Facility-Based Delivery during the Ebola Virus Disease Epidemic in Rural Liberia

Analysis from a Cross-Sectional, Population-Based Household Survey

John Ly, Vidiya Sathananthan, Thomas Griffiths, Zahir Kanjee, Avi Kenny, Nicholas Gordon, Gaurab Basu, Dale Battistoli, Lorenzo Dorr, Breeanna Lorenzen, Dana R. Thomson, Ami Waters, Uriah G. Moore, Ruth Roberts, Wilmot L. Smith, Mark J. Siedner, John D. Kraemer

Research output: Contribution to journalArticle

17 Citations (Scopus)

Abstract

Background: The Ebola virus disease (EVD) epidemic has threatened access to basic health services through facility closures, resource diversion, and decreased demand due to community fear and distrust. While modeling studies have attempted to estimate the impact of these disruptions, no studies have yet utilized population-based survey data. Methods and Findings: We conducted a two-stage, cluster-sample household survey in Rivercess County, Liberia, in March–April 2015, which included a maternal and reproductive health module. We constructed a retrospective cohort of births beginning 4 y before the first day of survey administration (beginning March 24, 2011). We then fit logistic regression models to estimate associations between our primary outcome, facility-based delivery (FBD), and time period, defined as the pre-EVD period (March 24, 2011–June 14, 2014) or EVD period (June 15, 2014–April 13, 2015). We fit both univariable and multivariable models, adjusted for known predictors of facility delivery, accounting for clustering using linearized standard errors. To strengthen causal inference, we also conducted stratified analyses to assess changes in FBD by whether respondents believed that health facility attendance was an EVD risk factor. A total of 1,298 women from 941 households completed the survey. Median age at the time of survey was 29 y, and over 80% had a primary education or less. There were 686 births reported in the pre-EVD period and 212 in the EVD period. The unadjusted odds ratio of facility-based delivery in the EVD period was 0.66 (95% confidence interval [CI] 0.48–0.90, p-value = 0.010). Adjustment for potential confounders did not change the observed association, either in the principal model (adjusted odds ratio [AOR] = 0.70, 95%CI 0.50–0.98, p = 0.037) or a fully adjusted model (AOR = 0.69, 95%CI 0.50–0.97, p = 0.033). The association was robust in sensitivity analyses. The reduction in FBD during the EVD period was observed among those reporting a belief that health facilities are or may be a source of Ebola transmission (AOR = 0.59, 95%CI 0.36–0.97, p = 0.038), but not those without such a belief (AOR = 0.90, 95%CI 0.59–1.37, p = 0.612). Limitations include the possibility of FBD secular trends coincident with the EVD period, recall errors, and social desirability bias. Conclusions: We detected a 30% decreased odds of FBD after the start of EVD in a rural Liberian county with relatively few cases. Because health facilities never closed in Rivercess County, this estimate may under-approximate the effect seen in the most heavily affected areas. These are the first population-based survey data to show collateral disruptions to facility-based delivery caused by the West African EVD epidemic, and they reinforce the need to consider the full spectrum of implications caused by public health emergencies.

Original languageEnglish (US)
Article numbere1002096
JournalPLoS Medicine
Volume13
Issue number8
DOIs
StatePublished - Aug 1 2016

Fingerprint

Ebola Hemorrhagic Fever
Liberia
Cross-Sectional Studies
Population
Odds Ratio
Confidence Intervals
Health Facilities
Surveys and Questionnaires
Logistic Models
Parturition
Social Desirability
Reproductive Health

ASJC Scopus subject areas

  • Medicine(all)

Cite this

Facility-Based Delivery during the Ebola Virus Disease Epidemic in Rural Liberia : Analysis from a Cross-Sectional, Population-Based Household Survey. / Ly, John; Sathananthan, Vidiya; Griffiths, Thomas; Kanjee, Zahir; Kenny, Avi; Gordon, Nicholas; Basu, Gaurab; Battistoli, Dale; Dorr, Lorenzo; Lorenzen, Breeanna; Thomson, Dana R.; Waters, Ami; Moore, Uriah G.; Roberts, Ruth; Smith, Wilmot L.; Siedner, Mark J.; Kraemer, John D.

In: PLoS Medicine, Vol. 13, No. 8, e1002096, 01.08.2016.

