Dear Editor,

The cases of human encephalitis by West Nile virus (WNV) recently diagnosed in northern Italy (Emilia Romagna and Veneto Regions), two of which occurred in elderly patients who experienced a fatal outcome (unpublished data), deserve special concern. This should apply, more in general, to the eco-epidemiology of all arthropod-borne infections, many of which are of zoonotic relevance. We are dealing, in fact, with a large group of viral (Zika virus, Dengue virus, Yellow Fever virus, Tick-Borne Encephalitis viruses, etc.), bacterial (Ehrlichia spp.) and protozoan (Plasmodium malariae, Leishmania spp., Trypanosoma spp., etc.) pathogens, a portion of whose life cycle takes place in an invertebrate host (insect or tick), from which the infectious agent, once acquired from an infected human or animal host, will be subsequently transferred to another susceptible, human or animal, host.
As far as WNV is specifically concerned, this zoonotic flaviviral pathogen showed up for the first time in Italy in 1998, thereby giving rise to a series of encephalomyelitis cases among horses from Tuscany Region (1).
Culex spp. mosquitoes - namely Culex pipiens - represent the main WNV vectors. Indeed, successful virus isolation has been obtained from Culex spp. mosquito pools recently sampled in Veneto Region (unpublished data).
Numerically speaking, arthropod-borne pathogens account for approximately two thirds of the biological noxae responsible for "emerging infectious diseases", 70% of which would originate, in turn, from one or more animal reservoirs, as definitely proven with the two betacoronaviruses SARS-CoV and MERS-CoV, while being largely plausible and highly suspect also in the case of the pandemic SARS-CoV-2 betacoronavirus (2).
The seven years between 2015 and 2021 have been the hottest ones ever recorded on Earth within the last 140 years, with this significantly impacting also the vectorial efficiency of arthropods toward their respective pathogens. Indeed, under the present meteo-climatological conditions insects and ticks are now being increasingly reported to overcome the autumn and winter seasons ("overwintering") far more easily than in past decades. These progressively higher and higher average temperatures are responsible, in fact, for a (more or less) consistent reduction of the life cycle and replication ("extrinsic incubation period") of the infectious pathogens carried inside insects' and ticks' bodies. Based upon the above, a progressive "transfer to northern latitudes" of arthropod-borne infections, of either viral or non-viral aetiology, has been documented in more or less recent years, as clearly shown by the emergence of bluetongue virus - carried by Culicoides spp. - among ruminants from northern European Countries (3), as well as by the detection of Leishmania spp. - carried by Phlebotomus spp. - in dogs from UK (4).
In consideration of the above and, most importantly, in view of the documented zoonotic potential of many viral and non-viral, arthropod-borne pathogens (including WNV), a "One Health"-based and multidisciplinary approach would be absolutely needed for an "ad hoc" management of the complex ecology and epidemiology of the infections caused by such agents, with this reminding us (once again!) that human, animal and environmental health are mutually and inextricably linked to each other.

References

1) Cantile C, Di Guardo G, Eleni C, Arispici M. (2000). Clinical and neuropathological features of West Nile virus equine encephalomyelitis in Italy. Equine Veterinary Journal 32:31-35. doi: 10.2746/042516400777612080.

2) Casalone C., Di Guardo G. (2020). Covid-19 and mad cow disease: So different yet so similar. Science (e.Letter), April 06, 2020.
https://www.science.org/do/10.1126/comment.742365.

3) Carpenter S., Wilson A., Mellor P.S. (2009). Culicoides and the emergence of bluetongue virus in northern Europe. Trends in Microbiology 17:172-178. doi: 10.1016/j.tim.2009.01.001.

4) McKenna M., Attipa C., Tasker S., Augusto M. (2019). Leishmaniosis in a dog with no travel history outside of the UK. Veterinary Record 184:441. doi: 10.1136/vr.105157.

