The data from this study falls under the three major themes in line with the three key questions.
Sub-themes emerged under each major theme, and the following table summarises these. For each subtheme, the main data sources are outlined. Participant codes are given for quotations. It was not possible during transcription to identify individuals within focus groups, hence group coding rather than individual coding is given. The exception was the teachers’ focus group which only had two participants (T1 and T2). FG denotes source as a focus group; I denotes source as an interview.
Major theme related to research question
Subthemes within major theme
Key informants on this subtheme
Vulnerability to teenage pregnancy
• ‘not their own child’
• ‘water for water’
• ‘sex for school fees/grades’
• the criminal justice system
Contraception and abortion
• young men’s focus group (YMFG)
• women’s leaders (WL)
• teachers’ focus group (T1 and T2)
• Government of Sierra Leone participants (GI)
• Senior NGO workers (NGO)
Vulnerability to maternal death once pregnant
Abuse and abandonment
• ‘just because she’s young it doesn’t mean she has to die’
Increased birth complications
• Delayed care seeking
Risk of death from anaemia and PPH
• young mothers’ focus groups (MFG)
• hospital midwives’ focus group (HMFG)
• community clinic health workers focus group (HWFG)
• senior midwives (SM)
• senior community leader (SCL)
Possible interventions to reduce maternal death in adolescents
Community-based blood donation
• blood donation experience
• women’s leaders
• young men’s focus group
• midwives and other health workers
Vulnerability to teenage pregnancy
By definition, teenagers who do not become pregnant cannot die from maternal causes. For this reason, it is valid to include within the results, analysis and discussion, factors which lead to teenage pregnancy alongside factors which lead to maternal death in pregnant teenagers.
Despite use of language such as ‘being in love’, the context for much of the sexual activity discussed in this study appears to define it as transactional; as a way of minimising the burden of the time-consuming duties of petty trading or water collection; for money to pay for school fees and other expenses; and as a condition proposed by school teachers for girls to pass exams or be promoted to the next school year. The lack of adult care and financial provision for girls who were living with extended family instead of their birth family seemed to exacerbate their exposure to all of these risks, although girls living within their own birth families were also under pressure to have transactional sex.
‘Not their own child’
Many households in Freetown include children and young people who are family relatives or unrelated to the family, as well as children born into the household. Often these additional children are sent from rural Sierra Leone to attend school or as a way of redistributing the economic burden when part of a family falls into poverty, due for example to the death of one parent.
When asked what makes some girls more vulnerable to pregnancy and maternal death, many participants proposed that living in a household other than the one into which you were born is a key vulnerability, citing ‘lack of proper care’ and ‘no-one to guide them’. Many girls in this situation are sent out to sell goods, either for their household, or to earn money to support themselves and pay for schooling if this need is not being met for them, risking exploitation:
The other thing is the trade the girls do from house to house. When they are hawking their trade, some older men will call to them saying ‘Come! I want to see or buy what you are selling’. He will call her into the house and say, ‘I will buy everything you are selling if you have sex with me.’ (WLI3)
And girls are faced with complex decisions with lose-lose outcomes:
Some go to school in the afternoon so in the morning they will have to do their trade before school. At a certain time before noon they will come home and get ready for school … (it can) take the whole day to sell and when a man offers to buy everything she has for sex, that can be tempting. (WLI2)
‘Water for water’
There are two seasons in Sierra Leone; the rainy season from around April to October, and the dry season from around November to March. Poor communities such as Kuntorloh have no water delivery infrastructure; in the rainy season water is harvested from roofs, but in the dry season water must be collected from community wells, which gradually dry up as the season progresses. Water collection is one of the time-consuming domestic duties which young people, particularly teenage girls, are responsible for; a task which can take five or six hours of queuing at the height of the dry season. Both research visits took place within the dry season, and participants were keen to talk about the risks associated with water collection, explaining that the queue can be bypassed by girls having sex with the youths who run the wells. A local expression ‘water for water’ was cited by several of the participants:
Teenagers get pregnant a whole lot because of the water crisis – ‘if you give me water, I’ll give you sex’. ‘Water for water’. Especially in February, March, those two months. Oh! Very tedious – water! (WLI1)
Participants clearly viewed this sex as transactional rather than coerced or forced and it was clear that this phenomenon was not an example of the risks cited in the literature about being raped whilst walking to the water points .
