Ebola has wrought havoc and claimed the lives of more than 6,800 people, almost all of whom were in West Africa and more than half of whom were Liberian, the World Health Organization (WHO) said on Monday. The UN health agency reported that as of December 13, there had been 18,464 cases of infection from the deadly virus in Liberia, Guinea and Sierra Leone, alone.
Liberia, long the hardest-hit country, has seen a decrease in the rate of transmission in recent weeks; admissions to treatment centers across the country have dropped to around 100 a week from more than 300 at the peak of the epidemic in September, according to the Wall Street Journal. But nevertheless, 100 people are left dead every week. 100 family members. 100 mothers, fathers, daughters, sons, sisters and brothers.
Those who live are rejected by their surviving relatives; a new wave of Liberian orphans are coerced into sex for money, for food or for shelter. Or, they’re raped, as they’re forced to fend for themselves, fetching resources like water alone, while overstretched security forces are engrossed in the urgency of the Ebola response. Or, they’re merely bored; schools are closed and thus social affairs are few and far between. Like bored teenagers across the globe, they’re both vulnerable to persuasion and consenting to sex.
“Girls, especially adolescent girls, are always at increased risk in emergencies, whether the emergency is a public health crisis as the one we are seeing with the Ebola outbreak or if the emergency is one caused by conflict, displacement due to a natural disaster, etc.,” Save the Children Emergency Adolescent Reproductive Health Specialist Seema Manohar told Her Report. “Schools in Liberia have been closed since the summer and adolescents are increasingly becoming restless. They are being teenagers as teenagers would be anywhere if they had to be home-bound. They are desperately bored and eager to socialize, spend time with their peers and do what teenagers do. So there is a strong possibility that young people are engaging in risky sexual behaviors, including consensual but unprotected sex.”
But these are young people in Liberia, where one in seven of them could die in pregnancy or childbirth…and they do. Even before the Ebola epidemic, 20 percent of girls experience sex before the age of 15, one in seven of whom does so against her will. According to UNICEF’s 2012 Progress for Children: A Report Card on Adolescents, Liberia is one of the top 10 countries with the highest rate of teenage pregnancies, where seven percent of girls give birth before 15 years old and 31 percent between the ages of 15 and 18 years.
But the country does not have the medical resources to deal with complications related to teenage pregnancy at present, Koala Oumarou, Country Director of Plan Liberia, has said.
Manohar added, “It’s hard to generalize what health facilities have or don’t have in terms of supplies, drugs, etc.(different counties had different experiences, rural vs. urban, hospitals vs. clinics, etc.) but they all required a heightened level of infection prevention & control, both in terms of trainings and supplies. Additionally, in the earlier days when health facilities were unsure if the patient had died of Ebola in the facility they ended up destroying most everything in the facility to ensure disinfection, so some health facilities are having to start from scratch.”
According to Manohar, Liberian adolescents under 18 years old are twice as likely to die or suffer pregnancy-related complications compared to women in their 20’s, and those under the age of 15 face five times more the risk.
The UK’s Disasters Emergency Committee (DEC) warns that with fistula, prolonged labor, miscarriages and stillbirths, the lack of sufficient care for pregnant teenagers is of particular concern in Liberia, where the maternal mortality ratio already showed a troubling trend in 2011, from 578 to 990 deaths per 100,000 live births. In 2011, just 37 percent of pregnant women had four or more antenatal visits, compared to 66 percent of women receiving such visits in 2010, according to UNICEF. The trend is only worsening, as aid agencies in Liberia are justifiably tied up with the Ebola response.
“A huge health concern has been that a lot of health facilities were closed down in the summer [for nearly four to five months] and are only slowly starting to open back up and offer services. One of the pivotal services offered by the primary health care clinics is antenatal care and delivery services to pregnant girls and women,” Manohar explained. “So in an emergency, when health services shut down, girls and women are at increased risks of maternal mortality and morbidity as they no longer have access to life-saving maternal and reproductive health services, namely having a delivery with a skilled birth attendant in a health facility set up to address any complications as well as critical post-natal care.”
While some health facilities stayed open to treat both Ebola and non-Ebola patients, a number of pregnant women and girls were, in fact, being turned away. “Health workers were fearful that it was an Ebola related case for which they didn’t have sufficient materials and training to deal with such excessive bleeding,” Seema explained. “Turning away women was not widespread but happened due to uncertainty of whether the bleeding was caused due to pregnancy complications or Ebola.”
Fortunately, there is now more guidance and protocols for recognizing and immediately treating pregnant women and girls who may visit an Ebola treatment unit or a community care center with bleeding. Liberia has set up a Reproductive, Maternal, Neonatal and Child Health (RMNCH) Task force to ensure the country has midwifery and birthing kits available with enhanced infection, prevention and control materials, as well as trainings for midwives and nurses to be able to safely handle deliveries. Similar kits are being made available for community-based trained traditional midwives for those of whom may not have access to reach a health facility and must perform home-based deliveries.
RMNCH Task Force training on safe deliveries using a higher degree of universal precautions and infection control measures will be conducted through the Ministry of Health and supported by WHO, the United Nations Population Fund (UNFPA), UNICEF and other INGOs.
But while there are efforts now in effect to better manage teenage pregnancies, the long-term outcome of having so many children out of school for such a prolonged period, could also mean that illiteracy, unemployment and ensuing poverty could escalate at alarming rates.
“Before Ebola, Liberia [was] beginning to emerge from [14 years of civil war], when thousands of young people missed out on school. Now the lack of open schools could mean yet another generation of illiterate young people, with the ensuing consequences of unemployment and poverty,” Manohar said. “Experts say the long-term consequences for the three worst affected countries could be catastrophic, reversing decades of socio-economic progress.”
From 2008-2012, the literacy rate for females was just 37.2 percent. Now, they’re finding their progress mired by the devastating epidemic, and school drop-out rates will only exacerbate as a result. Many girls fear they’ll be unable to return to school even after the outbreak, as they’ll have to care for their children and neither the time nor money to afford an education.
Nonetheless, Manohar is hopeful. “They are highly resilient, as communities who face adversity time and time again tend to be. And while there have definitely been setbacks with schools closing, I sense girls will return to schools again when they open, work hard and continue to aspire to complete their education,” she said of her experience with Liberians.