In Sierra Leone, many mothers face barriers to care; our current project aims to develop integrated care models to improve maternal and child health, and ultimately the health of all individuals affected by diabetes and hypertension.
14 April 2025 Andreea Enea
In Sierra Leone, the journey of motherhood is often fraught with challenges, such as limited access to quality care services and health education, difficulties in sustaining an effective referral system, and a shortage of skilled healthcare workers and essential equipment. These factors dramatically influence the health outcomes of both mothers and their children.
Hawa, a 28-year-old woman diagnosed with gestational diabetes (GDM), received essential prenatal care at her local clinic and at the district hospital where she was monitored and safely delivered her baby. Sadly, the infant succumbed to an infectious disease a month later. Through our current project, Hawa is regularly monitored at her local clinic.
Similarly, 24-year-old Adama experienced a stillbirth during her fourth pregnancy due to inadequate access to sustained care for hypertension and prevalent misconceptions about the condition. Her next pregnancy took a turn for the better with proper management of her hypertension and ongoing support from the local clinic, and she was able to give birth to a healthy baby. Now both Adama and her child are followed up at the local clinic.
These stories illustrate the complex challenges mothers face within a fragile and fragmented health system.
While Sierra Leone has made considerable progress in reducing maternal mortality—dropping from around 1,120 deaths per 100,000 live births in 2017 to 443 deaths in 2020 (World Health Organization, 2023)—the country still has high maternal mortality rates globally. The under-five mortality rate has considerably decreased to 10%, yet it remains among the highest in the world, according to WHO data. Challenges such as limited access to quality antenatal care (ANC), as well as postnatal care (PNC) especially in rural areas, hinder effective management of infections, obstetric complications, and other conditions.
These issues are compounded by the aftermath of the 11-year civil war and the 2014 Ebola outbreak, which have strained the health system. Moreover, many women face social barriers and financial constraints that restrict their access to necessary care for conditions like diabetes and hypertension during pregnancy. The majority of Sierra Leone’s population lives in rural areas where access to basic health services is severely limited. Healthcare professionals (HCPs) often face significant shortages of essential medicines and training, and many are willing to move to seek better career opportunities.
The healthcare landscape in Sierra Leone is significantly impacted by the burden of non-communicable diseases (NCDs), which accounted for 41% of mortality between 2019-2020 – hypertension being the second leading cause of maternal deaths – according to the Ministry of Health (MoH).
A widespread lack of disease awareness, severe medicine shortages, and insufficient diabetes services in public health facilities further complicate the settings. However, maternal and child health still are the main priority for the government, with growing interest in general NCD care – especially regarding the postpartum risk of developing type 2 diabetes in women diagnosed with GDM.
Given this context, we have been supporting various projects in Sierra Leone focusing on building a foundation for integrated diabetes and NCD care to respond to such challenges.
We have been collaborating closely with Doctors with Africa CUAMM, an Italian non-governmental organisation dedicated to promoting and protecting health across Africa, and the College of Medicine and Allied Health Sciences (COMAHS) —the first medical school in Sierra Leone and a key institution for health research and capacity strengthening.
Between 2017-2022, we supported two projects led by CUAMM aimed at integrating diabetes services with ANC in Sierra Leone.
The first project (WDF16-1375) established the first GDM clinic at Princess Christian Maternity Hospital (PCMH) and GDM screening protocols in ANC facilities. Extensive HCP training enhanced awareness and screening participation, while local radio campaigns improved community knowledge of risk factors. A key outcome was the development of a context-specific national GDM protocol and the first strategic NCD plan led by MoH.
A second project (WDF19-1968) expanded GDM care services in the Western Area and Pujehun districts and focused on promoting preventive behaviours. 60 MoH members trained in data collection, nutrition education, and counseling. A Technical Working Group was formed to support the integration of NCD policies, ensuring all healthcare units play a role in a continuum of care that addresses diabetes throughout pregnancy and beyond.
Between 2020-2022, we also supported a project led by COMAHS (WDF18-1611) across the rural and urban areas of the Western Area and the Connaught Hospital, to improve early detection and align NCD management with communicable disease programmes. Active engagement with the NCD Directorate, district medical officers, and local leaders led to the establishment of six dedicated NCD clinics – the first to combine community-based with facility screening. A total of 130 multidisciplinary teams were trained to reduce the risk of complications and premature deaths, reaching approximately 1.5 million people.
This foundation has laid the groundwork for our current project, Scaling-up diabetes and hypertension management in the Pujehun and Western Area Urban and Rural districts. This fourth project brings together the strengths and expertise of CUAMM and COMAHS in a promising partnership for integrated NCD care based on the progress made in GDM care.
This strategic collaboration addresses critical healthcare challenges through key initiatives:
• Strengthening health education: Enhancing health education and promotion in ante- and postnatal clinics, inpatient and outpatient facilities, and through community initiatives such as radio campaigns and events.
• Staff training: Educating CHWs on diabetes, hypertension, and HIP risk factors to promote effective linkage to primary care facilities.
