In the recent Ebola epidemic in Sierra Leone, an increase in birth-related fatalities resulted not from lack of health care provision, but through fear of attending facilities, according to a report published this week.
The study, prepared by Voluntary Service Overseas (VSO), WaterAid and the Liverpool School of Tropical Medicine, focuses on how the Ebola virus disease (EVD) affected the provision of maternal and newborn health services in Sierra Leone and what lessons could be learned.
Data was collected from 81 interviewees and 76 health care centers across the country, and the research was carried out from February to July 2015.
Despite a 3% increase in the number of health care workers overall and an improvement in the level of some aspects of care, including infection control, there was an increase in the number of birth-related fatalities.
Fatalities resulted from not seeking medical care
Researchers found that many women died in childbirth at home but could have survived if they had attended the health care centers.
The data shows:
- an 18% decrease in women accessing antenatal care
- a 22% decrease in women accessing postnatal care
- an 11% decrease in deliveries at health care centers
- a 30% increase in maternal deaths
- a 24% increase in newborn deaths
- that 7 out of 9 critical areas of maternity care were still provided.
Reasons people gave for avoiding facilities included fear of contracting EVD or being told they had it, and a belief that health care workers were part of an EVD conspiracy. A pre-existing tendency to go to traditional healers may have increased during the epidemic as mistrust of health care workers increased.
Pre-existing deficiencies in health care delivery also contributed to a lack of confidence. Prior to the outbreak, Sierra Leone already had some of the highest maternal and newborn deaths figures in the world, with an 81% shortfall in staffing in obstetrics/gynecology and a 68% shortfall in the number of midwives. The epidemic exacerbated the problems.
Reluctance to attend meant that some women approached health care facilities late and experienced increased complications, leading to fatalities.
Staff remained dedicated
Some services improved during the period, such as neonatal resuscitation and infection control. Others - for example, transfusions - became unavailable at times due to lack of drugs and equipment, again reducing confidence. The report concludes that the shortages were not related to EVD but were due to endemic problems, such as procurement issues.
The authors emphasize that adequate levels of appropriately trained personnel were always available to deal with maternity cases; health care workers made every effort to engage with the community and they remained persistent and dedicated. Overall, the services offered were not unduly impacted by EVD, although the uptake decreased, which could have been lessened through better communication and sensitization.
Women who had started using the service before the outbreak reported that the care they received was of a good quality and they understood the importance of the visits.
One mother said she had been encouraged to attend by the nurses, who told her that the earlier she started coming to the center, the more likely the baby was to survive.
Another user commented:
"I have been coming to the hospital, they have been treating me well. I had a problem some time ago and since I have been coming here they have been able to solve it."
Those who did attend were often those whose peers had shared positive experiences with them and encouraged them to attend, reflecting the importance of communication.
Based on the data collected, the authors believe It was public fear, rather than a lack of resilience in the service, that led to nonattendance, although there is still much room for improvement in availability and quality of maternal and newborn care within Sierra Leone.
The recommendations made include:
- Implementation of nationwide, long-term health education programs to inform the public about vital antenatal and postnatal care visits and assisted childbirth
- Ebola public awareness campaigns to be continued for the foreseeable future to avoid any re-emergence in "clear" districts
- Measures to increase public confidence, for example, improving the capacity of health care facilities and better provision of safe, quality services
- Total eradication of the disease still remaining in other districts
- In the event of any future outbreaks, taking measures to ensure that public confidence in services will not be derailed.
In August this year, Medical News Today reported that an existing drug could be used against Ebola.