Aminata* was pregnant and in labor, but the baby wouldn’t come. Medical staff at a Sierra Leonean health care facility were afraid to treat her obstructed labor, thinking she might have Ebola, so the 24-year-old was referred to an Ebola holding center. Her blood was sent to a special lab to test for the disease so she could be rushed to the operating room for a lifesaving cesarean section if the test was negative.
But Aminata died of complications from obstructed labor while medical staff awaited her report. Hours later, the lab results came back: negative. Aminata never had the virus. She and her baby had died a senseless death.
Ebola poses an enormous risk for pregnant women. But many pregnant women likely to die because of the outbreak are like Aminata: They never had the disease to begin with, but they’re unable to get the care they need.
A critical challenge is this: Many pregnancy complications mirror symptoms of Ebola. When a pregnant woman arrives at a West African clinic with vomiting, bleeding, or pre-term labor (common complications of pregnancy), a clinician’s first thought, rightfully, is of the deadly disease. In an ideal setting, that clinician would send this woman to a specialized Ebola unit to receive care by clinicians in personal protective equipment (PPE) and wait for an Ebola test.
The Sierra Leonean government and Partners In Health clinicians are working closely together to move toward that ideal at a Freetown hospital. Together they’ve progressed from the chaotic early days of the epidemic to an ever-improving model of care.
Challenges of care
Early in the epidemic, PIH clinicians say, beds for pregnant women were scarce in Ebola treatment units—a result of clinicians’ fear of infection as well as pregnant women’s poor outcomes. So some women were simply refused care.
Because of the fear of Ebola, everybody was scared, and clinical staff were running away.
In the general maternity wards, the staff and systems were unprepared to triage patients for Ebola, and many clinicians fled. What adds to the tragedy is that the majority of women presenting with these symptoms did not have Ebola; they just needed basic maternity care. Such care is possible only if clinicians can triage for Ebola, if safe beds for pregnant women and providers in PPE are available, and if rapid Ebola testing can be performed.
In the first months of the outbreak in Sierra Leone, that care wasn’t available.
“Because of the fear of Ebola, everybody was scared, and clinical staff were running away,” said Sister Elizabeth Koroma, who was a senior nurse anesthetist at Princess Christian Maternity Hospital in Freetown. (Sister is a courtesy title for supervising nurses.)
Princess Christian Maternity Hospital (PCMH) provides critical services for pregnant women. It’s the national maternity referral and teaching hospital, so many women seek treatment there for pregnancy complications, said Dr. AP Koroma, PCMH medical superintendent. And because complications and childbirth involve a great deal of fluids—and fluids can spread Ebola to inadequately protected providers—hospital staff members became increasingly rattled as the outbreak progressed.
In July, that fear drove many to leave their jobs, said Dr. Koroma (no relation to Sr. Koroma). The hospital remained opened but understaffed. Pregnant women with Ebola weren’t always separated from those who didn’t have the virus, and the disease had the potential to spread.
At the beginning of the outbreak, many national staff came to work regardless of the risk. ... This heroism should not be forgotten, and we should recognize that this outbreak would have been significantly worse if not for their sacrifice.
It was an extraordinarily difficult time for Sierra Leonean clinicians.
“There were only four beds in a small isolation unit that wasn’t well set up for infection control,” Dr. Koroma said. “It was taking three, four, and even five days for [Ebola] test results, and there was no space to house additional patients. Many were just lying on the floor in the outpatient department, Ebola and non-Ebola patients, and many died before they received care.”
Basic kindness also complicated the situation, Sr. Koroma said.
“It was hard to keep patients from mingling because patients were sympathetic to one another,” she said. “And in Sierra Leonean culture, we take care of each other.”
Sierra Leonean clinicians also wanted to take care of their patients—and many did so, despite often unsafe conditions.
“At the beginning of the outbreak, many national staff came to work regardless of the risk,” said Piero Pertile, PIH program officer at PCMH. “They put their own lives on the line long before the international aid community came to support them. This heroism should not be forgotten, and we should recognize that this outbreak would have been significantly worse if not for their sacrifice.”
But the clinicians who responded needed training in infection control, supplies to protect themselves and their patients, and systems to continue to support maternity care to save pregnant women’s lives.
PIH has collaborated with the Sierra Leonean Ministry of Health and Sanitation and other international partners to transform what was a small radiology unit at PCMH into a specialized Ebola holding unit, where pregnant women suspected of having Ebola are tested for the virus and receive care by staff in PPE while they await the results. In addition, PIH and Dr. Koroma’s team have leveraged this work to encourage the Dutch government to build an Ebola testing lab on the campus. Now, it is possible to know if a woman has Ebola in less than six hours.
