Nowhere to Go: The Challenges of Caring for Pregnant Women in Freetown During Sierra Leone’s Ebola Virus Epidemic
One of the 11 Ebola Treatment Centers built and operated by Médecins Sans Frontières (MSF) during the West Africa outbreak was the first of its kind: a Maternity Ebola Treatment Center (METC). Staffed with trained midwives, nurses, and obstetricians/gynecologists, the METC was established to provide Basic Emergency Obstetric Care (although not surgery) to pregnant women with confirmed Ebola virus disease and to those suffering from pregnancy complications that symptomatically overlapped with Ebola, who could not be admitted to any health care facility without two negative Ebola tests 48 hours apart.
This chapter describes the experiences of two coauthors, an obstetrician/gynecologist and a midwife, as frontline medical workers at the METC during the later phase of the outbreak. It also portrays how the MSF team navigated the challenges of balancing both sides of the ‘safety versus rapid access to care’ dilemma, especially in caring for pregnant women suspected of having Ebola. Lastly, through this lens, it addresses some broader consequences of the Ebola epidemic on maternal health in Sierra Leone.
KeywordsEbola Pregnancy Pregnancy complications Maternal mortality Maternal Ebola Treatment Center Sierra Leone Doctors Without Borders Médecins Sans Frontières
We would like to thank Patricia Lledo and Olimpia de la Rosa, who managed MSF-Spain’s maternal health response during the epidemic and who provided us with tireless support both while working at the METC and in the writing of this chapter. Additional thanks also go to Sonia Guinovart and Severine Caluwaerts for their insightful comments to this chapter and to Michelle Olakkengil and Eleonora D’Amore for expert editorial assistance.
- Baggi, F. M., Taybi, A., Kurth, A., Van Herp, M., Di Caro, A., Wölfel, R., et al. (2014). Management of pregnant women infected with Ebola virus in a treatment centre in Guinea, June 2014. Eurosurveillance, 19(49). Retrieved March 25, 2018, from http://www.eurosurveillance.org/content/10.2807/1560-7917.ES2014.19.49.20983.
- Bebell, L. M., & Riley, L. E. (2015). Ebola virus disease and Marburg disease in pregnancy: A review and management considerations for filovirus infection. Obstetrics & Gynecology, 125(6), 1293–1298. Retrieved March 24, 2018, from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4443859/.CrossRefGoogle Scholar
- Bjälkander, O., Grant, D., Berggren, V., Bathija, H., & Almroth, L. (2013). Female genital mutilation in Sierra Leone: Forms, reliability of reported status, and accuracy of related demographic and health survey questions. Obstetrics and Gynecology International, 2013, 680926. https://doi.org/10.1155/2013/680926. Retrieved March 24, 2018, from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3800578/.CrossRefGoogle Scholar
- Bower, H., Grass, J. E., Veltus, E., Brault, A., Campbell, S., Basile, A. J., et al. (2016). Delivery of an Ebola virus-positive stillborn infant in a rural community health center, Sierra Leone, 2015. American Journal of Tropical Medicine and Hygiene, 94(2), 417–419. https://doi.org/10.4269/ajtmh.15-0619.CrossRefGoogle Scholar
- Brolin Ribacke, K. J., Saulnier, D. D., Eriksson, A., & von Schreeb, J. (2016a). Effects of the West Africa Ebola virus disease on health-care utilization—A systematic review. Frontiers in Public Health. Retrieved March 24, 2018, from http://journal.frontiersin.org/article/10.3389/fpubh.2016.00222.
