Impact of Ebola outbreak on reproductive health services in a rural district of Sierra Leone: A prospective observational study

BMJ Open, Volume 9, No. 9, Year 2019

Interpretation

Objectives To assess the trends concerning utilisation of maternal and child health (MCH) services before, during and after the Ebola outbreak, quantifying the contribution of a reorganised referral system (RS). Design A prospective observational study of MCH services. Setting Pujehun district in Sierra Leone, 77 community health facilities and 1 hospital from 2012 to 2017. Main outcome measures MCH utililization was evaluated by assessing: (1) institutional deliveries, Cesarean-sections, paediatric and maternity admissions and deaths, and major direct obstetric complications (MDOCs), at hospital level; (2) antenatal care (ANC) 1 and 4, institutional delivery and family planning, at community level. Contribution of a strengthened RS was also measured. Results At hospital level, there is a significant difference between trends Ebola versus pre-Ebola for maternal admissions (7, 95% CI 4 to 11, p<0.001), MDOCs (4, 95% CI 1 to 7, p=0.006) and institutional deliveries (4, 95% CI 2 to 6, p=0.001). There is also a negative trend in the transition from Ebola to post-Ebola for maternal admissions (-7, 95% CI-10 to-4, p<0.001), MDOCs (-4, 95% CI-7 to-1, p=0.009) and institutional deliveries (-3, 95% CI-5 to-1, p=0.001). The differences between trends pre-Ebola versus post-Ebola are only significant for paediatric admissions (3, 95% CI 0 to 5, p=0.035). At community level, the difference between trends Ebola versus pre-Ebola and Ebola versus post-Ebola are not significant for any indicators. The differences between trends pre-Ebola versus post-Ebola show a negative difference for institutional deliveries (-7, 95% CI-10 to-4, p<0.001), ANC 1 (-6, 95% CI-10 to-3, p<0.001), ANC 4 (-8, 95% CI-11 to-5, p<0.001) and family planning (-85, 95% CI-119 to-51, p<0.001). Conclusions A stronger health system compared with other districts in Sierra Leone and a strengthened RS enabled health facilities in Pujehun to maintain service provision and uptake during and after the Ebola epidemic. Sierra Leone has four provinces that are divided into 14 districts. Pujehun is one of four districts in the southern province (figure 1). It has a population of ~375 000 inhabitants. The primary care network included 77 MoHS PHUs, 5 of which provide basic emergency obstetrics care (BEmOC). The secondary care system consists of the MoHS provided district hospital, which comprises the MCH complex, providing comprehensive emergency obstetric and newborn care (CEmONC) services. Connections between the community and health facilities are difficult because of the very poor condition of the roads. Furthermore, the district is divided by a major river (Moa River) and has a riverine area reachable only with boats, which further hinders access. The first case of Ebola in Pujehun district was reported on the 7 July 2014. The district was declared Ebola free on the 10 January 2015.28 A total of 49 patients were registered with a case fatality rate of 85.7% (42/49). Study area, the Pujehun district in Sierra Leone. In the Pujehun district, two ambulances managed by the District Health Management Team (DHMT) were functioning in the pre-Ebola period, but only 63% of the PHUs were able to use the service.12 23 Emergency calls were not coordinated by the hospital and the transport costs were covered by the patients, dissuading many from using the service. During the outbreak, people came to associate the ambulances with transporting Ebola-infected patients, which further discouraged their use. A 24-hour free-of-charge ambulance RS, transferring pregnant women with obstetric complications from the health centres to Pujehun hospital was implemented in January 2015. In the hospital, a call centre was established and the call centre number was distributed to all the 77 PHUs. Private calls were considered only in the case of an emergency or if the staff of the PHU were not available. After confirming an emergency condition together with the PHU staff, the hospital midwife had the responsibility to authorise the referral. A nurse on duty from the maternity hospital accompanied the driver in each referral. Health personnel at hospital and PHUs levels were trained on Life Saving Skills—Emergency Obstetric and Newborn Care, including referral criteria and definition of MDOCs.29 Referrals were carried out by three ambulances, two positioned in the Pujehun MCH complex, and a third one in Jendema, bordering Liberia, on the opposite side of the Moa River. Around the