The women who test positive are sent from the hospital to a separate Ebola treatment unit.
The key goal of the PCMH unit is to make sure pregnant women get the medical care they need. It’s critical that the doctors, nurses, and midwives providing that care feel comfortable and safe treating pregnant women, PIH Chief Medical Officer Dr. Joia Mukherjee said.
“They were doing the best they can in an impossible situation, and we were able to join hands and say, ‘In this facility, what’s the best thing we can do to give your staff the confidence to go back to work?’” Mukherjee said.
The new unit has helped Sierra Leonean clinicians overcome their fear, said Sr. Koroma, who was one of the lead nurses at the unit until March. Several have returned to work there since it opened, she said.
The Ministry of Health and PIH opened the unit in early December. It operates 24 hours a day and had admitted 204 women as of March 26.
Sister Elizabeth Koroma has cared for pregnant women in the midst of Ebola since the outbreak began last year in Sierra Leone. (Photo by Piero Pertile/Partners In Health)
High risk from the start
Pregnancy and childbirth were dangerous in Sierra Leone long before Ebola showed up. The country emerged from a decade-long civil war in 2002, and its health system continues to experience challenges. In 2013, 1,100 women died for every 100,000 live births, according to World Bank data. That’s the worst maternal mortality ratio in the world. By comparison, 28 women in the U.S. died for every 100,000 live births that year.
With Ebola present, those statistics could become even grimmer.
Pregnant women are not necessarily likelier to get Ebola than anyone else, according to the U.S. Centers for Disease Control and Prevention. But once they do have the virus, it is often fatal to the women and, to date, always so for their fetuses.
It is unclear why pregnant women’s lives are in particular danger after they get Ebola, said Dr. Theresa Cullen, who worked at the PCMH unit through PIH. Clinicians know that a woman’s physiology changes during pregnancy. Pregnancy weakens the immune system, Cullen said, which could increase a woman’s chances of dying from Ebola.
“Pregnant women who get Ebola have historically done very, very poorly,” said Dr. Regan Marsh, a PIH clinician who was part of the Ebola response in Sierra Leone. “Pregnant women definitely need specialized care. They need more intensive care; their babies need care.”
Of the 204 women admitted to the PCMH unit, 27 tested positive for Ebola, or 13 percent (Ebola was unconfirmed but suspected for six women). Nine Ebola-positive women died in the unit, and 18 were moved to Ebola treatment units.
Building a new model
But the main aim of the Ebola unit at PCMH is not to treat pregnant women with Ebola through the entire course of their illness. Rather, it is set up to provide interim care for pregnant women while it is determined whether they have Ebola. If a woman is found to have Ebola, she is transferred to an Ebola treatment unit as soon as a bed is available. Women who don’t have Ebola are moved to general wards for obstetric care.
“Pregnant women with suspected or confirmed Ebola can and should be given the same level of care as all other Ebola patients, if appropriate precautions are taken,” Pertile said.
Ninety-six people staff or support the small, free-standing Ebola unit at PCMH, Pertile said. That includes nurses and midwives, but it also includes Ebola-specific staff members such as chlorine sprayers.
After a woman is admitted, she is placed in a bed in either the “wet” or the “dry” area. Patients enter the wet area if they are emitting fluids, such as blood, vomit, or diarrhea. Others enter the dry area. The aim is to separate those likely to be positive and more infectious from those who may not be positive or who are less infectious.
All are then tested for Ebola. As recently as February, results took up to four days. But the new on-site lab services mean that test results can be available within four to six hours.
“Proper infection prevention and control, a dignified place to provide care as women wait for their results, and rapid lab testing are critical to the survival of pregnant and laboring women in the time of Ebola,” Mukherjee said.
While they await results, the women receive treatment such as intravenous fluid, antimalarial medication, and antibiotics: standard and essential care for women with pregnancy complications. Sometimes the babies come while women are in the unit, and clinicians in full PPE help deliver them. This is tricky, too.
“Management of labor is very difficult because you can’t touch patients in the same way that you would normally, and you can only spend so much time in PPE,” Sr. Koroma said. “Normally you have time to speak to patients and place a hand on their shoulder to reassure them, but this is not as easy with Ebola suspect pregnancies.”
And sometimes, if problems arise during this waiting period, little can be done. A woman with obstructed labor like Aminata can’t go to the operating room for a C-section, for example, until clinicians are sure she doesn’t have Ebola, said Dr. Michael Grady, an OBGYN who was PIH’s clinical lead at PCMH in January and February.
I am proud that we never gave up, even when things were very difficult. I am especially proud now that Ebola is going away.
