Sierra Leone was at the brink of recovery from an eleven years rebel war when it was struck by the Ebola virus disease (EVD) on the 25^th of May 2014. The EVD outbreak was felt nationwide. It accounted for the loss of over four thousand lives of Sierra Leoneans and many more in neighbouring Liberia and Guinea. Included in this loss in Sierra Leone were eleven medical doctors and an array of nurses, which left a dent in our fragile health delivery services. Many economic activities were brought to a standstill and that accounted for a significant drop in our economy from which we are yet to recover. In addition our sociological niche was seriously interrupted. For instance, movement even within our borders was severely restricted, burial rites were not performed as per cultural demand, hand shaking was forbidden, and the intimate care for families, friends, and neighbours was completely eroded. In essence, we were grossly subjected to a total sociological disorientation. 

Standing tall amongst the host of deprivations was the closure of schools and all education institutions, and games and sport activities. Our children and youths were left to waste their energies and talents as a result. This was so because meeting and touching increased the chances of spread of the EVD. The many deprivations and restrictions gave rise to loneliness, boredom, mischief, and a number of social misdemeanors, of which pronounced teenage pregnancy was key. Teenage pregnancy has long been a problem in Sierra Leone. In 2013 the country’s rate ranked among the ten highest in the world, with 28% of girls aged 15-19 pregnant or already having given birth at least once [1]. Anecdotal evidence points to an increase in these rates due to the Ebola crisis and the emergency measures put in place to respond to it [2]. 

Ebola has forced thousands of girls in Sierra Leone to have sex in return for money, water and school fees. The country experienced a spike in teenage pregnancies by as much as 47%, according to new research by charity Save the Children and shared exclusively with IBTimesUK [3]. A UNDP study in the eastern parts of the country conducted in 2015 found that teenage pregnancy went up by 65% while a study by Save the Children revealed a 47% rise across the country. The charity suggests that one reason for the increase was a rise in teenage girls exchanging sexual favours with older boys and men to survive.

During the Ebola crisis contraceptives were difficult to obtain as healthcare workers were focused on curtailing infection rates. Hospitals and health centres had also become places of infection that were avoided. "There was a fear that all healthcare workers had Ebola – that is why so many health workers resigned from their job during the crisis – due to the stigma in the community", Naomi, a support worker for the young mothers at an outreach centre in Freetown, explained [3].

These untimely pregnancies present many socio-economic hazards. For instance, they result to inter-family tensions and undermine family cohesiveness, malnutrition, infant mortality, maternal mortality, economic non-viability, disease and poverty. Notwithstanding a return of life to normal in Sierra Leone, a retrospect of the menace of the EVD is always vital for forestalling or containing any future recurrence. Such would lead us to probe into the impact of Ebola outbreak on teenage pregnancy in the Masuba community, one of the first and worst hit communities in Makeni city in the Northern Province of Sierra Leone. This purpose of prudent search remains vital even as the Masuba community remains to enjoy the health services of the Holy Spirit Hospital, the Masuba Health Center and the Masuba School of Midwifery, which themselves are testimonies to the scourge of Ebola outbreak related teenage pregnancy. This research is an attempt to investigate the impact of Ebola outbreak on teenage pregnancy in the Masuba community.

The EVD outbreak took Sierra Leone by surprise. It attacked when the nation’s health systems were ill equipped to contain it. In the struggle, there were cessations to many socioeconomic activities. Idleness and hardship intensified, and women, girls and children bore the brunt of it. Masuba community in Makeni, one of the first and worst hit areas in the Northern Province and a development deprived locality surged with teenage pregnancy. That intensified the struggle then. Even two years now after we became EVD free, families and the community have to grapple with the ensuing problems. Notwithstanding, a reliable research that seeks to inform the public about the impact of the EVD on teenage pregnancy in the community has not been conducted. This research is therefore directed to that purpose and seeks to investigate the impact of the EVD on teenage pregnancy in the Masuba community in view of informing the health systems for adequate response mechanisms for the problem as felt now and for preparing against any future EVD outbreak. The objectives of the research are as follows:

• To ascertain the surge in teenage pregnancies occasioned by the EVD outbreak in the Masuba community

