drugs and supplies. In this case, performance of these two signal functions that make a facility comprehensive EmONC were calculated for hospitals only. Eighty-two percent and 85 per cent of the hospitals respectively performed CS and blood transfusion in the last three months prior to the survey. However, there were a small proportion of CHCs/clinics (1 per cent each) that provided both signal functions.
0%
10%
20%
30%
40%
50%
60%
34%
41%
13%
5%7%
National
37%42%
15%
5%0%
CHCs/clinics
10%
31%
0%5%
54%
Hospitals
CEmONC BEmONC Almost there On the way Barely functioning
33
Figure 3.1.3: Percentage of facilities that performed each EmONC signal function in the last 3 months prior to the survey, Sierra Leone Rapid EmONC Assessment 2017
Table 3.1.2 also shows performance of the signal functions by district and operating agency. All facilities in all districts, except Port Loko (92 per cent) and Pujehun (87 per cent), provided parenteral antibiotics. Similarly, parenteral oxtocics was provided in all facilities of all districts except Western Urban (97 per cent), Bonthe (91 per cent) and Western Rural (86 per cent). All the facilities in Koinadugu, Tonkolili and Pujehun provided anticonvulsants for the treatment of pre-eclampsia/eclampsia. This signal function was least performed in Bombali. Assisted vaginal delivery (AVD) and removal of retained products of conception were the least performed basic signal functions with great variations among the districts. AVD was performed the most in Pujehun (100 per cent) and the least in Moyamba (0 per cent). Similarly, removal of retained products was performed in the highest proportion of facilities in Pujehun (87 per cent) and the lowest in Bombali (12 per cent). A similar percentage distribution was observed among districts for the performance of manual removal of placenta. Nine out of the 14 districts had all their facilities providing newborn resuscitation, with lower performance in Western Rural (69 per cent) and Kenema (72 per cent). CS and blood transfusion for those needed were performed in a very small number of facilities in all the districts. This could be reasoned out as CHCs/clinics outnumbered hospitals that are potentially performing these two signal functions. Unlike many other countries, private-for-profit health facilities were the least in performing all of the basic signal functions though a small number of private for-profit facilities were surveyed, in which the majority were clinics like government and private not-for-profit.
EmONC signal function
Total number
of facilities
Parenteral antibiotics
Parenteral oxytocics
Parenteralanticonvulsants
Manual removal of
placenta
Removal of retained products
Assisted vaginal delivery
Newborn resuscitation with bag and
mask
Surgery / caesarean
Blood transfusion
n % % % % % % % % %
National 173 99 98 72 61 46 32 90 11 12
District
Kailahun 9 100 100 75 87 56 56 100 6 6
Kenema 17 100 100 81 69 44 38 94 7 7
Kono 11 100 100 43 62 24 24 72 15 6
Table 3.1.2: Percentage of facilities that performed each EmONC signal function in the last three months, by district, facility type and operating agency, Sierra Leone Rapid EmONC Assessment 2017
0%
20%
40%
60%
80%
100% 99% 98%
72%61%
46%
32%
90%82%
85%
Parenteral A
ntibiotic
s
Parenteral Oxy
tocics
Parenteral Antic
onvulsants
Manual Removal o
f Place
nt a
Removal o
f Retained...
Assiste
d Vaginal D
elivery
Newborn re
susci
tatio
n with
.. .
Surge
ry / C
esarean*
Blood Transfusio
n*
Note: The percentage of facilities that performed blood transfusion or surgery is based on hospitals only.
34
EmONC signal function
Total number
of facilities
Parenteral antibiotics
Parenteral oxytocics
Parenteralanticonvulsants
Manual removal of
placenta
Removal of retained products
Assisted vaginal delivery
Newborn resuscitation with bag and
mask
Surgery / caesarean
Blood transfusion
n % % % % % % % % %
National 173 99 98 72 61 46 32 90 11 12
District
Bombali 14 100 100 28 12 12 20 92 15 15
Kambia 8 100 100 60 20 46 46 87 6 6
Koinadugu 7 100 100 100 85 54 69 100 8 8
Port Loko 14 92 100 79 68 44 31 100 20 20
Tonkolilii 9 100 100 100 63 63 38 100 13 13
Bo 23 100 100 69 50 36 20 86 13 6
Bonthe 12 100 91 73 55 46 23 82 9 9
Moyamba 12 100 100 68 82 32 0 100 5 9
Pujehun 8 87 100 100 100 87 100 100 7 7
Western Rural 8 100 86 69 55 69 14 69 4 4
Western Urban 21 100 97 81 69 50 30 90 19 31
Type of facility
Hospitals 39 100 97 82 85 74 62 95 82 85
CHCs/clinics 134 99 98 70 57 41 28 89 1 1
Operating agency
Public/Government 144 99 100 75 60 47 34 92 7 9
Private, for profit 8 100 64 42 64 22 7 64 30 15
Private, not-for-profit1 21 100 94 56 63 47 29 85 38 36
Table 3.1.2: Percentage of facilities that performed each EmONC signal function in the last three months, by district, facility type and operating agency, Sierra Leone Rapid EmONC Assessment 2017
Note. 1. Includes NGO, faith-based or mission facilities.
Choices regarding drugs and equipment for performing the signal functions
Provision of parenteral uterotonics: According to Table 3.1.2 and 3.1.6, 98 per cent of all the facilities at the national level provided parenteral uterotonics. Similarly, all the facilities in 11 districts and over 86 per cent of the facilities in Western Rural, Bonthe and Western Urban provided this signal function.
Oxytocin is the drug of choice for augmentation of labour and for active management of third stage of labour (AMTSL). In this regard, only two thirds (66 per cent) of the facilities that provided the signal function in the last three months prior to the survey used oxytocin only; while nearly a third of them (34 per cent) used both oxytocin and ergometrin. A similar percentage distribution was observed among districts, except Kailahun (all of the facilities that provided the signal function used oxytocin only), Kenema, Pujehun and Western Urban, in which the majority of the facilities used both drugs.
35
Table 3.1.3: Percentage distribution of facilities that administered parenteral uterotonics in the last 3 months, by type of oxytocic and district, Sierra Leone Rapid EmONC Assessment 2017
Total number
of facilities
Total number of facilities that administered
uterotonics in last 3 months
Among facilities that administered parenteral uterotonics in the last 3 months, percentage that used:
Oxytocin only Ergometrine only Both
n n % % %
National 173 170 66 0 34
District
Kailahun 9 9 100 0 0
Kenema 17 17 31 0 69
Kono 11 11 72 0 28
Bombali 14 14 63 0 37
Kambia 8 8 67 0 33
Koinadugu 7 7 85 0 15
Port Loko 14 14 79 0 21
Tonkolilii 9 9 88 0 12
Bo 23 23 92 0 8
Bonthe 12 11 85 0 15
Moyamba 12 12 82 0 18
Pujehun 8 8 13 0 87
Western Rural 8 7 68 0 32
Western Urban 21 20 31 0 69
Provision of parenteral anticonvulsants: Provision of anticonvulsants injection treats eclamptic seizures if given in a timely manner. According to WHO’s guidelines, magnesium sulphate injection is the drug of choice. As Table 3.1.2 and Table 3.1.4 show, 126 (72 per cent) of the 173 health facilities visited provided parenteral anticonvulsants in the last three months prior to the survey. However, only a little over one third of them (37 per cent) used magnesium sulphate only. Forty-four per cent of the facilities that provided parenteral anticonvulsants used both magnesium sulphate and diazepam. A very small proportion (2 per cent) of those facilities providing parenteral anticonvulsants used phenobarbital. Over 30 per cent of the facilities in Bombali, Western Urban and Rural, and Bonthe used diazepam only.
Table 3.1.4: Percentage distribution of facilities that administered parenteral anticonvulsants in the last 3 months, by type of medication and district, Sierra Leone Rapid EmONC Assessment 2017
Total number
of facilities
Total number of facilities that
administered parenteral anticonvulsants in last
3 months
Among facilities that administered anticonvulsants in the last 3 months, percentage that used:
Magnesium sulfate only Diazepam only Both Other (both +
Phenobarbital)
National 173 126 37% 17% 44% 2%
District
Kailahun 9 7 100% 0% 0% 0%
Kenema 17 14 0% 8% 85% 8%
Kono 11 5 56% 0% 44% 0%
Bombali 14 5 57% 30% 13% 0%
Kambia 8 5 67% 0% 33% 0%
36
Total number
of facilities
Total number of facilities that
administered parenteral anticonvulsants in last 3
months
Among facilities that administered anticonvulsants in the last 3 months, percentage that used:
Magnesium sulfate only Diazepam only Both Other (both +
Phenobarbital)
National 173 126 37% 17% 44% 2%
District
Koinadugu 7 7 69% 0% 31% 0%
Port Loko 14 11 57% 20% 23% 0%
Tonkolilii 9 9 88% 0% 12% 0%
Bo 23 16 55% 7% 39% 0%
Bonthe 12 9 13% 50% 38% 0%
Moyamba 12 8 20% 13% 67% 0%
Pujehun 8 8 13% 0% 74% 13%
Western Rural 8 5 20% 40% 40% 0%
Western Urban 21 17 3% 36% 60% 0%
Table 3.1.4: Percentage distribution of facilities that administered parenteral anticonvulsants in the last 3 months, by type of medication and district, Sierra Leone Rapid EmONC Assessment 2017
Removal of retained products of conception: As Tables 3.1.2 and 3.1.5 reveal, 82 (46 per cent) of the 173 facilities visited provided removal of retained products of conception using vacuum, dilation and curettage (D&C) or dilation and evacuation (D&E) procedures. Vacuum aspiration (57 per cent) was the most widely used procedure for the provision of this signal function in those facilities that removed retained products of conception. D&E and D&C were performed in 18 per cent and 17 per cent of the facilities that removed retained products of conception, respectively. Vacuum aspiration was the most widely used procedure when performing this signal function among all districts, except Kailahun, Bombali, Port Loko, Moyamba and Western Urban, in which they used other procedures most frequently than vacuum aspiration. Use of misoprostol for obstetric indication was also used widely as 41 per cent of the facilities that removed retained products used this drug.
Table 3.1.5: Percentage of facilities that removed retained products of conception in the last 3 months, by method and district, Sierra Leone Rapid EmONC Assessment 2017
Total number
of facilities
Total number of facilities that administered
removal of retained products in last 3 months
Among those that removed retained products of conception in last 3 months, percentage that used (multiple responses allowed):
Vacuum aspiration D & C D & E Misoprostol
National 173 82 57% 17% 18% 41%
District
Kailahun 9 5 33% 22% 45% 78%
Kenema 17 8 72% 22% 36% 22%
Kono 11 3 100% 0% 0% 39%
Bombali 14 2 31% 31% 31% 100%
Kambia 8 4 71% 14% 0% 42%
Koinadugu 7 4 71% 0% 0% 29%
Port Loko 14 7 23% 23% 18% 71%
Tonkolilii 9 6 100% 30% 20% 11%
Bo 23 9 87% 35% 9% 9%
Bonthe 12 6 50% 30% 30% 20%
37
Table 3.1.5: Percentage of facilities that removed retained products of conception in the last 3 months, by method and district, Sierra Leone Rapid EmONC Assessment 2017
Total number
of facilities
Total number of facilities that administered
removal of retained products in last 3 months
Among those that removed retained products of conception in last 3 months, percentage that used (multiple responses allowed):
Vacuum aspiration D & C D & E Misoprostol
National 173 82 57% 17% 18% 41%
District
Moyamba 12 4 14% 0% 0% 86%
Pujehun 8 7 85% 15% 24% 46%
Western Rural 8 5 20% 0% 0% 80%
Western Urban 21 12 59% 16% 30% 0%
Provision of AVD: According to Tables 3.1.2 and 3.1.6, AVD using vacuum extraction or forceps was the least performed basic signal function as only a third of the total facilities performed it. Regarding the methods, great majority (88 per cent) of the facilities provided the signal function used vacuum extraction than forceps (4 per cent) and both vacuum extraction and forceps (8 per cent). A similar percentage distribution was observed among all the districts. Unlike other districts, 18 per cent and 17 per cent of the facilities in Western Urban and Kenema respectively, used forceps delivery.
Table 3.1.6: Percentage distribution of facilities that performed assisted vaginal delivery in the last 3 months, by method and district, Sierra Leone Rapid EmONC Assessment 2017
Total number
of facilities
Total number of facilities that performed assisted vaginal delivery in last 3
months
Among facilities that performed assisted vaginal delivery in last 3 months, percentage that used:
Vacuum extractor only Forceps only Both
National 173 62 88% 4% 8%
District
Kailahun 9 5 100% 0% 0%
Kenema 17 7 67% 17% 17%
Kono 11 3 100% 0% 0%
Bombali 14 4 100% 0% 0%
Kambia 8 4 100% 0% 0%
Koinadugu 7 5 100% 0% 0%
Port Loko 14 5 100% 0% 0%
Tonkolilii 9 4 100% 0% 0%
Bo 23 5 85% 0% 15%
Bonthe 12 3 100% 0% 0%
Moyamba 12 0 0% 0% 0%
Pujehun 8 8 80% 0% 20%
Western Rural 8 1 100% 0% 0%
Western Urban 21 8 65% 18% 18%
Reasons for not performing the EmONC signal functions
Table 3.1.7 shows reasons for non-performance of the signal functions. The least performed signal function was AVD; over two thirds (68 per cent) of the facilities did not provide this service. Lack of equipment (58 per cent) was the most frequently cited reason, followed by no indication (50 per cent), lack of training (34 per cent), and lack of human resource to provide the signal function (17 per cent).
38
25World Health Organization (WHO). 2010. Monitoring the building blocks of health systems: a handbook of indicators and their measurement strategies. Geneva: World Health Organization. 26 WHO, UNFPA, UNICEF, AMDD. 2009. Monitoring emergency obstetric care: a handbook. Geneva: World Health Organization.27 Ministry of Health and Sanitation (MoHS). 2015. ‘Sierra Leone Basic Packages of Essential Health Services (BPEHS), 2015–2020’.
Similarly, the removal of retained products of conception was the second least performed signal function among all facilities. The main reason proffered for the non-performance was no indication that warranted AVD (72 per cent). Lack of drugs/equipment, lack of training and lack of human resources were other cited reasons.
Nationally, over a third of the facilities did not provide the manual removal of the placenta, the reason being no indication that required this service (92 per cent). A need for training (10 per cent) was also a reason cited in the three-month reference period. No indication (89 per cent), lack of drugs (11 per cent) and lack of training (10 per cent) accounted for the non-performance of parenteral anticonvulsants.
The provision of CS in hospitals was also challenged as 71 per cent of those that did not provide it mentioned management issues (providers desiring compensation, encouragement to use other alternatives, being uncomfortable or unwilling to perform this procedure), followed by lack of training (43 per cent) and lack of human resources (43 per cent) to provide surgery. A similar distribution of reasons was cited for the provision of blood transfusion.
Table 3.1.7: Percentage of facilities that performed each signal function in the last 3 months and reasons for non-performance, by signal function, Sierra Leone Rapid EmONC Assessment 2017
Signal function
Percentage of facilities that
performed the signal function
in the last 3 months n=173
Number of facilities
that did not perform
the signal function in the last 3 months
Percentage of facilities that responded that the procedure was not provided in the last 3 months due to (multiple responses allowed):
lack of human
resources
trainingneeded
lack ofsupplies/
equipment/drugs
weak management
unsupportive or no policy
noindication
% n % % % % % %
EmONC signal functions
Parenteral antibiotics 99 2 0 0 54 0 0 46
Parenteral oxytocics 98 3 0 0 29 0 0 71
Parenteral anticonvulsants 72 47 5 10 11 0 0 89
Manual removal of pla-centa 61 63 5 10 3 2 0 92
Removal of retained prod-ucts
46 91 10 19 29 4 1 72
Assisted vaginal delivery 32 111 17 34 58 3 1 50
Resuscitation of newborn with bag and mask
90 16 5 5 0 0 8 87
Caesarean section1 82 7 43 43 14 71 0 14
Blood transfusion1 85 6 0 17 50 67 0 33
Note: 1 Only hospitals are included (n = 39).
Readiness to provide and currently providing EmONC signal functions
In recent years, countries are increasingly interested in knowing not only the current performance and non-performance of facilities in providing EmONC signal functions, but also want to be able to plan based on a facility’s readiness to provide EmONC signal functions. Facility readiness is defined as the availability of at least one health worker cadre on staff who can provide the signal function and the availability of a minimum package of drugs, supplies and equipment 25,26,27. The minimum package of drugs, equipment and supplies are determined based on a country’s national standards or basic packages. Sierra Leone’s country core team adapted this minimum package of drugs, equipment and supplies (see Appendix B) and calculated it with this understanding.
39
Table 3.1.3A in the appendix and Figure 3.1.4 show the percentage of facilities that were ready to provide and currently provide each signal function, by facility type. First the tabulation was made for all facilities and then broken down by hospitals and CHCs/clinics.
Parenteral antibiotics: Readiness was very much lower than actual performance. In all facilities, readiness to provide parenteral antibiotics was below half (47 per cent) while there was actual performance of the signal function in the last three months prior to the survey in almost every facility (99 per cent). The low proportion of readiness was due to lack of the required drugs. Hospitals were more ready than mid-level facilities. The low readiness (47 per cent) compared with actual performance (99 per cent) implies that either inappropriate cadre had been providing parenteral antibiotics or staff used antibiotics that were not recommended in the national standards.
Parenteral uterotonics: Readiness was lower than actual performance. Facility readiness (92 per cent) and actual performance (98 per cent) of this signal function was higher across all facilities with little variation among hospitals and CHCs/clinics.
Parenteral anticonvulsants: Readiness was much higher than actual performance. Facility readiness (95 per cent) to provide this signal function was much higher than actual performance (72 per cent). This variation appears in both hospitals and CHCs/clinics, with the actual performance higher among hospitals than the rest of the facilities.
Manual removal of placenta: Readiness was very much higher than actual performance. Facility readiness (92 per cent) to provide this signal function was much higher than actual performance (61 per cent). The variation was similar in both hospitals and CHCs/clinics, with the actual performance being far higher among hospitals (85 per cent) than CHCs/clinics (57 per cent).
Removal of retained products of conception: Both readiness and performance were very low with actual performance higher than readiness. Nationally, just over a quarter (26 per cent) of the facilities were ready to provide this signal function. Actual performance was also below 50 per cent. Hospitals were better situated in both readiness (59 per cent) and actual performance (74 per cent) than CHCs/clinics (21 per cent and 41 per cent respectively). The low readiness of facilities to provide retained products of conception was exacerbated by the lack of equipment as only 43 per cent of CHCs/clinics and 62 per cent of hospitals were equipped with vacuum aspiration equipment.
AVD: Both readiness and performance were very low with readiness higher than performance. Nationally, only 42 per cent of the facilities were ready to provide AVD, while only a third (32 per cent) of the facilities were actually providing it. Hospitals were better in both readiness (72 per cent) and actual performance (62 per cent) than CHCs/clinics (38 per cent and 28 per cent respectively). One of the striking findings in this signal function was that readiness was higher in both higher and mid-level facilities; but performance was low. This could possibly be either because providers lacked skills or the confidence to perform AVD, seeing that the availability of HR and drugs, equipment and supplies in all types of facilities was better than performance.
Neonatal resuscitation with bag and mask: Both readiness and performance were good with readiness a little lower than performance. Nationally, 86 per cent of the facilities were ready to provide neonatal resuscitation, while 90 per cent of the facilities were actually providing it. Readiness and performance of newborn resuscitation was good across all facilities with little variation among hospitals and CHCs/clinics.
CS: Hospitals were the least ready to provide CS. Readiness was far lower than performance. Nationally, only 23 per cent of the hospitals were ready, while 82 per cent performed it. Ninety per cent of hospitals had at least one health worker cadre to provide CS; while only 23 per cent of them had the required drugs, equipment and supplies for surgery. This indicates that facilities might be providing the service in suboptimal conditions.
Blood transfusion: Hospitals were less ready than CHCs/clinics in providing blood transfusion. Readiness was much lower than performance. Only 46 per cent of the hospitals were ready to provide blood transfusion, while 85 per cent performed it. The contrast between very low readiness in terms of drugs, supplies, and equipment while being better staffed to provide blood transfusion is a cause for concern as blood transfusions might have been given in suboptimal conditions.
In general, facilities were better staffed than equipped and stocked with supplies to provide all of the signal functions. This implies that a shortage of drugs, supplies and equipment was an ongoing and real problem in facilities at all levels.
Of the seven basic signal functions, the facilities were the least ready to provide removal of retained products (26 per cent) and AVD (42 per cent).
40
Figure 3.1.4: Percentage of facilities that are ready to provide and currently providing each EmONC signal function, by facility type, Sierra Leone Rapid EmONC Assessment 2017
3.2 Indicator 2: Geographic distribution (national and subnational) of EmONC facilities
The national ratio of EmONC availability shows that it is at 85 per cent of the UN recommended figure. Availability of EmONC facilities varied across districts with none in Moyamba (0 per cent) and the highest in Pujehun (280 per cent). Four districts (Pujehun, Koinadugu, Bonthe and Kenema) exceeded the minimum recommended number of EmONC facilities while 8 out of the 14 districts (including Moyamba with zero EmONC facilities) were below the national average (85 per cent) (Figure 3.2.1).
Figure 3.2.1: Percentage of EmONC facilities compared with the UN recommended ratio, by district, Sierra Leone Rapid EmONC Assessment 2017
40% 80% 120% 160% 200% 240% 280%0%
Pujehu n
Koinadugu
Bonthe
Kenema
Kailahun
Western Ru ral
National
Kambia
Western Urba n
Tonkolili
Bo
Portloko
Kono
Bombal i
Moyamba
80% 60% 40% 20% 0%100%
Parenteralantibiotics
Parenteraloxytocics
Parenteralanticonvulsants
Manual r emovalof placen ta
Removal ofretained pr oducts
Assisted vaginaldelivery
Newbornresuscita tion
Caesareandelivery
Bloodtransfusio n
20% 40% 60% 80% 100%0%
Drugs, equipments, and supplies available Human resources available
Provided signal function in last 3 months
Hospital s CHSc/clinics
80% 60% 40% 20% 0%100%
Parenteralantibiotics
Parenteraloxytocics
Parenteralanticonvulsants
Manual r emovalof placen ta
Removal ofretained pr oducts
Assisted vaginaldelivery
Newbornresuscita tion
Caesareandelivery
Bloodtransfusio n
20% 40% 60% 80% 100%0%
Drugs, equipments, and supplies available Human resources available
Provided signal function in last 3 months
Hospital s CHSc/clinics
41
28 Ministry of Health and Sanitation. 2017. ‘National Health Sector Strategic Plan (2017–2021)’. 29 Statistics Sierra Leone. 2017. Sierra Leone 2015 Population and Housing Census - Thematic Report on Population Projections. Freetown, Sierra Leone: SSL30. Ministry of Health and Sanitation. 2008. ‘Nationwide Needs Assessment for Emergency Obstetric and Newborn Care Services in Sierra Leone’.31 Statistics Sierra Leone. 2014. ‘Sierra Leone Demographic and Health Survey’.
3.3 Indicator 3: Proportion of all births in EmONC facilities
Institutional delivery is one of the key EmONC indicators as it tells us that what proportion of pregnant women in the population accessed health facilities to give birth. As stipulated in the 2017–2021 health sector strategic plan,28 increasing institutional birth so that pregnant women received services from a skilled attendant is one of its priorities.
The total number of expected births for Sierra Leone for 2016 was 371,826 (calculated Crude Birth Rate multiplied by population, 7,296,402).29 The weighted total of births attended in all facilities with maternity services from January to December 2016 was 104,713 (Table 3.3.1). As shown in the table, the proportion of expected births attended to in health facilities (hospitals and CHCs/clinics) was 28 per cent in all facilities and only 10 per cent in fully functioning EmONC facilities. Western Rural (59 per cent) and Urban (49 per cent) had the highest proportion of women giving birth in all facilities, while Koinadugu (12 per cent) had the lowest, followed by Kono (13 per cent), and Tonkolili (14 per cent).
Proportion of births in health facilities 2016 has increased threefold from the 2008 EmONC assessment (10 per cent in all facilities) and fivefold in EmONC facilities (2 per cent in 2008).30 However, institutional delivery in 2016 was lower than the results shown in the 2013 DHS (54 per cent)31 by half. The DHS’s higher estimate may have included deliveries that took place in lower level health facilities such as health posts that were not included in this EmONC assessment. In addition, it is not clear that births attended in lower level health facilities (health posts) covered by the DHS are skilled. There is also a clear methodological difference between EmONC and DHS.
Percent of expected births that took place in:
- All facilities = 28%
- EmONC facilities =10%
42
Table 3.3.1: Percentage of expected births attended in all facilities and EmONC facilities, by district (EmONC Indicator 3), Sierra Leone Rapid EmONC Assessment 2017
Population1
Number of expected
births (CBR*pop)2
All facilities EmONC facilities
Number of births attended in all facilities (weighted)3
Percentage of expected births
Number of births attended in
EmONC facilities(weighted)3
Percentage of expected births
National 7,296,402 371,826 104,713 28% 39,022 10%
District
Kailahun 541,202 27,980 5,699 20% 2,020 7%
Kenema 629,457 32,291 9,684 30% 4,566 14%
Kono 522,301 29,771 3,735 13% 1,102 4%
Bombali 624,084 31,079 6,473 21% 1,678 5%
Kambia 355,469 20,297 4,651 23% 1,287 6%
Koinadugu 421,212 23,967 2,895 12% 1,979 8%
Port Loko 633,166 32,355 7,332 23% 1,459 5%
Tonkolilii 546,812 32,426 4,410 14% 1,968 6%
Bo 593,160 31,556 12,642 40% 3,163 10%
Bonthe 204,349 10,892 3,001 28% 734 7%
Moyamba 328,373 17,207 6,241 36% 0 0%
Pujehun 357,105 19,034 5,015 26% 4,204 22%
Western Rural 450,755 20,284 12,065 59% 3,390 17%
Western Urban 1,088,957 42,687 20,871 49% 11,472 27%
Note: 1. Source of Population Estimates: Statistics Sierra Leone. October 2017; ‘Sierra Leone 2015 Population and Housing Census - Thematic Report on Popula-tion Projections’, Freetown Sierra Leone.2. Crude birth rate = 49.8 (national) per 1,000 population with variations among districts. Source: Statistics Sierra Leone. October 2017; ‘Sierra Leone 2015 Population and Housing Census - Thematic Report on Nuptiality and Fertility’, Freetown, Sierra Leone.3. Births in all and EmONC facilities are weighted.
Location of institutional deliveries
Table 3.3.1A in the appendix refers to the percentage of institutional deliveries from the total deliveries by district, facility type, EmONC status, operating agency and location. As the number of CHCs visited was higher than the rest of the facility types, two thirds (66 per cent) of the deliveries happened in these CHCs. Hospitals constituted only 31 per cent of the total deliveries and the remaining 4 per cent were in private clinics. A similar percentage distribution was observed among districts with little variation in facility types.As far as institutional delivery is concerned, the first priority was to help pregnant women access the health facilities, and then to facilitate referral linkages to help them access better care. As shown in Figure 3.3.1, only 7 per cent of them took place in CEmONC facilities (hospitals) and 13 per cent in BEmONC facilities (mostly CHCs/clinics). This leaves the great majority of deliveries taking place in partially functioning EmONC facilities that missed only one or two signal functions (41 per cent) and that missed over two signal functions (39 per cent). In line with the national proportion, the majority of deliveries took place in partially functioning EmONC facilities in all districts. All of the deliveries in Kambia took place in partially functioning EmONC facilities (Table 3.3.2A).
As expected, the majority of deliveries were in government facilities. Nationally, a little over half (52 per cent) of the deliveries took place in urban areas. However, those deliveries happened more likely in rural locations in all districts except Western Rural and Urban that are urban-dominated districts (Table 3.3.2A).
43
Figure 3.3.1: Distribution of institutional deliveries according to EmONC status by type of facility, Sierra Leone Rapid EmONC Assessment 2017
Mode of institutional delivery
Table 3.3.2A and Figure 3.3.2 show the distribution of institutional deliveries by district, facility type, operating agency and location. From the weighted total deliveries attended in all facilities in 2016 (104,713), 92 per cent of them were spontaneous vaginal deliveries and only 7 per cent were caesarean. Instrumental deliveries constituted only 1 per cent and less than 1 per cent were laparotomies for a ruptured uterus. A similar percentage distribution was observed among districts, facility types and operating agencies. The highest incidence of CS was observed in Western Urban (12 per cent) and Bombali (11 per cent) and there were no occurrences in Western Rural. There was no destructive (craniotomies and embryotomies) delivery registered in any of the districts. The proximity of Western Rural to Western Urban might be one of the reasons that CEmONC facilities in Western Urban were easily accessed.
Figure 3.3.2: Percentage distribution of institutional delivery by mode of delivery and district, Sierra Leone Rapid EmONC Assessment 2017
10% 20% 30% 40% 50% 60% 70% 80% 90% 100%0%
Hospitals(n=31,891 )
Health cen ters/clinics(n=72,822 )
All facilities(n=104,713 )
CEmONC BEmONC Missing 1 or 2 signal functions Missing > 2 signal functions
0%
80%
100%
Weste
rn Rural
Moyamba
Kailahun
Kenema
Bonthe
Kambia
National
Portloko
Tonkolili
Koinadugu Bo
PujehunKono
Bombal i
Weste
rn Urba n
Spontaneous vaginal Instrumental vaginal Caesarean Other
44
3.4 Indicator 4: Met need for EmONC services
According to the UN handbook, it is estimated that 15 per cent of expected births in the population are likely to develop major direct obstetric complications. Complications of antepartum and postpartum haemorrhage/retained placenta, postpartum sepsis, severe pre-eclampsia and eclampsia, prolonged or obstructed labour, ruptured uterus, complications from abortion, and ectopic pregnancy were included in the met need for EmONC calculation. For the 12 months of 2016, a total of 55,774 women with complications was estimated. Of these, only a fifth of them (weighted total = 11,118) were treated in all facilities and 15 per cent received in EmONC facilities (Figure 3.4.1 and Table 3.4.1A in the appendix).
Met need varied widely among districts with the highest in Western Rural (43 per cent), followed by Western Urban (39 per cent) and the lowest in Kailahun (8 per cent). The high met need in Western Rural and Urban may be due to the easy access to the health facilities in these two districts that are urban dominated. It may also be driven by referrals made from the neighbouring districts for obstetric emergencies.
Figure 3.4.1: Percentage of women with expected major direct obstetric complications treated in EmONC and all facilities, by district, Sierra Leone Rapid EmONC Assessment 2017
Met need with post-abortion complications
Severe complications of abortion are among the major direct obstetric complications included in the met need. However, recording of obstetric complications are often challenged by different definitions and distinguishing between severe and non-severe ones. Such complications are most often underreported. In this regard, met need is calculated adding all post-abortion complications (PAC) irrespective of severity, to see the full picture of whether women in need of services are receiving them.
Table 3.4.2A presents met need with PAC. Nationally, met need has increased a little by 4 per cent in all facilities and by 3 per cent in EmONC facilities, (from 20 per cent and 15 per cent, respectively). The impact of the addition of PAC cases was visibly high in some regions (Western Rural and Urban saw an increase of 13 per cent each) and minimal in others (Kailahun, Kambia, Koinadugu, Port Loko, Tonkolili, Bonthe and Moyamba saw an increase of only 1 per cent each in all facilities).
0%5%
10%15%20%25%30%35%40%45%50%
Weste
rn
Rural
Pujehun
Weste
rn Urban
Kenema
National Bo
Bombal i
Koinadugu
KambiaKono
Tonkolili
Portloko
Kailahun
Bonthe
Moyamba
All facilities EmONC+
45
32. World Health Organization Human Reproduction Programme. “WHO Statement on caesarean section rates,” Reproductive Health Matters 23(45):149-50.
Location of major direct obstetric complications treated
Table 3.4.1A shows the proportion of major direct obstetric complications from the expected complications in the population, which was 20 per cent in all facilities. When we look in-depth at the proportion of these complications from the total institutional deliveries, it is 11 per cent and 8 per cent in all and EmONC facilities, respectively. Among districts, Koinadugu and Pujehun (18 per cent each) had the highest proportion of complicated deliveries and Moyamba had the lowest proportion (4 per cent). Similarly, regional and district hospitals had the highest proportions of complicated deliveries (36 per cent each), while CHCs had 5 per cent and clinics 2 per cent. This could partly be explained by the fact that either there were referrals of complicated cases from those lower level facilities or women who had developed obstetric complications directly accessed district and regional level facilities knowing higher level of care was available in those facilities. Government and private, not for-profit facilities had also the highest proportions of complicated deliveries, compared with private-for-profit.
Figure 3.4.2 displays a comparative analysis of where the expected births were attended and where the expected complications were treated. Of the total expected births (371,826) in the population, 11 per cent (weighted total = 39,022) were attended in EmONC facilities. Four in five deliveries in the population took place outside hospitals and CHCs/clinics. This meant that these many deliveries took place either in lower level facilities (health posts) or they were home deliveries. Similarly, if 15 per cent of the deliveries in the population were expected to develop major direct obstetric complications, only 20 per cent (11,118) were delivered or treated in hospitals and CHCs/clinics, leaving 80 per cent of them untreated out there in lower level facilities, at homes, or not reported in the health facilities.
Figure 3.4.2: Percentage distribution of expected births and expected major direct obstetric complications according to locations by EmONC grading, Sierra Leone Rapid EmONC Assessment 2017
3.5 Indicator 5: Caesarean deliveries as a proportion of all births
According to the EmONC handbook, population-based CS rates should be between 5 to 15 per cent for adequate obstetric service coverage. However, a recent WHO publication (consensus statement) stated that a population-based caesarean rate above 10 per cent is not associated with a reduction of maternal and newborn mortalities.32 In 2016, of the total expected births (371,826), the population-based caesarean rates in all facilities and EmONC facilities for Sierra Leone was only 2 per cent each. This caesarean rate is below the 5 per cent minimum recommended. District-level caesarean rates in all facilities ranged from 0 per cent in Western Rural to 6 per cent in Western Urban (Table 3.5.1A and Figure 3.5.1).
0%
20%
40%
60%
80%
100%
Expected births (n=371,826) Expected complications (n=55,774)
CEmONC BEmONC Missing 1 or 2 signal functions
Missing > 2 signal functions Not in facility
24,28014,742
38,499
27,193
267,112
6,8731,460
2,028
758
44,655
46
Figure 3.5.1: Percentage of expected births delivered by caesarean section in all facilities and EmONC facilities, by district, Sierra Leone Rapid EmONC Assessment 2017
Institutional caesarean rate
As indicated in section 3.5, population caesarean rate is the preferred rate for estimations. But, institutional caesarean rate is also useful and supplemental when we calculate it by facility type, operating agency and district. However, we need to be cautious in interpreting the institutional caesarean rate as it depends on the geographic location of facilities or proximities among facilities, level of care, referral networking and client mix.With the afore-mentioned assumptions, Table 3.5.2A and Figure 3.5.2 show the distribution of institutional caesarean rates among districts, operating agencies and locations. Nationally, the institutional caesarean rate among all facilities was 7 per cent. However, the rate in facilities that provided CS was 23 per cent. The CS rate in all facilities among districts varied widely from the lowest in Western Rural (0 per cent) to the highest in Western Urban (12 per cent).As shown in Figure 3.5.2, there was a remarkable difference in the institutional caesarean rates among government and private facilities; private facilities had double the rate than government facilities. However, the rate among facilities that provide CS was higher in government facilities than private.
Figure 3.5.2: Institutional caesarean delivery rate among all facilities and facilities that provide caesarean delivery by operating agency, Sierra Leone Rapid EmONC Assessment 2017
2% 4% 6% 8% 10% 12%0%
Western Ru ral
Kailahun
Moyamba
Koinadugu
Kambia
Tonkolili
Kono
Kenema
Bonthe
Portloko
National
Pujehu n
Bombal i
Bo
Western Urba n
All facilities EmONC facilities
0%
5%
10%
15%
20%
25%
30%
6%
26%
Government
11%
17%
11%
18%
All facilities Facilities that provide CS
47
3.6 Indicator 6: Direct obstetric case fatality rate Maternal deaths due to direct obstetric causes are related to pregnancies or management of these pregnancies. The international benchmark as stipulated in the EmONC handbook is less than 1 per cent. The DOCFR is the proportion of women with major direct obstetric complications in facilities who die before discharge. It is an indicator of the quality of how these complications are managed. Of the 11,118 weighted total of women with direct obstetric complications recorded, the 2017 Sierra Leone EmONC captured 306 maternal deaths due to direct obstetric complications with a 3 per cent DOCFR at the national level. The DOCFR among EmONC facilities was the same rate as in all facilities. The DOCFR is higher than the international benchmark (Table 3.6.1).
The DOCFR in all facilities varied widely among districts, from zero in Kono, Pujehun and Western Rural to a high of 13 per cent in Moyamba. Eleven out of 14 districts recorded above the internationally set baseline value (< 1 per cent) (Table 3.6.1).
