Maternal Health Care in the Time of Ebola: A Mixed-Method Exploration of the Impact of the Epidemic on Delivery Services in Monrovia

Public health emergencies like major epidemics in countries with already poor health infrastructure have the potential to set back efforts to reduce maternal deaths globally. The 2014 Ebola crisis in Liberia is claimed to have caused major disruptions to a health system not fully recovered after the country’s civil war, and is an important and relevant case for studying the resilience of health systems during crises. We use data on the utilization of maternal health care services from two representative surveys, one conducted before the outbreak of Ebola, the 2013 Liberian DHS, and another, smaller survey conducted in Monrovia in December 2014, during the height of the epidemic. We focus exclusively on data for women aged 18–49 residing in urban Monrovia, restricting our samples to 1,073 and 763 respondents from the two surveys respectively. We employ a mixed methods approach, combining a multinomial logit model with in-depth semi-structured interviews. Our regression analyses indicate that deliveries in public facilities declined whereas they increased for private facilities. Furthermore, overall facility delivery rates remained stable through the Ebola epidemic: the proportion of home births did not increase. Drawing on insights from extensive qualitative interviews with medical personnel and focus groups with community members conducted in Monrovia in August–September 2015 we attribute these survey findings to a supply side “substitution effect” whereby private clinics provided an important cushion to the shock leading to lower supply of government services. Furthermore, our interviews suggest that government health care workers continued to work in private facilities in their local communities when public facilities were closed. Our findings indicate that resources to shore up healthcare institutions should be directed toward interventions that support private facilities and health personnel working privately in communities during times of crisis so that these facilities are safe alternatives for women during crisis.