Principles of Midwifery Care during Virulent Outbreaks

*Erhuvwukorotu S. Kollie*

## **Abstract**

In recent past virulent disease outbreaks have ravaged different parts of the world. The impact have been felt worldwide. During these outbreaks health workers are usually at high risk for contracting the infections. Rendering maternal antenatal, intrapartum, and postnatal care can be challenging during these outbreaks. Some of these disease that have debuted fearsome outbreaks in the recent past are described briefly in terms of their characteristics, pathology, and treatments. The struggles involved in containing one of the outbreaks are highlighted. The dilemma that ensued as a result of seeking for balance between obligation, heroic midwifery interventions, and sense of calling have been explored. Special emphasis is accorded to highlighting the experiences of midwives during the recent 2014–2015 Ebola outbreak in West Africa. Recommended principles to guide midwifery practices suitable for sustaining the safety of families needing midwifery care and health care providers rendering midwifery care are described.

**Keywords:** Outbreaks, Midwifery care, Virulence, Ebola virus disease, midwifery interventions, safety

#### **1. Introduction**

During disease outbreaks health care workers (HCWs) are play important role which is primary to the control of further debilitating conditions and the maintenance the overall health of the public; this condition cuts across all populations worldwide [1]. As part of the solution several studies have identified principles for training and preparing health care workers (HCWs) to equip them for the competent handling of these difficult situations. There is evidence that the education of HCWs, including midwives, which involves training and preparation activities is very important to ensure that populations experiencing disease outbreak survive the event and recover meaningfully to optimum community health conditions. This involve equipping HCWs with skills vital for the conduction of competent surveillance, communication, reporting, and containment of outbreaks [2, 3]. It should be noted here that midwives operate under the domain of normal pregnancies, childbirth, and peuperium however, their clinical interventions during a virulent outbreak can become complicated with the high risk for contracting deadly diseases or transmitting the diseases to their patients. Several factors influence the availability and positive response of HCWs including midwives to contribute to the containment of the disease during disease outbreaks. Some of these factors include their willingness in spite of the risks involved such as uncertainty and insecurity. Other factors are their perceptions and attitudes towards their roles during disease

outbreaks [1, 4]. Scholars have identified that HCWs were somewhat willing to render care to victims during influenza virus epidemics [5–7]. Other studies have indicated differences in the rate of willingness of health workers to care for patients who are victims of virulent and life threatening epidemics, pandemics, and infectious diseases [8]. The study in [7] provided descriptions of the determinants of HCWs higher willingness to render care during epidemics; These include the type of disease outbreak (for example; it was shown that less virulent outbreaks were related with higher willingness of HCWs to continue to care for patients), also shown by studies that lower threat perceptions of health care workers are related with higher efficacy assertion (meaning higher assertion to being competent to handle the situation). It can be summarized then, that when disease outbreaks are less virulent, the threat perception of the outbreak are lower, while the selfdetermined ability to handle the situation becomes higher among HCWs. This results in a higher level of willingness by health care workers to continue to care for patients in the event of disease outbreaks. When outbreak of diseases were at its peak, the health care workers in close contact with victims, thereby putting them in a frontline position to salvage the situation, where recorded to express high rate of unwillingness to respond [1, 7]. One of such deadly disease outbreaks that have hit the world in recent past is the Ebola Virus disease that occurred in West Africa from 2014 to 2015. Studies to understand and describing the experiences of nurses and midwives and their willingness to care for patients during the Ebola disease outbreak have identified those factors that influenced midwives to care for patients during the fearsome outbreak [9]. It is important to note that during the Ebola outbreak in Liberia and West Africa as a whole, there was the great need to care for patients who had contracted the Ebola virus, but there was need also to pay attention to other patient populations who needed other health care services. Pregnant women, women in labor for child birth, and women who had just delivered their babies, newborn babies, and children with diverse conditions not related to Ebola were constantly in need of health care services [8].

