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King J, Tarway-Twalla AK, Dennis M, Twalla MP, Konwloh PK, Wesseh CS, Tehoungue BZ, Saydee GS, Campbell O, Ronsmans C. Readiness of health facilities to provide safe childbirth in Liberia: a cross-sectional analysis of population surveys, facility censuses and facility birth records. BMC Pregnancy Childbirth 2022; 22:952. [PMID: 36539750 PMCID: PMC9764703 DOI: 10.1186/s12884-022-05301-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2022] [Accepted: 12/12/2022] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND The provision of quality obstetric care in health facilities is central to reducing maternal mortality, but simply increasing childbirth in facilities not enough, with evidence that many facilities in sub-Saharan Africa do not fulfil even basic requirements for safe childbirth care. There is ongoing debate on whether to recommend a policy of birth in hospitals, where staffing and capacity may be better, over lower level facilities, which are closer to women's homes and more accessible. Little is known about the quality of childbirth care in Liberia, where facility births have increased in recent decades, but maternal mortality remains among the highest in the world. We will analyse quality in terms of readiness for emergency care and referral, staffing, and volume of births. METHODS We assessed the readiness of the Liberian health system to provide safe care during childbirth use using three data sources: Demographic and Health Surveys (DHS), Service Availability and Readiness Assessments (SARA), and the Health Management Information System (HMIS). We estimated trends in the percentage of births by location and population caesarean-section coverage from 3 DHS surveys (2007, 2013 and 2019-20). We examined readiness for safe childbirth care among all Liberian health facilities by analysing reported emergency obstetric and neonatal care signal functions (EmONC) and staffing from SARA 2018, and linking with volume of births reported in HMIS 2019. RESULTS The percentage of births in facilities increased from 37 to 80% between 2004 and 2017, while the caesarean section rate increased from 3.3 to 5.0%. 18% of facilities could carry out basic EmONC signal functions, and 8% could provide blood transfusion and caesarean section. Overall, 63% of facility births were in places without full basic emergency readiness. 60% of facilities could not make emergency referrals, and 54% had fewer than one birth every two days. CONCLUSIONS The increase in proportions of facility births over time occurred because women gave birth in lower-level facilities. However, most facilities are very low volume, and cannot provide safe EmONC, even at the basic level. This presents the health system with a serious challenge for assuring safe, good-quality childbirth services.
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Affiliation(s)
- Jessica King
- grid.8991.90000 0004 0425 469XLondon School of Hygiene and Tropical Medicine, Keppel St., London, WC1E 7HT UK
| | | | | | - Musu Pusah Twalla
- grid.442519.f0000 0001 2286 2283University of Liberia, Capitol Hill, 1000 Monrovia, Liberia
| | - Patrick K. Konwloh
- grid.490708.20000 0004 8340 5221Ministry of Health, P.O.Box 9009, 1000 Monrovia, Liberia
| | - Chea Sanford Wesseh
- grid.490708.20000 0004 8340 5221Ministry of Health, P.O.Box 9009, 1000 Monrovia, Liberia
| | | | - Geetor S. Saydee
- grid.442519.f0000 0001 2286 2283University of Liberia, Capitol Hill, 1000 Monrovia, Liberia
| | - Oona Campbell
- grid.8991.90000 0004 0425 469XLondon School of Hygiene and Tropical Medicine, Keppel St., London, WC1E 7HT UK
| | - Carine Ronsmans
- grid.8991.90000 0004 0425 469XLondon School of Hygiene and Tropical Medicine, Keppel St., London, WC1E 7HT UK
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Impacts of Internet Use on Chinese Patients' Trust-Related Primary Healthcare Utilization. Healthcare (Basel) 2022; 10:healthcare10102114. [PMID: 36292561 PMCID: PMC9602738 DOI: 10.3390/healthcare10102114] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2022] [Revised: 10/10/2022] [Accepted: 10/19/2022] [Indexed: 11/04/2022] Open
Abstract
Background: The internet has greatly improved the availability of medical knowledge and may be an important avenue to improve patients’ trust in physicians and promote primary healthcare seeking by reducing information asymmetry. However, very few studies have addressed the interactive impacts of both patients’ internet use and trust on primary healthcare-seeking decisions. Objective: To explore the impact of internet use on the relationship between patients’ trust in physicians and primary healthcare seeking among Chinese adults 18 years of age and older to understand the varieties of effects in different cities. Methods: Generalized linear mixed models were applied to investigate the interactive impacts of internet use and patients’ trust in physicians on primary healthcare seeking using pooled data from the China Family Panel Study of 2014 to 2018. We also compared these effects based on different levels of urbanization, ages, and PHC services. Results: Overall, a higher degree of patients’ trust (p < 0.001) was able to directly predict better primary healthcare seeking, and internet use significantly increased the positive effect of patients’ trust on primary healthcare seeking (p < 0.001). However, the marginal effect analysis showed that this effect was related to the level of patients’ trust and that internet use could reduce the positive effect of patients’ trust on primary healthcare seeking when the individual had a low level of trust (≤ 3 units). Further, the heterogeneity analysis indicated that the benefits from internet use were higher in cities with high urbanization, high aging, and high PHC service levels compared to cities with low levels of these factors. Conclusions: The internet use may enhance patients’ trust-related PHC utilization. However, this impact is effective only if patients’ benchmark trust remains at a relatively high level. Comparatively, the role of internet use is more effective in areas with high urbanization, high aging and high PHC level. Thus, with increasing accessibility to the internet, the internet should be regulated to disseminate correct healthcare information. Moreover, in-depth integration of the internet and PHC should be promoted to provide excellent opportunities for patient participation, and different strategies should be set according to each city’s characteristics.
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Mulenga-Cilundika P, Ekofo J, Kabanga C, Criel B, Van Damme W, Chenge F. Indirect Effects of Ebola Virus Disease Epidemics on Health Systems in the Democratic Republic of the Congo, Guinea, Sierra Leone and Liberia: A Scoping Review Supplemented with Expert Interviews. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:13113. [PMID: 36293703 PMCID: PMC9602680 DOI: 10.3390/ijerph192013113] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 08/31/2022] [Revised: 09/30/2022] [Accepted: 10/05/2022] [Indexed: 06/16/2023]
Abstract
Ebola Virus Disease (EVD) epidemics have been extensively documented and have received large scientific and public attention since 1976. Until July 2022, 16 countries worldwide had reported at least one case of EVD, resulting in 43 epidemics. Most of the epidemics occurred in the Democratic Republic of Congo (DRC) but the largest epidemic occurred from 2014-2016 in Guinea, Sierra Leone and Liberia in West Africa. The indirect effects of EVD epidemics on these countries' health systems, i.e., the consequences beyond infected patients and deaths immediately related to EVD, can be significant. The objective of this review was to map and measure the indirect effects of the EVD epidemics on the health systems of DRC, Guinea, Sierra Leone and Liberia and, from thereon, draw lessons for strengthening their resilience vis-à-vis future EVD outbreaks and other similar health emergencies. A scoping review of published articles from the PubMed database and gray literature was conducted. It was supplemented by interviews with experts. Eighty-six articles were included in this review. The results were structured based on WHO's six building blocks of a health system. During the EVD outbreaks, several healthcare services and activities were disrupted. A significant decline in indicators of curative care utilization, immunization levels and disease control activities was noticeable. Shortages of health personnel, poor health data management, insufficient funding and shortages of essential drugs characterized the epidemics that occurred in the above-mentioned countries. The public health authorities had virtually lost their leadership in the management of an EVD response. Governance was characterized by the development of a range of new initiatives to ensure adequate response. The results of this review highlight the need for countries to invest in and strengthen their health systems, through the continuous reinforcement of the building blocks, even if there is no imminent risk of an epidemic.
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Affiliation(s)
- Philippe Mulenga-Cilundika
- Centre de Connaissances en Santé en République Démocratique du Congo, Kinshasa 3088, Democratic Republic of the Congo
- School of Public Health, Faculty of Medicine, University of Lubumbashi, Lubumbashi 1825, Democratic Republic of the Congo
| | - Joel Ekofo
- Centre de Connaissances en Santé en République Démocratique du Congo, Kinshasa 3088, Democratic Republic of the Congo
| | - Chrispin Kabanga
- Centre de Connaissances en Santé en République Démocratique du Congo, Kinshasa 3088, Democratic Republic of the Congo
| | - Bart Criel
- Centre de Connaissances en Santé en République Démocratique du Congo, Kinshasa 3088, Democratic Republic of the Congo
- Institute of Tropical Medicine, 2000 Antwerp, Belgium
| | - Wim Van Damme
- Institute of Tropical Medicine, 2000 Antwerp, Belgium
| | - Faustin Chenge
- Centre de Connaissances en Santé en République Démocratique du Congo, Kinshasa 3088, Democratic Republic of the Congo
- School of Public Health, Faculty of Medicine, University of Lubumbashi, Lubumbashi 1825, Democratic Republic of the Congo
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Sexual and reproductive health services during outbreaks, epidemics, and pandemics in sub-Saharan Africa: a literature scoping review. Syst Rev 2022; 11:161. [PMID: 35945580 PMCID: PMC9361234 DOI: 10.1186/s13643-022-02035-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2021] [Accepted: 07/26/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The COVID-19 pandemic could worsen adolescent sexual and reproductive health (ASRH). We sought evidence on the indirect impacts of previous infectious disease epidemics and the current COVID-19 pandemic on the uptake of ASRH in sub-Saharan Africa (SSA) to design relevant digital solutions. METHODS We undertook a literature scoping review to synthesize evidence on the indirect impacts of COVID-19 on ASRH in SSA per the Arksey and O'Malley framework and PRISMA reporting guidelines. We conducted the search on PubMed, Embase, Google Scholar, and ResearchGate in June and November 2020. We included all peer-reviewed, English-language primary studies on the indirect impacts of infectious disease epidemics on the uptake of sexual and reproductive health (SRH) in SSA. RESULTS We included 21 of 42 identified studies. Sixteen studies (76.2%) quantitatively assessed utilization and access to SRH during epidemics. Five studies (2 [9.6%] qualitative and 3 [14.3%] mixed methods) explored factors affecting SRH services. All studies focused on adult populations, most often on labor and delivery (n = 13 [61.9%]) and family planning (n = 8 [38.1%]) outcomes. Although we sought out to assess all outbreaks, epidemics, and pandemics, the only relevant studies took place during the West African Ebola pandemic (n = 17 [80.9%]) and COVID-19 pandemic (n = 4 [19.0%]). One study (4.8%) highlighted adolescent-specific outcomes and condom use. Most studies found declined access to and utilization of facility delivery, antenatal care, family planning, and HIV care. One study noted an increase in adolescent pregnancies. However, other studies noted similar, or even increasing trends in access to and utilization of other SRH services (family planning visits; HIV diagnosis; ART initiation) during epidemics. Barriers to SRH uptake included factors such as a reduced ability to pay for care due to lost income, travel restrictions, and fear of infection. Supply-side barriers included lack of open facilities, workers, commodities, and services. Community-based peer delivery systems, telemedicine, and transport services improved SRH uptake. CONCLUSION Access to SRH services during epidemics among adolescents and young people in SSA is understudied. We found that no studies focused on SRH outcomes of abortion, emergency contraception, sexually transmitted infections, or cervical cancer. To improve access to and utilization of SRH during pandemics, we recommend the following; in terms of research, key standardized SRH indicators should be included in routine data collection, routine data should be disaggregated by age, gender, and geography to understand gaps in ASRH service delivery, and additional rigorous epidemiological and social-behavioral studies should be conducted. On implementation, community-based peer delivery systems and telemedicine, internet-based, and other technological solutions may better reach adolescent and young people in SSA.
