Written Friday March 6
On the day Abass died, I was on my way back to Freetown where I have been assigned to work at the holding center for pregnant women for the rest of my time here. Let me explain what that means:
With limited resources, it isn’t feasible to have Ebola Treatment Units in every town in Sierra Leone. Ebola Holding Units are used to isolate and treat suspected patients until their Ebola status can be confirmed. EHUs are peppered around the country, and patients with a wide variety of maladies show up there to be triaged to see if they fit the case definition for Ebola. If they do not, they will either be sent home or referred to a government hospital for further care. If they do show symptoms that make clinicians suspect they have Ebola, they are admitted to the holding unit and cared for until their Ebola blood test (called a PCR) comes back. Depending on the center, a PCR result can take anywhere from several hours to several days. The patients whose results come back positive are then transferred to a full Ebola Treatment Unit for care.
The holding unit where I now work is specifically for pregnant women, and it is the only one in the country. Even before Ebola, the state of obstetric care in Sierra Leone was abysmal. In 2010, one in every eighty-three women died in childbirth (that’s forty times higher than in the US). Since the outbreak, pregnant women have been completely abandoned.
The problem is that labor and common complications of pregnancy can look frighteningly like Ebola. If a pregnant woman showed up to triage in America complaining of abdominal pain, weakness, and nausea, we would assume she was in labor. But here, among healthcare workers who have watched their colleagues die, everyone sees Ebola. They also know that the mortality rate among pregnant woman with Ebola is nearly 100%, and with limited resources, a case can be made that time and medicine would be better spent on someone who has a chance of surviving. Add to that the fact that the viral load in the fetus, placenta, and amniotic fluid is very high (and even a normal labor is a very messy processs involving a LOT of bodily fluids), and suddenly a woman in labor looks like a bomb about to go off.
As a result, many pregnant woman have been isolated and essentially left to die since the outbreak began. Princess Christian Maternity Hospital (PCMH) is the only hospital for pregnant women in the entire country, and descriptions of it during the height of the outbreak are horrifying. A New Yorker article from last October makes it sound like hell on earth: “Inside the ward, a woman writhed and groaned on the floor in a pool of bleach and bloody diarrhea, a full body bag lying next to her. Staff entered and exited without properly donning protective gear. There was a shortage of numerous supplies, and used equipment was being discarded in a hole dug outside. A woman wandered between rooms, holding her dead infant.”
Since then, the situation at PCMH has improved, although it is still by no means ideal. On the compound that PCMH shares with the children’s hospital, PIH staff now help run a holding unit to care for pregnant women who would otherwise be turned away. The main hospital now cares only for pregnant women who are clearly Ebola negative; the others come to us.
Our unit is housed in what used to be the radiology building. Like Maforki ETU, the nurses station and donning and doffing areas have been added on to the original structure with tarps and wood. We have enough beds for nine women in three rooms, plus two little rooms with a bed in each designated for deliveries. There are six international PIH staff, and plenty of national nurses. Our family practice doctor leaves tomorrow, so for now we nurses will run the show.
In our small unit next door to the full hospital, we do the best we can to keep these women alive until they can receive proper care. Because we can’t be sure which patients are having common labor complications and which have Ebola, we do all of our care (and if necessary, deliveries) in full PPE. Although some of our patients do turn up positive (one this week and two the week before), we see many more complicated labors than we do Ebola. Unfortunately, the only way to distinguish between the two is to do a PCR blood test. A lab run by the Dutch has recently arrived on-site that can process our samples in several hours, but before that it could take days. On my third day at the holding unit, the Dutch lab’s generator was broken so no tests were being processed.
Unfortunately, the time it takes to get Ebola test results is the difference between life and death for many moms and their babies. If a woman shows up at triage hemorrhaging, for example, in America she would have an emergency cesarean section to save the lives of her and her baby. Here, bleeding is a sign of Ebola, so she must first come to our holding unit. No one will perform a c-section on a woman suspected of having Ebola. It would be too risky for the staff, and if she did have Ebola she would likely bleed to death during the surgery anyway. But for those woman who arrive likely bleeding because of a placenta previa or a uterine rupture, we hope we can keep them stable long enough to prove they are Ebola negative and get them to the operating room.
To make the situation worse, prenatal care has halted along with the rest of the country’s health systems since the outbreak began. Aminata* is a perfect example of this. She was the first patient I cared for at PCMH holding unit, and when I first saw her she was lying on the ground next to her bed, barely conscious. She had arrived at the hospital eclamptic – a condition of pregnancy in which high blood pressure causes seizures (for reference, I usually tell people that eclampsia is what Sybil died of in Downton Abbey, which, it’s worth noting, was 100 years ago). I have never seen an eclamptic patient in America. Because our moms get consistent prenatal care, the warning signs are identified early and I often see pregnant woman with PRE-eclampsia (essentially, we have caught them before the condition is serious enough to cause a seizure). In Sierra Leone, no one is caught at the pre-eclampsia stage.
Aminata had come to traige unconscious, and because she was living in a home that was quarantined due to contact with an Ebola case, no one at the main hospital would touch her. She was admitted to our holding center, and the national nurses reported that they had delivered her baby vaginally overnight, while she was still unconscious. Her first PCR had come back negative, but because she had come from a quarantined home, protocol required that she have another test three days later before the main hospital would take her or her baby.