Table 3.6.1: Direct obstetric case fatality rate (DOCFR) in all facilities and EmONC facilities, by district (EmONC Indicator 6), Sierra Leone Rapid EmONC Assessment 2017
All facilities EmONC facilities
Number of women with direct
complications (weighted)1
Number of maternal deaths by direct cause
(weighted)1DOCFR2
Number of women with direct
complications(weighted)1
Number of maternal deaths by direct cause
(weighted)1DOCFR2
National 11,118 306 3% 8,333 239 3%
District
Kailahun 318 14 4% 268 10 4%
Kenema 1,299 27 2% 1,004 27 3%
Kono 516 0 0% 424 0 0%
Bombali 823 28 3% 527 22 4%
Kambia 412 17 4% 311 17 5%
Koinadugu 518 12 2% 478 8 2%
Port Loko 620 28 5% 406 26 6%
Tonkolilii 616 18 3% 415 16 4%
Bo 826 46 6% 637 36 6%
Bonthe 203 5 2% 87 3 3%
Moyamba 280 37 13% 0 0 0%
Pujehun 881 0 0% 831 0 0%
Western Rural 1,315 4 0% 852 4 0%
Western Urban 2,491 71 3% 2,092 70 3%
Note:1. Direct complications and direct causes of maternal death include: APH, PPH, obstructed/prolonged labour, ectopic pregnancy, severe abortion complications, retained placenta, ruptured uterus, postpartum sepsis, severe pre-eclampsia/eclampsia. Excludes "other" direct complications or causes of death including non-severe abortion complications. 2. Direct Obstetric Case Fatality Rate = (number of maternal deaths by direct causes)/(number of women with direct complications).
Causes and patterns of maternal death by type of facility and operating agency
Despite the fact that the majority of the institutional deliveries took place in CHCs (66 per cent), the majority of maternal deaths occurred in district (34 per cent) and regional hospitals (22 per cent). This could be due to referrals from mid-level facilities to secondary level care before the mothers die (Table 3.6.2). The distribution of the causes of maternal death varied depending upon the type of facility and operating agency. Over two thirds (68 per cent) of the maternal deaths were direct obstetric causes and about a fifth (19 per cent) were unknown. Indirect obstetric causes constituted 14 per cent of the total maternal deaths.
48
Of the total maternal deaths in CHCs, the majority (86 per cent) were due to direct causes. In all hospitals, over three fourths of the maternal deaths were due to direct causes; except district hospitals that had 43 per cent unknown and another 12 per cent due to indirect obstetric causes. Similarly, maternal deaths due to direct causes constitute the highest proportion in facilities by operating agency. In particular, all maternal deaths that occurred in private for-profit facilities (100 per cent) were due to direct causes.
Table 3.6.2: Percentage distribution of all maternal deaths, by cause of death, type of facility and operating agency, Sierra Leone Rapid EmONC Assessment 2017
Facility type Facility type Operating agency
Total maternal
deaths (weighted)
n=475
National hospital
n=89
Regional hospital
n=104
Districthospital
n=163
Other hospital
n=44
CHC
n=75
Clinic
n=0
Government
n=431
Private for-profit
n=6
Private not-for-profit1
n=38
Direct causes 68% 74% 78% 45% 82% 86% . 66% 100% 79%
Obstructed/ prolonged labour 11% 0% 19% 8% 11% 21% . 11% 67% 3%
PPH/Retained placenta 16% 18% 20% 12% 14% 21% . 17% 0% 16%
Severe pre-eclampsia/eclampsia 16% 30% 12% 10% 27% 13% . 15% 33% 26%
APH 10% 19% 7% 8% 7% 11% . 10% 0% 8%
Severe complications of abortion 2% 3% 6% 0% 2% 0% . 2% 0% 3%
Postpartum sepsis 4% 2% 5% 2% 9% 3% . 3% 0% 11%
Ruptured uterus 3% 0% 6% 4% 2% 0% . 3% 0% 3%
Ectopic pregnancy 2% 1% 1% 1% 2% 6% . 2% 0% 3%
Other DOC 3% 0% 3% 1% 7% 11% . 3% 0% 8%
Indirect causes 14% 25% 10% 12% 11% 11% . 14% 0% 13%
Malaria 0% 0% 1% 0% 0% 0% . 0% 0% 0%
HIV/AIDS- related 1% 6% 1% 0% 2% 0% . 1% 0% 3%
Anaemia 10% 17% 8% 10% 5% 6% . 10% 0% 5%
Hepatitis 0% 0% 0% 0% 0% 0% . 0% 0% 0%
Other indirect causes 2% 2% 0% 1% 5% 6% . 2% 0% 5%
Unknown/unspecified causes 19% 1% 13% 43% 7% 2% . 20% 0% 8%
TOTAL 100% 100% 100% 100% 100% 100% . 100% 100% 100%
Note: 1. Percentages may not add up to 100 due to rounding.
Cause-specific case fatality rates
According to Table 3.6.1A and 3.6.2A in the appendix and Figure 3.6.1, postpartum haemorrhage/retained placenta (24 per cent) and severe pre-eclampsia/eclampsia (24 per cent) were the leading causes of all maternal deaths due to direct obstetric causes, followed by obstructed or prolonged labour (17 per cent).
49
Figure 3.6.1: Distribution of institutional maternal deaths due to direct obstetric causes
Figure 3.6.2 and Table 3.6.1A in the appendix also show the likelihood of a maternal death from a cause of direct obstetric complication. Ruptured uterus (7 per cent) and postpartum sepsis (7 per cent) had the highest cause-specific case fatality rates. Ectopic pregnancy, severe pre-eclampsia/eclampsia, and PPH/retained placenta were also the second highest cause-specific case fatality rates.
Figure 3.6.2: Cause-specific direct obstetric case fatality rates in all facilities, Sierra Leone Rapid EmONC Assessment 2017
3.7 Indicator 7: Intrapartum and very early neonatal death rate
The intrapartum and very early (pre-discharge) neonatal death rate is the proportion of births that result in an intrapartum stillbirth or a very early neonatal death (<24 hours). The purpose of this indicator is to measure the quality of intrapartum and newborn care. As shown in Figure 3.7.1 below and Table 3.7.1A and 3.7.2A in the appendix, the national intrapartum and very early neonatal death rate was 17 per 1,000 deliveries in all facilities. The rate in EmONC facilities (34 per 1,000 deliveries) was twice the rate in all facilities. In all facilities, Kono (34 per 1,000 deliveries) recorded the highest among districts, followed by Bombali, Western Urban, and Kambia with 28, 26 and 24 per 1,000 deliveries respectively. The lowest intrapartum and very early neonatal death rate was reported in Moyamba (2 per 1,000 deliveries). The rates in EmONC facilities were very much higher than in all facilities across all districts, except Moyamba (there was no EmONC facility). This could partly be explained by the fact that pregnant women with early signs of obstetric and newborn complications might be referred to EmONC facilities. The intrapartum and very early neonatal death rate in EmONC facilities from Kono (93 per 1,000 deliveries) was much higher than the rest of the districts.
PPH/Retained placenta
Obstructed/prolonged labour
APH
Postpartum sepsis
Other DOC
Ruptured uterus
Severe complications of abortion
Ectopic pregnancy
Severe pre-eclampsia/eclampsia
24%
24%
17%
15%
5%
5%
4%3%3% 3%
1% 2% 3% 4% 5% 6% 7%0%
Obstructed/ prolonged labo r
Severe complic ations of abo rtion
Other DOC
APH
PPH/Retained placenta
Severe pre-eclampsia/ eclampsi a
Ectopic pregnancy
Ruptured uterus
Postpartum sepsis
50
Figure 3.7.1: Intrapartum and very early neonatal death rate in all facilities, by district, Sierra Leone Rapid EmONC Assessment 2017
3.8 Indicator 8: Proportion of maternal deaths due to indirect causes
Indirect causes of maternal death result from previous existing disease or disease that developed during pregnancy, which was not due to direct obstetric causes, but the physiologic effects of pregnancy that ag-gravate them. There is no internationally accepted benchmark for this indicator. However, it gives insights about intervention strategies for major indirect causes that kill many women of reproductive age (examples are malaria, anaemia, HIV and hepatitis).
The 2017 Sierra Leone rapid EmONC assessment recorded a weighted total of 475 maternal deaths. Of these, 65 (14 per cent) were due to indirect causes in all facilities. The proportion in EmONC facilities was 15 per cent. In all facilities, the proportion of maternal deaths due to indirect causes range from zero per cent in Moyamba, Pujehun, and Western Rural to 35 per cent in Kailahun (Figure 3.8.1 and Table 3.8.1A in the appendix).
Figure 3.8.1: Percentage of maternal deaths due to indirect causes in all facilities, by district, Sierra Leone Rapid EmONC Assessment 2017
10% 20% 30% 40%0%
Kono
Bombal i
Western Urba n
Kambia
Tonkolili
Kailahun
Koinadugu
National
Bo
Portloko
Western Ru ral
Kenema
Pujehu n
Bonthe
Moyamba
10%5% 20%15% 30% 35%25% 40%0%
Kailahun
Kambia
Western Urba n
Portloko
Kenema
Bonthe
National
Koinadugu
Bombal i
Tonkolili
Bo
Western Ru ral
Pujehu n
Moyamba
Kono
35%
26%
24%
17%
16%
14%
14%
13%
13%
8%
2%
0%
0%
0%
0%
51
Figure 3.8.2: Post-abortion care women discharged with family planning by district, Sierra Leone Rapid EmONC Assessment 2017
Quality of registers
The Sierra Leone EmONC assessment also collected information on what type of register books were used in the health facilities. In addition, data collectors asked and physically observed whether those register books were complete (all columns filled) and up-to-date (as of the day of visit or the day before). The main reason why quality of record keeping was assessed was to indicate gaps in improving quality of data, as the accurate number of the registration of births, obstetric complications, newborn outcomes and associated statistics are highly dependent on these facility records. It was not possible to borrow the patient registration books for all the women who delivered in the health facilities to triangulate the data as that would have hampered the regular service delivery.
For example, collection of the number of women with indirect obstetric complications was a challenge in all facilities as programme interventions and their recordings were vertically implemented and had separate registers (number of women with malaria complications was higher than the number of women who delivered in 17 facilities during this EmONC assessment). This could have happened either because women went to separate facilities for treatment of malaria complications during their pregnancy and accessed different facilities when they gave birth, or the facility providers recorded repeated times in each they come for each time of a complication occurred. The labour and delivery register is the primary register for capturing deliveries and newborn outcomes. However, in most health facilities, it lacked details of direct and indirect obstetric causes of complications, and maternal and newborn outcomes. For example, abortions would be classified under sepsis or haemorrhage. There is also a potential for overlap or misclassification between an entry for ruptured uterus and prolonged/obstructed labour, or repeated counting of women whenever they visited the facility for complications, and such data was available only in reports.
Post-abortion and postpartum women discharged with family planning methods
Table 3.8.2A in the appendix and Figure 3.8.2 below show post-abortion and postpartum women discharged with contraceptives. Accordingly, of the 2,228 total post-abortion care cases, over half of them received FP methods. PAC cases discharged with FP methods varied remarkably among districts, with none reported in Kenema, Kono, and Koinadugu to all of the PAC cases in Moyamba.
From the weighted total deliveries (104,713) that occurred in 2016, post-partum women discharged with FP was extremely low (1 per cent) at the national level. District-level distribution also looks very low (Table 3.8.2A). The low performance might be attributed to the lack of recording this information by facilities, as post-partum women discharged with FP was widely observed during the data collection.
0%
20%
40%
60%
80%
100%
120%
Moyamba Bo
Weste
rn Rural
Bonthe
Weste
rn Urba n
Pujehun
Kambia
National
Tonkolili
Portloko
Kailahun
Bombal i
KenemaKono
Koinadugu
100% 98% 97%88%
75%61% 59%
46%
35% 35%22%
1% 0% 0% 0%
52
Table 3.8.1: Percentage of facilities that use registers, by type of facility and operating agency, Sierra Leone Rapid EmONC Assessment 2017
Type of facility Managing authority
All facilities Hospitals CHCs/clinics Public (government ) Private for-profit Private not-for-profit1
n=173 n=39 n=134 n=144 n=8 n=21
Type of register
Labour and delivery ward register 99% 97% 99% 100% 80% 100%
Operating theater register2 87% 8% 37% 41%
Maternal death register 27% 59% 23% 27% 7% 35%
Mother and neonatal register 77% 62% 79% 77% 78% 72%
PNC register 69% 49% 71% 69% 63% 71%
PAC register 28% 51% 25% 30% 15% 25%
PMTCT register 90% 85% 91% 91% 93% 84%
FP register 91% 74% 94% 94% 85% 65%
MDSR register/log book 34% 46% 32% 34% 22% 39%
Other (General/Referral/Admission) 46% 28% 49% 48% 29% 43%
Note: 1. Includes NGO and faith-based or mission health facilities2. Availability of this register was calculated for hospitals only. However, two private clinics with OT used OT an register.
Table 3.8.4A in the appendix shows the completeness of registers and how up-to-date they were. More specifically, we looked at this status for labour and delivery register in Figure 3.8.3 below by facility type. Despite 99 per cent of CHCs/clinics and 97 per cent of hospitals having labour and delivery registers, only three fourth (74 per cent) of CHCs/clinics and fewer than two thirds (63 per cent) of hospitals had the registers complete. Similarly, only 79 per cent of the facilities had up-to-date labour and delivery registers. CHCs/clinics were more likely to have the register complete and up-to-date than hospitals.
It was also observed that medical record numbers were not registered in many of the register books to take time to match whether the women who had developed complications were the same women who delivered in that specific facility. For example, there were cases where women delivered in a facility but there was no newborn outcome recorded; or women delivered at home and came for treatment of complications to a facility and were recorded as if they had delivered in the facility. Keeping the afore-mentioned data quality problems in mind, Table 3.8.1 below and Table 3.8.4A in the appendix examine which register books were used and which were complete and up-to-date. Almost all of the facilities, irrespective of type and ownership, had been using labour and delivery registers. The large majority of facilities were also using FP and PMTCT registers. Eighty-seven per cent of hospitals were using OT registers. The use of this register is low among hospitals that were expected to use this register (90 per cent of the total hospitals had OT). Use of maternal death, post-abortion care (PAC), maternal death surveillance and reporting (MDSR), and postnatal care (PNC) registers were very low across all facility types and operating agencies.
53
3.9 Comparison of EmONC indicators
In this section, we try to compare results of the 2017 and 2008 EmONC assessments on available data. However, there are methodological differences in the two surveys. The 2008 EmONC used a sample survey of hospitals, CHCs, community health posts, and maternal and child health posts. In addition, the data for the indicators was not weighted. In contrast, the 2017 EmONC captured a census of hospitals irrespective of their operating agency and a sample of CHCs that had delivery services at the time of the survey, and the data was weighted to reflect national and district level representation.
With this in mind, Sierra Leone has shown improvements in MNH care services since 2008 (Table 3.9.1). Availability of EmONC facilities, for example, has increased from 14 (24 per cent) to 62 (85 per cent). There were no BEmONC facilities in the country in 2008. In 2017, Sierra Leone had 41 BEmONC facilities, which is 71 per cent of the UN recommended target.
The proportion of births in all facilities in 2017 increased almost threefold from 2008 (10 per cent). The proportion of expected births delivered by CS in 2008 was calculated for EmONC facilities only (0.9 per cent), and the 2017 result was over twice that of 2008 (2 per cent). The met need for EmONC in 2017 (15 per cent) was twice that of 2008 (7 per cent) (Table 3.9.1).
DOCFR, in which the UN target is <1 per cent was 7 per cent in 2008 and 3 per cent in 2017, thus exceeding the international target. However, in 2017, we observed a reduction of the DOCFR by over half since 2008. In contrast, the intrapartum and very early neonatal death rate in the current EmONC was twice as high as that of the 2008 rate. Similarly, maternal deaths due to indirect obstetric causes rose a little from 14 per cent in 2008 to 15 per cent in 2017.
Figure 3.8.3: Percentage of facilities with a labour and delivery register that was complete andup-to-date, by facility type, Sierra Leone Rapid EmONC Assessment 2017
0%
20%
40%
60%
80%
100% 99%
73%79%
All facilities
97%
63% 61%
Hospitals
99%
74%
82%
CHCs/clinics
Register available Register complete Register up-to-date
54
Table 3.9.1: Comparison of EmONC indicators in 2008 and 2017, Sierra Leone Rapid EmONC Assessment 2017
2008 2017
All facilities EmONC facilities All facilities EmONC facilities
Indicator 1: Availability of EmONC
Recommended n 59 73
Actually functioning n (%) 14(24%) (85%)62
Actually functioning CEmONC n (%) 14(119%) (144%)21
Actually functioning BEmONC n (%) 0(0%) (71%)41
Indicator 2: Subnational availability of EmONC (% of minimum recommended EmONC facilities)
Kailahun 0% (92%)5
Kenema 1(18%) (143%)9
Kono 0% (19%)1
Bombali 3(71%) (16%)1
Kambia 1(34%) (84%)3
Koinadugu 1(35%) (166%)7
Port Loko 2(42%) (47%)3
Tonkolilii 0% (73%)4
Bo 1(18%) (67%)4
Bonthe 0% (147%)3
Moyamba 0% 0%
Pujehun 0% (280%)10
Western Rural 1(22%) (89%)4
Western Urban 4(37%) (73%)8
Indicator 3: Proportion of births in facilities 10% 2% 28% 10%
Indicator 4: Met need for EmONC (% of expected complications treated) 7% 20% 15%
Indicator 5: Proportion of births delivered by caesarean 0.9% 2.0% 2.0%
Indicator 6: DOCFR) 7% 3.0% 3.0%
Indicator 7: Intrapartum and very early neonatal death rateIntrapartum and very early neonatal death rate (per 1,000 deliveries) 17 34
Indicator 8: Proportion of maternal deaths due to indirect causes 14% 15%
55
CHAPTER 4PERFORMANCE OF OTHER MATERNAL AND NEWBORN HEALTH SERVICES
56
In this chapter, we do explain the routine MNH care services, other than the emergency MNH care indicators or signal functions that were described in the previous chapter.
4.1 Availability of routine services and performance of other maternal and newborn health services
Data collectors asked facility in-charges about other MNH services they provided. Data collectors did not verify whether those other MNH services were provided or not. It was based on self-reported responses. As shown in Table 4.1.1 below, all of the facilities had provided antenatal and PNC services at the national level. Ninety-two per cent of all facilities provided obstetric services 24 hours a day and seven days a week; 94 per cent provided neonatal services 24/7; 90 per cent provided post-abortion FP services; and 86 per cent had provided PAC services. Facilities in all districts provided obstetric and neonatal care services 24/7, except Bo and Bonthe, about 72–77 per cent of their facilities provided these services. Provision of the afore-mentioned services had no greater variations among districts, facility types or operating agency, except for the private-for-profit; only 57 per cent of them provided obstetric services 24/7.
Nationally, obstetric surgery, general and spinal anaesthesia services were provided in only 12, 12 and 11 per cent of facilities, respectively. As these services are mostly hospital-based, over 80 per cent of hospitals offered these services while only 2 per cent of the CHCs/clinics did so. Private facilities were likely to provide these services than government facilities. Mostly, hospitals are located in urban areas and such hospital-based higher level of care services were provided in urban locations than rural. Provision of 24/7 obstetric services among districts ranges from 4 per cent of the facilities in Western Rural to 26 per cent in Western Urban (Table 4.1.1).
Table 4.1.1: Percentage of facilities providing selected services by district, facility type, operating agency and location, Sierra Leone Rapid EmONC Assessment 2017
Total number of
facilities
Antenatal care
(ANC)
Postnatal Care (PNC)
Obstetric surgery((e.g, CS
General anaesthesia
Spinal a naesthesia
Obstetric services
24/7
Neonatal services 24/7
Post-abortion care (PAC)
Post-abortion family
planning (FP)
n % % % % % % % % %
National 173 100% 100% 12% 12% 11% 92% 94% 86% 90%
District
Kailahun 9 94% 100% 12% 12% 6% 100% 100% 87% 94%
Kenema 17 100% 100% 7% 13% 7% 94% 100% 88% 100%
Kono 11 100% 100% 15% 15% 15% 100% 100% 43% 53%
Bombali 14 100% 100% 15% 11% 11% 100% 100% 96% 96%
Kambia 8 100% 100% 6% 6% 6% 100% 100% 100% 73%
Koinadugu 7 100% 100% 8% 8% 8% 100% 100% 100% 100%
Port Loko 14 100% 100% 20% 20% 20% 100% 100% 76% 71%
Tonkolilii 9 100% 100% 13% 13% 13% 100% 100% 100% 100%
Bo 23 100% 100% 13% 9% 9% 77% 72% 77% 84%
Bonthe 12 100% 100% 9% 9% 9% 73% 73% 82% 82%
Moyamba 12 100% 100% 9% 9% 9% 100% 100% 82% 100%
Pujehun 8 100% 100% 7% 7% 7% 100% 100% 100% 100%
Western Rural 8 100% 100% 4% 4% 4% 86% 100% 100% 100%
Western Urban 21 100% 100% 26% 26% 26% 86% 86% 86% 93%
57
Total number of
facilities
Antenatal care
(ANC)
Postnatal Care (PNC)
Obstetric surgery((e.g, CS
General anaesthesia
Spinal a naesthesia
Obstetric services
24/7
Neonatal services 24/7
Post-abortion
care (PAC)
Post-abortion family
planning (FP)
n % % % % % % % % %
National 173 100% 100% 12% 12% 11% 92% 94% 86% 90%
Facility Type
Hospital 39 97% 100% 87% 82% 80% 100% 100% 90% 87%
CHC/Clinic 134 100% 100% 2% 2% 2% 91% 93% 86% 90%
Operating agency
Government/Public 144 100% 100% 8% 9% 8% 96% 96% 89% 92%
Private-for-profit 8 100% 100% 30% 22% 22% 52% 80% 73% 100%
Private not-for-profit1 21 100% 100% 44% 41% 38% 78% 78% 72% 65%
Location
Urban 67 99% 100% 28% 26% 26% 87% 89% 84% 88%
Rural 106 100% 100% 3% 4% 3% 95% 96% 88% 91%
Note. 1. Includes NGO, faith-based and mission facilities.
4.2 Performance of other maternal and newborn health services or routine signal functions in a three-month reference period
Facilities were asked whether other MNH services or routine signal functions – AMTSL, partograph for labour monitoring, essential newborn care for preterm or low birth weight babies, antenatal corticosteroids, KMC, repair of obstetric fistula, FP for post-abortion women) – were provided in the three-month reference period prior to the survey. As Table 4.2.1 describes, all of the facilities had provided AMTSL and had used a partograph for labour monitoring. Provision of FP methods for PAC cases, however, was reported only in 67 per cent of facilities. Provision of FP methods to PAC cases among districts varied widely with the highest in Kenema (94 per cent) and the lowest in Kono (43 per cent). As expected, hospitals (80 per cent) were more likely to provide FP to PAC cases than CHCs/clinics (65 per cent). Regarding the operating agency, there were marked differences, except the provision was more likely in government facilities than private.
Provision of KMC and corticosteroids for preterm and low birth weight babies: KMC was provided in 60 per cent of the facilities. Pujehun, Moyamba, Kono, Port Loko, and Kenema had over 80 per cent of the facilities providing KMC. Close to three fourth of the hospitals and 58 per cent of CHCs/clinics provided KMC in the three-month reference period. However, this assessment did not assess the provider’s real understanding of what KMC is as it is often misunderstood and interchangeably used as skin-to-skin care. On the other hand, corticosteroids were provided in only 30 per cent of the facilities (67 per cent of hospitals and 24 per cent of CHCs/clinics) at the national level. Provision of corticosteroids among districts ranges from none in Western Rural to 87 per cent in Pujehun and Kailahun (75 per cent).
Essential newborn care to premature and/or low birth weight babies: Like corticosteroids, provision of essential newborn care was also very low as only 45 per cent of the total facilities provided it. Marked variations were observed among districts in providing essential newborn care in the last three months prior to the survey.
Repair of obstetric fistula: Obstetric fistula may occur due to lack of access to higher level of care; and mostly available in hospitals that require skilled health worker cadre and drugs, equipment, supplies and facility set-up to manage obstetric fistula or surgery. In this regard, limited resources often challenge the service and mothers who develop obstetric fistula suffer from risks and its associated consequences. As indicated in Table 4.2.1, only 8 per cent of hospitals provided repair and treatment of obstetric fistula. These few facilities were distributed only in Tonkolili, Bo and Western Urban – all unfortunately private not-for-profit – and in the government-owned national/maternity hospital.
58
Table 4.2.1: Percentage of facilities that provided other MNH services/signal functions in the last 3 months, by district, facility type, operating agency, and location, Sierra Leone Rapid EmONC Assessment 2017
Total number of
facilities
Active management of
third stage of labour (AMTSL)
Used partograph to monitor
labour
Essential care to premature
and/or low birthweight babies
Antenatal corticosteriods
Kangaroo mother care
(KMC)
Staff available and trained to
repair obstetric fistula
Family planning methods been
provided to post-abortion women
n % % % % % % %
National 173 100% 100% 45% 30% 60% 1% 67%
District
Kailahun 9 100% 100% 87% 75% 75% 0% 75%
Kenema 17 100% 100% 69% 38% 81% 0% 94%
Kono 11 100% 100% 43% 6% 91% 0% 43%
Bombali 14 100% 100% 16% 8% 16% 0% 33%
Kambia 8 100% 100% 40% 33% 46% 0% 73%
Koinadugu 7 100% 100% 39% 23% 54% 0% 85%
Port Loko 14 100% 100% 84% 23% 84% 0% 50%
Tonkolilii 9 100% 100% 38% 26% 63% 7% 88%
Bo 23 100% 100% 45% 27% 73% 3% 70%
Bonthe 12 100% 100% 55% 18% 36% 0% 46%
Moyamba 12 100% 100% 46% 41% 96% 0% 46%
Pujehun 8 100% 100% 60% 87% 100% 0% 87%
Western Rural 8 100% 100% 14% 0% 14% 0% 55%
Western Urban 21 100% 97% 29% 39% 44% 3% 90%
Facility Type
Hospital 39 100% 97% 67% 67% 74% 8% 80%
CHC/Clinic 134 100% 100% 42% 24% 58% 0% 65%
Operating agency
Government/Public 144 100% 100% 46% 28% 60% 0% 68%
Private-for-profit 8 100% 100% 22% 15% 42% 0% 64%
Private not-for-profit1 21 100% 100% 47% 53% 68% 7% 58%
Location
Urban 67 100% 99% 37% 31% 49% 2% 68%
Rural 106 100% 100% 51% 29% 66% 1% 66%
Note: 1. Includes NGO, faith-based and mission facilities.
59
CHAPTER 5FACILITY INFRASTRUCTURE AND COMMUNICATION
60
Facility infrastructure is one of the key elements of the health system needed to provide quality health services. Adequate number of facilities with the required set-up, level and number of trained staff are important in saving the lives of mothers and newborns. In this chapter, we discuss the ratio of beds to deliveries, availability of separate rooms for MNH services, availability of electricity, water and modes of communication, and other infrastructure-related elements of the health system.
5.1 Ratio of beds to deliveries
The number and ratio of beds to deliveries are often used for criteria to determine the levels of care in the health facilities. However, there is no clear standard that quantifies number and ratio of beds in Sierra Leone. We used WHO’s standard of 30 to 32 beds for every 1,000 deliveries in the maternity and delivery rooms in the first-level referral facilities (like district hospitals) to compare availability of beds in Sierra Leone.33
As shown in Table 5.1.1 below, the ratio of maternity beds (obstetrics as well as labour and delivery) to 1,000 deliveries met the international standard of 30–32 beds. Western Rural and Urban, Bo, Pujehun and Kambia fell short of the minimum required ratio of beds to 1,000 deliveries. With 56 maternity beds to 1,000 deliveries, Kailahun and Kono had the highest ratio. Hospitals exceeded the minimum ratio of beds to 1,000 deliveries; while CHCs/clinics just met the standard. Private, not-for-profit facilities exceeded and government facilities met the standard. However, private for-profit facilities fell short of this standard. Location has no implication in meeting the standards of availability of beds.
Table 5.1.1 also shows ratio of beds exclusively for labour and delivery to 1,000 deliveries. Accordingly, the international standard sets six to eight; and Sierra Leone met this standard with seven beds per 1,000 deliveries, exclusively dedicated for labour and delivery. Compared against this standard, Western Rural and Urban, Bo, Pujehun, Kambia and Kenema district fell short.
Table 5.1.1: Ratio of maternity beds and couches to 1,000 deliveries, by facility type, operating agency and district, Sierra Leone Rapid EmONC Assessment 2017
Total number of
facilities
Number of institutional
deliveries in 2016
(weighted)
Number of:Ratio of
obstetrics beds to 1,000
deliveries 2
Ratio of labour and delivery
beds/couches to 1,000 deliveries
Ratio of obstetrics + labour and
delivery beds/couches to 1,000
deliveries
All beds/ couches
(weighted)
Beds exclusive for obstetrics
((weighted
Beds exclusive for labour & delivery (weighted)
% % %
National 173 104,713 6,983 2,649 722 25 7 32
District
Kailahun 9 5,699 441 260 59 46 10 56
Kenema 17 9,684 643 251 62 26 6 32
Kono 11 3,735 374 173 37 46 10 56
Bombali 14 6,473 766 193 65 30 10 40
Kambia 8 4,651 218 94 36 20 8 28
Koinadugu 7 2,895 365 122 38 42 13 55
Port Loko 14 7,332 546 194 51 26 7 33
Tonkolilii 9 4,410 536 147 37 33 8 42
Bo 23 12,642 742 193 58 15 5 20
Bonthe 12 3,001 280 95 48 32 16 48
Moyamba 12 6,241 428 193 47 31 8 38
Pujehun 8 5,015 238 117 24 23 5 28
Western Rural 8 12,065 399 157 56 13 5 18
Western Urban 21 20,871 1,006 462 104 22 5 27
33. WHO. 1991. ‘Essential elements of obstetric care at first referral level’.
61
Total number of
facilities
Number of institutional
deliveries in 2016
(weighted)
Number of:Ratio of
obstetrics beds to 1,000
deliveries 2
Ratio of labour and delivery
beds/couches to 1,000 deliveries
Ratio of obstetrics + labour and
delivery beds/couches to 1,000
deliveries
All beds/ couches
(weighted)
Beds exclusive for obstetrics
((weighted
Beds exclusive for labour & delivery (weighted)
National 173 104,713 6,983 2,649 722 25 7 32
Facility Type
Hospital 39 31,891 4,133 1,034 161 32 5 37
CHC/Clinic 134 72,822 2,850 1,615 561 22 8 30
Operating agency
Government/Public 144 88,025 5,341 2,151 591 24 7 31
Private-for-profit 8 4,856 287 102 38 21 8 29
Private not-for-profit1 21 11,832 1,355 396 93 33 8 41
Location
Urban 67 54,812 4,404 1,363 312 25 6 31
Rural 106 49,902 2,579 1,286 409 26 8 34
Note. 1. Except the number of facilities, the rest of the figures are weighted.2. According to the ‘Essential elements of obstetric care at first referral level’, (WHO, 1991) there should be 24 beds per 1,000 deliveries in the mater-nity ward (for both prenatal and postnatal patients). The labour and delivery room should have 6-8 beds. Overall, therefore, the standard would be approximately 30-32 beds for every 1,000 deliveries at a facility that would be considered 'first referral level'. This is the equivalent to a district-level hospital for about 100,000 population.3. Includes NGO, faith-based and mission facilities.
5.2 Availability of separate rooms or designated spaces for maternal and newborn health services
Table 5.2.1A in the appendix reveals the percentage of facilities with separate rooms or spaces for maternal and newborn care services. Nationally, 95 per cent of the facilities had separate rooms for antenatal care (ANC) and 77 per cent had a postpartum ward. Despite the fact that a great majority of the facilities (85 per cent) had a separate delivery room, only 17 per cent had a separate labour room and 17 per cent had labour and delivery together. All of the facilities in Kailahun, Port Loko and Moyamba had only a delivery room and no other separate room for labour.
Of the total hospitals, 90 per cent of them had an OT. Despite the fact that CHCs/clinics were not required to have an OT, 2 per cent of them (two private clinics with an obstetrician/gynaecologist) had an OT. Most of the hospitals and CHCs/clinics had corners for newborn first aid/care; but only 13 per cent of hospitals and none of the CHCs/clinics had a NICU. None of the facilities in Kailahun, Kono, Kambia, Koinadugu, Port Loko, Bonthe, Moyamba, Pujehun or Western Urban had a separate room for NICU. Private for-profit facilities had no separate room or space for NICU.
A KMC-designated area was available only in 45 per cent of the facilities at the national level, with none in the facilities in Kambia and 93 per cent and 91 per cent of the facilities in Pujehun and Moyamba, respectively. A similar proportion of hospitals (41 per cent) and CHCs/clinics (45 per cent) had a KMC area.
Forty-eight per cent and 6 per cent of all facilities had separate rooms for a laboratory and blood bank, respectively. Facilities with both laboratory and blood bank together were only 3 per cent. Nearly three quarters of hospitals had a separate room for a laboratory while only 44 per cent of CHCs/clinics had a separate room. None of the facilities in Moyamba reported having a separate laboratory room but 87 per cent of the facilities in Kambia had a laboratory. Having a separate room for a blood bank was reported only from hospitals (46 per cent), as expected. Generally, the availability of a blood bank was extremely low across all districts with the highest in Tonkolili (13 per cent) and the lowest in Moyamba (zero) and Western Rural (zero). Western Rural was the only district where none of the facilities had a separate room for a blood bank, or a laboratory and blood bank together.
62
Figure 5.2.1: Percentage of facilities with separate room or space for selected maternal and newborn services, by facility type, Sierra Leone Rapid EmONC Assesment 2017
5.3 Availability of electricity
Utilities like electricity and water are key elements for the daily operation of health facilities to help medical equipment work, and facilitate quality service delivery and infection prevention. The findings of Table 5.3.1 show the availability of electricity and whether there were interruptions or not by district, facility type, operating agency and location. Nationally, quite a large proportion of facilities (89 per cent) had a source of electricity. Private-owned and urban-centred facilities had better coverage of electricity than the rest of the groups. Nationally, below a third (30 per cent) of facilities were connected to the grid. Despite connection to the grid being very low, 61 per cent of the facilities had a solar-powered electric source. Seven out of the 14 districts had facilities with full coverage of electricity from any source; Bonthe had the lowest proportion of facilities (46 per cent) with electricity coverage, followed by Kenema (69 per cent). Solar power was very common in all districts, except in Western Urban (7 per cent), which was highly dependent on the power grid (93 per cent), and Koinadugu had 69 per cent of their facilities dependent on a generator. Rural facilities were highly likely to have solar-powered electricity rather than getting it from the grid or a generator.
Only 45 per cent of the facilities had a back-up generator, with the highest coverage among facilities in Kambia and the lowest in Pujehun (7 per cent) and Moyamba (9 per cent), where the facilities were highly dependent on solar-powered electricity. Hospitals were more likely to have a back-up generator (82 per cent) than CHCs/clinics (39 per cent). Privately owned facilities had better coverage with a back-up generator than government facilities.
Table 5.3.1: Percentage distribution of facilities according to source of electricity and, among those with electricity, percentage with functioning electricity at time of interview, by district, facility type, operating agency and location, Sierra Leone Rapid EmONC Assessment 2017
Total number of
facilities
Has a source of electricity
Among those with a source of electricity, the primary source is: Facilities
with back-up generator available
Number of facilities
with electric source
Among facilities with any electric source, duration of any interruption in last month
Power lines (grid) Generator Solar
No/interruption
for hours
Interruption <2 days
Interruption >2 days
% % % % % n % % %
National 173 89% 30% 9% 61% 45% 154 81% 2% 17%
District
Kailahun 9 87% 0% 7% 93% 21% 8 86% 0% 14%
Kenema 17 69% 23% 9% 68% 50% 12 64% 0% 36%
Kono 11 81% 12% 7% 82% 53% 9 88% 0% 12%
Bombali 14 92% 13% 4% 83% 44% 13 87% 4% 9%
Kambia 8 100% 0% 6% 94% 87% 8 87% 13% 0%
0%
20%
40%
60%
100%
80%
Antenatalcare room
Labour anddelivery
Labor room Deliveryroom
Postpartumward
Operatingtheater
Corner fornewborn
SeparateBlood bank
SeparateLaboratory
room
Laboratoryand blood
banktogether
National hospital Regional hospital District hospital
Other hospital CHC Private clinic
63
Total number of
facilities
Has a source of electricity
Among those with a source of electricity, the primary source is: Facilities
with back-up generator available
Number of facilities
with electric source
Among facilities with any electric source, duration of any interruption in last month
Power lines (grid) Generator Solar
No/interruption
for hours
Interruption <2 days
Interruption >2 days
% % % % % n % % %
National 173 89% 30% 9% 61% 45% 154 81% 2% 17%
District
Koinadugu 7 100% 0% 69% 31% 69% 7 85% 0% 15%
Port Loko 14 100% 26% 13% 61% 44% 14 95% 0% 5%
Tonkolilii 9 88% 8% 0% 92% 29% 8 100% 0% 0%
Bo 23 86% 36% 0% 64% 73% 20 73% 0% 27%
Bonthe 12 46% 0% 20% 80% 40% 6 90% 0% 10%
Moyamba 12 100% 9% 9% 82% 9% 12 100% 0% 0%
Pujehun 8 100% 0% 20% 80% 7% 8 100% 0% 0%
Western Rural 8 100% 72% 0% 28% 45% 8 59% 0% 41%
Western Urban 21 100% 93% 0% 7% 43% 21 68% 3% 29%
Facility Type
Hospital 39 100% 59% 28% 13% 82% 39 82% 5% 13%
CHC/Clinic 134 87% 25% 6% 69% 39% 115 81% 1% 18%
Operating agency
Government/Public 144 88% 27% 8% 65% 42% 127 81% 1% 18%
Private-for-profit 8 100% 57% 15% 29% 52% 8 72% 0% 29%
Private not-for-profit2 21 87% 48% 11% 41% 65% 19 93% 4% 4%
Location
Urban 67 91% 73% 10% 16% 48% 62 68% 2% 30%
Rural 106 87% 3% 8% 89% 42% 92 89% 1% 9%
Table 5.3.1: Percentage distribution of facilities according to source of electricity and, among those with electricity, percentage with functioning electricity at time of interview, by district, facility type, operating agency and location, Sierra Leone Rapid EmONC Assessment 2017
Note: 1 The difference between ‚has a source of electricity’ and ‚has electricity from the grid’ is the percentage of facilities with electricity whose source is either a generator, solar power, or other.
