Could Maternal Mortality in Sierra Leone be Worsened by COVID-19?

Image: concernusa.org

Emma Minor recently worked in Sierra Leone running in-country communications for the healthcare non-profit, Partners In Health (PIH). During this time, she wrote articles about PIH’s work – many of which profiled the organisation’s efforts, in partnership with Sierra Leone’s Ministry of Health and Sanitation, to strengthen maternal health services in Kono District.

Six years ago, Sierra Leone was fighting Ebola; today, like most countries around the world, the West African nation is in the midst of fighting another disease outbreak: COVID-19.

The Ebola outbreak not only killed thousands of people directly, it also worsened pre-existing health crises such as maternal mortality.

While Ebola rampaged the country, women in Sierra Leone’s risk of dying in childbirth – already the highest in the world – increased by an estimated 22 percent, leaving a detrimental impact. The World Health Organisation still cites Sierra Leone with the world’s highest maternal mortality rate: one out of every seventeen women will die during a pregnancy, a delivery, or its aftermath.

For many Sierra Leoneans, the COVID-19 outbreak has brought back memories of Ebola; leading to a nervousness, especially among pregnant women, about visiting the hospital. The race is on to protect these women and to prevent maternal deaths from increasing like they did during the Ebola crisis.

Nurse Isata Dumbuya runs women’s health services for Partners In Health in Sierra Leone. Here, she speaks to local leaders in Kono before the COVID-19 outbreak struck, about maternal health care available at her ward. Image: Emma Minor

Nurse Isata Dumbuya, 50, worked overseas in the NHS for 19 years before returning two years ago to her birthplace of Kono District – an eastern region of Sierra Leone famous for its diamond mines. Dumbuya runs women’s health services at Koidu Government Hospital (or KGH as it’s often called).

“You wouldn’t want to send anyone to KGH how it used to be,” said Dumbuya. “Everyone has a horror story to share.”

This was especially true during Ebola, she points out. “Hygiene was bad and there were no drugs,” Dumbuya reflected. “No one wanted to go to the hospital because people said, ‘You’ll either go in a body bag or you’ll leave in one’.”

Over the past few years working for Partners In Health (PIH), the global medical non-profit that supports KGH, Dumbuya has steadily transformed the hospital’s maternity ward, and she has provided training and mentorship to staff. Quality of care has risen together with patient trust and attendance.

But when news of the first COVID-19 case reached Kono in early March, women began walking away. “The hospital was cleared of patients within 24-hours. Patients just got up and left,” Dumbuya said.

She is concerned this latest outbreak will result in widespread, prolonged avoidance of hospitals. This was the case during Ebola, when by Lancet estimates, there was a 20 percent decrease in hospital-births – many pregnant women, fearful of contracting the virus at hospitals, opted for home-births instead without a trained clinician there to help when complications arose.

Dr. Marta Lado, Chief Medical Officer for Partners In Health in Sierra Leone, during the daily rounds at 34 Military Hospital in Freetown, where she and her colleagues discuss the health status and treatment path for each of COVID-19 patient. Image: Jon Lascher/ Partners In Health

 

Dr. Marta Lado and her colleagues at 34 Military Hospital treat and monitor Sierra Leone’s most critical COVID-19 patients. Image: Jon Lascher/ Partners In Health

Dr. Marta Lado, an infectious disease specialist who helped set up and operate one of the first Ebola treatment centres in Sierra Leone, spoke about the connection between COVID-19 and Ebola. “It’s complicated to ask people to change their mind-set,” she said. “But it is different this time. We are more ready for sure.”

Since Ebola, Lado has been the Chief Medical Officer for PIH in Sierra Leone. She is currently based in the capital city, Freetown, at 34 Military Hospital – a facility that was built after Ebola in preparation for future disease outbreaks.

“It’s run by the army. They know how to defend,” Lado said of 34 Military Hospital. “It’s a super high standard unit with biosecurity. People have been trained and drilled continuously.”

The hospital staff used their simulation training to spring to immediate action when the country’s first COVID-19 case was confirmed.

And Sierra Leone’s experience fighting Ebola accelerated the government’s response, too. “With Ebola, we could have saved thousands of lives, and money that was spent later on, if we had tackled it early,” said Dr. Mohamed Vandi, Director of Public Health Security, who is the senior-most health official leading the country’s COVID-19 response. “But we had no experiences and no resources. Now, we have the capacity and knowledge.”

Vandi continued, “We knew it [COVID-19] was knocking at our door. My initial aim was to be proactive to prevent it.” Indeed, Sierra Leone had put strict measures in place – such as cancelled flights, closed borders, hand washing and temperature check stations – before the first confirmed case. Not a trend seen in many other countries around the world.

So far, Sierra Leone has confirmed just over 1,103 cases of COVID-19. Approximately 80 percent of which have been near to Freetown, in easy reach of 34 Military Hospital.

But as cases spread further afield, Vandi has instructed that treatment centres be set up across the country. He said that a motivation behind this is to ease patients’ fears about long ambulance journeys. During Ebola, many patients died in transit to distant treatment facilities before reaching the care they desperately needed – a memory that haunts today’s COVID-19 patients.

Dr. Marta Lado prepares to treat COVID-19 patients at 34 Military Hospital, by donning personal protective equipment. Image: Jon Lascher/ Partners In Health

“We have seen a reduction in women at the hospital, a reduction in ambulance calls, and a reduction in referrals from other health centres,” said Lado.

But clinical staff are combatting this with compassion, she said. “Nurses are the roots of what we are doing here. They don’t hesitate about spending as much time as they can with patients. They do a lot of psychosocial support and engagement.”

Dumbuya described her focus on encouraging patients: “We have been out talking to women and leaders in the community about what’s going on around the world, and to stress that hospitals are still open for business,” she said. “We are trying to spread the word that Covid is very different to Ebola. We can get to people quicker, isolate them and give treatment.”

It is too soon to predict the long-term impact of COVID-19 on maternal mortality in Sierra Leone. However, experts are hopeful that the county’s rapid, efficient response to the outbreak, coupled with the provision of counselling for patients and communities, will go a long way in making women feel confident about continuing to access maternal services – a mind-set that was gravely lacking during Ebola.

At KGH, triage systems are firmly in place to separate COVID-19 patients from those seeking routine health services. At the time of writing, there were 16 confirmed cases of COVID-19 in Kono.

Dumbuya’s priority now, along with all of her PIH and KGH colleagues, is to prevent health care standards from dropping like they did during Ebola, and to continue fighting maternal mortality.

“Dying in childbirth is an ongoing emergency in Sierra Leone,” Dumbuya said. “The care we offer is intended to save women’s lives, but also to improve the maternal journey so that they return.”

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