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Impact of Ebola Outbreak on Reproductive Health Services in a Rural District of Sierra Leone: a Prospective Observational Study

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Impact of Ebola Outbreak on Reproductive Health Services in a Rural District of Sierra Leone: a Prospective Observational Study Open access Research BMJ Open: first published as 10.1136/bmjopen-2019-029093 on 4 September 2019. Downloaded from Impact of Ebola outbreak on reproductive health services in a rural district of Sierra Leone: a prospective observational study Gianluca Quaglio,1,2,3 Francesca Tognon,4 Livio Finos,5 David Bome,6 Santigie Sesay,6 Atiba Kebbie,7 Francesco Di Gennaro,8 Bienvenu Salim Camara,9 Claudia Marotta, 10 Vincenzo Pisani,7 Zainab Bangura,7 Damiano Pizzol,3 Annalisa Saracino,8 Walter Mazzucco, 10 Susan Jones,11 Giovanni Putoto3 To cite: Quaglio G, Tognon F, ABSTRACT Strengths and limitations of this study Finos L, et al. Impact of Ebola Objectives To assess the trends concerning utilisation of outbreak on reproductive health maternal and child health (MCH) services before, during ► The study uses data from a remote rural district in services in a rural district of and after the Ebola outbreak, quantifying the contribution Sierra Leone: a prospective Sierra Leone, with a 6-year observational period. of a reorganised referral system (RS). observational study. BMJ Open Data have been collected in a prospective way, re- Design A prospective observational study of MCH 2019;9:e029093. doi:10.1136/ ducing the potential bias in the accuracy of the data services. bmjopen-2019-029093 reported by other studies carried out in countries Setting Pujehun district in Sierra Leone, 77 community affected by Ebola. ► Prepublication history and health facilities and 1 hospital from 2012 to 2017. ► Data from pre, intra and post-Ebola periods allowed additional material for this paper Main outcome measures MCH utililization was evaluated are available online. To view comparisons between trends, something rarely car- by assessing: (1) institutional deliveries, Cesarean- please visit the journal (http:// ried out in countries heavily affected by Ebola. sections, paediatric and maternity admissions and deaths, dx. doi. org/ 10. 1136/ bmjopen- ► The data refer to a single area of Sierra Leone: the and major direct obstetric complications (MDOCs), at 2019- 029093). sample cannot be considered representative of the hospital level; (2) antenatal care (ANC) 1 and 4, institutional country as a whole. Received 14 January 2019 delivery and family planning, at community level. ► In addition to measures put in place to reduce the Revised 15 May 2019 Contribution of a strengthened RS was also measured. impact of the disease on mothers and children, Accepted 12 June 2019 Results At hospital level, there is a significant difference http://bmjopen.bmj.com/ Pujehun had far fewer Ebola cases than other dis- between trends Ebola versus pre-Ebola for maternal tricts, which may also have led to the utilisation of admissions (7, 95% CI 4 to 11, p<0.001), MDOCs (4, 95% CI health services. 1 to 7, p=0.006) and institutional deliveries (4, 95% CI 2 to 6, p=0.001). There is also a negative trend in the transition from Ebola to post-Ebola for maternal admissions (−7, 95% CI −10 to −4, p<0.001), MDOCs (−4, 95% CI −7 to −1, p=0.009) and mainly affecting three West African countries; institutional deliveries (−3, 95% CI −5 to −1, p=0.001). The Guinea, Sierra Leone and Liberia. Overall differences between trends pre-Ebola versus post-Ebola are 28 616 people were infected of which 11 310 on September 27, 2021 by guest. Protected copyright. only significant for paediatric admissions (3, 95% CI 0 to 5, died and the outbreak was declared a global p=0.035). At community level, the difference between trends 1 Ebola versus pre-Ebola and Ebola versus post-Ebola are not public health emergency by the WHO. Of significant for any indicators. The differences between trends the three countries affected, Sierra Leone pre-Ebola versus post-Ebola show a negative difference for had the most confirmed cases (8704), which institutional deliveries (−7, 95% CI −10 to −4, p<0.001), ANC accounted for 50% of all confirmed cases 1 (−6, 95% CI −10 to −3, p<0.001), ANC 4 (−8, 95% CI −11 to in West Africa, and 3589 deaths.2–4 All 14 © Author(s) (or their −5, p<0.001) and family planning (−85, 95% CI −119 to −51, districts in Sierra Leone were affected, but employer(s)) 2019. Re-use p<0.001). at different times and to varying degrees.5 permitted under CC BY-NC. No Conclusions A stronger health system compared with During the Ebola crisis, the population’s commercial re-use. See rights other districts in Sierra Leone and a strengthened RS trust in the national health system declined and permissions. Published by enabled health facilities in Pujehun to maintain service BMJ. in Sierra Leone, leading to an overall reduc- provision and uptake during and after the Ebola epidemic. For numbered affiliations see tion in the use of health services, including end of article. reproductive, maternal