For six weeks this past summer pregnant women in a large swath of eastern Sierra Leone were unable to find a single person to perform caesarean sections. Ebola was to blame.
The deadly virus, which kills about 70 percent of its west African victims, had killed two of four clinicians at the region’s main hospital. Another doctor had fled in fear and the remaining clinician was sick with another malady. Kenema Government Hospital—a facility that serves three districts with over one million people in the area—typically delivered around 150 babies and performed 17 C-sections each month before Ebola. But the lack of available, trained medical professionals, coupled with patients’ resistance to coming in for care—especially near where Ebola patients were being treated—led to a precipitous drop in their maternal patient count. Fear was also rampant among the hospital’s remaining patients. And other medical workers did not step in to perform C-sections in the absence of available doctors.
In July only 93 women came to the clinic to deliver their babies and none could have C-sections, says Laura Miller, a health coordinator at the International Rescue Committee who works in that area of Sierra Leone. And although there was only a small uptick in the maternal mortality at the hospital during that time (roughly 4 percent instead of 1 percent) the drop in the number of pregnant patients led caregivers to wonder if women were attempting home births and perhaps dying doing so, she says. Moreover, women who become ill after delivering their babies and going home often flies under the radar. “People are scared,” Miller says. “I think people are scared to go to the hospital because there is a lot of fear that people are going to get infected there. It’s a shame because a lot of work has been done over the last six years in Sierra Leone to improve the quality of maternal care.”
Deliveries at the hospital were at an all-time low this summer, Miller notes. In the worst-hit month, July, there was about a 25 percent decline. Patient anxiety also stemmed from the fact that the hospital, until last month, was the area’s main site for Ebola care, she says. Yet there were few alternatives for pregnant women. Of the handful of private care facilities in the area some had closed. And a nearby clinic, run by Doctors Without Borders in a different district, stopped accepting pregnant patients in July because they could no longer accept the risk to their staff. “We’re expecting maternal mortality to skyrocket,” says Lina Moses, a researcher with Tulane University who works on Lassa Fever in Sierra Leone. What’s more, recruiting medical workers to help with deliveries would be challenging because they are scared of being exposed to patients’ blood, even when the latter are not symptomatic of Ebola, she says.
Delivering a baby is a messy thing. Copious amounts of bodily fluids are expelled during a vaginal delivery. And during a C-section—where a clinician would normally be wearing protective equipment including a mask, apron and gloves that provide some modicum of protection for the surgeon—opening up the body and having close contact in an area where Ebola is rife can still be frightening.
In Sierra Leone there have been 4,862 Ebola cases and 1,130 deaths so far. And globally a total of 549 health care workers are known to have been infected with the virus, and 311 have died. Although Liberia, Sierra Leone and Guinea all had high maternal mortality prior to the epidemic the World Health Organization says it is expecting those countries’ numbers to get even worse, thanks to Ebola. “Although we do not have data, it is understood that lack of routine obstetric care will have a significant negative impact on maternal and newborn outcomes,” says Lisa Jane Thomas, a WHO medical officer who worked in Liberia for the past six weeks.
The story for pregnant patients with Ebola, especially, is grim. “At this point survival rates of pregnant women with Ebola are low,” Thomas says. Anecdotally, she adds, they are hearing about complications including stillbirths, neonatal death, postpartum hemorrhage and miscarriages with excessive bleeding. To help increase survival rates WHO, UNICEF and Save the Children drafted global guidance for safe delivery and newborn care in an Ebola outbreak but still fear of the disease is hampering care for pregnant patients. In fact, Armand Sprecher, a public health specialist with Doctors Without Borders, says that for patients with Ebola, maternal mortality is “near universal.”