title: The Impact of the West Africa Ebola Outbreak on Obstetric Health Care in Sierra Leone.
abstract: BACKGROUND
  As Sierra Leone celebrates the end of the Ebola Virus Disease (EVD) outbreak, we can begin to fully grasp its impact on already weak health systems. The EVD outbreak in West Africa forced many hospitals to close down or reduce their activity, either to prevent nosocomial transmission or because of staff shortages. The aim of this study is to assess the potential impact of EVD on nationwide access to obstetric care in Sierra Leone.
  
  
  RESULTS
  Community health officers collected weekly data between January 2014-May 2015 on in-hospital deliveries and caesarean sections (C-sections) from all open facilities (public, private for-profit and private non-profit sectors) offering emergency obstetrics in Sierra Leone. This was compared to official data of EVD cases per district. Logistic and Poisson regression analyses were used to compute risk and rate estimates. Nationwide, the number of in-hospital deliveries and C-sections decreased by over 20% during the EVD outbreak. The decline occurred early on in the EVD outbreak and was mainly attributable to the closing of private not-for-profit hospitals rather than government facilities. Due to difficulties in collecting data in the midst of an epidemic, limitations of this study include some missing data points.
  
  
  CONCLUSIONS
  Both the number of in-hospital deliveries and C-sections substantially declined shortly after the onset of the EVD outbreak. Since access to emergency obstetric care, like C-sections, is associated with decreased maternal mortality, many women are likely to have died due to the reduced access to appropriate care during childbirth. Future research on indirect health effects of health system breakdown should ideally be nationwide and continue also into the recovery phase. It is also important to understand the mechanisms behind the deterioration so that important health services can be reestablished.
authors.affiliation: Department of Public Health Sciences, Karolinska Institutet, Stockholm, Sweden.
authors.forename: Kim J
authors.initials: KJ
authors.lastname: Brolin Ribacke
authors.affiliation: Department of Surgery, St Olav Hospital, Trondheim, Norway.|CapaCare, Trondheim, Norway.
authors.forename: Alex J
authors.initials: AJ
authors.lastname: van Duinen
authors.affiliation: Department of Public Health Sciences, Karolinska Institutet, Stockholm, Sweden.
authors.forename: Helena
authors.initials: H
authors.lastname: Nordenstedt
authors.affiliation: Unit of Biostatistics, Institute of Environmental Medicine, Karolinska Institutet, Stockholm, Sweden.
authors.forename: Jonas
authors.initials: J
authors.lastname: Höijer
authors.affiliation: Department of Public Health and General Practice, Norwegian University of Science and Technology, Trondheim, Norway.
authors.forename: Ragnhild
authors.initials: R
authors.lastname: Molnes
authors.affiliation: Department of Public Health and General Practice, Norwegian University of Science and Technology, Trondheim, Norway.
authors.forename: Torunn Wigum
authors.initials: TW
authors.lastname: Froseth
authors.affiliation: Ministry of Health and Sanitation, Freetown, Sierra Leone.
authors.forename: A P
authors.initials: AP
authors.lastname: Koroma
authors.affiliation: Department of Public Health and General Practice, Norwegian University of Science and Technology, Trondheim, Norway.|Department of Obstetrics and Gynaecology, St Olav Hospital, Trondheim, Norway.
authors.forename: Elisabeth
authors.initials: E
authors.lastname: Darj
authors.affiliation: Department of Surgery, St Olav Hospital, Trondheim, Norway.|CapaCare, Trondheim, Norway.|Department of Cancer Research and Molecular Medicine, Norwegian University of Science and Technology, Trondheim, Norway.
authors.forename: Håkon Angel
authors.initials: HA
authors.lastname: Bolkan
authors.affiliation: Department of Public Health Sciences, Karolinska Institutet, Stockholm, Sweden.|Department of Infectious Diseases, Karolinska University Hospital, Stockholm, Sweden.
authors.forename: AnnaMia
authors.initials: A
authors.lastname: Ekström
mesh_terms: D000328:Adult; D003695:Delivery of Health Care; D036861:Delivery, Obstetric; D004196:Disease Outbreaks; D005260:Female; D019142:Hemorrhagic Fever, Ebola / Q000453:epidemiology*; D006801:Humans; D009774:Obstetrics; D012807:Sierra Leone / Q000453:epidemiology