• To determine how many of these pregnant teenagers went through gestation without complications

• To determine how many of these pregnant teenagers delivered at the health facility

• To show government’s intervention on family planning in the health facility

The findings of this research shall serve important purposes:

• It would help the Ministry of Health through both the local government and central government to respond to the lingering problems emanating from of teenage pregnancy resulting from the EVD outbreak not only in the Masuba community, but in all previously EVD stricken communities

• It would provide reliable procedure, information and guide to scholars and medics who may want to pursue similar research works in the future. For short, it would serve as a reliable reference material for similar studies in future

• It would add to the scholarly information on EVD and benefit not only the researcher, but the training institute and the Masuba health facility

This design and procedure in conducting the study, the population and sampling procedures and the instrument used for the collection of the data, as well as the analysis of the data are described below.

Design of the Research 

The researcher collected information about “The Impact of Ebola Virus Disease (EVD) Outbreak on Teenage Pregnancy in Masuba Community in Makeni City. The data collected were both qualitative and quantitative and the design was descriptive survey. The data was collected from the Masuba Health Centre after the designing of the instrument (questionnaire). Descriptive statistics involving frequency and percentage, calculated by Microsoft office excel, were used to analyses the data. From the analyzed data conclusion and recommendations were drawn.

The Study Area

The study was conducted in the Masuba Community in Makeni City in the Northern Province of Sierra Leone. This community was hard hit by EVD in the 2014/2015 outbreak in West Africa. It is located in the northern tip of the Makeni city. Major socio-economic activities in the area include education, bike riding, local middle level man power skilled jobs lige motor mechanics, carpentry, masonry, also petty trading and health work jobs. In the health and sanitation arena the Holy Spirit Hospital, the Masuba Health Centre and the Masuba School of Midwifery provide opportunities for treatment, health education and training, and an array of employment opportunities. This goal is pursued by the people of the area who are mostly Temne by tribe and more of Muslims (There is also an appreciable number of Limbas, Madingoes, Lokkos and Fullahs) though there is an appreciable number of Christians.

Population and Sample 

The population consisted of all teenagers pregnant 18 months before the outbreak of the EVD, those pregnant during the EVD outbreak, and those pregnant 18 months after the EVD outbreak. That was done in other to make way for better comparisons of services between pre-EVD, EVD and post-EVD outbreak periods. 

Sampling Procedure

Because it was difficult to gather the population members for interviews or focus group discussions, the researchers relied on information contained in the records of the Masuba Health Centre, which was the only functioning health facility in the masuba community that responded to the affairs of pregnant and lactating mothers. 

Instrumentation 

Questionnaire was developed to collect data pertinent to the study. Validity of the questionnaire was censured by building questions which strictly bear with the objectives of the study. Reliability was censured by the inputs of the expert (the supervisor) by effecting alterations, following pilot survey, which ensured that the questionnaire become adequate to the task.

Data Collection 

The questionnaire was hand delivered to the respondents (Sister-in-charge of the Masuba Health Centre). Since all the respondents were literate they needed only a little explanation and were left to answer the questions on their own. The researchers collected the questionnaire themselves and had 100% retrieval.

Data Analysis 

The data collected were subjected to simple calculations of frequencies and percentages by use of Microsoft excel. All statistics were presented in tables in the chapter of findings and discussions of this document. The data were analysed critically.

Surge in Teenage Pregnancies Occasioned by the Evd Outbreak 

Ascertaining the number of teenage pregnancies in the Masuba community during the EVD outbreak would show the real picture and the gravity of the neglect and deprivations that occured which possibly triggered the menace. To reliably pinpoint an increase in teenage pregnancy in the Masuba community during the Ebola Outbreak would involve comparing the number of teenage pregnancies in the Masuba community during the EVD outbreak with the rate of teenage pregnancy before the EVD outbreak in the community for the same length of period.

Approximately 95% of teenage pregnancies occur in developing countries with 36.4 million women becoming mothers before age 18 [4]. Sub-Saharan Africa had the highest prevalence of teenage pregnancy in the world in 2013 [4]. 

Africa has the world’s highest rates of adolescent pregnancy, a factor that affects the health, education, and earning potential of millions of African girls, according to a report released last month by the United Nations Population Fund (UNFPA).