It’s an agreement, as they are in love. It’s not a rape. The girls do not want to waste too much time at the stream or well. So, if the boy who controls the well or the water tap is the girl’s boyfriend... even if she has twenty or even fifty containers, he will make sure her containers are filled up first. So the girls get home a little bit earlier than normal. (WLI2)
For girls who are trying to attend school and study for exams this is a real dilemma:
Interviewer: what if a girl decides that she is not going to have sex?
(WLI3): you will stand there for the rest of the day you would not be able to get the water.
This participant, an older woman, expresses her frustration at the infrastructure deterioration which has allowed this problem to develop:
The dam has got to be repaired or worked on. In days gone by here in Freetown there used to be taps at every street junction. Then we never used to have this problem of young girls getting pregnant due to water crises. (WLI3)
Clearly, the task of collecting water during the dry season can present girls with difficult choices in terms of sexual behaviour, particularly in terms of freeing up time for study and school attendance.
Sex to pay for school fees and hidden charges, and school-based financial abuse
Sierra Leone does not provide free secondary school education; all families expect to pay school fees and many plan accordingly. However, it is the unpredictable, hidden costs which put additional strain on teenagers. Some of these charges are for ‘extra classes’, where teachers only partially cover the syllabus during regular school hours so that students are forced to pay directly to teachers to supplement normal school. Young people who have to source this money for themselves employ a range of strategies to do so, including girls engaging in transactional sex with older men, or ‘sugar daddies’:
The man that impregnated me was helping me a lot for my schooling, so I fell in love with him, but I was so small at the age of fourteen. (MFG).
Other more blatant financial abuse occurs when teachers require additional payments in exchange for a student passing an exam or being promoted to the next school year. This study describes a deeply entrenched system of extortion for grades and progression levied by individual teachers, both male and female:
It’s just like bidding. The highest bidder has the highest grade. If you give 10 000 Leones, you will have your 10 000 Leones grade. If somebody comes with 20 000 Leones, that person will automatically have a higher grade than you! Let’s say for example Salimatu comes to school, and she does not have that money. Automatically she will have to repeat (the school year). No matter how brilliant Salimatu is, she will have to repeat that class simply because she does not have that money to satisfy the teacher. You have to satisfy your teacher both in writing and in the financial aspect. (T1)
School attendance presents teenagers with a raft of financial challenges, even if their basic school fees are being paid. Having to find the extra money needed to access all of the curriculum, to ensure that assignments are graded or even to pay what are essentially bribes to teachers to pass exams and progress through school can put girls under pressure to have transactional sex with older men who can provide for them.
Sex for grades
An even more direct risk associated with schooling is the sexual abuse perpetrated by teachers whereby they arrange to have sex with female students in exchange for academic achievement [8,9,10,11]. This is identified as a pervasive issue, but one which young people are reluctant to discuss .
In the current study, this was borne out by the issue being discussed exclusively by professional participants rather than by the adolescents themselves. The practice appears to undermine the whole system upon which academic success is based:
Children who are not able to read or write and find it difficult to, you know, understand questions and pass exams … some male teachers exploit that situation by offering, asking them to offer sex for grades. (T2)
This seems to be a ubiquitous issue. The following refers to one of the most highly regarded girls’ schools in the country:
The other day my daughter was telling me ‘Mama, even when I’m submitting my assignment, my teacher is asking me for money.’ If you don’t give your child enough money to pay for the assignment, what happens? ‘Ah Mr X, I don’t get money’. ‘OK, meet me at my house’ ... If the girl doesn’t get pregnant, its infection. STI, HIV. That’s why HIV is as high as it is. (NGO1)
Whilst some of the sexual activity between older girls and teachers is initiated by the girls themselves, the data also demonstrates a deliberate targeting of very young girls, with evidence of abuse of girls in very early puberty:
Even in primary school, you see these girls have grown breasts, and maybe you are thinking ‘I don’t want to go to bed with this girl’, but your hands … you may want to like... touch her breasts, her buttocks, in that sexual way, after the class. (T1)
The evidence points towards this abuse being entrenched within the education system, with the implication that some teachers go into the profession to have easy sexual access to young girls:
One time when I was at the teacher training college, they asked us to give our names and school of choice for our teaching practice. And some of our colleagues gave their names for a female school for one reason ... the reason is to have more girls you see. There are schools who are marked as ‘sex schools’. Sex schools! The other day someone was telling me ‘ah that school over there. If you go there, you can have women until your tire.’ (T1)
The issue appears to go beyond individual teachers with reports of ‘sex for grades’ being accepted and even encouraged by school leaders. Participants also noted that, at times, boys are paid to investigate girls’ backgrounds as potential targets for coerced sex by teachers:
Some of these teachers, they use some of these boys to investigate these girls. Like for example they will say ‘Souri, I really want that girl. Go and look at the background of that girl. If they have any person that is strong in the family.’ And Souri will now go to the girl, and interview the girl. If he says they are poor, then automatically the teacher will take that as an advantage. (T1)
Various methods are used by teachers to pursue and control girls such as buying the girl a mobile phone, which she is then expected to use to send sexually explicit photos. This study data would indicate that this practice is commonplace, but that the taboo around it is stronger than the ‘sex for school fees’ issue.