How to use heat stable carbetocin and tranexamic acid for postpartum haemorrhage in practice

A. Metin Gülmezoglu1, Sara Rushwan1
1 Concept Foundation, Geneva, Switzerland
We welcome the paper by Tran et al [1]. There are increasing number of options for postpartum haemorrhage (PPH) prevention and management as recommended by WHO and the context is important. We agree that at the national level the first step is to update the national policies including the guidelines and essential medicine lists (EMLs). Since 2019, Concept Foundation and its partners have been working in 14 East and West African sub-Saharan countries to facilitate those updates [2]. We are pleased to report that in 10 out of the 14 countries – Burkina Faso, DRC, Ethiopia, Ghana, Ivory Coast, Liberia, Rwanda, Sierra Leone, South Sudan, and Uganda – the national guideline and/or EML were updated during this period.
The strength of the project lies in the engagement with policy makers, Ministry of Health officials, clinicians, professional associations, and civil society organizations concurrently. However, competing national policy priorities such as COVID-19, timing of the previous updates, political instability and national capacity and leadership (or lack of) can make the updating process long and challenging even when there is an agreement to update. Secondly, even when the updates happen, proactive dissemination and training within the country can also take time. Thirdly, in the case of heat-stable carbetocin (HSC), even when policy updates are accomplished, the regulatory approval that is essential for the drug to enter the country can take time.
In 2021, we expanded our collaboration to include the International Federation of Gynecology and Obstetrics (FIGO) and International Confederation of Midwives (ICM) and their national counterparts to support the transition from policy updates to the development of clinical management protocols and job aids. FIGO and ICM developed a generic protocol on PPH prevention and treatment [3] and engagements with key national stakeholders were held to discuss its usability and adaptability to the country context, and how it could support existing country practices. So far, Ethiopia, Ghana, Rwanda, and Uganda have developed a national PPH clinical protocol that has been approved by the Ministry of Health, and these countries will develop supporting job aids. This work is planned to be completed in 4 other countries – Burkina Faso, Liberia, Sierra Leone, and South Sudan.
The main determinant of choosing which drug(s) to use should be the presence of a skilled birth attendant and reliable cold chain and storage. The more established injectable uterotonics must be kept in cold chain and storage, and quality-assured products must be prioritized for procurement. Implementation considerations must include ensuring that staff know and adhere to the fact that HSC is contraindicated for labour induction and augmentation. HSC is often used for PPH treatment, but this is off-label and the benefits and potential harms are uncertain. Both HSC and tranexamic acid (TXA) should be considered for implementation in peripheral and referral levels of the health care system since at peripheral level the cold chain issues are likely to be more prevalent and the lifesaving role of a quality-assured uterotonic and timely administered TXA in cases of haemorrhage is likely to be crucial. The fact that there seems to be support for intramuscular administration for TXA will make implementation at the periphery easier [4]. In referral settings with surgical capacity, it is essential that TXA is kept in a place where accidental mix-up with local anesthetics that are used in intrathecal anesthesia is avoided, since there have been case reports of deaths due to accidental TXA administration into the intrathecal space [5,6]. 
We also agree that HSC and TXA should be carefully integrated into the health system in an enabling environment and considering the context perspectives mentioned above. Concept Foundation will conduct implementation pilots in Burkina Faso, Ethiopia, Ghana, Sierra Leone, and Uganda to assess appropriate use following training of healthcare providers, and integration of the two medicines into routine PPH care management. The results of this research will be useful in better understanding the enablers and barriers for successful introduction of essential PPH medicines into clinical practice.
Our experience demonstrates that there are several barriers to access essential, heat-stable PPH medicines that require operationalization of end-to-end thinking at the national level. By end-to-end thinking, we mean addressing the challenges from the highest national policy level right down to the practicing care provider in the most peripheral level of health care where childbirth takes place. To date, most existing programs have focused either on policy level change or health care provider behavior change. Our project adopts a holistic approach, that seeks to align normative change, clinical protocol development, pilot implementation, procurement, and product introduction.
Progress in our project presents a great opportunity to allow the objectives and approach to be achieved in most high-burden countries with modest resources. However, there is undoubtedly a greater need for investment in advocacy, training, and dissemination tools to support the implementation of national guidelines in a locally appropriate way, while ensuring the WHO recommendations are reflected accurately.

