Sexual and reproductive health in Ebola response: a neglected priority

As of March 2020, the Ebola outbreak in North Kivu and Ituri in the Democratic Republic of Congo (DRC) had claimed more than 2,200 lives. Women and girls make up 56% of the almost 3,500 confirmed cases. Stopping transmission of the virus has been the primary focus for the Ministry of Health and responding agencies, often to the detriment of other critical health services, including sexual and reproductive health (SRH).

Women, girls, men and boys continue to have SRH needs during conflicts and epidemics. Physiologically, women and girls bleed: due to menstruation, the side-effects of family planning and during abortions or obstetric emergencies. The case definition for Ebola includes ‘spontaneous abortion’ and ‘unexplained bleeding’ as criteria for isolation and testing. There is also significant overlap between the vague presenting symptoms of Ebola and pregnancy complications. The broad application of the case definition can therefore result in women and girls being prevented or delayed from getting appropriate (sometimes life-saving) care for non-Ebola health conditions, out of an overabundance of caution.

Assessment of the impact of Ebola on SRH in DRC

Between October and December 2019, the IRC conducted a programme assessment to document how the current DRC outbreak has impacted SRH access and provision, in order to develop concrete recommendations for this and future outbreaks. The assessment, which took place in five Ebola-affected health zones in North Kivu, involved group discussions and individual interviews with 120 people. Three routine health facilities were also evaluated for their SRH and Ebola readiness, and the team visited one Ebola Treatment Centre (ETC).

The assessment was structured around the Interagency Working Group for Reproductive Health in Crises’ Minimum Initial Service Package (MISP), a package of life-saving services implemented at the start of a humanitarian crisis to minimise negative SRH consequences, including maternal mortality and morbidity. Overall, it found that most SRH services were negatively affected by the outbreak. However, the negative effects of the outbreak on SRH have been mitigated over time in the 18 months since the start of the outbreak, with increased community sensitisation, testimonials from Ebola survivors about their treatment experience and deliberate hiring of Ebola response workers from local areas.

Activity 1: Identification of an agency to lead the implementation of the MISP

Under the pre-existing humanitarian response in conflicta ffected North Kivu, UNFPA was the designated lead SRH agency. However, Ebola coordination takes place parallel to the health cluster, with little interaction between the two, resulting in SRH being neglected in the face of the Ebola response. As one respondent put it: ‘We have the small voice of SRH, it’s hard to make your voice heard with all of the millions of [Ebola] money’. SRH-focused organisations may also fail to adapt their approach during Ebola, as they can suffer the same tunnel vision where they only see pre-existing SRH needs, without considering the added complexities created by the parallel coordination structure.

Activity 2: Prevent and manage the consequences of sexual violence

Protracted conflict drives pervasive sexual violence in North Kivu. Access to care for survivors of sexual violence has been affected, with healthcare workers describing survivors avoiding or delaying care.

Activity 3: Reduce transmission, mortality and morbidity from HIV and other STIs

The outbreak does not seem to have affected testing and treatment for HIV in routine (non-Ebola) healthcare facilities. However, such services were lacking in ETCs, with one informant admitting that HIV care had not been considered in their organisation’s ETC. STI testing and treatment appear to have benefited from the outbreak, with significant increases likely linked to Ebola-related free healthcare initiatives.

Scientific knowledge about the sexual transmission of Ebola continues to be debated. This has resulted in contradictory messages from response actors to communities, and confusion about how long Ebola survivors are thought to be able to transmit, with community members stating that Ebola could be transmitted sexually from 250 days to two years. Note: the length of time Ebola survivors can transmit could be up to 18 months, but the evidence is still in flux: see www.mdpi.com/1999-4915/10/12/683/htm. In a context where condom use is historically low, several respondents believed that the use of condoms was of increased importance during the Ebola outbreak: ‘More people are using condoms now in this Ebola time, because people are afraid of Ebola so they want to prevent’.

Activity 4: Prevent excess maternal and newborn morbidity and mortality

The Ebola outbreak has significantly affected women’s ability to seek timely care for pregnancy complications, with consequent impacts on the woman and the foetus. Maternal mortality is often attributed to delays in deciding to seek, gain access to and receive appropriate healthcare. This is known as the ‘Three Delays Model’, though the assessment found that the outbreak had added further delays:

• Delay 1: The fear of being sent away to the ETC for testing, or fear of catching Ebola at the health facility, deters women from seeking care for routine and emergency healthcare needs. ‘They come late because they are afraid of the Ebola so that’s why they delay.’

• Delay 2: It can take additional time to travel to a healthcare facility due to Ebola screening posts along major roads. Women may initially choose to go to a traditional healer, or to a pharmacy to seek medicine, out of fear of being sent to the ETC. Health facilities may also close temporarily during periods of heightened insecurity, further hampering women’s access to appropriate care: ‘She was very afraid to give birth because when she came to the health clinic they had closed for a week [due to healthcare workers having to flee violence], so she had to travel to the [large hospital] to deliver … by the time she got there after walking for a long time she delivered her baby within an hour’.
• Delay 3: On arriving at a health facility, women are triaged for signs or symptoms of Ebola, and if they meet the case definition they will be isolated (for the safety of staff and other patients), while waiting to be transferred to the ETC for testing. The broad crossover of pregnancy symptoms and the Ebola case definition, and the fact that some healthcare workers are not confident triaging, means that many pregnant women with complications are isolated. While in isolation, they may or may not be provided with an appropriate level of care for their health condition.