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Scoping Review on the Impact of Outbreaks on Sexual and Reproductive Health Services: Proposed Frameworks for Pre-, Intra-, and Postoutbreak Situations. BIOMED RESEARCH INTERNATIONAL 2021; 2021:9989478. [PMID: 34541003 PMCID: PMC8443356 DOI: 10.1155/2021/9989478] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/11/2021] [Accepted: 08/16/2021] [Indexed: 11/17/2022]
Abstract
Introduction Recent experiences from global outbreaks have highlighted the severe disruptions in sexual and reproductive health services that expose women and girls to preventable health risks. Yet, to date, there is no review studying the possible impact of outbreaks on sexual and reproductive health (SRH). Methodology. Studies reporting outbreaks impacting sexual and reproductive health and pregnancy outcomes were identified using MEDLINE, Embase, and ISI-WoS. Reported impacts were reviewed at systems, community, and legislative levels. Results The initial run listed 4423 studies; the 37 studies that met all inclusion criteria were mainly from Latin America and Africa. Studies on outbreaks of diseases like Zika and Ebola have documented declines in facility-based deliveries, contraceptive use, and antenatal and institutional care due to burdened healthcare system. Service usage was also impacted by a lack of trust in the healthcare system and system shocks, including workforce capacity and availability. At the community level, poverty and lack of awareness were critical contributors to poor access to SRH services. Assessing the target population's knowledge, attitude, beliefs, and behavior and using health literacy principles for communication were fundamental for designing service delivery. Online resources for SRH services were an acceptable medium of information among young adults. In outbreak situations, SRH and pregnancy outcomes were improved by implementing laboratory surveillance, free-of-cost contraceptive services, improved screening through professional training, and quality of care. In addition, mobile health clinics were reported to be effective in remote areas. Knowledge Contribution. In outbreaks, the interventions are categorized into preoutbreak, during, and postoutbreak periods. The proposed steps can help to improve and do course correction in emergencies. Though conducted before the COVID-19 crisis, the authors believe that lessons can be drawn from the paper to understand and mitigate the impact of the pandemic on sexual and reproductive health services.
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Shapira G, Ahmed T, Drouard SHP, Amor Fernandez P, Kandpal E, Nzelu C, Wesseh CS, Mohamud NA, Smart F, Mwansambo C, Baye ML, Diabate M, Yuma S, Ogunlayi M, Rusatira RJDD, Hashemi T, Vergeer P, Friedman J. Disruptions in maternal and child health service utilization during COVID-19: analysis from eight sub-Saharan African countries. Health Policy Plan 2021; 36:1140-1151. [PMID: 34146394 PMCID: PMC8344431 DOI: 10.1093/heapol/czab064] [Citation(s) in RCA: 117] [Impact Index Per Article: 39.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2021] [Revised: 04/01/2021] [Accepted: 05/27/2021] [Indexed: 12/31/2022] Open
Abstract
The coronavirus-19 pandemic and its secondary effects threaten the continuity of essential health services delivery, which may lead to worsened population health and a protracted public health crisis. We quantify such disruptions, focusing on maternal and child health, in eight sub-Saharan countries. Service volumes are extracted from administrative systems for 63 954 facilities in eight countries: Cameroon, Democratic Republic of Congo, Liberia, Malawi, Mali, Nigeria, Sierra Leone and Somalia. Using an interrupted time series design and an ordinary least squares regression model with facility-level fixed effects, we analyze data from January 2018 to February 2020 to predict what service utilization levels would have been in March-July 2020 in the absence of the pandemic, accounting for both secular trends and seasonality. Estimates of disruption are derived by comparing the predicted and observed service utilization levels during the pandemic period. All countries experienced service disruptions for at least 1 month, but the magnitude and duration of the disruptions vary. Outpatient consultations and child vaccinations were the most commonly affected services and fell by the largest margins. We estimate a cumulative shortfall of 5 149 491 outpatient consultations and 328 961 third-dose pentavalent vaccinations during the 5 months in these eight countries. Decreases in maternal health service utilization are less generalized, although significant declines in institutional deliveries, antenatal care and postnatal care were detected in some countries. There is a need to better understand the factors determining the magnitude and duration of such disruptions in order to design interventions that would respond to the shortfall in care. Service delivery modifications need to be both highly contextualized and integrated as a core component of future epidemic response and planning.
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Affiliation(s)
- Gil Shapira
- Development Research Group, The World Bank, 1818 H St NW, Washington, DC 20433, USA
| | - Tashrik Ahmed
- Development Research Group, The World Bank, 1818 H St NW, Washington, DC 20433, USA
| | | | - Pablo Amor Fernandez
- Development Research Group, The World Bank, 1818 H St NW, Washington, DC 20433, USA
| | - Eeshani Kandpal
- Development Research Group, The World Bank, 1818 H St NW, Washington, DC 20433, USA
| | - Charles Nzelu
- Nigeria Federal Ministry of Health, Federal Secretariat Complex, Phase III, Shehu Shagari Way, Central Business District, Abuja, Nigeria
| | | | - Nur Ali Mohamud
- Somalia Ministry of Health, Corso Somalia, Mogadishu, Somalia
| | - Francis Smart
- Sierra Leone Ministry of Health and Sanitation, Wilkinson Road, Freetown, Sierra Leone
| | | | - Martina L Baye
- Cameroun Ministére de la Sante Publiqué, Ave Marchand, Yaoundé, Cameroon
| | - Mamatou Diabate
- Ministère de la Santé et de l’Hygiène Publique du Mali, Cité Administrative Bamako, Bamako BP 232, Mali
| | - Sylvain Yuma
- Republique Democratique du Congo Ministére de la Sante, Boulevard du 30 juin #4310, Commune de la Gombe B.P. 3088 Kinshasa/Gombe, République Démocratique du Congo
| | - Munirat Ogunlayi
- The Global Financing Facility for Women, Children, and Adolescents, 1818 H ST NW, Washington, DC, 204333, USA
| | - Rwema Jean De Dieu Rusatira
- The Global Financing Facility for Women, Children, and Adolescents, 1818 H ST NW, Washington, DC, 204333, USA
| | - Tawab Hashemi
- The Global Financing Facility for Women, Children, and Adolescents, 1818 H ST NW, Washington, DC, 204333, USA
| | - Petra Vergeer
- The Global Financing Facility for Women, Children, and Adolescents, 1818 H ST NW, Washington, DC, 204333, USA
| | - Jed Friedman
- Development Research Group, The World Bank, 1818 H St NW, Washington, DC 20433, USA
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Yerger P, Jalloh M, Coltart CEM, King C. Barriers to maternal health services during the Ebola outbreak in three West African countries: a literature review. BMJ Glob Health 2021; 5:bmjgh-2020-002974. [PMID: 32895217 PMCID: PMC7476472 DOI: 10.1136/bmjgh-2020-002974] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2020] [Revised: 07/22/2020] [Accepted: 07/25/2020] [Indexed: 02/01/2023] Open
Abstract
Introduction The Ebola virus disease (EVD) outbreak in West Africa, affecting Guinea, Liberia and Sierra Leone from 2014 to 2016, was a substantial public health crisis with health impacts extending past EVD itself. Access to maternal health services (MHS) was disrupted during the epidemic, with reductions in antenatal care, facility-based deliveries and postnatal care. We aimed to identify and describe barriers related to the uptake and provision of MHS during the 2014–2016 EVD outbreak in West Africa. Methods In June 2020, we conducted a scoping review of peer-reviewed publications and grey literature from relevant stakeholder organisations. Search terms were generated to identify literature that explained underlying access barriers to MHS. Published literature in scientific journals was first searched and extracted from PubMed and Web of Science databases for the period between 1 January 2014 and 27 June 2020. We hand-searched relevant stakeholder websites. A ‘snowball’ approach was used to identify relevant sources uncaptured in the systematic search. The identified literature was examined to synthesise themes using an existing framework. Results Nineteen papers were included, with 26 barriers to MHS uptake and provision identified. Three themes emerged: (1) fear and mistrust, (2) health system and service constraints, and (3) poor communication. Our analysis of the literature indicates that fear, experienced by both service users and providers, was the most recurring barrier to MHS. Constrained health systems negatively impacted MHS on the supply side. Poor communication and inadequately coordinated training efforts disallowed competent provision of MHS. Conclusions Barriers to accessing MHS during the EVD outbreak in West Africa were influenced by complex but inter-related factors at the individual, interpersonal, health system and international level. Future responses to EVD outbreaks need to address underlying reasons for fear and mistrust between patients and providers, and ensure MHS are adequately equipped both routinely and during crises.
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Affiliation(s)
- Piper Yerger
- Institute for Global Health, University College London, London, UK.,Care Ring, Children and Family Services Center, Charlotte, North Carolina, USA
| | - Mohamed Jalloh
- Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden
| | | | - Carina King
- Institute for Global Health, University College London, London, UK .,Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden
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Iraqi M, Edri A, Greenshpan Y, Kundu K, Bolel P, Cahana A, Ottolenghi A, Gazit R, Lobel L, Braiman A, Porgador A. N-Glycans Mediate the Ebola Virus-GP1 Shielding of Ligands to Immune Receptors and Immune Evasion. Front Cell Infect Microbiol 2020; 10:48. [PMID: 32211339 PMCID: PMC7068452 DOI: 10.3389/fcimb.2020.00048] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2019] [Accepted: 01/24/2020] [Indexed: 12/14/2022] Open
Abstract
The Ebola Virus (EBOV) glycoprotein (GP) sterically shields cell-membrane ligands to immune receptors such as human leukocyte antigen class-1 (HLA-I) and MHC class I polypeptide-related sequence A (MICA), thus mediating immunity evasion. It was suggested that the abundant N-glycosylation of the EBOV-GP is involved in this steric shielding. We aimed to characterize (i) the GP N-glycosylation sites contributing to the shielding, and (ii) the effect of mutating these sites on immune subversion by the EBOV-GP. The two highly glycosylated domains of GP are the mucin-like domain (MLD) and the glycan cap domain (GCD) with three and six N-glycosylation sites, respectively. We mutated the N-glycosylation sites either in MLD or in GCD or in both domains. We showed that the glycosylation sites in both the MLD and GCD domains contribute to the steric shielding. This was shown for the steric shielding of either HLA-I or MICA. We then employed the fluorescence resonance energy transfer (FRET) method to measure the effect of N-glycosylation site removal on the distance in the cell membrane between the EBOV-GP and HLA-I (HLA.A*0201 allele). We recorded high FRET values for the interaction of CFP-fused HLA.A*0201 and YFP-fused EBOV-GP, demonstrating the very close distance (<10 nm) between these two proteins on the cell membrane of GP-expressing cells. The co-localization of HLA-I and Ebola GP was unaffected by the disruption of steric shielding, as the removal of N-glycosylation sites on Ebola GP revealed similar FRET values with HLA-I. However, these mutations directed to N-glycosylation sites had restored immune cell function otherwise impaired due to steric shielding over immune cell ligands by WT Ebola GP. Overall, we showed that the GP-mediated steric shielding aimed to impair immune function is facilitated by the N-glycans protruding from its MLD and GCD domains, but these N-glycans are not controlling the close distance between GP and its shielded proteins.
