Through this semester I have chosen the health topic of maternal health in Sierra Leone. On a deeper level though, I wanted to look into how the traditional and cultural views of Sierra Leoneans can have an impact or influence on maternal care and death rates among pregnant or post-pregnancy women. The mortality of pregnant women in Sierra Leone is significantly higher compared to other developing countries and as well as the more developed countries. These deaths often occur during pregnancy or childbirth and many of them could have been prevented by simple, cost-effective, community-based interventions. Unfortunately, though, the prevention opportunities that are put into place or that have been tried aren’t utilized by the community members. This lack of use is mostly because of traditions and cultural beliefs (Kanu 2014). The most influential determinants of health that affect the mothers of Sierra Leone are those of cultural and economic backgrounds. Sierra Leone has many deeply rooted traditions and cultural “norms” that don’t always mean proper and safe care for pregnant women. Also, similar to other African households, husbands provide the funds and thus determine what kind of care his wife will receive while pregnant. More often than not, the husbands want their partner to be in a natural, traditional state of mind and body for pregnancy and childbirth. This can result in poor medical care from professionals, restriction from interacting with anyone other than a spouse or family member, and sometimes complete isolation for the women (VOA News 2010). Often times, the women suffer from their husbands trying to live and stand by their traditions, rather than preventatively seek appropriate care for their pregnant significant other. Many of the Sierra Leoneans are also poorly educated, unable to support themselves well, and are thus in deprived economic standings. Being in a lower economic status brings geographic issues into play as well because many families live in rural areas with poor access to health care. There are some women that would like to receive care from a non-traditional clinic, but don’t have the means to travel or even pay for the services being offered in a larger area (Whitaker 2012). To critique the public health epidemic that Sierra Leone is struggling with, I will be using a critical medical anthropological theory. This will allow for discussion on the social behaviors and economic and political positions that influence the high rates of maternal deaths among Sierra Leonean women.
Becoming a mother is historically a source of joy, pain, and love. Unfortunately though, for many of the women in Sierra Leone, having a child can be very life-threatening. Hundreds of thousands of women die world wide each year as a result of pregnancy or childbirth leaving childbirth to remain among the leading cause of death for women globally. Sierra Leone has the worst maternal mortality with 1.360 mothers dying per 100,000 live births. This also means that roughly 1 in 17 mothers in Sierra Leone have a lifetime risk of death associated with childbirth (Mason 2016). Many of these deaths can be prevented by simple, cost-effective, community-based interventions, but often times, the preventative measures are not taken advantage of by the community members.
Using the critical medical anthropological theory, we can explain some of the causes of this health issue. The determinants of health that most prominently affect the pregnant women of Sierra Leone are those that are examined using this anthropological theory. These are inequalities of a social, economic, and political or governmental basis and they can easily be used in combination to describe the causes of high maternal death rates. Maternal death is not a problem that has one simple root cause. It is a problem that is incredibly multifaceted and by using this theory we can look at the problem from all points of view and see how it can have an impact differently on different women. Using the first portion, of social, we can see the engrained traditions and cultural influences. Traditionally, women are expected to go through pregnancy and delivery uninterrupted, natural, and somewhat isolated. Many women refuse to go to health centers and instead prefer to delivery at home by themselves or with a Traditional Birth Attendant. These attendants are also more preferred by men in Sierra Leone and play a critical role in assisting with the delivery of babies. This becomes a problem though, when a birthing attendant is unavailable or unable to reach a mother in labor. Only 42% of home births have a birthing attendant present and the rest simply give birth by themselves (Oyerinde 2013). There has been a great push by the government to rid the country of these Traditional Birthing Attendants to try to get more women to come to the health clinics, but it isn’t working. This creates a greater risk for women who refuse to go to health centers because of their personal, religious, or traditional beliefs because they have no proper medical supervision during a potentially life-threatening situation (Milton 2018).
This leads into the views that come from a government position. The government has tried to increase the amount of access to health clinics and provide more opportunities for care, but many people either live in desolate areas, or they don’t agree with getting government health care. Even though investments have been made to reconstruct the health system and spending has been increased and continues to increase, people have little trust in the care that they would be receiving. While these discrepancies and distrust has been around ever since the government started to try making changes, it was made even worse during the Ebola outbreaks, where people seemed to be dying without any cause or hope for treatment (Pieterse 2015). The political changes from the government are very intertwined with the social and cultural aspects of understanding the cause of high maternal death rates. Many people fear new or better practices because it is intimidating and challenges their ways of life and traditions that have been passed on through countless generations.
Diving deeper into the government standpoint leads to more political aspects that influence maternal death rates. Maternal mortality is an issue that spreads world-wide and no country goes untouched. Between 1990 and 2015, maternal death rates dropped by about 44%. However, even though this is a significant decrease of about 2.3% per year, this is still less than half of the desired decrease of 5.5% per year. Unfortunately, 99% of maternal deaths occur in developing countries, and more of half of those are occurring in sub-Saharan Africa where Sierra Leone is. When it comes to wondering, who takes responsibility, the World Health Organization has started to take strides to improving maternal health. In 2015, during the United Nations General Assembly, the UN Secretary-General Ban Ki-moon launched the Global Strategy for Women’s, Children’s and Adolescents’ Health, 2016-2030. This proposal serves as a road map and agenda to create an environment in which the women, children, and adolescents can not only survive, but also thrive and transform their lives to be better all around. Some of the components to their strategies are to address the inequalities in access to reproductive, maternal, and newborn health care services, ensure universal health coverage for reproductive, maternal, and newborn health care, address all cause maternal mortality, strengthen the health system to respond to the needs and priorities of women and girls, and to ensure accountability that will improve the quality of care and equity (World Health Organization 2018). Organizations are trying to work towards solving and bettering this health issue, but it is difficult to do when there are so many confounding variables that influence maternal mortality.