James Burton in World Facts placed Sierra Leone, having 119 teenage pregnancies out of every 1000 pregnancies, 10^th on the list of African countries with highest teen pregnancy rates and acknowledges that in several of these countries, teenage marriages are the major cause of teenage pregnancies.

In Table 1, the last six months towards the start of the EVD, January to June 2014, recorded the highest number of teenage pregnancy (497) which accounted for 56.16% of the all teenage pregnancies recorded 18 months before the EVD outbreak, and with a mean monthly number of 82.83 teenage pregnancies, which also accounted for 56.16% of the teenage pregnancies within the said 18 month period. 

It can be seen from the Table 1 that there was a sharp increase in teenage pregnancies every six months within the last eighteen months towards the start of the EVD. It shows that there had not been proper adherence to family planning. And such trends towards the EVD outbreak could be disastrous. It may also be related to the increase in the population of well paid workers (youths especially) who were mostly employed by mining and energy generation Companies amongst many others, having to contend with poor hungry girls in a fragile economy.

In Table 2, the last six months towards the End of the EVD, July to December 2015, recorded the highest number of teenage pregnancy (498) which accounted for 41.42% of the all teenage pregnancies recorded for 18 months of the EVD outbreak, and with a mean monthly number of 83.00 teenage pregnancies, which also accounted for 41.23% of the teenage pregnancies within the said 18 month period. 

It can be seen that during the first six months of the EVD outbreak, teenage pregnancy was higher than in the second six months of the EVD outbreak. This suggests that people were somehow adhering to the principle of no body contact with any person so ever and, therefore, minimized sexual contacts which eventually resulted in a decline in teenage pregnancy cases. However, we see a sharp rise in the number of teenage pregnancies towards the end of the EVD outbreak, thus indicating that sexually active people became confident of themselves with the decline in the cases of EVD affected and may have increased the rate of sexual contacts. That was the seeming recipe for the protraction of the EVD outbreak.

Table 1: Number of Teenage Pregnancies in the Masuba Health Center before the EVD Outbreak

Table 2: Number of Teenage Pregnancies at the Masuba Health Center during the EVD Outbreak

Source: Masuba Health Centre Records, January 2018

Table 3: Number of Teenage Pregnancies with or without Complications at the Masuba Health Center during the EVD Outbreak

Source: Masuba Health Centre Records, January 2018

Complications with Teenage Pregnancy during Evd Outbreak 

To determine how many of these pregnant teenagers went through gestation without complications is important because teenage pregnancy often presents with many complications, which lead to still birth and maternal mortality.

“Expectant teenage mothers are at risk for experiencing complications during pregnancy that can cause health issues for both mother and child. A lack of physical readiness for pregnancy, combined with risky lifestyle choices such as smoking and drug abuse, increase the chance of complications. Teens can increase the possibility of having a healthy pregnancy, and reduce possible complications, by seeking early prenatal care and following a healthy lifestyle, according to the March of Dimes.” Elizabeth Otto, 2017. 

Known birth complications associated with teenage pregnancies include low birth weight, premature labour, high blood pressure, and anaemia.

Further to the aforementioned, the American organization for Unplanned Pregnancy shares these as risks that are greater if you are pregnant before the age of 15 or you do not seek prenatal care: low birth weight/premature birth. Anemia (low iron levels) high bloodpressure/pregnancy induced hypertension, PIH (can lead to preeclampsia) a higher rate of infant mortality.

From the biological point of view, among the consequences of pregnancy in adolescence are the high rates of hypertensive disorders of pregnancy, anemia, gestational diabetes, delivery complications, and determining an increase in maternal and fetal mortality [5]. It is important to note that some studies showed an increased trend of prenatal, intrapartum, and postpartum intercurrent events among pregnant adolescents [6].

In Table 3, number of teenage pregnancies with complications was highest in the last six months (July – December, 2015) of the EVD outbreak, that is, 498 pregnancies which account for 41.23% of all recorded pregnancies at the Masuba Health Center. This was followed by that recorded in the first six months (July – December, 2014) of the EVD outbreak, that is, 448 pregnancies which accounted for 37.09%. The least occurrence of teenage pregnancy complications was in the second six months of the EVD outbreak (January – June, 2015), that is 262 pregnancies which accounted for 21.69% of the total number of pregnancies recorded at the Masuba Health Center. For the entire eighteen month period of consideration of the EVD outbreak, no case of teenage pregnancy complication was recorded.