and child services.6–8 Underlying factors for the decrease in the use Correspondence to Dr Gianluca Quaglio; INTRODUCTION of health services included fear of infection, gianluca. quaglio@ europarl. The 2014–2015 Ebola virus disease (EVD) for both healthcare workers and patients, the europa. eu outbreak was the most severe in history, underlying fragility of the health systems, the Quaglio G, et al. BMJ Open 2019;9:e029093. doi:10.1136/bmjopen-2019-029093 1 Open access BMJ Open: first published as 10.1136/bmjopen-2019-029093 on 4 September 2019. Downloaded from reduced numbers of available health personnel and the based at community health centres may often work alone death of healthcare workers due to EVD.9 10 It has been in isolated centres with limited support from clinical estimated that 30% of health workers who died of EVD in colleagues or management. By rotating staff through the West Africa were maternal and child health (MCH) care various facilities, they gain on the job training, peer support 11 providers. However, there were considerable variations and develop new working relationships. At the start of the in the reduction of health service uptake when looked at 6 12–14 Ebola epidemic, many expatriate healthcare workers in by district level in Sierra Leone. While districts such NGOs left Sierra Leone, negatively affecting care delivery as Kambia, Port Loko and Bonthe showed large reduc- and staff morale. The continued presence of international tions in facility-based delivery (between 38% and 41%), teams in the daily activities in Pujehun hospital and the the district of Pujehun showed only a 5% decrease in the acceptance of the professional risks by both national and same service. Similar geographic variations were seen in 12 13 international staff may have contributed to maintaining the reduction in antenatal care (ANC) visits. The number of confirmed EVD cases—and deaths—varied an attitude of ‘normality’ in an extremely stressful envi- ronment. This might also help to explain the population’s considerably by district. There were no >100 confirmed cases 17 18 in both Bonthe and Pujehun, and up to 4000 confirmed positive receptiveness towards the health services. cases in both Port Loko and Bombali.15 However, public Different types of referral systems (RSs) such as motor- fear of Ebola, regardless of the actual number of cases per bikes were present in the country in the pre-Ebola period district, may still have prevented many people from accessing to transport patients from the villages to the nearest services. The challenge of providing adequate levels of care health facility. Ambulances were also present in several during a humanitarian emergency such as the EVD crisis districts with 73% of health facilities nationwide having a was further exacerbated by the weak health system in Sierra functioning RS, 59% of them consisting of an ambulance Leone, particularly in rural areas where the poor condi- on call.12 23 In the Pujehun district, the RS was barely tion of the roads and high transport costs cause delays in functioning, only able to support the activity of a limited accessing services, and contribute to increased maternal and number of PHUs. The service was also entirely funded 16 neonatal mortality. by the patients themselves, resulting in underutilisation Doctors with Africa (DwA) CUAMM is an Italian non-gov- of the service. Utilisation was further reduced during the ernmental organization (NGO) working in Sierra Leone outbreak, when the ambulances were identified by the since 2012. It is present in the Pujehun district focusing on population with the transport of Ebola-infected patients, MCH care both at hospital and community level.17 18 In this and their use occasioned fear and distrust. In January paper, community level refers to peripheral health units 2015, in collaboration with the Ministry of Health and (PHUs), that is, all health facilities outside the hospital. As described in our previous reports,17 18 a number of Sanitation (MoHS) of Sierra Leone and UNICEF, DwA began the reorganisation and reinforcement of the RS, measures were put in place to control the Ebola epidemic http://bmjopen.bmj.com/ in the Pujehun district which might have reduced the transferring pregnant women and paediatric cases from impact of the disease on mothers and children compared PHUs to the Pujehun hospital. 18 with other districts. During this EVD epidemic, the Our previous studies provided information only on predominantly vertical focus on outbreak control was asso- three MCH indicators, namely paediatric admissions, mater- ciated with failures in providing effective care for routine nity admissions and institutional deliveries; in addition, it did health needs.19–21 In contrast, the approach implemented not assess the trends in the post-EVD period. Existing studies in the Pujehun district was not based on vertical actions examining the influence of EVD on MCH services targeted 24–27 and ‘humanitarian response to health emergencies with the outbreak and the immediate post-outbreak periods.
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