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 newborn death is common in Sierra Leone; significant reductions in both maternal and newborn mortality require
universal access to a skilled attendant during labor and delivery. When too few women use health facilities MDGs 4 and 5 targets
will not be met. Our objectives were to identify why women use services provided by TBAs as compared to health facilities;
and to suggest strategies to improve utilization of health facilities for maternity and newborn care services. Qualitative
data from focus group discussions in communities adjacent to health facilities collected during the 2008 Emergency Obstetric
and Newborn Care Needs Assessment were analyzed for themes relating to decision-making on the utilization of TBAs or health
facilities. The prohibitive cost of services, and the geographic inaccessibility of health facilities discouraged women from
using them while trust in the vast experience of TBAs as well as their compassionate care drew patients to them. Poor facility
infrastructure, often absent staff, and the perception that facilities were poorly stocked and could not provide continuum
of care services were barriers to facility utilization for maternity and newborn care. Improvements in infrastructure and
the 24-hour provision of free, quality, comprehensive, and respectful care will minimize TBA preference in Sierra Leone.