2 Includes NGO, faith-based and mission facilities.
Interruptions in electricity
Nowadays, electricity interruptions are most common in developing regions. In Sierra Leone, all of the facilities visited that had electricity experienced interruptions in the last month prior to the survey. But quite a large proportion of the facilities (81 per cent) had either no interruptions or interruptions only for a few hours, and 2 per cent had interruptions for not more than two days. Seventeen per cent of the total facilities that had electricity experienced interruptions for more than two days. This interruption is worrisome, as most mothers with direct obstetric complications require treatment in less than a couple of hours. Interruptions for more than two days were very common among facilities in Western Rural, Kenema, Western Urban and Bo. CHCs/clinics and facilities located in urban areas were likely to be more affected by longer interruptions than the rest of the groups. Longer electricity interruptions were more common in private for-profit and government facilities than non-profit facilities (Table 5.3.1 above).
64
5.4 Availability of water
Water is one of the basic necessities of life and a key amenity for health facilities. It is used for drinking, cooking, infection prevention, bathing and laundry. Like electricity, facility in-charges were asked about availability of water and sources of water in their respective health facilities. As Figure 5.4.1 and Table 5.3.1 below show, 94 per cent of the total facilities had a source of water. All facilities in all districts had water from any source except Western Rural (59 per cent), Bonthe (82 per cent), Tonkolili (88 per cent) and Kenema (94 per cent). All hospitals had water from any source and quite a large proportion of the CHCs/clinics also had water. When it comes to the primary source of water, the majority had a hand pump (43 per cent) as the primary source, followed by piped (29 per cent) and well (17 per cent). Borehole (7 per cent), rain (3 per cent) and river (1 per cent) were also cited as primary sources. Bombali had a majority of facilities using a well as a primary source. In the rest of the districts, a hand pump was the primary source.
More than half the hospitals had piped water as a primary source; while CHCs/clinics primarily depended on water from a hand pump. Most private facilities (profit and non-profit) used piped water as a primary source while government facilities, on the other hand, depended on piped water.
Figure 5.4.1: Percentage distribution of primary source of water (from those that had a source of water), Sierra Leone Rapid EmONC Assessment 2017
Table 5.4.1: Percentage distribution of facilities according to their primary source of water, by district and facility type, operating agency and location, Sierra Leone Rapid EmONC Assessment 2017
Total number of
facilities
Has a source
of water
Among those with a source of water, the primary source is: Number of facilities
with water source
Among those with a source of water:
Piped water
Handpump Well River Bore
hole Rain Water tanker
No/interruption
for hours
Shortage of water with <
2 days
Shortage of water with >
2 days
% % % % % % % % n % % %
National 173 94% 29% 43% 17% 1% 7% 3% 1% 166 94% 1% 5%
District
Kailahun 9 100% 0% 63% 31% 0% 6% 0% 0% 9 94% 0% 6%
Kenema 17 94% 43% 50% 7% 0% 0% 0% 0% 16 83% 4% 13%
Kono 11 100% 47% 47% 0% 0% 6% 0% 0% 11 100% 0% 0%
Bombali 14 100% 4% 25% 59% 0% 4% 9% 0% 14 88% 4% 9%
Kambia 8 100% 20% 54% 27% 0% 0% 0% 0% 8 100% 0% 0%
Piped water
Well
River
Bore hole
Rain
Water tanker
Hand pump29%
43%
17%
7%
1%
1% 3%
65
Table 5.4.1: Percentage distribution of facilities according to their primary source of water, by district and facility type, operating agency and location, Sierra Leone Rapid EmONC Assessment 2017
Total number of
facilities
Has a source
of water
Among those with a source of water, the primary source is: Number of facilities
with water source
Among those with a source of water:
Piped water
Handpump Well River Bore
hole Rain Water tanker
No/interruption
for hours
Shortage of water with <
2 days
Shortage of water with >
2 days
% % % % % % % % n % % %
National 173 94% 29% 43% 17% 1% 7% 3% 1% 166 94% 1% 5%
District
Koinadugu 7 100% 39% 46% 0% 0% 15% 0% 0% 7 85% 0% 15%
Port Loko 14 100% 44% 48% 8% 0% 0% 0% 0% 14 95% 0% 5%
Tonkolilii 9 88% 44% 14% 42% 0% 0% 0% 0% 8 100% 0% 0%
Bo 23 100% 33% 47% 13% 5% 3% 0% 0% 23 100% 0% 0%
Bonthe 12 82% 11% 72% 11% 0% 6% 0% 0% 10 100% 0% 0%
Moyamba 12 100% 32% 59% 9% 0% 0% 0% 0% 12 91% 0% 9%
Pujehun 8 100% 13% 74% 0% 0% 13% 0% 0% 8 100% 0% 0%
Western Rural 8 59% 47% 0% 24% 0% 30% 0% 0% 5 100% 0% 0%
Western Urban 21 100% 33% 21% 10% 0% 17% 14% 5% 21 90% 0% 10%
Facility Type
Hospital 39 100% 54% 10% 13% 0% 18% 0% 5% 39 87% 5% 8%
CHC/Clinic 134 93% 26% 48% 18% 1% 5% 3% 0% 127 95% 0% 5%
Operating agency
Government/Public 144 95% 27% 47% 18% 1% 5% 2% 1% 139 94% 0% 6%
Private-for-profit 8 72% 62% 0% 10% 0% 0% 28% 0% 7 100% 0% 0%
Private not-for-profit2 21 94% 36% 27% 15% 0% 23% 0% 0% 20 93% 7% 0%
Location
Urban 67 88% 34% 27% 17% 0% 15% 5% 2% 63 92% 1% 7%
Rural 106 97% 27% 52% 17% 1% 3% 1% 0% 103 95% 1% 4%
Note: 1. Includes NGO, faith-based and mission facilities.
Interruptions of water supply
As Table 5.4.1 above and Figure 5.4.2 below indicate, interruptions of water supply were not common as only 5 per cent of the facilities with a source of water (of the 94 per cent that had water) had interruptions for over two days and 1 per cent had fewer than 2 days. In Kenema, Koinadugu, Bombali, Western Urban and Moyamba, 9 to 17 per cent of the facilities had water shortages for a day or more. Five per cent of Kailahun and Port Loko facilities had shortages of water for two or more days in the past month prior to the survey. Shortage of water for over a day or longer was comparatively more common in hospitals and urban areas than in CHCs/clinics and rural-located facilities. This is really troublesome as most hospitals that provide a higher level of care are in urban areas.
66
Figure 5.4.2: Percentage distribution of facilities that had shortages of water for days (from those that had a source of water), Sierra Leone Rapid EmONC Assessment 2017
Functioning water in selected maternal health service areas
Facilities were inquired on availability of water in selected maternal health service areas. Among those facilities that had a water source, a high proportion of facilities (87 per cent) with labour and delivery room reported that they had water in the room. Similarly, facilities with postpartum ward mentioned that they had water (71 per cent) in the ward. From facilities with an OT, those that had water in the OT were found 14 per cent. Of all the hospitals that had water source and labour and delivery room available, they stated that they had water in the room (Table 5.4.1A in the appendix).
5.5 Infrastructure in the maternity ward
Data collectors asked facility in-charges a set of questions regarding availability of amenities such as lighting and heating in the maternity and the labour and delivery wards (Table 5.5.1). Most facilities (87 per cent) acknowledged that they had sufficient lighting during the day, but fewer than two thirds of the facilities said they had sufficient light during the night. Availability of sufficient lighting during the night ranged from the highest proportion of facilities in Kailahun (100 per cent) to the lowest in Bonthe (32 per cent). Quite a large proportion of the facilities said that they had means of ventilation (93 per cent) but only 24 per cent of them reported they had heating. A similar proportion of facilities also mentioned that they had functional fans or air-conditioning.
Ninety-two per cent of the facilities said they had a functioning toilet in the maternity ward. However, only 59 per cent had running water in the maternity ward. Running water was more likely available in hospitals than CHCs/clinics. Functioning toilets were universally available in all facilities in Kailahun, Kambia, Koinadugu, Tonkolili, Bo, Moyamba and Pujehun. Western Rural had the least proportion of facilities with a functioning toilet in the maternity ward (Table 5.5.1).
0%
40%
60%
80%
20%
100%
Kenema
Koinadugu
Bombal i
Weste
rn Urban
Moyamba
National
Portloko
Kailahun
Kono
Kambia
Tonkolili Bo
Bonthe
Pujehun
Weste
rn Rural
Shortage of water with > 2 days
No/interruption for hours
67
InfrastructureTotal
number of facilities
Sufficient light during
the day
Sufficient light at night
Means ofventilation
Running water
Functioning toilet
Means of heating
Functional fan or air
conditioning
Curtains/ means of providing
patient privacy
Waiting area for visitors
and family
n % % % % % % % % %
National 173 87% 61% 93% 59% 92% 24% 26% 64% 75%
District
Kailahun 9 94% 100% 100% 6% 100% 19% 6% 100% 94%
Kenema 17 94% 25% 94% 63% 94% 16% 10% 37% 50%
Kono 11 91% 72% 100% 91% 91% 43% 24% 43% 62%
Bombali 14 100% 79% 100% 58% 83% 4% 16% 83% 96%
Kambia 8 87% 87% 100% 20% 100% 40% 13% 73% 67%
Koinadugu 7 100% 69% 100% 69% 100% 8% 54% 69% 100%
Port Loko 14 100% 76% 100% 68% 92% 50% 39% 68% 82%
Tonkolilii 9 75% 75% 100% 63% 100% 56% 13% 75% 51%
Bo 23 81% 55% 86% 63% 100% 31% 44% 59% 91%
Bonthe 12 82% 32% 100% 55% 91% 55% 5% 50% 73%
Moyamba 12 100% 55% 100% 64% 100% 0% 14% 73% 91%
Pujehun 8 87% 87% 100% 47% 100% 34% 0% 60% 87%
Western Rural 8 72% 59% 72% 59% 59% 4% 31% 31% 45%
Western Urban 21 74% 47% 83% 76% 93% 12% 62% 88% 78%
Facility Type
Hospital 39 92% 82% 97% 95% 100% 41% 74% 85% 80%
CHC/Clinic 134 86% 58% 93% 54% 91% 22% 19% 61% 75%
Operating agencyGovernment/Public 144 89% 63% 95% 58% 93% 25% 23% 63% 75%
Private-for-profit 8 52% 37% 72% 37% 52% 15% 49% 72% 72%
Private not-for-profit1 21 85% 57% 91% 77% 100% 22% 43% 74% 82%
Location
Urban 67 81% 54% 86% 65% 86% 21% 47% 69% 75%
Rural 106 91% 66% 98% 56% 95% 26% 14% 62% 76%
Table 5.5.1: Percentage of facilities that have the indicated infrastructure in the maternity ward, by facility type, Sierra Leone Rapid EmONC Assessment 2017
Note. 1. For hospitals, the maternity area was likely to be a specific room and these questions were related to the infrastructure of that specific room. Health centres may not have had a specific room for a maternity ward and these questions were therefore related to whether the facility, in general, had the infrastructure. 2 Includes NGO, faith-based and mission facilities.
5.6 Availability of modes of communication
Communication plays a critical role in effective referral systems in the health system at all levels. Resources are always constrained and it is difficult to upgrade every lower level facility to a higher level of care; hence, communication plus transportation fill this gap by transferring patients that require a higher level of care or surgery from the lower level to referral facilities. In this regard, facility in-charges and logistics officers were asked whether they have access to the various types of communication systems. Table 5.6.1 below presents these findings.
On-site communication is the first priority for health workers to quickly access and make calls instead of having to reach out to communication systems outside the health facility, as most maternal and newborn complications require a rapid response. However, only 48 per cent of the facilities owned cell phones. Landlines seemed unavailable or non-functional in the health facilities across the country; only 5 per cent of the facilities had a landline inside the maternity and 2 per cent had one elsewhere in the compound. Despite a huge gap in the availability of facility-owned landlines or cell phones, personal cell phones were universally available in all facilities. If there was a policy of reimbursing health workers or individuals for airtime used, they could use their own phones for the facility’s needs, especially in critical situations.
68
Only 7 per cent of the facilities confirmed that they had such a policy. This implies that facilities communication and referrals were highly dependent on cell phones owned by staff and their willingness to use their cell phones.Availability of cell phones owned by facilities was more common in the Western Urban and Rural, Bonthe, Port Loko and Kambia districts. Kailahun reported no health facility owning cell phones (Table 5.6.1).
A two-way radio was one of the main communication mechanisms that health facilities used if they lack direct access to a network signal or telephone communications. Sierra Leone had only 2 per cent of the health facilities with a functioning two-way radio and its distribution is concentrated in just two of the 14 districts: Koinadugu at 15 per cent and Western Urban at 8 per cent.Taking together landlines, cell phones (owned by either the facility or staff), and two-way radio, we calculated whether a facility had at least one of these communication mechanisms. The findings showed that 100 per cent of the facilities had at least one. But the dominant contributor to this figure was cell phones owned personally by staff (Table 5.6.1).
As far as cell phone communication is concerned, availability of a network signal is crucial for its functionality. Table 5.6.1 also shows this finding and quite a large proportion of the facilities that had staff cell phones reported availability of a cell phone signal.
Total number
of facilities
On-site communication
Functioning public
telephone in vicinity
Among facilities that use individual cell phones:
Functioning landline
telephone in maternity
Functioning landline
telephone elsewhere in facility
Cell phone (owned
by(facility
Cell phone (owned by individual
staff)
Functioning two-way
radio
At least one functioning
mode of communication
on-site
A cell phone signal is
available in the facility
A policy is available to reimburse staff using their cell phones
n % % % % % % % % %
National 173 5% 2% 48% 98% 2% 100% 6% 88% 7%
District
Kailahun 9 0% 0% 0% 100% 0% 100% 0% 87% 21%
Kenema 17 0% 0% 44% 100% 0% 100% 3% 69% 9%
Kono 11 28% 0% 15% 100% 0% 100% 19% 81% 0%
Bombali 14 0% 0% 45% 100% 0% 100% 0% 100% 11%
Kambia 8 0% 0% 54% 100% 0% 100% 6% 100% 27%
Koinadugu 7 23% 0% 8% 100% 15% 100% 0% 100% 0%
Port Loko 14 5% 0% 66% 100% 0% 100% 0% 100% 5%
Tonkolilii 9 7% 0% 26% 100% 0% 100% 0% 88% 8%
Bo 23 0% 0% 58% 100% 0% 100% 16% 72% 4%
Bonthe 12 0% 0% 73% 100% 0% 100% 5% 100% 0%
Moyamba 12 0% 0% 23% 100% 0% 100% 0% 100% 0%
Pujehun 8 0% 0% 60% 100% 0% 100% 0% 74% 0%
Western Rural 9 0% 0% 69% 100% 0% 100% 28% 100% 4%
Western Urban 20 12% 12% 75% 83% 8% 100% 0% 80% 11%
Facility Type
Hospital 38 13% 5% 69% 97% 8% 100% 13% 97% 22%
CHC/Clinic 135 4% 1% 45% 98% 1% 100% 5% 87% 5%
Operating agencyGovernment/Public 145 3% 0% 44% 98% 1% 100% 5% 88% 6%
Private-for-profit 7 15% 15% 85% 93% 7% 100% 36% 92% 17%
Private not-for-profit1 21 14% 9% 71% 100% 3% 100% 3% 91% 11%
Location
Urban 65 8% 4% 66% 95% 3% 100% 7% 91% 12%
Rural 108 3% 0% 38% 100% 1% 100% 6% 87% 4%
Table 5.6.1: Percentage of facilities with a functional mode of communication, by district, facility type, operating agency and location, Sierra Leone Rapid EmONC Assessment 2017
Note. 1. Includes NGO, faith-based and mission facilities.
69
CHAPTER 6AVAILABILITY OF HUMAN RESOURCES
70
Availability of a qualified and trained health worker cadre is one of the six building blocks of a health system needed to provide quality healthcare services.34 The Sierra Leone rapid EmONC assessment had also collected basic information on staffing patterns, availability of health workers 24/7, health worker performance of EmONC signal functions and other routine maternal and newborn care services. During the data collection, qualifications of the health workers were not verified. Data collectors were trained to document what they were told by facility or maternity in-charges.
In this EmONC assessment, we had also analysed whether facilities had the required staffing or not based on the available national standards. For this assumption, we used Sierra Leone’s Basic Package of Essential Services (BPES) 2015–2020 document35 for CHCs and secondary hospitals (includes only district and regional hospitals). Comparison of staffing against standards for the afore-mentioned facilities was done only for government/public facilities. The standards in the private facilities were not available and from experience, it varies widely even at the same level of facilities. In addition, the targets/standards provided for each health worker did not reflect obstetric services exclusively as the health workers had been working in different wards with multiple service delivery functions.
6.1 Staffing target and patterns
As explained above, targets for selected facilities (CHCs, district and regional hospitals) were obtained from Sierra Leone’s BPES document. Standards were calculated by multiplying number of facilities by the number of health workers set for the specific facility. To see the bigger picture at the national level, we used some assumptions. We gave clinics the same weight as CHCs. For hospitals, we saw clear differences in the level of care among district, regional and maternity/national referral hospitals functioning a the tertiary level. Hence, we gave district and other hospitals the same weight. For regional hospitals, we assigned twice the standard assigned to district hospitals; and for tertiary hospitals, three times the standard assigned to district hospitals. This gives some insight about the availability of staff against standards although the assumptions and estimates are to some degree speculative due to a lack of information.
As shown in Table 6.1.1A in the appendix and Figures 6.1.1 and 6.1.2, there was a chronic shortage of health workers in general, except for obstetricians/gynaecologists and general surgeons. The adequate number of obstetrician/gynaecologists is based on the assumptions we made, although this may need to be interrogated more fully. The shortages had affected all government facilities except the national/maternity hospital in Freetown. For example, Sierra Leone required having a weighted total of 716 midwives based on the calculations made, but there were only 477 available in those government facilities. This leaves a gap of 239 midwives in the country. Similarly, there was a deficit of 1,112 nurses in the country among government facilities. The numbers of SACHOs required and available were equal and the standard was met for this category of health worker. Obstetrician/gynaecologist was the only health worker category that exceeded its minimum requirement (22 needed and 27 available).
Figure 6.1.1: Number of health workers required and number available for nurses, MCHAides, CHOs, midwives and lab technicians, Sierra Leone Rapid EmONC Assessment
34 World Health Organization. 2010. Monitoring the building blocks of health systems: a handbook of indicators and their measurement strategies. Geneva: WHO.35 Ministry of Health and Sanitation. 2015. ‘Sierra Leone Basic package of essential health services 2015-2020’.
0
500
1000
1500
2000
2500
3500
30003018
1906
Nurse
1154
660
Nurse Auxilliary(MCHAides)
868
359
Community Health
716
477
Midwife
399 264
Lab Technician
Target Available
71
Figure 6.1.2: Number of health workers required and number available for MDs, nurse anaesthetist, emergency surgical officers, obstetrician/gynaecologists, general surgeons, paediatricians, anaesthesiologists and neonatologists, Sierra Leone Rapid EmONC Assessment 2017
Another way of comparing availability of health workers was measuring it against a facility’s self-reported established positions or created positions calculated for each health worker cadre in the last 12 months prior to the survey. With this assumption, Table 6.1.1 below presents the findings of the net gain or gap based on established positions, currently available, staff left, and staff posted/hired. Numbers in parentheses are gaps or net loss.
According to Table 6.1.1, there were shortages of staff in all categories of health workers except obstetrician/gynaecologist and general surgeon categories among hospitals. A huge shortage of nurses (1,232) was observed among hospitals, followed by CHOs (303), midwives (72), lab technicians (65), nurse anaesthetists (27), and MDs (GPs) (18). CHCs/clinics had a shortfall of MCHAides (514), CHOs (206), midwives (166), and lab technicians (70). Nurses exceeded established positions by 120 in CHCs/clinics. Although CHC/clinics do not require the availability of an obstetrician/gynaecologist or an MD, there were three obstetrician/gynaecologists and two MDs found in CHCs/clinics as a surplus. Table 6.1.1 also shows the availability of volunteers by different categories of health workers who support the service delivery. Hospitals had 298 nurse volunteers, 57 lab technicians and a few other cadres. However, there were no volunteer neonatologists, anaesthesiologists (MD) or nurse anaesthetists in the 12-month reference period. CHCs/clinics, on the other hand, had 333 nurses, 251 MCHAides, 72 CHOs, and 7 midwives as volunteers.
Table 6.1.1: Total number of health workers currently working, who left and who were posted in the last 12 months, by type of facility and cadre of health worker, Sierra Leone Rapid EmONC Assessment 2017
Health worker cadre
Hospitals (n=39)
Established positions
CHCs/Clinics (n=134)
In the last 12 months In the last 12 months
Established positions
Currently employed
Surplus/ (Gap)
Staffleft
Staff posted/
hired
Net gain (loss) Volunteers Currently
employedSurplus/
(Gap) Staff
left
Staff posted/
hired
Net gain (loss) Volunteers
Obstetrician/Gynaecologist
22 24 2 7 8 1 5 - 3 3 0 0 - 0
MD (GP) 126 108 (18) 28 34 6 7 - 2 2 0 0 - 0
General surgeon
22 23 1 6 4 (2) 4 - 0 - 0 0 - 0
Paediatrician 13 11 (2) 5 6 1 2 - 0 - 0 0 - 0
Neonatologist 4 0 (4) 0 0 - 0 - 0 - 0 0 - 0
SACHO 25 25 - 8 12 4 3 - 0 - 0 0 - 0
CHO 384 81 (303) 12 4 (8) 7 484 278 (206) 50 81 31 72
Midwife 336 264 (72) 25 60 35 7 380 214 (166) 31 55 24 6
0
40
80
120
160
126
110
Medical d
octor (G
P)
114
87
Nurse Anesth
etist
25 25 22 27
Obstetri
cian/G
ynaeco
logist
22 23
General Su
rgeon
13 11
Pediatricia
n
5 3
Anaesthesio
logist (M
D)
4 0
Neonatologist
Target Available
72
Table 6.1.1: Total number of health workers currently working, who left and who were posted in the last 12 months, by type of facility and cadre of health worker, Sierra Leone Rapid EmONC Assessment 2017
Health worker cadre
Hospitals (n=39)
Established positions
CHCs/Clinics (n=134)
In the last 12 months In the last 12 months
Established positions
Currently employed
Surplus/ (Gap)
Staffleft
Staff posted/
hired
Net gain (loss)
VolunteersCurrently employed
Surplus/ (Gap)
Staffleft
Staff posted/
hired
Net gain (loss)
Volunteers
Nurse Auxiliary (MCHAides)
62 82 20 6 11 5 9 1,092 578 (514) 120 173 53 251
Nurse 2,580 1,348 (1,232) 85 85 - 298 438 558 120 88 122 34 333
Anaesthesiologist (MD)
5 3 (2) 1 1 - 0 - 0 - 0 0 - 0
Nurse Anaesthetist
114 87 (27) 4 10 6 0 - 0 - 0 0 - 0
Lab Technician 287 222 (65) 7 13 6 57 112 42 (70) 6 6 - 39
6.2 Availability of health workers 24/7
Availability of qualified and skilled health workers 24/7 is crucial to attend to patients, as labour, delivery and obstetric emergencies can occur at any time of the day or night. This requires facilities to be open 24/7. Health worker cadres whose presence is critical to the management of obstetrics and newborn emergencies are obstetrician/gynaecologists, MDs, SACHOs, midwives, anaesthetists and neonatologists. Table 6.2.1 shows the overall availability of health workers in hospitals and CHCs/clinics and whether the cadre was available on-site or on-call on weekdays or weekends, during the day and at night.
From Monday through Friday, all hospitals with the cadre present had an MD, general surgeon, paediatrician, SACHO, midwife, nurse and anaesthesiologist available on-site during the day. Within the same period, many hospitals (93 to 97 per cent) had an obstetrician/gynaecologist, CHO, MCHAide, nurse anaesthetist and lab technician available. Their availability at night was far lower than in CHCs/clinics. One per cent of the CHCs/clinics that had an obstetrician/gynaecologist and MD, all of them reported having them on-site during the day. They had also an obstetrician/gynaecologist during the night. Almost all CHCs/clinics had a CHO, midwife, MCHAide and a nurse, Monday through Friday, during the day. However, their availability at night was lower. CHCs/clinics compensated the lack of availability of these cadres on an on-call basis, particularly during the night.
On weekends, only 39 per cent of hospitals had an obstetrician/gynaecologist on-site during the day and 22 per cent at night. An MD was available in only 45 per cent and 37 per cent of the hospitals during the day and at night, respectively. SACHOs were available on-site in 55 per cent of the hospitals during the day and in 40 per cent of the hospitals at night. Availability of a midwife, nurse and MCHAide in hospitals was higher both during the day and at night over the weekends and holidays.
Among CHCs/clinics, the presence of a CHO over the weekends and holidays was observed in 79 per cent of them during the day and in 54 per cent of them at night. Seventy four to 86 per cent of the CHCs/clinics had a midwife, nurse and MCHAide on-site during the day over the weekends and holidays. Availability of this set of cadres during the night and on-call basis was very low.
In general, across all health worker cadres and facility types, staff were more likely to be available on-site during the day than at night from Monday through Friday and during the weekends. The unavailability at night was greatest among obstetrician/gynaecologists, paediatricians, surgeons and MDs in hospitals, and lab technicians in CHCs/clinics.
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Table 6.2.1: Staff coverage during a typical week, percentage of hospitals and CHCs/clinics with health workers present on site and on call at certain times, by health worker cadre, Sierra Leone Rapid EmONC Assessment 2017
Percentage of facilities with cadre present
Mon-Fri daytime1 Mon-Fri night1 Sat-Sun/holidays daytime1 Sat-Sun/holidays night1
On-site On-call On-site On-call On-site On-call On-site On-call
Hospitals (n=39)
Obstetrician/Gynaecologist 46% 94% 6% 28% 67% 39% 61% 22% 72%
MD (GP) 97% 100% 0% 40% 61% 45% 55% 37% 63%
General surgeon 51% 100% 0% 35% 65% 50% 50% 30% 70%
Paediatrician 31% 100% 0% 8% 83% 33% 58% 8% 83%
Neonatologist 0% . . . . . . . .
SACHO 51% 100% 0% 45% 55% 55% 45% 40% 60%
CHO 77% 93% 7% 57% 40% 67% 33% 60% 40%
Midwife 97% 100% 0% 92% 5% 92% 8% 87% 8%
Nurse Auxiliary (MCHAides) 80% 97% 0% 97% 0% 97% 0% 90% 3%
Nurse 100% 100% 0% 100% 0% 97% 3% 97% 3%
Anaesthesiologist (MD) 8% 100% 0% 67% 33% 67% 33% 67% 33%
Nurse Anaesthetist 87% 97% 3% 50% 44% 56% 41% 44% 47%
Lab Technician 95% 97% 3% 60% 35% 81% 19% 57% 35%
CHCs/clinics (n=134)
Obstetrician/Gyanecologist 1% 100% 0% 100% 0% 0% 100% 0% 100%
MD (GP) 1% 100% 0% 0% 100% 100% 0% 0% 100%
General surgeon 0% . . . . . . . .
Paediatrician 0% . . . . . . . .
Neonatologist 0% . . . . . . . .
SACHO 0% . . . . . . . .
CHO 88% 98% 2% 66% 31% 79% 20% 54% 42%
Midwife 70% 99% 1% 70% 27% 74% 27% 59% 38%
Nurse Auxiliary (MCHAides) 99% 99% 1% 77% 20% 84% 14% 70% 25%
Nurse 79% 100% 0% 76% 21% 86% 14% 70% 27%
Anaesthesiologist (MD) 0% . . . . . . . .
Nurse Anaesthetist 0% . . . . . . . .
Lab Technician 20% 94% 6% 40% 37% 59% 38% 31% 41%
Note: 1. Columns may not add up to 100% due to rounding and missing information.
6.3 Regulatory policies and practices in performance of EmONC signal functions and other maternity and newborn health services
According to Sierra Leone’s national policies on HR and basic package of essential services, Table 6.3.1A in the appendix provides a national picture of what type of health worker cadre is supported by policy to provide EmONC signal functions and other MNH routine services. It helps to compare this table with Table 6.3.1 to see what the policy allows and what the health workers on the ground (health facilities) are actually doing to provide each EmONC signal function and other MNH service. To interpret what Table 6.3.1A presents, “Y” means the specific cadre is supported by the policy to provide the signal function or routine MNH service indicated in each column, and “N” means the cadre is not supported by the policy to provide that specific EmONC service in the specified health facility level. Accordingly, an obstetrician/gynaecologist is allowed to provide all of the basic and comprehensive EmONC signal functions at the hospital level except giving anaesthesia. The policy supports a midwife in providing all basic EmONC signal functions and the provision of antenatal corticosteroids and immediate newborn care services. As shown in Figure 6.3.1 below, all hospitals and almost all CHCs/clinics had at least one health worker cadre to provide parenteral antibiotics, oxytocics, anticonvulsants, manual removal of placenta and newborn resuscitation. Almost all of the hospitals had HR to provide Evacuation and Curettage or D&C and vacuum extraction. Availability of employees to provide forceps delivery was reported only in 46 per cent of hospitals and 18 per cent of CHCs/clinics.
74
Figure 6.3.1: Percentage of facilities with at least one health worker cadre to provide each of the EmONC signal functions, by facility type, Sierra Leone Rapid EmONC Assessment 2017
Table 6.3.1 below presents the availability of at least one of the health worker cadres, and the performance of each signal function/routine MNH service provided by the specific cadre. To correctly interpret the table, we must see first the percentage of health facilities that have at least one of the cadre present/on staff. Then one should look at the percentage of hospitals or CHCs/clinics with the cadre on staff that performs each signal function (numerator), out of the total percentage of facilities that reported having at least one of the cadres on staff (denominator). For example, 46 per cent of hospitals reported having at least one obstetrician/gynaecologist on staff. Of these hospitals, more than 83 per cent had this cadre providing all of the basic and comprehensive EmONC signal functions except performance of forceps delivery (only 39 per cent of the hospitals provided forceps delivery by this cadre). Almost all of the hospitals had at least oone MD and over 74 per cent of the hospitals with an MD present provided the basic EmONC signal functions with this cadre. SACHOs were available in a little over half of the hospitals and of these, over 90 per cent of the hospitals provided all the EmONC signal functions with this cadre except provision of oxytocics and anticonvulsants, with only 75 per cent of the hospitals providing these two signal functions by this specific cadre.
Midwives are one of the key personnel in hospitals providing such life-saving maternal and newborn signal functions. Ninety-seven per cent of the hospitals had at least one midwife on staff, and all these hospitals provided parenteral antibiotics, parenteral anticonvulsants and newborn resuscitation. Qite a large proportion (over 84 per cent) provided other basic EmONC signal functions and other MNH services by a midwife. A large proportion also provided the two comprehensive EmONC signal functions by SACHO, obstetrician/gynaecologist, MD and a surgeon; this proportion was higher than those provided by the rest of the cadres.
Among CHCs/clinics, CHOs, midwives and nurses are the key staff that provide EmONC signal functions and other MNH services. Eighty-eight, 79 and 70 per cent of the CHCs/clinics reported having at least one CHO, nurse and midwife, respectively. A huge proportion of these CHCs/clinics reported having these cadres provide parenteral drugs, and newborn resuscitation. When it comes to procedures, the proportion of CHCs/clinics that provided these procedural signal functions by a CHO was higher than those providing these services by a midwife or a nurse. Only 1 per cent of CHCs/clinics reported having at least one obstetrician/gynaecologist and an MD. All of these CHCs/clinics provided the majority of the EmONC signal functions by these two cadres. CHCs/clinics did not have a paediatrician, neonatologist, SACHO and anaesthesiologist/nurse anaesthetist that provided any of the EmONC signal fucntions.
Table 6.3.1 also shows hospitals and CHCs/clinics with each cadre present that received training on EmONC and immediate newborn care. In hospitals, midwives were far more likely to be trained in EmONC and immediate newborn care than the rest of the cadres. In CHCs/clinics, all the facilities that reported having an obstetrician/gynaecologist and MD had the cadres trained in EmONC and immediate newborn care. Over 80 per cent of them also reported that they had CHOs, midwives and nurses trained in EmONC and immediate newborn care.
0%
20%
40%
60%
100%
80%
Oxytocic
s
Oxytocic
s
Anti-convu
lsants
Manual remova
l of p
lacenta
E&C or D&C
Vacuum extr
action
Force
ps
Newborn resu
scitat
ion with
...
Cesarean delivery
Blood transfu
sion fo
r the m
other
Hospitals (n=39) CHCs/clinics (n=134)
75
Table 6.3.1: Percentage of facilities that provide EmONC signal functions, by health worker cadre, Sierra Leone Rapid EmONC Assessment 2017
Facilities with at least one of the cadre on
staff
Parenteral drugsProcedures
Cadre trained on:Assisted vaginal delivery
Antibiotics Oxytocics Anti-convulsants
Manual removal
of placenta
Removal of retained products
MVA /Evacuation
and Curettage
Vacuum extraction Forceps
Newborn resuscitation with bag and
mask
Cesarean delivery
Blood transfusion
for the mother
EmONC
Newborn resuscitation with bag and
mask
% n
Hospitals (n=39)
Health worker cadre
Obstetrician/Gynaecologist
46 18 94% 89% 89% 89% 94% 94% 39% 83% 89% 67% 78% 83%
MD (GP) 97 38 97% 76% 79% 79% 74% 74% 32% 79% 63% 68% 63% 71%
General surgeon 51 20 85% 65% 70% 70% 55% 60% 40% 55% 75% 75% 60% 60%
Paediatrician 31 12 75% 33% 67% 25% 25% 25% 25% 83% 17% 33% 33% 75%
SACHO 51 20 95% 75% 75% 90% 95% 90% 35% 90% 90% 90% 75% 75%
CHO 77 30 93% 83% 87% 77% 60% 57% 17% 73% 23% 57% 77% 83%
Midwife 97 38 100% 97% 100% 95% 84% 87% 32% 100% 13% 79% 90% 100%
Nurse 100 39 97% 85% 87% 72% 33% 36% 13% 87% 10% 64% 72% 87%
Anaesthesiologist (MD)/ Anaesthetist
90 35 80% 51% 37% 11% 9% 11% 6% 69% 6% 37% 31% 51%
Lab Technician 95 37 14% 0% 0% 0% 0% 0% 0% 0% 3% 11% 0% 0%
CHCs/clinics (n=134)
Health worker cadre
Obstetrician/Gynaecologist
1% 1 100% 100% 100% 100% 0% 0% 0% 100% 100% 100% 100% 100%
MD (GP) 1% 1 100% 100% 100% 100% 100% 0% 0% 0% 0% 0% 100% 100%
CHO 88% 119 99% 92% 95% 90% 63% 58% 17% 97% 2% 2% 80% 93%
Midwife 70% 93 100% 100% 98% 99% 71% 71% 16% 100% 1% 2% 92% 98%
Nurse 79% 104 99% 98% 98% 71% 23% 23% 5% 93% 1% 2% 63% 90%
Lab Technician 20% 27 4% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0%
In hospitals, the proportion that provided normal delivery by a midwife (100 per cent) and a nurse (85 per cent) was higher than the rest of the cadres. Similarly, the proportion of hospitals that provided the administration of uterotonics by a midwife, SACHO and obstetrician/gynaecologist was higher than the rest. Provision of corticosteroids, FANC, PMTCT and FP by a midwife or a nurse was more common than the rest of the cadres in hospitals.