Teenage pregnancies with complication were high in the first six months (July – December, 2014) of the EVD outbreak, declined in the second six months (January – June, 2015), and then surge again in the last six months (July – December, 2015) of the EVD outbreak. This observable trend in teenage pregnancies complications could be associated with the community response to prevention of the EVD, in the sense that at the beginning of the outbreak there were many unbelievers of the EVD, and they could not adhere to the preventive measures, so that many engaged in unguided sex and many of those pregnant failed to report to the health facilities due to fear and ignorance. With the intensification of EVD spread messages, there was a higher percentage of positive response to the message of spread of the EVD, and that may have resulted to the observed decline in teenage pregnancy complications. By the end of the EVD outbreak when isolated cases were only being reported in the country, many people reverted to the careless behaviours including delay in reporting pregnancy at health facilities, which accelerated the spread of the EVD.

In Table 4, highest teenage pregnancy complications were reported in the last six months (July – December, 2015) of the EVD outbreak, that is, 441 cases, which accounted for 46.22% of the overall cases. This was followed by the complications reported in the first six months (July – December, 2014) of the EVD outbreak (270 cases), which accounted for 28.30% of the total cases recorded for the eighteen months under survey. The records also show that fevers and anemia occur as the most reported the complications. Fevers recorded as highest pregnancy complications for the first (July – December, 2014) and second six month (January – June, 2015) durations of the EVD outbreak. Fevers and anemia were followed by STIs in occurrence. 

Teenage pregnancies with complications were high in the first six months (July – December, 2014) of the EVD outbreak (28.30%), lower in the second six month (January – June, 2015) duration of the EVD outbreak (25.47), and highest (46.22) in the last six months (July – December, 2015) of the EVD outbreak. This trend in occurrence of pregnancies with complications is also seen to directly responding to the then behavior of reluctance to accepting the EVD spread message, then to overwhelming acceptance after thorough sensitization which gave way to more responsible behaviours, and later by the end of the EVD outbreak a neglect of the positive behaviours adopted to combat the EVD spread.

Anaemia and fevers occurring as most common complications may not be devoid of the occurrence of malaria. Malaria abound where mosquito infestations are rife. It poses a great risk to pregnant mothers as that may result in still birth. 

Table 4: Teenage Pregnancy Complications Reported at the Masuba Health Center during the EVD Outbreak

Source: Masuba Health Centre Records, January, 2018 Grand Total no. of pregnancy complication cases reported = 954

Table 5: Number and Condition of Teenage Mothers Delivering at the Masuba Health Center during the EVD Outbreak

Source: Masuba Health Centre Records, January, 2018 Total no. of delivery and referred cases = 1,523

Delivery by Teenage Mothers during the Evd Outbreak 

These complications related to teenage pregnancy could best be avoided by delivering at health facilities. There is a well-functioning maternal and infant health facility at Masuba to this effect. It is of essence, therefore, to determine how many of these pregnant teenagers delivered at the health facility.

Childbirth at a young (i.e. ≤19 years old) or advanced maternal age (i.e. ≥35 years old) is associated with increased risk of adverse maternal perinatal outcomes, such as postpartum hemorrhage, eclampsia, and cephalopelvic disproportion, as well as adverse infant outcomes including preterm birth, poor fetal growth, low birth weight, and neonatal mortality [7-8]. Further, in analyses that controlled for demographics and clinical confounders, they found that complications with the highest odds among women, 11–18 years of age, compared to 25-29 year old women, included preterm delivery, chorioamnionitis, endometritis, and mild preeclampsia. Pregnant women who were 15-19 years old had greater odds for severe preeclampsia, eclampsia, postpartum hemorrhage, poor fetal growth, and fetal distress. Pregnant women who were ≥35 years old had greater odds for preterm delivery, hypertension, superimposed preeclampsia, severe preeclampsia, and decreased risk for chorioamnionitis. Older women (≥40 years old) had increased odds for mild preeclampsia, fetal distress, and poor fetal growth. Their findings underscore the need for pregnant women to be aware of the risks associated with extremes of age so that they can watch for signs and symptoms of such complications.