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Affiliation(s)
- Muhammed Iraqi
- The Shraga Segal Department of Microbiology, Immunology and Genetics, Faculty of Health Sciences, Ben-Gurion University of the Negev, Be'er Sheva, Israel
| | - Avishay Edri
- The Shraga Segal Department of Microbiology, Immunology and Genetics, Faculty of Health Sciences, Ben-Gurion University of the Negev, Be'er Sheva, Israel
| | - Yariv Greenshpan
- The Shraga Segal Department of Microbiology, Immunology and Genetics, Faculty of Health Sciences, Ben-Gurion University of the Negev, Be'er Sheva, Israel
| | - Kiran Kundu
- The Shraga Segal Department of Microbiology, Immunology and Genetics, Faculty of Health Sciences, Ben-Gurion University of the Negev, Be'er Sheva, Israel.,National Institute for Biotechnology in the Negev, Ben-Gurion University of the Negev, Be'er Sheva, Israel
| | - Priyanka Bolel
- The Shraga Segal Department of Microbiology, Immunology and Genetics, Faculty of Health Sciences, Ben-Gurion University of the Negev, Be'er Sheva, Israel
| | - Avishag Cahana
- The Shraga Segal Department of Microbiology, Immunology and Genetics, Faculty of Health Sciences, Ben-Gurion University of the Negev, Be'er Sheva, Israel
| | - Aner Ottolenghi
- The Shraga Segal Department of Microbiology, Immunology and Genetics, Faculty of Health Sciences, Ben-Gurion University of the Negev, Be'er Sheva, Israel
| | - Roi Gazit
- The Shraga Segal Department of Microbiology, Immunology and Genetics, Faculty of Health Sciences, Ben-Gurion University of the Negev, Be'er Sheva, Israel
| | - Leslie Lobel
- The Shraga Segal Department of Microbiology, Immunology and Genetics, Faculty of Health Sciences, Ben-Gurion University of the Negev, Be'er Sheva, Israel
| | - Alex Braiman
- The Shraga Segal Department of Microbiology, Immunology and Genetics, Faculty of Health Sciences, Ben-Gurion University of the Negev, Be'er Sheva, Israel
| | - Angel Porgador
- The Shraga Segal Department of Microbiology, Immunology and Genetics, Faculty of Health Sciences, Ben-Gurion University of the Negev, Be'er Sheva, Israel.,National Institute for Biotechnology in the Negev, Ben-Gurion University of the Negev, Be'er Sheva, Israel
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Quaglio G, Tognon F, Finos L, Bome D, Sesay S, Kebbie A, Di Gennaro F, Camara BS, Marotta C, Pisani V, Bangura Z, Pizzol D, Saracino A, Mazzucco W, Jones S, Putoto G. Impact of Ebola outbreak on reproductive health services in a rural district of Sierra Leone: a prospective observational study. BMJ Open 2019; 9:e029093. [PMID: 31488479 PMCID: PMC6731846 DOI: 10.1136/bmjopen-2019-029093] [Citation(s) in RCA: 33] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVES To assess the trends concerning utilisation of maternal and child health (MCH) services before, during and after the Ebola outbreak, quantifying the contribution of a reorganised referral system (RS). DESIGN A prospective observational study of MCH services. SETTING Pujehun district in Sierra Leone, 77 community health facilities and 1 hospital from 2012 to 2017. MAIN OUTCOME MEASURES MCH utililization was evaluated by assessing: (1) institutional deliveries, Cesarean-sections, paediatric and maternity admissions and deaths, and major direct obstetric complications (MDOCs), at hospital level; (2) antenatal care (ANC) 1 and 4, institutional delivery and family planning, at community level. Contribution of a strengthened RS was also measured. RESULTS At hospital level, there is a significant difference between trends Ebola versus pre-Ebola for maternal admissions (7, 95% CI 4 to 11, p<0.001), MDOCs (4, 95% CI 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 institutional deliveries (-3, 95% CI -5 to -1, p=0.001). The differences between trends pre-Ebola versus post-Ebola are only significant for paediatric admissions (3, 95% CI 0 to 5, p=0.035). At community level, the difference between trends Ebola versus pre-Ebola and Ebola versus post-Ebola are not significant for any indicators. The differences between trends pre-Ebola versus post-Ebola show a negative difference for institutional deliveries (-7, 95% CI -10 to -4, p<0.001), ANC 1 (-6, 95% CI -10 to -3, p<0.001), ANC 4 (-8, 95% CI -11 to -5, p<0.001) and family planning (-85, 95% CI -119 to -51, p<0.001). CONCLUSIONS A stronger health system compared with other districts in Sierra Leone and a strengthened RS enabled health facilities in Pujehun to maintain service provision and uptake during and after the Ebola epidemic.
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Affiliation(s)
- Gianluca Quaglio
- European Parliamentary Research Services (EPRS), European Parliament, Brussels, Belgium
- Department of International Health/CAPHRI, University of Maastricht, Maastricht, The Netherlands
- Operational Research Unit, Doctors with Africa CUAMM, Padua, Italy
| | - Francesca Tognon
- Department for Woman and Child Health, University of Padua, Padua, Italy
| | - Livio Finos
- Department of Developmental Psychology and Socialisation, University of Padua, Padua, Italy
| | - David Bome
- Ministry of Health and Sanitation, Freetown, Sierra Leone
| | - Santigie Sesay
- Ministry of Health and Sanitation, Freetown, Sierra Leone
| | - Atiba Kebbie
- Department for Woman and Child Health, Pujehun Hospital, Pujehun, Sierra Leone
| | | | - Bienvenu Salim Camara
- National Centre for Training and Research in Rural Health of Maferinyah, Forécariah, Guinea
| | - Claudia Marotta
- Department of Science for Health Promotion and Mother to Child Care, University of Palermo, Palermo, Italy
| | - Vincenzo Pisani
- Department for Woman and Child Health, Pujehun Hospital, Pujehun, Sierra Leone
| | - Zainab Bangura
- Department for Woman and Child Health, Pujehun Hospital, Pujehun, Sierra Leone
| | - Damiano Pizzol
- Operational Research Unit, Doctors with Africa CUAMM, Padua, Italy
| | | | - Walter Mazzucco
- Department of Science for Health Promotion and Mother to Child Care, University of Palermo, Palermo, Italy
| | - Susan Jones
- Department of Nursing and Midwifery, School of Human and Health Sciences, University of Huddersfield, London, UK
| | - Giovanni Putoto
- Operational Research Unit, Doctors with Africa CUAMM, Padua, Italy
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10
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Buser JM, Munro-Kramer ML, Carney M, Kofa A, Cole GG, Lori JR. Maternity waiting homes as a cost-effective intervention in rural Liberia. Int J Gynaecol Obstet 2019; 146:74-79. [PMID: 31026343 DOI: 10.1002/ijgo.12830] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2018] [Revised: 11/12/2018] [Accepted: 04/25/2019] [Indexed: 11/09/2022]
Abstract
OBJECTIVE To analyze the cost-effectiveness of maternity waiting homes (MWHs) in rural Liberia by examining the cost per life saved and economic effect of MWHs on maternal mortality. METHODS A cost-effectiveness analysis was used to evaluate costs and economic effect of MWHs on maternal mortality in rural Liberia to guide future resource allocation. A secondary data analysis was performed based on a prior quasi-experimental cohort study of 10 rural primary healthcare facilities, five with a MWH and five without a MWH, that took place from October 30, 2010 to February 28, 2015. RESULTS Calculations signified a low cost per year of life saved at MWHs in a rural district in Liberia. Total population-adjusted number of women's lives saved over 3 years was 6.25. CONCLUSION While initial costs were considerable, over a period of 10 or more years MWHs could be a cost-effective and affordable strategy to reduce maternal mortality rates in Liberia. Discussion of the scaling up of MWH interventions for improving maternal outcomes in Liberia and other low- and middle-income countries is justified. Findings can be used to advocate for policy changes to increase the apportionment of resources for building more MWHs in low resource settings.
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Affiliation(s)
- Julie M Buser
- Department of Health Behavior and Biological Sciences, University of Michigan School of Nursing, Ann Arbor, MI, USA
| | - Michelle L Munro-Kramer
- Department of Health Behavior and Biological Sciences, University of Michigan School of Nursing, Ann Arbor, MI, USA
| | - Monica Carney
- Department of Economics and Accounting, College of the Holy Cross, Worcester, MA, USA
| | - Alphonso Kofa
- Ministry of Health, Bong County Health Team, Suakoko, Bong County, Liberia
| | - G Gorma Cole
- Ministry of Health, Bong County Health Team, Suakoko, Bong County, Liberia
| | - Jody R Lori
- Department of Health Behavior and Biological Sciences, University of Michigan School of Nursing, Ann Arbor, MI, USA
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11
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Karmbor-Ballah EG, Fallah MP, Silverstein JB, Gilbert HN, Desai IK, Mukherjee JS, Farmer PE, Richardson ET. Maternal mortality and the metempsychosis of user fees in Liberia: A mixed-methods analysis. SCIENTIFIC AFRICAN 2019. [DOI: 10.1016/j.sciaf.2019.e00050] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022] Open
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12
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Tarr-Attia CK, Boiwu GH, Martínez-Pérez G. 'Birds of the same feathers fly together': midwives' experiences with pregnant women and FGM/C complications - a grounded theory study in Liberia. Reprod Health 2019; 16:18. [PMID: 30764836 PMCID: PMC6376772 DOI: 10.1186/s12978-019-0681-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2018] [Accepted: 02/06/2019] [Indexed: 12/03/2022] Open
Abstract
Background In Liberia, approximately 70% of the women of the North-Central and North-Western regions could have undergone female genital mutilation/cutting (FGM/C) in their childhood during a traditional ceremony marking their entrance into Sande, a secret female society. Little is known about FGM/C from Liberian women’s perspective. This study aimed to understand the health implications of FGM/C as perceived by qualified female midwives. Methods This qualitative study was conducted in 2017 in Monrovia, Liberia’s capital. Twenty midwives were approached. Of these, seventeen consented to participate in in-depth interviews. A thematic guide was used to gain insights about their knowledge on FGM/C and their experiences attending women victims of FGM/C. A feminist interpretation of constructivist grounded theory guided data generation and analysis. Results The midwives participants described how clitoridectomy was the most common FGM/C type done to the girls during the Sande initiation ceremonies. Sexual impairment and intrapartum vulvo-perineal laceration with subsequent hemorrhage were described as frequent FGM/C-attributable complications that some midwives could be unable to address due to lack of knowledge and skills. The majority of midwives would advocate for the abandonment of FGM/C, and for the preservation of the traditional instructions that the girls in FGM/C-practicing regions receive when joining Sande. The midwives described how migration to urban areas, and improved access to information and communication technologies might be fuelling abandonment of FGM/C. Conclusion Liberian midwives need tailored training to provide psychosexual counseling, and to attend the obstetric needs of pregnant women that have undergone FGM/C. In spite of FGM/C being seemingly in the decline, surveillance at clinic-level is warranted to prevent its medicalization. Any clinic- or community-based training, research, prevention and awareness intervention targeting FGM/C-practicing populations should be designed in collaboration with Sande members, and acknowledging that the Liberian population may place a high value in Sande’s traditional values.
