Nature | Editorial



Fatal fallout

The Ebola epidemic has had a dire effect on the health prospects of pregnant women.

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The late stages of pregnancy are a difficult time for most women, but try to imagine what it must be like right now for would-be new mothers in rural areas of Sierra Leone, Guinea or Liberia. Their eight or nine months of pregnancy have already been over­shadowed by the ravages of the Ebola outbreak. Now, when they start to feel abdominal cramps, they are faced with an impossible choice.

Before the epidemic, health educators urged pregnant women with complications to report to clinics. But the nearest clinic is typically a journey of a day or more away — and stories abound of friends and relatives who went to the hospital, only to be told that they had Ebola and never come home.

Pregnant women who do brave the journey are often denied care. Some end up delivering their babies alone on floors or in the backs of ambulances. What would you do — would you make the journey?

Now put yourself in the place of the hospital nurse greeting a heavily pregnant woman who arrives at a triage department, weary from her journey, and complaining of abdominal pain. Such pain is, after all, a classic symptom of Ebola, and although the numbers of cases are easing, you have seen colleagues and friends help pregnant women with Ebola, only to contract the virus and die. The woman’s pain worsens and she goes into labour. Would you help? Or, to protect yourself, would you leave her squirming on the floor to deliver the baby herself?

As we explore in a News Feature on page 24, women and health workers in West Africa are facing decisions like these every day. It helps to explain how, as new infections of Ebola are finally being brought under control and the world’s attention moves on, the outbreak’s devastating impact on maternal health will linger for years.

Pregnant women are uniquely vulnerable to the effects of Ebola, and it is extremely difficult to distinguish the disease’s symptoms from routine pregnancy complications. And those who care for these women take their lives in their hands: pregnancy and childbirth necessarily expose carers to potentially infectious bodily fluids. As a result, many doctors, nurses and clinics have refused to treat any pregnant woman who presents with symptoms that could mark her as having Ebola. The United Nations Population Fund (UNFPA) has estimated that the maternal mortality rate — the annual number of maternal deaths per 100,000 live births — may double as a result. And this is happening in countries that already had among the worst maternal-health records in the world.

“Pregnant women are uniquely vulnerable to the effects of Ebola.”

Some health workers have been brave enough to continue caring for pregnant women during the Ebola epidemic. These include doctors with the medical-aid group Médecins Sans Frontières (Doctors Without Borders) who have devised innovative ways to treat these women and have opened clinics specifically to care for these most vulnerable patients.

Samuel Batty and Amadu Jawara, two Sierra Leonean community health workers, have also stepped up. Both were assigned to work at a hospital in Freetown. When many nurses and doctors abandoned their posts, Batty and Jawara did not.

In November, Batty and Jawara assisted a pregnant woman with a fever. They gave her medication and her fever improved. Assuming that she had malaria, Batty examined her using no special Ebola precautions. It was a fatal mistake. Soon after, Batty himself died of the disease. Even after seeing his friend die, Jawara has continued to care for patients, knowing that they have nowhere else to turn. He estimates that he has performed 100 Caesarean sections.

Community health workers would not usually perform such a procedure. Both Batty and Jawara were trained in surgical skills through a programme run by the Norwegian non-governmental organization CapaCare in conjunction with the Sierra Leonean health ministry. The programme exemplifies an approach called surgical task-shifting, which attempts to redress the dearth of medical personnel in countries such as Sierra Leone by training health workers to give lifesaving care that might otherwise be unavailable to patients in under-resourced areas. CapaCare estimates that, by August 2014, approximately half the surgical procedures performed by its students were emergency obstetric procedures.

There is debate over the ethics of task-shifting: some worry that it risks exposing patients to substandard care. But the epidemic shows that the people trained by CapaCare are extraordinarily committed to their patients. In this setting, many people faced a choice of being cared for by Jawara, Batty and their counterparts or receiving no care at all.

Sierra Leone had only seven obstetricians before the outbreak began. The UNFPA is seeking US$56 million to fund a new initiative to reopen health services for pregnant women and to recruit more than 500 midwives, doctors and health workers across the outbreak region. International donors should support this initiative.

Training more doctors and finding ways to incentivize them to stay in West Africa are priorities to help the region replace health workers who have lost their lives fighting the epidemic, and task-shifting has proved that it can be part of the solution. The Capa­Care programme is currently on hold as a result of the deaths of Batty and another trainee. Restarting medical programmes, including ones such as this, are crucial as the region fights to end the outbreak and begin the long recovery process.

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