In CHCs/clinics, CHOs, midwives and nurses were the most common set of cadres that provide other MNH services. The 100 per cent shown for ob/gyn and MD was because of the very small number of denominators (only one ob/gyn and one MD available in a private clinic).
Tables 6.3.4A and 6.3.5A in the appendix present HR to provide EmONC signal functions and other MNH services, by district, in hospitals and CHCs/clinics.
All hospitals had at least one health worker cadre on staff to provide all the basic EmONC signal functions across all districts except in Port Loko where only 75 per cent of the hospitals had an HR to provide removal of retained products and Western Urban where 91 per cent of the hospitals had an HR to provide AVD. HR coverage to provide CS and blood transfusion was universally available in all districts except Bo and Western Urban. All hospitals in all districts had an HR to attend to a normal delivery and to provide corticosteroids for pre-term labour. Provision of immediate newborn care had also 100 per cent HR coverage in all hospitals across all districts, except in Kailahun (50 per cent), Tonkolili (50 per cent) and Western Urban (82 per cent).
76
In CHCs/clinics, HR coverage is available to provide parenteral drugs, manual removal of placenta and newborn resuscitation in almost all districts. Availability of HR to provide AVD and the removal of retained products of conception was higher in Kailahun and Pujehun districts than the rest. Availability of a health worker to provide CS and blood transfusion among CHCs/clinics was concentrated only in Kailahun, Kono and Western Urban districts. Coverage of HR for the provision of other essential services (normal delivery, corticosteroids for preterm labour, FANC, PMTCT and FP) was high in almost all CHCs/clinics in all districts. Provision of immediate newborn care had the least HR coverage among CHCs/clinics in all districts.
6.4 Ratio of midwives to 1,000 institutional deliveries and 10,000 population
To tackle the rising global need for skilled birth attendants, one of the readily available planning benchmarks is the number of midwives available per 1,000 deliveries. This benchmark was derived from the assumption that a midwife can attend an average of 175 births during a typical year36. This workload is more easily conceptualized as six midwives required to provide care for 1,000 births in a year. Table 6.4.1 shows the number of midwives for every 1,000 institutional deliveries in each district. These figures were calculated using the number of institutional deliveries conducted at a facility within the 12-month reference period.
Nationally, the number of midwives per 1,000 institutional deliveries was five, which was less than the international benchmark of six. Only 4 out of the 14 districts met this standard (Western Urban, Koinadugu, Kono and Bombali). The lowest ratio of midwives per 1,000 deliveries was reported in Kenema with two per 1,000 deliveries. The rest of the districts had three to five midwives per 1,000 institutional deliveries.
Table 6.4.1: Number of midwives per 1,000 institutional deliveries and per 10,000 population and number of physicians, midwives and nurses per 10,000 population by district, Sierra Leone Rapid EmONC Assessment 2017
Population1Number of
deliveries in facilities
Number of midwives in
facilities
Number of midwives per 1,000
institutionaldeliveries 2
Number of midwives per 10,000
population2
Number of physicians,
midwives, and nurses in all
facilities
Number of physicians, midwives,
and nurses per 10,000
population 2
National 7,296,402 104,713 478 5 0.7 2,670 4
District
Kailahun 541,202 5,699 19 3 0.4 101 2
Kenema 629,457 9,684 24 2 0.4 270 4
Kono 522,301 3,735 21 6 0.4 63 1
Bombali 624,084 6,473 36 6 0.6 176 3
Kambia 355,469 4,651 18 4 0.5 52 1
Koinadugu 421,212 2,895 19 7 0.5 51 1
Port Loko 633,166 7,332 20 3 0.3 89 1
Tonkolilii 546,812 4,410 24 5 0.4 86 2
Bo 593,160 12,642 41 3 0.7 404 7
Bonthe 204,349 3,001 14 5 0.7 37 2
Moyamba 328,373 6,241 23 4 0.7 83 3
Pujehun 357,105 5,015 17 3 0.5 62 2
Western Rural 450,755 12,065 47 4 1.0 241 5
Western Urban 1,088,957 20,871 156 7 1.4 956 9
Note: 1. Source of Population Estimates: Statistics Sierra Leone. October 2017; ‘Sierra Leone 2015 Population and Housing Census - Thematic Report on Population Projections’, Freetown Sierra Leone.2. Source of information: World Health Organization. 2010. ‘Monitoring the building blocks of health systems: a handbook of indicators and their measurement strategies’.
36 United Nations Population Fund. 2011. The State of the World’s Midwifery. New York: United Nations Population Fund
77
According to WHO’s handbook of monitoring the building blocks of health systems, the number of health workers per 10,000 population by cadre is the health workforce indicator that is most commonly reported internationally and helps to understand the workforce stock of a country, Table 6.4.1 above and Figure 6.4.1 below show the ratio of midwives alone, and physicians, midwives, and nurses combined, per 10,000 population.37 The international benchmark for the combined cadre is 23 per 10,000 population. With this assumption, the national and district-level proportion of midwives per 10,000 population was observed as below one. Only Western Urban and Rural had one midwife per 10,000 populations. Similarly, the number of physicians, midwives and nurses per 10,000 population was not also met anywhere in the country. The national combined figure was four, with the highest ratio in Western Urban (nine physicians, midwives and nurses per 10,000 populations), followed by Bo (seven per 10,000 population). The lowest number was recorded in Kono, Kambia, Koinadugu and Port Loko.
Figure 6.4.1: Ratio of midwives per 1,000 deliveries, and physicians, midwives and nurses combined per 10,000 population, by district, Sierra Leone Rapid EmONC Assessment 2017
37. World Health Organization. 2010. Monitoring the building blocks of health systems: a handbook of indicators and their measurement strategies. Geneva: WHO.
0
3
6
9
12
15
18
21
24
Weste
rn Urban Bo
Weste
rn Rural
Kenema
National
Bombal i
Moyamba
Bonthe
Pujehun
Tonkolili
Kambia
Portloko
KoinaduguKono
Kailahun
Number of midwives per 1,000 deliveries (standard = 6)
Number of physicians, midwives, and nurses per 10,000 population (standard = 23)
78
CHAPTER 7AVAILABILITY OF DRUGS, EQUIPMENT AND SUPPLIES
79
A continuous and uninterrupted availability of drugs, medical supplies and equipment is the cornerstone of quality service delivery.38,39 A service availability and readiness assessment in six countries including Sierra Leone indicated that lack of access to essential medicines and supplies was one of the main obstructions to service delivery in low- and middle-income countries40. This chapter describes the availability of essential drugs, medical supplies and equipment in the pharmacy, labour and delivery or maternity, OT and laboratory wards.
7.1 Management and stock-out of drugs
As shown in Table 7.1.1A in the appendix and Figure 7.1.1 below, all of the facilities had a pharmacy or supply of medicines. Nationally, 94 per cent of the facilities had a drug inventory register. Of these, 90 per cent had the register up-to-date. All hospitals had a drug inventory register and it was up-to-date. Ninety-five per cent of CHCs and 77 per cent of clinics had the register; while over 86 per cent of CHCs and clinics had the register up-to-date.
Figure 7.1.1: Percentage of facilities with a pharmacy/supply of medicines, with a drug inventory register, and whose drug inventory register was up-to-date, by type of facility, Sierra Leone Rapid EmONC Assessment 2017
Table 7.1.1A also describes the source of medicines, gloves, syringes and medical and infection prevention supplies. For a large majority of the facilities, the government was the major source of medicine supplies. A similar proportion of the facilities reported the government as the primary source of gloves, syringes, medical and infection prevention supplies. For medicines, very few of the facilities cited private pharmacy (3 per cent), and NGO/mission organizations (3 per cent) as a primary source. Except hospitals which were mostly private and cited private facilities or NGOs/mission, the rest of the facilities received medicines, gloves, syringes and supplies from government suppliers.
When medicines are ordered
Table 7.1.2A in the appendix reveals different ordering schedules for medicines in the pharmacy, labour and delivery, maternity wards and OT. In the pharmacy, 84 per cent of the facilities ordered drugs and supplies each week/month/quarter of the year and 9 per cent ordered whenever stock reached a reorder level.In the labour and delivery, and maternity wards, 72 per cent and 69 per cent of the facilities ordered drugs and supplies every week/month or quarter for each ward, respectively. Twelve per cent of the facilities ordered drugs and supplies in the maternity ward on a patient-by-patient basis.In the OT, close to two thirds of the facilities ordered each week, month and quarter; nearly a quarter of them ordered whenever stocks ran out. Clinics also had the same ordering schedules (when stocks ran out) for drugs. 38 World Health Organization. 2007. ‘Everybody’s business. Strengthening health systems to improve health outcomes. WHO’s framework for action’. 39 World Health Organization. 2002. ‘WHO Policy Perspectives on Medicines 5: Promoting rational use of medicines: core components’. WHO/EDM/2002.3, http://apps.who.int/iris/bitstream/10665/67438/1/WHO_EDM_2002.3.pdf, accessed 21 May 2018.40 Kathryn O’Neill, et al. 2013. “Monitoring service delivery for universal health coverage: the Service Availability and Readiness Assessment,” Bulletin of the World Health Organization 91(12):923-931. doi:10.2471/BLT.12.116798.
0%
20%
40%
60%
100%
80%
All facil
ities
National/M
aternity...
Regional H
ospita
l
Distric
t Hosp
ital
Other Hosp
ital
CHCsClin
ics
Has a pharmacy/drug store/supply of medicineHas drug inventory register (among facilities with a pharmacy/supply of medicine)Drug inventory register is up-to-date (among facilities with a drug inventory register)
80
Common causes of delays in delivery of supplies
As Table 7.1.3A in the appendix and Figure 7.1.2 below show, the most common cause of delay in the supply of medicines was stock-out at the central store (45 per cent), followed by administrative difficulties (21 per cent) in hospitals. In CHCs/clinics, inadequate transport (45 per cent) and stock-out at the central store (40 per cent) were the two most common causes of delays.
In government-owned hospitals, the most common reason was stock-out at the central store (67 per cent) while for CHCs/clinics, inadequate transport was the main reason (44 per cent). Similarly, for private for-profit hospitals, finances (40 per cent) was the most dominant problem while for CHCs/clinics it was inadequate transport (55 per cent). Among private not-for-profit hospitals, inadequate transport, administrative difficulties, and financial problems were equally dominant. However, for non-profit CHCs/clinics, stock-out at the central store (47 per cent) was the main reason for the delay of deliveries medicines and supplies.
Figure 7.1.2: Percentage distribution of facilities with a pharmacy or supply of medicines that reported most common causes of delays in delivery of medicines and supplies by facility type and operating agency, Sierra Leone Rapid EmONC Assessment 2017
Access to pharmacies and pharmacy-related items
Out of the total facilities with a pharmacy or supply of medicines, 94 per cent of them had their pharmacies accessible 24 hours a day and seven days a week (24/7). National/maternity hospitals and all hospitals (regional and others) had a 24/7 accessible pharmacy. However, only 81 per cent of the clinics had a 24/7 accessible pharmacy (Table 7.1.1).
All hospitals and clinics used a “first-expired-first-out” drug supply management system. However, 97 per cent of the CHCs reported that they used this system of drug management, leaving a gap of 3 per cent that was not clear what drug management system they were using other than “first-expiry-first-out”. Despite this gap, all of the facilities reported that a regular mechanism existed that ensured expired drugs were not distributed.
Almost all types of health facilities reported that there was a mechanism in place to protect drugs from moisture, heat or infestation. Four in five facilities indicated that they refrigerated required drugs like oxytocin. But such a practice was low among clinics, in which they might not have such drugs in stock.
Inadequate transport Financial problems
Stock out at central store
20% 40% 60% 80% 100%0%
Government (n=123 )
All hospitals (n=38)
Government (n=21 )
Hospitals
CHCs/clinics
All CHCs /clinics (n=134 )
81
Nationally, among the facilities that reported they refrigerated required drugs, only 43 per cent had an electric or gas-powered refrigerator and 88 per cent had a solar-powered refrigerator. Solar-powered refrigerators were more common among clinics and CHCs than the rest of the facilities.
Table 7.1.1: Percentage of facilities with a pharmacy or supply of medicines that reported on pharmacy-related items, by facility type, Sierra Leone Rapid EmONC Assessment 2017
All facilities (n=172)1
National/ maternity
hospital (n=1)Regional
hospital (n=3) Districthospital(n=17)
Other hospital(n=17
CHCs(n=124)
Clinics(n=10)
Pharmacy is accessible 24 hours a day 94% 100% 100% 94% 100% 95% 81%
"First-expired-first-out" system in use1 97% 100% 100% 100% 100% 97% 100%
Regular mechanism exists to ensure that expired drugs are not distributed
100% 100% 100% 100% 100% 100% 100%
Drugs are protected from moisture, heat or infestation1
98% 100% 100% 100% 100% 97% 100%
Required drugs are refrigerated (e.g., oxytocin) 82% 100% 100% 88% 88% 88% 15%
Among facilities storing required drugs in functioning refrigerator:
Power source of main refrigerator storing drugs
Electricity/Gas 43% 100% 100% 73% 87% 36% 100%
Solar 88% 0% 50% 40% 73% 93% 100%
Note: 1. One private hospital didn't have a supply of medicine.2. 'Other hospitals' include private-for-profit, NGO and faith-based.
Stock-out of some essential drugs
Looking at the stock-out of essential drugs – antibiotics, magnesium sulphate, oxytocin, ketamine, and atropine – in the last 12 months, Table 7.1.5A in the appendix and Figure 7.1.3 show that a third of the facilities experienced a stock-out of antibiotics in the last 12 months. The highest stock-out of antibiotics was reported from other hospitals. There was no stock-out at the national/maternity hospital.
Magnesium sulphate was stocked out in one fifth of the facilities at the national level. Two of the three regional hospitals experienced a stock-out of magnesium sulphate in the last 12 months prior to the survey. Eight per cent of clinics and 6 per cent of other hospitals never had a supply of magnesium sulphate in the specified reference period. Oxytocin was stocked out in only 17 per cent of the total facilities and 1 per cent of them never had oxytocin in the last 12 months. Like magnesium sulphate, two of the three regional hospitals had a stock-out of oxytocin. It was more stocked out at the time of the survey than the previous year prior to the survey.
Nationally, ketamine was stocked out in only 19 per cent of the facilities. Nearly three fourths (81 per cent of CHCs and 79 per cent of clinics) of the facilities reported that they never had ketamine. Atropine was also stocked out in a quarter of the facilities.
In general, most of the facilities had stocked out of essential drugs at the time of the survey than the time previous period over a year.
82
Figure 7.1.3: Percentage of facilities with a pharmacy or supply of medicines that reported stock-out of some essential drugs in the last 12 months, Sierra Leone Rapid EmONC Assessment 2017
7.2 Availability of essential drugs
Tables 7.2.1A to 7.2.3A in the appendix and Figure 7.2.1 below present a glimpse of availability of drugs used for EmONC signal functions and other MNH services.
Antibiotics: Ninety-one per cent of the facilities (all hospitals and 90 per cent of CHCs/clinics) had one or more antibiotics related to EmONC signal functions and emergencies. Amoxicillin (86 per cent) was the most widely stocked antibiotic in all facilities, followed by ceftriaxone (76 per cent), and erythromicin (66 per cent). Clindamycin (7 per cent) and cephazoline sodium (9 per cent) were the least available antibiotics. Cefaxime (11 per cent), oral fluctoxacillin (for newborns) (11 per cent), cefotaxime injection (for newborns) (15 per cent) and chloramphenicol (injection) (16 per cent) were also the least available antibiotics in all facilities.
Anticonvulsants: Nationally, 96 per cent of the facilities (all hospitals, 97 per cent of CHCs and 79 per cent of clinics) had one or more anticonvulsants. Diazepam – injection (91 per cent) and magnesium sulphate – injection (89 per cent) were the two most commonly available anticonvulsants in all facilities.
Antihypertensives: Eighty-seven per cent of the facilities (all national and regional hospitals, 94 per cent of district hospitals, 88 per cent of other hospitals and CHCs, and 79 per cent of clinics) stocked one or more antihypertensives. Methyldopa (94 per cent) was widely available while labetalol (8 per cent) was the least available antihypertensive in all facilities.
Oxytocics/prostaglandins: Nationally, 96 per cent of the facilities (all hospitals, 97 per cent of CHCs, and 79 per cent of clinics) had one or more oxytocics. Oxytocin was widely available in 92 per cent of the facilities. Prostaglandin was the least available (only 4 per cent of the facilities stocked it). Misoprostol was available in only 34 per cent of the facilities.
Drugs used in emergencies: Nationally, 95 per cent of the facilities (all hospitals, 96 per cent of CHCs and 70 per cent of clinics) had one or more drugs used in emergencies. The most commonly stocked drugs were promethazine and adrenaline found in 82 per cent and 80 per cent of the facilities, respectively. Naloxone was the least available drug, stocked in only 5 per cent of the facilities, followed by nitroglycerine (6 per cent) and diphenhydramine (7 per cent).
Table 7.2.2A presents the percentage of facilities stocking anaesthetics, analgesics, tocolytics, steroids, IV fluids, antimalarial and ARV drugs. Anaesthetics were stocked in 82 per cent of facilities. Lignocaine/lidocaine was the most commonly stocked anaesthetic, available in almost all facilities while halothane was only available in 6 per cent of facilities. Analgesics were available in 83 per cent of facilities. The most widely available analgesic was paracetamol, which was found in 89 per cent of the facilities; pethidine was the least available – found only in 8 per cent of the facilities. Tocolytics were stocked in only a quarter of facilities. Salbutamol was the most commonly stocked tocolytic, available in 85 per cent of facilities (all hospitals and clinics and 74 per cent of CHCs). Steroids were available in 79 per cent of facilities and the most commonly stocked steroid was dexamethasone injection, available in 73 per cent of facilities.
10% 20% 30% 40%0%
Oxytocin
Magnesium sulf ate
Magnesium sulf ate
Atropine
Antibiotics 37%
25%
21%
19%
17%
83
Overall, 92 per cent of health facilities had one or more IV fluids. Glucose 5 per cent (89 per cent) and normal saline (85 per cent) were the most widely available IV fluids; dextran (15 per cent) was the least available. Nationally, 92 per cent of health facilities had one or more antimalarial drug. Fansidar was the most widely available antimalarial drug; found in 94 per cent of the facilities. Chloroquine was the least and found in only 7 per cent of facilities – none of the national/maternity, regional and district hospitals had chloroquine. ARV drugs were found in 84 per cent of the facilities with combined ARVs for the mother as the most commonly available drug and combined ARVs for the newborn as the least available. The national/maternity hospital had none of the ARVs except nevarapine for the mother and the baby (Table 7.2.2A).
Figure 7.2.1: Percentage of facilities that had drugs related to the signal functions and emergencies, and anaesthetics and other drugs, Sierra Leone Rapid EmONC Assessment 2017
Table 7.2.1 below shows the percentage of facilities that had selected contraceptives and other drugs and supplies in stock on the day of the survey. Nationally, almost all of the facilities had one or more modern contraceptive methods in stock. Eighty-nine per cent of the facilities had a male condom, 77 per cent had implants, 73 per cent had oral contraceptives, 62 per cent had female condoms, 59 per cent had intrauterine devices (IUDs) and 53 per cent had a three-month injectable contraceptive in stock. Emergency contraception was available in two thirds of the facilities. Emergency contraception was available in only one of the three regional hospitals.
Table 7.2.1 also presents the percentage of facilities stocking other drugs. Most of the facilities had insecticide-treated bed nets (93 per cent), oral rehydration solution (87 per cent), tetanus toxoid vaccine (86 per cent), and ferrous sulphate or fumarate (83 per cent). The least stocked drugs in this category were anti RhO (D) immunoglobulin (5 per cent), heparin (9 per cent) and sodium citrate (10 per cent). Vitamin K (for newborns) was stocked in only 35 per cent of facilities. It was available in national/maternity, all district and all other hospitals. However, vitamin K was available in only a quarter of CHCs, 38 per cent of clinics and two of the three regional hospitals. Gentian violet paint, sodium citrate, anti-tetanus serum and anti-Rhesus (D) immunoglobulin were not available in national/maternity and regional hospitals.
25% 50% 75% 100%0%
Oxytocics 96%
Anticonvulsants
Drugs used in eme rgencies
Antibiotics
Antihypertensives
96%
95%
91%
87%
Antiretrovirals
Anesthetics
Steroids
Tocolytics
84%
Analgesics 83%
Antimalarial s 92%
IV Fluid s 92%
82%
75%
25%
ANAESTHETICS AND OTHER DRUGS
DRUGS FOR SIGNAL FUNCTIONS AND…
84
Table 7.2.1: Percentage of facilities with a pharmacy or supply of medicines that had contraceptives and other drugs, by type of facility, Sierra Leone Rapid EmONC Assessment 2017
All facilities n=1721
National/ maternity hospital
n=1
Regional hospital
n=3
Districthospital
n=17 Other hospital
n=17 CHCsn=124
Clinics n=10
Contraceptives (any) 98% 100% 100% 94% 94% 99% 100%
Combined oral contraceptives 73% 0% 67% 94% 50% 72% 82%
Implants 77% 100% 67% 88% 50% 81% 47%
3-month injectables 53% 100% 33% 100% 50% 48% 69%
IUDs 59% 100% 0% 81% 31% 63% 26%
Male condoms 89% 100% 67% 94% 88% 90% 79%
Female condoms 62% 100% 0% 56% 56% 68% 18%
Emergency contraception 66% 100% 33% 81% 50% 68% 52%
Other drugs
Vitamin K (newborn) 35% 100% 67% 100% 100% 25% 38%
Nystatin (oral) 76% 0% 100% 88% 77% 79% 37%
Oral rehydration solution 87% 100% 67% 100% 94% 85% 90%
Gentian violet paint 23% 0% 0% 29% 59% 21% 18%
Ferrous sulfate or fumarate 83% 100% 100% 88% 100% 82% 69%
Folic acid 76% 100% 100% 94% 100% 73% 69%
Heparin 9% 100% 0% 41% 41% 6% 0%
Magnesium trisilicate 66% 100% 100% 100% 71% 65% 47%
Sodium citrate 10% 0% 0% 24% 29% 9% 0%
Anti-tetanus serum 18% 0% 0% 35% 41% 15% 26%
Tetanus toxoid vaccine 86% 0% 33% 59% 82% 89% 83%
Anti-Rho (D) immune globulin 5% 0% 0% 12% 29% 4% 0%
Insecticide-treated bednets (ITNs) 93% 100% 0% 65% 77% 98% 91%
Note: 1. One private hospital didn't have a supply of medicine. 2. 'Other hospitals' include private-for-profit, NGO and faith-based.
7.3 Availability of materials, equipment, supplies and guidelines in labour and delivery, and maternity wards
Materials for infection prevention
Table 7.3.1 below presents availability of materials for infection prevention in the labour and delivery ward. A great majority (more than 90 per cent) had gloves, a trash bin, a covered trash bin for contaminated waste, a puncture-proof sharps container, heavy-duty gloves and a decontamination container. The least available infection prevention material was a mayo stand to establish a sterile field, found in only 38 per cent of the facilities. Chlorhexidine was the most widely available disinfectant, found in 91 per cent of facilities.
The national/maternity hospitals and most regional, district and other hospitals had all the infection prevention materials and disinfectants.
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Table 7.3.1: Percentage of facilities that have the indicated materials for infection prevention in the maternity area, by type of facility, Sierra Leone Rapid EmONC Assessment 2017
All facilities
n=1721
National/ maternity hospital
n=1
Regional hospital
n=3
Districthospital
n=17
Otherhospital
n=17
CHCs
n=124
Clinics
n=10
Basic items
Soap 86% 100% 67% 88% 100% 84% 100%
Antiseptics 82% 100% 67% 88% 100% 85% 45%
Gloves 98% 100% 100% 94% 100% 97% 100%
Heavy duty gloves 91% 100% 100% 94% 94% 89% 100%
Non-sterile protective clothing 85% 100% 100% 77% 89% 85% 79%
Decontamination container 91% 100% 100% 94% 89% 91% 92%
Bleach or bleaching powder 61% 100% 67% 94% 83% 60% 29%
Prepared disinfection solution (Berekina) 80% 100% 33% 94% 78% 82% 53%
Regular trash bin 97% 100% 100% 100% 100% 98% 90%
Covered contaminated-waste trash bin 96% 100% 100% 100% 100% 95% 92%
Puncture proof sharps container 96% 100% 100% 100% 100% 95% 100%
Mayo stand to establish sterile field 38% 100% 33% 71% 78% 35% 16%
Disinfectants and antiseptics
Chlorhexidine 91% 100% 100% 94% 78% 91% 90%
Ethanol 26% 100% 33% 47% 33% 25% 11%
Povidone iodine 83% 100% 67% 88% 89% 83% 81%
Note: 1. For hospitals, the maternity area is likely to be a specific room and these questions are related to the infection prevention items available in that specific room. Health centres may not have a specific room devoted for a maternity and these questions are therefore related to whether the facility, in general, has the infection prevention items available. 2. 'Other hospitals' include private for-profit, NGO and faith-based.
Guidelines and protocols
As shown in Figure 7.3.1 and Table 7.3.1A in the appendix, over 90 per cent of facilities had FANC, HIV PMTCT (maternal and newborn dosing), immediate newborn care, infection prevention for HIV/AIDS, and FP guidelines. Eighty-seven per cent had guidelines for management of obstetric and newborn complications, and 69 per cent had KMC guidelines. Safe abortion and post-abortion care guidelines were available in 51 per cent and 71 per cent of the facilities, respectively. Despite the fact that all facilities were expected to have all of these guidelines and protocols, safe and post-abortion care and FP guidelines were not available in the national/maternity hospital.
86
Figure 7.3.1: Percentage of facilities that had indicated MNH guidelines, Sierra Leone Rapid EmONC Assessment 2017
Supplies and equipment for newborns
Immediate newborn care should be provided to newborns in all settings as part of essential newborn care. These include warming, drying, stimulation, hygiene and thermal care. These are the first and immediate steps in neonatal resuscitation and these interventions require availability of adequate functional equipment and supplies. In line with this, Table 7.3.2A in the appendix and Figure 7.3.2 below present availability of supplies and newborn resuscitation equipment. A foetal stethoscope was available in almost all health facilities (97 per cent), a baby-weighing scale was found in 89 per cent of facilities and a neonatal resuscitation table was available in 86 per cent of the facilities. The least available equipment/supplies were fluorescent tubes for phototherapy, found only in district and other hospitals (2 per cent), and the icterometer, found in 3 per cent of facilities.
The neonatal resuscitation pack consists of essential basic equipment to ensure adequate resuscitation of the newborn: mucus extractor, infant facemasks ambu (ventilatory) bag, suction catheter, suction apparatus and mucus trap for suction. Over 90 per cent of the facilities had a mucus extractor, infant face masks (sizes 0,1,2) and an ambu (ventilator) bag. The least available equipment for newborns was the infant laryngoscope (9 per cent) and neither the regional hospitals nor the national/maternity hospital had this equipment. Suction catheter, disposable uncuffed tracheal tubes, and suction apparatus were not available in the national/maternity hospital.
Figure 7.3.2: Percentage of facilities with selected newborn resuscitation pack, Sierra Leone Rapid EmONC Assessment 2017
20% 40% 60% 80% 100%0%
Safe abortion
Kangaroo mother care (KMC)
Postabortion care
Management of obstetric and newborn…
Infection prevention for HIV/AIDS…
Immediat e newborn ca re
HIV PM TCT (maternal and newborn dosing )
Focused ant enatal car e
Family plannin g
51%
69%
71%
87%
91%
92%
92%
93%
93%
20% 40% 60% 80% 100%0%
Infant laryngoscope wit hspare bulb & ba teries
tubes (siz es 2.0 to 3.5)
Endotracheal tubes 3.5, 3.0
Suction appa ratus: Foot –or electrically -operated
Mucus tr ap for suction
Suction cathet er 10, 12 Ch
Infant face masks (sizes 0, 1, 2 )
Ambu ( Ventilatory) ba g
Mucus extractor
9%
11%
19%
27%
46%
79%
90%
96%
96%
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Basic diagnostic, resuscitation equipment and supplies for other procedures in the maternity area
As shown in Table 7.3.3A in the appendix, 96 per cent of the facilities had stethoscopes and a WHO-modified partograph. Blood pressure apparatus was also found in 86 per cent of facilities. The national/maternity hospital had all the diagnostics indicated except blood sugar testing sticks and pulse oximeter, that were not found in the hospital. Most CHCs had the indicated diagnostic materials/equipment except ultrasound equipment, pulse oximeter and blood sugar testing tubes, which were found in very low proportion of the CHCs (9 to 17 per cent).
Table 7.3.3A also describes supplies available in the maternity area. Kidney basins, scissors, syringes (1ml, 2ml, 5ml, 10ml), HIV rapid test kits, urinary catheters, IV cannulae, measuring tape, sponge bowls, needles and syringes (10–20cc), catheter for IV line, IV infusion stand, dressing forceps and a watch or clock were present in more than 80 per cent of health facilities. A surgeon’s hand brush with nylon bristles and nasogastric tubes were found in fewer than half of the facilities.
As Table 7.3.2 below shows, nationally, only one fifth of the facilities had episiotomy/perinatal/vaginal/cervical repair packs or sets. The full set was not available in the national/maternity hospital; they were missing sponge (ring) forceps, stitch scissors, and dissecting forceps (toothed). The most widely available equipment in this set in the maternity or labour and delivery wards was the artery forceps (large/small) (86 per cent) and the least available was the vaginal speculum (cusco – Hamilton Bailey ) found in 45 per cent of facilities.
Among the equipment used for AVD, the vacuum extractor with different size cups was widely available, found in 45 per cent of the facilities. The least available equipment was obstetric forceps (breech), available only in 13 per cent of facilities. The proportion of facilities with an AVD set or pack was very low as only 12 per cent of them had it. None of the equipment in the set was available in the national/maternity hospital (Table 7.3.2).
Table 7.3.2 also shows equipment used for uterine evacuation. Only 10 percent of facilities had the full set. Again, the national/maternity hospital lacked the full set, it had only the vaginal speculum (Sims), sponge (ring) forceps or uterine packing forceps, and uterine forceps (Vulsellum Downs 241 mm s/s). Vaginal speculum (Sims), sponge (ring) forceps or uterine packing forceps were the most widely available uterine evacuation equipment in all facilities. Among the equipment for MVA (removal of retained products of conception), vacuum aspirators or syringes were the most widely available found in 51 per cent of the facilities. Only 8 per cent of facilities had the MVA set or pack, there were none in the maternity hospital and clinics, and only 5 per cent of the CHCs had it.
Table 7.3.2: Percentage of facilities with items for cervical/perineal repair pack and equipment for other procedures in the maternity area, by type of facility, Sierra Leone Rapid EmONC Assessment 2017
All facilities
(n=172)1
National/ maternity hospital
(n=1)
Regional hospital
(n=3)
Districthospital(n=17)
Other hospital
(n=17)
CHCs
(n=124)
Clinics
(n=10)
Episiotomy/perineal/vaginal/cervical repair pack
Sponge (ring) forceps 73% 0% 100% 94% 89% 71% 74%
Artery forceps large/small 86% 100% 100% 94% 100% 85% 84%
Needle holder 74% 100% 100% 94% 83% 74% 53%
Sutures 50% 100% 100% 94% 83% 46% 29%
Stitch scissors 57% 0% 67% 88% 72% 55% 38%
Dissecting forceps, toothed 69% 0% 67% 88% 83% 68% 53%
Vaginal speculum, large (Sims) 60% 100% 100% 94% 72% 58% 47%
Vaginal speculum, Cusco (Hamilton Bailey) 45% 100% 100% 77% 67% 39% 55%
% facilities with all items above 20% 0% 33% 65% 56% 14% 21%
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Table 7.3.2: Percentage of facilities with items for cervical/perineal repair pack and equipment for other procedures in the maternity area, by type of facility, Sierra Leone Rapid EmONC Assessment 2017
All facilities
n=1721
National/ maternity hospital
n=1
Regional hospital
n=3
Districthospital
n=17
Other hospital
n=17CHCs
n=124
Clinics
n=10
Vacuum extraction / forceps delivery
Vacuum extractor with different size cups 73% 0% 100% 94% 89% 71% 74%
Obstetric forceps, outlet 86% 100% 100% 94% 100% 85% 84%
Obstetric forceps, mid-cavity 74% 100% 100% 94% 83% 74% 53%
Obstetric forceps, breech 50% 100% 100% 94% 83% 46% 29%
% facilities with vacuum extractor, outlet and mid-cavity forceps
57% 0% 67% 88% 72% 55% 38%
Uterine evacuation
Vaginal speculum (Sims) 51% 100% 100% 94% 67% 49% 32%
Sponge (ring) forceps or uterine packing forceps 48% 100% 100% 82% 67% 46% 21%
Dissecting forceps, serrated jaws 250 mm s/s 41% 0% 100% 77% 67% 38% 21%
Towel clip 27% 0% 100% 65% 61% 23% 11%
Ovum forceps, green haigh 240 mm s/s 21% 0% 100% 53% 39% 16% 30%
Uterine forceps Vulsel Teales 3x4 teeth curved s/s
28% 0% 67% 59% 50% 23% 30%
Uterine forceps Vulsellum Downs 241 mm s/s 26% 100% 100% 53% 50% 21% 30%
Uterine dilators, sizes 13-27 (French) 27% 0% 100% 77% 50% 21% 21%
Sharp uterine curettes, size 0 or 00 22% 0% 100% 59% 56% 16% 21%
Blunt uterine curettes, size 0 or 00 21% 0% 100% 59% 50% 16% 21%
Uterine sound 27% 0% 67% 65% 39% 24% 21%
% facilities with all items above 10% 0% 67% 35% 22% 7% 11%
MVA
Vacuum aspirators/syringes 51% 100% 100% 82% 39% 54% 0%
Silicone lubricant (for lubricating O-ring) 22% 0% 33% 65% 44% 20% 0%
Other oil (for lubricating O-ring) 19% 0% 33% 35% 44% 18% 0%
Flexible cannulae, 4 – 6 mm 41% 100% 100% 77% 50% 40% 15%
Flexible cannulae, 7-12 mm 38% 100% 100% 77% 50% 36% 15%
% facilities with syringes, one type of lubricant, and all cannulae
8% 0% 33% 29% 39% 5% 0%
Note: 1. For hospitals, the maternity area was likely to be a specific room and these questions were related to the items available in that specific room. Health centres may not have had a specific room devoted to maternity and these questions were therefore related to whether the facility, in general, had the items available. Note, however, that the MVA equipment for both hospitals and health centres could have been located anywhere in the facility. 2. 'Other hospitals' include private for-profit, NGO and faith-based.
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Table 7.3.3 below describes the percentage of facilities that had separate equipment in each category and delivery set/pack, a dressing instrument set and gynaecological equipment. Almost all of the facilities had at least one complete delivery set. Cord ties, gloves, long gloves, gauze swabs, cord-cutting scissors, and kocher’s artery forceps (18cm CVD) were the most widely available supplies and equipment in the delivery set, found in over 86 per cent of the facilities. Among the dressing instrument sets, the gally pot (s/s), scissors (sharp point straight 120 mm s/s), and dissecting forceps (Lane’s 1x2 teeth 140 mm) were the most widely available equipment, found in 82 per cent, 77 per cent and 74 per cent of the facilities, respectively. Dressing instruments were mostly available in the national/maternity hospital. Fewer than 48 per cent of the facilities had all of the gynaecological equipment.
In general, the national/maternity hospital had a chronic shortage of equipment and supplies used for providing basic and comprehensive EmONC signal functions.
