In 2014, an Ebola crisis hit West Africa. The epidemic was catastrophic, taking more than 11,000 lives. The long-term impact has yet to be fully understood. Across Liberia, Sierra Leone, and Guinea, health systems were crippled and hard-won progress made in child, maternal and adult health was lost when hospitals became hot zones and basic services were suspended. Prior to the Ebola epidemic, Liberia had made improving maternal health a national priority, which resulted in substantial gains in facility-based delivery rates. Nationally, facility based delivery rates increased from 38% to 56% between the 2007 and 2013 demographic and health surveys.

 A new study published in PLOS Medicine examines the collateral harm of the Ebola crisis on maternal health and shows a 30% reduction in the odds of facility-based delivery among women who gave birth during the Ebola Virus Disease (EVD) epidemic in rural Liberia. The study, which is the first known household survey examining the collateral harm to pregnancy services in areas affected by the West African Ebola epidemic, provides important insights on the indirect health consequences of Ebola on maternal and child health, and the broader primary health system.

“Big belly women don’t want to go to the hospital. They have fear to go.”

At the height of the EVD epidemic, data gathered by Last Mile Health’s Community Health Worker Leaders and Research, Monitoring, and Evaluation (RM&E) team highlighted one of many indirect effects of the epidemic: some pregnant women, or big belly women, were afraid to seek care at hospitals or clinics.

To investigate if fear altered a mother’s decision to deliver in a health facility, Last Mile Health’s RM&E team collected data on Ebola-related knowledge, attitudes, and practices through a baseline survey conducted in Liberia’s remote Rivercess County. This survey, known as the Last Mile Survey, is our gold standard for assessing the health status of the populations we serve, which guides the design of health care programs and allows us to evaluate changes over time.

The study is the first population-based survey data to illustrate the disruptions to facility-based delivery caused by the West African EVD epidemic. The analysis shows an 30% reduction in the odds of facility-based delivery among women who gave birth during the EVD epidemic. This equates to a 7.5 percentage point reduction, from 70.4% to 62.9%. Furthermore, of the women who gave birth during the EVD epidemic, women who reported that they believed that there was a risk of Ebola transmission in health facilities had a 41% reduction in the odds of delivering in a facility.

The study was conducted in Rivercess County, which had relatively few confirmed Ebola cases and no official health facility closures. “Given that, our results most likely underestimate the impact on facility births in high-burden areas where there were closures,” said John Kraemer, assistant professor of health systems administration at Georgetown University School of Nursing & Health Studies and advisor to Last Mile Health.

In the aftermath of the outbreak, our team has continued the effort of providing essential health services by deploying health professionals across Rivercess County – reaching full county-coverage in March 2016. This study emphasizes the power of health workers to build trust within communities and ameliorate fear of health facilities. Throughout the EVD epidemic and afterwards, Last Mile Health’s community health professionals have educated pregnant women and their families about Ebola and how it relates to their care during pregnancy and delivery, thereby easing any fears in order to ensure safe care for both mothers and their newborns.

This study has highlighted key lessons to integrate not only in our work at Last Mile Health, but also in the work of rebuilding the ravaged health systems in West Africa. It underscores the critical need to maintain focus on long-term health system reconstruction after the EVD epidemic. Community health workers should play a vital role, as they can enable continuity of services by providing basic health services in the community and linking patients to education and higher level care, while also helping to strengthen the community’s ability to monitor and respond to outbreaks.

As Last Mile Health Medical Director Dr. John Ly said, “Building and maintaining stronger health systems will be critical to preventing future global public health emergencies.” Last Mile Health is supporting the Government of Liberia and the Ministry of Health to build a more robust health system, and a historic health worker program was launched just last week that will deploy over 4,000 health workers to reach 1.2 million Liberians.  This study will advance Liberia’s efforts to build a resilient health workforce and strengthen the primary health system for the long-term.

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