The use of a mobile obstetric emergency system to improve obstetric referrals in Bong County, Liberia: A pre-post study.

OBJECTIVE: Liberia experiences an unmet need for cesarean section with about 5% population coverage, lower than 9%-19% coverage associated with improved maternal and newborn outcomes. Delays in the referral process for comprehensive emergency obstetric and newborn care (CEmONC) services due to ineffective communication between a rural health facility (RHF) and a district hospital contribute to the low CS rate. This study examined the association between mobile obstetric emergency system (MORES) implementation and referral time for obstetric emergencies as well as maternal/newborn outcomes. METHODS: A pre-post descriptive analysis was conducted on data collected from 20 rural health facilities (RHFs) and two hospitals in Bong County. Women with referral data from both RHFs and hospitals were matched and information including transfer time, reasons for referral, and maternal and newborn outcomes were extracted. Descriptive analysis and logistic regression models examined the relationship between the intervention's implementation and mode of delivery, maternal outcome, newborn outcome, and transfer time from RHF to district hospital. Ethics approval was obtained from two study centers. RESULTS: Women had higher odds of undergoing a CS at endline (OR: 1.86 95% CI: 0.99-3.46) compared to baseline. Additionally, newborns had lower odds of showing non-vigorous symptoms (OR: 0.31; 95% CI: 0.14-0.68), defined as a newborn with poor respiratory effort, muscle tone, or heart rate. There was no significant association between the intervention's implementation and transfer time. CONCLUSION: The MORES intervention is a promising means to increase timely care seeking along the referral pathway which may enhance access to cesarean section as well as improved newborn outcome in low- and middle-income countries.

Verbal autopsy analysis of maternal mortality in Bong County, Liberia: a retrospective mixed methods study.

BACKGROUND: While the medical contributors to maternal mortality are well known, the contextual contributors are less known and understudied. Liberia has one of the highest maternal mortality rates in sub-Saharan Africa, with recent increases in maternal deaths in rural Bong County. The purpose of this study was to better classify the contextual factors leading up to maternal deaths and to develop a list of recommendations to prevent future similar deaths. METHODS: A retrospective mixed method study was conducted examining 35 maternal deaths in Bong County, Liberia using verbal autopsy reports from 2019. An interdisciplinary death audit team reviewed and analysed the maternal deaths to determine the contextual causes of the maternal death. FINDINGS: This study identified three contextual causes: limited resources (materials, transportation, facility, staff), inadequate skills and knowledge (staff, community, family, patient), and ineffective communication (between providers, between health facilities and hospitals, and between provider and patient/family). Of these, inadequate patient education (54.28%), inadequate staff education and training (51.42%), ineffective communication between health facilities and hospitals (31.42%), and inadequate materials (28.57%) were most frequently mentioned. CONCLUSION: Maternal mortality remains an issue in Bong County, Liberia, due to addressable contextual causes. Interventions to ameliorate these preventable deaths include ensuring availability of resources and transportation through improved supply chain and health system accountability. Recurring training should be provided to healthcare workers which involves husbands, families and communities. Innovative means for providers and facilities to communicate clearly and consistently should also be prioritised to prevent future maternal deaths in Bong County, Liberia.

Sustainable palm weevil farming as nutrition supplementation at maternity waiting homes in Liberia.

BACKGROUND: Food insecurity is a global health challenge exacerbated by COVID-19. In Liberia, two-thirds of pregnant women are anemic, one-third of children are stunted, and 70% of households experienced food insecurity due to COVID-19. Edible insects are a nutritious, environmentally responsible, and cost-effective dietary supplement used throughout sub-Saharan Africa. Rearing palm weevil insects at maternity waiting homes (MWHs)-residential dwellings near hospitals where pregnant women await childbirth and receive postpartum services-could serve as a nutritious supplement for expectant mothers in Liberia and provide an income generating activity for MWHs. METHODS: Following a one-day training, sixteen participants established palm weevil rearing sites at four MWHs in Liberia. Pre- and post-knowledge scores were assessed immediately prior to and following training. Pre-and post-knowledge scores were analyzed using paired t-test. Participants tracked two palm weevil rearing cycles (four months), using harvest amounts, turnover, barriers to implementation, and income generated as metrics. The number of women attending MWHs was recorded throughout the study period (July-December 2020). RESULTS: Sixteen participants from four MWHs completed the training and two rearing cycles (four months) successfully. All participants showed statistically significant increases in knowledge scores following the one-day workshop with a pre-test score of 2.31 and post-test score of 7.75 out of 10 (p < 0.001). Over the 6-month study, 217 women stayed in four MWHs. Larval production from the various rearing centers ranged from 120 to 721 larvae, with all four sites producing enough palm weevil to sustain MWH residents who desired to consume the insects. One site successfully commercialized its harvest to sell approximately 50% for a total of 2,000 LD (13 USD) in income. Three of the four sites continued edible insect production beyond the four-month study period. CONCLUSIONS: An edible insect project using palm weevil larva is one promising intervention as a nutrition supplement for expectant mothers at pre-established MWHs in rural Liberia. Edible insect rearing also has potential as an income generating activity for MWHs. Future studies should focus on addressing common barriers of remote implementation and metric tracking during the COVID-19 pandemic and reinforcing infrastructure to protect larvae rearing supplies.

Maternity waiting homes in Liberia: Results of a countrywide multi-sector scale-up.