Table 7.3.3: Percentage of facilities with delivery and dressing instrument items, and gynaecological equipment in the maternity area, by type of facility, Sierra Leone Rapid EmONC Assessment 2017
All facilities
n=1721
National/ maternity hospital
n=1
Regional hospital
n=3
Districthospital
n=17
Other hospital
n=17
CHCs
n=124
Clinics
n=10
Delivery pack set
Kocher’s artery forceps 18 cm CVD 86% 100% 100% 94% 100% 85% 84%
Sponge (ring) forceps 73% 0% 100% 94% 89% 71% 74%
Dissecting forceps standard pattern 145 mm s/s
73% 0% 100% 88% 89% 70% 82%
Pean artery forceps straight, 140 mm s/s 63% 0% 33% 94% 78% 60% 74%
Cord-cutting scissors curved 135 mm s/s 89% 100% 100% 94% 83% 89% 92%
Cord ties 99% 100% 100% 100% 100% 100% 85%
Episiotomy scissors, angular, 145 mm s/s 73% 0% 67% 88% 83% 73% 55%
Straight stitch scissors 135 75% 100% 67% 94% 83% 73% 82%
Gloves 98% 100% 100% 100% 100% 99% 90%
Long gloves 94% 100% 100% 100% 94% 95% 79%
Plastic sheeting 87% 100% 100% 88% 94% 86% 90%
Gauze swabs 93% 100% 100% 88% 89% 92% 100%
Cloth 51% 100% 100% 65% 78% 47% 55%
Percentage of facilities with at least 1 complete delivery set
99% 100% 100% 100% 100% 99% 100%
Number of complete delivery sets (unweighted total)
462 8 15 63 77 281 18
Dressing instrument set
Gally pot s/s 82% 100% 100% 82% 78% 84% 65%
Dissecting forceps Lane’s 1x2 teeth 140 mm 74% 0% 100% 77% 78% 72% 92%
Needle holder, Mayo hegar’s 180 mm s/s 71% 100% 100% 94% 83% 69% 63%
Scissors, sharp point straight 120 mm s/s 77% 100% 100% 94% 78% 74% 92%
Scissors, Metzenbalem flat s/s curved 180 mm 67% 100% 67% 88% 78% 65% 63%
Sponge (ring) forceps 60% 0% 100% 88% 72% 55% 74%
Artery forceps, Halstead, mosquito 130 mm straight s/s
59% 0% 100% 88% 78% 53% 74%
90
Table 7.3.3: Percentage of facilities with delivery and dressing instrument items, and gynaecological equipment in the maternity area, by type of facility, Sierra Leone Rapid EmONC Assessment 2017
All facilities n=1721
National/ maternity hospital
n=1
Regional hospital
n=3
District hospital
n=17
Otherhospital2
n=17
CHCs
n=124
Clinics
n=10
Gynaecological equipment
SIMS or other type vaginal speculum 48% 100% 67% 77% 83% 42% 57%
Cuscos or other type speculum, virgin size 75x17 mm
33% 100% 67% 71% 67% 26% 45%
Cuscos or other type speculum, sm., heavy pattern 80x32mm
38% 100% 67% 77% 67% 33% 36%
Uterine sound, uterine Horrock’s graduated 305 mm s/s
27% 0% 100% 65% 67% 21% 21%
Tenaculum 30% 100% 100% 77% 67% 27% 0%
Scissors, straight, sharp 145 mm s/s 46% 100% 67% 77% 78% 42% 34%
Note: 1. For hospitals, the maternity area was likely to be a specific room and these questions were related to the items available in that specific room. Health centres may not have had a specific room devoted to maternity and these questions were therefore related to whether the facility, in general, had the items available. 2. ‚Other hospitals’ include private for-profit, NGO and faith-based.
Autoclave room equipment
Availability of an autoclave, sterilization equipment and an incinerator is shown in Table 7.3.4A . An autoclave (with temperature and pressure gauges) was found in over half of the facilities and CHCs although fewer than one fifth of the facilities had a separate autoclave room. All regional hospitals and the national/maternity hospital had a separate autoclave room while clinics did not and very few CHCs did. A hot air sterilizer (dry oven), steam sterilizer/pressure cooker (kerosene or electric heated), and sterilization drum stand were found in less than 20 per cent of all facilities. A functioning incinerator was available in close to four fifth of the facilities. Availability of an incinerator was low in clinics, found only in 27 per cent of them.
Furniture and amenities
Table 7.3.4 below presents selected furniture and amenities in the maternity ward. Nationally, beds were widely available, available in 95 per cent of facilities, followed by the examination table (77 per cent). A filled oxygen cylinder and stretcher with trolley were the least available amenity, found in 14 per cent and 21 per cent of the facilities, respectively. A large majority of the facilities (96 per cent) had empty beds clean and ready for the next patients. Regarding availability of number of beds, 71 per cent of the facilities had one to five beds in storage and over a quarter of the facilities had more than five beds in storage. Quite a low proportion of the facilities (17 per cent) mentioned that facilities provided food to patients. Provision of food was not a common practice among clinics and CHCs.
Facility cleanliness is one of the key criteria for infection prevention and safe and clean service delivery. Only 17 per cent of the facilities had spills or trash observed on their floors. Regional hospitals and the national/maternity hospital had no spills or trash on their facility floors. However, nearly a quarter of district hospitals had this problem.
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Table 7.3.4: Percentage of facilities with selected furnishings and amenities in the maternity area, by type of facility, Sierra Leone Rapid EmONC Assessment 2017
All facilities n=1722
National/ maternity hospital
n=1
Regional hospital
n=3
Districhospital
n=17
Other hospital
n=17
CHCs
n=124
Clinics
n=10
Furnishings
Instrument trolley 37% 0% 100% 94% 67% 33% 11%
Instrument tray 75% 100% 100% 100% 89% 76% 39%
Beds 95% 100% 100% 94% 94% 96% 84%
Linens 67% 0% 33% 77% 94% 66% 59%
Blankets for cold weather 63% 0% 0% 71% 39% 64% 74%
Water filter (or other means to make potable water available to patients and staff)
35% 100% 100% 100% 100% 100% 85%
Filled O2 cylinder with carrier + key to open valve 14% 100% 67% 77% 67% 6% 0%
Wheelchair 42% 100% 100% 94% 94% 37% 18%
Stretcher with trolley 21% 100% 67% 65% 72% 14% 11%
Examination table 77% 100% 100% 88% 94% 78% 48%
Labour/delivery table with stirrups 67% 100% 100% 88% 89% 68% 18%
Labour/delivery table without stirrups 50% 100% 33% 77% 72% 47% 46%
Bed availability and storage3
Empty beds for next patients are available 71% 0% 67% 88% 100% 70% 48%
Empty beds are clean and ready 96% 0% 100% 100% 100% 96% 78%
Facility has any beds in storage
Facility has 1 - 5 beds in storage 71% 0% 0% 0% 11% 81% 73%
Facility has > 5 beds in storage 29% 0% 100% 100% 89% 19% 27%
Miscellaneous items
Food is provided to patients by facility 17% 100% 100% 77% 28% 13% 0%
Liquid spills or trash observed on floors 17% 0% 0% 24% 11% 17% 15%
Note: 1. For hospitals, the maternity area was likely to be a specific room and these questions were related to the items available in that specific room. Health centres may not have had a specific room devoted to a maternity ward and these questions were therefore related to whether the facility, in general, had the items available. 2. ‚Other hospitals’ include private for-profit, NGO and faith-based.
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7.4 Availability of operating theatre equipment
Figure 7.4.1 and Table 7.4.1 below examine availability of an OT and of those that had a separate operating room. Ninety per cent of all hospitals had an OT. All the regional hospitals, the national/maternity hospital, 94 per cent of other hospitals and only 82 per cent of district hospitals had an OT. Among lower-level facilities that were not expected to have an OT, 1 per cent of CHCs and clinics had an OT. Of those hospitals that had an OT, only 46 per cent had a separate OT room for obstetric patients. The national/maternity hospital, two of the three regional hospitals and below 43 per cent of district and other hospitals had a separate OT room for obstetric patients.
Figure 7.4.1: Percentage of hospitals with an OT for obstetric patients and of those with an OT, percentage with a separate OT room, Sierra Leone Rapid EmONC Assessment 2017
Table 7.4.1 also shows a list of basic items in the OT and equipment used for obstetric laparotomy and CS. Accordingly, all hospitals had an operating table, syringes (5ml and 10ml). Ninety-eight per cent, 95 per cent, 92 per cent and 88 per cent of hospitals had needles (21, 22, 23), surgical drapes, syringes (20ml) and adjustable lights, respectively.
Of the long list of obstetric laparotomy and CS equipment (24 items), over 90 per cent of the hospitals had all the equipment except six of them – triangular point suture needles (7.3cm size 6), round bodied needles (no. 12 size 6), double ended abdominal retractors (Richardson), suction nozzle and intestinal clamps (curved /22.5cm/ and straight /22.5cm/). They were available in 75 per cent to 88 per cent of the hospitals and only two thirds of the hospitals had a mini-laparotomy kit. This kit was available in two of the three regional hospitals and in 79 per cent and 71 per cent of district and other hospitals, respectively (Table 7.4.1).
Table 7.4.1: Percentage of hospitals with an OT that had selected equipment and supplies, Sierra Leone Rapid EmONC Assessment 2017
All hospitals (n=35)
National/ maternity hospital
(n=1)Regional hospital
(n=3) District hospital
(n=14) Other
hospital(n=17)1
Basic items
Operating table 100% 100% 100% 100% 100%
Light- adjustable, shadowless 86% 100% 67% 86% 100%
Surgical drapes 95% 100% 67% 93% 100%
Syringes 5ml 100% 100% 100% 100% 100%
Syringes 10ml 100% 100% 100% 100% 100%
Syringes 20ml 92% 100% 67% 93% 94%
Needles 21, 22, 23 98% 100% 100% 100% 94%
0%
20%
40%
60%
80%
100%90%
All hospitals(n=39)
100%
National/MaternityHospital (n=1)
100%
Regional Hospital(n=3)
82%
District Hospital(n=17)
94%
Other Hospital(n=18)
Facility has an operating theatre Facility has separate OT room
93
Table 7.4.1: Percentage of hospitals with an OT that had selected equipment and supplies, Sierra Leone Rapid EmONC Assessment 2017
All hospitals (n=35)
National/ maternity hospital (n=1)
Regional hospital (n=3)
District hospital(n=14)
Other hospital(n=17)1
Obstetric laparotomy / caesarean delivery pack
Stainless steel instrument tray with cover 98% 100% 100% 100% 94%
Towel clips 91% 100% 100% 93% 100%
Sponge forceps, 22.5 cm 98% 100% 100% 93% 100%
Straight artery forceps, 16 cm 100% 100% 100% 100% 100%
Uterine haemostasis forceps, 20 cm 95% 100% 100% 93% 94%
Needle holder 98% 100% 100% 93% 100%
Surgical knife handle/No 3 98% 100% 100% 100% 94%
Surgical knife handle/No 4 98% 100% 100% 93% 100%
Surgical knife blades 100% 100% 100% 100% 100%
Triangular point suture needles/7.3 cm/size 6 75% 100% 67% 64% 77%
Round-bodied needles/No 12/size 6 88% 100% 67% 100% 94%
Abdominal retractor/size 3 91% 100% 100% 93% 100%
Abdominal retractors/double-ended (Richardson) 81% 100% 100% 71% 94%
Operating scissors, curved, blunt pointed (Mayo) 17cm 93% 100% 100% 100% 100%
Operating scissors, straight, blunt pointed (Mayo) 17cm 100% 100% 100% 100% 100%
Scissors, straight, 23 cm 98% 100% 100% 100% 94%
Suction nozzle 78% 100% 100% 71% 88%
Suction tube, 22.5 cm, 23 French gauge 95% 100% 100% 86% 100%
Intestinal clamps, curved (Dry), 22.5 cm 78% 100% 100% 79% 82%
Intestinal clamps, straight, 22.5 cm 81% 100% 100% 71% 94%
Dressing (non-toothed tissue) forceps/15 cm 93% 100% 100% 100% 100%
Dressing (non-toothed tissue) forceps/25 cm 98% 100% 100% 93% 100%
Sutures (different sizes and types) 92% 100% 100% 79% 100%
Mini-laparotomy kit 66% 100% 67% 79% 71%
Note: 1. 'Other hospitals' include private-for-profit, NGO and faith-based.
As shown in Table 7.4.2, anaesthesia apparatus (draw-over system) and suction apparatus (foot operated) were available in 54 per cent and 57 per cent of hospitals, respectively. Oxygen cylinder with manometer and flow meter was also found in 60 per cent of hospitals’ OTs. Sixty per cent of hospitals had endotracheal tubes with cuffs (8mm), 63 per cent had intubating forceps and 63 per cent had endotracheal tube connectors. The national/maternity hospital had no anaesthetic facemasks, endotracheal tubes with cuffs (8 mm and 10mm), spinal needles (18–25 gauges), anaesthetic apparatus, or oxygen cylinders.
Table 7.4.2 also describes basic equipment used for craniotomy procedures in the OTs. Surprisingly, only 26 to 29 per cent of the hospitals had this essential equipment for craniotomy procedures. Again, the national/maternity hospital had none.
94
Table 7.4.2: Percentage of hospitals with an OT and with anaesthesia equipment and supplies, Sierra Leone Rapid EmONC Assessment 2017
All hospitals (n=35)
National/ maternity hospital (n=1)
Regional hospital (n=3)
District hospital(n=14)
Other hospital(n=17)1
Anaesthesia equipment and supplies
Anaesthetic face masks 97% 0% 100% 100% 100%
Oropharyngeal airways 91% 100% 100% 86% 94%
Laryngoscopes (with spare bulbs and batteries) 74% 100% 67% 79% 71%
Endotracheal tubes with cuffs (8 mm) 71% 0% 100% 64% 77%
Endotracheal tubes with cuffs (10 mm) 60% 0% 100% 50% 65%
Intubating forceps (Magill) 63% 100% 33% 57% 71%
Endotracheal tube connectors: 15 mm plastic (connect directly to breathing valve; three for each tube size)
63% 100% 100% 57% 59%
Spinal needles (18-gauge to 25-gauge) 91% 0% 100% 93% 94%
Suction apparatus: Foot-operated 57% 100% 33% 64% 53%
Suction apparatus: Electric 89% 100% 100% 79% 94%
Anaesthesia apparatus (draw-over system) 54% 0% 100% 79% 29%
Oxygen cylinders with manometer and flowmeter (low flow) tubes and connectors
60% 0% 67% 43% 77%
Craniotomy equipment
Decapitation hook Jardine’s s/s 26% 0% 0% 29% 29%
Craniotomy forceps Brawn’s s/s 29% 0% 0% 36% 29%
Embryotomy scissors 29% 0% 33% 36% 24%
Perforator 26% 0% 33% 21% 29%
Note: 1. 'Other hospitals' include private-for-profit, NGO, and faith-based
7.5 Availability of laboratory equipment and supplies for blood transfusion
Table 7.5.1A in the appendix presents the availability of laboratories and laboratory equipment and supplies. Of all the facilities, only 51 per cent had laboratories. Hospitals were more likely to have laboratories than CHCs (46 per cent) and clinics (21 per cent). Among the facilities that had laboratories, only 78 per cent had a set of laboratory guidelines. Availability of laboratory guidelines was also more common among hospitals than CHCs or clinics.Availability of a blood bank refrigerator and blood typing and cross-matching reagents are crucial equipment and supplies needed to save the lives of women who are at risk of haemorrhage. However, a blood bank refrigerator was available in only 17 per cent of the facilities. This equipment was found only in 5 per cent of district and 65 per cent of other hospitals. Blood typing and cross-matching reagents were also found in fewer than a quarter of the facilities. Among blood collection and screening tests, the HIV test was available in a large majority of the facilities (87 per cent). But hepatitis B and C tests and syphilis tests were available only in 25 to 28 per cent of the facilities (Table 7.5.1A in the appendix).
Table 7.5.2A in the appendix examines laboratory supplies. Among facilities that had a laboratory, 95 per cent of them had a microscope. Most of the facilities had shortages of laboratory supplies. Lack of a CD 4 machine was severe among all hospitals including regional, district and other hospitals; they were found only in 6 per cent of them. The availability of a spectrophotometer (symex, screenplus) and ammonia were also affected as only 6 per cent and 7 per cent of the facilities with a laboratory had these supplies. Of the 96 facilities that had a laboratory, 390 blood units were found during data collection.
95
CHAPTER 8REFERRAL SYSTEM
96
A well-functioning and effective referral system at all levels plays a pivotal role in improving life-saving care for reducing maternal and neonatal deaths and morbidities. The health system alone cannot be responsive enough to establish such a dynamic referral system; but other systems should also be functional and effective like road networks, communications and logistics (ambulances and other transport systems). Referral-related questions were asked in Module 1 (infrastructure and facility identification) and captured very important elements of availability of obstetric and neonatal care 24/7, transportation including availability of ambulances, distance and time to the nearest surgical facilities, and management of ambulance and vehicle maintenance. The findings provide insights about planning elements for improving quality of care across Sierra Leone.
8.1 Availability of emergency services 24/7
Facilities were asked whether they provide obstetric and neonatal care 24 hours a day and seven days a week. This is purely a self-reported response, and as shown in Figure 3.6.1 below, a great majority of hospitals and CHCs/clinics affirmed the provision of emergency services 24/7. Eight of the 14 districts had all facilities providing obstetric and neonatal care 24/7. The lowest proportion of facilities that provided the service 24/7 was reported in Western Urban (74 per cent).
Figure 8.1.1: Percentage of facilities with obstetric and neonatal care 24/7, by district, Sierra Leone Rapid EmONC Assessment 2017
8.2 Distance and time to the nearest facilities with surgical services
Distance to the nearest surgical facilities
Knowing the distance and time to the nearest facility with surgical capacity is very helpful to manage referrals and evidence-based planning for medical care and logistics; particularly for mid- and lower-level facilities that often do referrals for higher level of care. As Figure 8.2.1 below and Table 8.2.1A in the appendix reveal, despite the fact that only four out of the 39 hospitals had no OT, seven of them were not providing surgical services (three of them had an OT). In addition, of the seven hospitals, six of them were in a distance range of 25 kilometres. Since CHCs/clinics are not expected to provide surgical services, distance information is widely important for all of them. The majority of CHCs/clinics (46 per cent) were in a radius of 25 kilometres. A little over a quarter of CHCs were between 26–50 kilometres and only 19 per cent of them were above 50 kilometres away. Western Rural, Bonthe, Bo, Kono, Western Urban, Pujehun and Tonkolili had the majority of CHCs/clinics in the range of 25 kilometres. Kambia, Koinadugu, and Moyamba had a greater proportion of their CHCs/clinics over 50 kilometres from the nearest surgical facilities. Expectedly, most urban CHCs/clinics were in proximity to the nearest surgical facilities compared to rural.
20% 40% 60% 80% 100%0%
Pujehu n
Bo
Tonkolili
Portloko
Koinadugu
Kambia
Kono
Kailahun
Kenema
National
Bombal i
Moyamba
Bonthe
Western Ru ral
Western Urba n
97
Figure 8.2.1: Percentage distribution of CHCs/clinics according to distance to the nearest facilities with surgical services, by district, Sierra Leone Rapid EmONC Assessment 2017
Time to the nearest surgical facilities
Time to reach the nearest facilities with surgical capacity is highly dependent on the type of road and topography. Table 8.2.2A in the appendix and Figure 8.2.1 below show, five of the seven hospitals that did not have surgical services required under 30 minutes to access the nearest surgical facilities. Of the total CHCs/clinics that did not have surgical capacity (133 out of 134), the majority (40 per cent) required over an hour to access the nearest surgical facilities. Port Loko, Western Urban and Bo had a majority of their CHCs/clinics accessing the nearest surgical facilities within 30 minutes. In the rest of the districts their CHCs/clinics were an hour or more away from the nearest facilities with surgical capacity.
Figure 8.2.2: Percentage distribution of CHCs/clinics according to time to the nearest facilities with surgical services, by district, Sierra Leone rapid EmONC Assessment 2017
26-50 kms >50 kms Don't know/ missing
20% 40% 60% 80% 100%0%
Western Ru ral
Bonthe
Bo
Kono
Western Urba n
Pujehu n
Tonkolili
National
Bombal i
Portloko
Koinadugu
Kenema
Kailahun
Kambia
Moyamba
<30 min 30-59 min Don't know/ missing
20%10% 40%30% 60%50% 80%70% 100%90%0%
Portloko
Western Urba n
Bo
Koinadugu
Kono
National
Kenema
Bonthe
Bombal i
Tonkolili
Kailahun
Moyamba
Western Ru ral
Pujehu n
Kambia
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8.3 Availability of means of transport
According to Table 8.3.1 below, only a fifth of the total facilities had a functioning motor vehicle ambulance, 1 per cent had a motorcycle ambulance, and 7 per cent of them had other motor vehicles. The availability of a motor vehicle ambulance among districts varied widely with the highest in Koinadugu (69 per cent) and the lowest in Kambia (6 per cent) and Kenema (7 per cent). Almost all of the hospitals had a motor vehicle ambulance while only 11 per cent of CHCs/clinics reported availability. Private facilities were more likely to have motor vehicle ambulance than government-owned facilities.
Table 8.3.1 also shows the availability of at least one functioning mode of motorized transport. Nationally, a little under a quarter of the facilities had at least one functioning mode of motorized transport. Districts like Kambia (6 per cent), Kenema (13 per cent), Tonkolili (13 per cent), Kono (15 per cent) and Bombali (15 per cent) had the lowest proportion of facilities with at least one functioning mode of motorized transport.
Of other forms of transport, the stretcher (63 per cent) was more common than a bicycle or animal-drawn cart functioning as an ambulance or transportation for the health facilities. Over 80 per cent of the facilities in Tonkolili, Kailahun, Moyamba, Kambia, Koinadugu and Kenema used this form of transportation. Surprisingly, hospitals more commonly used stretchers as a means of transportation than CHCs/clinics.
Table 8.3.1: Percentage of facilities with a functional mode of transport, by district, facility type, operating agency and location, Sierra Leone Rapid EmONC Assessment 2017
Total number of
facilities
Motorized transport Other forms of transport
Functioning motor vehicle
ambulance
Functioning Motorcycle ambulance
Functioning other motor
vehicle
At least one functioning
mode of motorized transport
Functioning bicycle
ambulance
Functioning animal drawn
cartStretcher
National 173 21% 1% 7% 23% 0.3% 0.0% 63%
District
Kailahun 9 37% 0% 6% 37% 0.0% 0.0% 94%
Kenema 17 7% 3% 13% 13% 0.0% 0.0% 81%
Kono 11 15% 0% 15% 15% 0.0% 0.0% 24%
Bombali 14 15% 0% 15% 15% 0.0% 0.0% 58%
Kambia 8 6% 0% 0% 6% 0.0% 0.0% 87%
Koinadugu 7 69% 8% 0% 69% 7.7% 0.0% 85%
Port Loko 14 28% 0% 0% 28% 0.0% 0.0% 50%
Tonkolilii 9 13% 0% 7% 13% 0.0% 0.0% 100%
Bo 23 16% 0% 3% 16% 0.0% 0.0% 27%
Bonthe 12 18% 0% 0% 18% 0.0% 0.0% 50%
Moyamba 12 23% 0% 0% 23% 0.0% 0.0% 91%
Pujehun 8 34% 0% 7% 34% 0.0% 0.0% 34%
Western Rural 8 17% 4% 4% 27% 0.0% 0.0% 45%
Western Urban 21 27% 3% 15% 32% 0.0% 0.0% 74%
Facility Type
Hospital 39 95% 10% 39% 95% 2.6% 0.0% 82%
CHC/Clinic 134 11% 0% 2% 14% 0.0% 0.0% 60%
Operating agency
Government/Public 144 17% 1% 3% 19% 0.4% 0.0% 62%
Private for-profit 8 30% 0% 0% 32% 0.0% 0.0% 37%
Private not-for-profit1 21 54% 3% 40% 59% 0.0% 0.0% 80%
Location
Urban 67 35% 3% 15% 37% 0.9% 0.0% 62%
Rural 106 13% 1% 2% 15% 0.0% 0.0% 63%
Note: 1. Includes NGO, faith-based and mission facilities.
99
8.4 Maintenance and management of vehicles
Table 8.4.1A in the appendix and Figure 8.4.1 below present availability of funds and tools for maintenance of motorized transport and fuel for continuous functionality. Of those facilities (53 of the 173) that had at least one mode of motorized transport, 88 per cent of them had an available source of tools/spare parts for maintenance. All of the facilities that had at least one mode of motorized transport in all districts mentioned that they had the tools/spare parts for maintenance, except facilities in Bombali, Kenema, Pujehun and Western Rural, in which only 50 per cent, 52 per cent, 61 per cent and 79 per cent of them respectively had the tools/spare parts. Both hospitals and CHCs/clinics had a similar proportion of facilities reported with maintenance arrangements.
With regard to availability of funds for maintenance, nationally, 82 per cent of the facilities with at least one mode of motorized transport affirmed availability. Most of the districts had facilities with the funds available. However, only half of the facilities with at least one mode of motorized transport in Bonthe had the funds available, followed by Kenema (52 per cent) and Kailahun (66 per cent).
Table 8.4.1A also shows the percentage of facilities with a responsible body or person in charge of managing motorized vehicles. Accordingly, the majority of the facilities with one mode of motorized transport had a facility administrator managing it, followed by another body (Transport Officer/Operations Manager, Midwife, Military Commandant, etc.) (15 per cent), Facility Director (10 per cent) and District Health Office (10 per cent).
Figure 8.4.1: Number of facilities with at least one mode of motorized transport and available tools/spare parts, funds, and fuel for maintenance and transporting clients, by district, Sierra Leone Rapid EmONC Assessment 2017
8.5 Referrals out due to obstetric and newborn indications
As shown in Table 8.5.1, of the total deliveries, referral out due to obstetric indications was 4 per cent. Referrals made due to newborn indications were less than 1 per cent from the total deliveries. Despite the number of women who developed complications being inflated due to recording and registration problems, particularly due to malaria-related complications, referrals made due to obstetric complications increased to 7 per cent for women with complications. For women who developed direct or indirect obstetric complications, Western Rural referred the highest proportion (23 per cent) and the lowest was Bonthe (1 per cent).
0
2
4
6
8
10
12
Weste
rn Urban
Koinadugu
Portloko Bo
Kailahun
Bombal i
Kenema
Bonthe
Moyamba
Pujehun
Weste
rn RuralKono
Tonkolili
Kambia
At least one functioning mode of motorized transport
Have available source of tools, spare parts and mechanics for maintenance
Have funds available today if needed for maintenance/repair
100
Most of the time, referrals are common and frequent from lower to higher level of care facilities. Thus, referrals out from hospitals were very low, with only 2 per cent and 3.5 per cent of women with direct or indirect complications (12,280) admitted to hospitals referred out due to obstetric and newborn indications, respectively. CHCs/clinics referred 9 per cent of the total number of women with complications (40,346) that came to their facilities. This suggests that CHCs/clinics were not prepared to manage most maternal and newborn complications. Similarly, the proportion of women with complications referred from government facilities due to obstetric indications (8 per cent) was higher than in private facilities.
Despite the fact that these referrals were recorded from register books from facilities, there is the possibility that a woman can potentially be referred to a higher level of care facility without any documentation or without being admitted to the facility she accessed first. Most referrals data were collected from a referral register and not from labour and delivery. Hence, there may be the possibility of underreporting or double counting at different facilities. On the other hand, field experience tells us that feedback to the referral sending facilities was weak and it may not be easy to know whether a woman received treatment at referral receiving facilities or not.
Table 8.5.1: Number and percentage distribution of referrals out due to obstetric and newborn indications by district, facility type and operating agency, Sierra Leone Rapid EmONC Assessment 2017
Total deliveries (weighted)
Total women with direct or indirect
complication (weighted)
Referrals out due to obstetric indications (weighted)
Referrals out due to newborn indications (weighted)
n % of deliveries
% of women with
complicationsn % of
deliveries
% of women with
complications
National 104,713 52,626 3,876 4% 7% 464 0.4% 0.9%
District
Kailahun 5,699 2,349 136 2% 6% 1 0.0% 0.0%
Kenema 9,684 4,538 104 1% 2% 2 0.0% 0.0%
Kono 3,735 1,788 32 1% 2% 2 0.1% 0.1%
Bombali 6,473 5,960 104 2% 2% 8 0.1% 0.1%
Kambia 4,651 2,531 58 1% 2% 0 0.0% 0.0%
Koinadugu 2,895 1,813 42 1% 2% 12 0.4% 0.7%
Port Loko 7,332 3,535 301 4% 9% 2 0.0% 0.1%
Tonkolilii 4,410 2,129 88 2% 4% 0 0.0% 0.0%
Bo 12,642 5,908 300 2% 5% 16 0.1% 0.3%
Bonthe 3,001 2,090 21 1% 1% 4 0.1% 0.2%
Moyamba 6,241 1,729 34 1% 2% 0 0.0% 0.0%
Pujehun 5,015 3,135 355 7% 11% 0 0.0% 0.0%
Western Rural 12,065 7,799 1,755 15% 23% 0 0.0% 0.0%
Western Urban 20,871 7,323 546 3% 7% 418 2.0% 5.7%
Facility Type
Hospital 31,891 12,280 221 1% 2% 434 1.4% 3.5%
CHC/Clinic 72,822 40,346 3,655 5% 9% 30 0.0% 0.1%
Operating agency
Government/Public 88,025 48,618 3,819 4% 8% 445 0.5% 0.9%
Private for-profit 4,856 702 13 0% 2% 11 0.2% 1.6%
Private not-for-profit1 11,832 3,306 44 0% 1% 8 0.1% 0.2%
Location
Urban 67 35% 3% 15% 37% 0.9% 0.0% 62%
Rural 106 13% 1% 2% 15% 0.0% 0.0% 63%
101
CHAPTER 9CONCLUSION AND RECOMMENDATIONS
102
9.1 Conclusion
The 2017 EmONC assessment identified the gaps and progress made since the 2008 EmONC, which was the first assessment taken as a benchmark. Coverage of EmONC facilities in Sierra Leone increased dramatically since 2008 (from 24 per cent to 85 per cent of the UN recommendation). But the distribution of the EmONC facilities varied widely among districts with some having a chronic problem in the availability of EmONC facilities. The proportion of institutional deliveries also rose from 10 per cent in 2008 to 28 per cent in 2016. Yet, 72 per cent of the expected births happened either at homes or at lower level of health facilities (health posts), in which skilled birth attendance is always a debate and they often lack the required drugs, equipment and supplies to manage complications. Institutional delivery was very low in Koinadugu, Kono and Tonkolili. Even in the 28 per cent of the expected births that took place in hospitals and CHCs/clinics, over 80 per cent of the deliveries took place in facilities that missed one or more signal functions.
Governments are always constrained by a lack of resources and Sierra Leone is no different. As a priority, instead of stretching to upgrade every lower level facility, it is advisable to define the national network of EmONC facilities by focusing on a targeted number of those facilities that have an important catchment area (within 2 hours travel time) and were missing only one or two signal functions. These facilities are distributed across all districts with the highest needed in Bo (10 facilities), followed by Western Urban (nine facilities), Kenema, Port Loko, and Moyamba (seven facilities each), Kailahun and Bonthe (five each) to the lowest in Kambia and Koinadugu (two each).
Facility readiness to provide EmONC signal functions is one of the crucial elements of analysis useful for planning. As readiness was defined in section 3.9, both hospitals and CHCs/clinics were better staffed than being equipped and supplied. This meant most of the facilities were challenged by a lack of adequate and required drugs, equipment and supplies to provide all the nine EmONC signal functions. More specifically, of the seven basic EmONC signal functions, facilities were the least ready to provide removal of retained products of conception (26 per cent) and AVD (42 per cent).
Maternal and newborn care services are highly dependent on the availability of qualified and skilled health workers. This assessment shows severe shortages of all categories of health workers, except surprisingly, obstetrician/gynaecologists and general surgeons. The shortage affects all government health facilities, except the national/maternity hospital with few gaps in nurses and lab technicians. A huge gap was observed among nurses (1,112), CHOs (509), MCHAides (494) and midwives (239).
Utilities like electricity, water, and communication materials are very helpful to facilitate quality service delivery. Despite a large proportion of facilities (89 per cent) with a source of electricity, districts like Bonthe and Kenema had gaps in the availability of electricity as only 46 per cent and 69 per cent of their facilities had a source of electricity. Even in districts with greater coverage of electricity, interruptions for a day or more were common in many of the districts. Similarly, availability of water was quite encouraging at the national level, but there was a severe shortage in 41 per cent of the facilities in Western Rural. Availability of a functioning toilet was present in almost every facility across the country, except in Western Rural, where it was found only in 59 per cent of the facilities. On-site communication mechanisms also were found to exist in almost every facility, but were challenged by the fact that facility communication was highly dependent on individual cell phones, which were very widely available, yet a reimbursement policy for this usage did not exist.
Referrals is one of the critical elements of a health system; particularly for the lower level of care facilities that often do not provide a full spectrum of health services. This assessment shows only 21 per cent of the facilities had a functioning motor vehicle ambulance while 23 per cent of the facilities had at least one mode of transportation. This leaves a huge gap to be filled in order to have an effective referral system in the country. Half of the districts fell below the national average in having at least one mode of transportation. The distance and time to reach the nearest facility with surgical services were also assessed and the results show one of the seven hospitals and over a third of CHCs/clinics that did not provide surgical services were within the distance radius of over 25 kilometres of surgical facilities. Seven out of 14 districts were in this distance range.
103
9.2 Recommendations
Recommendations were crafted based on the gaps identified in this assessment. In addition, the country core team reviewed the feasibility of these recommendations to effectively respond to gaps and strategize interventions. The recommendations are organized into the thematic areas: coverage and readiness; other MNH services; data quality of EmONC services; infrastructure; HR; drugs/equipment/supplies; and referral systems.
9.2.1 Coverage and readiness for EmONC
9.2.1.1: Coverage of EmONC facilities was not met as it was found to be at 85 per cent of the UN recommended level.
Gaps
• Moyamba and Western Rural had a gap of one CEmONC facility each though CEmONC coverage at the national level was 148 per cent from the recommended;
• A gap of 11 BEmONC facilities in Kono, Bombali, Kambia, Port Loko, Tonkolili, Bo, Moyamba, and Western Rural and Urban.
• Of all the facilities, 41 per cent of them were missing only one or two signal functions and have the potential for upgrading to make them fully functioning BEmONC facilities.
• Only 10 per cent of the expected births took place in EmONC facilities. Of the total births, over 80 per cent of them happened in facilities that missed one or more signal functions.
• Met need for EmONC was only 15 per cent, way below the UN standard of 100 per cent. Ten of the 14 districts were even below the national average. This implies that 85 per cent of the expected complications were delivered or treated in a non-EmONC facility or the complications had never been reported.
Recommendations
• Work with partner organizations and donor agencies to prioritize resources to fill the afore-mentioned prioritized gaps (upgrading those facilities that miss one or two signal functions and a gap of CEmONC facilities in Moyamba and Western Rural districts). In upgrading these facilities, considerations of Geographic Information System mapping and referral networking are crucial, as distance and time to reach the nearest facilities with surgical services should be the primary assumption for equity.
• Designate EmONC facilities based on the recommended EmONC targets in each district and the following two elements of referral networking:
• (1) Geo-spatial catchment population to facility proportion • (2) The minimal distance and time radius (within two hours of reach) to the nearest surgical facilities • In the short term, support the existing EmONC facilities in providing good patient care with regular
monitoring• Work with other line Ministries’ and offices (like the roads authority) to simultaneously improve
facility’s road access
9.2.1.2: Low readiness to provide parenteral antibiotics in all facilities
Gaps
• Only 47 per cent of the facilities were ready to provide parenteral antibiotics, while almost all facilities were actually providing them it in the three-month reference period.
• The low readiness in both hospitals and CHCs/clinics was exacerbated by a lack of required drugs though there was a time difference in the question of availability of drugs (at the time of the survey) and performance of the signal function (last three months prior to the survey). Even if 91 per cent of facilities had one or more antibiotics, clindamycin was available in only 7 per cent of facilities, ampicillin in 34 per cent, metronidazole (injection) in 44 per cent, gentamicin (injection) in 56 per cent.
• The low readiness yet high provision might also imply either inappropriate cadre had been providing parenteral antibiotics or staff used antibiotics that were not recommended in the national standards.
104
Recommendations
• Facilities that lack the drugs of choice mentioned above should be supplied to effectively provide parenteral antibiotics.
• Further investigation or study should be conducted if facilities are providing antibiotics that were not recommended or inappropriate cadres are providing the drugs. It is important to build the capacities of midwives (both through training and deployment of additional midwives) to ensure provision of parenteral antibiotics by appropriate cadres; particularly in CHCs/clinics.
9.2.1.3: Low provision of parenteral anticonvulsants, among CHCs/clinics
Gaps
Although 70 per cent of CHCs/clinics were ready to provide parenteral anticonvulsants, only 22 per cent actually provided it in the three-month reference period. The main reason for the non-provision was no indication (89 per cent).
Recommendations
• With the available data, it is very difficult to recommend concrete strategies, as we do not know the full spectrum of demand and supply side gaps. But, we recommend further investigation as to why pregnant women with hypertensive disorders are not visiting mid- and lower-level level facilities, while pre-eclampsia/eclampsia and PPH/retained placenta were the two leading causes of maternal deaths in Sierra Leone (each constitute16 per cent of the total maternal deaths).
• Triangulate this EmONC data with MDSR information to explore case management and location of maternal deaths.
• If women with hypertensive disorders access CHCs/clinics and they should be referred immediately, training of health workers in CHCs/clinics may be needed, as there could be lack of confidence among providers to, as an example, provide the loading dose of magnesium sulphate.
9.2.1.4: Hospitals and CHCs/clinics were least ready to remove retained products of conception (among the BEmONC signal functions)
Gaps
• Readiness of both hospitals and CHCs/clinics were primarily challenged by lack of MVA kits for the removal of retained products
• Nationally, only a little over a quarter (26 per cent) of the facilities were ready to provide this signal function. Actual performance was also below half.
• Vacuum aspirators/syringes were available in only 51 per cent of the facilities. Facilities with syringes, one type of lubricant and all cannulae were only 8 per cent.
Recommendations
As a priority equip facilities with MVA kits to provide this critical life-saving service.
9.2.1.5: Performance and readiness to provide AVD were low
Gaps
• Nationally, only 42 per cent of the facilities were ready to provide AVD, while only a third (32 per cent) of the facilities were actually providing it.
