ADDRESSING SEXUAL, REPRODUCTIVE, & MATERNAL HEALTH ISSUES IN THE CONTEXT OF EBOLA A FIELDWORK EXPERIENCE AT THE WORLD HEALTH ORGANIZATION AMY BHOPAL

Agenda ① Introduction ② Key Objectives ③ Clinical Vignettes ④ Critical Issues ⑤ Existing Guidelines ⑥ Current Guidance ⑦ Questions/Comments

① INTRODUCTION

World Health Organization WHO is the directing and coordinating authority for health within the United Nations system. It is responsible for providing leadership on global health matters, shaping the health research agenda, setting norms and standards, articulating evidence-based policy options, providing technical support to countries and monitoring and assessing health trends.

Organization of WHO Headquarters

Reproductive Health & Research Department WHO/RHR’s work is premised on the need to achieve access to and quality of sexual and reproductive health, in order to meet the needs of diverse populations, particularly the most vulnerable. It is shaped around the five components of WHO’s Global reproductive health strategy: Improving antenatal, perinatal, postpartum and newborn care; Providing high-quality services for family planning, including infertility services; Eliminating unsafe abortion; Combating sexually transmitted infections, including HIV, reproductive tract infections, cervical cancer and other sexual and reproductive health morbidities; Promoting sexual health.

② KEY OBJECTIVES

Objectives 1. Analyze the current impact of the Ebola outbreak in key affected areas on sexual, reproductive, and maternal health. a. Develop and present research analysis summary findings in the context of Ebola. b. Review and evaluate existing guidelines and recommendations. c. Analyze the key public health issues in sexual, reproductive, and maternal health concerns raised by Medical Officer Lisa Thomas and affiliates in Liberia. 2. Deepen skills in collaboration and coordination within a complex organizational and implementation structure and have general familiarization with the Reproductive Health and Research department

③ CLINICAL VIGNETTES

Pregnant Women in West Africa 1. Unknown Patient X: A woman, of unknown age and Ebola status (confirmed, probable, or suspected) died in front of the WHO/UNICEF Liberia country office of post partum hemorrhage (PPH). 2. Unknown Patient Y: A pregnant woman in labor, of unknown age, was rejected from receiving pregnancy related-care to many clinics in the surrounding area. She was picked up and transported via ambulance to the only ETU clinic that was willing to admit her. She was not a suspected Ebola case but had contacted with an infected person 3. MSF Patient Z: In Guinea, a pregnant woman, at 5 months gestation, presented with EVD eventually recovered. She was offered termination and declined. One month later, she delivered a macerated stillborn baby.

Men convalescing from EVD 1. The government of India has detained a 26 year old male traveling back from Liberia. He has recovered from EVD and is serologically clear of the virus. He was given a medical clearance but since his bodily fluids are testing positive for the disease, he is said to be released once and all bodily fluids test negative.

④ CRITICAL ISSUES

Utilization of pregnancy-related services are down Malaria prevention services (IPT2 from 47.8% to 29.4%), Prenatal care w/in 6 wks (41% to 25%), Antenatal care (65% to 40%), Syphilis and HIV testing. Prior Ebola outbreak studies have shown pregnant women are at an increased risk for spontaneous abortions, antepartum and post partum hemorrhage. Current CFR is >90% Neonatal CFR is 100% Lactating Mothers are at high risk for transmitting the virus to children through breast milk. Maternal Health Issues

Sexual & Reproductive Health Issues Bodily fluids such as semen and vaginal secretions have shed EVD RNA virus for up to 91 and 33 days, respectively. Reproductive HealthSexual Health Birth Spacing - After a miscarriage or induced abortion, WHO recommends a minimum 6-month interval to the next pregnancy in order to reduce risks of adverse maternal and perinatal outcomes. Contraception - Women may be reluctant to receive progestin injectables due to contamination and may result in increased rates of unintended pregnancies.

