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Devastating Effects of Ebola on Maternal Health

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49.5% of the global population are female however it is just now widely accepted that the wellbeing of women is a crucial cornerstone in building healthy communities. Approximately 210 million women become pregnant each year, making maternal health an imperative part of sustainable development. {Graham, 2016 #324} Nonetheless, deaths linked with pregnancy, childbirth, and post-partum complications are increasingly becoming a smaller portion of women’s overall health burden. This criticism suggests that focusing on this small aspect of women’s health leads to a situation in which researchers ignore important factors that may be worsening women’s health. {Knaul, 2016 #329}The current maternal health discourse within global health tends to limit it to the narrow period that stretches from pregnancy to six weeks after childbirth {Knaul, 2016 #329} for which the greatest risks are unsafe abortions, pre-eclampsia, haemorrhage and infections.

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Since the first Safe Motherhood Conference in Nairobi in 1987, maternal health has occupied space in the global policy arena and its inclusion in both the Millennium Development Goals and the Sustainable Development Goals helped to achieve a 44% reduction in global maternal mortality from 1990 to 2015. The results of Alkema et al. (2016) study drew figures from 171 countries and showed that the global MMR had dipped from 385 deaths per 100,000 live births in 1990 to 216 deaths per 100,000 live births in 2015. Even with the highlighted progress, the achievements are still well below the SDGs maternal mortality objective and WHO reports that up to 830 women die daily from pregnancy and childbirth related complications. {Alkema, 2016 #328}

Maternal deaths follow the same inequity patterns seen in most disease burdens, women of lower income quintiles and living rurally are at greater risk and the majority of deaths occur within developing countries with over half of these in Sub-Saharan Africa alone. {Zureick-Brown, 2013 #325} There is an extensive range of indictors that can be utilised for monitoring and evaluating maternal health; governance and supply chain indicators look at inputs and processes, outputs can be measured with indictors for service access and availability, while service coverage indictors and mortality indictors quantify outcomes and impact respectively. {Moller, 2018 #327} The outbreak occurred at a time when Sierra Leone’s healthcare system was reeling from the effects of civil war and the country’s government was in the process of revamping it (Figueroa, et al., 2018). The outbreak of Ebola prompted several outcomes that had devastating consequences on maternal health. These outcomes included the massive loss of healthcare personnel (Figueroa, et al., 2018), the closure of healthcare facilities in the affected regions (Ribacke, et al., 2016), the surge in women’s mistrust towards healthcare personnel (Jones, et al., 2017), and the reduction in healthcare workers’ willingness to provide care to expectant women in need of infection-control services (Hayden, 2015).

The subsequent dip in access and quality contributed to significant increases in MMR, with data suggesting that MMR rose to levels previously recorded when the country was in the midst of a civil war (Figueroa, et al., 2018). Access to antenatal care (ANC) is a critical component of maternal health. For safe deliveries, reduced maternal mortality, decreased risk of pregnancy-related complications, and the betterment of other important aspects of maternal health, the World Health Organization (WHO) recommends four ANC visits (Caulker, et al., 2017). These four ANC visits are so important that the WHO lists them among the 11 indicators that healthcare practitioners ought to focus on when evaluating child and reproductive health (Caulker, et al., 2017). Countries with suboptimal ANC coverage have some of the highest MMRs in the world. Sierra Leone’s limited ANC coverage had pushed its MMR to 1165 deaths per 100,000 live births in the years prior to the 2014 Ebola outbreak (Caulker, et al., 2017). Civil war, poverty, and other causes had decimated the country’s ANC coverage (Caulker, et al., 2017). A 2013 survey revealed that although women in Sierra Leone initiated the first ANC visit, many did not attend all the four ANC visits as recommended by WHO. The sorry state of ANC coverage and the resultant spike in MMR underlines the essence of the four mandatory ANC visits. The illustration demonstrates the risks that mothers face when they fail to undertake the visits. As the data from Sierra Leone suggests, failure to undertake ANC visits has catastrophic consequences on maternal health.