• Sixty-eight per cent of the facilities did not provide AVD in the three-month reference period. Lack of equipment (58 per cent) was the most frequently cited reason for the non-performance; followed by no indication (50 per cent), lack of training (34 per cent), and lack of human resources to provide the signal function (17 per cent).
• Only 12 per cent of facilities had a vacuum extractor, outlet or mid-cavity forceps. No such equipment was available in the national/maternity hospital, two or the three regional hospitals and 53 per cent of district hospitals.
105
Recommendations
• As a matter of urgency supply facilities with AVD equipment as facilities are highly likely to miss this signal function to fully function as EmONC.
• Boost provider’s knowledge and motivation through in-service training to perform this signal function.• Facilities that have no surgical services (seven hospitals and almost all CHCs/clinics) should be
encouraged to use AVD with a proper referral system to facilitate surgery if needed.
9.2.1.6: Hospitals were least ready to perform CS
Gaps
• Only 23 per cent of hospitals were ready to provide CS. • Lack of equipment contributed to the low readiness of hospitals; anaesthesia apparatus was available
in only 54 per cent and oxygen cylinder found in 60 per cent of hospitals.
Recommendations
• Equip all hospitals that lack the necessary anaesthesia apparatus and oxygen cylinders to provide surgery services.
• The quality of care associated with CS needs to be investigated, particularly in government hospitals, that provided CS at a higher rate (26 per cent) than private facilities. Based on WHO’s recent evidence about CS, over 10 per cent CS rate is not a guarantee to save the lives of mothers and their newborns.
9.2.1.7: Readiness of hospitals to perform blood transfusion was low
Gaps
• Only 46 per cent of hospitals were ready to provide blood transfusions. • Over 80 per cent of hospitals actually provided blood transfusions. This implies that facilities might
have provided blood transfusion under suboptimal conditions.• Lack of equipment and supplies contributed to the low readiness of hospitals:
- Refrigerator for blood bank was available in 59 per cent of districts and 65 per cent of other hospitals;- Microscopes were available in one of the regional, 24 per cent of district, and 41 per cent of other hospitals;- Only 65 per cent of district hospitals had blood typing and cross-matching reagents.
Recommendations
• Equip all hospitals with refrigerators, compound microscopes, blood typing and cross matching reagents to provide uninterrupted blood transfusions for those in need.
• Further study is recommended to identify where the hospitals get their supply of blood and to ensure a steady supply chain as this assessment did not capture the source of blood supplies.
9.2.2 Other MNH services
9.2.2.1 Low provision of FP methods for PAC cases
Gaps
Only 59 per cent of the facilities at the national level provide PAC FP methods. In Koinadugu, Kono, Kenema, and Bombali districts, fewer than 1 per cent of the facilities provided FP methods for PAC cases.
Recommendations
Ensure counselling and supply of FP methods for PAC cases, as almost all facilities (98 per cent) had any of the modern contraceptives in stock.
106
9.2.2.2 Low coverage of KMC
Gaps
• KMC was provided in only 60 per cent of the facilities. Western Rural and Urban, Bonthe, Bombali, Kambia, and Koinadugu had no facility providing KMC.
• Field observation and anecdotal information informed us that providers often consider KMC as only skin-to-skin care of a newborn.
• Availability of KMC guidelines was only 69 per cent at the national level and 52 per cent in clinics, 56 per cent private hospitals, 59 and 67 per cent in district and regional hospitals respectively and 72 per cent in CHCs.
Recommendations
Train midwives and nurses in KMC as a priority and distribute of KMC guidelines as KMC is a key intervention for saving newborn lives, especially for low birth weight babies. Though small, the proportion of low birth weight babies in this assessment was 3.4 per cent (of the weighted total of live births 103,056).
9.2.2.3 Low performance of respectful maternity care
Gaps
• Thirty-nine per cent of facilities did not have sufficient lights at night.• Seventy-four per cent of the facilities did not have fans or air-conditioning in their maternity areas.• Thirty-six per cent of facilities did not have curtains as a means of privacy for patients.• Twenty-five per cent did not have a waiting area in the maternity area for visitors and family.• Nine per cent of CHCs/clinics did not have functioning toilets, particularly in Western Rural, Bombali,
Kono, Kenema, Bonthe, Portloko and Western Urban districts.
Recommendations
It is known that respectful maternity care improves institutional delivery and thereby the treatment of major direct obstetric complications. It also improves the met need for EmONC. Hence, it is imperative to fulfil the above mentioned infrastructure amenities in all facilities and districts that lack such amenities.
9.2.3 Poor data quality of EmONC services
Gaps
• Unavailability of OT register in 13 per cent of hospitals; unavailability of maternal death (63 per cent), PNC (31 per cent), PAC (72 per cent) and MDSR (66 per cent) of facilities.
• Despite a large proportion of facilities with a labour and delivery registers, only 73 per cent and 79 per cent of them respectively had the register complete and up-to-date. Other registers were even less complete and up-to-date than the labour and delivery registers.
• The data showed that the number of newborn outcomes was lower than the number of deliveries; or the number of women with complications was higher than the number of deliveries in a facility (for example, the number of women who developed malaria might be higher than the number of women who delivered in a facility).
Recommendations
• Standardize and distribute register books to better capture complete data on types of deliveries, newborn outcomes, complications and maternal and neonatal deaths.
• Use a medical record number to synchronize with patient cards and register books to consistently capture the different services a woman or a neonate receives in different wards;
• Strengthen the monitoring system of EmONC services as part of the existing or improved system of HMIS/DHIS2 to ensure an evidence-based and responsive health system decision-making process.
• Provide up-to-date training of health providers on the improved HMIS/recording and reporting mechanisms and associated tools as observed in the gaps.
• Work with other agencies to improve civil registration and vital statistics system both at health facility as well as at the different levels of administrative units.
107
9.2.4 Infrastructure
9.2.4.1: Low coverage of beds to deliveries ratio according to international standards in some districts.
Gaps
• Western Rural and Urban, Bo, Pujehun and Kambia had facilities that fell short of the 30 to 32 beds per 1,000 deliveries minimum required ratio.
• Recommendations• In the short term: Conduct individual facility analyses to inform the redistribution of beds intra-
district; make sure BEmONC facilities are prioritized (after the regional/district dissemination). • In the medium term: Procure and distribute beds to the facilities in those districts mentioned, as per
their need and space requirements.
9.2.4.2: Gaps in availability of separate rooms/spaces in the maternity for the provision of EmONC services.
Gaps
• Labour and delivery: No national standard for labour and delivery rooms or spaces or equipment, despite some guidance in the national documents.
• ANC room/space: Five per cent of the total facilities did not have an ANC room/space.• PNC room/space: Only 77 per cent of the total facilities had a separate room/space for PNC services.• Newborn care infrastructure:
- Only 13 per cent of hospitals had an NICU or special baby care unit. None of the facilities in Kailahun, Kono, Kambia, Koinadugu, Port-Loko, Bonthe, Moyamba, Pujehun, and Western Urban had a separate room for NICU.- Nationally, 55 per cent of facilities do not have a separate area for KMC:
Recommendations
• The MoHS, in collaboration with its partners, should come up with a holistic facility standard, not only for HR, but also for infrastructure set-up (adequate room/space size per facility type). The standard should also be disseminated to facility providers and policy makers.
• Many of the facilities that lacked the afore-mentioned separate rooms/spaces may require expansion of wards or construction of additional wards/rooms. In this case, the MoHS should do an in-depth analysis of facilities requiring such rooms/spaces to develop and implement a doable plan of action. In line with this:
- All facilities that provide delivery services should have separate ANC, labour and delivery, and PNC rooms/spaces;- For KMC area, either designate a space within the PNC ward as an immediate solution or establish a room/space with KMC guidelines, a table and chair; - All four hospitals that did not have OT should have the infrastructure to provide surgical services that saves women who develop major direct obstetric complications.
• NICU: The MoHS should develop a standard for the NICU levels of care at first referral, secondary and tertiary level facilities. In addition, an appropriate analysis should be done to equitably expand NICU services in the country, as many of neonatal complications require immediate care for newborns at intensive care units or immediate referrals to the NICU sites.
9.2.4.3: Low coverage of blood bank in district and private hospitals.
Gaps
• Availability of blood banks was extremely low among district hospitals: only 53 per cent of them had a separate blood bank, while 28 per cent had both the laboratory and blood bank together.
• Similarly, 28 per cent of private hospitals had a separate blood bank and another 28 per cent had blood bank and laboratory together.
108
Recommendations
• Conduct an in-depth analysis of district and private hospitals with no blood bank to equitably establish blood banks and services that facilitate surgical services and blood transfusion that are in need of it. Geo-spatial mapping is crucial to assist the distribution of blood banks. Since resources are always constrained, prioritize district hospitals that provide surgical services for the immediate establishment of blood banks and strengthen central or regional blood banks as source of blood units for the rest of the facilities that lacked blood banks.
• MoHS should develop a standard of blood banks and their services depending on facility tier levels.
9.2.4.4: Shortage of electricity in health facilities, particularly in CHCs/clinics
Gaps
• Thirteen per cent of CHCs/clinics did not have any source of electricity power.• Seventeen per cent of the total facilities that had electricity experienced interruptions for more than
two days.• Only lower than two thirds of the facilities said they had sufficient light during the night, lowest in
Bonthe (32 per cent) and highest in Kailahun (100 per cent).
Recommendations
• Electrify rural CHCs with an alternative power source – solar power. Prioritize, Bonthe, Koinadugu and the Western area.
• Provide standby generators and solar facilities to all EmONC facilities that do not have them, especially in Moyamba and Pujehun, and make funds available on time for running and servicing them.
• The MoHS should work with the electricity authority to advocate for the government to supply electricity from the national grid to all EmONC facilities.
9.2.4.5: Shortage of water supplies in health facilities, particularly in CHCs/clinics.
Gaps
• Seven per cent of CHCs/clinics that provided delivery services had no source of water.• Of those facilities that had a water source, only 54 per cent of hospitals and 26 per cent of CHCs/
clinics had piped water.• Inadequate supply of water was more prevalent in Western Rural, Bonthe, and Tonkolili.
Recommendations
• Availability of an improved water supply is imperative for EmONC service delivery 24 hours a day and seven days a week. Hence, the Government of Sierra Leone should provide access to improved water supply (piped, well, hand pump, and protected rain water harvesting).
• Supply of improved water should be prioritized in facilities in Western Rural, Bonthe and Tonkolili.
9.2.4.6: Inadequate availability of communication materials/equipment in health facilities
Gaps
• Communication in health facilities was highly dependent on the staff’s personal cell phones as only 48 per cent of the total facilities had facility-owned cell phones and only 2 per cent of the total facilities had two-way radio communication. Kailahun reported having no health facility with a facility-owned cell phone.
• Only 7 per cent of facilities that used staff cell phones had a policy of reimbursement.
109
Recommendations
Using landline telephone is not common in Sierra Leone and hence the use of cell phones and two-way radio will be the options commonly available. The MoHS should ensure that facilities that do not have a means of communication have cell phones with adequate air time, or a policy of reimbursing staff using their cell phones for facility-related communications, to ensure effective service delivery and referral systems.
9.2.5 Human resources
9.2.5.1: Shortages of HR to provide EmONC services 24/7
Gaps
• Severe shortage of availability of all categories of health workers, except obstetrician/gynaecologists and general surgeons. The shortage affected all government health facilities, except the national/maternity hospital with few gaps only in nurses and lab technicians.
• A huge gap was observed among nurses (needed 1,112), (CHOs) (needed 509), MCHAides (needed 494), and midwives (needed 239). Lab technicians, nurse anaesthetists and MDs were also among the deficits.
• Availability of health worker cadres 24/7 was a challenge in most sites; particularly among obstetrician/gynaecologists, paediatricians, surgeons and MDs in hospitals and lab technicians in the CHCs/clinics. The assessment shows staff were more likely to be on site during the day, Monday through Friday, than at night or during the weekends and holidays.
Recommendations
• In the short term: The MoHS should review the existing standards (Basic Packages of Essential Health Services) in relation to quantity, staff rotation and deployment of staffing practices. In addition, the MoHS should establish/strengthen the staff posting committee to respond to districts HR needs.
• Support training institutions to scale up their training capacity both in terms of quantity and quality; particularly training of midwives, nurses, medical officers, SACHOs and pharmacists/pharmacy technicians to fill in the gaps. Accelerate the training of obstetricians, gynaecologists, paediatricians, anaesthesiologists, midwives, CHOs and SECHNs.
• To improve availability of HR 24/7 and during the night and holiday shifts, the MoHS should leverage resources, in collaboration with partners, to institute the following mechanisms either one by one or in combination:
- Introduce performance-based incentives;- construct living quarters;- provide communication facilities like cell phones;- institute policy of remote area allowance;- introduce staff rotation and relocation strategies to urban areas so that health workers improve their skills, - organize different technical and short-term trainings and professional seminars to boost knowledge;- develop/strengthen the performance appraisal system to encourage staff competition and improve service delivery;- provide community support: district officers need to ensure that the staff are well cared for.
9.2.5.2: Low ratio of midwives per 1,000 institutional deliveries in many of the districts
Gaps
Only four districts (Western Urban, Koinadugu, Kono and Bombali) met the standard; and none of the districts met the health worker to population ratio.
Recommendations
• The MoHS should review the results of the EmONC assessment by facility in terms of HR to clearly redeploy and implement retention of EmONC-trained midwives in the 10 districts that did not meet the international standards of seven midwives per 1,000 deliveries.
110
• The MoHS should also establish a committee to review the current staffing patterns according to infrastructure set-up/standards and supply side to workout on deployment and redeployment plans.
• Provide regular supportive supervision to mentor midwives and provide on-the-job training and make sure that facilities have qualified midwives on staff.
• The MoHS should work with responsible bodies to incorporate EmONC training into midwifery training schools:
- Revisit midwifery training curricula to scale up training of more midwives. The MoHS should also explore the possibility of implementing a Direct Entry Midwifery system;- Look into the possibility of upgrading the skills of MCHAides.
9.2.6 Drugs, equipment and supplies
9.2.6.1: Stock-out of essential drugs
Gaps
• Gentamicin and ampicillin injections were available only in 72 per cent and 73 per cent of the facilities, respectively. Two of the three regional hospitals did not have gentamicin as one of the drugs of choice. Metronidazole (injection), penicillin G (Benzyl) and procaine benzyl penicillin were not available in the national/maternity hospital.
• Magnesium sulphate (injection) was stocked out in 21 per cent of the facilities in the last 12 months prior to the survey.
• Oxytocin was also stocked out in 17 per cent of the facilities (two of the regional hospitals and 63 per cent of private clinics had stock-outs of oxytocin)
• Ketamine and atropine were stocked out in 19 per cent and 25 per cent of the facilities, respectively.• Vitamin K and nystatin (oral) for newborn were available only in 35 per cent and 76 per cent of
facilities respectively.• Among hospitals, the most frequently mentioned cause of refilling facilities with drugs and supplies
was “stock-out at central store” (45 per cent). Among CHCs/clinics, “inadequate transport” (45 per cent) and “stock-out at central store” (40 per cent) were the most common causes of delays in supplying drugs and supplies.
Recommendations
• The MoHS and its relevant bodies should strengthen the national procurement system to properly place orders based on forecasts and quantification systems at all levels. The following recommendations might be worth considering:
- Strengthen the national logistics management information system to inform facilities and procurement entities to place orders before the stock-level reaches a minimum;- Build the capacity of pharmacists/pharmacy technicians and logistics officers (including staff at central store) in the logistics management information system and ensure all the required tools and forms are available in all facilities year round;- Make use of the report, request and issue voucher (RRIV) system for requesting and receiving drugs and supplies to facilitate quantification and procurement;- Improve availability of logistic officers/staff at the central store and district health offices to ensure an effective supply chain system;- Improve transportation and delivery of drugs and supplies to CHCs/clinics as transportation was one of their problems;- Improve the drug storage system in the health facilities to stock essential life-saving drugs and supplies;- Provide regular supportive supervision and monitoring of facilities and central store to solve problems in a timely manner.
9.2.6.2: Lack of some essential life saving medicines for mothers and newborns in all facilities
Gaps
Pre-eclampsia and eclampsia are one of the leading causes of maternal death and magnesium sulphate injection with 50 per cent concentration was available only in 77 per cent of district hospitals and 65 per cent of private hospitals.
111
• Ergometrine injection and misoprostol were also available in only 59 per cent and 34 per cent of the facilities, respectively.
• Antenatal corticosteroids (betamethasone and dexamethasone injections) for preterm labour were available only in 22 per cent and 73 per cent of facilities.
Recommendations
• The MoHS should ensure a continuous supply of the above-mentioned life-saving medicines in all facilities.
• Strengthen the supply chain system in the country to stock such essential medicines and ensure an uninterrupted supply of medicines 24/7.
9.2.6.3: Insufficient supply of guidelines and protocols
Gaps
Not all guidelines and protocols were available in all facilities. In particular, the management of obstetrics and newborns package was available in only 87 per cent of facilities, PAC in 71 per cent, KMC in 69 per cent and safe abortion care guideline in 51 per cent of the facilities.
Recommendations
• The MoHS should work on revisions (if needed), reproduction and distribution of these guidelines to all facilities.
• It is also required to provide orientation and training for health workers in these guidelines.
9.2.6.4: Shortage of equipment and supplies in labour and delivery/maternity
Gaps
• MVA kits were available in 8 per cent of the facilities.• Uterine evacuation kits were found in 10 per cent of the facilities.• Vacuum extraction kits were also available in 12 per cent of facilities.• Kits for episiotomy, perinatal, vaginal and cervical repair were available in 20 per cent of the
facilities.
Recommendations
The MoHS should do an in-depth analysis of the facilities missing these kits and ensure their supply.
9.2.6.5: Shortage of equipment and supplies for the newborn
Gaps
• Radiant warmers were not available in many of the hospitals.• Incubator, icterometer, fluorescent tubes for phototherapy to treat jaundice, apnoea monitor and
small cups for breast milk expression were not available in the majority of the hospitals.• Rectal thermometers for newborns were not available in the maternity and regional hospitals.• Suction apparatus (foot or electric) and mucus trap for suction were available in 27 per cent and 46
per cent of the facilities.• Resuscitation tables were not available in 14 per cent of the facilities.• Ten per cent of the facilities were missing infant face masks (size 0 or 1).
Recommendations
• The MoHS should procure and supply facilities with these equipment and supplies to save the lives of newborns as per the national and/or international standards.
• There is also a need to develop/revise equipment standards not only for newborn equipment, but also for all equipment in the labour and delivery/maternity, OT, and laboratory.
• Ensure facilities are following compliance and proper use of equipment through mentoring and coaching.
112
9.2.6.6: Lack of refrigerators in some hospitals and almost all CHCs/clinics
Gaps
A refrigerator is an important part of laboratory equipment, needed to refrigerate medicines like Oxytocin and reagents for blood transfusion. However, only 2 per cent of CHCs had a refrigerator, none of the clinics, 59 per cent of district hospitals and 65 per cent of private hospitals.
Recommendations
The MoHS should explore further why refrigerators were not available in the facilities and should plan for and supply this equipment. Some facilities might have it but they may not be working.
9.2.6.7: Lack of ultrasound in almost half of the district hospitals
Gaps
An ultrasound was available in only 53 per cent of the district hospitals.
Recommendations
All of the district hospitals that have no ultrasound should be supplied with a functional ultrasound and they should also receive appropriate training on how to maintain it.
9.2.6.8: Lack of autoclave in many facilities
Gaps
Close to half of CHCs, 29 per cent and 22 per cent of district and private hospitals and four fifth of clinics had no autoclave.
Recommendations
• Unavailability of an autoclave in these facilities should further be explored. The functionality of an autoclave requires a good power source.
• The MoHS should work with partners to supply facilities that lacked an autoclave.
9.2.6.9: Lack of functioning incinerators in district and private hospitals and CHCs/clinics
Gaps
Twelve per cent of the facilities did not have a functioning incinerator.
Recommendations
In collaboration with the MoHS, district health offices should work on constructing an incinerator or maintaining the existing one in each of the facilities that reported none.
9.2.7 Referrals for EmONC
9.2.7.1: Lack of emergency transportation for referral services
Gaps
• Only 21 per cent of the facilities had a functioning motor vehicle ambulance. Twenty-three per cent of facilities had at least one mode of transportation. Kambia, Kenema, Tonkolili, Kono, Bombali, Bo and Bonthe had the lowest proportion of facilities (6 per cent to 18 per cent) having at least one mode of transportation.
• Over a third of CHCs/clinics were over 25 kilometres away from the nearest surgical facility. Seven out of 14 districts had facilities in this distance range.
113
• Of the total CHCs/clinics that did not have surgical capacity (133 out of 134), the majority (40 per cent) required over an hour to access the nearest surgical facilities.
• Fifty-three per cent of CHCs were referring women to hospitals for the treatment of major direct obstetric complications.
Recommendations
• Availability of emergency transportation in all facilities is mandatory, as most of the major direct obstetric complications require anywhere up to two hours to reach the nearest higher level of care with surgical capacities. The MoHS should work with partners to make emergency transportation available:
- All hospitals that do not have a vehicle ambulance should have one on-site;- All CHCs/clinics should have either a motorized vehicle ambulance at the district health office within the reachable distance and time of the catchment facilities or they should have a motorcycle or tricycle ambulance if resources are constrained, in the short term;- Vehicles ambulances should have emergency equipment, supplies, drugs, and drivers trained in first aid.
114
APPENDICES
115
Hos
pita
lsCH
Cs/C
linic
sAl
l Fac
iliti
es
Tota
l num
ber
of
hosp
itals
CEm
ON
C1BE
mO
NC2
Part
ially
fu
nctio
ning
Tota
l num
ber
of
heal
th c
entr
es/
clin
ics
(wei
ghte
d)CE
mO
NC
BEm
ON
CPa
rtia
lly
func
tioni
ng
Tota
l num
ber
of fa
cilit
ies
(wei
ghte
d)CE
mO
NC
BEm
ON
CPa
rtia
lly
func
tioni
ng
Nat
iona
l39
210
1827
20
4123
131
121
4124
9
Dis
tric
t
Kaila
hun
21
01
150
411
171
412
Kene
ma
22
00
280
721
302
721
Kono
11
00
170
017
181
017
Bom
bali
41
03
220
022
261
025
Kam
bia
11
00
150
213
161
213
Koin
adug
u1
10
012
06
613
16
6
Port
Lok
o4
30
116
00
1620
30
17
Tonk
olili
i2
20
013
02
1115
22
11
Bo5
20
328
02
2633
22
29
Bont
he2
10
120
02
1822
12
19
Moy
amba
20
02
200
020
220
022
Puje
hun
11
00
130
94
141
94
Wes
tern
Rur
al1
00
127
04
2328
04
24
Wes
tern
Urb
an11
50
627
03
2438
53
30
Ope
ratin
g ag
ency
Gov
ernm
ent/
Publ
ic21
140
724
50
4120
426
614
4121
1
Priv
ate
for-
profi
t5
00
59
00
914
00
14
Priv
ate
not-
for-
profi
t113
70
618
00
1831
70
24
Loca
tion
Urb
an33
170
1683
011
7211
617
1188
Rura
l6
40
219
00
3115
919
64
3116
1
App
endi
x A
: Tab
les
Not
e:
I. Co
mpr
ehen
sive
Em
erge
ncy
Obs
tetr
ic a
nd N
ewbo
rn C
are.
2. B
asic
Em
erge
ncy
Obs
tetr
ic a
nd N
ewbo
rn C
are.
3. In
clud
es N
GO
, fai
th-b
ased
and
mis
sion
faci
litie
s.
Tabl
e 3.
1.1A
: Dis
trib
utio
n of
wei
ghte
d fa
cilit
ies
acco
rdin
g to
Em
ON
C st
atus
, by
faci
lity
type
, dis
tric
t, o
pera
ting
age
ncy,
and
loca
tion
, Si
erra
Leo
ne R
apid
Em
ON
C A
sses
smen
t 20
17
116
Table 3.1.2A: Percentage distribution of facilities according to number of EmONC signal functions1, by district, facility type, operating agency and location, Sierra Leone Rapid EmONC Assessment 2017
CEmONC BEmONC Almost there On the way Barely functioning
Total number of facilities3
n % n % n % n % n % n %
National 21 7% 20 13% 69 41% 55 34% 8 5% 173 100%
District
Kailahun 1 6% 2 25% 5 56% 1 13% 0 0% 9 100%
Kenema 2 7% 4 25% 7 44% 4 25% 0 0% 10 100%
Kono 1 6% 0 0% 3 28% 7 66% 0 0% 11 100%
Bombali 1 4% 0 0% 3 16% 9 72% 1 9% 12 100%
Kambia 1 6% 1 13% 2 27% 3 40% 1 13% 13 100%
Koinadugu 1 8% 3 46% 2 31% 1 15% 0 0% 14 100%
Port Loko 3 15% 0 0% 7 53% 4 32% 0 0% 15 100%
Tonkolilii 2 13% 1 12% 4 50% 2 25% 0 0% 16 100%
Bo 2 6% 1 5% 10 44% 9 41% 1 5% 17 100%
Bonthe 1 5% 1 9% 5 41% 4 36% 1 9% 18 100%
Moyamba 0 0% 0 0% 7 59% 5 41% 0 0% 19 100%
Pujehun 1 7% 5 66% 2 27% 0 0% 0 0% 20 100%
Western Rural 0 0% 1 14% 3 41% 2 28% 2 17% 21 100%
Western Urban 5 13% 1 7% 9 46% 4 24% 2 10% 22 100%
Type of facility
Hospitals 21 54% 0 0% 12 31% 4 10% 2 5% 25 100%
CHCs/clinics 0 0% 20 15% 57 42% 51 37% 6 5% 26 100%
Operating agency
Government/Public 14 5% 20 15% 57 41% 49 36% 4 3% 29 100%
Private for-profit 0 0% 0 0% 5 57% 1 7% 2 36% 30 100%
Private not-for-profit1 7 23% 0 0% 7 34% 5 29% 2 15% 31 100%
Location
Urban 17 15% 4 9% 24 37% 17 30% 5 9% 34 100%
Rural 4 2% 16 16% 45 43% 38 36% 3 3% 35 100%
Note: 1. Which signal functions are missing cannot be determined in this table.2. All n’s are unweighted figures.3. EmONC grading is defined as by the number of signal functions performed in each facility in the last 3 months prior to the survey. Accordingly, CEmONC = all 9 signal functions, BEmONC = all 7 basic signal functions, Almost there = missing only 1 or 2 basic signal functions, On the way = missing 3 or 4 basic signal functions, Barely functioning’ = missing 5 or 6 signal functions; and Non-EmONC = performing none of the basic signal functions.3. Unweighted number of facilities4. Includes NGO, faith-based or mission facilities
117
Tabl
e 3.
1.3A
: Per
cent
age
of fa
cilit
ies
that
are
rea
dy t
o pr
ovid
e an
d cu
rren
tly
prov
ide
each
Em
ON
C si
gnal
func
tion
, by
faci
lity
type
, Sie
rra
Leon
e Ra
pid
EmO
NC
Ass
essm
ent
2017
All f
acili
ties
Hos
pita
lsCH
Cs/c
linic
s
Faci
lity
had
requ
ired
:Fa
cilit
y w
as
read
y to
pr
ovid
e (s
uppl
ied
and
staff
ed)1
Faci
lity
prov
ided
si
gnal
fu
nctio
ns in
la
st 3
mon
ths
Faci
lity
had
requ
ired
:Fa
cilit
y w
as
read
y to
pr
ovid
e (s
uppl
ied
and
staff
ed)1
Faci
lity
prov
ided
si
gnal
fu
nctio
ns
in la
st 3
m
onth
s
Faci
lity
had
requ
ired
:Fa
cilit
y w
as r
eady
to
pro
vide
(s
uppl
ied
and
staff
ed)1
Faci
lity
prov
ided
si
gnal
fu
nctio
ns in
la
st 3
mon
ths
Dru
gs,
equi
pmen
t, an
d su
pplie
s
Hum
an
reso
urce
sD
rugs
, equ
ipm
ent,
and
supp
lies
Hum
an
reso
urce
sD
rugs
, equ
ipm
ent,
and
supp
lies
Hum
an
reso
urce
s
EmO
NC
sign
al fu
nctio
nsPa
rent
eral
an
tibio
tics
47%
100%
47%
99%
69%
100%
69%
100%
44%
100%
44%
99%
Pare
nter
al
uter
oton
ics
93%
99%
92%
98%
95%
100%
95%
97%
93%
99%
92%
98%
Pare
nter
al
antic
onvu
lsan
ts95
%99
%95
%72
%97
%10
0%97
%82
%95
%99
%94
%70
%
Man
ual r
emov
al o
f pl
acen
ta94
%98
%92
%61
%97
%10
0%97
%85
%93
%97
%91
%57
%
Rem
oval
of r
etai
ned
prod
ucts
29%
67%
26%
46%
62%
97%
59%
74%
24%
62%
21%
41%
Assi
sted
vag
inal
de
liver
y48
%65
%42
%32
%72
%10
0%72
%62
%44
%60
%38
%28
%
New
born
re
susc
itatio
n w
ith
bag
and
mas
k88
%98
%86
%90
%90
%10
0%90
%95
%88
%97
%86
%89
%
Caes
area
n de
liver
y3%
13%
3%11
%23
%90
%23
%82
%0%
2%0%
1%
Bloo
d tr
ansf
usio
n6%
13%
6%12
%49
%90
%46
%85
%0%
2%0%
1%
Not
e: 1
. The
re a
re tw
o co
mpo
nent
s to
bei
ng „
read
y” to
pro
vide
a s
igna
l fun
ctio
n: th
e av
aila
bilit
y of
a m
inim
um p
acka
ge o
f dru
gs, e
quip
men
t and
sup
plie
s,
and
the
avai
labi
lity
of a
t lea
st o
ne c
adre
who
pro
vide
s th
e si
gnal
func
tion.
118
Nat
iona
lD
istr
ict
Kaila
hun
Kene
ma
Kono
Bom
bali
Kam
bia
Koin
adug
uPo
rt L
oko
Tonk
olili
iBo
Bont
heM
oyam
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jehu
nW
este
rn
Rura
lW
este
rn
Urb
an
Tota
l del
iver
ies
104
,713
5
,699
9
,684
3
,735
6
,473
4
,651
2
,895
7
,332
4
,410
1
2,64
2 3
,001
6
,241
5
,015
1
2,06
5 2
0,87
1
Faci
lity
type
Nat
iona
l hos
pita
l6%
27%
Regi
onal
hos
pita
l5%
18%
26%
14%
Dis
tric
t hos
pita
l9%
10%
0%30
%0%
12%
38%
13%
23%
0%7%
5%19
%0%
11%
Oth
er h
ospi
tal
12%
7%7%
0%19
%0%
0%13
%6%
27%
15%
17%
0%0%
17%
CHC
66%
82%
75%
71%
54%
88%
62%
74%
71%
59%
67%
75%
81%
91%
34%
Priv
ate
clin
ic4%
0%0%
0%1%
0%0%
0%0%
0%11
%3%
0%9%
11%
EmO
NC
stat
us
Part
ially
func
tioni
ng84
%93
%93
%96
%76
%10
0%92
%87
%94
%73
%75
%80
%10
0%91
%71
%
BEm
ON
C5%
0%0%
0%0%
0%8%
6%0%
20%
0%0%
0%9%
3%
CEm
ON
C11
%7%
7%4%
24%
0%0%
7%6%
7%26
%20
%0%
0%26
%
Ope
ratin
g ag
ency
Gov
ernm
ent
63%
65%
53%
71%
74%
72%
32%
80%
55%
75%
76%
100%
16%
72%
45%
Priv
ate
for-
profi
t14
%25
%22
%0%
0%15
%30
%0%
16%
7%10
%0%
65%
28%
5%
Priv
ate
not-
for-
profi
t123
%10
%25
%30
%26
%12
%38
%20
%29
%19
%15
%0%
19%
0%50
%
Area
Urb
an52
%28
%28
%42
%46
%12
%47
%28
%23
%47
%42
%19
%38
%82
%10
0%
Rura
l48
%72
%73
%58
%54
%88
%54
%72
%78
%53
%58
%81
%62
%18
%0%
Tabl
e 3.
3.2A
: Per
cent
age
dist
ribu
tion
of w
eigh
ted
inst
itut
iona
l del
iver
ies
acco
rdin
g to
dis
tric
t, fa
cilit
y ty
pe, o
pera
ting
age
ncy,
Em
ON
C st
atus
an
d ar
ea/l
ocat
ion
Sier
ra L
eone
Rap
id E
mO
NC
Ass
essm
ent
2017
Not
e: 1
Incl
udes
NG
O, f
aith
-bas
ed a
nd m
issi
on fa
cilit
ies.
119
Table 3.3.3A : Percentage distribution of institutional deliveries according to district, facility type, operating agency, and location Sierra Leone Rapid EmONC Assessment 2017
Number of deliveries (weighted)
Mode of delivery (weighted)
Spontaneous vaginal
Instrumental vaginal Destructive1 Caesarean Laparotomy2 Total
National 104,713 92% 1% 0.0% 7% 0.1% 100%
District
Kailahun 5,699 96% 1% 0% 3% 0.0% 100%
Kenema 9,684 95% 1% 0% 4% 0.0% 100%
Kono 3,735 89% 1% 0% 9% 0.4% 100%
Bombali 6,473 87% 2% 0% 11% 0.0% 100%
Kambia 4,651 95% 2% 0% 4% 0.1% 100%
Koinadugu 2,895 92% 1% 0% 6% 0.8% 100%
Port Loko 7,332 93% 0% 0% 7% 0.1% 100%
Tonkolilii 4,410 92% 2% 0% 6% 0.1% 100%
Bo 12,642 91% 1% 0% 8% 0.1% 100%
Bonthe 3,001 95% 0% 0% 5% 0.0% 100%
Moyamba 6,241 98% 0% 0% 2% 0.0% 100%
Pujehun 5,015 91% 2% 0% 7% 0.0% 100%
Western Rural 12,065 98% 2% 0% 0% 0.0% 100%
Western Urban 20,871 86% 2% 0% 12% 0.0% 100%
Type of facility
National hospital 5,716 67% 3% 0% 30% 0.0% 100%
Regional hospital 5,121 75% 3% 0% 22% 0.2% 100%
District hospital 8,994 72% 4% 0% 24% 0.6% 100%
Other hospital 12,060 82% 3% 0% 16% 0.0% 100%
CHC 68,985 99% 1% 0% 0% 0.0% 100%
Private clinic 3,837 100% 0% 0% 0% 0.0% 100%
Operating agency
Government/Public 88,025 93% 1% 0% 6% 0.1% 100%
Private for-profit 4,856 88% 0% 0% 11% 0.0% 100%
Private not-for-profit1 11,832 86% 3% 0% 11% 0.1% 100%
Location
Urban 54,812 86% 2% 0% 12% 0.1% 100%
Rural 49,902 99% 1% 0% 1% 0.0% 100%
Note: 1. Destructive delivery includes craniotomies and embryotomies.2. Laparotomy for ruptured uterus.3. Includes NGO, faith-based and mission facilities.
120
Table 3.4.1A: Percentage of women with expected major direct obstetric complications treated in all facilities and EmONC facilities, by district (EmONC Indicator 4 - Met Need), Sierra Leone Rapid EmONC Assessment 2017
Expected births1
Expected complications2
All facilities EmONC facilities
Number of women with major direct obstetric complications
treated in All facilities (weighted)3
Met need
Number of women with major direct complications treated in EmONC facilities
(weighted)3
Met need
National 371,826 55,774 11,118 20% 8,333 15%
District
Kailahun 27,980 4,197 318 8% 268 6%
Kenema 32,291 4,844 1,299 27% 1,004 21%
Kono 29,771 4,466 516 12% 424 9%
Bombali 31,079 4,662 823 18% 527 11%
Kambia 20,297 3,045 412 14% 311 10%
Koinadugu 23,967 3,595 518 14% 478 13%
Port Loko 32,355 4,853 620 13% 406 8%
Tonkolilii 32,426 4,864 616 13% 415 9%
Bo 31,556 4,733 826 17% 637 13%
Bonthe 10,892 1,634 203 12% 87 5%
Moyamba 17,207 2,581 280 11% 0 0%
Pujehun 19,034 2,855 881 31% 831 29%
Western Rural 20,284 3,043 1,315 43% 852 28%
Western Urban 42,687 6,403 2,491 39% 2,092 33%
Note: 1.Expected births are calculated as (population) * (crude birth rate).2.Expected complications are calculated as 15% of the number of expected births.3.Major complications include: ruptured uterus, postpartum sepsis, severe pre-eclampsia/eclampsia, severe complications of abortion, antepartum hemorrhage, obstructed/prolonged labour, postpartum haemorrhage/retained placenta, and ectopic pregnancy (excludes „other” direct obstetric complications). Figures are weighted.