References:

[1] Tran NT, Schulte-Hillen C, et al. How to use heat-stable carbetocin and tranexamic acid for the prevention and treatment of postpartum haemorrhage in low-resource settings. BMJ Global Health. 2022; 7:e008913.
[2] Concept Foundation, Country Support page. Geneva; 2021. https://www.conceptfoundation.org/what-we-do/country-support/. Accessed April 28, 2022.
[3] International Federation of Gynecology and Obstetrics (FIGO), Current FIGO projects, IAP page, Project Resources. London; 2022. https://www.figo.org/improving-access-essential-medicines-reduce-postpar.... Accessed April 29, 2022.
[4] Arribas M, Roberts I, et al. WOMAN-PharmacoTXA trial: Study
protocol for a randomised controlled trial to assess the pharmacokinetics and
pharmacodynamics of intramuscular, intravenous and oral administration of
tranexamic acid in women giving birth by caesarean section. Wellcome Open Res. 2021; 6:157.
[5] Patel S, Robertson B, et al. Catastrophic drug errors involving tranexamic acid administered during spinal anaesthesia. Anaesthesia. 2019; 74: 904-914.
[6] Palanisamy A, Kinsella SM. Spinal tranexamic acid – a new killer in town. Anaesthesia. 2019; 74: 831-833.

The activities in this narrative were supported by funding from MSD, through its MSD for Mothers initiative and are the sole responsibility of the authors. MSD for Mothers is an initiative of Merck & Co., Inc., Rahway, NJ, USA

Dear Editor,

I am extremely puzzled by the lack of any response regarding my proposed comments regarding this article. I've submitted my comments twice, but they have not been published. I cannot imagine why. It appears to be a discretionary censorship, which is of course contrary to BMJ's published editorial policies which generally favor respectful discourse. I would greatly appreciate an explanation and an appeal to a larger panel of BMJ editors.

To repeat...for the third time,... regarding this article:

There is a growing interest in developing evidenced based standards for public health policy initiatives.[1] In response to this effort, Burris et al have put forward their own initial effort to identify the potential effects of laws regulating abortion on women’s health.[2] Unfortunately, they apparently failed to include in their research team anyone with familiarity with the literature regarding the negative physical and psychological effects of coerced and unnecessary abortions. This is not a minor oversight.

Regarding the issue of women’s autonomy, increasing legal access to abortion is a double-edged sword. Easier access makes it easier for women to choose abortion for their own self-interests, but it also makes it easier for those pressuring women into unwanted abortions to abuse women’s rights.[3]

Coerced abortions are especially common among women enslaved in sex trafficking.[4,5] But it is also common within households precisely because every pregnancy impacts not just the pregnant woman, but also male partners, parents, employers, and society at large . . . as evidenced by advocates of population control who have sought and implemented public policies that discourage birth.[3]

As many as 64% of American women acknowledging a history of abortion report having felt pressured to abort by others.[6] Similarly, a 2021 study of women seeking abortion found that only 42% described their pregnancy as never wanted.[7] The pressure to abort a pregnancy that might otherwise be welcomed typically comes from their male partners, parents, employers and social services officials.[8]

As might be imagined, negative psychological reactions to abortion are more common when women feel pressured into an abortion or have other conflicting maternal interests and moral beliefs.[6,9] These are just a few of the 15 risk factors identified by the APA for negative psychological reactions. They include: terminating a pregnancy that is wanted or meaningful; perceived pressure from others to terminate a pregnancy; perceived opposition to the abortion from partners, family, and/or friends; lack of perceived social support from others; various personality traits (e.g., low self-esteem, a pessimistic outlook, low-perceived control over life); a history of mental health problems prior to the pregnancy; feelings of stigma; perceived need for secrecy; exposure to antiabortion picketing; use of avoidance and denial coping strategies; feelings of commitment to the pregnancy; ambivalence about the abortion decision; low perceived ability to cope with the abortion; history of prior abortion; and late term abortion.[9] The best evidence indicates that the vast majority of women undergoing abortion have one or more of these risk factors.[9]

Even assuming that the negative psychological associated with abortion, including increased risk of substance abuse,[9] postpartum psychiatric risks,[10] sleep disorders,[11] posttraumatic stress disorder,[9] and suicidal ideation and other risk taking behaviors[9] are entirely due to coerced and unwanted abortions, the importance of laws intended to prevent unwanted abortions should not be ignored…but that is precisely what Burris et al have done.

For example, one of the reasons for laws requiring parental involvement or notification are to help prevent a minor from undergoing a coerced abortion at the behest of the male partner or his family. They are also intended to prevent a minor from fearfully consenting to an otherwise unwanted or unnecessary abortion because of a mistaken fear that the minor’s parents will reject her because of her sexual activity and will not support her desire to keep the pregnancy.