It seems apparent that for teenage girls in Sierra Leone, graduating from secondary school is not a simple matter of completing assignments on time and studying for exams. On the contrary, for some young women, pursuing an education seems to be a minefield of risk and difficult decisions where the benefits of an education have to be weighed against the risks of pregnancy, infection and the trauma of unwanted sex.
The criminal justice system
With pressure from groups such as Legal Access through Women Yearning for Equality Rights and Social Justice (LAWYERS), legislation is in place in Sierra Leone to address underage sex and child abuse, and it is the first pillar of the 2013 teenage pregnancy reduction strategy. Despite this, prosecutions, whether of family members or professionals like teachers, are rare. In the literature [8, 10], and throughout this research, two common scenarios emerge; of families negotiating a financial settlement themselves, and of families reporting the issue to the police but this process being undermined by senior community members pleading that the man be released for his ‘good character’.
I think on one or two occasions, I’ve heard of the teacher being taken to the police. But … all the senior members of the society will come; ‘Oh, let this man go, he is a teacher. He’s actually doing very well in this community. Please don’t let this teacher go down to prison.’ (CBOI)
This senior community leader expressed frustration with the deficiencies in the legal system, proposing a zero-tolerance approach:
Even the government are unable to … interpret and implement the law properly. When someone has done something bad they should be in prison. If someone dies in pregnancy the person responsible should be charged with murder. If this is done to one, two or three persons as a sample, the others will be afraid. But most of those who commit such offense are freed one after the other. (SCLI)
However, the picture is not entirely bleak. The national strategy is clear in laying out the legislative framework around child rights and gender-based violence, providing a common understanding of the way ahead, and some NGOs are building on this platform, providing training for community leaders on identifying and dealing with child abuse. The director of one CBO explained how he feels things are changing:
In the past, there was lots of compromising on sexual abuse cases … but in the past three months, we have supported the prosecution of up to four or five sexual abuse cases of children between the ages of eleven and thirteen. All of them, when these cases are in court, the perpetrators have been remanded in prison. (CBOI)
There was also evidence that attitudes around abuse by professionals may be starting to change; examples were cited of recent imprisonments of policemen who had been prosecuted for child abuse. However, even though the will to implement legislation may be changing, capacity is a very real barrier; NGO and GoSL participants highlighted the lack of resources as an additional barrier in rural areas:
In certain far remote communities, where you do not have magistrates court sittings … if a victim is staying in the community which is about 50 or 100 miles to where the court is, without all of this support, transportation, shelter, then she definitely will not come. (GI1)
Despite a legislative framework being in place to deal with sexual abuse, there currently appear to be a number of barriers to fully implementing this legislation, including a lack of political will to take the issue seriously, a lack of logistical infrastructure to facilitate trials and prosecutions, and a lack of support to girls who choose to put their heads above the parapet and challenge the inherent gender norms and power imbalances to which society generally and the education system specifically are subject.