- Brolin Ribacke, K., van Duinen, A., Nordenstedt, H., Höijer, J., Molnes, R., Froseth, T., et al. (2016b). The impact of the West Africa Ebola outbreak on obstetric health care in Sierra Leone. PLoS One, 11(2), e0150080. Retrieved March 25, 2018, from http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0150080.CrossRefGoogle Scholar
- Caluwaerts, S., Fautsch, T., Lagrou, D., Moreau, M., Camara, A. M., Günther, S., et al. (2015). Dilemmas in managing pregnant women with Ebola: 2 case reports. Clinical Infectious Diseases, 62(7), 903–905. Retrieved March 25, 2018, from https://academic.oup.com/cid/article/62/7/903/2462754.CrossRefGoogle Scholar
- Caluwaerts, S. & Kahn, P. (2019). Ebola and pregnant women: Providing maternity care at Médecins Sans Frontières treatment centers. In D. A. Schwartz, J. N. Anoko, & S.A. Abramowitz (Eds.), Pregnant in the time of Ebola: Women and their children in the 2013-2015 West African epidemic. New York: Springer.Google Scholar
- Conde-Agudelo, A., Belizan, J. M., & Lammers, C. (2005). Maternal-perinatal morbidity and mortality associated with adolescent pregnancy in Latin America: Cross-sectional study. American Journal of Obstetrics and Gynecology, 192(2), 342–349. https://doi.org/10.1016/j.ajog.2004.10.593.CrossRefPubMedGoogle Scholar
- Delamou, A., El Ayadi, A. M., Sidibe, S., Delvaux, T., Camara, B. S., Sandouno, S. D., et al. (2017). Effect of Ebola virus disease on maternal and child health services in Guinea: A retrospective observational cohort study. The Lancet Global Health, 5(4), e448–e457. https://doi.org/10.1016/S2214-109X(17)30078-5.CrossRefGoogle Scholar
- Deaver, J. E., & Cohen, W. R. (2015). Ebola virus screening during pregnancy in West Africa: Unintended consequences. Journal of Perinatal Medicine. https://doi.org/10.1515/jpm-2015-0118.
- Dunn, A. C., Walker, T. A., Redd, J., Sugerman, D., McFadden, J., Singh, T., et al. (2015). Nosocomial transmission of Ebola virus disease on pediatric and maternity wards: Bombali and Tonkolili, Sierra Leone, 2014. American Journal of Infection Control, 44(3), 269–272. https://doi.org/10.1016/j.ajic.2015.09.016.CrossRefPubMedGoogle Scholar
- Dynes, M. M., Miller, L., Sam, T., Vandi, M. A., & Tomezyk, B. (2015). Perceptions of the risk for Ebola and health facility use among health workers and pregnant and lactating women—Kenema District, Sierra Leone, September 2014. MMWR Morbidity and Mortality Weekly Report, 63(51), 1226–1227. Retrieved April 13, 2018, from https://www.cdc.gov/mmwr/preview/mmwrhtml/mm6351a3.htm.
- Evans, D. K., Goldstein, M., & Popova, A. (2015). Health-care worker mortality and the legacy of the Ebola epidemic. The Lancet Global Health, 3(8), e439–e440. Retrieved March 24, 2018, from http://www.thelancet.com/journals/langlo/article/PIIS2214-109X(15)00065-0/fulltext.CrossRefGoogle Scholar
- Iyengar, P., Kerber, K., Howe, C. J., & Dahn, B. (2015). Services for mothers and newborns during the Ebola outbreak in Liberia: The need for improvement in emergencies. PLoS Currents Outbreaks, 7, pii: ecurrents.outbreaks.4ba318308719ac86fbef91f8e56cb66f. Retrieved March 24, 2018, from http://currents.plos.org/outbreaks/article/services-for-mothers-and-newborns-during-the-ebola-outbreak-in-liberia-the-need-for-improvement-in-emergencies/.
- Jones, S., Gopalakrishnan, S., Ameh, C., White, S., & van den Broek, N. (2016). “Women and babies are dying but not of Ebola”: The effect of the Ebola virus epidemic on the availability, uptake and outcomes of maternal and newborn health services in Sierra Leone. BMJ Global Health, 1(3), e000065. https://doi.org/10.1136/bmjgh-2016-000065. Retrieved March 24, 2018, from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5321347/.CrossRefGoogle Scholar
- Lledo, P., Guinovart, S., Bernasconi, A., Flevaud, L., Segers, N., & Saint-Sauveur, J. F. (2016). Impact of Ebola outbreak on pregnant Ebola negative-tested women [version 1]. F1000Research, (5), 840 (poster).Google Scholar
- Médecins Sans Frontières. (2012, November). Safe Delivery: Reducing maternal mortality in Sierra Leone and Burundi. Retrieved March 25, 2018, from https://www.doctorswithoutborders.org/news-stories/special-report/safe-delivery-reducing-maternal-mortality-sierra-leone-and-burundi.
