Factors contributing to delays in accessing health facility-based maternal delivery services in Sierra Leone, 2018: A community-based cluster survey.

BACKGROUND: With a Maternal Mortality Ratio (MMR) of 516 deaths per 100,000 live-births, Sierra Leone hosts one of the highest maternal mortalities in globally. National data indicates that over 98% of maternal deaths are related to delays in accessing obstetric services. This study sought to examine factors contributing to delays in accessing maternal delivery services as perceived by women in Sierra Leone. METHODS: We conducted a community-based survey among women who delivered from May 1, 2017 to June 30, 2018, in four districts of Sierra Leone. Delay one was defined as perceived delays in deciding to seek facility-based delivery. Delay two was defined as perceived delays reaching the health facility for delivery services. Data on participants' socio-demographics, delay one, delay two, three and determinants of delays one and two and three were collected using questionnaires. We calculated frequencies and proportions for factors contributing to delays as well as Prevalence Odds Ratios (POR) to identify risk factors for the delays. RESULTS: A total of 614 mothers were interviewed, median age 28 years (range, 14-52 years). The prevalence of Delay One was 23.3% (143/614), and Delay Two was 26.9% (165/614). Mother with secondary education were associaited with delay one (aPOR = 2.3; 95% CI:1.14, 4.46). These was an association between perceived delay-two and previous pregnancy-related complications (aPOR = 1.6; 95% CI:1.071, 2.538) and poor condition of roads (POR = 2.34; 95%CI, 1.15, 4.77). Additinally, there was an association between delay-three and previous-related complication during last pregnancy (aPOR = 1.9; 95% CI: 1.055, 3.67). CONCLUSIONS: This study revealed a high prevalence of perceived delays one and two for mothers to access obstetric services. Delays were mainly related to transport difficulties, low knowledge of pregnancy-related complications, and costly obstetric services. A practical strategy for birth preparedness and readiness to reduce delays is urgently needed.

Systems thinking for health emergencies: use of process mapping during outbreak response.

Process mapping is a systems thinking approach used to understand, analyse and optimise processes within complex systems. We aim to demonstrate how this methodology can be applied during disease outbreaks to strengthen response and health systems. Process mapping exercises were conducted during three unique emerging disease outbreak contexts with different: mode of transmission, size, and health system infrastructure. System functioning improved considerably in each country. In Sierra Leone, laboratory testing was accelerated from 6 days to within 24 hours. In the Democratic Republic of Congo, time to suspected case notification reduced from 7 to 3 days. In Nigeria, key data reached the national level in 48 hours instead of 5 days. Our research shows that despite the chaos and complexities associated with emerging pathogen outbreaks, the implementation of a process mapping exercise can address immediate response priorities while simultaneously strengthening components of a health system.

Household Transmission of Ebola Virus: Risks and Preventive Factors, Freetown, Sierra Leone, 2015.

Background: Knowing risk factors for household transmission of Ebola virus is important to guide preventive measures during Ebola outbreaks. Methods: We enrolled all confirmed persons with Ebola who were the first case in a household, December 2014-April 2015, in Freetown, Sierra Leone, and their household contacts. Cases and contacts were interviewed, contacts followed prospectively through the 21-day incubation period, and secondary cases confirmed by laboratory testing. Results: We enrolled 150 index Ebola cases and 838 contacts; 83 (9.9%) contacts developed Ebola during 21-day follow-up. In multivariable analysis, risk factors for transmission included index case death in the household, Ebola symptoms but no reported fever, age <20 years, more days with wet symptoms; and providing care to the index case (P < .01 for each). Protective factors included avoiding the index case after illness onset and a piped household drinking water source (P < .01 for each). Conclusions: To reduce Ebola transmission, communities should rapidly identify and follow-up all household contacts; isolate those with Ebola symptoms, including those without reported fever; and consider closer monitoring of contacts who provided care to cases. Households could consider efforts to minimize risk by designating one care provider for ill persons with all others avoiding the suspected case.