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Affiliation(s)
- Christine K Tarr-Attia
- Saint Joseph's Catholic Hospital, Monrovia, Liberia.,African Women's Research Observatory (AfWORO), Barcelona, Spain
| | | | - Guillermo Martínez-Pérez
- African Women's Research Observatory (AfWORO), Barcelona, Spain. .,NGO Nutrition Without Borders The Gambia, Centre for Rehabilitation and Education in Nutrition, Basse Santa Su, URR, The Gambia. .,Faculty of Health Sciences, University of Saragossa, Saragossa, Spain.
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13
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Wilhelm JA, Helleringer S. Utilization of non-Ebola health care services during Ebola outbreaks: a systematic review and meta-analysis. J Glob Health 2019; 9:010406. [PMID: 30701070 PMCID: PMC6344071 DOI: 10.7189/jogh.09.010406] [Citation(s) in RCA: 55] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
Abstract
Background Beyond their direct effects on mortality, outbreaks of Ebola Virus Disease (EVD) might disrupt the provision of health care services in affected countries, possibly resulting in an increase in the number of deaths from non-EVD causes. We conducted a systematic review and meta-analysis of studies documenting the impact of EVD outbreaks on health care utilization. Methods We searched PubMed, Embase, Scopus, Web of Science, Cumulative Index to Nursing and Allied Health Literature (CINAHL), Global Health, Pascal and grey literature to identify observational studies that compared indicators of health care utilization before and during the outbreak. We identified 14 752 unique citations, 22 of which met inclusion criteria. All were related to the 2013-2016 West African EVD outbreak. From the 22 studies, we extracted 235 estimates of the relative change in health care utilization during the EVD outbreak. We used multivariate regression to estimate the average effect of the outbreak on health care utilization, and to assess heterogeneity across study characteristics. Findings On average, health care utilization declined by 18.0% during the outbreak (95% Confidence Interval: -26.5%, -9.5%). The observed declines in health care utilization were largest in settings affected by higher levels of EVD incidence (>2.5 cases per 100 000 per week) whereas utilization did not change in settings with EVD incidence less than 0.5 cases per 100 000 per week. Declines in utilization were greater for inpatient care and for deliveries than for outpatient care. They were also larger in studies based on small samples of health facilities, suggestive of publication bias. However, several studies based on larger samples of facilities also observed declines in health care utilization. Conclusions During the West African EVD outbreak, the utilization of health services declined significantly. During outbreaks of EVD, attention needs to be paid to the disruption of the health services, which can have large indirect health impacts.
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Affiliation(s)
- Jess Alan Wilhelm
- Johns Hopkins University, Bloomberg School of Public Health, Department of International Health, Baltimore, Maryland, USA
| | - Stéphane Helleringer
- Johns Hopkins University, Bloomberg School of Public Health, Deptartment of Population, Family, and Reproductive Health, Baltimore, Maryland, USA
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14
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Martínez-Pérez G, Lansana DP, Omeonga S, Gupta H, Breeze-Barry B, González R, Bardají A, Sarukhan A, Goteh JDK, Tody E, Cisteró P, Benda B, Kercula JD, Kibungu FD, Meyer García-Sípido A, Bassat Q, Tarr-Attia CK, Mayor A. Prevalence of Plasmodium falciparum infection among pregnant women at first antenatal visit in post-Ebola Monrovia, Liberia. Malar J 2018; 17:357. [PMID: 30314489 PMCID: PMC6186138 DOI: 10.1186/s12936-018-2506-z] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2018] [Accepted: 10/06/2018] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Disruption of malaria control strategies during the West African 2014-2016 Ebola epidemic led to an increase in malaria-attributable mortality. However, recent data on malaria infection in vulnerable groups, such as pregnant women, are lacking in this post-Ebola scenario. This cross-sectional study aimed to assess the prevalence of Plasmodium falciparum infection and of molecular markers of drug resistance among pregnant women attending antenatal care in Monrovia, capital of Liberia. METHODS From October 2016 to June 2017, all pregnant women attending their first antenatal care visit at the Saint Joseph's Catholic Hospital, Monrovia, were invited to participate in the study. In addition to their routine antenatal care tests, capillary blood spotted onto filter papers were collected from all consenting participants to determine presence of P. falciparum by real-time quantitative PCR. Molecular markers of anti-malarial drug resistance were assessed through Sanger sequencing and quantitative PCR in specimens positive for P. falciparum analysis. RESULTS Of the 195 women participants, 24 (12.3%) were P. falciparum-positive by qPCR. Infected women tended to be more commonly primigravidae and younger than uninfected ones. Parasite densities were higher in primigravidae. Fever was more frequently detected among the infected women. No statistically significant association between P. falciparum infection and haemoglobin levels or insecticide-treated net use was found. While high prevalence of genetic polymorphisms associated with chloroquine and amodiaquine resistance were detected, no molecular markers of artemisinin resistance were observed. CONCLUSION Plasmodium falciparum infections are expected to occur in at least one in every eight women attending first ANC at private clinics in Monrovia and outside the peak of the rainy season. Young primigravidae are at increased risk of P. falciparum infection. Molecular analyses did not provide evidence of resistance to artemisinins among the P. falciparum isolates tested. Further epidemiological studies involving pregnant women are necessary to describe the risk of malaria in this highly susceptible group outside Monrovia, as well as to closely monitor the emergence of resistance to anti-malarials, as recommended by the Liberian National Malaria Control Programme.
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Affiliation(s)
- Guillermo Martínez-Pérez
- ISGlobal, Hospital Clínic-Universitat de Barcelona, Barcelona, Spain. .,Saint Joseph's Catholic Hospital, Oldest Congo Town, PO Box 10-512, 1100, Monrovia, Liberia.
| | - Dawoh Peter Lansana
- Saint Joseph's Catholic Hospital, Oldest Congo Town, PO Box 10-512, 1100, Monrovia, Liberia
| | - Senga Omeonga
- Saint Joseph's Catholic Hospital, Oldest Congo Town, PO Box 10-512, 1100, Monrovia, Liberia
| | - Himanshu Gupta
- ISGlobal, Hospital Clínic-Universitat de Barcelona, Barcelona, Spain
| | - Bondey Breeze-Barry
- Saint Joseph's Catholic Hospital, Oldest Congo Town, PO Box 10-512, 1100, Monrovia, Liberia
| | - Raquel González
- ISGlobal, Hospital Clínic-Universitat de Barcelona, Barcelona, Spain
| | - Azucena Bardají
- ISGlobal, Hospital Clínic-Universitat de Barcelona, Barcelona, Spain
| | - Adelaida Sarukhan
- ISGlobal, Hospital Clínic-Universitat de Barcelona, Barcelona, Spain
| | - James D K Goteh
- Liberia Medicines and Health Products Regulatory Authority, Monrovia, Liberia
| | - Edith Tody
- Saint Joseph's Catholic Hospital, Oldest Congo Town, PO Box 10-512, 1100, Monrovia, Liberia
| | - Pau Cisteró
- ISGlobal, Hospital Clínic-Universitat de Barcelona, Barcelona, Spain
| | - Benard Benda
- Saint Joseph's Catholic Hospital, Oldest Congo Town, PO Box 10-512, 1100, Monrovia, Liberia
| | - Juwe D Kercula
- Liberia Medicines and Health Products Regulatory Authority, Monrovia, Liberia
| | - Fanta D Kibungu
- Saint Joseph's Catholic Hospital, Oldest Congo Town, PO Box 10-512, 1100, Monrovia, Liberia
| | | | - Quique Bassat
- ISGlobal, Hospital Clínic-Universitat de Barcelona, Barcelona, Spain.,Centro de Investigação em Saúde de Manhiça (CISM), Maputo, Mozambique.,ICREA, Pg. Lluís Companys 23, 08010, Barcelona, Spain.,Pediatrics Infectious Diseases Unit, Pediatrics Department, Hospital Sant Joan de Déu (University of Barcelona), Barcelona, Spain
| | - Christine K Tarr-Attia
- Saint Joseph's Catholic Hospital, Oldest Congo Town, PO Box 10-512, 1100, Monrovia, Liberia
| | - Alfredo Mayor
- ISGlobal, Hospital Clínic-Universitat de Barcelona, Barcelona, Spain.,Centro de Investigação em Saúde de Manhiça (CISM), Maputo, Mozambique
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15
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Theuring S, Koroma AP, Harms G. "In the hospital, there will be nobody to pamper me": a qualitative assessment on barriers to facility-based delivery in post-Ebola Sierra Leone. Reprod Health 2018; 15:155. [PMID: 30219070 PMCID: PMC6139160 DOI: 10.1186/s12978-018-0601-9] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2018] [Accepted: 09/11/2018] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Sierra Leone has one of the highest maternal mortality rates in the world. Encouraging the use of skilled birth attendance in health facilities is an important step in the endeavor to increase the number of safe deliveries. However, public trust in health facilities has been greatly damaged during the Ebola epidemic outbreak in Sierra Leone in 2014/2015, and little is known about external and intrinsic barriers to facility-based delivery (FBD) in the country since the end of the Ebola epidemic. METHODS We conducted a qualitative study on FBD in Princess Christian Maternity Hospital, Freetown, which is the national referral maternity hospital in Sierra Leone. We performed six focus group discussions with providers, pregnant women and recent mothers surrounding experiences, attitudes and behaviors regarding FBD and potential barriers. Discussions were tape recorded, transcribed and evaluated through content analysis. RESULTS Women in our study were overall technically aware of the higher safety linked with FBD, but this often diverged from their individual desire to deliver in a supportive and trusted social and traditional environment. Close relatives and community members seemed to be highly influencial regarding birth practices. Many women associated FBD with negative staff attitudes and an undefined fear. Logistic issues regarding transportation problems or late referral from smaller health centers were identified as frequent barriers to FBD. CONCLUSIONS More supportive staff attitudes and acceptance of an accompanying person throughout delivery could be promising approaches to increase women's confidence in FBDs. However, these approaches also imply revising health systems structures, like staff working conditions that are conducive for a friendly atmosphere, sufficient space in delivery wards allowing the women to bring a birth companion, or like the establishment of a reliable peripheral ambulance system to ensure transportation and fast referral.