When I found Aminata lying on the floor, her little baby boy was wrapped in a lapa on her mattress a few feet away from her. She was not aware enough to know that he’d been born. My colleague and I lifted her onto the mattress and began to clean her up when I saw her eyes roll back into her head and her eyelids begin to flutter. I knew what was happening only from books, and it took me a moment to process that I was seeing my first eclamptic seizure. A second later her arms began to twitch, and her whole body followed. I turned her onto her side while my colleague shouted out to the Green Zone for medications. A minute passed, maybe two. Aminata continued to seize while we waited for medications to be drawn up and handed in to us. I felt like I was in a nightmare.
Aminata’s seizure spontaneously resolved just before her medications arrived. Among other things, we treated her with intramuscular injections of magnesium sulfate, though in the US she would have been on an IV drip under constant supervision. In an Ebola holding unit, where the heat often drives us out of our suits and away from our patients in under an hour, there is no way to continuously monitor an extremely ill woman. There are also no IV pumps to make sure the exact dose is administered, and no lab testing to check the level of magnesium in her blood.
Despite all this, Aminata has come around. One of the PIH-ers who has been working at PCMH for weeks told me that they often see good outcomes in eclamptic mothers, despite their shockingly late arrival for treatment. When I visited Aminata yesterday she was lethargic but completely conscious, a huge improvement from the day before. I unwrapped her baby and put him on her bare chest, and she stared down at him in wonder.
Unfortunately these two are not out of the woods yet. The little boy is small (to the naked eye, anyway; we don’t have an infant scale) and not interested in breastfeeding. We have been feeding him formula while we encourage Aminata to keep trying, but it’s not a viable long-term solution for a woman who can’t afford the formula, let alone clean water to mix it with. But soon their fate will be out of our hands. Aminata’s second Ebola test came back negative, so we cannot keep her in our unit any longer. The day before, the woman in the bed next to her turned out to be Ebola positive. Every minute Aminata spends in our holding unit puts her and her baby at risk for catching Ebola from someone else. Aminata is no longer ill enough to be admitted to the main maternity hospital, so she’ll go home with her family tonight. In America, I would refer her to a lactation specialist to make sure her baby eats and gains enough weight. Here, there’s no such thing.
The sad truth about this job is that I can take on my own small role, and nothing more. I wish I had the time and resources to follow up on Aminata, but in reality I barely have a moment to chart on the care I gave her, before some other issue falls at my feet. Yesterday one of the lab personnel saw a pregnant woman wandering around alone in the hospital compound, vomiting. Without touching her, she guided her to our holding unit, where the 17-year-old told our nurses that her mother, father, sister, and brother had died of Ebola. She said she had come to the hospital when she started to have vomiting and diarrhea, and had been turned away at triage. For the past three days, she had been sleeping in the hospital compound, being sick in the lab stairwell.
After a fair amount of horror at the idea that an Ebola-positive young woman had been wandering around the compound spreading infectious fluids everywhere, we got to the bottom of her story. Her family had actually passed away three months ago, longer than the incubation period, so she hadn’t really had Ebola contact. If she was going to catch Ebola from her relatives, she would have gotten sick in the first 21 days. The nurses at triage confirmed that they had seen her and turned her away since she didn’t meet case definition: Her vital signs were fine, no fever, just a pregnant woman with morning sickness. She’d told them that the person she was staying with since her family died had kicked her out of the house, and she had essentially turned up at the hospital out of desperation.
We all breathed a little easier knowing that, based on her history, it was unlikely that she had Ebola. Her blood test came back later that day and confirmed that she was negative. Like Aminata, this young woman now poses a problem that we aren’t equipped to solve. She insists that she has no place to go and no one to turn to now that we must discharge her. With no social worker and no idea what options we have, we PIH-ers turned to the national staff to help us come up with a solution for her. The last I heard before I head to leave for the day was that the staff was collecting some money for her. She’ll get her discharge package from us (clothes, medicines, and a certificate saying she tested negative for Ebola) and presumably they’ll send her on her way.
As the Ebola outbreak gets under control and the Sierra Leonean government attempts to return to normal healthcare, the issue of pregnant women will continue to be a problem. No one quite knows what to do with them. Over dinner tonight we got a call asking us to admit a woman in labor coming from a quarantined home. My colleague asked the usual questions, trying to get a sense of how likely it was that the woman had Ebola. As she untangled the story, it turned out that this woman was not in fact in labor – just very pregnant, and looking like she was about to pop. She had no symptoms of Ebola, no fever, no indication that she was sick at all. But she was hours away in Port Loko district in a quarantined home, looking like she might go into labor at any moment and making everyone very nervous. Couldn’t we just hold on to her until she went into labor?
The trouble with pregnant women in the setting of Ebola is that they’re all in a gray area. If this woman had not been pregnant, she would have remained quarantined in her home and only been brought to a holding center if she began to show symptoms. According to case defintion, she has no business being in a treatment center. But when she goes into labor, who will care for her? With no maternity care available in Port Loko, can we reasonably ask an untrained traditional birth attendant to do this delivery without PPE under the assumption that the mother is Ebola negative? If we tell her to come to our unit when she goes into labor, will she get here in time?
No matter what decision we make, it won’t affect just this one woman. We’re told there are actually ten women in quarantined homes in Port Loko in various stages of pregnancy. We can’t take them all at our holding unit. They would more than fill all of our beds, and we would have no space to care for the women from Freetown who continue to show up needing care. Much as we’d like to, we can’t take on all the pregnant women in Sierra Leone in day. We are at ground zero for rebuilding maternal care in this country, doing the best we can one day and one patient at at time.
*Names changed to protect privacy