Coping with the new disease with a recorded high mortality rate within the region, including development of treatment protocols, was a serious concern in the region. The situation was complicated further because the needed resources were not available in countries in the region (one of which was Liberia). These resource constraints included experienced experts in treatment and care for patients with Ebola. This inadequacy was caused by conditions created by the emergence from civil war in which lead to limited availability of health resources and a dysfunctional health care system in [8]. In addition, Ebola virus disease symptoms are not easily differentiated from other endemic diseases like malaria, gastroenteritis, or cholera [10]. The Ebola virus disease manifest symptoms that could be similar to other infectious diseases, meanwhile these symptoms are fatal. This caused high tension and anxiety among the health care workers and their attitude towards every patient who sought care changed in such a way that all patients were treated as suspected cases [11]. In appreciating the complexity of the new epidemic, in a statement about the Ebola outbreak in Liberia made by the World Health Organization (WHO) [12] it was reported that the highest number of deaths ocured in Liberia. This was also recorded as the most devastating outbreak of Ebola since it first emerged in 1976 in the Democratic Republic of Congo. When the epidemic reached its peak between August and September 2014, it was estimated that 300 to 400 new cases every week were reported. The situation in the country was very tragic; the treatment centers were overflowing with patients (which included women in labour, some of which delivered their babies in front of health care facilities). Horrific scenes were recorded were patients died on the hospital premises unattended to and bodies abandoned there for days. Local and International flights were

#### *Principles of Midwifery Care during Virulent Outbreaks DOI: http://dx.doi.org/10.5772/intechopen.95596*

cancelled, and domestic supplies of food, gas, fuel ran low. Public places such as schools, businesses offices, border control, open markets, and most health institutions were closed down. Fear and uncertainty about the future—for families, for communities, and for the country and its economy was the common feeling in the country. The health care workers continued to play their roles in the management of patients, though supplies of personal protective equipment, training and preparation for safety procedures were inadequate. This led to the report of 375 health care workers who became infected and loss of the lives of 189 HCWs [12].

The enigma of the Ebola outbreak was associated to the challenges that were then posed to HCWs within the West African Region by the International Council of Nurses (ICN) [13]. Ebola infections according to the ICN [13] were contracted by health care workers which resulted in the debilitating effects on the health system; that included the closing down of hospitals, the reduction in the health care workforce, and a distrusted health system. It was reported also that health care workers were 21–32 times more likely to be infected with Ebola than were other adults in the general population [13]. In the three countries that were affected; Liberia, Guinea, and Serra Leone, 50% of all health care workers infected were nurses, 12% were physicians and medical students, and 7% were laboratory workers. These numbers of deaths of health care workers reflected the need to improve and strengthen safety policies, supply of adequate protective equipment, and the appropriate preparation and training for all HCWs. The International Council of Nurses recommended to governments to ensure the creation of safe working environments for health care workers as a prerequisite to providing care to Ebola patients. The ICN also recommended that nurses and midwives require proper training and education, prompt provision of protective equipment, and to take up an active, frontline role in the development of policies pertaining to the prevention of infection transmission and patient care [13].

The understanding of the high risks associated with giving care to infected patients during virulent outbreaks for midwives, attention should be increased and placed on the safety issues, social processes, and the needed to develop a more realistic policy that will meet the needs of midwives. There is also the need to describe what midwives went through during the epidemic while caring for Ebola and non-Ebola patients, which involved midwives' decision making about rendering or not rendering care to patients during the Ebola outbreak. This will serve as eye opener for other midwives to appreciate and understand the principles that they would need to internalize and utilize whenever necessary to render care to women and their families who in need of midwifery care during virulent outbreaks.

## **2. Disease that have caused virulent outbreaks in recent past**

Some of the disease that have debuted fearsome outbreaks in the recent past are described very briefly in terms of their characteristics, pathology, and treatments. These diseases include Ebola virus disease, Avian influenza, Cholera, Yellow fever, Middle East Respiratory Syndrome Coronavirus, Marburg virus disease, and Zika virus infection. The COVID-19 disease debuted in 2019 and is currently ravaging the world (**Table 1**).

