Differences in health indicators across distinct geographic areas have been noted in other contexts  and recent studies have called for additional research exploring regional variability in the delivery of maternal and child health services in sub-Saharan Africa . In line with this, our study identifies discrepancies in maternal and child health indicators across two separate contexts, the mainland and the riverine, both served by the same district health management team. Results suggest no significant differences in the demographic make-up of both groups, allowing us to compare them for the purpose of the study. Specifically, we found no differences in age, education and marital status, all of which are well recognised as important determinants of women accessing maternal health services [21–24]. There were however, four main differences across maternal and child health indicators between the riverine and mainland found in this study.
In terms of reproductive health services, women on the mainland reported a higher use of family planning (traditional or modern), compared to women in the riverine. There were also key differences in place of delivery between the riverine and the mainland, with the mainland reporting more frequent facility based deliveries and a greater use of skilled birth attendants. More importantly, further stratification suggests that the differences for children born in a health centre and in the presence of a SBA or TBA only existed for children born after the introduction of the FHCI. In particular, the increased rates were significant on the mainland for health centre and SBA deliveries, and there was a significant decrease in reported TBA presence at births. However, in the riverine there was no difference seen between pre- and post-FCHI. Thirdly, child immunisation rates, with the exception of measles, were higher on the mainland. While differences existed whether children had been born prior to the initiation of the FHCI, the differences were less pronounced for children born after the introduction of the FHCI. Lastly, fewer households in the riverine had access to safe and/or treated water in comparison to households on the mainland. Taken together, our results point to the need for more resources to be put into reproductive, maternal, and child health services in the riverine. Specifically, the Bonthe DHMT should consider directing more resources towards increasing access to family planning, delivery services, and skilled birth attendants. More immunisation efforts are also needed in the riverine and additional investment is necessary to improve water and sanitation services. The following sections draw from the extant literature to explore the potential reasons for these observed differences and make suggestions for how these could be addressed.
A recent systematic review of drivers and deterrents of accessing a health centre for reproductive and maternal health in sub-Saharan Africa identified maternal education, parity, household socioeconomic status, rural or urban dwelling, distance to a health facility and number of ANC visits as the factors most consistently associated with having a facility based delivery . Place of delivery can also be influenced by a women’s social circle  and by factors such as the influence and education levels of the head of household . Similarly, attitudinal resistance, awareness of services, societal and cultural pressures, socioeconomic barriers, availability of transport, access to appropriate services, and perceived quality of care are commonly cited barriers to reproductive health services [26–33]. The last three are characteristic of health system failures and of particular relevance to a district health management team.
Availability of transport and access to appropriate health services
Among other environmental factors, accessibility and availability of transport are commonly noted throughout the literature to impact on health service . In this study, the difficult terrain characteristic of the riverine may partly explain why women in the riverine are more likely to give birth at home rather than in a health centre. The topography of the riverine requires that one navigate a complex system of rivers, lagoons and estuaries both on foot and by boat. With previous studies linking long travel times to increases in child mortality [35–37], it is important that pregnant women access a health centre at the time of delivery. As a recommendation, the DHMT might consider the use of maternity waiting homes, or a facility within reach of a health centre that provides emergency obstetric care . Maternal waiting homes have been employed in other low-income contexts, including neighbouring Liberia, where they were found to be an effective strategy for increasing the use of skilled birth attendants and improving maternal and neonatal health . As, if not more important, than ensuring a safe and clean environment for delivery however, is the availability of a skilled health worker.
In addition to restricting access to care, difficult geographical conditions can also result in poor living and working conditions for health staff. Studies have highlighted the lowered performance of health workers on remote islands such as those represented in the riverine  and other remote peripheral health units in Sierra Leone have also shown significant inefficiencies . Poor working conditions in turn, are associated with poor performance, increases in attrition rates, and difficulties recruiting health workers, as individuals prefer not to be posted to remote and difficult locations with poor infrastructure and far away from their family [42–44]. The terrain and remoteness of Bonthe District make it an unpopular location for health workers, with the riverine being particularly understaffed. The DHMT may want to consider additional incentives as a means of enticing health workers to the riverine. Salary top-ups and other non-financial incentives such as providing free housing and further education opportunities were found to impact on the willingness of nurses to work in remote areas of Tanzania . In addition, the DHMT may want to select health workers who are more intrinsically motivated  and who originate from very remote areas, as they have been found to express a greater willingness to take up a remote position . To maintain the equitable delivery of MCH services, it is imperative that less resourced areas have in place strategies to maintain a satisfied health workforce.
Widely recognised as effective preventative practices, child immunisation and appropriate water and sanitation are important determinants of maternal and child health [47, 48]. In contexts with scare human resources for health, enlisting the help of alternative cadres of health worker, such as the community health workers (CHWs), is recommended for the effective delivery of preventative maternal and child health care interventions . CHWs are considerably less expensive to train, are selected by the very communities they serve, and with adequate training, can help address many of the cultural barriers often associated with delayed or inconsistent access to health care services [50, 51]. The use of CHWs may be particularly appropriate for the riverine, given its remoteness and difficult topography.