Jendema area, 15 PHUs were located serving a population of ~80 000 inhabitants. Referrals in this area were made using the ambulances and by transferring patients at the river crossing point via a barge or a motor boat, depending on the flow rate of the river. Paediatric referrals were performed using private motor bikes available in the villages and hired from PHUs staff without the involvement of the call centre. A referral form describing the clinical case and the justification for the referral was distributed to all the PHUs. The bike rider, after bringing the patient to the paediatric ward, delivered the referral form and received the reimbursement. For all patients carried to the hospital information was collected, including demographics, location and the reason for contacting the RS. Community awareness activities were organised about the RS through meetings and radio discussions held by the DMHT, hospital health personnel and local authorities. A prospective observational study using routinely collected health services data, from January 2012 to December 2017, was carried out. Three time periods were considered: pre-Ebola period (1 January 2012 to 30 May 2014); Ebola period (1 June 2014 to 28 February 2015); post-Ebola period (1 March 2015 to 31 December 2017). We considered the Ebola period from 1 month before the first confirmed case in the district (ie, June 2014) to 1 month after the country being declared Ebola-free (ie, February 2015). This was done because in Sierra Leone the outbreak had started in other districts of the country before the first case registered in Pujehun and continued to affect other districts until November 2015. It is realistic to assume that public fear of potential EVD cases and lack of confidence in the health services persisted in the Pujehun population during that time.14 In addition, expanding the Ebola period enabled a full assessment of the impact of the disease with an adequate comparison with the two long periods before and after the Ebola epidemic. Data on MCH indicators were prospectively collected from hospital registers (maternity ward, delivery unit, paediatric ward, operating theatre). The following variables were collected on a monthly basis: (1) paediatrics admissions; (2) paediatric deaths; (3) maternity admissions; (4) maternal deaths; (5) deliveries; (6) C-sections; (7) MDOC cases. MDOC cases were collected using a dedicated database within the hospital and confirmed by a gynaecologist. All hospital maternal deaths were reviewed by DHMT and classified according to Maternal Death Surveillance and Response policy by MoHS. Paediatric deaths did not include stillbirths and early neonatal deaths, but only deaths of children admitted to the paediatric ward. At community level, the following variables were collected from the local district Health Management Information System: (1) family planning consultations per month; (2) deliveries per month; (3) ANC 1 per month; (4) ANC 4 per month. Different variables were collected from the two types of sites, based on the different services provided at community level (BEmOC) and at hospital level (CEmONC). Quarterly review meetings were organised with the staff in charge of the health facilities to address data discrepancies in the reports. Technical assistance was provided to the DHMT to improve timeliness, completeness and accuracy of data regarding CEmOC and BEmONC services. For the RS, data were collected from records of all of the study sites, including delivery registers, delivery logbooks, prenatal registers, referral registers and death registers. Additional data were collected from the ambulance database and logbook. Records in the database were then validated by cross-checking the records with registers at the study sites. For each indicator, a segmented seasonal autoregressive model of order 1 was estimated. The segments defined the three periods: before the EVD epidemic (January 2012 to May 2014), during the epidemic (June 2014 to February 2015) and after the epidemic (March 2015 to December 2017). Differences were considered statistically significant at p<0.05. The analysis was performed using R.30 The full description of the methodology of the statistical analysis is available in online supplementary annex 1. bmjopen-2019-029093supp001.pdf No patients were involved in defining the research question or the outcome measures, nor were they involved in the design and implementation of the study. There are no plans to involve patients in the dissemination of the results. The full statistical analysis is available in online supplementary annex 2. bmjopen-2019-029093supp002.pdf

