Guinea study finds drops in facility-based births during West Africa Ebola crisis

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The following is a guest post by Janine Barden O’Fallon, PhD, MEASURE Evaluation

Guinea was one of the three most affected countries in the longest and deadliest outbreak of Ebola Virus Disease ever recorded (2014–2015). The disease also had the indirect effects on access to health services and potential mortality from other conditions.

My colleagues and I were involved with a rapid assessment in Guinea to understand how the delivery and utilization of routine maternal, newborn, and child health services may have been affected by the strain Ebola placed on the health system and its clients. Our results are summarized in a chapter of a new book, Pregnant in the Time of Ebola, which examines the effects of Ebola in West Africa. 

The aim of the study, commissioned by USAID in Guinea and performed by MEASURE Evaluation, was a quick yet systematic look at the status of maternal, newborn, and child health services delivered in selected facilities in the quarter before recognition of the Ebola outbreak, compared to the conditions existing in the quarter approximately one year later, in 2014. We expected that diseases such as malaria, pneumonia, and typhoid may have gone untreated and that routine maternal health, skilled-attendant deliveries, and childhood immunizations could have decreased — due to Ebola-related effects, such as clinic closures, patients fearful of contracting Ebola if they visited clinics, or patients with Ebola-like symptoms being turned away.

Even before the Ebola outbreak, the health system capacity in Guinea was unlikely to withstand the severe shock posed by a fast-moving infectious disease complicating routine healthcare services, which already lagged by global standards. Some examples pertinent to maternal, newborn, and child health:

  • The maternal mortality ratio — a chief indicator of maternal health —was 650 per 100,000 live births, (2012) one of the world’s highest.
  • Facility-based deliveries accounted for only 41 percent of births, and the contraceptive prevalence rate was a mere six percent.
  • Under-five mortality was 101 per 1,000 live births, with malaria as the top cause of death. Only 36.5 percent of children received full immunizations.
  • The numbers of physicians, nurses, midwives, dentists, pharmacists, etc., in Guinea was fewer than 1.5 per 10,000 population, and per capita government spending on health was US$9 per year.

The method to determine the extent of decline in service uptake and delivery during Ebola included a convenience sample of monthly data from public facilities on a number of MNCH services. Structured interviews were held with facility directors and MNCH service providers, and a retrospective facility records review spanning 15 months. Our study covered 12 prefectures from Guinea’s four geographic zones and 45 facilities—the central hospital of a prefecture or city district plus two facilities serving the nearby community. 

We found some dramatic declines in service utilization in some of the Ebola-affected areas. For example, the number of women giving birth in facilities with a skilled birth attendant in the hardest-hit prefectures of N’Zérékoré and Conakry fell by 87 percent over seven months after the outbreak began. Matam Maternity Hospital in Conakry saw only 123 patients from July through September 2014, compared to 760 patients for the same quarter the year before. Surveyed hospitals in “Ebola Active” districts had an initial increase in outpatient visits between January–March 2014, followed by steady declines throughout the remainder of 2014. Hospitals in the “Ebola Inactive” and “Ebola Changing” status zones showed the largest declines in outpatient visits in the final quarter of 2014, when the outbreak was at its peak.

The decline was due to lack of service uptake during the outbreak. Only a small percentage of surveyed providers reported that services had been suspended due to Ebola. Not only were clinics avoided by the population, but health workers were stigmatized by the community for fear that they carried Ebola or even were deliberately spreading it. 

Interviews with providers also revealed another finding—one that perhaps had been expected—suggesting that morbidity and mortality from common causes such as childbirth outside hospitals, and diseases such as malaria, diarrhea, measles, and infantile pneumonia far exceeded deaths from Ebola. 

Our review concluded that community-level factors were important to Guinea’s inability to contain Ebola, and that patients need to be central to health care systems in order to maintain high levels of service uptake during stressful times. As investments are building the capabilities and responsiveness of Guinea’s health system, the expectation is that communities will gain trust in these systems and utilize available services.

For more information on MEASURE Evaluation, funded by USAID, and the project’s work on Ebola, visit www.measureevaluation.org and https://www.measureevaluation.org/@@search?SearchableText=ebola 

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