Table 3.4.2A: Percentage of women expected to experience major direct obstetric complications (+ PAC cases) who developed complications and delivered in all and EmONC facilities, by district (EmONC Indicator 4 - Met Need with PAC), Sierra Leone Rapid EmONC Assessment 2017
Expected births1
Expected complications2
All facilities EmONC facilities All facilities EmONC facilities
Number of women with major DOCs4 that deliver
in all facilities (weighted)
Met need
Number of women with major DOCs4 that deliver in EmONC facilities
(weighted)
Met need
Number of women with major
DOCs4 (+PAC) that deliver in
all facilities (weighted)
Met need
Number of women with major
DOCs4 (+PAC) that deliver in EmONC facilities
(weighted)
Met need
National 371,826 55,774 11,118 20% 8,333 15% 13,346 24% 9,835 18%
District
Kailahun 27,980 4,197 318 8% 268 6% 359 9% 309 7%
Kenema 32,291 4,844 1299 27% 1,004 21% 1520 31% 1,210 25%
Kono 29,771 4,466 516 12% 424 9% 603 14% 504 11%
Bombali 31,079 4,662 823 18% 527 11% 1010 22% 680 15%
Kambia 20,297 3,045 412 14% 311 10% 464 15% 352 12%
Koinadugu 23,967 3,595 518 14% 478 13% 545 15% 505 14%
Port Loko 32,355 4,853 620 13% 406 8% 675 14% 453 9%
Tonkolilii 32,426 4,864 616 13% 415 9% 694 14% 484 10%
Bo 31,556 4,733 826 17% 637 13% 1005 21% 806 17%
Bonthe 10,892 1,634 203 12% 87 5% 219 13% 87 5%
121
Table 3.4.2A: Percentage of women expected to experience major direct obstetric complications (+ PAC cases) who developed complications and delivered in all and EmONC facilities, by district (EmONC Indicator 4 - Met Need with PAC), Sierra Leone Rapid EmONC Assessment 2017
Expected births1
Expected complications2
All facilities EmONC facilities All facilities EmONC facilities
Number of women with major DOCs4 that deliver
in all facilities (weighted)
Met need
Number of women with major DOCs4 that deliver in EmONC facilities
(weighted)
Met need
Number of women with major
DOCs4 (+PAC) that deliver in
all facilities (weighted)
Met need
Number of women with major
DOCs4 (+PAC) that deliver in EmONC facilities
(weighted)
Met need
National 371,826 55,774 11,118 20% 8,333 15% 13,346 24% 9,835 18%
District
Moyamba 17,207 2,581 280 11% - 0% 310 12% - 0%
Pujehun 19,034 2,855 881 31% 831 29% 909 32% 853 30%
Western Rural 20,284 3,043 1315 43% 852 28% 1701 56% 1,061 35%
Western Urban 42,687 6,403 2491 39% 2,092 33% 3334 52% 2,531 40%
Note: 1. DOC - Direct obstetric complications; PAC - Post abortion care. 2. Expected births are calculated as (population) * (crude birth rate) 3. Expected complications are calculated as 15% of the number of expected births 4. Major DOCs include: ruptured uterus, postpartum sepsis, severe pre-eclampsia/eclampsia, severe complications of abortion, antepartum hemorrhage, obstructed/prolonged labour, postpartum hemorrhage/retained placenta, and ectopic pregnancy (excludes „other” DOCs). Figures are weighted.
Table 3.4.3A: Number and percentage distribution of women with major direct obstetric complications who were treated in all and EmONC facilities by district, facility type and operating agency, Sierra Leone Rapid EmONC Assessment 2017
Total deliveries (weighted)
All facilities EmONC facilities
Total major DOC (weighted)3
Percentage of women with major DOC4
Total major DOC (weighted)3
Percentage of women with major DOC4
National 104,713 11,118 11% 8,333 8%
District
Kailahun 5,699 318 6% 268 6%
Kenema 9,684 1,299 13% 1,004 21%
Kono 3,735 516 14% 424 9%
Bombali 6,473 823 13% 527 11%
Kambia 4,651 412 9% 311 10%
Koinadugu 2,895 518 18% 478 13%
Port Loko 7,332 620 8% 406 8%
Tonkolilii 4,410 616 14% 415 9%
Bo 12,642 826 7% 637 13%
Bonthe 3,001 203 7% 87 5%
Moyamba 6,241 280 4% 0 0%
Pujehun 5,015 881 18% 831 29%
Western Rural 12,065 1,315 11% 852 28%
Western Urban 20,871 2,491 12% 2,092 33%
Facility type
National hospital 5,716 1,098 19% 1,098 19%
Regional hospital 5,121 1,856 36% 1,856 36%
District hospital 8,994 3,255 36% 3,057 34%
Other hospital 12,060 1,152 10% 862 7%
CHC 68,985 3,683 5% 1,460 2%
Private clinic 3,837 74 2% 0 0%
122
Table 3.4.3A: Number and percentage distribution of women with major direct obstetric complications who were treated in all and EmONC facilities by district, facility type and operating agency, Sierra Leone Rapid EmONC Assessment 2017
Total deliveries (weighted)
All facilities EmONC facilities
Total major DOC (weighted)3
Percentage of women with major DOC4
Total major DOC (weighted)3
Percentage of women with major DOC4
National 104,713 11,118 11% 8,333 8%
Operating agency
Government 88,025 9,916 11% 7,471 8%
Private for-profit 4,856 73 2% 0 0%
Private not-for-profit2 11,832 1,129 10% 862 7%
Note: 1. DOC - Direct obstetric complications.2. Includes NGO, faith-based and mission facility.3. Major DOCs include: ruptured uterus, postpartum sepsis, severe pre-eclampsia/eclampsia, severe complications of abortion, antepartum hemorrhage, obstructed/prolonged labour, postpartum hemorrhage/retained placenta, and ectopic pregnancy (excludes „other” DOCs).4. We want what % of institutional deliveries were complicated cases, not a % distribution. There is some noise in this analysis because technically women with abortions are not included in „deliveries” (denominator) but DOC includes severe complications due to abortion.
Table 3.5.1A: Percentage of all expected births by caesarean section in all facilities and in EmONC facilities, by District (EmONC Indicator 5), Sierra Leone Rapid EmONC Assessment 2017
Expected births1
All facilities EmONC facilities
Number of caesareans (weighted)
Percentage of expected births by
caesarean
Number of caesareans (weighted)
Percentage of expected births by caesarean
National 371 ,826 6,851 2% 5,695 2%
District
Kailahun 27,980 168 1% 165 1%
Kenema 32,291 383 1% 383 1%
Kono 29,771 341 1% 341 1%
Bombali 31,079 736 2% 304 1%
Kambia 20,297 168 1% 168 1%
Koinadugu 23,967 180 1% 180 1%
Port Loko 32,355 489 2% 407 1%
Tonkolilii 32,426 273 1% 273 1%
Bo 31,556 990 3% 650 2%
Bonthe 10,892 149 1% 126 1%
Moyamba 17,207 106 1% 0 0%
Pujehun 19,034 364 2% 364 2%
Western Rural 20,284 0 0% 0 0%
Western Urban 42,687 2,504 6% 2,334 5%
Note: 1. Expected births are calculated as (population) * (crude birth rate).
123
Table 3.5.2A: Caesarean delivery as a proportion of institutional deliveries in all facilities and facilities that provide caesarean section, by district, operating agency and area/location, Sierra Leone Rapid EmONC Assessment 2017
All facilities All facilities that provide CS2
Total institutional deliveries in all
Facilities (weighted)
Total deliveries by CS in All facilities
(weighted)Percentage CS
Total institutional deliveries in facilities
that provide CS (weighted)
Total deliveries by CS in EmONC
facilities (weighted)Percentage CS
National 104,713 6,851 7% 29,720 6,820 23%
District
Kailahun 5,699 168 3% 591 165 28%
Kenema 9,684 383 4% 2,406 383 16%
Kono 3,735 341 9% 1,257 341 27%
Bombali 6,473 736 11% 2,931 736 25%
Kambia 4,651 168 4% 569 168 30%
Koinadugu 2,895 180 6% 1,107 180 16%
Port Loko 7,332 489 7% 1,874 489 26%
Tonkolilii 4,410 273 6% 1,275 273 21%
Bo 12,642 990 8% 4,874 990 20%
Bonthe 3,001 149 5% 667 149 22%
Moyamba 6,241 106 2% 302 106 35%
Pujehun 5,015 364 7% 939 364 39%
Western Rural 12,065 0 0% 4 0 0%
Western Urban 20,871 2,504 12% 10,924 2,476 23%
Operating agency
Government 88,025 4,969 6% 19,237 4,941 26%
Private for-Profit 4,856 558 11% 3,341 558 17%
Private not-for-profit 11,832 1,324 11% 7,142 1,321 18%
Area/location
Urban 54,812 6,536 12% 27,737 6,508 23%
Rural 49,902 315 1% 1,983 312 16%
Note: 1. CS - delivery by Cesarean section.2. All facilities that provide CS in the last three months prior to the survey irrespective of their EmONC status.
Table 3.6.1A: Direct cause-specific obstetric case fatality rates in all facilities, by cause, Sierra Leone Rapid EmONC Assessment 2017
Direct causesNumber of women with
direct complications (weighted)2
Number of maternal deaths by direct cause
(weighted)
Cause-specific case fatality rate
Percentage Maternal deaths (%age calculated from all maternal deaths
due to DOC)
Obstructed/ prolonged labour 4,023 54 1% 17%
PPH/Retained placenta 2,123 78 4% 24%
Severe pre-eclampsia/eclampsia 2,049 77 4% 24%
APH 1,547 48 3% 15%
Severe complications of abortion2 707 10 1% 3%
Postpartum sepsis 255 17 7% 5%
Ruptured uterus 212 14 7% 4%
Ectopic pregnancy 204 9 4% 3%
Other DOC 986 15 2% 5%
Total direct causes 12,106 321 3% 100%
Note: 1. DOC - Direct Obstetric Complications. 2. Women with less severe abortion complications are not included. If a woman died of abortion, by definition she died of severe complications.
124
Table 3.6.2A: Number and percentage distribution of direct and indirect complications and maternal deaths, Sierra Leone Rapid EmONC Assessment 2017
Women with complications (weighted) Maternal deaths (weighted)
n % n %
Total direct complications/causes 12,106 23% 321 68%
Obstructed/ prolonged labour 4,023 8% 54 11%
PPH/retained placenta 2,123 4% 78 16%
Severe pre-eclampsia / eclampsia 2,049 4% 77 16%
APH 1,547 3% 48 10%
Severe complications of abortion1 707 1% 10 2%
Postpartum sepsis 255 0% 17 4%
Ruptured uterus 212 0% 14 3%
Ectopic pregnancy 204 0% 9 2%
Other DOC 986 2% 15 3%
Total indirect complications/causes 40,521 77% 65 14%
Malaria 36 ,297 69% 1 0%
HIV/AIDS-related 2,830 5% 7 1%
Anemia 1,184 2% 46 10%
Hepatitis 66 0% 0 0%
Other indirect causes 144 0% 10 2%
Unknown/unspecified causes 89 19%
Total 52,627 100% 475 100%
All facilities EmONC facilities
Number of institutional
deliveries (weighted)
Number of stillbirths
(macerated) (weighted)
Number of intrapartum
deaths (fresh
stillbirths) (weighted)
Number of very early neonatal deaths
(weighted)1
Intrapartum + very early
neonatal death rate (per 1000
deliveries)2
Number of institutional
deliveries (weighted)
Number of stillbirths
(macerated) (weighted)
Number of intrapartum
deaths (fresh
stillbirths) (weighted)
Number of very early neonatal deaths
(weighted)1
Intrapartum + very early
neonatal death rate (per 1000
deliveries)2
National 104,713 2,024 1,474 271 17 39,022 1,450 1,114 222 34
District
Kailahun 5,699 78 83 17 18 2,020 16 41 16 28
Kenema 9,684 177 85 2 9 4,566 131 47 2 11
Kono 3,735 120 122 5 34 1,102 103 103 0 93
Bombali 6,473 139 149 32 28 1,678 70 76 11 52
Kambia 4,651 57 93 18 24 1,287 44 56 18 57
Koinadugu 2,895 78 49 0 17 1,979 62 39 0 20
Port Loko 7,332 122 70 8 11 1,459 101 62 3 45
Tonkolilii 4,410 104 76 8 19 1,968 78 63 8 36
Bo 12,642 219 151 49 16 3,163 127 108 43 48
Bonthe 3,001 33 16 0 5 734 20 12 0 16
Moyamba 6,241 29 13 0 2 0 0 0 0 0
Pujehun 5,015 78 8 26 7 4,204 78 8 26 8Western Rural 12,065 262 108 8 10 3,390 150 69 0 20
Western Urban 20,871 528 452 98 26 11,472 470 429 95 46
Table 3.7.1A: Intrapartum and very early neonatal death rate in all facilities and in EmONC facilities, by district (EmONC Indicator 7), Sierra Leone Rapid EmONC Assessment 2017
Note:1.Very early neonatal death was defined as a death occuring within 24 hours after delivery.2.Intrapartum and very early neonatal death rate = (intrapartum + v. early neonatal deaths)/(number of deliveries).
125
All facilities EmONC facilities
Total facilities Hospitals CHCs/clinics Total facilities Hospitals CHCs/clinics
n % n % n % n % n % n %
Newborn outcomes1 106,554 100% 32,864 100% 73,690 100% 39,910 100% 25,006 100% 14,904 100%
Live births (≥2500 grams) 97,985 92% 26,893 82% 71,092 96% 34,007 85% 19,804 79% 14,203 95%
Live births (<2500 grams) 3,456 3% 2,047 6% 1,409 2% 2,020 5% 1,677 7% 343 2%
Live births with unspecified birth weights 1,615 2% 1,394 4% 221 0% 1,319 3% 1,313 5% 6 0%
Fresh stillbirths (≥2500 grams) 859 1% 693 2% 166 0% 694 2% 628 3% 66 0%
Fresh stillbirths (<2500 grams) 221 0% 185 1% 36 0% 178 0% 165 1% 13 0%
Fresh stillbirths (unspecified birth weight) 393 0% 205 1% 188 0% 242 1% 178 1% 64 0%
Macerated stillbirths (≥2500 grams) 1,122 1% 891 3% 231 0% 817 2% 745 3% 72 0%
Macerated stillbirths (<2500 grams) 222 0% 174 1% 48 0% 150 0% 150 1% 0 0%
Stillbirths (unspecified birth weight and/or timing of fetal death) 681 1% 382 1% 299 0% 483 1% 346 1% 137 1%
Very early neonatal deaths (first 24 hours)1 271 100% 201 100% 70 100% 222 100% 178 100% 44 100%
Very early neonatal deaths (first 24 hours; > 2.5 kg) 118 44% 75 37% 43 62% 104 47% 69 39% 35 80%
Very early neonatal deaths (first 24 hours; < 2.5 kg) 75 28% 60 30% 15 21% 59 27% 50 28% 9 20%
Very early neonatal deaths (first 24 hours; unspecified birth weight)
78 29% 66 33% 12 17% 59 27% 59 33% 0 0%
Table 3.7.1A: Intrapartum and very early neonatal death rate in all facilities and in EmONC facilities, by district (EmONC Indicator 7), Sierra Leone Rapid EmONC Assessment 2017
Note: 1. Data weighted.
All facilities EmONC facilities
Number of maternal deaths due to indirect
cause (weighted)1
All maternal deaths (weighted)2
Percentage of all maternal deaths due to indirect
cause
Number of maternal deaths due to indirect
cause (weighted)1
All maternal deaths (weighted)2
Percentage of all maternal deaths due to indirect
cause
National 65 475 14% 57 385 15%
District
Kailahun 8 23 35% 8 18 44%
Kenema 7 43 16% 7 41 17%
Kono 0 38 0% 0 38 0%
Bombali 5 38 13% 2 28 7%
Kambia 9 34 26% 5 30 17%
Koinadugu 2 15 13% 2 11 18%
Port Loko 6 36 17% 6 34 18%
Tonkolilii 2 25 8% 2 23 9%
Bo 1 53 2% 1 43 2%
Bonthe 1 7 14% 1 4 25%
Moyamba 0 48 0% 0 0 0%
Pujehun 0 15 0% 0 15 0%
Western Rural 0 4 0% 0 4 0%
Western Urban 23 97 24% 23 96 24%
Table 3.8.1A: Percentage of maternal deaths due to indirect causes in all facilities and EmONC facilities, by district (EmONC Indicator 8), Sierra Leone Rapid EmONC Assessment 2017
Note: 1. Includes maternal deaths due to malaria, anaemia, HIV-AIDS related, hepatitis and other indirect causes.2. Includes all recorded maternal deaths in facilities regardless of cause (also includes maternal deaths due to unknown cause).
126
PAC cases (weighted) PAC women discharged with FP method (weighted) All deliveries (weighted) Postpartum women discharged
with FP method (weighted)
n n % n n %
National 2,228 1,324 59% 104,713 778 1%
District
Kailahun 41 9 22% 5,699 77 1%
Kenema 220 0 0% 9,684 0 0%
Kono 87 0 0% 3,735 0 0%
Bombali 187 2 1% 6,473 30 0%
Kambia 52 24 46% 4,651 24 1%
Koinadugu 27 0 0% 2,895 23 1%
Port Loko 55 19 35% 7,332 0 0%
Tonkolilii 78 27 35% 4,410 28 1%
Bo 178 174 98% 12642 62 0%
Bonthe 16 14 88% 3001 5 0%
Moyamba 30 30 100% 6241 12 0%
Pujehun 28 17 61% 5015 0 0%
Western Rural 386 374 97% 12065 517 4%
Western Urban 843 636 75% 20871 0 0%
Table 3.8.2A: Distribution of post-abortion and post-partum cases discharged with FP method by district, Sierra Leone Rapid EmONC Assessment 2017
Note: 1.PAC = post-abortion care.2.PP = Postpartum cases.3.FP = family planning.
All facilities Hospitals CHCs/Clinics
Total facilities with the register
Percentage with
register complete
Percentage with register up-to-date
Total hospitals with the register
Percentage with register
complete
Percentage with register up-to-date
Total CHCs/ Clinics with the register
Percentage with register
complete
Percentage with register up-to-date
Registers
Labour and delivery ward register
171 73% 79% 38 63% 61% 133 74% 82%
Operating theater register 36 62% 64% 34 65% 68% 2 39% 39%
Maternal death register 54 42% 47% 23 74% 74% 31 30% 36%
Maternal and neonatal register
130 59% 68% 24 54% 54% 106 59% 69%
PNC register 117 58% 69% 19 58% 68% 98 58% 69%
PAC register 52 53% 54% 20 75% 80% 32 46% 46%
PMTCT register 156 53% 59% 33 64% 64% 123 52% 59%
FP register 154 55% 63% 29 69% 66% 125 54% 63%
MDSR register/log book 59 55% 56% 18 72% 67% 41 52% 53%
Other
(General/Referral/Admission)
77 57% 71% 11 73% 73% 66 56% 71%
Table 3.8.3A : Number and percentage of facilities with good qualities (complete and up-to-date) of a register by facility type, Sierra Leone Rapid EmONC Assessment 2017
127
Table 5.2.1A: Percentage of facilities with separate room or space for select maternal and newborn services, by district, facility type, managing authority, and location, Sierra Leone Rapid EmONC Assessment 2017
Total number of facilities
Antenatal care room
Labour and
delivery together
Labour room
Deliveryroom
Postpartumward
Operatingtheater
Neonatal Care Unit
((NICU
Corner for newborn first aid/
care
KMC area
Separate blood bank
Separate Laboratory
room
Laboratory and blood
bank together
National 95% 17% 17% 85% 77% 13% 2% 96% 45% 6% 48% 3% 3%
District
Kailahun 9 94% 0% 0% 100% 100% 12% 0% 100% 87% 6% 82% 6%
Kenema 17 100% 25% 25% 75% 100% 7% 3% 94% 81% 3% 50% 0%
Kono 11 100% 34% 34% 66% 81% 15% 0% 91% 38% 6% 62% 0%
Bombali 14 100% 12% 12% 88% 75% 15% 4% 100% 11% 8% 75% 0%
Kambia 8 100% 20% 20% 80% 87% 6% 0% 100% 0% 6% 87% 0%
Koinadugu 7 85% 8% 8% 92% 69% 8% 0% 100% 62% 8% 23% 0%
Port Loko 14 100% 0% 0% 100% 92% 20% 0% 100% 63% 10% 47% 5%
Tonkolilii 9 100% 7% 7% 93% 75% 13% 7% 100% 31% 13% 75% 0%
Bo 23 100% 30% 30% 80% 81% 13% 3% 73% 56% 9% 50% 0%
Bonthe 12 91% 9% 9% 91% 36% 9% 0% 100% 9% 5% 14% 5%
Moyamba 12 100% 0% 0% 100% 82% 9% 0% 100% 91% 0% 0% 9%
Pujehun 8 100% 60% 60% 40% 60% 7% 0% 87% 93% 7% 47% 0%
Western Rural 8 72% 4% 4% 96% 72% 4% 4% 100% 14% 0% 45% 0%
Western Urban 21 90% 22% 22% 78% 69% 28% 0% 100% 21% 5% 33% 11%
Facility type
Hospital 39 95% 41% 41% 59% 97% 90% 13% 97% 41% 46% 74% 23%
CHC/Clinic 134 95% 13% 13% 88% 74% 2% 0% 95% 45% 0% 44% 0%
Operating agency
Government/Public 144 96% 14% 14% 87% 79% 8% 2% 95% 47% 5% 48% 2%
Private for-profit 8 64% 0% 0% 100% 78% 37% 0% 93% 29% 0% 37% 7%
Private not-for-profit1 21 100% 44% 44% 56% 63% 44% 3% 100% 36% 16% 50% 13%
Location
Urban 67 89% 20% 20% 80% 74% 29% 4% 99% 35% 12% 40% 7%
Rural 106 98% 14% 14% 87% 80% 3% 1% 93% 51% 2% 52% 1%
Note: 1. CHC - Community Health Centre2. KMC - Kangaroo Mother Care3. Includes NGO, faith-based and mission facilities
Total number of facilities with a water source
Labour and delivery room Operating theatre room Postpartum ward
Facilities with a functioning water
source
Room not available
Facilities with a functioning water
source
Room not available
Facilities with a functioning water
source
Room not available
National 166 87% 0% 14% 82% 71% 9%
District
Kailahun 9 100% 0% 12% 88% 87% 0%
Kenema 16 74% 0% 7% 93% 60% 0%
Kono 11 91% 0% 15% 85% 72% 0%
Bombali 14 58% 0% 15% 76% 37% 25%
Kambia 8 87% 0% 6% 94% 73% 13%
Table 5.4.1 A : Percentage of facilities with functioning water source in selected maternal health service areas of the facility, by district, facility type, operating agency and location, Sierra Leone Rapid EmONC Assessment 2017
128
Total number of facilities with a water source
Labour and delivery room Operating theatre room Postpartum ward
Facilities with a functioning water
source
Room not available
Facilities with a functioning water
source
Room not available
Facilities with a functioning water
source
Room not available
National 166 87% 0% 14% 82% 71% 9%
District
Koinadugu 7 100% 0% 8% 77% 85% 0%
Port Loko 14 92% 0% 20% 80% 92% 0%
Tonkolilii 8 86% 0% 15% 85% 86% 0%
Bo 23 91% 0% 13% 80% 81% 9%
Bonthe 10 78% 0% 11% 89% 44% 33%
Moyamba 12 91% 0% 9% 64% 82% 0%
Pujehun 8 100% 0% 7% 80% 47% 13%
Western Rural 5 100% 0% 6% 94% 53% 0%
Western Urban 21 93% 0% 28% 72% 86% 14%
Facility type
Hospital 39 100% 0% 90% 8% 97% 0%
CHC/Clinic 127 85% 0% 2% 93% 67% 10%
Operating agency
Government/Public 139 88% 0% 8% 88% 69% 8%
Private for-profit 7 72% 0% 52% 48% 100% 0%
Private not-for-profit2 20 85% 0% 47% 35% 76% 16%
Location
Urban 63 88% 0% 33% 66% 74% 11%
Rural 103 87% 0% 3% 90% 69% 8%
Table 5.4.1 A : Percentage of facilities with functioning water source in selected maternal health service areas of the facility, by district, facility type, operating agency and location, Sierra Leone Rapid EmONC Assessment 2017
Note: 1.Other sources include rainwater, spring (maintained or not maintained). 2.Includes NGO, faith-based and mission facilities.
129
Tabl
e 6
.3.1
A: R
egul
ator
y po
licie
s fo
r Em
ON
C si
gnal
func
tion
s, b
y he
alth
wor
ker
cadr
e, S
ierr
a Le
one
Rapi
d Em
ON
C A
sses
smen
t 20
17
Nor
mal
va
gina
l de
liver
y
Adm
inis
ter
pare
nter
al
anti
biot
ics
Adm
inis
ter
uter
oton
ic
drug
s (e
.g.,
pare
nter
al
oxyt
ocin
, is
opro
stol
)
Adm
inis
ter
pare
nter
al
Per
form
man
ual
rem
oval
of
plac
enta
Per
form
rem
oval
of
ret
aine
d p
rodu
cts:
MVA
Per
form
rem
oval
of
ret
aine
d :p
rodu
cts
Per
form
ass
iste
d v
agin
al d
eliv
ery:
w/
vacu
um
Perf
orm
as
sist
ed
vagi
nal
deliv
ery:
w/
forc
eps
Perf
orm
ne
onat
al
Obs
tetr
ical
su
rger
y (e
.g.
cesa
rean
se
ctio
n)
Perf
orm
bl
ood
tran
sfus
ion
Adm
inis
ter
pare
nter
al
Prov
ide
cort
icos
tero
ids
for
pret
erm
la
bour
Prov
ide
imm
edia
te
new
born
ca
re
Obs
tetr
icia
n /
gyna
ecol
ogis
t Y
YY
YY
YY
YY
YY
YN
YY
MD
(GP)
YY
YY
YY
YY
NY
NY
NN
Y
Gen
eral
sur
geon
N
YN
NN
NN
NN
YY
YN
NY
Paed
iatr
icia
nN
YN
NN
NN
NN
NN
YN
NY
Neo
nato
logi
stN
YN
NN
NN
NN
NN
YN
NY
SACH
Os
YY
YY
YY
YY
YY
YY
NY
Y
CHO
sN
YN
NN
NN
NN
NN
NN
NN
Mid
wife
Y
YY
YY
YY
YY
YN
NN
YY
Nur
seY
YY
YN
NN
NN
NN
NN
YY
Anae
sthe
siol
ogis
t (M
D)/
Anae
sthe
tist
NY
YY
NN
NN
NN
NY
YN
Y
Lab
Tech
nici
anN
NN
NN
NN
NN
NN
YN
NN
130
Table 7.1.1A: Percentage of facilities with a supply of medicines with registers and sources of drugs and supplies, by type of facility, Sierra Leone Rapid EmONC Assessment 2017
All facilities National/maternity hospital
Regional hospital
District hospital
Other hospital1 CHCs Clinics
Among all facilities (n=173) (n=1) (n=3) (n=17) (n=18) (n=124) (n=10)
Facility has pharmacy/drug store or a supply of medicine 100% 100% 100% 100% 100% 100% 100%
Among facilities with a pharmacy/drug store or a supply of medicine (n=173) (n=1) (n=3) (n=17) (n=18) (n=124) (n=10)
Drug inventory register exists 94% 100% 100% 100% 100% 95% 77%
Drug inventory register exists and is up-to-date (observed) 90% 100% 100% 100% 100% 89% 86%
Major source of medicine for facility
Government 94% 100% 100% 94% 12% 99% 92%
Private pharmacy 3% 0% 0% 6% 47% 0% 0%
NGO / Mission 3% 0% 0% 0% 29% 1% 8%
Other 1% 0% 0% 0% 12% 0% 0%
Primary source for gloves, syringes and medical supplies2
Government 93% 100% 100% 88% 12% 99% 92%
Private pharmacy 2% 0% 0% 6% 35% 0% 0%
NGO/Mission 4% 0% 0% 0% 47% 1% 8%
Other 1% 0% 0% 6% 6% 0% 0%
Primary source for infection prevention supplies1
Government 92% 100% 100% 88% 18% 97% 92%
Private pharmacy 2% 0% 0% 6% 29% 0% 0%
NGO/Mission 6% 0% 0% 0% 47% 3% 8%
Other 1% 0% 0% 6% 6% 0% 0%
Table 7.1.2A : Percentage of facilities with a pharmacy or supply of medicines that reported stock-out of drugs in the last 12 months, by type of facility, Sierra Leone Rapid EmONC Assessment 2017
Note: 1. Other hospital includes private for-profit, NGO, or faith-based hospital.
All facilities (n=172)1
National/ maternity hospital
(n=1)
Regional hospital
(n=3)
District hospital (n=17)
Other hospital2
(n=17)
CHCs (n=124)
Clinics (n=10)
Antibiotics (in the last 12 months)
Ampicillin 73% 100% 67% 65% 29% 78% 56%
Gentamicin (injection) 72% 100% 50% 55% 60% 72% 86%
Metronidazole (injection) 92% 0% 100% 67% 100% 93% 100%
Penicillin G (Benzyl) 88% 0% 100% 50% 100% 89% 84%
Procaine benzyl penicillin (procaine penicillin G) 93% 0% 100% 50% 100% 93% 100%
Magnesium sulfate
No stock outs in the last 12 months 63% 100% 67% 94% 82% 56% 60%
Stock out in last 12 months 37% 0% 33% 6% 18% 44% 40%
Currently out of stock 53% 0% 0% 50% 57% 54% 57%
Within last month 15% 0% 0% 0% 43% 18% 0%
Within 3 months 20% 0% 50% 25% 0% 23% 16%
Within 6 months 5% 0% 50% 0% 0% 6% 0%
Within 12 months 7% 0% 0% 25% 0% 0% 27%
Never had this drug 1% 0% 0% 6% 6% 0% 8%
131
Table 7.1.2A : Percentage of facilities with a pharmacy or supply of medicines that reported stock-out of drugs in the last 12 months, by type of facility, Sierra Leone Rapid EmONC Assessment 2017
All facilities (n=172)1
National/ maternity hospital
(n=1)
Regional hospital
(n=3)
District hospital (n=17)
Other hospital2
(n=17)
CHCs (n=124)
Clinics (n=10)
Oxytocin
No stock outs in the last 12 months 82% 100% 33% 82% 94% 87% 37%
Stock out in last 12 months 17% 0% 67% 18% 6% 12% 63%
Currently out of stock 53% 0% 50% 67% 100% 41% 70%
Within last month 7% 0% 0% 33% 0% 0% 17%
Within 3 months 37% 0% 50% 0% 0% 53% 14%
Within 6 months 3% 0% 0% 0% 0% 6% 0%
Within 12 months 0% 0% 0% 0% 0% 0% 0%
Never had this drug 1% 0% 0% 0% 0% 1% 0%
Ketamine
No stock outs in the last 12 months 9% 100% 33% 53% 77% 2% 0%
Stock out in last 12 months 19% 0% 67% 29% 24% 17% 21%
Currently out of stock 52% 0% 50% 40% 25% 57% 50%
Within last month 13% 0% 0% 20% 25% 13% 0%
Within 3 months 5% 0% 0% 20% 0% 5% 0%
Within 6 months 8% 0% 50% 0% 25% 0% 50%
Within 12 months 22% 0% 0% 20% 25% 26% 0%
Never had this drug 72% 0% 0% 18% 0% 81% 79%
Atropine
No stock outs in the last 12 months 48% 100% 67% 71% 77% 49% 0%
Stock out in last 12 months 25% 0% 33% 18% 18% 28% 11%
Currently out of stock 52% 0% 0% 33% 67% 51% 100%
Within last month 7% 0% 0% 0% 0% 8% 0%
Within 3 months 21% 0% 0% 0% 0% 24% 0%
Within 6 months 6% 0% 0% 0% 33% 6% 0%
Within 12 months 13% 0% 100% 67% 0% 11% 0%
Never had this drug 27% 0% 0% 12% 6% 24% 90%
Note: 1.One private hospital didn't have a supply of medicine. 2.'Other hospitals' include private for-profit, NGO and faith-based.
Table 7.2.1A: Percentage of facilities with a pharmacy or supply of medicine that have drugs related to the signal functions and emergencies, by type of facility, Sierra Leone Rapid EmONC Assessment 2017
All facilities (n=172)1
National/ maternity hospital
(n=1)
Regional hospital
(n=3)
District hospital (n=17)
Other hospital2
(n=17)
CHCs (n=124)
Clinics (n=10)
Antibiotics (Any) 91% 100% 100% 100% 100% 90% 90%
Amoxicillin 86% 100% 100% 100% 94% 82% 100%
Ampicillin 34% 0% 33% 41% 88% 27% 49%
Cephazoline sodium 9% 0% 33% 18% 29% 7% 12%
Cefixime 11% 100% 67% 59% 53% 3% 12%
Ceftriaxone 76% 100% 100% 88% 94% 77% 41%
Cefotaxime Injection (for newborn) 15% 0% 33% 18% 18% 14% 12%
Chloramphenicol (injection) 16% 0% 67% 24% 59% 11% 23%
Clindamycin 7% 0% 0% 18% 53% 4% 0%
Cloxacillin sodium 20% 100% 100% 77% 77% 10% 12%
132
Table 7.2.1A: Percentage of facilities with a pharmacy or supply of medicine that have drugs related to the signal functions and emergencies, by type of facility, Sierra Leone Rapid EmONC Assessment 2017
All facilities (n=172)1
National/ maternity hospital
(n=1)
Regional hospital
(n=3)
District hospital (n=17)
Other hospital2
(n=17)
CHCs (n=124)
Clinics (n=10)
Erythromicin 66% 100% 100% 71% 94% 65% 53%
Oral flucloxacillin (for newborn) 11% 100% 0% 24% 35% 8% 17%
Gentamicin (injection) 56% 100% 33% 71% 100% 52% 50%
Metronidazole (injection) 44% 100% 33% 65% 94% 38% 53%
Penicillin G (benzyl/x-pen) 41% 0% 67% 71% 88% 37% 23%
Procaine benzylpenicillin 48% 0% 33% 71% 47% 50% 12%
Trimethoprim/sulfamethoxazole 50% 100% 100% 65% 71% 48% 29%
Tetracycline eye ointment/drops 44% 100% 100% 94% 77% 38% 29%
Anticonvulsants (Any) 96% 100% 100% 100% 100% 97% 79%
Magnesium sulfate (injection) - 50% Concentration 89% 100% 100% 77% 65% 93% 77%
Magnesium sulfate (injection) - Concentration other than 50% 45% 100% 0% 65% 53% 45% 29%
Diazepam (injection) 91% 100% 67% 94% 94% 93% 66%
Phenobarbital (injection) 23% 0% 33% 53% 29% 22% 0%
Phenytoin (diphenylhydantoin) 12% 0% 67% 53% 65% 5% 0%
Antihypertensives (Any) 87% 100% 100% 94% 88% 88% 79%
Hydralazine 37% 100% 67% 94% 67% 33% 0%
Labetalol 8% 0% 0% 19% 40% 6% 0%
Methyldopa 94% 100% 100% 94% 87% 95% 90%
Nifedipine 31% 100% 67% 94% 87% 22% 23%
Oxytocics (Any) 96% 100% 100% 100% 100% 97% 79%
Ergometrine (injection) 59% 100% 33% 71% 100% 57% 43%
Methylergometrine maleate 52% 100% 67% 71% 59% 51% 39%
Misoprostol 34% 100% 100% 53% 59% 31% 23%
Oxytocin 92% 100% 67% 88% 94% 94% 77%
Prostaglandin E2 (dinoprostone) 4% 0% 0% 18% 12% 3% 0%
Drugs used in emergencies (any) 95% 100% 100% 100% 100% 96% 70%
Adrenaline (epinephrine) 80% 100% 67% 94% 82% 80% 63%
Aminophylline 18% 100% 33% 53% 71% 11% 11%
Atropine 58% 100% 100% 82% 82% 58% 11%
Calcium gluconate 66% 100% 33% 65% 71% 68% 37%
Digoxin 10% 100% 0% 29% 65% 5% 11%
Diphenhydramine 7% 0% 67% 29% 29% 3% 0%
Ephedrine 16% 100% 0% 47% 71% 11% 0%
Frusemide 34% 100% 100% 94% 88% 27% 11%
Hydrocortisone 42% 100% 67% 77% 82% 39% 0%
Naloxone 5% 0% 0% 18% 41% 1% 11%
Nitroglycerine 6% 0% 0% 12% 47% 2% 11%
Promethazine 82% 100% 67% 100% 82% 82% 67%
Note: 1. One private hospital didn't have a supply of medicine.2. 'Other hospitals' include private for-profit, NGO and faith-based.