Contraception and abortion
Access to contraception is recognised as a vital component in reducing adolescent pregnancy and maternal death [12,13,14], and an important part of the national strategy is to make contraceptives more accessible, available and affordable for adolescents. There is work in progress to train health workers in family planning methods, including implants, and to make government clinics adolescent-friendly by allocating trained staff to treat teenagers, with, in some clinics, a separate room to accommodate them. Marie-Stopes and other NGOs are also popular providers. Health workers made a distinction between Freetown and the provinces in regard to contraceptive services, saying that they are well stocked with contraceptives in Freetown, but this is not always the case in the more remote rural areas. Despite availability, health workers identified ongoing stigma as the major reason why girls do not access family planning in Freetown.
Though implants, known in Freetown as ‘captain bands’ have increased in popularity, with younger girls there is a concern about being ‘found out’ due to the visibility of the implant, particularly in the few days after insertion. There was also evidence of myths and taboos around contraceptive use:
They listen to the people in the street that says it gives cancer, so they’re afraid. (HWFG)
However, as the midwives pointed out, child spacing for adolescents is particularly important to allow them to finish developing. A major concern amongst the midwives was that girls who were too ashamed to use the clinics often turned to unqualified suppliers whom they referred to as ‘quacks’. This often also included performing unsafe abortions, which the midwives perceived to be a significant contributor to maternal mortality, although rarely counted as such:
And not only are many of them dying of childbirth, they are dying of abortion. Most of the mothers, because of the embarrassment and everything, take them for abortion. And they die, and they don’t talk about it. (MWI)
Several of the young mothers described methods they had used to attempt an abortion:
In the village, when I knew that I was pregnant, I drank a lot of herbs to destroy the pregnancy. (MFG1)
I drank loads of Seven-up with blue clothes dye in it. (MFG1)
And several told of how boyfriends or parents had tried to persuade them to have an abortion, but they had refused or avoided it.
Despite significant advances in the supply and range of contraception available to women in Sierra Leone, there are persistent issues of availability in rural areas, and accessibility for stigmatised groups such as adolescents. The use of unregulated contraception and abortion put these younger women at additional risk.
Vulnerability to maternal death once pregnant
Many women in Sierra Leone have had a child in adolescence. As mentioned, the country has a very high teenage pregnancy rate, and one might reasonably conclude that this would normalise and reduce the stigma associated with teenage pregnancy. This study indicates that this is not the case, with teenage pregnancy being a significant social determinant of poor health outcomes for mother and baby. It carries a stigma which is associated with maltreatment of pregnant teenagers and low uptake of maternal and child health services in this group. Despite health workers and midwives in this study insisting that low maternal age in itself should not be a cause of maternal mortality and morbidity, there are upstream factors at work which strongly influence the likelihood of very young pregnant women surviving pregnancy and thriving as mothers.
Abuse and abandonment
A strong narrative amongst participants was that girls who find themselves pregnant are very likely to be rejected by their families. Most of the young mothers in the study had been afraid to tell their parents, particularly their fathers, fearing physical abuse:
So my father came home … and said if he meets me in the home he is going to shoot me with a gun since he was a policeman. (MFG1)
My elder brother was so annoyed that I was beaten and I was wounded on my back and the sore was there for a long time on my back. (MFG2)
All girls reported being told to show the man who ‘owned the pregnancy’, and for those for whom the boyfriend ‘denied the pregnancy’, some returned home after a cooling off period, often mediated by their mother or another female family member. Where this was not possible, some remained away from home with friends or lived in abandoned buildings, often with no reliable source of support. When the baby’s father was prepared to ‘own the pregnancy’, an arrangement was often made for financial support to the girl’s family, or for the girl to live at the man’s house. Girls in this situation had very mixed experiences – some were treated well, and others were made to sleep on the floor and given heavy domestic duties and very little to eat.
So I went to auntie Ami’s parlour, and I slept there on the hard tiles until nine months and was ready to have the baby. They didn’t feed me. Auntie Ami fed me once a day and let me sleep in her parlour because I did her washing and her dishes. (MFG2)
They threw her out of the home and she went and stayed with the boy who was an apprentice with a taxi cab driver, so they were sleeping in cars. She was cold, anaemic, not enough blood and was not eating well. She was sharing a plate of rice with her partner. She died. (WL2)
Other studies have found that this arrangement confers higher risk of emotional and sexual abuse for the girl, and higher risks of physical and mental health problems [8, 15].
