Afi Delali Degbey
Date of Defense:
December 18, 2020
This executive summary describes a part of the Field Experience conducted with the Rural Health Care Initiative (RHCI). The project consisted of the evaluation of the Mbaomi Mothers’ Waiting Home (MMWH), built and operated by RHCI to address the high infant and maternal mortality rate in Tikonko, Sierra Leone.
Sierra Leone has the worst maternal mortality rate in the world with 1,360 maternal deaths per 100,000 live births in 2015 according to UNICEF. The causes of maternal death in this country are related to hemorrhage, infection, obstructed labor, and eclampsia. Other influencing factors include a poor health care system, lack of resources, and shortage of well-trained health care workers. Tikonko Chiefdom in Bo District, Southern Province in Sierra Leone, is made of over 25 villages with only one small government-run Health Center for medical care, labor, and delivery. The nearest hospital is seven miles away. Although seven miles may seem a short distance, it is a formidable barrier when faced with unpaved roads and little to no access to motorized transportation. The government of Sierra Leone passed a law in 2010 that all births were to take place at health centers, making it illegal for informal birth attendants to do home deliveries. However, in attempting to comply with the new law, many women had to walk for hours while in labor to get to the Community Health Center. Often women would deliver their baby while en route, on a dirt path, in the dark night, and sometimes during heavy rains. Consequently, the obstacle of distance becomes a contributing factor to the high maternal and child deaths and health complications. With 10% of health care workers dying of Ebola between 2014 and 2015, the already weak health care system became further damaged. A need assessment conducted by RHCI in 2013 revealed the need for a Maternity Waiting Home and a strengthening of the existing government community health center in Tikonko.
RHCI is a nonprofit organization in the state of Minnesota, formed in 2011 by members of the Sierra Leone diaspora and their friends, particularly health care workers. In 2014, it became an independent 501(c)3 nonprofit. The mission of RHCI is to partner with rural communities in Sierra Leone to rebuild the health care system and to overcome one of the highest maternal and child mortality rates in the world.
Experience: This field experience was based in Minnesota, under the supervision of Dr. Carol Nelson, Executive Director for RHCI. The learning objectives of the field experience included a collaboration with staff in reviewing and analyzing data collected from the MMWH, the production of documents to share with donors, and the establishment of a monitoring and evaluating system for the program. To meet these objectives, we performed the following work:
• Collaborated with RHCI staff to design the survey questionnaires
• Developed a logic model for the program
• Performed data cleaning
• Performed data analysis
• Worked in collaboration with RHCI staff to produce a report outlining major findings from the evaluation
• Attended a bi-weekly meeting with the Executive Director of RHCI
The organization plans to establish a monitoring and evaluation system for the MMWH. Thus, this initial evaluation project would serve to set up a monitoring and evaluation system that could be improved in the future. The evaluation also intended to obtain information, which will enable recommendations for adjustments and improvements in the program implementation. Finally, the result served as a baseline for future evaluations. Another main purpose of this initial evaluation is to quantify the usage of MMWH, determine the effectiveness of MMWH (factors contributing to its success or its failure), and to determine if this type of project in Sierra Leone will contribute to a decrease in maternal and newborn mortality.
Our analysis was performed using the statistical software R. The summary statistics revealed that from the opening in January 2018 to February 2019, the birth waiting home welcomed 238 women who spent an average of 24.9 days at MMWH with a minimum of 0 day (came and delivered the same day) and a maximum of 85 days. These women came from 59 villages, including villages outside of Tikonko chiefdom. 200 women came from villages that were less than ten miles away from the birth waiting home. 18 women came from villages located between 10 – 20 miles from the center, two women came from a village situated over 20 miles and 18 women came from unknown or unrecorded villages. The data exploration revealed that women aged 30 plus with more than 2 children tend to stay for lesser days compared to young first-time moms. However, we found out through the survey that women with more than one child prior to their current pregnancy expressed the desire to stay longer at the birth waiting home. We aimed to comprehend whether duration in days (dependent variable) is explained by independent variables such as mother’s age, the number of live births per woman, and the number of children alive by doing a multivariable regression analysis. We obtained a very low r square (0.1212). This indicates that the relation between duration and the independent variables is weak. A total of 36 participants responded to the survey. The analysis shows that overall, women are very pleased with the staff and are very grateful for the service provided. From the test analytics, we observe that frequent words used in the survey responses are “good’ “well” “happy” “thank you” “enjoyed” “encouraged” “love”. In the first set of survey results received, which include over 13 survey participants, 10 expressed the desire to stay longer at the birth waiting home. Considering other answers in the survey, we understood that the Birth Waiting Home is a place where women find rest. For instance, the question “why do you want to stay longer at the Mbaomi Mothers’ Waiting Home?” generates the following answers “Because of bed rest” “because it is a place of hope” “Because of the privilege I got from the home” “Because of the accommodation in the home” “to reduce stress for me”.
Lessons Learned: This field experience provided me the opportunity to apply the knowledge learned in my evaluation course. It also allowed me to exercise global health competencies in the domain of capacity strengthening. My statistical analysis skills in excel and R improved from this experience.
For sustainability concerns and improvement in data collection we recommended that RHCI
• Put in place an ID number system for the villages. This will increase accuracy in data records and improve analysis in future evaluation.
• Define clear indicators and capture the indicators in the patient record.
• Use ultrasound to determine pregnancy age for a better estimate of the delivery date.
• Consider establishing patient admission based on a referral from the local health post and community health workers in the future.
• Train community health workers to educate villagers on the real purpose of the birth waiting home to prevent unnecessary overutilization of the birth waiting home.
Conclusion: RHCI has been successful in promoting the Mbaomi Mothers’ Waiting Home. Women in Tikonko chiefdom are using the birth waiting home and are satisfied with the services offered to them. However, it is important to limit the duration of stay at the birth waiting home to an optimum number of days to maintain efficiency in resource management. Also, it is important to point out that it is too soon to identify how much the Birth Waiting Home is preventing maternal and infant death in Tikonko Chiefdom; hence, the need for future better-organized evaluation.
Thukral, A., Lockyer, J., Bucher, S. L., Berkelhamer, S., Bose, C., Deorari, A., … Shaw, B. (2015). Evaluation of an educational program for essential newborn care in resource limited settings: Essential Care for Every Baby. BMC Pediatrics, 15(1), 71.
UNICEF 2016 At a Glance: Sierra Leone Retrieved at
WHO (2015)Trends in Maternal Mortality: 1990 to 2015, Estimates by WHO, UNICEF, UNFPA, World Bank Group and the United Nations Population Division, Retrieved athttp://apps.who.int/iris/bitstream/handle/10665/193994/WHO_RHR_15.23_eng.pdf ?sequence=1