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PLOS BLOGS Speaking of Medicine and Health

Navigating Ebola: Women’s Health in a Bloody Epidemic

By guest contributor Benjamin Black

Ebola epidemics summon the world’s attention. Newspapers and reporters are quick to remind their audiences of the disease’s deadly nature, supporting their stories with images of hazmat suits and body bags. But as with all emergencies, what is seen is only the tip and below lies a complex mass of other hardships and suffering. Women and girls living within Ebola epidemic affected areas are disproportionately impacted, facing immense challenges often unseen and unreported.

Ebola Virus Disease (EVD) has a high mortality and is difficult to differentiate from other common ailments. It is spread through contact with the body fluids of the infected. Healthcare workers are at greater risk of transmission, making the decision around which patients to suspect of EVD (and isolate till a negative test result) and who to treat for common ailments (allowing entry into the health centre) uniquely challenging. In the 2014 – 2016 West African Ebola epidemic healthcare providers were thirty-two times more likely to die from EVD than their local population.

Managing pregnancy-related complications requires decisive and timely actions. Delays in recognition of a problem, reaching a facility and receiving treatment are known to increase maternal morbidity and mortality. The symptoms of EVD (including fever, exhaustion, intrauterine fetal death and bleeding) mimic those of pregnancy-complications, especially in poorer countries where women may present late and with multiple pathologies at once. If getting an EVD test result takes hours or days, decision-making at the maternity department becomes even more precarious – if wrong it can be deadly for the woman or the staff. If triage is performed by the unacquainted in obstetrics, there risks being misdiagnosis and stigmatization of women seeking urgent maternity care.

Further issues arise when women and girls are trapped in a legally restrictive framework for termination of pregnancy. If abortion is illegal, it becomes hazardous to explain why one might be bleeding in early pregnancy, if one doesn’t explain they risk being wrongly confined with other patients suspected of EVD. The result being women and girls in need of post-abortion care may further delay seeking care, risking their health, or go to a non-medical provider for alternative treatment.

Within the EVD symptoms special attention is given to unexplained bleeding, however in times of Ebola fear often rules over logic. This can result in health workers, keen not to miss an EVD patient, interpreting this as “all bleeding is suspected Ebola”, and patients avoiding attendance in case they who are classified as suspected EVD. A study during the 2018 -2020 Ebola epidemic in Democratic Republic of Congo documented staff uncertainty around pregnancy-related bleeding, but also the common side effects of contraception, menstrual irregularity and bleeding from trauma. In one interview, a sexual assault survivor reported avoiding seeking clinical care fearing her bleeding would raise suspicion of EVD, as a result she missed time-critical emergency contraception and STI/HIV prophylaxis.

Women and girls who find themselves admitted into an Ebola Treatment Centre (ETC) face additional challenges, whether awaiting a test result or confirmed to have EVD. Until recently menstrual hygiene management had been overlooked in ETCs, ensuring there are adequate supplies of pads, washing facilities and private spaces for women with vaginal bleeding is vital. Similarly, giving clear instructions on how to dispose of sanatory products is imperative to maintain infection control standards. Those who are pregnant are at increased risk of obstetric complications, such as premature labour and haemorrhage. At the start of 2014 the mortality rate for pregnant women with EVD was estimated to be close to 90%, however with simple measures this has dropped, the maternal mortality is now considered to probably be the same as for non-pregnant women of the same age. Pregnancy-complications can be managed in an ETC, however if the correct medication and skills are not available maternal mortality can rapidly climb back up. Where potential treatments and vaccines are available, there is often hesitation in offering them to pregnant and breastfeeding women – hopefully errors from previous epidemics will prevent this from occurring again.

As Uganda works to quench the flames of this most recent epidemic, the women and girls living in the affected areas must also navigate the changing social landscape of lockdowns, curfews, militarisation and slumping economy. All of these are linked to increased sexual violence and exploitation, and where this is pre-existing these changes risk exacerbating those vulnerabilities and worsening the situation for women and girls.

The knock-on effects of humanitarian emergencies impact women and girls at multiple levels. Ebola epidemics present additional challenges. It’s vital these are recognised, prepared for and mitigated from the response outset. Recent history has shown us what happens if we don’t.

About the author:

Dr Benjamin Black is an obstetrician/gynaecologist and specialist advisor in sexual and reproductive health for Médecins Sans Frontières and international humanitarian organisations. Dr Black has provided clinical care in Ebola epidemics to those infected and in the continuation of maternal and reproductive health services. He has researched, advised and written international guidance on Ebola and reproductive health, and supported governments in their preparations and response. His book, Belly Woman: Birth, Blood & Ebola; The Untold Story was published in October 2022. He tweets at @benjamblack

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