Increased birth complications
‘Just because she’s young, it doesn’t mean she has to die’
Midwives were clear in their discussions that it is poverty and abandonment which set a girl up for maternal death rather than age per se. A strong theme which all the midwives and other health workers came back to repeatedly was ‘just because she’s young, it doesn’t mean she has to die’. They acknowledged that young girls can be less developed and need specialist midwifery and obstetric care, but were adamant that with the right care, they should be no more destined to death than an older woman.
So it doesn’t mean she’s a teenager, she should die. (No, exactly!) If we know the risk, if she goes through the normal antenatal care, where they screen her, test the blood haemoglobin level, do head to toe assessment, palpation and all, she should receive care just as any woman who is pregnant, if we have proper, functioning systems in place. (HMFG)
They consistently attributed adolescent maternal death to lack of care; both family care and delayed midwifery care, and were clear that one did not have to look very far upstream to discover the source of medical risks such as anaemia, malaria, pre-eclampsia and infections. Poor diet led to anaemia, and delayed care seeking meant that girls were missing out on life-saving antenatal care; blood tests for infection and haemoglobin level, antimalarial medication, iron supplements, blood pressure checks, and the health talks given at every antenatal clinic appointment:
And because of the inexperience, they don’t know when there is a raised pressure only because they refuse to come to the antenatal … and by the time they come to the hospital they come convulsing, fitting. You see them dying. (SMI1)
They reported teenagers often not registering at all with a health care provider in pregnancy, then presenting late in labour, often only accompanied by friends and lacking any adult support, and they related concealed pregnancies directly to maternal death.
Particularly for girls in rural areas, early marriage was seen by the midwives as a risk factor. For these girls, though living without stigma and in the safety of either their parents’ or husband’s family home, delay in care seeking was a major issue, often a result of the lack of decision-making ability of women within traditional families:
In the provinces, when the chief wants that young grownup girl, he convinces the relatives. After marrying her she becomes pregnant. Maybe she does not even attend antenatal clinic. When it comes to delivery, complication arise. To let them refer that case to the big hospital, it’s a problem. Maybe the husband is not around, then the relatives do not have money and they do not have a say over that woman so they delay to make decision. So after they have made the final decision to take the woman, transportation! Maybe the road is not good, there is no ambulance for the patient to come to the hospital. So after the patient has arrived now in the big hospital … maybe we need blood for this patient, there is no doctor to see this patient … if she comes in with bleeding, obviously she will lose her life. (HMFG)
Clearly, teenagers who die around the time of childbirth suffer from the same obstetric conditions which befall older pregnant women, but youth in itself should not confer additional risk when considered as part of a risk assessment – a concept which the midwives clearly articulated. Obstetric risks were perceived to be magnified by delayed care seeking and the poor physical condition in which girls go into labour.
Risk of death from Anaemia and PPH
In Sierra Leone, as in many other countries in Sub-Saharan Africa, most donated blood is given by family members during an emergency. Although there were some contradictory versions of how the blood bank operates in Freetown, it was commonly reported that for a patient to be given a blood transfusion, two donors were required to donate into the blood bank. Discussions with midwives from both the peripheral clinics and the referral hospital described a clear policy for minimising the risks of anaemia and post-partum haemorrhage; all women are given iron supplements and advised on diet, and haemoglobin level is checked at 36 weeks of pregnancy, when women are urged to involve family members in identifying potential blood donors:
When the mother attends ANC, and they tell her she will need blood … she will ask her family, saying ‘look here, I’ve been going to ANC and they say I will need blood, so what I want you to do, as a family is to be thinking who will give blood’... it’s all part of birth preparedness. (HMFG)
But with limited success:
…well most of the time they tell them but they don’t comply, they don’t accept that there’s a problem, and then you see them running helter-skelter. (HMFG)
Where a donor cannot be found, most participants stated that non-related donors can be paid at a high premium to donate. Where people cannot afford to pay a donor, participants reported that emergency blood is given if available but that this is not always the case, to the frustration of clinicians and community leaders:
We don’t have much blood in the blood bank. They end up dying. We can help but we cannot give more than what we have. (SMI3)
Someone would have to pay for blood. I have been there on about seven occasions when young girls died there. They have that problem there. There is no free blood. People do not volunteer to give blood. Unless your relative volunteers to give blood on your behalf, if not so you would have to buy. (WL3)
The severity of the situation was all too apparent when the first author donated her blood at the country’s main referral hospital; it was the only unit of A+ blood in the blood bank.