AI Digest

Study Justification:

The study aimed to assess the impact of the Ebola outbreak on reproductive health services in a rural district of Sierra Leone. The justification for the study was to understand the trends in maternal and child health (MCH) service utilization before, during, and after the Ebola outbreak. The study also aimed to quantify the contribution of a reorganized referral system (RS) in maintaining service provision and uptake during and after the epidemic.

Highlights:

1. The study found that there was a significant difference in trends for maternal admissions, major direct obstetric complications (MDOCs), and institutional deliveries between the Ebola and pre-Ebola periods at the hospital level.
2. The transition from Ebola to post-Ebola showed a negative trend for maternal admissions, MDOCs, and institutional deliveries.
3. At the community level, there were no significant differences in trends between the Ebola and pre-Ebola periods or the Ebola and post-Ebola periods for any indicators.
4. The study concluded that a stronger health system and a strengthened RS enabled health facilities in Pujehun district to maintain service provision and uptake during and after the Ebola epidemic.

Recommendations:

Based on the findings, the study recommends the following:

1. Strengthening the referral system to ensure timely and appropriate care for pregnant women with obstetric complications.
2. Improving community awareness about the referral system to increase utilization of maternal and child health services.
3. Enhancing the capacity of health personnel at both hospital and community levels in emergency obstetric and newborn care, including referral criteria and management of MDOCs.

Key Role Players:

To address the recommendations, the following key role players are needed:

1. District Health Management Team (DHMT)
2. Hospital health personnel
3. Local authorities
4. Community health workers
5. Ambulance drivers
6. Nurses and midwives
7. Gynaecologists

Cost Items for Planning Recommendations:

While the actual cost is not provided, the following cost items should be considered in planning the recommendations:

1. Training programs for health personnel on emergency obstetric and newborn care
2. Communication and awareness campaigns for the community
3. Operational costs for the referral system, including ambulances and fuel
4. Data management and monitoring systems
5. Infrastructure improvements, such as road repairs and transportation facilities
6. Equipment and supplies for maternal and child health services
Please note that the provided information is based on the description of the study and may not include all details.

Strength of Evidence

The strength of evidence for this abstract is 7 out of 10.
The evidence in the abstract is moderately strong. The study design is a prospective observational study, which provides valuable information. The study collected data from multiple sources and used statistical analysis to assess trends. However, the abstract does not provide information on the sample size or the specific methods used for data collection and analysis. To improve the strength of the evidence, the abstract should include more details on the study methodology, such as the sample size, sampling technique, and statistical tests used. Additionally, providing information on the limitations of the study would help readers assess the reliability of the findings.

