On Saturday, September 20th, a woman whom I’ll call Isabel arrived at Princess Christian Maternity Hospital, in Freetown, Sierra Leone, the only such facility in the country. She was eight and a half months pregnant with her first child, and she had a fever, nausea, and diarrhea. These symptoms are not uncommon in pregnancy; they are also three of the red flags for Ebola infection. Hospital attendants guided her into a holding area, drew her blood for an Ebola test, and instructed her to sit. The father of the baby waited outside the hospital gates with Isabel’s extended family.

“She looked completely healthy,” Gabriel Warren, who runs West African Medical Missions, a nonprofit in Sierra Leone, told me. (Warren spends much of his free time helping to maintain P.C.M.H.’s safety protocols; I spoke with him several times last week.) He guessed that Isabel, who was well dressed and wore her long hair in braids, was in her mid-twenties. She arrived in good humor. Two days later, when the Ebola test came back positive, Warren and members of the hospital staff questioned the results. The testing center was overrun, and mistakes—mixed-up vials, contaminated blood samples—had become increasingly common. But protocol could not be broken, and Isabel was moved into the Ebola ward. Two other women had died there the night before, and scattered bloodstains remained on the walls. If Isabel didn’t already have Ebola, Warren worried, she soon would.

The World Health Organization recently estimated that the mortality rate for the epidemic in West Africa stands at seventy per cent. Ebola may, like other viral infections, be especially deadly to pregnant women. A study of the 1995 Ebola outbreak in Kikwit, Zaire, which was much smaller than the present one, found that the virus killed fourteen of the fifteen pregnant women it infected. (The only infant delivered at full term died within three days.) This may have to do with how pregnancy alters the immune system. To the human body, a fetus is not so different from a virus-infected cell or a cancer—it has its own D.N.A., distinct from the mother’s, and grows at a furious pace. To protect the developing fetus, the mother’s body tamps down its own immune response, suppressing its ability to fight the infection appropriately. In 2009, for instance, during the H1N1 influenza pandemic in the United States, seventeen per cent of infected pregnant women died; the mortality rate for the rest of the population was only 0.02 per cent.

In the case of the West African Ebola epidemic, these conditions create an ethical and practical quandary. Needles, beds, nurses, doctors, intravenous fluids, sterile protective gear—everything is in short supply. The sick and dying are overwhelming the medical system. When pregnant women with Ebola are in labor, they bleed copiously; the blood and amniotic fluid are highly infectious, as is the mother’s sweat. Moreover, most Ebola treatment units do not have staff trained in obstetrics or midwifery. A woman’s due date is often irrelevant; if she is not already in labor or near term, the infection may cause a spontaneous abortion. Inexperienced staff find themselves at a high risk of contamination by a patient whom they believe is likely to die anyway, and they are aware that whatever time and medicine they give to the pregnant woman is time and medicine that her neighbor will not receive.

As a consequence, an unwritten code has emerged: infected pregnant women are often not permitted in the standard Ebola wards. “The hospitals are neglecting them—they won’t even allow them in,” a Sierra Leonean nurse told me, speaking on the condition of anonymity. Warren has seen the effect of this exclusion at a variety of treatment centers. “They aren’t given preferential treatment,” he said. “They aren’t even given beds. They get put in an area where they get no interventions. They are assumed to die.” Priority is given to the patients whom the health-care workers believe they can save. In effect, pregnant women are being triaged last. Most end up at P.C.M.H.

A recent United Nations report on P.C.M.H. found that the hospital has been all but forgotten: “Barriers erected at both the entrance and the exit had the doors open with no security noted. Visitors could easily have walked into the area.” Inside the ward, a woman writhed and groaned on the floor in a pool of bleach and bloody diarrhea, a full body bag lying next to her. Staff entered and exited without properly donning protective gear. There was a shortage of numerous supplies, and used equipment was being discarded in a hole dug outside. A woman wandered between rooms, holding her dead infant. According to Warren, the U.N. has threatened to shut P.C.M.H. down.