OBJECTIVE: Descriptions of maternity waiting homes (MWHs) as an intervention to increase facility delivery for women living in remote geographic areas dates back to the 1950s, yet there is limited information on the scale-up and sustainability of MWHs. The objective of this study was to describe the evolutionary scale-up of MWHs as a component of health system strengthening efforts and document the successes, challenges, and barriers to sustainability in Liberia. METHODS: Data were collected from a national sample of 119 MWHs in Liberia established between 2010-2018. The study used a mixed method design that included focus group discussions, individual interviews, logbook reviews, and geographic information systems. Qualitative data were grouped into themes using Glaser's constant comparative method. Quantitative data were analyzed using negative binomial regression to measure the differences in the counts of monthly stays at facilities with different funding sources and presence of advisory committee. Additionally, each MWH was geo-located for purposes of geo-visualization. RESULTS: In the years since the original construction of five MWHs, an additional 114 MWHs were constructed in 14 of the 15 counties in Liberia. Monthly stays at facilities funded by community were 2·5 times those funded by NGOs (IRR, 2·46, 95% CI 1·33-4·54). Attributes of sustainability included strong local leadership/active community engagement and community ownership and governance. CONCLUSION: Success factors for scale-up and sustainability included strong government support through development of public policy, local and county leadership, early and sustained engagement with communities, and self-governance. A multi-pronged approach with strong community engagement is key to the scale-up and sustainability of MWHs as an intervention to increase facility delivery for women living the farthest from a healthcare facility.

Acceptability and feasibility of insect consumption among pregnant women in Liberia.

Maternity waiting homes (MWHs) in Liberia promote facility-based delivery to reduce maternal mortality. However, women often must bring their own food and supplies to MWHs, which makes food insecurity a barrier to the utilisation of MWHs. Consumption of edible indigenous insects is a common practice and has notable nutritional benefits but has not been studied in Liberia as a potential solution to food insecurity at MWHs. The purpose of this study is to (a) examine the acceptability of insect consumption in the context of Liberian beliefs, (b) identify species commonly consumed by pregnant women in Liberia, and (c) examine the feasibility of harvesting insects as food and income generation for women staying at MWHs. Focus groups were conducted at 18 healthcare facilities in Liberia. Participants included chiefs, community leaders, women of reproductive age, traditional birth attendants, women staying at MWHs, and male partners. Focus group participants identified many different species of insects consumed by pregnant women in the community as well as the perceived health impacts of insect consumption. They also described their own experiences with insect hunting and consumption and the perceived marketability of insects, particularly palm weevil larvae. The results of these discussions demonstrate that insect consumption is an acceptable practice for pregnant women in rural Liberia. These findings suggest that it is feasible to further explore the use of palm weevil larvae as dietary supplementation and income generation for women staying at MWHs in Liberia.

Utilization of maternity waiting homes: before, during, and after the Ebola virus disease outbreak in Bong County, Liberia.

BACKGROUND: Maternity waiting homes (MWHs) are used to increase the number of women delivering at health care facilities. The first MWHs in Liberia were opened in 2012, prior to the Ebola virus disease (EVD) outbreak. METHODS: Longitudinal data were collected from registries on MWH use, antenatal care, postnatal care and facility deliveries from 2012 to 2016 to assess MWH utilization. RESULTS: All indicators examined declined during the EVD outbreak, but within 6 months of the cessation of the outbreak they returned to pre-EVD levels. CONCLUSIONS: Findings suggest MWH utilization remained stable after international funding ceased and EV affected the region.

A case series study on the effect of Ebola on facility-based deliveries in rural Liberia.

BACKGROUND: As communities' fears of Ebola virus disease (EVD) in West Africa exacerbate and their trust in healthcare providers diminishes, EVD has the potential to reverse the recent progress made in promoting facility-based delivery. Using retrospective data from a study focused on maternal and newborn health, this analysis examined the influence of EVD on the use of facility-based maternity care in Bong Country, Liberia, which shares a boarder with Sierra Leone - near the epicenter of the outbreak. METHODS: Using a case series design, retrospective data from logbooks were collected at 12 study sites in one county. These data were then analyzed to determine women's use of facility-based maternity care between January 2012 and October 2014. The primary outcome was the number of facility-based deliveries over time. The first suspected case of EVD in Bong County was reported on June 30, 2014. Heat maps were generated and the number of deliveries was normalized to the average number of deliveries during the full 12 months before the EVD outbreak (March 2013 - February 2014). RESULTS: Prior to the EVD outbreak, facility-based deliveries steadily increased in Bong County reaching an all-time high of over 500 per month at study sites in the first half of 2014 - indicating Liberia was making inroads in normalizing institutional maternal healthcare. However, as reports of EVD escalated, facility-based deliveries decreased to a low of 113 in August 2014. CONCLUSION: Ebola virus disease has negatively impacted the use of facility-based maternity services, placing childbearing women at increased risk for morbidity and death.

Texting From the Bush: Data Collection Using SMS Text Messaging in Areas of Low Network Coverage From Low-Literacy Providers.

Mobile health technology, specifically Short Message Service (SMS), provides a low-cost medium to transmit data in real time. SMS has been used for data collection by highly literate and educated health care workers in low-resource countries; however, no previous studies have evaluated implementation of an SMS intervention by low-literacy providers. The Liberian Ministry of Health and Social Welfare identified a lack of accurate data on the number of pregnancies from rural areas. To capture these data from 11 rural communities in Liberia, 66 low-literate traditional midwives and 15 high-literate certified midwives were trained to report data via SMS. Data were reported via a 9-digit code sent from Java-based mobile phones. Study aims included determining the following components of SMS transmission: success rate, accuracy, predictors of successful transmission, and acceptance. Success rate of SMS transmission was significantly higher for certified midwives than for traditional midwives. The error rate was significantly higher for traditional midwives than for certified midwives. Years of education was the only predictor of successful SMS transmission. Traditional midwives and certified midwives accepted the intervention, although certified midwives found it easier to use. Certified midwives performed significantly better than did traditional midwives. SMS texting interventions should be targeted to health care workers with higher rates of literacy.