#### **2.1 Ebola virus disease**

According to WHO [10] Ebola viral disease (EVD) can cause fatal complications among humans up to about 90%. Wild animals transmit the virus to humans and then human to human transmission occurs through physical interactions between


#### **Table 1.**

*Disease outbreaks occurrence in the past ten years.*

them. The clinical manifestations of Ebola infection starts to show between 2 to 10 days after a humans contract the virus. People can only transmit the virus during the period that they are. Survival critically depends on the provision of early supportive care which include rehydration and symptomatic treatment because there is currently no standard pharmacologic treatment to destroy the virus [10]. Ebola virus disease or EVD occurred first in 1976 in two concurrent outbreaks in Eastern Africa: one in Nzara, Sudan, and the other in Yambuku, Democratic Republic of Congo [10]. EVD is caused by a virus called Filoviridae, one of the viruses included in the family of hemorrhagic fever viruses that cause uncontrolled bleeding complications accompanied with fevers. The natural host for the Ebola virus are fruit bats [14]. When humans come in close contact with the fluids such as blood, body secretions, other bodily fluids of animals such as chimpanzees, gorillas, fruit bats, monkeys, forest antelope, and porcupines that are infected by the Ebola virus and/or are found ill or dead or in the rain forest, the humans contract the virus [14]. Transmission of Ebola virus among humans occurs when humans come in direct contact with fluiids and body parts of other humans. For example when broken skin or mucous membranes of one human come into contact with the blood, secretions, or body fluids of other ihumans who are infected by the virus, even when they come in contact with materials (such as, bed clothing) contaminated with body fluids of other infected people. Once a person is infected with the virus they remain infectious throughout, as long as they virus remains in them and after death occurs due to the disease [10]. People infected with the Ebola Virus are not infectious until the symptoms begin to show, these symptoms begin to manifest between 2 to 21 days after infection. The Symptoms include headaches, fever that occurs suddenly, sore throat, muscle pain, fatigue, vomiting and diarrhea, skin rashes, clinical signs of renal and hepatic dysfunction, and internal and external bleeding (Symptoms of Ebola virus disease, para.1) [10]. The diagnosis of EVD can be difficult due to the indistinct clinical signs and symptoms compared to other infectious diseases however, laboratory tests can be used to confirm that a person in infected with the Ebola Virus. Examples of the laboratory tests that can be used to confirm EVD include antibody-capture enzyme-linked immunosorbent assay, antigen-capture detection tests, serum neutralization test, reverse transcriptase polymerase chain reaction assay, electron microscopy, and virus isolation by cell culture. EVD has no developed treatment yet. However, there is a range of potential treatments including blood products administration, immune therapies, drug

#### *Principles of Midwifery Care during Virulent Outbreaks DOI: http://dx.doi.org/10.5772/intechopen.95596*

therapies, and vaccines which are currently being developed. Survival depends the provision of early supportive care which include rehydration and symptomatic treatment because there is currently no standard pharmacologic treatment to destroy the virus [10]. The skills and protocols involved in nursing care for patients with EVD are undergoing development. Some scholars have suggest the following as nursing interventions emanating from the experiences of nurses who were directly involved in the care of EVD patients:

The improvements made in the treatment techniques makes it now possible to render adequate care for EVD challenged patients with much better clinical results.


Midwifery interventions require touch; which is the main medium that people connect with each other. Touch is an important part of the midwife-patient relationship and may be the unavoidable aspects of the caring relationship between midwives and their patients [16]. Nurses and midwives use touch to promote healing and provide comfort and care to their patients. Touching patients is done in different kind of ways during every interaction; for instance, when measuring vital signs, bathing their patients, changing positions of patients in bed, assisting patients to leave their bed to walk or sit in a chair [16]. When midwives touch their patients, especially during the Ebola outbreak, it speaks volumes in terms of reassures them that the midwife is not afraid to be near them and that they are not alone. Though direct skin-to-skin contact is not wise nor acceptable, it is recommended that when midwives treat EVD patients, despite the layers of protective equipment, they need to seek for avenues to intentionally touch their patients in a deliberate and meaningful way that will provide care, comfort and connection between the midwife and the patient [16].