The literature from Sierra Leone consistently points to good parental communication, especially with mothers, as a protective factor for risky sexual behaviour and early pregnancy, but that parents lack confidence to discuss these issues [15, 16]. This study aligns with that; the country director of an international NGO addressing teenage pregnancy prevention in a rural area described ‘overwhelming numbers of parents wanting to join in’ with their interventions to equip parents with knowledge and skills to support their children.
This was reinforced by several of the professional participants referring to their own feelings of inadequacy in this area:
We the parents also, to some extent, we are to be blamed ... because we don’t make our children our friends. We have that communication barrier... some of us think that there is certain information that has to be hidden from these children, then they go astray as a result of that. You have to talk to your child! (HMFG)
Many girls reported knowing very little about sex and pregnancy before they conceived. Several girls interviewed did not know they were pregnant until a family member or relative noticed their body shape changing and took them for a test. Regarding outcomes for girls once pregnant, the ability to communicate with, and good care by family members were recognised as being protective, especially in avoiding the dangers of concealed pregnancy and abortion:
What is most dangerous thing is this abortion, because some of them are so afraid of their parents and usually it’s the boyfriend who took them to non-qualified people. (MW1)
Regarding criteria for a young woman to move on positively with her life after a pregnancy, it is unsurprising that having supportive family relationships has been shown to be highly advantageous. Several professional participants referred to themselves or colleagues who had had a teenage pregnancy, but had progressed to a successful professional career due to good family support. Currently, all pregnant girls are forced to drop out of school as there is a controversial ban on ‘visibly pregnant’ girls attending school or sitting exams, which for some girls adds to the stigma and isolation they experience . The capacity to either return to education or pursue vocational training appears to be important for mental wellbeing, avoiding rapid subsequent pregnancies, and being able to provide for their children, thus breaking the cycle of poverty. These two young mothers, enrolled at Conforti, a vocational training provider, express this:
Now that I have given birth and decided to come for that training, I have joined the PPA so I will not give birth again. (MFG1)
But I bless this institution, training us. I wasn’t feeling good about myself, I just saw myself as a drop-out, I really felt it! (MFG1)
However, the additional expense of school expenses on top of providing for an additional child is often prohibitive for families. At the time of the study, LNP was providing free training in trade-based skills to local youth, and this was considered a huge community asset:
That (the Institute’s graduation) was very good. Some might want to learn but are not able to pay for the education. The parents might not be rich enough to pay. But if they learn a trade they will be able to provide for themselves and their children. (SCLI))
For girls who have been abandoned by their family, or are living with the baby’s father’s family with little support, there is a recognised need for other adults in the community to act in the capacity of trusted adult. One participant, an older mother of five, had recognised this in her local community and been informally supporting pregnant girls for the previous five years. She described her strategy; ensuring the girl accesses health care whilst attempting to advocate for her within the family context:
I had this urge, feeling and burden for children who are thirteen, fourteen, fifteen, in schools. This was bubbling inside me so … I started working with the girls that have been expelled from their family homes. I usually accompany them to talk to their parent, saying things like ‘it’s like a loaded gun - once the trigger is pulled it cannot be recalled. The only thing we can do is to take care of the girl’. I am thankful to God I have never had a victim or death... I will take the pregnant girl for check-up with a nurse making sure that everything about the pregnancy is alright then I will approach the parents. I do pray before I go to speak to the parents as some of them can be very bitter saying I would not accept the girl as she has chosen to be sexually active. Let her go and get married. I will say to them ‘this child is yours, a marriage can end but the girl will be the one who look after you when you are old.’ I will gather other people to help with the negotiation. Most times this is successful. (WL3)
She also described her strategy to ensure that the girls had enough money to feed themselves well and buy things for their baby; supporting them to start a small business and supervising their savings.