Abstract

Sierra Leone has four provinces that are divided into 14 districts. Pujehun is one of four districts in the southern province (figure 1). It has a population of ~375 000 inhabitants. The primary care network included 77 MoHS PHUs, 5 of which provide basic emergency obstetrics care (BEmOC). The secondary care system consists of the MoHS provided district hospital, which comprises the MCH complex, providing comprehensive emergency obstetric and newborn care (CEmONC) services. Connections between the community and health facilities are difficult because of the very poor condition of the roads. Furthermore, the district is divided by a major river (Moa River) and has a riverine area reachable only with boats, which further hinders access. The first case of Ebola in Pujehun district was reported on the 7 July 2014. The district was declared Ebola free on the 10 January 2015.28 A total of 49 patients were registered with a case fatality rate of 85.7% (42/49). Study area, the Pujehun district in Sierra Leone. In the Pujehun district, two ambulances managed by the District Health Management Team (DHMT) were functioning in the pre-Ebola period, but only 63% of the PHUs were able to use the service.12 23 Emergency calls were not coordinated by the hospital and the transport costs were covered by the patients, dissuading many from using the service. During the outbreak, people came to associate the ambulances with transporting Ebola-infected patients, which further discouraged their use. A 24-hour free-of-charge ambulance RS, transferring pregnant women with obstetric complications from the health centres to Pujehun hospital was implemented in January 2015. In the hospital, a call centre was established and the call centre number was distributed to all the 77 PHUs. Private calls were considered only in the case of an emergency or if the staff of the PHU were not available. After confirming an emergency condition together with the PHU staff, the hospital midwife had the responsibility to authorise the referral. A nurse on duty from the maternity hospital accompanied the driver in each referral. Health personnel at hospital and PHUs levels were trained on Life Saving Skills—Emergency Obstetric and Newborn Care, including referral criteria and definition of MDOCs.29 Referrals were carried out by three ambulances, two positioned in the Pujehun MCH complex, and a third one in Jendema, bordering Liberia, on the opposite side of the Moa River. Around the Jendema area, 15 PHUs were located serving a population of ~80 000 inhabitants. Referrals in this area were made using the ambulances and by transferring patients at the river crossing point via a barge or a motor boat, depending on the flow rate of the river. Paediatric referrals were performed using private motor bikes available in the villages and hired from PHUs staff without the involvement of the call centre. A referral form describing the clinical case and the justification for the referral was distributed to all the PHUs. The bike rider, after bringing the patient to the paediatric ward, delivered the referral form and received the reimbursement. For all patients carried to the hospital information was collected, including demographics, location and the reason for contacting the RS. Community awareness activities were organised about the RS through meetings and radio discussions held by the DMHT, hospital health personnel and local authorities. A prospective observational study using routinely collected health services data, from January 2012 to December 2017, was carried out. Three time periods were considered: pre-Ebola period (1 January 2012 to 30 May 2014); Ebola period (1 June 2014 to 28 February 2015); post-Ebola period (1 March 2015 to 31 December 2017). We considered the Ebola period from 1 month before the first confirmed case in the district (ie, June 2014) to 1 month after the country being declared Ebola-free (ie, February 2015). This was done because in Sierra Leone the outbreak had started in other districts of the country before the first case registered in Pujehun and continued to affect other districts until November 2015. It is realistic to assume that public fear of potential EVD cases and lack of confidence in the health services persisted in the Pujehun population during that time.14 In addition, expanding the Ebola period enabled a full assessment of the impact of the disease with an adequate comparison with the two long periods before and after the Ebola epidemic. Data on MCH indicators were prospectively collected from hospital registers (maternity ward, delivery unit, paediatric ward, operating theatre). The following variables were collected on a monthly basis: (1) paediatrics admissions; (2) paediatric deaths; (3) maternity admissions; (4) maternal deaths; (5) deliveries; (6) C-sections; (7) MDOC cases. MDOC cases were collected using a dedicated database within the hospital and confirmed by a gynaecologist. All hospital maternal deaths were reviewed by DHMT and classified according to Maternal Death Surveillance and Response policy by MoHS. Paediatric deaths did not include stillbirths and early neonatal deaths, but only deaths of children admitted to the paediatric ward. At community level, the following variables were collected from the local district Health Management Information System: (1) family planning consultations per month; (2) deliveries per month; (3) ANC 1 per month; (4) ANC 4 per month. Different variables were collected from the two types of sites, based on the different services provided at community level (BEmOC) and at hospital level (CEmONC). Quarterly review meetings were organised with the staff in charge of the health facilities to address data discrepancies in the reports. Technical assistance was provided to the DHMT to improve timeliness, completeness and accuracy of data regarding CEmOC and BEmONC services. For the RS, data were collected from records of all of the study sites, including delivery registers, delivery logbooks, prenatal registers, referral registers and death registers. Additional data were collected from the ambulance database and logbook. Records in the database were then validated by cross-checking the records with registers at the study sites. For each indicator, a segmented seasonal autoregressive model of order 1 was estimated. The segments defined the three periods: before the EVD epidemic (January 2012 to May 2014), during the epidemic (June 2014 to February 2015) and after the epidemic (March 2015 to December 2017). Differences were considered statistically significant at p<0.05. The analysis was performed using R.30 The full description of the methodology of the statistical analysis is available in online supplementary annex 1. bmjopen-2019-029093supp001.pdf No patients were involved in defining the research question or the outcome measures, nor were they involved in the design and implementation of the study. There are no plans to involve patients in the dissemination of the results. The full statistical analysis is available in online supplementary annex 2. bmjopen-2019-029093supp002.pdf

Materials

Innovations

Based on the provided information, here are some potential innovations that could improve access to maternal health:

1. Strengthened Referral System: Implementing a well-coordinated and efficient referral system, similar to the one used during the Ebola outbreak in Pujehun district, can help ensure that pregnant women with obstetric complications are promptly transferred from community health facilities to hospitals for appropriate care.

2. Improved Transportation: Enhancing transportation infrastructure, such as roads and river crossings, can facilitate easier access to healthcare facilities for pregnant women residing in remote or difficult-to-reach areas.

3. Mobile Health (mHealth) Solutions: Utilizing mobile technology, such as SMS reminders for antenatal care appointments or telemedicine consultations, can help overcome geographical barriers and improve communication between healthcare providers and pregnant women.

4. Community Awareness Programs: Organizing community awareness activities, including meetings and radio discussions, can help educate the population about the importance of maternal health services and address any misconceptions or fears that may hinder access to care.

5. Training and Capacity Building: Providing training to healthcare personnel at both the hospital and community levels on emergency obstetric and newborn care, including referral criteria and management of maternal complications, can improve the quality of care and increase confidence in the healthcare system.

It is important to note that these recommendations are based on the specific context of the study in Pujehun district, Sierra Leone. Implementing these innovations would require careful consideration of the local healthcare infrastructure, resources, and cultural factors.