Grady returned to Sierra Leone at the end of March to supervise maternal health care. Despite the challenges he experienced providing maternity care in the time of Ebola, he said he was proud of the health services that the Sierra Leonean and PIH clinicians provided.
He, along with Nurse Emily Havener and Cullen, praised local colleagues such as Sr. Koroma.
“They’re really the heroes of the story,” Grady said. “We go in for a month or several months at a time, but they’re there day in and day out. These are their fellow citizens, what they call their Sierra Leonean sisters.”
Sr. Koroma, who now works as a critical care nurse at Connaught Hospital, is proud, too.
“I am proud that we never gave up, even when things were very difficult,” she said. “I am especially proud now that Ebola is going away. I am proud to work with your team [PIH], who helped bring us the support that we needed to treat patients.”
Cullen worked alongside Sr. Koroma in December and January and said Koroma led the unit with authority and compassion.
“She was like a chameleon or a stealth bomber: She’d always be there. You’d be in crisis, and suddenly she was there. You’d wonder how she knew to do that.”
OBGYN Dr. Michael Grady said he believes more work lies ahead in the effort to improve care for pregnant women in Sierra Leone. (Photo by Jon Lascher/Partners In Health)
It just makes it even more tragic if somebody dies unnecessarily in labor because of the fear of Ebola. That’s the tragedy here.
Tragedy and hope
Of the 204 women admitted to the unit, 171 tested negative for Ebola: 84 percent. That statistic seems positive, but it suggests that some pregnant women whose lives could be saved by surgery or other interventions are dying instead. Placing them in an Ebola suspect unit, even briefly, could result in delays in needed obstetric care. The on-site, rapid laboratory test is expected to improve these outcomes.
Fifteen Ebola-negative women and 17 Ebola-negative babies have died in the PCMH unit.
“It just makes it even more tragic if somebody dies unnecessarily in labor because of the fear of Ebola,” Grady said. “That’s the tragedy here.”
Cullen said she saw more maternal death in her five weeks in Sierra Leone than she had in her life—she’s been practicing medicine since 1984.
Maternal death has serious consequences for families. Children are four times likelier to die if their mother dies before they reach age 10, compared with children whose mothers are alive. The risk of death after loss of a mother is even higher for infants. A mother’s death also comes with socioeconomic consequences; children whose mothers die are less likely to finish school.
“Mothers are the ones who take care of everyone,” Marsh said. “The mother is the real center of health for the families—and that’s not unique to Sierra Leone; that’s true in the U.S. The implications of maternal death are really, really high.”
Although these deaths occurred far too often, most Ebola-negative women at the PCMH unit have survived to be discharged (89 of 171) or transferred for general hospital care (65 of 171).
The unit has had increasingly hopeful moments. Cullen noted that many of the midwives there had worked in rural Sierra Leone, where they were the only providers of maternal care for miles. This resulted in a wealth of experience.
“The beauty is that we brought skills and they brought skills, and we found this common way to work together,” Cullen said.
PIH clinicians and the Sierra Leonean nurses and midwives established protocols to make sure the unit provided high-quality care, she said.
One of Havener’s top moments was helping a woman in the unit give birth to a daughter. Both were Ebola-negative.
“She had a little peanut of a girl, and we ended up starting the baby on antibiotics,” Havener said. “So when we discharged her we sent her to a special unit for babies so she could finish her antibiotics. Every day her mom would come over and say hello and smile and say thank you. … That was really special; we got to go see her baby and remember there were positive outcomes, too.”
What lies ahead
The Ebola situation is changing rapidly. According to World Health Organization figures, Liberia had zero new cases to Sierra Leone’s nine new cases in the week ending April 5. Guinea reported 21 cases that week. Cumulative recorded cases exceed 25,500, and more than 10,500 people have died.
The Ebola unit at PCMH will scale down from 11 beds to eight as the outbreak slows. But Grady believes the fight is far from over.
The success story is that people can survive from Ebola.
“We’re getting ahead of the curve on Ebola, and I think it’s important to chase it down to zero,” he said. “The aftermath is going to demonstrate that much more needs to be done to save women’s lives. The work really lies ahead more so than it has in the past. I think it will be years recovering from the effects of this on the country.”
Dr. Koroma expressed hope, saying hospital staff members who know that Ebola-positive women have been screened out can treat pregnant women without fearing for their own lives. And Sr. Koroma, after watching the epidemic unfold, also is hopeful.
“The success story is that people can survive from Ebola,” she said. “And when you develop infection control systems, you can help mothers with Ebola and mothers who do not have Ebola and provide safety and confidence to the providers. People can still survive when early treatment is given, and if the fight is put in place, the transmission chain can be broken and save others from being infected.”
*The patient’s name has been changed to protect privacy.
Read more about PIH's Ebola response here.