But in Table 1, the benefit of “prevention of unwanted, unnecessary or unsafe legal abortions” is not identified in the list of “plausibly related outcomes” for any of the types of laws considered. Nor is there any consideration of “saved costs” and in regard to fewer treatments for the negative health effects associated with unwanted abortion.[9]

Numerous studies have also found a strong link between induced abortion and subsequent pre-mature and low-birth weight deliveries.[12] In the context of the United States, the increased medical costs in treating subsequently pre-maturely born children just to the point of hospital discharge apportions out to approximately $100,000 per 100,000 abortions. Therefore, any reduction in abortion rates that may result from laws that reduce the risk of coerced and unwanted abortions would produce significant health care savings, would reduce the risk of lifelong health complications associated with premature and low birth weight deliveries, and would save numerous lives among later planned pregnancies. But again, none of these benefits appear in Table 1.

Moreover, literally every record linkage study (eleven in total) examining reproductive outcomes associated with mortality has shown that abortion is associated with an increased risk of premature death among women exposed to abortion.[13] There is even a dose effect, with each abortion increasing the risk of an early death by approximately 50 percent.[13] At least a part of this increased risk is due to the increased risk of within a year of an abortion.[14,15] But even if we again assume that all these risks attach only to unwanted abortions (presuming that if a woman truly wants an abortion according to her own guiding lights, she will experience no psychological harm), the fact remains that any law which may help to reduce the rate of unwanted abortions is likely to reduce mortality rates and thereby increase work productivity and gross national product. But, yet again, the positive plausible outcomes have been omitted from Table 1

Notably, “unintended childbirth” is one plausible outcome that Burris et al have associated with every type of law identified in Table 1. But that outcome is poorly defined. When, and how often, is “unintended childbirth” a benefit to women and when is it a harm? Countless women report great satisfaction and blessing from their subsequent delivery of unplanned pregnancies. In fact, the Turnaway Study found that among all the women who were denied a late term abortion, 60% reported being happy about continuing their pregnancies, and by the time the child was born, only 12% still wished they could have had the abortion.[16] The bottom line is that many “unintended” and even “unwanted” pregnancies are associated with a mix of feelings, a mix that in the long run often result in a “welcomed” child, one that is valued not because the child was planned but simply it is the woman’s and her family’s child. Given that Burris et al are arguing for better research to support policy decisions, the importance of better research to identify when and how often unintended pregnancies result in a welcomed child should be a priority, as well as research to identify public policies that can help to make it easier for families to welcome unintended children.

Finally, Burris et al have failed to identify in the list of potential legal interventions laws governing informed consent, risk disclosure and pre-abortion screening for risk factors identifying women who may be at greater risk of being coerced or may feel pressured by social circumstance to agree to an abortion contrary to their moral beliefs and/or maternal desired.

In short, Burris et al’s analysis has failed to fully describe or analyze the plausible effects of statutes and public policies intended to protect women from unwanted, unnecessary and unsafe legal abortions. Simply declaring abortion legal does not necessarily render them safe and effective for all women in any and all circumstances of an “unintended” pregnancy.

Unfortunately, “unintended” pregnancies are often more unwanted by others (including population control activists) than they are by the pregnant themselves. In many cases, women are resiliently willing to embrace their unintended pregnancies as a welcomed-children. Often, it is only the hostility of others, and the accompanying pressure to submit to unwanted abortions, that is the true attack on women’s rights and autonomy.

Laws designed to identify and alleviate the pressures on women to undergo unwanted and unnecessary abortion should be pursued and implemented to save lives, reduce costs, and increase the well-being of both women and their children.

Competing Interest
David Reardon is the Director the Elliot Institute which sponsors peer reviewed medical research, promotes post-abortion healing programs, and advocates for laws requiring pre-abortion screening for coercion and other risk factors associated with negative outcomes for women.