In a study on maternal age and risk of labor and delivery complications, pregnant women with EVD also appear to be at an increased risk of fetal loss and pregnancy-associated hemorrhage. In previous outbreaks in Africa, infants born to mothers with EVD have not survived, but whether Ebola virus was the cause of death has not always been known.Historically, pregnant women with EVD were thought to be at increased risk of severe illness and death due to altered immune function and placental infection [9].

In Table 5 above, reporting on the number and condition of 1035 teenage mothers delivering at the Masuba Health Centre during the EVD outbreak, 100% safe delivery was recorded, but there were a considerable number of deliveries with complications (mostly STIs) (471 teenage deliveries) which is 45.5%. Seventeen complications, that is, 1.64% were referred. Highest safe delivery percentage (41.54%) and highest deliveries with complications (244 cases accounting for 51. 80%) were recorded for the last six month period of the EVD outbreak (July – December, 2015), while highest number of referred deliveries occurred during the first six months (July – December, 2014) of the EVD outbreak. 

The overwhelming rate of safe child deliveries dealt with within the Masuba Health Centre, during the EVD outbreak in the Masuba community could be due to factors like having a well trained and committed and motivated staff, a better equipped health facility, and a conscious crop of pregnant women (who likely would have been sensitized by the able staff of the health facility). Such works well to save mothers and neonates from fatalities. Therefore, a few cases were referred and most of the complications were treated in the facility. 

It is however interesting to note that 954 pregnancy complication cases were reported at the Masuba Health Centre during the EVD outbreak, while 1,523 deliveries and delivery referrals were made. This shows that the facility accommodated for delivery many more teenage pregnancies who never reported at the center during gestation, and possibly some who even reported at the facility during pregnancy may have pursued delivery in other facilities. Such flexibilities do not encourage a largescale case-by-case inquiry, which could have been the ideal case of this research. 

Table 6: Family Planning Interventions and Services Provided by Government in the Masuba Health Centre during the Pre-EVD Outbreak, EVD Outbreak, and Post-EVD Outbreak Periods

Source: Masuba Health Centre Records, January, 2018

Government’s Intervention on Family Planning in Masuba Before, during and after the Evd Outbreak 

To show Government’s intervention on family planning in the health facility is important because family planning services help to prevent teenage pregnancies through advice, counseling, and bodily medical interventions. These facilities are decentralized in Sierra Leone and available in each district.

The 2014/2015 Ebola outbreak was the most sustained in history. In an ecological study involving all the health facilities during pre-Ebola (1 March 2013 to 28 February 2014), intra-Ebola (1 March 2014 to 28 February 2015) and post-Ebola (1 March to 31 July 2016) periods in Macenta district in Guinea, comparing trends in family planning, antenatal care, and institutional deliveries over the period before, during and after the outbreak, utilization of family planning declined from a monthly average of 531 visits during the pre-Ebola period to 242 visits in the peak month of the Ebola outbreak (51% decline) but recovered in the post-Ebola period [10].

Reproductive health management aligns with WHO guidelines [11]. According to these guidelines, women are expected to complete three or more ANC visits during pregnancy and at least 90% of all deliveries are expected to be done in health facilities with a minimum of 5% through caesarean section [11].

Summary

Based on the findings and the ensuing discussions it is evident that:

• There was a sharp increase in teenage pregnancies every six months within the last eighteen months towards the start of the EVD, implying that there had not been proper adherence to family planning 

• During the first six months of the EVD outbreak, teenage pregnancy was higher than in the second six months of the EVD outbreak. This suggests that people were somehow adhering to the principle of no body contact with any person so ever

• Teenage pregnancies with complication were high in the first six months (July – December, 2014) of the EVD outbreak, declined in the second six months (January – June, 2015), and then surge again in the last six months (July – December, 2015) of the EVD outbreak. This could have resulted from the denial phase of the existence and spread of the EVD disease, the acceptance and taking responsibility phase and the relaxation of responsibility taking phase

• Anaemia and fevers occurred as the most common complications, and may not be devoid of the occurrence of malaria. They were seconded by STIs