Affordability is also an important factor when considering the equitable access to transport and health services. Though the FHCI theoretically removed user fees, studies report that women have continued to pay for services since the initiation of the scheme . Unfortunately, these findings are not uncommon in free health care initiatives [53, 54], with patients continuing to pay out-of-pocket for transport, medical supplies, and for informal payments requested by health centre staff. These expenses are likely higher in areas such as the riverine, where there are longer distances to travel to the health facility, resources are scarcer or more difficult to obtain, and where the working conditions for health staff are considerably worse. A more recent study conducted in Sierra Leone on the impact of removal of user fees showed that more educated women were more likely to benefit from their removal, with no impact on service utilisation across wealth quartiles . As McKinnon et al.’s  review notes, the removal of user fees alone is not enough to reduce inequalities in the delivery of health care. Barriers that impact on socioeconomic inequalities, and access to quality service need to be addressed and included within national plans if Sierra Leone is to implement their FHCI equitably and efficiently amongst its population.
Perceived quality of care
It is worth noting that along with the introduction of the FHCI, Sierra Leone also made illegal the practice of deliveries being assisted by a traditional birth attendant (TBA) . The decision to give birth in the presence of a TBA is largely influenced by cultural and societal norms, with individuals reporting a more personal relationship, better quality care, and greater trust in TBAs. Similarly, a lack of available or inaccessible health facilities and/or a poor opinion of hospital services and staff also contribute to a preferred use of TBA [31, 57]. TBAs are also considered to be more affordable, as they are amenable to being paid in-kind or by instalments . These factors may all contribute to our observation of greater TBA use and a greater prevalence of women giving birth at home in the riverine.
While the Bonthe DHMT is well aware of the legal standing of TBAs, they must acknowledge the value that some women place on TBAs. In the absence of a greater number of trained health providers posted to the riverine, TBAs remain an important resource for the transmission of health messaging and to increase service utilisation. For example, TBAs are an important resource to encourage pregnant women to come to the health centre to attend antenatal services and when engaged appropriately, and like community health workers , can act as an important bridge between communities and more formal health systems . Consideration should be given for how to best engage TBAs in Bonthe District, as an important strategy to achieve a more equitable maternal health care service.
Equity, not equality
While the Government of Sierra Leone (GoSL) currently provides health resources to the Bonthe DHMT through both the Bonthe Municipal Council (located in the riverine), and Bonthe District Council (located on the mainland), resources are allocated on the basis of population with little consideration for typography, difficulty of access, and the demographic profiles of potential health care users. The results of this study indicate that the riverine may be disproportionately disadvantages by a lack of resources. Contingencies for areas of greater need should be developed and implemented, which includes increased availability of skilled health workers, more focused immunisation campaigns, and greater resources to address the lack of access to water and sanitation. In other words, initiating a free MCH programme alone is not enough to reduce disparities within populations and resources in Bonthe District should be allocated to specific health centres on the basis of need, rather than on the basis population. In addition, routine monitoring of national and district data should be conducted to capture “health systems input, quantities and prices and health services outputs to facilitate regular efficiency analyses” . Early involvement of stakeholders is particularly important in the early stages of MCH programmes as they can provide important suggestions for programme re-alignment, and how to meet end-user expectations . Helping programmes better plan for service delivery is important to ensure access to care for more vulnerable populations and to deliver equitable health services. Additional research into the reasons for the observed discrepancies will be important to further inform the implementation of health activities and the distribution of resources going forward.
Sierra Leone post-Ebola
Data from this study was collected prior to the Ebola outbreak that afflicted Sierra Leone and its neighbouring countries of Guinea and Liberia. The recent outbreak resulted in over 3950 deaths in Sierra Leone alone  and has left an already under-resourced and overstretched health system in a severe crisis. With 6.85 % of Sierra Leone’s health workforce being lost to the Ebola virus, some predict an increase in maternal and infant mortality of 74 and 13 %, respectively . The tragic loss of health staff has the potential to result in an estimated 4022 additional women dying during pregnancy and childbirth per year across Sierra Leone, Guinea and Liberia, reminiscent of levels during the civil conflict .
Findings during the outbreak have indicated a decrease in RMCH service utilization , with evidence that Ebola has disproportionately affected women and children . In the aftermath of Ebola, it is predicted that its devastating consequences will again most be felt by women and children . It is therefore not unreasonable to assume that the discrepancies observed in this study will be exacerbated as a result of the recent Ebola outbreak, causing a further decay of the health care system and an even greater shortage of health workers.
The challenge for Sierra Leone will be to rebuild and strengthen its health system in an efficient and equitable manner. As these findings show, considering existing discrepancies and contextual conditions, over and above populations numbers, are essential to ensure equitable – not just equal - distribution of maternal and child health resources.
This study is not without its share of limitations. Notably, sampling errors may have occurred during the development of the sampling frame, impacted by the non-availability of community maps. Similarly, only households where someone was present during the day were sampled, excluding houses where people were away working or caring for their farms. In addition, a pocketing effect may have been introduced due to the random number generators for first house selection. This pocketing effect could influence certain indicators, such as immunisation rates. Bias may also have been introduced during the data collection process. This includes social-desirability bias, which has been noted in other studies regarding reporting of breastfeeding and child health indicators and recall bias, for those indicators (fever, diarrhoea, ARIs) that were collected based on the primary caregiver’s perception of illness without validation by a medical professional. In addition, this survey was conducted during the dry season, which may impact on the reported incidence of certain diseases, notably diarrhoea, which is more prevalent during the rainy season.