References

1. Rehfuess EA, Stratil JM, Scheel IB, Portela A, Norris SL, Baltussen R. The WHO-INTEGRATE evidence to decision framework version 1.0: integrating WHO norms and values and a complexity perspective. BMJ Glob Heal [Internet]. 2019 Jan 1 [cited 2022 Jan 13];4(Suppl 1):e000844. Available from: https://gh.bmj.com/content/4/Suppl_1/e000844
2. Burris S, Ghorashi AR, Cloud LF, Rebouché R, Skuster P, Lavelanet A. Identifying data for the empirical assessment of law (IDEAL): A realist approach to research gaps on the health effects of abortion law. BMJ Glob Heal [Internet]. 2021 Jun 1 [cited 2022 Jan 13];6(6):e005120. Available from: https://gh.bmj.com/content/6/6/e005120
3. Reardon DC. Abortion decisions and the duty to screen: clinical, ethical, and legal implications of predictive risk factors of post-abortion maladjustment. J Contemp Health Law Policy. 2003;20(1):33–114.
4. Coyle C. Sex Trafficking. In: MacNair RM, editor. Peace Psychology Perspectives on Abortion. Kansas City. MO: Feminism & Nonviolence Studies Association; 2016.
5. Lederer L, Wetzel C. The Health Consequences of Sex Trafficking and Their Implications for Identifying Victims in Healthcare Facilities. Ann Heal Law. 2014;23(1):61.
6. Rue VM, Coleman PK, Rue JJ, Reardon DC. Induced abortion and traumatic stress: A preliminary comparison of American and Russian women. Med Sci Monit. 2004;10(10):SR5–16.
7. Biggs MA, Neilands TB, Kaller S, Wingo E, Ralph LJ. Developing and validating the Psychosocial Burden among people Seeking Abortion Scale (PB-SAS). Vaingankar JA, editor. PLoS One [Internet]. 2020 Dec 10 [cited 2021 Feb 8];15(12 December):e0242463. Available from: https://dx.plos.org/10.1371/journal.pone.0242463
8. Elliot Institute. Forced Abortion in America: A Special Report [Internet]. Springfield IL; 2004. Available from: https://afterabortion.org/new-elliot-institute-report-exposed-americas-f...
9. Reardon DC. The abortion and mental health controversy: A comprehensive literature review of common ground agreements, disagreements, actionable recommendations, and research opportunities. SAGE Open Med [Internet]. 2018;6:205031211880762. Available from: http://journals.sagepub.com/doi/10.1177/2050312118807624
10. Reardon DC, Craver C. Effects of pregnancy loss on subsequent postpartum mental health: A prospective longitudinal cohort study. Int J Environ Res Public Health [Internet]. 2021 Feb 2 [cited 2021 Mar 17];18(4):1–11. Available from: https://pubmed.ncbi.nlm.nih.gov/33672236/
11. Reardon DC, Coleman PK. Relative treatment rates for sleep disorders and sleep disturbances following abortion and childbirth: a prospective record-based study. Sleep. 2006;29(1):105–6.
12. Calhoun BC, Shadigian E, Rooney B. Cost consequences of induced abortion as an attributable risk for preterm birth and impact on informed consent. J Reprod Med. 2007;52(10):929–37.
13. Reardon DC, Thorp JM. Pregnancy associated death in record linkage studies relative to delivery, termination of pregnancy, and natural losses: A systematic review with a narrative synthesis and meta-analysis. SAGE Open Med [Internet]. 2017 Dec 13 [cited 2018 Aug 15];5:205031211774049. Available from: http://journals.sagepub.com/doi/10.1177/2050312117740490
14. Gissler M, Berg C, Bouvier-Colle M-H, Buekens P. Injury deaths, suicides and homicides associated with pregnancy, Finland 1987-2000. Eur J Public Health. 2005 Oct;15(5):459–63.
15. Reardon D, Strahan T, Thorp … J. Deaths Associated with Abortion Compared to Childbirth-A Review of New and Old Data and the Medical and Legal Implications [Internet]. J. Contemp. Health …. 2003. Available from: http://heinonlinebackup.com/hol-cgi-bin/get_pdf.cgi?handle=hein.journals...
16. Foster DG. The Turnaway Study: ten years, a thousand women, and the consequences of having--or being denied--an abortion. New York, NY: Scribner; 2020. p. 360.

To the editor,

With interest we read the recent paper by Caviglia et al, describing the relation between prehospital ambulance time and outcome in terms of maternal and perinatal outcomes in the setting of Sierra Leone1. Sierra Leone has one of the highest rates of maternal (1360 in 100.000 life births) and infant (87 in 1.000 births) mortality worldwide2. The National Emergency Medical Service (NEMS) was designed and started in this country, an effort by or in collaboration with part of the authors of the current manuscript3. The results show that longer prehospital ambulance times are associated with poor outcome. Furthermore, only in the capital and its surroundings the 2-hour target is met in a high percentage of patients, with only 24-65% of patients meeting this mark in the more rural areas of the country. The authors conclude that there are still major geographical barriers for timely access to care, and that any intervention to strengthen the existing primary health system may help reduce maternal and perinatal mortality.