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Affiliation(s)
- Stefanie Theuring
- Institute of Tropical Medicine and International Health, Charité- Universitätsmedizin, Augustenburger Platz 1, 13353, Berlin, Germany.
| | - Alimamy Philip Koroma
- Department of Obstetrics and Gynecology, Princess Christian Maternity Hospital, Freetown, Sierra Leone
| | - Gundel Harms
- Institute of Tropical Medicine and International Health, Charité- Universitätsmedizin, Augustenburger Platz 1, 13353, Berlin, Germany
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16
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Henwood PC, Bebell LM, Roshania R, Wolfman V, Mallow M, Kalyanpur A, Levine AC. Ebola Virus Disease and Pregnancy: A Retrospective Cohort Study of Patients Managed at 5 Ebola Treatment Units in West Africa. Clin Infect Dis 2018; 65:292-299. [PMID: 28379374 PMCID: PMC5850452 DOI: 10.1093/cid/cix290] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2016] [Accepted: 03/29/2017] [Indexed: 11/14/2022] Open
Abstract
Background. Reliable data are lacking on pregnancy outcomes during Ebola virus disease (EVD) epidemics. We aimed to characterize symptoms and outcomes among pregnant women admitted to Ebola treatment units (ETUs) with suspected and confirmed EVD to better inform obstetric management. Methods. We analyzed a retrospective cohort of reproductive-aged women presenting to 5 West African ETUs from September 2014 to September 2015. We compared clinical symptoms, risk of EVD diagnosis, and mortality between pregnant and nonpregnant women. Results. Of 729 reproductive-aged women admitted to study ETUs, 44 (6%) reported pregnancy. Thirteen of 44 pregnant women (30%) tested EVD positive; 6 of 13 (46%) died. Pregnant women were less likely than nonpregnant women to report anorexia, asthenia, diarrhea, fever, myalgias/arthralgias, nausea, or vomiting (P < .05) at admission. Pregnant women with suspected EVD had the same risk, however, of laboratory-confirmed EVD (30% vs 24%, P = .38). While pregnant women with confirmed EVD had similar Ebola viral loads on presentation to nonpregnant women, as measured by initial cycle threshold (26.4 vs 23.2, P = .16), they were less likely to have myalgias/arthralgias (P< .001) and vomiting (P = .02). Both all-cause mortality (14% vs 19%, P = .39) and EVD-specific mortality (46% vs 54%, P = .60) were not significantly different between pregnant and nonpregnant women. Two neonates born live in the ETU died within 8 days. Conclusions. We find no evidence to support a difference in the risk of death between pregnant women with suspected or confirmed EVD compared to nonpregnant women. Limited data suggest poor fetal and neonatal outcomes in EVD-affected pregnancies.
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Affiliation(s)
- Patricia C Henwood
- Department of Emergency Medicine, Brigham and Women's Hospital/Harvard Medical School, Boston, Massachusetts.,International Medical Corps, Los Angeles, California
| | - Lisa M Bebell
- Division of Infectious Diseases, Department of Medicine, Massachusetts General Hospital, and Massachusetts General Hospital Center for Global Health, Boston
| | | | | | | | | | - Adam C Levine
- International Medical Corps, Los Angeles, California.,Department of Emergency Medicine, Warren Alpert Medical School, Brown University, Providence, Rhode Island
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17
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Wagenaar BH, Augusto O, Beste J, Toomay SJ, Wickett E, Dunbar N, Bawo L, Wesseh CS. The 2014-2015 Ebola virus disease outbreak and primary healthcare delivery in Liberia: Time-series analyses for 2010-2016. PLoS Med 2018; 15:e1002508. [PMID: 29462138 PMCID: PMC5819774 DOI: 10.1371/journal.pmed.1002508] [Citation(s) in RCA: 66] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2017] [Accepted: 01/16/2018] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND The aim of this study is to estimate the immediate and lasting effects of the 2014-2015 Ebola virus disease (EVD) outbreak on public-sector primary healthcare delivery in Liberia using 7 years of comprehensive routine health information system data. METHODS AND FINDINGS We analyzed 10 key primary healthcare indicators before, during, and after the EVD outbreak using 31,836 facility-month service outputs from 1 January 2010 to 31 December 2016 across a census of 379 public-sector health facilities in Liberia (excluding Montserrado County). All indicators had statistically significant decreases during the first 4 months of the EVD outbreak, with all indicators having their lowest raw mean outputs in August 2014. Decreases in outputs comparing the end of the initial EVD period (September 2014) to May 2014 (pre-EVD) ranged in magnitude from a 67.3% decrease in measles vaccinations (95% CI: -77.9%, -56.8%, p < 0.001) and a 61.4% decrease in artemisinin-based combination therapy (ACT) treatments for malaria (95% CI: -69.0%, -53.8%, p < 0.001) to a 35.2% decrease in first antenatal care (ANC) visits (95% CI: -45.8%, -24.7%, p < 0.001) and a 38.5% decrease in medroxyprogesterone acetate doses (95% CI: -47.6%, -29.5%, p < 0.001). Following the nadir of system outputs in August 2014, all indicators showed statistically significant increases from October 2014 to December 2014. All indicators had significant positive trends during the post-EVD period, with every system output exceeding pre-Ebola forecasted trends for 3 consecutive months by November 2016. Health system outputs lost during and after the EVD outbreak were large and sustained for most indicators. Prior to exceeding pre-EVD forecasted trends for 3 months, we estimate statistically significant cumulative losses of -776,110 clinic visits (95% CI: -1,480,896, -101,357, p = 0.030); -24,449 bacille Calmette-Guérin vaccinations (95% CI: -45,947, -2,020, p = 0.032); -9,129 measles vaccinations (95% CI: -12,312, -5,659, p < 0.001); -17,191 postnatal care (PNC) visits within 6 weeks of birth (95% CI: -28,344, -5,775, p = 0.002); and -101,857 ACT malaria treatments (95% CI: -205,839, -2,139, p = 0.044) due to the EVD outbreak. Other outputs showed statistically significant cumulative losses only through December 2014, including losses of -12,941 first pentavalent vaccinations (95% CI: -20,309, -5,527, p = 0.002); -5,122 institutional births (95% CI: -8,767, -1,234, p = 0.003); and -45,024 acute respiratory infections treated (95% CI: -66,185, -24,019, p < 0.001). Compared to pre-EVD forecasted trends, medroxyprogesterone acetate doses and first ANC visits did not show statistically significant net losses. ACT treatment for malaria was the only indicator with an estimated net increase in system outputs through December 2016, showing an excess of +78,583 outputs (95% CI: -309,417, +450,661, p = 0.634) compared to pre-EVD forecasted trends, although this increase was not statistically significant. However, comparing December 2013 to December 2017, ACT malaria cases have increased 49.2% (95% CI: 33.9%, 64.5%, p < 0.001). Compared to pre-EVD forecasted trends, there remains a statistically significant loss of -15,144 PNC visits within 6 weeks (95% CI: -29,453, -787, p = 0.040) through December 2016. CONCLUSIONS The Liberian public-sector primary healthcare system has made strides towards recovery from the 2014-2015 EVD outbreak. All primary healthcare indicators tracked have recovered to pre-EVD levels as of November 2016. Yet, for most indicators, it took more than 1 year to recover to pre-EVD levels. During this time, large losses of essential primary healthcare services occurred compared to what would have been expected had the EVD outbreak not occurred. The disruption of malaria case management during the EVD outbreak may have resulted in increased malaria cases. Large and sustained investments in public-sector primary care health system strengthening are urgently needed for EVD-affected countries.
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Affiliation(s)
- Bradley H. Wagenaar
- Department of Global Health, University of Washington, Seattle, Washington, United States of America
- Partners in Health, Monrovia, Liberia
- Health Alliance International, Seattle, Washington, United States of America
- * E-mail:
| | - Orvalho Augusto
- Department of Global Health, University of Washington, Seattle, Washington, United States of America
- Health Alliance International, Seattle, Washington, United States of America
- Universidade Eduardo Mondlane, Maputo, Mozambique
| | - Jason Beste
- Partners in Health, Monrovia, Liberia
- Brigham and Women’s Hospital, Boston, Massachusetts, United States of America
- Harvard Medical School, Boston, Massachusetts, United States of America
| | | | | | | | - Luke Bawo
- Ministry of Health, Monrovia, Liberia
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18
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Luckow PW, Kenny A, White E, Ballard M, Dorr L, Erlandson K, Grant B, Johnson A, Lorenzen B, Mukherjee S, Ly EJ, McDaniel A, Nowine N, Sathananthan V, Sechler GA, Kraemer JD, Siedner MJ, Panjabi R. Implementation research on community health workers' provision of maternal and child health services in rural Liberia. Bull World Health Organ 2017; 95:113-120. [PMID: 28250511 PMCID: PMC5327932 DOI: 10.2471/blt.16.175513] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2016] [Revised: 10/07/2016] [Accepted: 10/09/2016] [Indexed: 12/02/2022] Open
Abstract
Objective To assess changes in the use of essential maternal and child health services in Konobo, Liberia, after implementation of an enhanced community health worker (CHW) programme. Methods The Liberian Ministry of Health partnered with Last Mile Health, a nongovernmental organization, to implement a pilot CHW programme with enhanced recruitment, training, supervision and compensation. To assess changes in maternal and child health-care use, we conducted repeated cross-sectional cluster surveys before (2012) and after (2015) programme implementation. Findings Between 2012 and 2015, 54 CHWs, seven peer supervisors and three clinical supervisors were trained to serve a population of 12 127 people in 44 communities. The regression-adjusted percentage of children receiving care from formal care providers increased by 60.1 (95% confidence interval, CI: 51.6 to 68.7) percentage points for diarrhoea, by 30.6 (95% CI: 20.5 to 40.7) for fever and by 51.2 (95% CI: 37.9 to 64.5) for acute respiratory infection. Facility-based delivery increased by 28.2 points (95% CI: 20.3 to 36.1). Facility-based delivery and formal sector care for acute respiratory infection and diarrhoea increased more in agricultural than gold-mining communities. Receipt of one-or-more antenatal care sessions at a health facility and postnatal care within 24 hours of delivery did not change significantly. Conclusion We identified significant increases in uptake of child and maternal health-care services from formal providers during the pilot CHW programme in remote rural Liberia. Clinic-based services, such as postnatal care, and services in specific settings, such as mining areas, require additional interventions to achieve optimal outcomes.
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Affiliation(s)
- Peter W Luckow
- Geisel School of Medicine at Dartmouth College, Hanover, United States of America (USA)
| | | | | | - Madeleine Ballard
- Department of Social Policy and Intervention, University of Oxford, Oxford, England
| | | | | | | | | | | | | | | | | | - Netus Nowine
- Grand Gedeh County Health Team, Ministry of Health, Monrovia, Liberia
| | | | - Gerald A Sechler
- Division of Global Health Equity, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Boston, MA, 02115, USA
| | - John D Kraemer
- Department of Health Systems Administration, Georgetown School of Nursing and Health Studies, Washington, USA
| | - Mark J Siedner
- Department of Medicine, Harvard Medical School, Boston, USA
| | - Rajesh Panjabi
- Division of Global Health Equity, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Boston, MA, 02115, USA
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19
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Caulker VML, Mishra S, van Griensven J, Moosa A, Najjemba R, Shringarpure K, Chan AK. Life goes on: the resilience of maternal primary care during the Ebola outbreak in rural Sierra Leone. Public Health Action 2017; 7:S40-S46. [PMID: 28744438 DOI: 10.5588/pha.16.0083] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2016] [Accepted: 01/09/2017] [Indexed: 11/10/2022] Open
Abstract
Setting: All 100 health facilities providing maternal services in Moyamba, Sierra Leone, a rural district that experienced a smaller Ebola outbreak than other areas. Objective: To compare trends in antenatal care (the first and fourth visit [ANC1 and ANC4]), delivery, and postnatal care (PNC1) service utilisation before, during and after the Ebola outbreak (2014-2016). Design: Cross-sectional study using secondary programme data. Results: A total of 211 Ebola cases occurred in Moyamba District. The mean number of monthly ANC visits remained stable over time, except for the subset of care provided via outreach visits where, compared with before the outbreak (n = 390), ANC1 visits declined during (n = 331, P = 0.002) and after the outbreak (n = 342, P = 0.03). Most (>97%) deliveries occurred in health facilities, assisted by maternal and child health aides (>80%). During the outbreak, the mean number of community-based deliveries per month declined from 31 to 21 (P = 0.03), and the mean number of deliveries performed by midwives increased from 49 to 78 (P < 0.001) compared with before the outbreak. Before, during and after Ebola, there was no significant change in the mean number of live births (respectively n = 1134, n = 1110, n = 1162), maternal PNC1 (respectively n = 1110, n = 1105, n = 1165) or neonatal PNC1 (respectively n = 1028, n = 1050, n = 1085). Conclusion: In a rural district less affected by Ebola transmission than other areas, utilisation of maternal primary care remained robust, despite the outbreak.
