National Consultancy: Study to investigate Delays in Emergency Obstetric Care

Background and Study Justification:

Despite substantial progress in post-conflict reconstruction, Liberia maintains one of the highest maternal mortality ratios (MMR) globally. While clinical causes—such as hemorrhage, sepsis, and eclampsia—are well-documented, the primary drivers of mortality remain the structural and behavioral barriers that prevent women from accessing timely care.

As of 2026, maternal mortality remains a preeminent public health challenge in Liberia. Although there has been a gradual downward trend over the past decade, the current data reveal a staggering burden.

The 2022 Liberia Population and Housing Census (LPHC) reports approximately 854 deaths per 100,000 live births. This is over 12 times higher than the Sustainable Development Goal (SDG) target of fewer than 70, highlighting a significant gap in maternal safety.

On average, six to seven women die weekly from pregnancy-related causes. Obstetric hemorrhage remains the leading cause of death (25%), followed by sepsis, eclampsia, and complications from unsafe abortions.

A stark divide exists between counties; the MMR in rural areas is 1,024, significantly higher than the 694 recorded in urban centers.

This study intends to utilize the Three Delays Model (Thaddeus and Maine, 1994) to identify systemic challenges in six high-burden counties: Montserrado, Nimba, Bong, Grand Bassa, Rivercess, and Grand Gedeh.

In these counties, maternal deaths often occur not due to a lack of medical knowledge, but because interventions are unreachable or arrive too late. A critical data gap exists regarding why patients continue to bypass facility-based deliveries and why referral systems frequently collapse during emergencies.

Data from 2024–2026 indicates that while skilled birth attendance has risen above 80%, the mortality rate has not declined at a proportional pace. This suggests that facility access alone is insufficient; the quality of emergency care (Delay 3) and the efficiency of the referral process (Delay 2) are now the most critical hurdles to reducing maternal deaths in Liberia.

Purpose of consultancy:

The primary objective of this study is to document the most prevalent delays contributing to maternal mortality in the country.

The specific objectives are as follows:

• Identify the specific socio-cultural factors that result in Delay 1 (delay in the decision to seek care).
• Map the transportation bottlenecks and other logistical barriers (Delay 2) that impede emergency obstetric referrals.
• Assess the capacity (Delay 3) of designated health facilities to provide timely quality care.

Develop evidence-based policy recommendations and strategic interventions to mitigate the primary delays impacting maternal health and delivery outcomes.

Scope of work:(Description of services, activities, or outputs)

The consultant will design and lead implementation in coordination with the MOH to investigate and document maternal mortality- related delays in six high-burden counties: Montserrado, Nimba, Bong, Grand Bassa, Rivercess, and Grand Gedeh.

Methodology

The study will employ a mixed-methods (hybrid) approach, combining qualitative and quantitative techniques to identify and document the delays impacting maternal health across the six targeted counties.

The consultant will lead the design and develop a structured questionnaire and coordinate their administration to gather statistically significant data on the delays that lead to maternal deaths.

A series of Focus Group Discussions (FGDs) will be organized and conducted with Trained Traditional Midwives (TTMs) and members of Health Facility Development Committees (HFDC) to capture in-depth perspectives on community-level barriers.

Expected results:

1. Inception Report
2. Study Protocol
3. Field Mission Report on data collection
4. Draft Survey Report
5. Final Study Report

Duration and working schedule:

Place where services are to be delivered:

The study will be conducted in all six counties (Montserrado, Nimba, Bong, Grand Bassa, Rivercess, and Grand Gedeh), with Monrovia being the main station of the consultant.

Delivery dates and how work will be delivered (e.g., electronic, hard copy, etc.):

From August 10 to October 10, 2026, the consultant is scheduled to execute and complete the "Three Delays" study on maternal mortality.

Monitoring and progress control, including reporting requirements, periodicity format, and deadline:

The Specialist for Data and Evidence in coordination with the MOH, will provide daily oversight and work closely with the consultant and the MOH to ensure smooth implementation. Following the established timeline, the Specialist and the MOH will conduct an initial review of all deliverables before submission to the Deputy Representative for final approval.

Supervisory arrangements:

Program Specialist, Data and Evidence

Required expertise, qualifications, and competencies, including language requirements:

The Consultant will meet the following criteria:

• A seasoned Public Health Specialist Social scientists with 5 to 10 years’ experience
• Proven experience in the conduct of qualitative and quantitative studies in a similar context
• Excellent writing and organizational skills in workshop facilitation
• Excellent analytical skills and a high capacity to synthesize information.
• A thorough knowledge of the United Nations system in general and of UNFPA in particular would be an asset.
• Fluency in English

Roles and responsibilities of the Ministry of Health :

To align with the national 365-Day Maternal and Neonatal Death Reduction Strategy, the Ministry of Health (MOH) will actively engage with UNFPA and the consultant to ensure that the study findings accurately reflect localized realities and address the root causes of mortality.

The MOH will ensure the following:

1. Partner Coordination: Work closely with UNFPA to maximize institutional ownership and data utilization.
2. Approvals: Secure all required ethical and administrative clearances.
3. Recruitment: Jointly select consultant and study participants in partnership with relevant MOH departments.
4. Field Monitoring: Participate in direct monitoring of the study
5. Protocol & Tool Review: Review and approve the study protocol and both paper/electronic tools before data collection begins
6. Data & Reporting: Participate in data analysis and provide final approval for the study report.

UNFPA will provide the consultant with the necessary administrative support and resources to complete the task effectively and on schedule.