Innovations to reduce maternal mortality and build research capacity in Sierra Leone

CRIBS is a multidisciplinary global health research group funded by the NIHR that builds on research partnerships spanning the last decade, and that has formalised collaborations between King’s College London and the University of Sierra Leone, with strong support from the Ministry of Health and Sanitation, iNGO Welbodi Partnership, National Emergency Medical Services (NEMS) (the national Ambulance service), community based solutions NGO Lifeline Nehemiah project, and the midwifery schools across the country.

The overall aim of this research group is to develop and implement simple, scalable innovations to reduce maternal mortality and exchange and build research capacity and expertise in Sierra Leone. Core workstreams include: CRADLE 5, SIPHRE, APRICOT and PINEAPPLE, and 2YoungLives, and cross-cutting workstreams include community engagement and involvement and research capacity strengthening.

CRADLE 5

CRADLE-5 is a hybrid cluster stepped wedge trial that is evaluating the implementation and effectiveness of the real-world national scale up of the CRADLE Vital Signs Alert device and obstetric emergency training across rural Sierra Leone. This trial follows a pilot implementation rollout which targeted half of the country. The trial will finish in June 2023 and has so far collected primary outcome data on over 2230 women (1401 stillbirths, 284 eclamptic fits, 121 maternal deaths and 53 hysterectomies). The intervention has reached 669 healthcare facilities across 8 districts of Sierra Leone (achieving its target of reaching more than 95% of facilities in all districts).

More than 2,100 CRADLE devices have been distributed and 311 CRADLE Champions have been trained, reaching 2002 frontline healthcare workers. The reach of this programme of work has been impressive and all members of the CRADLE management, implementing and research teams have worked extremely hard, going above and beyond for the women and babies of Sierra Leone. It is anticipated that more than 230,000 women will benefit from CRADLE over the course of the year, once national scale up is achieved.

SIPHRE, APRICOT and PINEAPPLE

SIPHRE, APRICOT & PINEAPPLE are three ongoing observational studies taking place at one of the main hospitals in Freetown, the capital of Sierra Leone. SIPHRE aims to determine the ability of shock index (heart rate divided by the systolic blood pressure) to predict bad outcomes due to bleeding and infection in pregnant women, compared to conventional vital signs monitoring. The team have recruited more than 500 women to date, and have expanded data collection to 20 health facilities, to evaluate shock index in sick women referred from the community to the hospital (rural and urban).

APRICOT is validating a point of care creatinine (a waste product that comes from normal wear and tear of muscles in the body) device to detect acute kidney damage in pregnancy and have recruited more than 400 women.

PINEAPPLE is assessing placental growth factor (PlGF)-based testing to help diagnose suspected pre- eclampsia (now recommended by NICE in the UK). This is a point of care finger prick version of the test and to our knowledge a world first, with exciting potential both in a low and high income settings. More than 150 women have been recruited, and data collection has expanded to antenatal clinics. The team has rapidly expanded to 22, made up of data collectors and research assistants.

2YoungLives (2YL)

2YoungLives (2YL) is a locally developed community-based mentoring scheme for adolescent pregnant girls for up to one year after birth. It has been piloted in a few areas since 2017, and we are now conducting a pilot cluster trial to formally assess the feasibility and implementation of the mentoring scheme in other communities. Since July 2022, more than 250 girls have been recruited from the twelve trial clusters (rural and urban) in five districts, and qualitative work is ongoing.

So far, there has been lots of learning in relation, for example, on community engagement and involvement in some communities, the under-reporting of age at health facilities and relocation, expectations from parents, and the positive effect of 2YL on mentors and coordinators. There has been national and international interest and 2YL has been featured on the 2022 UNFPA State of the World Population Report, the BBC World Service ‘People fixing the World’' the Let Girls Learnt Section from the Evening Standard and a comment in the Lancet Child & Adolescent Health.

Gi4 SaveLife

Linked to 2YoungLives, 'Gi4SaveLife' is a community-hospital partnership project funded by the ESRC (LNP and Koidu government hospital in Kono District) which aims to maximise expertise in community-led voluntary blood donation, and the hospital’s well-functioning and adequately equipped blood bank. Since last July, the team have conducted six sessions in each of three communities. Recently, LNP received the Sierra Leone NGO Award 2022 for Outstanding Performance in the NGO Sector, and commitment to best practice. They have extensive experience in community engagement, and their work guide decisions within our ongoing and evolving workstreams with all community stakeholders, to ensure the different programmes are built and owned by those who will ultimately benefit from it.

Building research capacity

Exchanging and building research capacity and expertise at individual, institutional and national level is crucial for CRIBS. We are working together and supporting three PhD students, four Masters in public health students and more than 20 research staff and early career researchers, plus many opportunities for training and development. For example, we co-developed a 3-day practical course 'Designing clinical research' with an opportunity to develop local ideas into a research proposal, and a total of eight projects with more than 15 participants (e.g. midwives, doctors, data collectors, nutritionists, pharmacists, public health staff, community and gender specialists) were awarded competitive seed funding. Other activities include a journal club for local early career researchers, basic IT skills learning and hands-on sessions to share experiences from conducting qualitative research and photovoice in Sierra Leone.

More recently, a ground-breaking maternal health policy lab has been co-organised in Sierra Leone, bringing together clinicians, researchers, key stakeholders from government and communities to collaborate in providing improved care and clinical outcomes for pregnant women with pre-eclampsia and their babies. The meeting brought together a diverse, passionate and engaged group of nearly 40 participants including among others: Government members, programme managers, NGO project leaders, academics, health care workers, including community health workers, nurses, midwives, clinical officers and senior obstetricians and paediatricians, as well as community representatives from different religious groups and vulnerable populations.

Group discussions and feedback sessions centred around tailored interventions to sustainable improve care for pre-eclampsia as well as integrate novel evidence into policy (i.e. integrated public health education campaigns, a dedicated ‘Centre for Pre-eclampsia’ Care) and commitment strategies for implementing this approach. Our experience confirmed policy labs are a fantastic tool to facilitate change.

Read more about CRIBS Sierra Leone