Pregnancy in the Ebola Epidemic – An update

By Kelsey Berry

A few weeks ago, I posted on this blog a discussion of an ethical dilemma in the treatment of Ebola-infected pregnant women in West Africa. I wanted to follow-up with two brief updates concerning Ebola and pregnancy in West Africa.

First, Medecins Sans Frontieres has opened the first care center specializing in treatment for Ebola-infected pregnant women in Sierra Leone. The care center will have 80 beds once it is fully operational and at present has one patient under care. In my last post I called for greater investigation into the reasons underlying higher mortality rates among Ebola-infected pregnant women, claiming that the causes of disparate outcomes in various population groups may be important to determine the justifiability of outcome-driven resource allocation. The new care center is ideally positioned to investigate and perhaps parse out biological, practice based, and institutional factors contributing to the disparity. There are some remaining questions — for instance, will capacity be reserved solely for pregnant women or other infected individuals seeking care? Further, we have already seen that MSF is investing resources in caring for a population for whom survival rates are nearly zero in the current Ebola epidemic; will continued commitment to treating this population depend upon observed changes in survival rates or other outcomes; or will the mere provision of care continue to justify the center if outcomes don’t improve measurably? This is a development I will continue to follow.

Second, we are beginning to see some of the indirect effects of Ebola on antenatal and postnatal care. Sierra Leone has the highest maternal mortality rate and 4th highest neonatal mortality rate in the world, and the Ebola epidemic may further raise the risk of adverse outcomes. In a recent CDC Morbidity and Mortality Weekly Report, Dynes et al. 2015 report that during May-July 2014, routine maternal and newborn health service use declined across Kenema District (a high infection area); with antenatal care visits decreasing by 29% and postnatal care visits decreasing by 21% compared to the previous months. In a focus group with pregnant and lactating women facilitated by the same researchers, these declines in care-seeking behavior were primarily attributed to fear of contracting Ebola at a facility, and secondarily attributed to mistrust of physicians. Further statistics on care-seeking behavior in the general population during the same time and information on broader trends in antenatal and postnatal visits is needed to fully understand the implications of this report. However, we should be wary of whether amplified perception of risk and mistrust expressed by pregnant and lactating women may be fueled by the specific treatment of pregnant women during the epidemic so far. For instance, as I noted in my last post, pregnant women seeking Ebola treatment may be de-prioritized for Ebola treatment. Further, women presenting to facilities with urgent pregnancy related complications may not receive needed maternal care, in part because physicians lack access to timely Ebola laboratory testing and are hesitant to expose themselves to bodily fluids potentially carrying the virus. Both kinds of interactions may reduce care-seeking behavior over the long term among pregnant women.

We should keep our eyes and attention on these issues as they continue to unfold, considering also how Ebola and the ways in which health workers respond to it will indirectly impact both health systems and future population health.

kelseyberry

kelseyberry

At the conclusion of her fellowship year, Kelsey Berry was a PhD candidate in health policy and ethics at Harvard University. She holds a BA in political philosophy and neuroscience from Princeton University. Kelsey's research interests include theories of justice in global health, partiality and fairness in resource allocation, and ethical issues in the health of vulnerable populations. Kelsey was a 2014-2015 Student Fellow at the Petrie-Flom Center, during which she worked on a research project entitled "Rights and Duties Against Conditional Funding Agreements in Global Aid." The paper presents a normative argument for holding global health development assistance channeled through non-governmental organizations to standards of egalitarian justice, and assesses PEPFAR's "anti-prostitution pledge," which was challenged in a landmark 2013 Supreme Court case, relative to these standards. Kelsey's other work includes empirical research on issues in mental health policy, like assessing progress in achieving equitable insurance coverage for mental health disorders subsequent to the 2008 federal mental health parity law and the Affordable Care Act. She planned to continue such work with the Department of Health Care Policy at Harvard Medical School, and on a 2015-2016 training grant with the National Institute of Mental Health.

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