Considering the recent EVD epidemic in Sierra Leone which left many stigmatised orphans, and the effect of the internal migration of teenagers away from families in the provinces to Freetown, this simple community-based mentoring intervention has the potential to benefit other orphaned, abandoned or otherwise isolated adolescent mothers in Freetown.
Community-based blood donation
Blood donation in Sierra Leone is complex, with social norms around who can donate blood to whom. It is rare for a husband to donate blood for his wife, with the woman’s birth family usually donating in this case:
Yes, because for example if I was pregnant, my sister would be more willing to give blood for me, or my brother, so that nothing will happen to me. Rather than my husband. (NGOI1)
It is the dads that give blood more than the husbands. (SMI1)
Whereas if a child needs blood, this will invariably be donated by the child’s father:
For children, most times the father does it. The fathers are willing. But they will not give for their wife. I don’t know what the issue is. (NGOI1)
This study identified altruism as a strong motivator for blood donation in Freetown:
Just because when people meet me and they explain to me ‘you need to help us in this situation’, I just need to do it, because that is my only way to help them. (YMFG)
But found that a significant barrier was HIV testing; either fear of discovering their status, or fear of their status being told to a family member:
Yes, I think people will be afraid to be tested, in case at the end of the day the doctor says, ‘you have HIV’ (YMFG)
People are afraid. People don’t want to be tested because of hepatitis and HIV. So, they dodge. Some husbands they prefer to give money to donors to getting them tested, or maybe some of them know their status, they hide it from the wife, and they don’t want to expose it. (NGO1)
This fear of stigma was all too fresh to participants after the recent EVD epidemic where affected people were ostracised by the community:
In this country, when I say this person has HIV, they will just run away from you, it will just turn like Ebola. (YMFG)
A further barrier was fear of the process; in a focus group of young men, there was clear lack of knowledge, with questions asked about how much blood was taken, whether it hurt, and whether your body could recover. Lastly, some common myths were raised:
People say when you give blood you die. When you give blood, you become sick. (WLI2)
Some people think if they come and take one pint of blood from them they will die tomorrow. It is just fear. (YMFG)
All participants with whom blood donation was discussed believed that a donor should be compensated for what their body had lost in the process of donation:
Even for someone to be able to give blood they should be able to have food to eat. If not so they will be anaemic. (YMFG)
This was not considered a payment, and the donation was still classified as voluntary. For one young man who had donated blood five times to non-family members, being thanked also seemed to be an important motivator:
The one I remember was (name). I was thinking that at the end of the day, I paid my transport to go there … I was thinking that when he got well, he would say ‘hey man thank you’, but … he couldn’t even look at me, but I had already done it, so I just let him forget about it. All the (other) four people, I’ve been happy to keep them alive, but for him, I was so angry about it, because he’s my brother (non-relative), so I was thinking he would say something like ‘thank you’. (YMFG)
In terms of strategies to recruit non-related volunteer donors, more overt compensation is more important. For example, health staff are offered days off in exchange for a unit of blood. It was evident that various models had been tried to recruit donors, but with limited sustainability:
There was an NGO who was paying people to donate blood. The donors were fed well. But the problem with our country we have so many groups which have been set up by so many NGOs who would come and start something, but it is for short time it does not last. (HWFG)
A potential solution was discussed with midwives and a group of young men from LNP, of having a local blood donation register, whereby a direct communication between the clinic midwife and the co-ordinator of the register would ensure that a donor could be sent to the referral hospital directly if a woman had to be referred for bleeding. This midwife felt that not having any mechanism for compensation would be a barrier as, again, being fed a meal was a minimum expectation of donors:
They would have to eat to replace that. We would not be able to keep this service going. It is not easy to get people to donate blood. Some people will do it once but they would make excuses the second time. They will say that they have not eaten since the morning. (MWI)
Blood donation experience
The literature also shows a clear association between the first blood donation experience and the likelihood that the donor will donate again , and it was clear from the young man who was a multiple donor that his experience had been positive, that he had felt well cared for and given food:
If you donate your blood, they will take care of you, explain to you how it’s supposed to be, during the blood donation, or after the blood donation. They will explain to you ‘sit down first and take a little bit of bread’. (YMFG)
Other potential barriers to a local community register was the fear that donors might be taken for granted when there were other family members able to donate; this would need to be part of a further consultation on compensation mechanisms and eligibility.