”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

Drevin, Gustaf; Mölsted Alvesson, Helle; van Duinen, Alex; Bolkan, Håkon A; Koroma, Alimamy P; Von Schreeb, Johan

â–º Ebola is a recurring health system hazard that constitutes significant threats to healthcare staff. â–º Clear policies must be in place to ensure their protection especially for the surgical workforce. â–º Failure to better support caesarean section providers might reduce the health system's ability to provide essential life-saving surgery in times of need and expose the surgical workforce to significant danger. burden of disease caused by the epidemic, in addition to maintaining routine health services. 9 The health system of Sierra Leone, badly damaged by the 1991-2002 Civil War, consists of public, private and private not-for-profit sectors. It faced multiple barriers to effective health service delivery before the EVD outbreak affected the country in early 2014. The health workforce is unevenly distributed between rural and urban areas, and there is a shortage of specialised healthcare staff. 10 Maternal (1 360 per 100 000 live births) and under-5 (110.5 per 1 000 live births) mortality rates in Sierra Leone are among the highest globally. 11 12 Caesarean section (CS) is an essential health service that potentially saves lives when performed for the right indication. The WHO proposes that 10% of women attempting to deliver will require a CS. 13 Before the EVD outbreak, CS was the most common major surgery performed in Sierra Leone. 14 15 In 2012, the CS rate was 2.1%. 16 The high unmet need can be attributed to a number of barriers, such as lack of finances, staff, equipment and healthcare infrastructure. 14 17-21 Despite these challenges, a study found that public hospitals in Sierra Leone unexpectedly maintained or even increased CS volumes during the EVD outbreak. 22 While most studies focus on the negative impact of healthcare provision following the EVD outbreak, there is a need to increase the knowledge about successful examples of resilience. 23 In line with recent calls to understand the 'recurrent failings' of interventions in humanitarian crises and develop surgical guidelines for EVD, 7 24 25 we explore factors that influenced the continuation of CS provision at public hospitals during the 2014-2016 EVD outbreak in Sierra Leone, from the perspective of CS providers.