Séverine Caluwaerts

Ebola in Africa: beyond epidemics, reproductive health in crisis

According to WHO, more than 5000 people have died from Ebola, including 240 health workers. We are deeply concerned about the devastating effect of Ebola on reproductive health in Guinea, Liberia, and Sierra Leone in the context of continuous deterioration of socioeconomic conditions and general health in aff ected countries. The indirect negative effect of Ebola on reproductive health stems mainly from the desertion of already understaffed health facilities by health-care workers who are fearful of contracting Ebola. This fear is further increased because most reproductive health life-saving interventions include handling blood or bodily fluids from patients whose Ebola status is often unknown and health staff often do not have access to appropriate protection. Most referral maternity wards in the three most affected countries (Guinea, Liberia, and Sierra Leone) do not have equipment to do real-time screening for Ebola (eg, PCR), which could lead to the denial of care for women suspected to be pregnant. Additionally, the absence of providers offering relevant services, the inability to differentiate between Ebola and other febrile diseases, and the fear of contracting Ebola at a health facility can prevent users seeking reproductive health services. Statistics from Matam maternity hospital in Conakry, Guinea, show a substantial drop in attendance between March, 2014, and September, 2014, compared with 2013 (fi gure). A decrease in paediatric or maternal admissions because of fear of contracting Ebola has also been reported by Medecins Sans Frontieres in Sierra Leone. We are concerned that women in need of reproductive health care because of pregnancy, childbirth, and post-partum related complications, including haemorrhage, eclampsia, obstructed labour, and abortion, will not have necessary and even life-saving care and attention. United Nations Population Fund estimates that 15% of the 800 000 women who will give birth in the next 12 months in Guinea, Liberia, and Sierra Leone could die of complications because of inade quate emergency obstetric care, and thousands of others could develop devastating pathological conditions, such as obstetric fistula. Increased support to fight Ebola is needed in Guinea, Liberia, and Sierra Leone coupled, with specific attention to reproductive health services. Adequate measures, including health system strengthening and community mobilisation coupled with an enabling environment for provision of emergency obstetric care, need to be put in place urgently to avoid devastating short-term and long-term effects for thousands of women.

Dilemmas in managing pregnant women with Ebola: 2 case reports

We report 2 cases of Ebola viral disease (EVD) in pregnant women who survived, initially with intact pregnancies. Respectively 31–32 days after negativation of the maternal blood EVD-polymerase chain reaction (PCR) both patients delivered a stillborn fetus with persistent EVD-PCR amniotic fluid positivity.

Ebola viral disease and pregnancy

Ebola viral disease’s interaction with pregnancy is poorly understood and remains a particular challenge for medical and para-medical personnel responding to an outbreak. This review article is written with the benefit of hindsight and experience from the largest recorded Ebola outbreak in history. We have provided a broad overview of the issues that arise for pregnant women and for the professionals treating them during an Ebola outbreak. The discussion focuses on the specifics of Ebola infection in pregnancy and possible management strategies, including the delivery of an infected woman. We have also discussed the wider challenges posed to pregnant women and their carers during an epidemic, including the identification of suspected Ebola-infected pregnant women and the impact of the disease on pre-existing health services. This paper outlines current practices in the field, as well as highlighting the gaps in our knowledge and the paramount need to protect the health-care workers directly involved in the management of pregnant women.

First Newborn Baby to Receive Experimental Therapies Survives Ebola Virus Disease

Abstract A neonate born to an Ebola virus–positive woman was diagnosed with Ebola virus infection on her first day of life. The patient was treated with monoclonal antibodies (ZMapp), a buffy coat transfusion from an Ebola survivor, and the broad-spectrum antiviral GS-5734. On day 20, a venous blood specimen tested negative for Ebola virus by quantitative reverse-transcription polymerase chain reaction. The patient was discharged in good health on day 33 of life. Further follow-up consultations showed age-appropriate weight gain and neurodevelopment at the age of 12 months. This patient is the first neonate documented to have survived congenital infection with Ebola virus.

Unregulated usage of labour-inducing medication in a region of Pakistan with poor drug regulatory control: characteristics and risk patterns

Background In developing countries such as Pakistan, poor training of mid-level cadres of health providers, combined with unregulated availability of labour-inducing medication can carry considerable risk for mother and child during labour. Here, we describe the exposure to labour-inducing medication and its possible risks in a vulnerable population in a conflict-affected region of Pakistan. Methods A retrospective cohort study using programme data, compared the outcomes of obstetric risk groups of women treated with unregulated oxytocin, with those of women with regulated treatment. Results Of the 6379 women included in the study, 607 (9.5%) received labour-inducing medication prior to reaching the hospital; of these, 528 (87.0%) received unregulated medication. Out of 528 labour-inducing medication administrators, 197 (37.3%) traditional birth attendants (also known as dai) and 157 (29.7%) lady health workers provided unregulated treatment most frequently. Women given unregulated medication who were diagnosed with obstructed/prolonged labour were at risk for uterine rupture (RR 4.1, 95% CI: 1.7–9.9) and severe birth asphyxia (RR 3.9, 95% CI: 2.5–6.1), and those with antepartum haemorrhage were at risk for stillbirth (RR 1.8, 95% CI: 1.0–3.1). Conclusions In a conflict-affected region of Pakistan, exposure to unregulated treatment with labour-inducing medication is common, and carries great risk for mother and child. Tighter regulatory control of labour-inducing drugs is needed, and enhanced training of the mid-level cadres of healthcare workers is required.

