”For this one, let me take the risk”: why surgical staff continued to perform caesarean sections during the 2014–2016 Ebola epidemic in Sierra Leone

Abstract

IntroductionRoutine health service provision decreased during the 2014–2016 Ebola virus disease (EVD) outbreak in Sierra Leone, while caesarean section (CS) rates at public hospitals did not. It is unknown what made staff provide CS despite the risks of contracting EVD. This study explores Sierra Leonean health worker perspectives of why they continued to provide CS.MethodsThis qualitative study documents the experiences of 15 CS providers who worked during the EVD outbreak. We interviewed surgical and non-surgical CS providers who worked at public hospitals that either increased or decreased CS volumes during the outbreak. Hospitals in all four administrative areas of Sierra Leone were included. Semistructured interviews averaged 97 min and healthcare experience 21 years. Transcripts were analysed by modified framework analysis in the NVivo V.11.4.1 software.ResultsWe identified two themes that may explain why providers performed CS despite EVD risks: (1) clinical adaptability and (2) overcoming the moral dilemmas. CS providers reported being overworked and exposed to infection hazards. However, they developed clinical workarounds to the lack of surgical materials, protective equipment and standard operating procedures until the broader international response introduced formal personal protective equipment and infection prevention and control practices. CS providers reported that dutifulness and sense of responsibility for one’s community increased during EVD, which helped them justify taking the risk of being infected. Although most surgical activities were reduced to minimise staff exposure to EVD, staff at public hospitals tended to prioritise performing CS surgery for women with acute obstetric complications.ConclusionThis study found that CS surgery during EVD in Sierra Leone may be explained by remarkable decisions by individual CS providers at public hospitals. They adapted practically to material limitations exacerbated by the outbreak and overcame the moral dilemmas of performing CS despite the risk of being infected with EVD.

Barriers to maternal health services during the Ebola outbreak in three West African countries: a literature review

“…Three papers made no mention of fear or mistrust as a barrier to MHS, 13 21 22 while another recognised fear among healthcare workers (HCWs) that did not impede service provision. 23 Multidimensional fear cut across every dimension of the healthcare access framework and was experienced by MHS users and providers in Guinea, Liberia and Sierra Leone. The literature evidenced that pregnant women feared multiple aspects of engaging with healthcare: acquiring EVD at health facilities; being transferred to an EVD treatment centre; the appearance of HCWs in personal protective equipment (PPE); receiving disrespectful care; and the possible refusal of MHS.…”

“…Three papers made no mention of fear or mistrust as a barrier to MHS, 13 21 22 while another recognised fear among healthcare workers (HCWs) that did not impede service provision. 23 …”

“… 3 In Sierra Leone, Drevin et al reported that closure of private health facilities increased the burden of demand for caesarean sections in the public sector. 23 Even when facilities remained open, quarantines and travel restrictions, imposed to facilitate EVD control, worsened geographic accessibility to MHS for both service users and some non-governmental organisation (NGO)-staffed providers. 33 35…”

“…As EVD is transmitted via bodily contact with infected individuals, a strict ‘no touch’ policy was enacted in health systems across Guinea, Liberia and Sierra Leone, which posed a barrier to MHS. 27 31 35 It was reported that HCWs in some contexts did not touch patients until proven EVD negative 23 27 29 The symptoms of EVD often mimic those of obstetric emergencies, and EVD triage and screening processes were inefficient. 29 32 One study in Sierra Leone reported that the difficult differential diagnosis caused pregnant women to wait in an EVD treatment centre until proven EVD negative before they were transferred to the maternity unit.…”

Understanding the Effect of COVID-19 Pandemic on Emergency Surgical Care Delivery in India: A Multicenter Cross-Sectional Study

“…This was documented by healthcare workers' narratives in another study documenting Ebola pandemic. [22] The number of caesareans picked up and even increased within six months in the Ebola epidemic. We will need longer follow up period to assess the trends.…”