Ebola weakens maternal health by restricting women’s access to ANC. Ebola epidemics occasion a massive decline in antenatal care coverage. Figures drawn from studies (Ribacke, et al., 2016; Hayden, 2015) into the impact of Ebola on antenatal care (ANC) utilization many mothers opt out of the services in the aftermath of an outbreak. Studies on the utilization of ANC services reveal massive changes after an Ebola outbreak. In Sierra Leone, ANC coverage declined between 22% and 27% in the second half of 2014 (Ribacke, et al., 2016; Jones, et al., 2016). During this period, Sierra Leone’s Moyamba district recorded a 50% decline in ANC visits while Kenema district recorded a 29% drop in ANC visits (Ribacke, et al., 2016). Similarly, Liberia reported a 9% to 14% drop in ANC visits prior to the peak of the Ebola outbreak (Ribacke, et al., 2016). These patterns of similarity in the declining ANC visits confirms the link between Ebola outbreak and women’s reluctance to utilize ANC services. They suggest that ANC coverage declines after Ebola outbreaks.

Nonetheless, weaknesses in the quality of ANC services in Sierra Leone may have combined with Ebola to worsen women’s access. The Ebola outbreak occurred in Sierra Leone at a time when the country was still smarting from the effects of a debilitating civil war and its maternal health services were of a poor quality (Koroma, et al., 2017). During a cross-sectional 2014 survey on 97 health centres and three hospitals in the Northern provinces of Sierra Leone, Koroma et al. (Koroma, et al., 2017) conducted 100 interviews with ANC providers, conducted 486 interviews with expectant women, and undertook 276 observations to determine the quality of ANC, childbirth services, and postnatal care services (Koroma, et al., 2017). The results indicated that the quality of ANC services was poor (Koroma, et al., 2017). The results revealed that only 27% of the pregnant women who visited the facilities and hospitals for free ANC services were examined (Koroma, et al., 2017). Further, the results showed that only 2% of the women who participated in the interview were screened during their first ANC visit (Koroma, et al., 2017). These findings led the researchers to conclude that there was need for the government to intensify the monitoring of these facilities to ensure that they comply with national standards. The claims suggest that Sierra Leone’s ANC was on its knees at the time of the Ebola epidemic. They indicate that the public had already lost faith in the ANC services. The Ebola outbreak worsened the situation by intensifying the women’s reluctance to visit the hospitals and healthcare facilities for ANC services.

The findings on the state of the ANC services suggest that create the impression that observed decline in ANC visits was a consequence of the poor ANC coverage rather than the Ebola outbreak. They suggest that Ebola would have had a minimal impact on the uptake of ANC services if the quality of Sierra Leone’s ANC was consistent with international standards. In such an environment, the healthcare system would have become resilient and the uptake of ANC services would have remained stable throughout the period of outbreak. An analysis of various studies reveals that this conclusion is misleading. Many studies (Hayden, 2015; Ribacke, et al., 2016; Jones, et al., 2017; Jones, et al., 2016) have investigated the moderators of the limited ANC coverage during the 2014 Ebola outbreak in Sierra Leone. The results of those studies (Hayden, 2015; Ribacke, et al., 2016; Jones, et al., 2017; Jones, et al., 2016) indicate that several factors contributed to the dip in pregnant women’s access to ANC services.

These factors include the closure of healthcare facilities (Ribacke, et al., 2016), the shortage of healthcare workers (Figueroa, et al., 2018), and the increase in healthcare workers’ mistrust towards patients (Hayden, 2015). Hayden (2015), in her treatise on the effect of Ebola on Sierra Leone’s maternal care services, recounts a story of a pregnant woman who bled to death because nurses did not want to attend to her. The nurses believed that they would increase their exposure to Ebola by attending to her (Hayden, 2015). Therefore, the claim that the healthcare system would have withstood the Ebola epidemic and women’s ANC visits would have remained stable throughout the period is misleading. In the midst of an Ebola outbreak, panic and fear spread throughout the healthcare system. This panic occasions a massive turnover of healthcare workers, as many opt to resign as a way of reducing their exposure to the disease. In response to the loss of staff, hospitals and other healthcare facilities shut down. In such an environment, an effective healthcare system would crumble under the weight of the mass resignations and the widespread closure of hospitals.

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