AI Innovations Description

The study titled “Impact of Ebola outbreak on reproductive health services in a rural district of Sierra Leone: A prospective observational study” aimed to assess the trends in maternal and child health (MCH) service utilization before, during, and after the Ebola outbreak in Pujehun district, Sierra Leone. The study also evaluated the contribution of a reorganized referral system (RS) in maintaining service provision and uptake during and after the epidemic.

The findings of the study showed significant differences in trends between the Ebola and pre-Ebola periods for maternal admissions, major direct obstetric complications (MDOCs), and institutional deliveries at the hospital level. However, there was a negative trend in the transition from Ebola to post-Ebola for these indicators. At the community level, the differences in trends between the Ebola and pre-Ebola periods, as well as the Ebola and post-Ebola periods, were not significant for any indicators.

The study highlighted the importance of a strengthened health system and a reorganized referral system in enabling health facilities in Pujehun to maintain service provision and uptake during and after the Ebola epidemic. The implementation of a 24-hour free-of-charge ambulance RS, along with training of health personnel on emergency obstetric and newborn care, played a crucial role in facilitating referrals and ensuring access to maternal health services.

Based on these findings, the recommendation to improve access to maternal health would be to strengthen health systems and implement a well-coordinated referral system. This could include measures such as establishing a call center for emergency referrals, providing free transportation for pregnant women with obstetric complications, training health personnel on emergency care, and raising community awareness about the referral system. By improving the efficiency and accessibility of maternal health services, more women can receive timely and appropriate care, leading to better maternal and child health outcomes.

AI Innovations Methodology

Based on the provided description, here are some potential recommendations to improve access to maternal health:

1. Strengthening the referral system: The study mentioned the implementation of a reorganized referral system (RS) that facilitated the transfer of pregnant women with obstetric complications from health centers to the district hospital. This recommendation could involve further enhancing the RS by improving coordination, increasing the number of ambulances, and ensuring timely and efficient referrals.

2. Community awareness and education: Organizing community awareness activities through meetings, radio discussions, and involvement of local authorities can help educate the community about the importance of maternal health services and the availability of the referral system. This can help reduce fear and increase confidence in utilizing the services.

3. Improving transportation infrastructure: The study highlighted the challenges in accessing health facilities due to poor road conditions and the presence of a major river. Investing in improving transportation infrastructure, such as repairing roads and providing reliable river-crossing options, can significantly improve access to maternal health services.

4. Training and capacity building: Providing training to health personnel at both hospital and community levels on emergency obstetric and newborn care, including referral criteria and management of maternal complications, can enhance their skills and confidence in handling maternal health cases.

To simulate the impact of these recommendations on improving access to maternal health, a methodology could include the following steps:

1. Define indicators: Identify specific indicators that reflect access to maternal health services, such as the number of institutional deliveries, antenatal care visits, and maternal and neonatal mortality rates.

2. Data collection: Collect data on the identified indicators from relevant sources, such as hospital registers, community health information systems, and referral system records. Ensure the data covers the pre-Ebola, Ebola, and post-Ebola periods to capture the trends and changes over time.

3. Segmented seasonal autoregressive modeling: Apply a segmented seasonal autoregressive model to analyze the data and estimate the impact of the recommendations on the indicators. This modeling approach can account for seasonal variations and identify any significant differences between the periods.

4. Statistical analysis: Conduct statistical analysis using appropriate methods, such as hypothesis testing, to determine the significance of the differences observed in the indicators before, during, and after the Ebola outbreak. Consider a p-value of less than 0.05 as statistically significant.

5. Interpretation and reporting: Interpret the results of the statistical analysis and provide a clear and concise summary of the impact of the recommendations on improving access to maternal health. Present the findings in a report or publication, highlighting the key findings and implications for policy and practice.

It is important to note that the methodology described above is a general outline and may need to be adapted based on the specific data availability, context, and research objectives.

Authors & Co-Authors

Statistics:

Citations: 32

Authors: 16

Identifiers:

DOI: 10.1136/bmjopen-2019-029093

Research Areas:

Community Interventions, Health System and Policy, Infectious Diseases, Maternal Access, Maternal and Child Health, Quality of Care, Sexual and Reproductive Health, Social Determinants

Study Countries:

Liberia, Multi-Countries, Sierra Leone

Study Design:

Cohort Study, Cross Sectional Study

Study Approach:

Quantitative

Participants Gender:

Female