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Affiliation(s)
- V M L Caulker
- District Health Management Team, Ministry of Health and Sanitation, Moyamba District, Moyamba, Sierra Leone
| | - S Mishra
- Division of Infectious Diseases, Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | | | - A Moosa
- District Health Management Team, Ministry of Health and Sanitation, Moyamba District, Moyamba, Sierra Leone
| | - R Najjemba
- Makerere University College of Health Sciences, Kampala, Uganda
| | - K Shringarpure
- Preventive and Social Medicine, Baroda Medical College, Vadodara, India
| | - A K Chan
- Division of Infectious Diseases, Department of Medicine, University of Toronto, Toronto, Ontario, Canada.,Dignitas International, Zomba, Malawi
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Kamara MH, Najjemba R, van Griensven J, Yorpoi D, Jimissa AS, Chan AK, Mishra S. Increase in acute malnutrition in children following the 2014-2015 Ebola outbreak in rural Sierra Leone. Public Health Action 2017; 7:S27-S33. [PMID: 28744436 PMCID: PMC5515560 DOI: 10.5588/pha.16.0084] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2016] [Accepted: 12/05/2016] [Indexed: 02/02/2023] Open
Abstract
Setting: All health facility and community malnutrition screening programmes in Tonkolili, a rural Ebola-affected district in Sierra Leone. Objectives: Before the Ebola disease outbreak, Sierra Leone had set a goal to reduce the prevalence of severe acute malnutrition (SAM) in children aged <5 years to <0.2%. We compared the number of children screened, diagnosed and treated for malnutrition before, during and after the outbreak (2013-2016). Design: This was a retrospective cross-sectional study. Results: Health facility screening declined from 16 805 children per month pre-outbreak to 13 510 during the outbreak (P = 0.02), and returned to pre-outbreak levels after the outbreak. Community-based screening remained stable during the outbreak, and increased by 30% post-outbreak (P < 0.001). The proportion diagnosed with moderate acute malnutrition using mid-upper arm circumference increased from respectively 3.6% and 5.1% pre-outbreak in the community and health facilities to 8.2% and 7.9% post-outbreak (P < 0.001, P = 0.003). The proportion of children diagnosed with SAM using a weight-for-age ratio at health facilities increased from 1.5% pre-outbreak to 3.5% post-outbreak (P = 0.003). On average, for every four children diagnosed with SAM per month, one child completed SAM treatment. Conclusion: After a decline in screening during the Ebola outbreak, diagnoses of acute malnutrition increased post-outbreak. Nutrition programmes need to be strengthened to pre-empt such effects in the event of future Ebola outbreaks.
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Affiliation(s)
- M H Kamara
- Sierra Leone Ministry of Health and Sanitation, Magburaka, Sierra Leone
| | - R Najjemba
- School of Public Health, Makerere College of Health Sciences, Kampala, Uganda
| | | | - D Yorpoi
- Sierra Leone Ministry of Health and Sanitation, Magburaka, Sierra Leone
| | - A S Jimissa
- Sierra Leone Ministry of Health and Sanitation, Magburaka, Sierra Leone
| | - A K Chan
- Dignitas International, Zomba, Malawi
- Division of Infectious Diseases, Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - S Mishra
- Division of Infectious Diseases, Department of Medicine, University of Toronto, Toronto, Ontario, Canada
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Shannon FQ, Horace-Kwemi E, Najjemba R, Owiti P, Edwards J, Shringarpure K, Bhat P, Kateh FN. Effects of the 2014 Ebola outbreak on antenatal care and delivery outcomes in Liberia: a nationwide analysis. Public Health Action 2017; 7:S88-S93. [PMID: 28744445 DOI: 10.5588/pha.16.0099] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2016] [Accepted: 01/31/2017] [Indexed: 11/10/2022] Open
Abstract
Setting: All health facilities, public and private, in Liberia, West Africa. Objectives: To determine access to antenatal care (ANC), deliveries and their outcomes before, during and after the 2014-2015 Ebola outbreak. Design: This was a descriptive cross-sectional study. Result: During the Ebola outbreak in Liberia, overall monthly reporting from health facilities plunged by 43%. Access to ANC declined by 50% and reported deliveries fell by one third during the outbreak. Reported deliveries by skilled attendants and Caesarian section declined by respectively 32% and 60%. Facility-based deliveries dropped by 35% and reported community deliveries fell by 47%. There was an overall decline in reported stillbirths, maternal and neonatal deaths, by 50%, during the outbreak. ANC, reported deliveries and related outcomes returned to pre-outbreak levels within one year following the outbreak. Conclusion: The Liberian health system was considerably weakened during the Ebola outbreak and had difficulties providing basic maternal health services. In the light of the major reporting gaps during the Ebola period, and the reduced use of health facilities for maternal care, these findings highlight the need for measures to avoid such disruptions during future outbreaks.
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Affiliation(s)
| | | | - R Najjemba
- Makerere University College of Health Sciences, Kampala, Uganda
| | - P Owiti
- Academic Model Providing Access to Healthcare (AMPATH), Eldoret, Kenya.,International Union Against Tuberculosis and Lung Disease, Paris, France
| | - J Edwards
- Operational Research Unit (LUXOR), Médecins Sans Frontières, Brussels Operational Centre, Brussels, Belgium.,Johns Hopkins University, School of Public Health, Baltimore, Maryland, USA
| | | | - P Bhat
- Ministry of Health, Government of Karnataka, India
| | - F N Kateh
- Ministry of Health, Monrovia, Liberia
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22
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Lori JR, Munro-Kramer ML, Shifman J, Amarah PNM, Williams G. Patient Satisfaction With Maternity Waiting Homes in Liberia: A Case Study During the Ebola Outbreak. J Midwifery Womens Health 2017; 62:163-171. [PMID: 28376559 DOI: 10.1111/jmwh.12600] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2016] [Revised: 10/26/2016] [Accepted: 11/14/2016] [Indexed: 11/30/2022]
Abstract
INTRODUCTION Liberia in West Africa has one of the highest maternal mortality ratios in the world (990/100,000 live births). Many women in Liberia live in rural, remote villages with little access to safe maternity services. The World Health Organization has identified maternity waiting homes (MWHs) as one strategy to minimize the barrier of distance in accessing a skilled birth attendant. However, limited data exist on satisfaction with MWHs or maternal health care in Liberia. METHODS This mixed-methods case study examines women's satisfaction with their stay at a MWH and compares utilization rates before and during the Ebola outbreak. From 2012 to 2014, 650 women who stayed at one of 6 MWHs in rural Liberia during the perinatal or postnatal period were surveyed. Additionally, 60 semi-structured interviews were conducted with traditional providers, skilled birth attendants, and women utilizing the MWHs. Quantitative analyses assessed satisfaction rates before and during the Ebola outbreak. Content analysis of semi-structured interviews supplemented the quantitative data and provided a lens into the elements of satisfaction with the MWHs. RESULTS The majority of women who utilized the MWHs stated they would suggest the MWH to a friend or relative who was pregnant (99.5%), and nearly all would utilize the home again (98.8%). Although satisfaction with the MWHs significantly decreased during the Ebola outbreak (P < .001), participants were satisfied overall with the MWHs. Content analysis identified areas of satisfaction that encompassed the themes of restful and supportive environment as well as areas for improvement such as lacking necessary resources and loneliness. DISCUSSION This case study demonstrated that women using MWHs in Bong County, Liberia are generally satisfied with their experience and plan to use an MWH again during future pregnancies to access a skilled birth attendant for birth. Women are also willing to encourage family and friends to use MWHs.
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23
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Delamou A, Ayadi AME, Sidibe S, Delvaux T, Camara BS, Sandouno SD, Beavogui AH, Rutherford GW, Okumura J, Zhang WH, De Brouwere V. Effect of Ebola virus disease on maternal and child health services in Guinea: a retrospective observational cohort study. LANCET GLOBAL HEALTH 2017; 5:e448-e457. [PMID: 28237252 PMCID: PMC6530984 DOI: 10.1016/s2214-109x(17)30078-5] [Citation(s) in RCA: 129] [Impact Index Per Article: 18.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/13/2016] [Revised: 01/11/2017] [Accepted: 01/23/2017] [Indexed: 12/02/2022]
Abstract
Background The 2014 west African epidemic of Ebola virus disease posed a major threat to the health systems of the countries affected. We sought to quantify the consequences of Ebola virus disease on maternal and child health services in the highly-affected Forest region of Guinea. Methods We did a retrospective, observational cohort study of women and children attending public health facilities for antenatal care, institutional delivery, and immunisation services in six of seven health districts in the Forest region (Beyla, Guéckédou, Kissidougou, Lola, Macenta, and N’Zérékoré). We examined monthly service use data for eight maternal and child health services indicators: antenatal care (≥1 antenatal care visit and ≥3 antenatal care visits), institutional delivery, and receipt of five infant vaccines: polio, pentavalent (diphtheria, tetanus, pertussis, hepatitis B virus, and Haemophilus influenzae type b), yellow fever, measles, and tuberculosis. We used interrupted time series models to estimate trends in each indicator across three time periods: pre-Ebola virus disease epidemic (January, 2013, to February, 2014), during-epidemic (March, 2014, to February, 2015) and post-epidemic (March, 2015, to Feb, 2016). We used segmented ordinary least-squares (OLS) regression using Newey-West standard errors to accommodate for serial autocorrelation, and adjusted for any potential effect of birth seasonality on our outcomes. Findings In the months before the Ebola virus disease outbreak, all three maternal indicators showed a significantly positive change in trend, ranging from a monthly average increase of 61 (95% CI 38–84) institutional deliveries to 119 (95% CI 79–158) women achieving at least three antenatal care visits. These increasing trends were reversed during the epidemic: fewer institutional deliveries occurred (–240, 95% CI −293 to −187), and fewer women achieved at least one antenatal care visit (–418, 95% CI −535 to −300) or at least three antenatal care visits (–363, 95% CI −485 to −242) per month (p<0·0001 for all). Compared with the negative trend during the outbreak, the change in trend during the post-outbreak period showed that 173 more women per month (95% CI 51–294; p=0·0074) had at least one antenatal care visit, 257 more (95% CI 117–398; p=0·0010) had at least three antenatal care visits and 149 more (95% CI 91–206; p<0·0001) had institutional deliveries. However, although the numbers for these indicators increased in the post-epidemic period, the trends for all stagnated. Similarly, the increasing trend in child vaccination completion during the pre-epidemic period was followed by significant immediate and trend reductions across most vaccine types. Before the outbreak, the number of children younger than 12 months who had completed each vaccination ranged from 5752 (95% CI 2821–8682) for tuberculosis to 8043 (95% CI 7621–8464) for yellow fever. Immediately after the outbreak, significant reductions occurred in the level of all vaccinations except for yellow fever for which the reduction was marginal. The greatest reductions were noted for polio and tuberculosis at −3594 (95% CI −4811 to −2377; p<0·0001) and −3048 (95% CI −5879 to −216; p=0·0362) fewer vaccines administered, respectively. Compared with pre-Ebola virus disease outbreak trends, significant decreases occurred for all vaccines except polio, with the trend of monthly decreases in the number of children vaccinated ranging from −419 (95% CI −683 to −155; p=0·0034) fewer for BCG to −313 (95% CI–446 to −179; p<0·0001) fewer for pentavalent during the outbreak. In the post-Ebola virus disease outbreak period, vaccination coverage for polio, measles, and yellow fever continued to decrease, whereas the trend in coverage for tuberculosis and pentavalent did not significantly differ from zero. Interpretation Most maternal and child health indicators significantly declined during the Ebola virus disease outbreak in 2014. Despite a reduction in this negative trend in the post-outbreak period, the use of essential maternal and child health services have not recovered to their pre-outbreak levels, nor are they all on a course that suggests that they will recover without targeted interventions.