• There was an overwhelming rate of safe child deliveries and one only, though not negligible complicated delivery was dealt with within the health facility during the EVD outbreak in the Masuba Health Center. A few cases were, however, referred and most of the complications were treated in the facility

• Government family Planning interventions during the pre-EVD outbreak were the same as Post- EVD outbreak. The first intervention is counseling on the different types of family planning and their side effects and includes the services of providing clients with both male and female condoms, IUCDs and Tardell, while the second was blood test to rule out pregnancy and the related services are the provision of Depo, pills, microgunon, and microlut. Interventions during the EVD outbreak period was “No injectables and no invasive procedures”, which had the accompanying services of provision of condoms, especially male condoms and pills – both cop and pop. The second intervention was sensitization on abstinence because of the EVD with the related service of abstinence

The EVD outbreak increased the number of teenage pregnancies markedly in the Masuba community, pregnancies with complications markedly reduced in the middle period of the outbreak. Teenage mother deliveries at the Masuba Health Centre were overwhelmingly safe with only a few referrals. Government Family Planning interventions during the EVD outbreak were the non-injectables, non-invasive, and sensitization, while that in pre and post-EVD outbreak periods were counseling, pregnancy tests, alongside the injectables, pills, condoms, and invasive methods.

Recommendations

Therefore, our recommendations to the clients, players and processes involved in the health delivery systems at the Masuba community as pertains the pre-EVD, EVD and post-EVD situations surrounding teenage pregnancies are:

• Ebola virus disease (EVD) prevention methods must be continued to emphasize in the Masuba community and Sierra Leone at large; in the Masuba Health Centre and all health facilities in Sierra Leone This will help the Masuba community and the country as a whole to maintain healthy and sanitary status at all times, so keeping EVD away

• There must be aggressive approaches to discourage teenage pregnancy in all communities, schools, media, religious congregations, etc. because teenage pregnancy goes with many complications, and which may lead to fatalities

• Health facilities in Masuba and nationwide must be well equipped and be in EVD preemptive preparedness, and provided with the requisite Family Planning support. As well, health workers must be adequately trained, encouraged and motivated and committed to service

1. United Nations Population Fund. UNFPA’s contribution to the Ebola virus disease response: Adaptability and agility in action. UNFPA, 2015, pp. 5.

2. Lisa, D. et al. I. Researching livelihoods and services affected by conflicts: Teenage pregnancy after Ebola in Sierra Leone. Secure Livelihoods Research Consortium, Dec. 2015.

3. Whyte, L. “Ebola crisis sparks teen pregnancy surge as girls face sexual exploitation.” IBTimes UK, 2016.

4. United Nations Population Fund. Annual report. UNFPA, 2013.

5. Azevedo, D.V. and H.A. Sampaio. “Fatores de risco associados à gestação na adolescência.” Femina, vol. 31, no. 5, 2003, pp. 457–464.

6. De Carvalho, R. C. et al. “Fatores preditivos de hipertensão gestacional em adolescentes primíparas: análise do pré-natal, da MAPA e da microalbuminúria.” Arquivos Brasileiros de Cardiologia, vol. 87, no. 4, 2006, pp. 487–495.

7. Cunnington, A.J. “What’s so bad about teenage pregnancy?” Journal of Family Planning and Reproductive Health Care, vol. 27, no. 1, 2001, pp. 36–41.

8. Fraser, A. M. et al. “Association of young maternal age with adverse reproductive outcomes.” New England Journal of Medicine, vol. 332, no. 17, 1995, pp. 1113–1118.

9. Mupapa, K. et al. “Ebola hemorrhagic fever and pregnancy.” Journal of Infectious Diseases, vol. 179, suppl. 1, 1999, pp. S11–S12.

10. Bienvenu, S.C. et al. “Effect of the 2014–2015 Ebola outbreak on reproductive health services in a rural district of Guinea: An ecological study.” Transactions of the Royal Society of Tropical Medicine and Hygiene, vol. 111, no. 1, Jan. 2017, pp. 22–29.

11. World Health Organization. Maternal, reproductive and women’s health: Guidelines. World Health Organization, 2016. Accessed 11 Dec. 2016.