• Delay 4: If a woman needs to be transferred to the ETC for testing, the ambulance can take up to an hour to reach her, with further delays while she travels to the ETC. In some facilities it is possible to do a local blood test to check for Ebola, but the results may take several hours.
• Delay 5: Women experiencing pregnancy complications who are transferred to an ETC still require obstetric care, and many will not be Ebola-positive. In an ETC dataset with admissions up until October 2019, of the 426 pregnant women who were referred for Ebola virus testing (EVD): 15% had EVD, the rest had a non-EVD cause for their symptoms. Final test results can take from six to 48 hours from admission, resulting in cases where women who test negative are still in the ETC when they go into labour. Decisions around offering obstetric interventions varied between ETCs. Deciding to take a suspected or confirmed Ebola patient for an invasive procedure (like a cesarean section) is complex where the safety of healthcare workers must be carefully considered.

Activity 5: Prevention of unintended pregnancy

Many women and men stated that ‘Ebola time is a good time to plan your family. The women can take the [contraceptive] methods now and have another baby after the outbreak’. A number of women (including healthcare workers) reported using various pregnancy prevention methods for fear of being sent to the ETC should they have pregnancy complications. Unfortunately, the full range of modern contraceptives was not provided in ETCs (for patients or healthcare workers) and were rarely available at primary health care facilities.

Activity 6: Plan for comprehensive SRH integrated in primary healthcare services

Although access to SRH services has improved, key gaps remain in the access to and quality of comprehensive SRH services at the primary care level. Healthcare workers reported that the Ebola outbreak had improved some aspects of care at their facilities, mainly related to infection prevention and control (IPC), and they are eager that these improvements should be maintained post-outbreak.

Other priority activity: safe abortion care should be made available to the full extent of the law

The DRC ratified the Maputo protocol in 2018, making access to safe abortion care legal in some circumstances. It was not clear if the Ebola outbreak had increased or decreased the number of women inducing an unsafe abortion, though as one healthcare worker noted: ‘Since the start of the epidemic all bleeding is a suspect [Ebola case]. Even when it’s an abortion, even if you induced your own abortion, it’s a suspect [Ebola case]’. The assessment found that some ETCs have appropriate medication and equipment to provide safe abortion care, but it was not clear if protocols for this existed and safe abortion care was largely unavailable at primary health care facilities and ETCs.

Recommendations

These recommendations were developed to improve SRH care during the current DRC outbreak, but should also be considered in preparedness efforts for future outbreaks of Ebola and other viral hemorrhagic fevers.

1. SRH services should be embedded in Ebola response from the outset, ensuring the mainstreaming of SRH within the response, together with Ebola-sensitive SRH services. The MISP should be activated, with the transition to comprehensive SRH services as soon as possible.
2. Reduce delays at every stage of the patient journey, particularly for women experiencing obstetric complications. Work with the Ebola response coordination structure to ensure that triage processes and care for pregnant women in ETCs reduce unnecessary delays in receiving appropriate care, while maintaining a universal level of IPC. Rapid Ebola testing and novel Ebola prevention and care technologies should be offered to pregnant women where possible. Positive messaging about improved survival for early careseeking (for pregnancy complications and Ebola) and policies to facilitate this behaviour (i.e. free healthcare) should be implemented.
3. Mitigate SRH risks during and after Ebola outbreaks by providing modern family planning methods and comprehensive abortion care at routine health services and in ETCs for those who choose to delay or terminate pregnancy. Uninterrupted HIV care should be provided at ETCs. Condom use should be promoted to reduce STIs and sexual Ebola transmission for Ebola survivors and the general population, particularly for people who sell sex or who are at risk of commercial sexual exploitation. Messages about sexual transmission of Ebola should be harmonised and non-stigmatising.
4. Evidence-based guidelines for SRH care in an Ebola context must be developed by experts from relevant fields, and must include the delivery of services in ETCs, in routine health facilities and in communities. These guidelines must be made available to frontline staff (in a variety of languages) and regularly updated with new evidence.

Conclusion

Outbreaks of viral hemorrhagic fevers are unlikely to become less frequent in future. Uptake of recommendations from assessments like this one are imperative to ensure we do not continue to make the same mistakes, neglecting critical aspects of routine healthcare when the efforts and energy of the humanitarian health community are focused on stopping transmission of a novel pathogen. Meeting the SRH needs of communities, especially women and girls, during an outbreak is crucial to prevent excess morbidity and mortality.

Gillian McKay is a global health consultant. Benjamin Black is an obstetric and gynaecology humanitarian advisor. Alice Janvrin and Erin Wheeler are with the International Rescue Committee. To read the (much more comprehensive) programme assessment, go to www.rescue.org/report/not-all-bleeds-ebola-how-drc-outbreak-impacts-reproductive-health.