Maternal deaths have doubled in the epicenter of the Democratic Republic of Congo’s Ebola outbreak, as pregnant women avoid hospitals and medical staff and supplies are diverted to fight the virus.

The disruption is leaving women vulnerable to otherwise treatable complications including preeclampsia, malaria and obstructed labor, even when they aren’t infected with Ebola, according to Paulina Ospina, director of maternal and child health with Direct Relief, a U.S.-based medical aid group.

“They’re not dying from Ebola,” Ospina said. “They’re dying from complications that are treatable.”

The mounting toll is exposing two threats to mothers and babies from the world’s fastest-growing Ebola outbreak: The breakdown of routine maternity care and the largely unknown consequences for those who contract Bundibugyo, a rare form of the virus that’s been little studied in pregnancy.

More than 4,400 confirmed infections and 2,000 deaths have been recorded across five provinces, Congo’s National Institute of Public Health said Tuesday.

Some 63,700 pregnant women are estimated to live in Congo’s Ebola-affected areas, according to the United Nations Population Fund.

Africa Centres for Disease Control and Prevention is scheduled to review data Thursday on pregnancy outcomes in the current outbreak. Relatively few pregnancies have been identified and reports of unusually severe outcomes remain anecdotal until the data are analyzed, Salim Abdool Karim, who chairs Africa CDC’s emergency committee, said in an interview.

In Ituri Province, maternal-death rates have doubled since May 25, with an average of more than six deaths registered per week, national data show. The proportion of those deaths occurring outside health facilities almost doubled to 17.4%.

Avoiding care

At Bénédicte Clinic in Bunia, Ituri’s capital, prenatal registrations have fallen to about 10 a month from around 60 before the outbreak, the clinic’s medical director told the Associated Press. Some women fear contracting Ebola at health facilities or being isolated if symptoms such as fever raise suspicion that they have the disease.

The collateral toll is beginning to reshape the response. Congo is finalizing a roughly $940 million plan that will include maintaining essential health services alongside efforts to contain Ebola, the World Health Organization’s representative in the country, Anne Ancia, told reporters Wednesday.

During a recent visit to an Ebola treatment center in Lita, Ancia said she saw a woman die from blood loss following an obstetric complication.

Congo entered the epidemic with one of the world’s heaviest maternal mortality burdens. About 19,000 women died from pregnancy-related causes in 2023, tied with India and behind only Nigeria, according to the latest UN estimates.

Ebola can make obstetric emergencies particularly difficult to manage. Fever and bleeding may raise suspicion of the virus, while childbirth exposes health workers to large amounts of potentially infectious blood and other body fluids.

“If you have a woman who has acute hemorrhage, that may be too long,” Ospina said of waiting for Ebola test results. “She’s at risk of dying from bleeding out.”

Previous epidemics suggest the effects can persist long after transmission subsides. Antenatal visits, hospital births and postnatal care fell during the 2014-16 West Africa Ebola epidemic, according to a review published in 2022. One Sierra Leone study found maternal mortality at health facilities increased 34% and stillbirths rose 24%.

For women who contract Ebola while pregnant, the danger is different. The virus can cross the placenta while it is circulating in the mother’s blood and directly infect the fetus, according to David Schwartz, an Atlanta-based pathologist and medical epidemiologist who studies infectious diseases in pregnancy.

“The placentas are loaded with virus,” Schwartz said. Fetal infection has historically been almost universally fatal, though rare survivors have been reported.

“We have no hard metrics yet on the case fatality rate amongst pregnant mothers, newborns or infants,” he said of the current outbreak.

Evidence is particularly scarce for Bundibugyo. One published account from a 2012 outbreak in Congo describes a woman infected seven months into pregnancy who delivered prematurely and died the following day. Her infant died at eight days old.

The WHO plans to include pregnant women and children in a late-stage trial of Merck & Co.’s Ervebo vaccine against Bundibugyo, subject to ethics and regulatory approval. Ervebo is approved against Zaire Ebola, though animal studies suggest it may offer cross-protection against Bundibugyo.

Existing studies haven’t found evidence of increased pregnancy loss associated with Ervebo, though relatively few pregnancies have been studied.

“When you’re dealing with an infection that has close to a hundred percent case fatality rate amongst affected fetuses, the good outweighs the bad,” Schwartz said.

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