Obstetric interventions during an Ebola epidemic are deeply challenging say two new commentaries published today (14 January) in BJOG: An International Journal of Obstetrics and Gynaecology (BJOG).
Dr Benjamin Black, a specialist registrar in obstetrics and gynaecology, who has been working in Sierra Leone with Médecins Sans Frontières (MSF), describes in the first commentary, the situation and dilemmas facing healthcare workers working in West Africa within an Ebola epidemic, where maternity services are already limited and maternal mortality rates are high.
Ebola is highly infectious and is spread through contact with human bodily fluids. Women are a high risk group in terms of possible exposure to the virus and subsequently transmitting it due to their predominant caregiver role.
Dr Black states that one of the biggest challenges facing healthcare workers is differentiating between a woman presenting with an obstetric emergency, where prompt intervention is necessary and potentially life-saving, and one who may have suspected Ebola and where invasive procedures should be limited.
He also states that due to the nature of obstetrics, healthcare workers are exposed to bodily fluids such as blood, amniotic fluid, urine and faeces placing them at very high-risk of transmission.
Moreover, he states that there is insufficient evidence around asymptomatic pregnant women who would normally be classified as non-contagious, for example if a woman exhibits symptoms shortly after a caesarean section.
Dr Black also discusses the situation in Ebola-affected regions where health structures are deserted of staff and patients. Many healthcare staff have died from the virus or many fear working and have turned to industrial action.
He concludes by saying: "Denying people adequate access to healthcare is a violation of their human rights, however, obstetric interventions are deeply challenging. Meeting the maternal health needs in the region while the epidemic is ongoing will require continual assessment of minimising the risk to healthcare workers whilst enabling them to provide much needed lifesaving care."
The second commentary by three Public Health England (PHE) authors also discusses Ebola in pregnancy and considers what evidence exists in relation to risks and clinical outcomes with a focus on breastfeeding and transmission of the disease, fetal infection through the placenta, pregnancy outcomes and neonatal outcomes.
The commentary states that much of our understanding of Ebola comes from previous outbreaks in resource-limited settings in Africa, a very different healthcare context to the UK.
It emphasises that there is limited evidence underpinning our knowledge with very few studies reporting on maternal and fetal outcomes. While high neonatal mortality rates have been previously reported, it hasn't always been known whether these deaths were caused by Ebola or the many other causes of high infant mortality.
Dr Aileen Kitching, from Public Health England and co-author of the commentary, has previously worked as a clinician with MSF in Liberia. She said:
"The current Ebola outbreak, the worst since Ebola was identified in 1976, provides a stark reminder of the human consequences of the disease.
"As we learn more about the disease and transmission, we must continually review our approach to its management based on the latest evidence. It is a huge challenge meeting the complex maternal health needs in West Africa whilst protecting healthcare workers during this epidemic."
John Thorp, BJOG Deputy Editor-in-chief, added:
"The Ebola outbreak is devastating for the region and these two powerful commentaries provide fresh insight into the challenges facing those practicing obstetrics and delivering care in an incredibly difficult situation with limited resources."