Rapid assessment of Ebola impact on reproductive health services and service seeking behaviour in Sierra Leone

The current outbreak of Ebola Virus Disease, EVD or Ebola, in West Africa is the longest and largest Ebola outbreak to date. In addition to the direct impact of deaths and infection from Ebola, the outbreak is exacerbating already weak health systems and threatening to reverse progress made in recent years improving reproductive, maternal, neonatal, adolescent, and child health (RMNCAH) in Sierra Leone.

The Government of Sierra Leone, its Ministry of Health and Sanitation, and development partners have set in motion plans to inform evidence-based approaches to mitigate further impact on health outcomes. This report adopts a mixed-method approach to understand the context in which RMNCAH care is being used (demand) and provided (supply). Namely, the key objectives of this report are to:

  1. Identify RMNCAH care-seeking behaviour and care practices by women, adolescents and children; and identify the socio-cultural practices of women being caregivers in Ebola context through focus group discussions;

  2. Identify RMNCAH service providers’ attitude and practices in light of the Ebola through key informant interviews;

  3. Synthesise secondary data on service utilisation and availability since the onset of Ebola;

  4. Estimate the drop in utilisation of RMNCAH services as a result of the Ebola outbreak; and

  5. Estimate the impact of the reduced coverage of RMNCAH services on maternal neonatal, child deaths and unplanned pregnancies.

Findings from this report identify that the indirect negative effects of Ebola on RMNCAH service utilisation are based primarily upon fear of contracting Ebola among health providers and women from one another.

In particular, findings highlight:

A lack of trust in the health system to provide adequate protection of its own staff and users Health providers’ fear is resulting in desertion of already understaffed health facilities or limiting the standard of care provided to patients, particularly women in labour

Communities report being turned away from facilities and avoiding facilities for fear of contracting Ebola

Health staff often lack adequate protection and training in infection prevention control (IPC) and Ebola case management

The readiness to provide adolescent and youth-friendly services is lacking in many facilities.

Health service utilisation has dropped as a result of these factors, and the modelling shows deteriorating RMNCAH health outcomes if the level of service utilisation observed in the wake of the outbreak were to continue after December 2014. Comparing modelled RMNACH outcomes in the current Ebola outbreak to a hypothetical situation without Ebola suggests:

An average of 22% more maternal deaths and 25% more newborn deaths over the year May 2014 - April 2015

A higher burden of unplanned pregnancies in three districts for which there is adequate HMIS data (Kailahun, Port Loko and Kenema), as adolescents report having more time to spend recreationally, less interaction with school-based SRH programmes and more transactional sex

Estimates for unplanned pregnancies range from an increase of 44% in Kenema, to 172% in Kailahun when compared to a hypothetical situation without Ebola.

The next steps that the Government of Sierra Leone and their developing partners take will be crucial to saving the lives of vulnerable women, adolescents and newborns. Findings from this study highlight key issues to be taken into consideration to mitigating the impact of Ebola, both immediately, and in the longer-term. Crucially, there is a need to prioritise immediate provision of personal protective equipment and IPC training to health providers. There is also a need to provide specialist emergency obstetric and neonatal care for women suspected of having Ebola, which will require continual assessment of how to minimise the risk to healthcare workers and enable them to safely continue caring for their patients. In the longer-term, securing investments in professional education to train and retain adequate numbers of health providers is essential to meet RMNCAH needs. This will include continued scale up of interventions to reduce unwanted pregnancies, alongside massive scale up of training of health care providers.