⑤ EXISTING GUIDELINES

WHO Guidelines Clinical Practice Handbook for Safe Abortion Safe Abortion: Technical and Policy Guidance for Health Systems Managing Incomplete Abortion Midwifery Education Module 6 Pregnancy, Childbirth, Postpartum and Newborn Care: A Guide for Essential Practice Managing Complications in Pregnancy and Childbirth: A Guide for Midwives and Doctors WHO recommendations for the prevention and treatment of postpartum haemorrhage. Report of a WHO Technical Consultation on Birth Spacing Interim Infection Prevention and Control Guidance for Care of Patients with Suspected or Confirmed Filovirus Haemorrhagic Fever in Health-Care Settings, with Focus on Ebola

6 Priority Questions ① Do male or female condoms, if used correctly and consistently, provide protection against the sexual transmission of the Ebola virus from convalescing patients? ② Are there any adverse drug interactions between medications used to treat Ebola virus and combined- or progestogen- only contraceptive pills in women of reproductive age being treated for the Ebola virus? ③ In the communities of Ebola outbreak regions, what strategies of community mobilization/education compared to nothing an effective and safe strategy to improve/maintain utilization of pregnancy-related care services (i.e. antenatal/intrapartum/postpartum care/skilled birth attendance)? ④ Among pregnant women residing in Ebola outbreak regions, is self- administration of oral misoprostol compared to oxytocin injections a safe alternative for prevention and treatment of postpartum haemorrhage? ⑤ Should Lactating mothers in Ebola outbreak regions either (i) diagnosed with Ebola, (ii) suspected to have Ebola, or (iii) suspected to have Ebola without a diagnosis safely breastfeed compared to infant formula to improve neonatal mortality? ⑥ What is the minimum Ebola infection and prevention measures required during labour and childbirth of both vaginal and caesarean deliveries compared to nothing to reduce perinatal infection of Ebola virus from (i) health care workers to mothers, (ii) or baby infection/mother-to- health worker infection?

6 Priority Questions ① Do male or female condoms, if used correctly and consistently, provide protection against the sexual transmission of the Ebola virus from convalescing patients? ② Are there any adverse drug interactions between medications used to treat Ebola virus and combined- or progestogen- only contraceptive pills in women of reproductive age being treated for the Ebola virus? ③ In the communities of Ebola outbreak regions, what strategies of community mobilization/education compared to nothing an effective and safe strategy to improve/maintain utilization of pregnancy-related care services (i.e. antenatal/intrapartum/postpartum care/skilled birth attendance)? ④ Among pregnant women residing in Ebola outbreak regions, is self- administration of oral misoprostol compared to oxytocin injections a safe alternative for prevention and treatment of postpartum haemorrhage? ⑤ Should Lactating mothers in Ebola outbreak regions either (i) diagnosed with Ebola, (ii) suspected to have Ebola, or (iii) suspected to have Ebola without a diagnosis safely breastfeed compared to infant formula to improve neonatal mortality? ⑥ What is the minimum Ebola infection and prevention measures required during labour and childbirth of both vaginal and caesarean deliveries compared to nothing to reduce perinatal infection of Ebola virus from (i) health care workers to mothers, (ii) or baby infection/mother-to- health worker infection?

⑥ CURRENT GUIDANCE

Safe Delivery & Newborn Care for “Non- Ebola” Patients in Ebola Affected Communities ① Key considerations for the provision of safe delivery and postnatal services in the context of the Ebola outbreak in health facilities and for home deliveries ② Operations – procurement of health kits to trained health professionals and/or CHWs

Standard Operating Procedures for Pregnant women affected with Ebola in ETUs Recommendations ① Human resources, PPE, material and setup, waste management Labor and delivery procedures ① Induction of labor ② Routine antibiotic prophylaxis, antimalarial treatment, no invasive procedures, prolonged labor, no fetal monitoring Common obstetric complications ① PPH, retained placenta, retained products of conception Discharge post delivery or post abortion Family Planning

EBOLA VIRUS IN SEMEN OF MEN WHO HAVE RECOVERED FROM EBOLA Sexual transmission of Ebola virus disease has not been documented. Men who have recovered from Ebola virus disease should be aware that seminal fluid may be infectious for as long as three months after onset of symptoms. Because of the potential to transmit the virus sexually during this time, they should maintain good personal hygiene after masturbation, and either abstain from sex or practice safe sex using condoms for three months after onset of symptoms.

⑦ QUESTIONS/COMMENT S