- Milland, M., & Bolkan, H. A. (2015). Enhancing access to emergency obstetric care through surgical task shifting in Sierra Leone: Confrontation with Ebola during recovery from civil war. Acta Obstetricia et Gynecologica Scandinavica, 94(1), 5–7. Retrieved March 24, 2018, from https://obgyn.onlinelibrary.wiley.com/doi/full/10.1111/aogs.12540.CrossRefGoogle Scholar
- Neal, S., Matthews, Z., Frost, M., Fogstad, H., Camacho, A. V., & Laski, L. (2012). Childbearing in adolescents aged 12-15 years in low resource countries: A neglected issue. New estimates from demographic and household surveys in 42 countries: Childbearing in adolescents aged 12-15 years. Acta Obstetricia et Gynecologica Scandinavica, 91(9), 1114–1118. https://doi.org/10.1111/j.1600-0412.2012.01467.x.CrossRefPubMedGoogle Scholar
- Raftery, P., Condell, O., Wasunna, C., Kpaka, J., Zwizwai, R., Nuha, M., et al. (2018). Establishing Ebola Virus Disease (EVD) diagnostics using GeneXpert technology at a mobile laboratory in Liberia: Impact on outbreak response, case management and laboratory systems strengthening. PLoS Neglected Tropical Diseases, 12(1), e0006135. https://doi.org/10.1371/journal.pntd.0006135.CrossRefPubMedPubMedCentralGoogle Scholar
- Save The Children. (2014). Ending newborn deaths—Ensuring every baby survives. Retrieved March 24, 2018, from http://www.savethechildren.org/atf/cf/%7B9def2ebe-10ae-432c-9bd0-df91d2eba74a%7D/ENDING-NEWBORN-DEATHS_2014.PDF.
- Statistics Sierra Leone--SSL and ICF International. (2014). Sierra Leone Demographic Health Survey 2013. Freetown, Sierra Leone: SSL and ICF International. Retrieved March 24, 2018, from http://dhsprogram.com/pubs/pdf/FR297/FR297.pdf.
- UNFPA. (2015). Rapid assessment of Ebola impact on reproductive health services and service seeking behaviour in Sierra Leone. Retrieved March 23, 2018, from https://reliefweb.int/report/sierra-leone/rapid-assessment-ebola-impact-reproductive-health-services-and-service-seeking.
- Wahome, W. M. (2014). Quarantines in Sierra Leone: Putting people first in the Ebola crisis. Oxfam. Retrieved March 23, 2018, from https://www.oxfam.org/sites/www.oxfam.org/files/file_attachments/quarantines_in_sierra_leone_-_putting_people_first_in_the_ebola_crisis.pdf.
- WHO. (2014a). Case definition recommendations for Ebola or Marburg virus diseases. Retrieved March 24, 2018, from http://www.who.int/csr/resources/publications/ebola/ebola-case-definition-contact-en.pdf.
- WHO. (2014b). Ebola response roadmap situation report—19 November 2014. Retrieved March 24, 2018, from http://apps.who.int/iris/bitstream/10665/144032/1/roadmapsitrep_19Nov14_eng.pdf?ua=1.
- WHO. (2015a). Ebola in Sierra Leone: A slow start to an outbreak that eventually outpaced all others. WHO. Retrieved March 25, 2018, from http://www.who.int/csr/disease/ebola/one-year-report/sierra-leone/en/.
- WHO. (2015b). Ebola Situation Report. 7 January 2015. Retrieved from http://apps.who.int/iris/bitstream/10665/147112/1/roadmapsitrep_7Jan2015_eng.pdf?ua=1&ua=1.
- WHO. (2015c). Ebola virus disease in pregnancy: Screening and management of Ebola cases, contacts, and survivors. Retrieved from http://apps.who.int/iris/bitstream/10665/184163/1/WHO_EVD_HSE_PED_15.1_eng.pdf.
- WHO. (2015d, April). WHO statement on cesarean section rates: Executive summary. Retrieved on March 25, 2018, from http://apps.who.int/iris/bitstream/handle/10665/161442/WHO_RHR_15.02_eng.pdf;jsessionid=62FF53FFE61EAAF3B136880E88FF72D0?sequence=1.
- WHO. (2016a). Ebola outbreak 2014-2015. Retrieved from http://www.who.int/csr/disease/ebola/en/.
- WHO. (2016b). WHO Statement on end of Ebola flare-up in Sierra Leone. Retrieved March 23, 2018, from http://www.who.int/mediacentre/news/statements/2016/end-flare-ebola-sierra-leone/en/.
- WHO, UNFPA, UNICEF, & Mailman School of Public Health. (2009). Monitoring emergency obstetric care: A handbook. Retrieved March 24, 2018, from http://www.who.int/reproductivehealth/publications/monitoring/9789241547734/en/.
- WHO, UNICEF, UNFPA, The World Bank, & The United Nations Population Division. (2014). Trends in maternal mortality: 1990 to 2013. Estimates by WHO, UNICEP, UNFPA, The World Bank and the United Nations Population Division. Retrieved March 23, 2018, from http://www.who.int/reproductivehealth/publications/monitoring/maternal-mortality-2013/en/.