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Affiliation(s)
- Alexandre Delamou
- Department of Public Health, Gamal University of Conakry, Conakry, Guinea; Centre national de formation et de recherche en santé rurale de Maferinyah, Forécariah, Guinea; Woman and Child Health Research Centre, Institute of Tropical Medicine, Antwerp, Belgium.
| | - Alison M El Ayadi
- University of California, Bixby Center for Global Reproductive Health, San Francisco, CA, USA
| | - Sidikiba Sidibe
- Department of Public Health, Gamal University of Conakry, Conakry, Guinea; Centre national de formation et de recherche en santé rurale de Maferinyah, Forécariah, Guinea
| | - Therese Delvaux
- Woman and Child Health Research Centre, Institute of Tropical Medicine, Antwerp, Belgium
| | - Bienvenu S Camara
- Centre national de formation et de recherche en santé rurale de Maferinyah, Forécariah, Guinea
| | - Sah D Sandouno
- Department of Public Health, Gamal University of Conakry, Conakry, Guinea
| | - Abdoul H Beavogui
- Centre national de formation et de recherche en santé rurale de Maferinyah, Forécariah, Guinea
| | - Georges W Rutherford
- Global Health Sciences, Department of Epidemiology and Biostatistics, University of California, San Francisco, CA, USA
| | - Junko Okumura
- Institute of Tropical Medicine, Nagasaki University, Nagasaki, Japan
| | - Wei-Hong Zhang
- Ecole de Santé Publique, Université libre de Bruxelles (ULB), Brussels, Belgium
| | - Vincent De Brouwere
- Woman and Child Health Research Centre, Institute of Tropical Medicine, Antwerp, Belgium
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"Ebola kills generations": Qualitative discussions with Liberian healthcare providers. Midwifery 2016; 45:44-49. [PMID: 27998827 DOI: 10.1016/j.midw.2016.12.005] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2016] [Revised: 12/04/2016] [Accepted: 12/08/2016] [Indexed: 11/23/2022]
Abstract
OBJECTIVE the purpose of this study was to explore healthcare providers' perceptions and reactions to the Ebola Virus Disease (EVD) epidemic. DESIGN a descriptive, qualitative study design was employed. Focus groups were conducted with Liberian healthcare providers who participated in care of patients with EVD. SETTING the study was conducted in Bong County, Liberia (population: 333,000), which was severely affected, with over 650 reported cases and close to 200 deaths by the end of 2015. PARTICIPANTS the total sample of 58 participants, included 11 nurses, ten traditional birth attendants (TBAs), four midwives, 28 general community health volunteers, three physician assistants, one community member and one pharmacy dispenser. MEASUREMENTS AND FINDINGS five core themes related to changes in healthcare practices and interactions since the EVD outbreak were identified based on the results of the focus groups; fear, stigma, resource constraints, lack of knowledge and training, and shifting cultural practices. KEY CONCLUSIONS this work represents a preliminary understanding of Liberian healthcare workers reactions to the EVD epidemic, and highlights the significant issues they faced as they attempted to care for patients and protect themselves. IMPLICATIONS FOR PRACTICE while the EVD epidemic has been declared over, preparedness activities for future disease outbreaks must continue. This study can inform future healthcare policy initiatives as well as preparedness activities targeted towards healthcare workers in low resource settings.
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Elston JWT, Cartwright C, Ndumbi P, Wright J. The health impact of the 2014-15 Ebola outbreak. Public Health 2016; 143:60-70. [PMID: 28159028 DOI: 10.1016/j.puhe.2016.10.020] [Citation(s) in RCA: 193] [Impact Index Per Article: 24.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2016] [Revised: 10/14/2016] [Accepted: 10/17/2016] [Indexed: 11/25/2022]
Abstract
OBJECTIVES The 2014-15 outbreak in West Africa was the largest and deadliest Ebola outbreak recorded; however, there remains uncertainty over its wider health consequences. Our objective was to provide a comprehensive overview of the impact of the Ebola outbreak on population health in the three most affected countries: Sierra Leone, Liberia and Guinea. STUDY DESIGN Narrative review. METHODS A narrative overview of the peer-reviewed and grey literature related to the impact and consequences of the Ebola outbreak was conducted, synthesizing the findings of literature retrieved from a structured search of biomedical databases, the Web and references of reviewed articles. RESULTS The impact of the Ebola outbreak was profound and multifaceted. The health system was severely compromised due to overwhelming demand, healthcare workers deaths, resource diversion and closure of health facilities. Fear of Ebola and healthcare workers led to a breakdown in trust in health systems. Access to healthcare was compromised. Substantial reductions in healthcare utilization were reported including over 80% reductions in maternal delivery care in Ebola-affected areas, 40% national reductions in malaria admissions among children <5 years and substantial reductions in vaccination coverage. Socio-economic impacts included reduced community cohesion, education loss, reduced child protection, widespread job losses and food insecurity. Increased morbidity and mortality and reduced expected life expectancy were reported. CONCLUSIONS This review highlights the scope and scale of the consequences of the Ebola outbreak on population health. Sustained commitment of the international community is required to support health system re-building and to urgently address unmet population health needs.
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Affiliation(s)
- J W T Elston
- Field Epidemiology Training Programme, Public Health England, Blenheim House, Duncombe Street, Leeds, LS1 4PL, UK; Health Education Yorkshire and the Humber, Willow Terrace Road, University of Leeds, Leeds, LS2 9JT, UK.
| | - C Cartwright
- Health Education Yorkshire and the Humber, Willow Terrace Road, University of Leeds, Leeds, LS2 9JT, UK
| | - P Ndumbi
- European Programme for Intervention Epidemiology Training (EPIET), Instituto de Salud Carlos III, Madrid, 28029, Spain
| | - J Wright
- Bradford Institute for Health Research, Bradford Royal Infirmary, Temple Bank House, Duckworth Lane, Bradford, BD9 6RJ, UK
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Ansumana R, Keitell S, Roberts GMT, Ntoumi F, Petersen E, Ippolito G, Zumla A. Impact of infectious disease epidemics on tuberculosis diagnostic, management, and prevention services: experiences and lessons from the 2014-2015 Ebola virus disease outbreak in West Africa. Int J Infect Dis 2016; 56:101-104. [PMID: 27818362 PMCID: PMC7110799 DOI: 10.1016/j.ijid.2016.10.010] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2016] [Accepted: 10/17/2016] [Indexed: 12/19/2022] Open
Abstract
Twenty-eight percent of the world's 9.6 million new tuberculosis (TB) cases are in the World Health Organization Africa Region. The Mano River Union (MRU) countries of West Africa have made incremental investments into TB control programs over the past two decades. The devastating 2014–2015 Ebola virus disease (EVD) outbreak in Guinea, Liberia, and Sierra Leone had a significant impact on all sectors of the healthcare system, including TB prevention and control programs. Vaccination of the under-fives for TB with BCG was adversely affected by the EVD epidemic, and the deaths of numerous healthcare workers deprived the weak healthcare systems of much needed human resources. There is an urgent need to improve the ability of countries and regions to sustain functioning health systems during outbreaks so that other disease control programs (like those for TB, malaria, and HIV) are not compromised during the emergency measures of a severe epidemic.
The World Health Organization (WHO) Global Tuberculosis Report 2015 states that 28% of the world's 9.6 million new tuberculosis (TB) cases are in the WHO Africa Region. The Mano River Union (MRU) countries of West Africa–Guinea, Sierra Leone, and Liberia–have made incremental sustained investments into TB control programmes over the past two decades. The devastating Ebola virus disease (EVD) outbreak of 2014–2015 in West Africa impacted significantly on all sectors of the healthcare systems in the MRU countries, including the TB prevention and control programmes. The EVD outbreak also had an adverse impact on the healthcare workforce and healthcare service delivery. At the height of the EVD outbreak, numerous staff members in all MRU countries contracted EBV at the Ebola treatment units and died. Many healthcare workers were also infected in healthcare facilities that were not Ebola treatment units but were national hospitals and peripheral health units that were unprepared for receiving patients with EVD. In all three MRU countries, the disruption to TB services due to the EVD epidemic will no doubt have increased Mycobacterium tuberculosis transmission, TB morbidity and mortality, and decreased patient adherence to TB treatment, and the likely impact will not be known for several years to come. In this viewpoint, the impact that the EVD outbreak had on TB diagnostic, management, and prevention services is described. Vaccination against TB with BCG in children under 5 years of age was affected adversely by the EVD epidemic. The EVD outbreak was a result of global failure and represents yet another ‘wake-up call’ to the international community, and particularly to African governments, to reach a consensus on new ways of thinking at the national, regional, and global levels for building healthcare systems that can sustain their function during outbreaks. This is necessary so that other disease control programmes (like those for TB, malaria, and HIV) are not compromised during the emergency measures of a severe epidemic.
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Affiliation(s)
- Rashid Ansumana
- Mercy Hospital Research Laboratory, Kulanda Town, Bo, Sierra Leone; Department of Community Health and Clinical Studies, Njala University, Kowama Campus, Bo, Sierra Leone.
| | - Samuel Keitell
- Department of Community Health and Clinical Studies, Njala University, Kowama Campus, Bo, Sierra Leone
| | - Gregory M T Roberts
- Department of Community Health and Clinical Studies, Njala University, Kowama Campus, Bo, Sierra Leone
| | - Francine Ntoumi
- Fondation Congolaise pour la Recherche Médicale, Brazzaville, Republic of Congo; Institute for Tropical Medicine, University of Tübingen, Tübingen, Germany
| | - Eskild Petersen
- Institute of Clinical Medicine, University of Aarhus, Aarhus, Denmark; The Royal Hospital, Muscat, Oman
| | - Giuseppe Ippolito
- Lazzaro Spallanzani National Institute for Infectious Diseases, IRCCS, Rome, Italy
| | - Alimuddin Zumla
- Centre for Clinical Microbiology, Division of Infection and Immunity, University College London, and the National Institute of Health Research Biomedical Research Centre at UCL Hospitals, London, UK
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Abstract
As of the end of March 2016, the West Africa epidemic of Ebola virus disease (Ebola) had resulted in a total of 28,646 cases, 11,323 of them fatal, reported to the World Health Organization. Guinea, Liberia, and Sierra Leone were most heavily affected, but Ebola cases were exported to several other African and European countries as well as the United States, with limited further transmission, including to healthcare workers. We review the descriptive epidemiology of the outbreak, novel aspects and insights concerning the unprecedented response, scientific observations, and public health implications. The large number of Ebola survivors has highlighted the frequency of persistent symptoms and the possibility of virus persistence in sanctuary sites, sometimes leading to delayed transmission. Although transmission appears to have ceased in 2016, the West Africa Ebola epidemic has profoundly influenced discussions and practice concerning global health security.