A cross-sectional study of indications for cesarean deliveries in Médecins Sans Frontières facilities across 17 countries.

To review the major indications for cesareans performed by Médecins Sans Frontières (MSF) personnel from the Operational Center Brussels.

Provision of emergency obstetric care at secondary level in a conflict setting in a rural area of Afghanistan – is the hospital fulfilling its role?

BackgroundProvision of Emergency Obstetric and Neonatal Care (EmONC) reduces maternal mortality and should include three components: Basic Emergency Obstetric and Neonatal Care (BEmONC) offered at primary care level, Comprehensive EmONC (CEmONC) at secondary level and a good referral system in-between. In a conflict-affected province of Afghanistan (Khost), we assessed the performance of an Médecins Sans Frontières (MSF) run CEmONC hospital without a primary care and referral system. Performance was assessed in terms of hospital utilisation for obstetric emergencies and quality of obstetric care.MethodsA cross-sectional study using routine programme data (2013–2014).ResultsOf 29,876 admissions, 99% were self-referred, 0.4% referred by traditional birth attendants and 0.3% by health facilities. Geographic origins involved clustering around the hospital vicinity and the provincial road axis. While there was a steady increase in hospital caseload, the number and proportion of women with Direct Obstetric Complications (DOC) progressively dropped from 21% to 8% over 2 years. Admissions for normal deliveries continuously increased. In-hospital maternal deaths were 0.03%, neonatal deaths 1% and DOC case-fatality rate 0.2% (all within acceptable limits).ConclusionsDespite a high and ever increasing caseload, good quality Comprehensive EmONC could be offered in a conflict-affected setting in rural Afghanistan. However, the primary emergency role of the hospital is challenged by diversion of resources to normal deliveries that should happen at primary level. Strengthening Basic EmONC facilities and establishing an efficient referral system are essential to improve access for emergency cases and increase the potential impact on maternal mortality.

Emergency Obstetric Care in a Rural District of Burundi: What Are the Surgical Needs?

Objectives In a rural district hospital in Burundi offering Emergency Obstetric care-(EmOC), we assessed the a) characteristics of women at risk of, or with an obstetric complication and their types b) the number and type of obstetric surgical procedures and anaesthesia performed c) human resource cadres who performed surgery and anaesthesia and d) hospital exit outcomes. Methods A retrospective analysis of EmOC data (2011 and 2012). Results A total of 6084 women were referred for EmOC of whom 2534(42%) underwent a major surgical procedure while 1345(22%) required a minor procedure (36% women did not require any surgical procedure). All cases with uterine rupture(73) and extra-uterine pregnancy(10) and the majority with pre-uterine rupture and foetal distress required major surgery. The two most prevalent conditions requiring a minor surgical procedure were abortions (61%) and normal delivery (34%). A total of 2544 major procedures were performed on 2534 admitted individuals. Of these, 1650(65%) required spinal and 578(23%) required general anaesthesia; 2341(92%) procedures were performed by ‘general practitioners with surgical skills’ and in 2451(96%) cases, anaesthesia was provided by nurses. Of 2534 hospital admissions related to major procedures, 2467(97%) were discharged, 21(0.8%) were referred to tertiary care and 2(0.1%) died. Conclusion Overall, the obstetric surgical volume in rural Burundi is high with nearly six out of ten referrals requiring surgical intervention. Nonetheless, good quality care could be achieved by trained, non-specialist staff. The post-2015 development agenda needs to take this into consideration if it is to make progress towards reducing maternal mortality in Africa.

Caesarean sections in rural Burundi: how well are mothers doing two years on?

SETTING A caesarean section (C-section) is a life-saving emergency intervention. Avoiding pregnancies for at least 24 months after a C-section is important to prevent uterine rupture and maternal death. OBJECTIVES Two years following an emergency C-section, in rural Burundi, we assessed complications and maternal death during the post-natal period, uptake and compliance with family planning, subsequent pregnancies and their maternal and neonatal outcomes. METHODS A household survey among women who underwent C-sections. RESULTS Of 156 women who underwent a C-section, 116 (74%) were traced; 1 had died of cholera, 8 had migrated and 31 were untraceable. Of the 116 traced, there were no post-operative complications and no deaths. At hospital discharge, 83 (72%) women accepted family planning. At 24 months after hospital discharge (n = 116), 23 (20%) had delivered and 17 (15%) were pregnant. Of the remaining 76 women, 48 (63%) were not on family planning. The main reasons for this were religion or husbands non-agreement. Of the 23 women who delivered, there was one uterine rupture, no maternal deaths and three stillbirths. CONCLUSIONS Despite encouraging maternal outcomes, this study raises concerns around the effectiveness of current approaches to promote and sustain family planning for a minimum of 24 months following a C-section. Innovative ways of promoting family planning in this vulnerable group are urgently needed.