Curriculum development is crucial and important so that student midwives would be given a robust understanding of the knowledge, skills, and attitudes necessary to care for patients in the event of public health emergencies like the Ebola outbreak. For instance, Teachers at Emory's Nell Hodgson Woodruff School of Nursing worked is collaboration with their colleagues at the Centers for Disease Control and Prevention (CDC) to create and deliver a course that they titled, "Introduction to Complex Humanitarian Emergencies for Nurses." This course utilized presentations and active learning exercises that examined the methods needed to provide and manage public health emergency situations that require prompt care and opportunities for leadership. This could be applied and contextualized to midwifery and nursing schools in West Africa and globally as a continuous education program to update and improve midwifery care during disease outbreaks [17].

#### **2.2 Avian influenza**

The avian influenza viruses are zoonotic influenza viruses are resident in birds and cause Avian influenza commonly called bird flu. These animal influenza viruses are distinct from human seasonal influenza viruses and they do not easily become contagious and transmit from human to human. Occasionally through direct or indirect contact they infect humans and cause diseases that could lead to death. Avian influenza A(H5N1) first outbreak was in 1997 in a poultry in Hong Kong. It became widespread in 2003 from Asia to Europe to Africa. A(H5N1) occurs naturally in wild waterfowl, but it can spread easily to domestic poultry. The disease is transmitted to humans through contact with infected bird feces, nasal secretions, or secretions from the mouth or eyes. Also it is suspected that bird flu could be contacted by consuming improperly cooked poultry or eggs from infected birds, eggs should never be served runny. Bird meat when not properly cooked to an internal temperature of 165°F (73.9°C) could pose a risk. Symptoms of bird flu include cough, diarrhea, respiratory difficulties, fever (over 100.4°F or 38°C), headache, muscle aches, malaise, runny nose, and sore throat. Treatments may vary because different types of avian influenza can cause different symptoms. Most times antiviral medication such as oseltamivir (Tamiflu) or zanamivir (Relenza) can help alleviate the severity of the disease, especially when the medication is taken within 48 hours after symptoms first appear. Further management would be to place those infected in isolation to avoid spreading the virus to others [18].

#### **2.3 Cholera**

Cholera is an acute form of diarrhoeal disease, if not treated it can kill within hours. Several studies have identified approximately that every year there are 1.3 million to 4.0 million cases of cholera, and 21 000 to 143 000 deaths worldwide due to cholera. Most cases presents no or mild symptoms. Treatment with oral rehydration solution would be effective in such cases. More severe cases will require quick and immediate treatment with intravenous fluids and antibiotics. Control measures involve the provision of safe water and sanitation, safe oral cholera vaccines, improvements in water and sanitation [19].

#### **2.4 Yellow fever**

Yellow fever is caused by a virus found in parts of Africa and South America. The virus is spread to people by the bite of a mosquito. Symptoms of the illness ranges from fever with aches and pains to severe liver disease with bleeding and yellow colored skin (known as jaundice). Yellow fever presents first set of symptoms which include sudden onset of fever, chills, severe headache, back pain, general body aches, nausea, vomiting, fatigue, and weakness. Most persons improve after the initial presentation. After a brief remission ranging from hours to a day, about 15% of infection cases progress to develop sever symptoms which include high fever, jaundice, bleeding, and eventually shock and failure of multiple organs. Treatment is symptomatic and includes provision of rest, fluids, and use of pain relievers and medication to reduce fever to relieve symptoms of aching and fever. Yellow fever patients should be hospitalized for supportive care and close observation, they should be provided with material to protect them from more mosquito bites (by encouraging that they stay indoors and stay under a mosquito net). This should be adhered to for up to 5 days after the symptoms like fever begins. This will allow the yellow fever virus in their bloodstream to be unavailable to uninfected mosquitoes, thereby putting a halt to the further transmission of the virus and containing the risks posed

to other people around the patients. There is no medicine to treat the infection yet. Prevention is advisory which include use insect repellent, wear long-sleeved shirts and long pants outdoors, and get vaccinated. The incubation period (time from infection until illness) when people get infected is typically 3–6 days [20].
