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The post-Ebola baby boom: time to strengthen health systems

2016; Elsevier BV; Volume: 388; Issue: 10058 Linguagem: Inglês

10.1016/s0140-6736(16)31895-5

1474-547X

Ryan McBain, Eugene Wickett, Jean Claude Mugunga, Jason Beste, Patrick Konwloh, Joia S. Mukherjee,

Global Security and Public Health

The west African Ebola virus disease epidemic was the most catastrophic and far-reaching Ebola outbreak to date, resulting in more than 11 000 deaths and generating case fatality rates as high as 70%.1WHOER TeamEbola virus disease in west Africa—the first 9 months of the epidemic and forward projections.N Engl J Med. 2014; 371: 1481-1495Crossref PubMed Scopus (1158) Google Scholar Liberia alone exceeded 10 000 confirmed cases, with close to half of patients infected (4810) dying.2Centers for Disease Control and Prevention2014 Ebola outbreak in west Africa—case counts. Centers for Disease Control and Prevention, Atlanta, GA2016Google Scholar In 2015, WHO released guidelines for declaring the end of the outbreak,3WHOCriteria for declaring the end of the Ebola outbreak in Guinea, Liberia or Sierra Leone. World Health Organization, Geneva2015Google Scholar and on May 9, 2015, WHO announced that Liberia had officially passed the established criteria. Over the course of the epidemic, attention was drawn to the weak health systems that existed in the preceding years and decades.4Gostin LO Friedman EA A retrospective and prospective analysis of the west African Ebola virus disease epidemic: robust national health systems at the foundation and an empowered WHO at the apex.Lancet. 2015; 385: 1902-1909Summary Full Text Full Text PDF PubMed Scopus (133) Google Scholar There was also broad consensus within the global health community concerning the need for greater investment in health-system strengthening to reduce the potential for similar outbreaks in the future.5Gostin LO Ebola: towards an International Health Systems Fund.Lancet. 2014; 384: e49-e51Summary Full Text Full Text PDF PubMed Scopus (62) Google Scholar Evidence here, using data from the Liberian Ministry of Health's health management information system,6Liberia Ministry of Health and Social WelfareLiberia Health Management Information System.http://liberia.dhis2.org/dhis/dhis-web-commons/security/login.actionDate: 2016Google Scholar indicates two main effects of the Ebola epidemic on facility childbirths in Liberia. First, in the initial 6 months of the outbreak in Liberia—between March and August, 2014—facility-based childbirths sharply declined. This decrease was likely to be caused by fear of delivery at facilities where Ebola was present, closure of facilities, and fear of transmission of the disease through physical contact. Second, the May, 2015, declaration of Liberia being Ebola-free has translated to a short-term baby boom, or temporary spike in the country's facility-based childbirth rate. Over the past 5 months, Liberia has observed a 33% increase in the number of deliveries by skilled birth attendants, compared with the preceding 17 months (figure). This marked increase, beginning in February, 2016, coincides with a 9-month interval—the gestational period for a full-term pregnancy—following Liberia's first declaration of being Ebola-free. By use of routinely obtained local data from the Ministry of Health and interrupted time series analysis (ITSA),7Linden A Conducting interrupted time-series analysis for single-and multiple-group comparisons.Stata J. 2015; 15: 480-500Crossref Google Scholar we found both these trends to be significant at the country level. Part of the observed increase in facility-based childbirths could be due to reinstatement of routine services and improved access to care as greater resources were invested in health facilities after the epidemic. However, the 9-month lag in childbirths in health facilities, and the magnitude and suddenness of the increase, suggest that Liberia is undergoing a demographic change corresponding with the cessation of the outbreak. This has substantial implications for the health systems in Liberia and its neighbouring countries, Sierra Leone and Guinea. First, it should be said that the baby boom might have been anticipated by historical instances in which factors like disease, war, and displacement have led to temporary spikes in birth rates. In the context of Liberia, fertility rates have been in steady decline over the past 10 years, a reflection of ongoing demographic and epidemiological transitions.8World BankFertility rate, total (births per woman).http://data.worldbank.org/indicator/SP.DYN.TFRT.IN?locations=LRDate: 2016Google Scholar However, these data indicate a reversal in these trends, and suggest that Sierra Leone can also anticipate an increase in facility births over coming months, as it was declared Ebola-free several months after Liberia. Second, from a health systems perspective, the influx of health facility childbirths places immediate constraints on a system that is already weak and in need of continued international support. Liberia has one of the highest maternal mortality rates in the world.9World BankMaternal mortality ratio (modeled estimate, per 100 000 live births).http://data.worldbank.org/indicator/SH.STA.MMRT?locations=LRDate: 2016Google Scholar Given the increased number of births observed, now is a pivotal time for the international community to invest in the strengthening of health systems. In the wake of the Ebola epidemic, international health organisations and funders have withdrawn from the landscape; and in just the past several months the US Government has diverted over US$500 million in Ebola relief efforts to combat Zika virus.10Howell Jr, T Democrats blame GOP for Obama administration's painful cuts to fund Zika trials.The Washington Times. Aug 15, 2016; Google Scholar Finally, looking prospectively, these data serve as a reminder that efforts to strengthen health systems should serve to equip countries like Liberia over the long term, including for the thousands of newborns delivered in just the past several months. Research on the so-called demographic dividend of baby booms shows that countries with robust health and education systems that are equipped for such events can harness them to have dramatic, positive effects on overall economic growth.11Bloom DE Canning D Policy forum: public health. The health and wealth of nations.Science. 2000; 287: 1207-1209Crossref PubMed Scopus (439) Google Scholar In the short term, efforts to strengthen the cascade of health care—including programmes targeting maternal mortality and deaths of children younger than 5 years—should be an important focus of attention, funding, and intervention. Otherwise, health systems that continue to be ill equipped to handle this baby boom will be an unfortunate legacy of the Ebola epidemic and future infectious disease outbreaks. We declare no competing interests.