Research output: Contribution to journalArticle

Ly, J, Sathananthan, V, Griffiths, T, Kanjee, Z, Kenny, A, Gordon, N, Basu, G, Battistoli, D, Dorr, L, Lorenzen, B, Thomson, DR, Waters, A, Moore, UG, Roberts, R, Smith, WL, Siedner, MJ & Kraemer, JD 2016, 'Facility-Based Delivery during the Ebola Virus Disease Epidemic in Rural Liberia: Analysis from a Cross-Sectional, Population-Based Household Survey', PLoS Medicine, vol. 13, no. 8, e1002096. https://doi.org/10.1371/journal.pmed.1002096
Ly, John ; Sathananthan, Vidiya ; Griffiths, Thomas ; Kanjee, Zahir ; Kenny, Avi ; Gordon, Nicholas ; Basu, Gaurab ; Battistoli, Dale ; Dorr, Lorenzo ; Lorenzen, Breeanna ; Thomson, Dana R. ; Waters, Ami ; Moore, Uriah G. ; Roberts, Ruth ; Smith, Wilmot L. ; Siedner, Mark J. ; Kraemer, John D. / Facility-Based Delivery during the Ebola Virus Disease Epidemic in Rural Liberia : Analysis from a Cross-Sectional, Population-Based Household Survey. In: PLoS Medicine. 2016 ; Vol. 13, No. 8.
@article{bc658ddb8a714b3cae75e3fb71c99e77,
title = "Facility-Based Delivery during the Ebola Virus Disease Epidemic in Rural Liberia: Analysis from a Cross-Sectional, Population-Based Household Survey",
abstract = "Background: The Ebola virus disease (EVD) epidemic has threatened access to basic health services through facility closures, resource diversion, and decreased demand due to community fear and distrust. While modeling studies have attempted to estimate the impact of these disruptions, no studies have yet utilized population-based survey data. Methods and Findings: We conducted a two-stage, cluster-sample household survey in Rivercess County, Liberia, in March–April 2015, which included a maternal and reproductive health module. We constructed a retrospective cohort of births beginning 4 y before the first day of survey administration (beginning March 24, 2011). We then fit logistic regression models to estimate associations between our primary outcome, facility-based delivery (FBD), and time period, defined as the pre-EVD period (March 24, 2011–June 14, 2014) or EVD period (June 15, 2014–April 13, 2015). We fit both univariable and multivariable models, adjusted for known predictors of facility delivery, accounting for clustering using linearized standard errors. To strengthen causal inference, we also conducted stratified analyses to assess changes in FBD by whether respondents believed that health facility attendance was an EVD risk factor. A total of 1,298 women from 941 households completed the survey. Median age at the time of survey was 29 y, and over 80{\%} had a primary education or less. There were 686 births reported in the pre-EVD period and 212 in the EVD period. The unadjusted odds ratio of facility-based delivery in the EVD period was 0.66 (95{\%} confidence interval [CI] 0.48–0.90, p-value = 0.010). Adjustment for potential confounders did not change the observed association, either in the principal model (adjusted odds ratio [AOR] = 0.70, 95{\%}CI 0.50–0.98, p = 0.037) or a fully adjusted model (AOR = 0.69, 95{\%}CI 0.50–0.97, p = 0.033). The association was robust in sensitivity analyses. The reduction in FBD during the EVD period was observed among those reporting a belief that health facilities are or may be a source of Ebola transmission (AOR = 0.59, 95{\%}CI 0.36–0.97, p = 0.038), but not those without such a belief (AOR = 0.90, 95{\%}CI 0.59–1.37, p = 0.612). Limitations include the possibility of FBD secular trends coincident with the EVD period, recall errors, and social desirability bias. Conclusions: We detected a 30{\%} decreased odds of FBD after the start of EVD in a rural Liberian county with relatively few cases. Because health facilities never closed in Rivercess County, this estimate may under-approximate the effect seen in the most heavily affected areas. These are the first population-based survey data to show collateral disruptions to facility-based delivery caused by the West African EVD epidemic, and they reinforce the need to consider the full spectrum of implications caused by public health emergencies.",
author = "John Ly and Vidiya Sathananthan and Thomas Griffiths and Zahir Kanjee and Avi Kenny and Nicholas Gordon and Gaurab Basu and Dale Battistoli and Lorenzo Dorr and Breeanna Lorenzen and Thomson, {Dana R.} and Ami Waters and Moore, {Uriah G.} and Ruth Roberts and Smith, {Wilmot L.} and Siedner, {Mark J.} and Kraemer, {John D.}",
year = "2016",
month = "8",
day = "1",
doi = "10.1371/journal.pmed.1002096",
language = "English (US)",
volume = "13",
journal = "Nature Methods",
issn = "1548-7091",
publisher = "Public Library of Science",
number = "8",

}

TY - JOUR

T1 - Facility-Based Delivery during the Ebola Virus Disease Epidemic in Rural Liberia

T2 - Analysis from a Cross-Sectional, Population-Based Household Survey

AU - Ly, John

AU - Sathananthan, Vidiya

AU - Griffiths, Thomas

AU - Kanjee, Zahir

AU - Kenny, Avi

AU - Gordon, Nicholas

AU - Basu, Gaurab

AU - Battistoli, Dale

AU - Dorr, Lorenzo

AU - Lorenzen, Breeanna

AU - Thomson, Dana R.

AU - Waters, Ami

AU - Moore, Uriah G.

AU - Roberts, Ruth

AU - Smith, Wilmot L.

AU - Siedner, Mark J.

AU - Kraemer, John D.