Another way to analyze the cause of this health issue in Sierra Leone is to look at the way the economic standing of a mother influences the type of care they get and how they are looked after during pregnancy and delivery. Many of the women at risk for death during pregnancy and/or delivery live in rural areas, desolate regions, and under the poverty line. The majority of men and women, alike, are illiterate and uneducated leaving them unable to obtain a supportive job that will provide them with the basic necessities (Statistics Sierra Leone and ICF Macro 2009). The areas that they live in are usually very far from a hospital or health clinic and it is unrealistic, sometimes impossible, for the mothers to get to one of these places of care. If they can’t get proper medical attention or are unable to pay anyone local to assist, they are again put at a much greater risk for death during pregnancy or delivery, or after delivery. Unfortunately, even with some free, government ran health clinics women are still dying because many families do not approve of the non-traditional, Westernized, care that a government clinic will provide (Whitaker 2012).
In my opinion, after all of the research I have done on this topic during this semester and considering the critical medical anthropological theory, I think the biggest causes of high maternal death rates in Sierra Leone come from cultural traditions and determinants. Even when considering the economic and political determinants, they usually revolve back around to cultural traditions. I have learned that the women of Sierra Leone are private people that depend upon their families and their spouses during pregnancy and when families are that tightly knit, they are very likely to have strong traditions and cultural connections. The government has been working towards providing more resources for pregnant women, but they aren’t being utilized because they aren’t currently the norm. As previously mention, we can see that the great majority of maternal deaths occur in developing countries and I think this is largely because many of the developing countries don’t trust Western medicine. In Westernized countries, the care and medicine that pregnant women receive is so “normal” that few people consider that bringing this knowledge and practice to underdeveloped countries might be very frightening and not easily trusted. Underdeveloped countries are commonly embedded in their cultural beliefs, norms, and traditions, and this seems to be the biggest factor that plays into maternal death rates in Sierra Leone.
The women of Sierra Leone are facing a great issue maternal mortality and it’s something that has been plaguing the country for decades. During this semester I have been researching the causes and factors that impact maternal mortality the most. These deaths are mostly preventable, but the opportunities that would need to be taken often aren’t. Using the critical medical anthropological theory, I have been able to critique this health issue and determine what the main causes are. In Sierra Leone, many women are held back from getting proper health care because of the social and economic determinants of health. The majority of mothers live below the poverty line and are subject to social and cultural traditions that aren’t always in their best interest. These determinants lead to the major causes of high maternal death rates being because of social and economic determinants of health. As discussed, there are political and governmental aspects that do play a role in this health issue, but they are often relinked back to the economic aspects and social traditions that create the opinions of those affected. It’s very easy to look from an outside point of view and just wonder, why don’t these women just take advantage of the clinics that the government offers? But when you analyze the culture, their background, the people, and the traditions the answer is not that simple. The social and economic influences that impact maternal death rates are so intensely intertwined that there is no simple answer of how to fix this problem. This health issue is one that will take years, maybe decades to fix. Having such a multifaceted health issue makes for needing a multifaceted solution that is detailed and will hold someone accountable for results. I hope that we will see maternal death rates decrease in Sierra Leone soon, but it’s an effort that needs to have support and backing from the entire world.
Kanu, Joseph Sam., Tang, Yang., & Liu, Yawen. (2014). Assessment on the Knowledge and Reported Practices of Women on Maternal and Child Health in Rural Sierra Leone: A Cross-Sectional Survey. Vallely A, ed. PLoS ONE. doi:10.1371/journal.pone.0105936.
Mason, Harriet. (2016, May 26). Making strides to improve maternal health in Sierra Leone. Retrieved from https://www.unicef.org/childsurvival/sierraleone_91206.html
Milton, Betty. (2018, January 24). Sierra Leone News: Traditional Birth Attendants… The unsung heroes. Awoko Newspaper. Retrieved from https://awoko.org/2018/05/31/sierra-leone-news-traditional-birth-attendants-the-unsung-heroes/
Oyerinde, Koyejo., Harding, Yvonne., Amara, Philip. et al. (2013). A Qualitative Evaluation of the Choice of Traditional Birth Attendants for Maternity Care in 2008 Sierra Leone: Implications for Universal Skilled Attendance at Delivery. Maternal and Child Health Journal 17: 862. https://doi-org.proxy1.cl.msu.edu/10.1007/s10995-012-1061-4
Pieterse, Pieternella., & Lodge, Tom. (November 2015). When free healthcare is not free. Corruption and mistrust in Sierra Leone’s primary healthcare system immediately prior to the Ebola outbreak. International Health. Pages 400–404.
VOA. (2010, October 22). “Some Traditional Practices May Affect Maternal Health in Sierra Leone.” VOA. https://www.voanews.com/a/sierra-leone-tradition-maternal-mortality-79343832/416449.html
Whitaker, Kati. (2012). “Is Sierra Leone Right to Ban Traditional Birth Attendants?”. Guardian News and Media. https://www.theguardian.com/global-development/poverty-matters/2012/jan/17/traditional-birth-attendants-sierra-leone
World Health Organization. (2018, February 16). Maternal mortality. Retrieved from http://www.who.int/news-room/fact-sheets/detail/maternal-mortality