• Improving healthcare facilities: Enhancing the capacity of primary healthcare facilities to manage non-complicated diabetes, hypertension, and HIP.
• Capacity development for data collection: Building skills in NCD data collection and analysis through training programs focusing on digitization and quality assurance.
• Strengthening of national coordination mechanisms for quality NCD management: Organising national events focused on diabetes and hypertension, coordinating technical working groups and engaging stakeholders to advocate for improved NCD care and scale-up support for interventions.
This synergy ensures continuity of care by linking the management of GDM and hypertension during pregnancy with general care for NCDs.
While CUAMM focuses on managing HIP, including eclampsia and pre-eclampsia, COMAHS targets diabetes and hypertension in postpartum women and the general adult population. This collaboration guarantees comprehensive care for mothers affected by diabetes during and after pregnancy, and long-term care for patients with NCDs.
The project marks the first comprehensive NCD initiative assisting the MoH in establishing a decentralised and integrated model within the public health system outside Western Area, with potential scalability to other districts.
By integrating NCD management with reproductive health and nutrition, the partnership aims to enhance diabetes management for both prenatal and postpartum patients to drastically improve maternal and child health outcomes in the country.
The experiences of the two young mothers mentioned in the beginning illustrate the sensitive intricacies of maternal health and the crucial need for comprehensive ante- and postnatal care services.
Their stories also shed light on the major barriers that many women still face, such as limited access to affordable and quality care, low health literacy, and the need for integrated support systems.
During a recent visit to our partners leading the current project in Sierra Leone, WDF's programme manager Mikkel Pape Dysted had the opportunity to meet the two mothers and the nurse who attended to them.
Hawa (28) had access to care last year but experienced an unfortunate outcome. It was her fourth pregnancy, and she felt extremely weak and thirsty. During a visit to the Zimmi Community Health Centre, Hawa got diagnosed with gestational diabetes.
‘The nurse referred me to the Pujehun Hospital where I was confirmed positive and given medication for a month’, Hawa recalls. The hospital team agreed on a plan for the delivery. She had been monitored and advised on diet by the local nurse but her blood sugar levels didn’t improve. Hawa's husband took her to the hospital for delivery. ‘I was likely to have a big baby, but they couldn’t operate me’, she shares, due to a lipoma that posed a challenge for the surgery.
After two weeks of diabetes treatment and monitoring, labour was induced.
Despite access to proper care during her pregnancy and a safe delivery, unexpected postpartum complications led to the loss of her baby one month later due to an infection, emphasising the need for robust postnatal services alongside antenatal care. Now, Hawa manages her blood sugar with diet: ’The nutritional advice made me feel better. I can feel the difference between that time and now.’ Thanks to the current WDF-supported project, Hawa is now regularly monitored at the clinic.
Adama (24) faced different circumstances. During her fourth pregnancy, she developed complications related to hypertension at 24 weeks. ‘I had swollen legs and arms, so I went to see the nurse, who referred me to the Pujehun Hospital’.
Prior to her symptoms, she regularly visited the nurse at the Zimmi Community Health Centre. ’In month seven, Adama rapidly developed hypertension; she was having general edema, gastric pain, and headaches that didn't respond to analgesics’, the nurse explains.
Recognising the alarming signs, she referred Adama to the hospital for observation. However, due to her family’s financial difficulties, Adama had to leave the hospital and interrupted the treatment.
The nurse engaged the community, aware of Adama’s personal situation and part of the project activities as well, to help her go back to the hospital. Unfortunately, Adama's hypertension remained uncontrolled, leading to the need for induced labour.
After experiencing a stillbirth, the young mother approached her next pregnancy with caution. ‘I continued to monitor her blood pressure until she got better’, the nurse explains. ‘I informed her about her risk of pre-eclampsia and the need to keep a close eye on her condition’. This time, there were no complications, and she delivered safely. ‘It didn’t happen again, and my child and I are fine now’, Adama shares. The mother and her baby receive support and monitoring at the local clinic.
Hawa and Adama’s lived experiences highlight various aspects of the same critical need for access to care before and after pregnancy, integrated models, and sustained investment in maternal health services in Sierra Leone.
Our partners have actively engaged community-level stakeholders, which is essential for fostering ownership and achieving positive health outcomes. To this end, the project has trained four mother support groups, each with 54 members, along with 20 peer educator groups focused on promoting health awareness in the community.
Other highlights of the progress made include:
Despite these advancements, challenges persist, including high expectations concerning inadequate resources, staff turnover, and gaps in the referral system. The MoH is aware of these issues and is working to address them. There is also an urgent need for extensive follow-up and improved communication within facilities, stronger coordination and sustained supply chain, as our partners explain.
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Looking ahead, we envision a fully integrated diabetes management system that not only streamlines screening and treatment processes but also provides continuous support for patients. By enhancing collaboration among healthcare and community health workers and families, we aim to significantly reduce maternal and child health complications related to diabetes and hypertension. Our collective goal is to ensure that every mother and child has access to the necessary care and education.