133
Table 7.2.2A: Percentage of facilities with a pharmacy or supply of medicines that have anaesthetics and other drugs, by type of facility, Sierra Leone Rapid EmONC Assessment 2017
All facilities (n=172)1
National/ maternity hospital
(n=1)
Regional hospital
(n=3)
District hospital (n=17)
Other hospital2
(n=17)
CHCs (n=124)
Clinics (n=10)
Anaesthetics (any) 82% 100% 100% 94% 94% 81% 79%
Halothane 6% 100% 33% 50% 31% 0% 0%
Ketamine 16% 0% 67% 81% 94% 5% 0%
Lignocaine/Lidocaine 2% or 1% 99% 100% 100% 100% 100% 99% 100%
Analgesics (any) 83% 100% 100% 100% 100% 79% 90%
Acetylsalicylic acid 58% 100% 100% 82% 65% 58% 26%
Indomethacin 8% 0% 0% 12% 12% 8% 0%
Morphine 10% 0% 33% 53% 29% 4% 12%
Paracetamol 89% 100% 100% 100% 100% 88% 88%
Pethidine 8% 0% 0% 41% 29% 3% 10%
Tocolytics (any) 25% 100% 67% 82% 88% 18% 8%
Indomethacin 20% 0% 0% 14% 13% 26% 0%
Ritodrine 15% 0% 0% 14% 13% 17% 0%
Salbutamol 85% 100% 100% 100% 100% 74% 100%
Steroids (any) 75% 100% 100% 94% 100% 73% 70%
Betamethasone (injection) 22% 100% 67% 63% 59% 14% 15%
Dextamethasone (injection) 73% 100% 67% 81% 94% 71% 64%
Prednisone 46% 100% 33% 69% 65% 43% 33%
Prednisolone corticosteriod 43% 0% 0% 69% 65% 44% 0%
IV Fluids (any) 92% 100% 100% 100% 100% 94% 64%
Dextrose 76% 100% 67% 77% 88% 75% 70%
Dextran 15% 0% 33% 41% 24% 12% 16%
Glucose 5% 89% 100% 67% 88% 94% 89% 86%
Glucose 10% 28% 0% 0% 41% 53% 27% 16%
Glucose 40% or 50% 53% 0% 33% 59% 59% 54% 29%
Normal saline 85% 100% 67% 88% 88% 85% 84%
Ringer's lactate 82% 100% 100% 88% 100% 79% 100%
Antimalarials (any) 92% 100% 100% 100% 94% 92% 81%
Chloroquine 7% 0% 0% 0% 31% 5% 13%
Fansidar 94% 100% 100% 100% 100% 92% 100%
Artemisium-based combination therapy (ACT) (coartem, arthemeter) 63% 100% 100% 71% 88% 59% 68%
Quinine dihydrochloride
Antiretrovirals (any) 84% 100% 67% 77% 88% 86% 74%
Nevaripine (for mother 62% 100% 100% 62% 60% 64% 35%
Nevaripine (for newborn) 65% 0% 100% 85% 87% 63% 53%
Post-HIV exposure prophylactic treatment 57% 0% 50% 77% 93% 57% 25%
Combined ARVs for mother 81% 0% 100% 100% 93% 84% 26%
Combined ARVs for newborn 44% 0% 50% 69% 80% 43% 11%
Note: 1.One private hospital didn't have a supply of medicine.
134
Table 7.2.3A: Percentage of facilities with a pharmacy or supply of medicines that had contraceptives and other drugs, by type of facility, Sierra Leone Rapid EmONC Assessment 2017
All facilities (n=172)1
National/ maternity hospital
(n=1)
Regional hospital
(n=3)
District hospital (n=17)
Other hospital2
(n=17)
CHCs (n=124)
Clinics (n=10)
Contraceptives (any) 98% 100% 100% 94% 94% 99% 100%
Combined oral contraceptives 73% 0% 67% 94% 50% 72% 82%
Implants 77% 100% 67% 88% 50% 81% 47%
3 month injectables 53% 100% 33% 100% 50% 48% 69%
IUDs 59% 100% 0% 81% 31% 63% 26%
Male condoms 89% 100% 67% 94% 88% 90% 79%
Female condoms 62% 100% 0% 56% 56% 68% 18%
Emergency contraception 66% 100% 33% 81% 50% 68% 52%
Other drugs
Vitamin K (newborn) 35% 100% 67% 100% 100% 25% 38%
Nystatin (oral) (for newborn) 76% 0% 100% 88% 77% 79% 37%
Oral rehydration solution 87% 100% 67% 100% 94% 85% 90%
Gentian violet paint 23% 0% 0% 29% 59% 21% 18%
Ferrous sulfate or fumarate 83% 100% 100% 88% 100% 82% 69%
Folic acid 76% 100% 100% 94% 100% 73% 69%
Heparin 9% 100% 0% 41% 41% 6% 0%
Magnesium trisilicate 66% 100% 100% 100% 71% 65% 47%
Sodium citrate 10% 0% 0% 24% 29% 9% 0%
Anti-tetanus serum 18% 0% 0% 35% 41% 15% 26%
Tetanus toxoid vaccine 86% 0% 33% 59% 82% 89% 83%
Anti-Rho (D) immune globulin 5% 0% 0% 12% 29% 4% 0%
Insecticide-treated bednets (ITNs) 93% 100% 0% 65% 77% 98% 91%
Note: 1. One private hospital didn't have a supply of medicine. 2. 'Other hospitals' include private for-profit, NGO and faith-based.
Table 7.3.1A : Percentage of facilities that have the indicated guidelines in the maternity ward, by type of facility, Sierra Leone Rapid EmONC Assessment 2017
Guidelines or protocols All facilities (n=172)1
National/ maternity hospital
(n=1)
Regional hospital
(n=3)
District hospital (n=17)
Other hospital2
(n=17)
CHCs (n=124)
Clinics (n=10)
Management of obstetric and newborn complications1 87% 100% 100% 82% 83% 88% 81%
Immediate newborn care 92% 100% 67% 88% 89% 94% 81%
Kangaroo Mother Care 69% 100% 67% 59% 56% 72% 52%
Focused antenatal care 93% 100% 67% 82% 83% 95% 90%
HIV PMTCT (maternal and newborn dosing) 92% 100% 67% 94% 83% 94% 84%
Infection prevention for HIV/AIDS (universal precautions) 91% 100% 67% 94% 89% 92% 82%
Safe abortion 51% 0% 33% 77% 39% 53% 21%
Post-abortion care 71% 0% 67% 88% 67% 75% 21%
Family planning 93% 0% 67% 88% 67% 97% 90%
Note1. Includes a package of guidelines on management of obstetric complications (e.g., postpartum haemorrhage, AMTSL, use of oxytocin, misoprostol, etc)2. 'Other hospitals' include private for-profit, NGO and faith-based.
135
Table 7.3.2A : Percentage of facilities with basic and emergency newborn supplies and equipment in the maternity area1, by type of facility, Sierra Leone Rapid EmONC Assessment 2017
All facilities (n=172)1
National/ maternity hospital
(n=1)
Regional hospital
(n=3)
District hospital (n=17)
Other hospital2
(n=17)
CHCs (n=124)
Clinics (n=10)
Supplies and equipment needed for newborn
Fetal stethoscope 97% 100% 100% 100% 100% 96% 100%
Rectal thermometer for newborn 23% 0% 0% 41% 50% 21% 18%
Low reading thermometer (32 or 35 degree C) 53% 0% 100% 59% 67% 52% 46%
IV fluid (neonatal giving) set/umbilical catheter 51% 100% 67% 65% 56% 48% 63%
Baby weighing scale 89% 100% 100% 94% 94% 90% 74%
Neonatal resuscitating table 86% 100% 100% 77% 89% 88% 76%
Incubator 8% 0% 0% 12% 28% 8% 0%
Radiant warmer 12% 100% 33% 41% 39% 9% 0%
Icterometer 3% 0% 33% 12% 11% 2% 0%
Fluorescent tubes for phototherapy to treat jaundice 2% 0% 0% 6% 28% 0% 0%
Apnoea monitor 9% 0% 33% 47% 22% 6% 0%
Paladay / small cup for breast milk expression 27% 0% 0% 41% 61% 25% 15%
Towels or cloth for newborn 36% 100% 0% 24% 67% 37% 8%
Neonatal resuscitation pack
Mucus extractor 96% 100% 100% 100% 94% 97% 92%
Infant face masks (sizes 0, 1, 2) 90% 100% 67% 94% 89% 92% 76%
Ambu (Ventilatory) bag 96% 100% 100% 100% 94% 96% 92%
Suction catheter 10, 12 Ch 79% 0% 33% 94% 78% 79% 76%
Infant laryngoscope with spare bulb & batteries 9% 0% 0% 29% 33% 5% 21%
Endotracheal tubes 3.5, 3.0 19% 0% 33% 41% 50% 15% 21%
Disposable uncuffed tracheal tubes (sizes 2.0 to 3.5) 11% 0% 67% 29% 28% 8% 11%
Suction apparatus: Foot – or electrically-operated 27% 0% 67% 71% 67% 21% 19%
Mucus trap for suction 46% 100% 67% 59% 72% 43% 48%
Note: 1. For hospitals, the maternity area was likely to be a specific room and these questions were related to the equipment and supplies available in that specific room. Health centres may not have had a specific room devoted for a maternity ward and these questions were therefore related to whether the facility, in general, had the equipment and supplies available. 2. 'Other hospitals' include private for-profit, NGO and faith-based.
Table 7.3.3A : Percentage of facilities with basic diagnostics and supplies in the maternity area1, by type of facility, Sierra Leone Rapid EmONC Assessment 2017
All facilities (n=172)1
National/ maternity hospital
(n=1)
Regional hospital
(n=3)
District hospital (n=17)
Other hospital2
(n=17)
CHCs (n=124)
Clinics (n=10)
Diagnostics
Ultrasound 17% 100% 100% 53% 83% 9% 8%
BP cuff 85% 100% 100% 100% 100% 82% 91%
Stethoscope 96% 100% 100% 100% 100% 94% 100%
Clinical oral thermometer 60% 100% 33% 65% 44% 62% 53%
Uristix (dip stick for protein in urine) 66% 100% 67% 82% 78% 67% 41%
Blood sugar testing sticks 24% 0% 33% 71% 83% 17% 21%
Partographs (modified WHO form) 96% 100% 100% 100% 94% 96% 92%
Pulse oximeter 16% 0% 33% 65% 78% 10% 0%
136
Table 7.3.3A : Percentage of facilities with basic diagnostics and supplies in the maternity area1, by type of facility, Sierra Leone Rapid EmONC Assessment 2017
All facilities (n=172)1
National/ maternity hospital
(n=1)
Regional hospital
(n=3)
District hospital (n=17)
Other hospital2
(n=17)
CHCs (n=124)
Clinics (n=10)
Supplies
Kidney basins 98% 100% 100% 100% 94% 98% 100%
Sponge bowls 81% 100% 67% 100% 72% 81% 73%
Scissors 97% 100% 100% 100% 94% 96% 100%
Needles and Syringes (10-20cc) 84% 100% 100% 100% 94% 82% 82%
Syringes (1ml, 2ml, 5ml, 10ml) 93% 100% 100% 100% 94% 93% 85%
Needles (23-25 gauge) 79% 100% 100% 82% 94% 78% 81%
Suture needles/suture materials3 52% 100% 100% 100% 89% 46% 39%
Catheter for IV line (16-18)3 85% 100% 100% 100% 89% 86% 60%
IV Infusion stand(s) 84% 100% 100% 100% 94% 85% 48%
Urinary catheters 91% 100% 100% 100% 94% 93% 70%
IV cannulae 91% 100% 100% 100% 94% 89% 100%
Adult ventilator bag and mask 75% 100% 67% 100% 78% 77% 40%
Mouth gag 53% 0% 33% 71% 78% 51% 45%
Dressing forceps 89% 0% 100% 94% 72% 89% 100%
Surgeon’s handbrush w/ nylon bristles 35% 0% 67% 88% 61% 30% 21%
Watch or clock with second hand that can be easily seen 88% 100% 67% 88% 100% 89% 74%
Measuring tape 96% 100% 67% 100% 100% 98% 77%
Nasogastric tubes 48% 0% 67% 82% 78% 46% 18%
HIV rapid test kits 93% 100% 100% 94% 94% 95% 69%
Note: 1. For hospitals, the maternity area was likely to be a specific room and these questions were related to the equipment and supplies available in that specific room. Health centres may not have had a specific room devoted for a maternity ward and these questions were therefore related to whether the facility, in general, had the equipment and supplies available. 2. 'Other hospitals' include private-for-profit, NGO and faith-based.
Table 7.3.5A : Percentage of facilities with autoclave, sterilization and incineration items in the maternity area, by type of facility, Sierra Leone Rapid EmONC Assessment 2017
All facilities (n=172)1
National/ maternity hospital
(n=1)
Regional hospital
(n=3)
District hospital (n=17)
Other hospital2
(n=17)
CHCs (n=124)
Clinics (n=10)
Autoclave, sterilization equipment and incineration
Separate autoclave room 19% 100% 100% 53% 61% 15% 0%
Autoclave (with temperature and pressure gauges) 52% 100% 100% 71% 78% 52% 21%
Hot air sterilizer (dry oven) 16% 100% 67% 24% 39% 13% 9%
Steam sterilizer 58% 100% 100% 65% 56% 58% 47%
Steam Instrument sterilizer / Pressure cooker (electric) 20% 100% 67% 41% 44% 18% 0%
Sterilizer / pressure cooker (kerosene heated) 19% 100% 0% 24% 22% 20% 0%
Sterilization drum 57% 100% 100% 71% 72% 57% 30%
Sterilization drum stand 20% 100% 67% 47% 44% 18% 0%
Functioning incinerator 78% 100% 100% 71% 89% 82% 27%
Note: 1.For hospitals, the maternity area was likely to be a specific room and these questions were related to the items available in that specific room. Health centres may not have had a specific room devoted to a maternity ward and these questions were therefore related to whether the facility, in general, had the items available. 2.'Other hospitals' include private-for-profit, NGO and faith-based.
137
Table 7.5.1A: Percentage of facilities with a laboratory and among those the percentage with equipment and supplies for blood transfusion, by type of facility, Sierra Leone Rapid EmONC Assessment 2017
All facilities National/ Maternity hospital
Regional hospital
District hospital
Other hospital CHCs Clinics
Among all facilities (n=173) (n=1) (n=3) (n=17) (n=18) (n=124) (n=10)
Facility has a laboratory 51% 100% 100% 100% 94% 46% 21%
Among facilities with a laboratory (n=96) (n=1) (n=3) (n=17) (n=17) (n=56) (n=2)
Facility has set of guidelines for laboratory 78% 100% 100% 94% 82% 75% 50%
Equipment & supplies for blood transfusions
Refrigerator 17% 100% 100% 59% 65% 2% 0%
Test tubes - small size 44% 100% 33% 77% 88% 31% 50%
Test tubes - medium size 40% 100% 0% 71% 82% 27% 100%
Slides (microscope) 64% 0% 67% 82% 82% 58% 100%
Compound microscope 13% 100% 33% 24% 41% 7% 0%
Microscope illuminator 21% 100% 33% 53% 53% 11% 0%
Blood lancets 56% 100% 100% 94% 88% 42% 100%
Cotton wool 66% 100% 100% 94% 88% 56% 100%
Rack 53% 100% 67% 77% 88% 44% 50%
8.5 g/l Sodium Chloride solution 43% 0% 67% 59% 77% 35% 50%
20% Bovine albumin 11% 100% 33% 24% 18% 7% 0%
Centrifuge (electric) 26% 100% 100% 94% 82% 3% 50%
Centrifuge (hand driven) 10% 0% 0% 24% 47% 3% 0%
37o Water bath (or incubator) 15% 100% 67% 59% 29% 5% 0%
Pipettes volumetric, 1ml 28% 0% 0% 53% 94% 14% 50%
Pipettes volumetric, 2ml 23% 0% 0% 53% 82% 12% 0%
Pipettes volumetric, 3ml 20% 0% 0% 41% 77% 10% 0%
Pipettes volumetric, 5ml 21% 0% 0% 47% 82% 10% 0%
Pipettes volumetric, 10ml 15% 0% 0% 35% 82% 4% 0%
Pipettes volumetric, 20ml 15% 0% 0% 29% 71% 5% 0%
Pipette holder of 10 pieces 13% 0% 33% 24% 53% 4% 50%
Blood typing and cross-matching reagents 23% 100% 100% 65% 88% 5% 0%
Bags for collecting blood 18% 100% 67% 71% 77% 0% 0%
Airway needle for collecting blood 24% 0% 100% 77% 77% 8% 0%
Artery forceps 20% 100% 33% 29% 71% 9% 50%
Anticoagulant bottles/ vacuum system 14% 100% 0% 47% 65% 2% 0%
Scale for blood collection 13% 100% 100% 35% 53% 2% 0%
Hepatitis B test 28% 100% 100% 82% 88% 7% 50%
Hepatitis C test 25% 100% 100% 82% 94% 5% 0%
HIV test 87% 100% 100% 88% 94% 85% 100%
Syphilis test 38% 100% 67% 77% 94% 25% 0%
Note: 1. 'Other hospitals' include private-for-profit, NGO and faith-based.
138
Table 7.5.2A: Percentage of facilities with a laboratory that have basic laboratory supplies, by type of facility, Sierra Leone Rapid EmONC Assessment 2017
All facilities (n=96)
National/ Maternity hospital
(n=1)
Regional hospital
(n=3)
District hospital (n=17)
Other hospital (n=17)
CHCs (n=56)
Clinics (n=2)
Basic laboratory supplies
Microscope 95% 100% 100% 100% 100% 95% 50%
Immersion oil 81% 0% 33% 94% 100% 79% 50%
Glass rods 55% 0% 0% 53% 65% 59% 0%
Sink or staining tank 70% 100% 67% 82% 82% 67% 50%
Measuring cylinder (25 ml) polypropylene 23% 0% 0% 35% 77% 16% 0%
Measuring cylinder (50 ml) polypropylene 17% 0% 33% 29% 71% 8% 0%
Measuring cylinder (100 ml) polypropylene 18% 0% 33% 41% 88% 5% 0%
Measuring cylinder (250 ml) polypropylene 18% 0% 67% 35% 82% 3% 50%
Measuring cylinder (500 ml) polypropylene 18% 0% 67% 35% 82% 3% 50%
Wash bottle 39% 0% 67% 59% 53% 33% 50%
Bottle containing buffered water 44% 100% 0% 47% 77% 40% 50%
Timer clock with alarm 59% 100% 67% 65% 82% 57% 0%
Rack for drying slides 83% 100% 100% 82% 100% 81% 50%
Giemsa stain 53% 0% 67% 82% 100% 41% 50%
Wright stain 18% 0% 0% 24% 12% 20% 0%
May Grunwald stain 10% 0% 0% 12% 12% 10% 0%
Funnel and filter paper 59% 0% 0% 59% 94% 56% 50%
Methanol 67% 0% 33% 59% 94% 66% 50%
Refrigerator for laboratory supplies 44% 100% 100% 88% 88% 31% 0%
Glass containers 55% 0% 33% 59% 77% 54% 0%
Counting chamber (Differential counter) 30% 0% 100% 77% 88% 12% 50%
Pipette (5 ml) 43% 0% 33% 53% 82% 36% 50%
Pipette (graduated, 1.0 ml) 28% 0% 0% 29% 82% 20% 50%
Dropping pipette 45% 0% 33% 71% 88% 35% 50%
Cover slips 55% 0% 0% 77% 94% 48% 50%
Petri dishes 27% 0% 100% 47% 71% 15% 50%
Bowls, kidney dishes, stainless steel, different sizes 43% 100% 33% 41% 88% 36% 50%
Tork diluting solution 19% 100% 33% 41% 71% 7% 0%
Tally counter 24% 0% 67% 71% 88% 5% 50%
Haemoglobinometer + hydrochloride acid solution 22% 100% 0% 24% 47% 16% 50%
Spectrophotometer (symex, screenplus) 6% 100% 67% 18% 18% 0% 0%
Microhaematocrit centrifuge (manual or electric) 18% 100% 33% 59% 77% 3% 0%
Scale/balance for reading results 26% 100% 67% 24% 47% 22% 0%
Heparinized capillary tubes (75 mm x 1.5 mm) 29% 100% 33% 47% 77% 17% 50%
Spirit lamp 43% 100% 67% 47% 53% 41% 0%
Ethanol 60% 100% 0% 41% 88% 58% 100%
Dip sticks (Coubec-10 or URS-10) 47% 100% 0% 47% 88% 44% 0%
Test-tubes 66% 100% 67% 82% 100% 56% 100%
Test-tube holder/rack 57% 100% 67% 82% 100% 47% 50%
Beaker: 100 ml 22% 100% 33% 41% 59% 13% 0%
Beaker: 250 ml 20% 100% 67% 29% 59% 9% 50%
Beaker: 1000 ml 12% 0% 67% 18% 59% 4% 0%
139
Table 7.5.2A: Percentage of facilities with a laboratory that have basic laboratory supplies, by type of facility, Sierra Leone Rapid EmONC Assessment 2017
All facilities (n=96)
National/ Maternity hospital
(n=1)
Regional hospital
(n=3)
District hospital (n=17)
Other hospital (n=17)
CHCs (n=56)
Clinics (n=2)
Basic laboratory supplies
Ammonia 7% 0% 0% 12% 41% 2% 0%
Lugol’s iodine solution 21% 100% 33% 35% 77% 10% 0%
CD 4 machine 6% 100% 33% 35% 6% 0% 0%
Units of blood ready for transfusion 390 70 137 107 76 0 0
Note: 1.. 'Other hospitals' include private-for-profit, NGO and faith-based.
Table 8.2.1A: Percentage distribution of facilities according to distance to nearest facility that provides surgical services by facility type and district, Sierra Leone Rapid EmONC Assessment 2017
Hospitals CHCs/clinics
Number of hospitals
that provided surgery in the last 3 months
Number of hospitals that did
not provide surgery in the last 3 months
Among facilities that did not provide surgery, distance to nearest facility that provided surgery in the last 3 months
Number of hospitals
that provided surgery in the last 3 months
Number of hospitals that did
not provide surgery in the last 3 months
Among health centres/clinics that did not provide surgery, distance to nearest facility that provided
surgery in the last 3 months
≤25 kms
26-50 kms
>50 kms
Don't know/
missing
≤25 kms
26-50 kms
>50 kms
Don't know/
missing
National 32 7 86% 0% 0% 14% 1 133 46% 26% 19% 9%
District
Kailahun 1 1 100% 0% 0% 0% 0 7 27% 40% 27% 7%
Kenema 2 0 . . . . 0 15 32% 46% 21% 0%
Kono 1 0 . . . . 1 9 60% 20% 20% 0%
Bombali 4 0 . . . . 0 10 41% 41% 18% 0%
Kambia 1 0 . . . . 0 7 13% 13% 60% 13%
Koinadugu 1 0 . . . . 0 6 33% 17% 50% 0%
Port Loko 4 0 . . . . 0 10 38% 38% 13% 13%
Tonkolilii 2 0 . . . . 0 7 46% 23% 31% 0%
Bo 4 1 0% 0% 0% 100% 0 18 67% 11% 11% 11%
Bonthe 2 0 . . . . 0 10 70% 20% 10% 0%
Moyamba 1 1 100% 0% 0% 0% 0 10 10% 10% 40% 40%
Pujehun 1 0 . . . . 0 7 46% 23% 15% 15%
Western Rural 1 0 . . . . 0 7 70% 30% 0% 0%
Western Urban 7 4 100% 0% 0% 0% 0 10 59% 11% 0% 30%
Location
Urban 28 5 80% 0% 0% 20% 1 33 68% 17% 2% 12%
Rural 4 2 100% 0% 0% 0% 0 100 37% 29% 26% 8%
140
Table 8.2.2A: Percentage distribution of facilities according to time to nearest facility that provides obstetric surgery, by facility type and district, Sierra Leone Rapid EmONC Assessment 2017
Hospitals CHCs/clinics
Number of hospitals
that provided surgery in the last 3 months
Number of hopitals
that did not provide
surgery in the last 3 months
Among hospitals that did not provide surgery, time to nearest facility that provided surgery in
the last 3 months
Number of health centres/
clinics that provided surgery in the last 3 months
Number of health centres/clinics that did
not provide surgery in the last 3 months2
Among health centres/clinics that did not provide surgery, time
to nearest facility that provided surgery in the last 3 months
<30 min
30-59 min
≥1 hour
Don't know/
missing
<30 min
30-59 min
≥1 hour
Don't know/
missing
National 31 7 71% 14% 0% 14% 1 133 25% 25% 40% 9%
District
Kailahun 1 1 100% 0% 0% 0% 0 7 13% 13% 73% 0%
Kenema 2 0 . . . . 0 15 21% 39% 39% 0%
Kono 1 0 . . . . 1 9 27% 13% 47% 13%
Bombali 4 0 . . . . 0 10 18% 18% 59% 5%
Kambia 1 0 . . . . 0 7 0% 27% 73% 0%
Koinadugu 1 0 . . . . 0 6 33% 17% 50% 0%
Port Loko 4 0 . . . . 0 10 63% 19% 19% 0%
Tonkolilii 2 0 . . . . 0 7 15% 31% 54% 0%
Bo 4 1 0% 0% 0% 100% 0 18 44% 30% 19% 7%
Bonthe 2 0 . . . . 0 10 20% 30% 40% 10%
Moyamba 1 1 100% 0% 0% 0% 0 10 10% 10% 30% 50%
Pujehun 1 0 . . . . 0 7 0% 38% 46% 15%
Western Rural 1 0 . . . . 0 7 0% 44% 56% 0%
Western Urban 6 4 75% 25% 0% 0% 0 10 59% 11% 0% 30%
Location
Urban 25 5 60% 20% 0% 20% 1 33 43% 22% 20% 15%
Rural 6 2 100% 0% 0% 0% 0 100 17% 26% 49% 7%
Table 8.4.1A: Percentage of facilities with at least one mode of functional motorized transport and maintenance mechanisms, by district, facility type, operating agency and location, Sierra Leone Rapid EmONC Assessment 2017
Total number
of facilities
At least one functioning
mode of motorized transport
Facilities with at least one mode of functioning motorized transport
Have a responsible body to ensure that motorized vehicles are in order
Have available source of
tools, spare parts and mechanics
for maintenance
Have funds available today if
needed for maintenance/
repair
Have sufficient
fuel available to transport women and newborns if
needed
Facility Director
Facility Administrator
District Health Office
Other body1
No one/ Not
applicable
National 173 53 88% 82% 85% 10% 63% 10% 15% 3%
District
Kailahun 9 4 100% 66% 84% 0% 32% 68% 0% 0%
Kenema 17 3 52% 52% 52% 0% 52% 0% 0% 48%
Kono 11 2 100% 100% 100% 63% 37% 0% 0% 0%
Bombali 14 4 50% 75% 100% 0% 25% 0% 75% 0%
Kambia 8 1 100% 100% 100% 0% 100% 0% 0% 0%
Koinadugu 7 5 100% 89% 100% 22% 78% 0% 0% 0%
Port Loko 14 5 100% 100% 82% 0% 100% 0% 0% 0%
Tonkolilii 9 2 100% 100% 100% 0% 100% 0% 0% 0%
141
Table 8.4.1A: Percentage of facilities with at least one mode of functional motorized transport and maintenance mechanisms, by district, facility type, operating agency and location, Sierra Leone Rapid EmONC Assessment 2017
Total number
of facilities
At least one
functioning mode of
motorized transport
Facilities with at least one mode of functioning motorized transport
Have a responsible body to ensure that motorized vehicles are in order
Have available source of
tools, spare parts and
mechanics for maintenance
Have funds available today if
needed for maintenance/
repair
Have sufficient
fuel available to transport women and newborns if
needed
Facility Director
Facility Administrator
District Health Office
Other body1
No one/ Not
applicable
National 173 53 88% 82% 85% 10% 63% 10% 15% 3%
District
Bo 23 5 60% 80% 100% 40% 60% 0% 0% 0%
Bonthe 12 3 100% 50% 75% 0% 50% 50% 0% 0%
Moyamba 12 3 100% 100% 100% 0% 100% 0% 0% 0%
Pujehun 8 3 61% 79% 100% 0% 21% 0% 79% 0%
Western Rural 8 3 79% 100% 21% 0% 21% 0% 79% 0%
Western Urban 21 10 100% 76% 84% 8% 84% 8% 0% 0%
Facility Type
Hospital 39 36 87% 76% 87% 8% 81% 3% 8% 0%
CHC/Clinic 134 17 89% 88% 83% 11% 42% 19% 23% 6%
Operating agency
Government/Public 144 34 86% 77% 77% 6% 56% 15% 18% 4%
Private-for-profit 8 4 100% 100% 100% 25% 75% 0% 0% 0%
Private not-for-profit2 21 15 90% 90% 100% 14% 76% 0% 10% 0%
Location
Urban 67 34 91% 79% 79% 11% 66% 2% 20% 0%
Rural 106 19 83% 86% 93% 7% 57% 22% 7% 7%
Note1 Includes: Transport Officer/Opertion Manager, Midwife, Military Commandant, and Quam 2. Includes NGO, faith-based, or mission facilities.
Appendix B. Minimum required drugs, equipment and supplies for determining readiness to perform EmONC signal functions
Signal function Minimum required drugs, equipment, and supplies
Antibiotics
Hospitals:
Ampicillin AND (metronidazole OR clindamycin) AND gentamicin
-OR-
Ceftriaxone AND (clindamycin OR metronidazole) AND gentamicin
Community Health Centres/clinics:
Ampicillin AND gentamicin
-OR-
Ceftriaxone AND gentamicin
Oxytocics
Oxytocin
-OR-
Ergometrine (injection)
Anticonvulsants
Magnesium sulphate (any concentration)
-OR-
Diazepam
142
Appendix B. Minimum required drugs, equipment and supplies for determining readiness to perform EmONC signal functions
Signal function Minimum required drugs, equipment, and supplies
Manual removal of placenta Long-sleeve gloves (elbow length OR disposal exam gloves)
Removal of retained products
MVA/EVA equipment: Complete MVA kit OR (electric aspirator AND dilators) OR (vacuum aspirator AND lubricant
AND various sized cannulae) AND local anaesthesia
-OR-
D&C equipment: (Sharp curettes OR blunt curettes) AND uterine dilators AND local anaesthesia
AVD
Functioning vacuum extractor AND different size cups
-OR-
ForcepsResuscitate newborn with bag and mask Ambu bag and masks (0 or 1) AND suction equipment (mucus extractor OR suction aspirator OR mucus trap)
Obstetric surgery/ caesarean
Functioning anaesthesia machine AND (halothane OR ketamine)
-OR-
Regional anaesthesia (ligno/lido 2% OR 1%)
-AND-
Having an OT, functioning oxygen cylinders AND operating table AND functioning adjustable light
Blood transfusion
All facilities:
Reagents for blood typing/cross matching AND functioning refrigerator for blood bank
If the source of blood is not the central blood supply it must be direct donation or a facility blood bank:
Items listed above AND empty blood bags AND microscope AND blood tests for Hep B, Hep C, HIV and syphilis
Sources: 1. World Health Organization. 2010. Monitoring the building blocks of health systems: a handbook of indicators and their measurement strategies. 2. WHO, UNFPA, UNICEF, AMDD. 2009. Monitoring emergency obstetric care: a handbook. Geneva: World Health Organization. 3. Ministry of Health and Sanitation (MoHS). 2015. ‘Sierra Leone Basic Packages of Essential Health Services (BPEHS), 2015–2020’.
Appendix C. List of Technical Working Group members and data collectors
Supervisors Data collectors
Seibatu Bonnie Dennis Davies
Andrew Kemoh Paul KattaMariama Kanneh Frederick J. MomohErnest Jabbie Sarah Grace SandyGassimu Fofanah Hannah WilliamsUmu Bayoh Andrew S. KamaraMohammed A Sesay Aiah JimmyChristiana L Sankoh Princess A. FodayMuskula Conteh John TawarallyCecilia Woode Isata J. KamaraMbalu Kamara Eddie MoussaSahid Dumbuya Dora BoyleLauretta Wusman Emmanuel LuseniAminata E Lahai Samuel D. Nautty
Josephine Jackson
Saad Barrie
Desmond Conteh
Roselyn Finney
Marian Browne
William George
Mohammed T. Bayoh
Marie Koroma
Alusine Sesay
Marie Smith
Fasuluku Bayoh
Harris Josiah
Abdul Farama
143
Appendix D. List of facilities surveyed
District Hospital CHC Clinic
Western Area - Freetown
Rokupa Government Hospital Grassfield CHC WESLEYAN Marie Stopes (Kissy) Clinic
United Methodist Church Urban Centre Hospital Kissy CHC PAYCY's Clinic
Macauley Street Government Hospital Waterloo CHC Benguema Military (MI Room) ClinicKingtom Police Hospital Calaba Town CHC Borah Maternity ClinicPrincess Christian Maternity Hospital Goderich CHC Elshadai ClinicSierra Leone-China Teaching Hospital Hastings CHC Jui Police (MI Room) ClinicLumley Government Hospital Regent (Western Rural) CHC Mutual Faith ClinicWilberforce 34 Military Hospital Tombo (York Rural) CHC Konikay ClinicKingharman Road Hospital St Joseph's CHC Marie Stopes (Aberdeen Rd) ClinicAberdeen Women Centre Hospital Ross Road CHC Marie Stopes (Ahmed Drive) OutreachChoithrams Memorial Hospital Wellington CHC Red Cross (Pultney Street) ClinicDr Victor Willoughby Memorial Hospital SLIMS ClinicBlue Shield Hospital
Bo
Bo Government Hospital Gondama (Tikonko) CHC Marie Stopes (Kakua) ClinicGilas Hospital Jembe CHCKindoyal Hospital Koribondo CHCMercy Ships (Kakua) Hospital Mongere CHCSerabu Mission Hospital New Police Barracks CHC
Ngalu CHCNgolahun (Bumpe Ngao) CHCNjala (Komboya) CHCSerabu (Bumpe Ngao) CHCSumbuya (Lugbu) CHCAgape CHCBumpe CHCDamballa CHCGbotima CHCGboyama CHCGerehun CHCYemoh Town CHCYamandu CHC
Pujehun District
Pujehun Government Hospital Bandajuma CHCBumpeh (Galliness Perri) CHCGbondapi CHCJendema CHCPotoru CHCSahn (Malen) CHCZimmi CHC
Kenema District
Kenema Government Hospital Baama CHC Nongowa Military (MI Room) ClinicPanguma Mission Hospital Baoma Oil Mill CHC
Bendu Mameima CHCDodo CHCGegbwema CHCGorahun CHCJoru CHCLargo CHCLevuma (Kandu Leppiama) CHCLowoma (Lower Bambara) CHCSamai Town CHCSendumei CHCTalia (Nongowa) CHCTongo Field CHC
Kailahun District
Kailahun Government Hospital Buedu CHC Marie Stopes (Luawa) ClinicNixon Methodist Hospital Daru CHC
Jojoima CHCKoindu CHCMarie Stopes (Luawa) ClinicPendembu (Upper Bambara) CHCSandaru (Penguia) CHCSegbwema CHC
144
Appendix D. List of facilities surveyed
District Hospital CHC Clinic
Port Loko District
Port Loko Government Hospital Gbinti CHC
St John of God Catholic Clinic (Mabesseneh) Konta-Line CHCBai Bureh Memorial Hospital Lunsar CHCLungi Government Hospital Mahera CHC
Mange CHCMasiaka (Koya) CHCPepel CHCPetifu (Lokomasama) CHCRogbere CHCTagrin CHC
Koinadugu District
Kabala Government Hospital Bendugu (Mongo) CHC Nasarah ClinicKondembaia CHCKurubonla CHCSinkunia CHCYiffin CHC
Kono District
Koidu Government Hospital Adama Marth Memorial CHCBaiama CHC
Kangama (Kangama) CHC
Kayima CHCKoakoyima CHCKomba Yendeh CHCMotema CHCTombodu CHCYengema (Nimikoro) CHCYormandu CHC
Tonkolili District
Masanga Leprosy Hospital Massingbi CHC
Magburaka Government Hospital Mathoir CHC
Yele CHC
Bendugu (Sambaya Bendugu) CHCBumbuna CHCMabom CHCMakali (Kunike Barina) CHC
Bombali District
Holy Spirit Hospital Batkanu CHC Red Cross (Bombali Sebora) ClinicKamakwie Wesleyan Hospital Binkolo CHCMabenteh Community Hospital Gbendembu Wesleyan CHCMakeni Government Hospital MBALU KAMARA
Kalangba (Gbendembu Ngowahun)CHCKamabai CHCKamaranka CHCMateboi CHC
Bonthe District
Bonthe Government Hospital Bendu CHC Red Cross (Mattru) ClinicMattru UBC Hospital Gambia CHC St Joseph's Clinic
Gbamgbama CHCMadina (Bum) CHCMattru Jong CHCMogbwemo CHCTihun CHCYoni (Sittia) CHC
Moyamba District
UMC Rotifunk Hospital Bauya (Kongbora) CHCMoyamba Government Hospital Bradford CHC
Gbangbatoke CHCMokanji CHCMoyamba Junction CHCNjala University CHCRotifunk CHCShenge CHCTaiama (Kori) CHC
145
Appendix D. List of facilities surveyed
District Hospital CHC Clinic
Kambia District
Kambia Government Hospital Barmoi Munu CHC
Kawula CHC
Kukuna CHC
Kychom CHC
Mambolo (Kambia) CHCMapotolon CHCKamassasa CHC
146
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