The director of the U.S. Centers for Disease Control mission in Sierra Leone, Joseph Bresee, told me that decisions about how to triage pregnant women were “made on a patient-care level, not a national level.” Oliver Johnson, the director of a health partnership organized in Sierra Leone through King’s College London, acknowledged that pregnant Ebola patients are difficult to manage, and knew of two nurses who appeared to have died of the disease after serving as midwives. He said that the issue of how best to deal with pregnant women who have Ebola “is a challenging medical-ethics scenario. There’s no easy answer.”

In addressing the questions posed by a disaster such as this one—should a doctor treat the thirty-three-year-old man with two children, or the fifty-year-old nurse whose children are fully grown?—bioethicists have mostly come to agree that the sickest should be treated first. Two potential exceptions include patients who are likely to die no matter the intervention, and patients who can be saved only by measures that it would be financially or logistically impossible to deliver to everyone else.

By this formulation, according to Nir Eyal, a bioethicist at Harvard Medical School who has studied disaster triage, pregnant women rank low on the priority list. If something like the Kikwit mortality rate applies to the present Ebola outbreak, then around five per cent of infected pregnant women survive, compared with thirty per cent of the general population. As Eyal put it, “That means what’s needed to justify giving regular priority to a pregnant woman is a willingness to allow six other people to perish to save her.” But if the Kikwit figure is wrong, Eyal added, then the exclusion of pregnant women from Ebola wards is, too.

It’s possible that the perceived high mortality rate is self-perpetuating: health workers believe that pregnant women are likelier to die from Ebola, so these patients receive suboptimal care. Suppose pregnant women were prioritized: Would more aggressive intervention improve their survival rate? No research appears to have addressed that question (though it’s worth noting that the first reported survivor of Ebola in Sierra Leone was a pregnant woman).

Eight hundred thousand women in Guinea, Liberia, and Sierra Leone will give birth in the coming year, according to a recent report by the United Nations Population Fund (U.N.F.P.A.). Even before the outbreak, these nations were among the deadliest places in the world to be an expectant mother. In 2010, one of every eighty-three women in Sierra Leone died during childbirth, a rate more than forty times higher than in the United States, and nearly two hundred and fifty times higher than in Sweden. That year, the government instituted free maternal health care, and since then the country had been making steady gains. Ebola threatens to undo all that progress. Virtually all prenatal, obstetric, and postnatal care has been paralyzed. The U.N.F.P.A. estimates that, of the women projected to give birth in the next year, a hundred and twenty thousand are at risk of dying from obstetric complications due to improper medical support. And since women, especially mothers, tend to be the ones caring for family members who have fallen ill with Ebola—cleaning up vomit and blood, usually without protective equipment—they are even more at risk. Currently, as many as seventy-five per cent of all the people infected with Ebola in West Africa are women.

Help may be a long way off. Gabriel Warren is lobbying for resources. “At every meeting, I bring it up and then I am ignored. I tell them we don’t have supplies, and then I am ignored,” he said. There have been rumors that the government will hire midwives for every Ebola-treatment center. But then the country may face a bigger dilemma. With midwives mustered to the Ebola units, who will help uninfected pregnant women deliver their babies? The over-all price tag is daunting. The U.N.F.P.A. report suggests that more than sixty-four million dollars in funding is needed to stem the coming onslaught of maternal deaths in Guinea, Sierra Leone, and Liberia. Even before any conversation takes place about the ethics of which mothers to treat first, a large sum of money needs to materialize, and fast.

Isabel went into labor at P.C.M.H. She delivered, without complications, a crying, hungry, and healthy-appearing baby girl. But a second blood test confirmed the first—Isabel had Ebola. The baby and her mother waited in the treatment unit. On the fifth day, the baby stopped eating, and on the sixth she died in Isabel’s arms. “When her child died, a team came, wearing full astronaut suits, took the baby out in a body bag, and placed it in the room next to her,” Warren said. Though Isabel was emotionally wrecked, her body remained strong and healthy. By the seventh day, her symptoms had subsided, and she was soon transferred to a standard treatment center, an apparent survivor.

http://www.newyorker.com/tech/elements/ebola-maternity-ward