Exploration of Opportunities and Barriers to Reduce Maternal Mortality in Liberia

Abstract

Background: Liberia has one of the highest maternal mortality rates in the world. Despite improvements in maternal mortality in many low and middle-income countries over the past decade, the rate in Liberia has increased during this time. Therefore, a biosocial analysis of this problem is crucial to help identify and address barriers to women's access and utilization of quality maternal health care services throughout Liberia. Methods: We analyzed the 258 maternal death reviews reported to the National Public Health Institute of Liberia (NPHIL) between January and December 2017. These data were complemented by in-depth qualitative interviews of 12 facility-based health workers, 12 peripartum mothers, 11 trained traditional midwives (TTMs) and 9 family members of women who died from a pregnancy-related cause. Results: Forty percent of reported deaths occurred in the 25-34 age group, 36% of deaths were due to haemorrhage, 29 % of women died within 24 hours after delivery, and 74% of the deaths occurred at a health facility. Most notably, the number of deaths reported to the government (only 258 from January-December 2017) was significantly less than the number expected based on the population, crude birth rate, and the maternal mortality ratio. Qualitative findings highlighted 1) financial burdens on patients as they are required to purchase drugs and medical supplies; 2) an inefficient system of referral by traditionally trained midwives to delivery facilities; 3) issues of transportation; 4) a dearth of trained health workers; and 5) a lack of respect for patients. Conclusions: The majority of maternal deaths in Liberia are not being reported to the government. This has implications for reducing mortality rates since structural barriers to quality care are not being identified nor addressed by the government through central health system. In addition, these findings undermine the narrative of the "resilient health system" and suggest surveillance for pandemic disease may likewise be inadequate. Reducing maternal mortality in Liberia must prioritize poverty alleviation, human resources for health, maintenance of supply chains, improved roads and ambulance services, better outcomes reporting, and the promotion of patient rights.