The elaborate NEMS system, including 81 fully equipped and staffed ambulances with a centralized operations centre, was operational since 2018, with the last districts connected to the service in 2019. The system was managed by the local ministry of health and sanitation (MoHS) and funded through the governmental budget, with help from the World Bank, Doctors with Africa (CUAMM, Padua, Italy), the Regional Government of Veneto (Italy) and the Research Center in Emergency and Disaster Medicine (CRIMEDIM, Università del Piemonte Orientale, Italy)3. According to the triage classifications, most “red” indications were maternal/perinatal emergencies, making this the most important focus of the service3.

We have seen the contribution of NEMS in our rural 80-bed hospital in Yele, Tonkolili district, with a catchment population of 150.000. The 2 ambulances stationed in our catchment area, together with ambulances sending referrals from elsewhere, presented an average of over 2 patients per 24 hours to our hospital for emergency services. We used NEMS ourselves for referrals to third-line indications upon indication. As a response to this well-functioning service, have scaled down our ambulance services with the number of drivers and vehicles reduced as they were no longer needed. In line with the NEMS-focus, the majority of presentations were maternal/perinatal admissions; we saw frequent advanced stage diseases due to first delays and in some cases second delays in light of the Three Delays framework. Still, despite the impressive pathology, there were many mothers that could receive proper care and return home in stable condition with a healthy newborn.

Fast forward not even 2 years after the connection of the last district, when the NEMS service was released to the MoHS on the first of January 2021. While ambulances frequented the hospital in December 2020, this came to a total stillstand one month later. As of that moment, the number of presentations by NEMS dropped from over 2 patients per day to one patient in the 9 months after. Due to financial troubles, the whole service collapsed. NEMS ambulances are currently gathering dust on the parking lots of governmental hospitals. Inquiry with hospitals in other districts showed a comparable drop in NEMS presentations after release of the service.

The case of NEMS may be a positive and negative example at the same time. The development of a nationwide ambulance service in a low-income country with high maternal and neonatal mortality is to be applauded. During the time NEMS was in service, the authors demonstrate that a respectable percentage of patients can be transferred to a hospital in time despite large distances and poor road conditions. Furthermore, as shorter prehospital times lead to improved outcome, the service was an important part of the health infrastructure of Sierra Leone.
The current situation with a powerless ambulance service is worse than when NEMS came into service. Before, hospitals had their own ambulance services and drivers, and were sometimes able to pick up patients from peripheral health units through intensified communication. Nowadays, hospitals have scaled down on their number of drivers and ambulances due to the presence of NEMS, and NEMS itself is unavailable for transportation of the needy. To us, it is unclear whether mismanagement, a premature program release, actual financial constraints or perhaps even corruption brought the NEMS-program to its current state. As such, the contrary of the research implications came true: due to the unavailability of the service, a lower percentage of mothers is able to reach hospitals, which will inevitably lead to an increase in maternal and neonatal mortality.

In conclusion, the authors demonstrate the NEMS-service has resulted in swift transport of patients to the proper health facilities, thereby reducing the maternal and perinatal mortality. The premature program release to the local government however has resulted in the unavailability of ambulance services, both by NEMS and local hospitals, thereby likely increasing the already worrisome maternal and perinatal mortality. The important lessons are that the development and deployment of an elaborate ambulance service is possible in sub-Saharan African countries, but premature release of such programs to local government that lack sustainable and durable resources to continue programs, may result in a situation that is worse than before the service started.

1 Caviglia M, Putoto G, Conti A, et al. Association between ambulance prehospital time and maternal and perinatal outcomes in Sierra Leone: a countrywide study. BMJ Glob Heal 2021; 6: e007315.
2 Trends in maternal mortality: 1990 to 2015: estimates by WHO, UNICEF, UNFPA, World Bank Group and the United Nations Population Division. Geneva: World Health Organization; 2015. , 2015.
3 Caviglia M, Dell’aringa M, Putoto G, et al. Improving access to healthcare in sierra leone: The role of the newly developed national emergency medical service. Int J Environ Res Public Health 2021; 18: 1–12.