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Affiliation(s)
- Terrence Q Lo
- Center for Global Health, Centers for Disease Control and Prevention, Atlanta, Georgia 30333; , , ,
| | - Barbara J Marston
- Center for Global Health, Centers for Disease Control and Prevention, Atlanta, Georgia 30333; , , ,
| | - Benjamin A Dahl
- Center for Global Health, Centers for Disease Control and Prevention, Atlanta, Georgia 30333; , , ,
| | - Kevin M De Cock
- Center for Global Health, Centers for Disease Control and Prevention, Atlanta, Georgia 30333; , , ,
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28
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Brolin Ribacke KJ, Saulnier DD, Eriksson A, von Schreeb J. Effects of the West Africa Ebola Virus Disease on Health-Care Utilization - A Systematic Review. Front Public Health 2016; 4:222. [PMID: 27777926 PMCID: PMC5056406 DOI: 10.3389/fpubh.2016.00222] [Citation(s) in RCA: 123] [Impact Index Per Article: 15.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2016] [Accepted: 09/26/2016] [Indexed: 11/21/2022] Open
Abstract
Significant efforts were invested in halting the recent Ebola virus disease outbreak in West Africa. Now, studies are emerging on the magnitude of the indirect health effects of the outbreak in the affected countries, and the aim of this study is to systematically assess the results of these publications. The methodology for this review adhered to the Prisma guidelines for systematic reviews. A total of 3354 articles were identified for screening, and while 117 articles were read in full, 22 studies were included in the final review. Utilization of maternal health services decreased during the outbreak. The number of cesarean sections and facility-based deliveries declined and followed a similar pattern in Guinea, Liberia, and Sierra Leone. A change in the utilization of antenatal and postnatal care and family planning services was also seen, as well as a drop in utilization of children's health services, especially in terms of vaccination coverage. In addition, the uptake of HIV/AIDS and malaria services, general hospital admissions, and major surgeries decreased as well. Interestingly, it was the uptake of health service provision by the population that decreased, rather than the volume of health service provision. Estimates from the various studies suggest that non-Ebola morbidity and mortality have increased after the onset of the outbreak in Sierra Leone, Guinea, and Liberia. Reproductive, maternal, and child health services were especially affected, and the decrease in facility deliveries, cesarean sections, and volume of antenatal and postnatal care visits might have significant adverse effects on maternal and newborn health. The impact of Ebola stretches far beyond Ebola cases and deaths. This review indicates that indirect health service effects are substantial and both short and long term, and highlights the importance of support to maintain routine health service delivery and the maintenance of vaccination programs as well as preventative and curative malaria programs, both in general but especially in times of a disaster.
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Affiliation(s)
- Kim J. Brolin Ribacke
- Health Systems and Policy Research Group, Department of Public Health Sciences, Karolinska Institutet, Stockholm, Sweden
| | - Dell D. Saulnier
- Health Systems and Policy Research Group, Department of Public Health Sciences, Karolinska Institutet, Stockholm, Sweden
| | - Anneli Eriksson
- Health Systems and Policy Research Group, Department of Public Health Sciences, Karolinska Institutet, Stockholm, Sweden
| | - Johan von Schreeb
- Health Systems and Policy Research Group, Department of Public Health Sciences, Karolinska Institutet, Stockholm, Sweden
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Facility-Based Delivery during the Ebola Virus Disease Epidemic in Rural Liberia: Analysis from a Cross-Sectional, Population-Based Household Survey. PLoS Med 2016; 13:e1002096. [PMID: 27482706 PMCID: PMC4970816 DOI: 10.1371/journal.pmed.1002096] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/11/2015] [Accepted: 06/17/2016] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND The Ebola virus disease (EVD) epidemic has threatened access to basic health services through facility closures, resource diversion, and decreased demand due to community fear and distrust. While modeling studies have attempted to estimate the impact of these disruptions, no studies have yet utilized population-based survey data. METHODS AND FINDINGS We conducted a two-stage, cluster-sample household survey in Rivercess County, Liberia, in March-April 2015, which included a maternal and reproductive health module. We constructed a retrospective cohort of births beginning 4 y before the first day of survey administration (beginning March 24, 2011). We then fit logistic regression models to estimate associations between our primary outcome, facility-based delivery (FBD), and time period, defined as the pre-EVD period (March 24, 2011-June 14, 2014) or EVD period (June 15, 2014-April 13, 2015). We fit both univariable and multivariable models, adjusted for known predictors of facility delivery, accounting for clustering using linearized standard errors. To strengthen causal inference, we also conducted stratified analyses to assess changes in FBD by whether respondents believed that health facility attendance was an EVD risk factor. A total of 1,298 women from 941 households completed the survey. Median age at the time of survey was 29 y, and over 80% had a primary education or less. There were 686 births reported in the pre-EVD period and 212 in the EVD period. The unadjusted odds ratio of facility-based delivery in the EVD period was 0.66 (95% confidence interval [CI] 0.48-0.90, p-value = 0.010). Adjustment for potential confounders did not change the observed association, either in the principal model (adjusted odds ratio [AOR] = 0.70, 95%CI 0.50-0.98, p = 0.037) or a fully adjusted model (AOR = 0.69, 95%CI 0.50-0.97, p = 0.033). The association was robust in sensitivity analyses. The reduction in FBD during the EVD period was observed among those reporting a belief that health facilities are or may be a source of Ebola transmission (AOR = 0.59, 95%CI 0.36-0.97, p = 0.038), but not those without such a belief (AOR = 0.90, 95%CI 0.59-1.37, p = 0.612). Limitations include the possibility of FBD secular trends coincident with the EVD period, recall errors, and social desirability bias. CONCLUSIONS We detected a 30% decreased odds of FBD after the start of EVD in a rural Liberian county with relatively few cases. Because health facilities never closed in Rivercess County, this estimate may under-approximate the effect seen in the most heavily affected areas. These are the first population-based survey data to show collateral disruptions to facility-based delivery caused by the West African EVD epidemic, and they reinforce the need to consider the full spectrum of implications caused by public health emergencies.
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Dahl BA, Kinzer MH, Raghunathan PL, Christie A, De Cock KM, Mahoney F, Bennett SD, Hersey S, Morgan OW. CDC's Response to the 2014-2016 Ebola Epidemic - Guinea, Liberia, and Sierra Leone. MMWR Suppl 2016; 65:12-20. [PMID: 27388930 DOI: 10.15585/mmwr.su6503a3] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022] Open
Abstract
CDC's response to the 2014-2016 Ebola virus disease (Ebola) epidemic in West Africa was the largest in the agency's history and occurred in a geographic area where CDC had little operational presence. Approximately 1,450 CDC responders were deployed to Guinea, Liberia, and Sierra Leone since the start of the response in July 2014 to the end of the response at the end of March 2016, including 455 persons with repeat deployments. The responses undertaken in each country shared some similarities but also required unique strategies specific to individual country needs. The size and duration of the response challenged CDC in several ways, particularly with regard to staffing. The lessons learned from this epidemic will strengthen CDC's ability to respond to future public health emergencies. These lessons include the importance of ongoing partnerships with ministries of health in resource-limited countries and regions, a cadre of trained CDC staff who are ready to be deployed, and development of ongoing working relationships with U.S. government agencies and other multilateral and nongovernment organizations that deploy for international public health emergencies. CDC's establishment of a Global Rapid Response Team in June 2015 is anticipated to meet some of these challenges. The activities summarized in this report would not have been possible without collaboration with many U.S. and international partners (http://www.cdc.gov/vhf/ebola/outbreaks/2014-west-africa/partners.html).
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Brolin Ribacke KJ, van Duinen AJ, Nordenstedt H, Höijer J, Molnes R, Froseth TW, Koroma AP, Darj E, Bolkan HA, Ekström A. The Impact of the West Africa Ebola Outbreak on Obstetric Health Care in Sierra Leone. PLoS One 2016; 11:e0150080. [PMID: 26910462 PMCID: PMC4766087 DOI: 10.1371/journal.pone.0150080] [Citation(s) in RCA: 63] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2015] [Accepted: 02/09/2016] [Indexed: 12/20/2022] Open
Abstract
Background As Sierra Leone celebrates the end of the Ebola Virus Disease (EVD) outbreak, we can begin to fully grasp its impact on already weak health systems. The EVD outbreak in West Africa forced many hospitals to close down or reduce their activity, either to prevent nosocomial transmission or because of staff shortages. The aim of this study is to assess the potential impact of EVD on nationwide access to obstetric care in Sierra Leone. Methods and Findings Community health officers collected weekly data between January 2014—May 2015 on in-hospital deliveries and caesarean sections (C-sections) from all open facilities (public, private for-profit and private non-profit sectors) offering emergency obstetrics in Sierra Leone. This was compared to official data of EVD cases per district. Logistic and Poisson regression analyses were used to compute risk and rate estimates. Nationwide, the number of in-hospital deliveries and C-sections decreased by over 20% during the EVD outbreak. The decline occurred early on in the EVD outbreak and was mainly attributable to the closing of private not-for-profit hospitals rather than government facilities. Due to difficulties in collecting data in the midst of an epidemic, limitations of this study include some missing data points. Conclusions Both the number of in-hospital deliveries and C-sections substantially declined shortly after the onset of the EVD outbreak. Since access to emergency obstetric care, like C-sections, is associated with decreased maternal mortality, many women are likely to have died due to the reduced access to appropriate care during childbirth. Future research on indirect health effects of health system breakdown should ideally be nationwide and continue also into the recovery phase. It is also important to understand the mechanisms behind the deterioration so that important health services can be reestablished.
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Affiliation(s)
- Kim J. Brolin Ribacke
- Department of Public Health Sciences, Karolinska Institutet, Stockholm, Sweden
- * E-mail:
| | - Alex J. van Duinen
- Department of Surgery, St Olav Hospital, Trondheim, Norway
- CapaCare, Trondheim, Norway
| | - Helena Nordenstedt
- Department of Public Health Sciences, Karolinska Institutet, Stockholm, Sweden
| | - Jonas Höijer
- Unit of Biostatistics, Institute of Environmental Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Ragnhild Molnes
- Department of Public Health and General Practice, Norwegian University of Science and Technology, Trondheim, Norway
| | - Torunn Wigum Froseth
- Department of Public Health and General Practice, Norwegian University of Science and Technology, Trondheim, Norway
| | - AP Koroma
- Ministry of Health and Sanitation, Freetown, Sierra Leone
| | - Elisabeth Darj
- Department of Public Health and General Practice, Norwegian University of Science and Technology, Trondheim, Norway
- Department of Obstetrics and Gynaecology, St Olav Hospital, Trondheim, Norway
| | - Håkon Angel Bolkan
- Department of Surgery, St Olav Hospital, Trondheim, Norway
- CapaCare, Trondheim, Norway
- Department of Cancer Research and Molecular Medicine, Norwegian University of Science and Technology, Trondheim, Norway
| | - AnnaMia Ekström
- Department of Public Health Sciences, Karolinska Institutet, Stockholm, Sweden
- Department of Infectious Diseases, Karolinska University Hospital, Stockholm, Sweden
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