title: Facility-Based Delivery during the Ebola Virus Disease Epidemic in Rural Liberia: Analysis from a Cross-Sectional, Population-Based Household Survey.
abstract: The Ebola virus disease (EVD) epidemic has threatened access to basic health services through facility closures, resource diversion, and decreased demand due to community fear and distrust. While modeling studies have attempted to estimate the impact of these disruptions, no studies have yet utilized population-based survey data.
  
  
  
  We conducted a two-stage, cluster-sample household survey in Rivercess County, Liberia, in March-April 2015, which included a maternal and reproductive health module. We constructed a retrospective cohort of births beginning 4 y before the first day of survey administration (beginning March 24, 2011). We then fit logistic regression models to estimate associations between our primary outcome, facility-based delivery (FBD), and time period, defined as the pre-EVD period (March 24, 2011-June 14, 2014) or EVD period (June 15, 2014-April 13, 2015). We fit both univariable and multivariable models, adjusted for known predictors of facility delivery, accounting for clustering using linearized standard errors. To strengthen causal inference, we also conducted stratified analyses to assess changes in FBD by whether respondents believed that health facility attendance was an EVD risk factor. A total of 1,298 women from 941 households completed the survey. Median age at the time of survey was 29 y, and over 80% had a primary education or less. There were 686 births reported in the pre-EVD period and 212 in the EVD period. The unadjusted odds ratio of facility-based delivery in the EVD period was 0.66 (95% confidence interval [CI] 0.48-0.90, p-value = 0.010). Adjustment for potential confounders did not change the observed association, either in the principal model (adjusted odds ratio [AOR] = 0.70, 95%CI 0.50-0.98, p = 0.037) or a fully adjusted model (AOR = 0.69, 95%CI 0.50-0.97, p = 0.033). The association was robust in sensitivity analyses. The reduction in FBD during the EVD period was observed among those reporting a belief that health facilities are or may be a source of Ebola transmission (AOR = 0.59, 95%CI 0.36-0.97, p = 0.038), but not those without such a belief (AOR = 0.90, 95%CI 0.59-1.37, p = 0.612). Limitations include the possibility of FBD secular trends coincident with the EVD period, recall errors, and social desirability bias.
  
  
  
  We detected a 30% decreased odds of FBD after the start of EVD in a rural Liberian county with relatively few cases. Because health facilities never closed in Rivercess County, this estimate may under-approximate the effect seen in the most heavily affected areas. These are the first population-based survey data to show collateral disruptions to facility-based delivery caused by the West African EVD epidemic, and they reinforce the need to consider the full spectrum of implications caused by public health emergencies.
authors.affiliation: Medical Team, Last Mile Health, Zwedru, Liberia.
authors.forename: John
authors.initials: J
authors.lastname: Ly
authors.affiliation: Monitoring and Evaluation Team, Last Mile Health, Zwedru, Liberia.
authors.forename: Vidiya
authors.initials: V
authors.lastname: Sathananthan
authors.affiliation: Monitoring and Evaluation Team, Last Mile Health, Zwedru, Liberia.
authors.forename: Thomas
authors.initials: T
authors.lastname: Griffiths
authors.affiliation: Division of Global Health Equity, Brigham and Women's Hospital, Boston, Massachusetts, United States of America.
authors.forename: Zahir
authors.initials: Z
authors.lastname: Kanjee
authors.affiliation: Monitoring and Evaluation Team, Last Mile Health, Zwedru, Liberia.
authors.forename: Avi
authors.identifier: 0000-0002-9465-7307
authors.initials: A
authors.lastname: Kenny
authors.affiliation: Monitoring and Evaluation Team, Last Mile Health, Zwedru, Liberia.
authors.forename: Nicholas
authors.identifier: 0000-0002-9570-3168
authors.initials: N
authors.lastname: Gordon
authors.affiliation: Monitoring and Evaluation Team, Last Mile Health, Zwedru, Liberia.|Cambridge Health Alliance, Cambridge, Massachusetts, United States of America.|Harvard Medical School, Boston, Massachusetts, United States of America.
authors.forename: Gaurab
authors.identifier: 0000-0002-7531-4886
authors.initials: G
authors.lastname: Basu
authors.affiliation: Implementation Team, Last Mile Health, Cestos City, Liberia.
authors.forename: Dale
authors.initials: D
authors.lastname: Battistoli
authors.affiliation: Implementation Team, Last Mile Health, Cestos City, Liberia.
authors.forename: Lorenzo
authors.initials: L
authors.lastname: Dorr
authors.affiliation: Implementation Team, Last Mile Health, Cestos City, Liberia.
authors.forename: Breeanna
authors.initials: B
authors.lastname: Lorenzen
authors.affiliation: Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts, United States of America.
authors.forename: Dana R
authors.initials: DR
authors.lastname: Thomson
authors.affiliation: Medical Team, Last Mile Health, Zwedru, Liberia.
authors.forename: Ami
authors.initials: A
authors.lastname: Waters
authors.affiliation: Rivercess County Health Team, Liberian Ministry of Health and Social Welfare, Cestos City, Liberia.
authors.forename: Uriah G
authors.identifier: 0000-0002-9822-8796
authors.initials: UG
authors.lastname: Moore
authors.affiliation: Rivercess County Health Team, Liberian Ministry of Health and Social Welfare, Cestos City, Liberia.
authors.forename: Ruth
authors.initials: R
authors.lastname: Roberts
authors.affiliation: Rivercess County Health Team, Liberian Ministry of Health and Social Welfare, Cestos City, Liberia.
authors.forename: Wilmot L
authors.initials: WL
authors.lastname: Smith
authors.affiliation: Harvard Medical School, Boston, Massachusetts, United States of America.|Center for Global Health, Massachusetts General Hospital, Boston, Massachusetts, United States of America.
authors.forename: Mark J
authors.identifier: 0000-0003-3506-842X
authors.initials: MJ
authors.lastname: Siedner
authors.affiliation: Department of Health Systems Administration, Georgetown University, Washington, DC, United States of America.|African Studies Program, Georgetown University, Washington, DC, United States of America.
authors.forename: John D
authors.initials: JD
authors.lastname: Kraemer
mesh_terms: D000328:Adult; D016000:Cluster Analysis; D036861:Delivery, Obstetric / Q000706:statistics & numerical data*; D058872:Epidemics; D005191:Family Characteristics; D005260:Female; D019142:Hemorrhagic Fever, Ebola / Q000453:epidemiology*; D006801:Humans; D007988:Liberia / Q000453:epidemiology; D008427:Maternal Health Services / Q000706:statistics & numerical data / Q000600:supply & distribution; D011247:Pregnancy; D019035:Rural Health Services / Q000706:statistics & numerical data* / Q000600:supply & distribution; D011795:Surveys and Questionnaires; D055815:Young Adult