PY - 2016/8/1

Y1 - 2016/8/1

N2 - Background: The Ebola virus disease (EVD) epidemic has threatened access to basic health services through facility closures, resource diversion, and decreased demand due to community fear and distrust. While modeling studies have attempted to estimate the impact of these disruptions, no studies have yet utilized population-based survey data. Methods and Findings: We conducted a two-stage, cluster-sample household survey in Rivercess County, Liberia, in March–April 2015, which included a maternal and reproductive health module. We constructed a retrospective cohort of births beginning 4 y before the first day of survey administration (beginning March 24, 2011). We then fit logistic regression models to estimate associations between our primary outcome, facility-based delivery (FBD), and time period, defined as the pre-EVD period (March 24, 2011–June 14, 2014) or EVD period (June 15, 2014–April 13, 2015). We fit both univariable and multivariable models, adjusted for known predictors of facility delivery, accounting for clustering using linearized standard errors. To strengthen causal inference, we also conducted stratified analyses to assess changes in FBD by whether respondents believed that health facility attendance was an EVD risk factor. A total of 1,298 women from 941 households completed the survey. Median age at the time of survey was 29 y, and over 80% had a primary education or less. There were 686 births reported in the pre-EVD period and 212 in the EVD period. The unadjusted odds ratio of facility-based delivery in the EVD period was 0.66 (95% confidence interval [CI] 0.48–0.90, p-value = 0.010). Adjustment for potential confounders did not change the observed association, either in the principal model (adjusted odds ratio [AOR] = 0.70, 95%CI 0.50–0.98, p = 0.037) or a fully adjusted model (AOR = 0.69, 95%CI 0.50–0.97, p = 0.033). The association was robust in sensitivity analyses. The reduction in FBD during the EVD period was observed among those reporting a belief that health facilities are or may be a source of Ebola transmission (AOR = 0.59, 95%CI 0.36–0.97, p = 0.038), but not those without such a belief (AOR = 0.90, 95%CI 0.59–1.37, p = 0.612). Limitations include the possibility of FBD secular trends coincident with the EVD period, recall errors, and social desirability bias. Conclusions: We detected a 30% decreased odds of FBD after the start of EVD in a rural Liberian county with relatively few cases. Because health facilities never closed in Rivercess County, this estimate may under-approximate the effect seen in the most heavily affected areas. These are the first population-based survey data to show collateral disruptions to facility-based delivery caused by the West African EVD epidemic, and they reinforce the need to consider the full spectrum of implications caused by public health emergencies.

AB - Background: The Ebola virus disease (EVD) epidemic has threatened access to basic health services through facility closures, resource diversion, and decreased demand due to community fear and distrust. While modeling studies have attempted to estimate the impact of these disruptions, no studies have yet utilized population-based survey data. Methods and Findings: We conducted a two-stage, cluster-sample household survey in Rivercess County, Liberia, in March–April 2015, which included a maternal and reproductive health module. We constructed a retrospective cohort of births beginning 4 y before the first day of survey administration (beginning March 24, 2011). We then fit logistic regression models to estimate associations between our primary outcome, facility-based delivery (FBD), and time period, defined as the pre-EVD period (March 24, 2011–June 14, 2014) or EVD period (June 15, 2014–April 13, 2015). We fit both univariable and multivariable models, adjusted for known predictors of facility delivery, accounting for clustering using linearized standard errors. To strengthen causal inference, we also conducted stratified analyses to assess changes in FBD by whether respondents believed that health facility attendance was an EVD risk factor. A total of 1,298 women from 941 households completed the survey. Median age at the time of survey was 29 y, and over 80% had a primary education or less. There were 686 births reported in the pre-EVD period and 212 in the EVD period. The unadjusted odds ratio of facility-based delivery in the EVD period was 0.66 (95% confidence interval [CI] 0.48–0.90, p-value = 0.010). Adjustment for potential confounders did not change the observed association, either in the principal model (adjusted odds ratio [AOR] = 0.70, 95%CI 0.50–0.98, p = 0.037) or a fully adjusted model (AOR = 0.69, 95%CI 0.50–0.97, p = 0.033). The association was robust in sensitivity analyses. The reduction in FBD during the EVD period was observed among those reporting a belief that health facilities are or may be a source of Ebola transmission (AOR = 0.59, 95%CI 0.36–0.97, p = 0.038), but not those without such a belief (AOR = 0.90, 95%CI 0.59–1.37, p = 0.612). Limitations include the possibility of FBD secular trends coincident with the EVD period, recall errors, and social desirability bias. Conclusions: We detected a 30% decreased odds of FBD after the start of EVD in a rural Liberian county with relatively few cases. Because health facilities never closed in Rivercess County, this estimate may under-approximate the effect seen in the most heavily affected areas. These are the first population-based survey data to show collateral disruptions to facility-based delivery caused by the West African EVD epidemic, and they reinforce the need to consider the full spectrum of implications caused by public health emergencies.

UR - http://www.scopus.com/inward/record.url?scp=84988959501&partnerID=8YFLogxK

UR - http://www.scopus.com/inward/citedby.url?scp=84988959501&partnerID=8YFLogxK

U2 - 10.1371/journal.pmed.1002096

DO - 10.1371/journal.pmed.1002096

M3 - Article

VL - 13

JO - Nature Methods

JF - Nature Methods

SN - 1548-7091

IS - 8

M1 - e1002096

ER -