”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

These findings reflect previously reported sources of motivations during EVD: professional duty, religion and responsibility for one's community. [38] [39] [40] Similar motivations have been reported in other studies by rural midwives, who also continued to offer basic maternity services during the EVD outbreak. 38 39 In addition, community health officers bridged primary healthcare efforts to the formal health systems, partly thanks to internal motivation but also because of their customary high standing in the community. 40 These narratives challenge the literature on staff morale in emergencies. Previously, concern for self and family has been suggested to outweigh professional duties during disasters, the so called 'disaster dilemma'. 41 In comparison, it is remarkable that at least one of our study participants even lied to the family about performing surgery. These intrinsic motivations might explain the remarkable productivity demonstrated by surgical care providers in Sierra Leone during EVD. 22 Although late, the international EVD response facilitated surgery at a stage when individual adaptations and improvisation could not further increase CS rates. Staff reported that the scale-up of the global response with rapid EVD tests, protocols, materials and IPC helped to maintain CS services. [42] [43] [44] Although financial motivations were not specifically assessed in this study, previous experience and reports from Sierra Leone indicate that the lack of regular salary payment and shortage of financial incentives caused significant problems, even riots and strikes among healthcare providers. 45 46 Adapting to clinical challenges This study also found that CS providers adapted stepwise to the obstacles posed by the EVD outbreak. Individual efforts were central to CS provision, as surgical champions had to work around pre-existing challenges, such as the shortages of protective gear, safety procedures and surgically skilled providers. CS providers minimised touching, reduced operation durations, isolated suspected EVD cases and postponed elective surgery, thereby minimising potential EVD exposure while allowing some degree of surgical activity.