PORT LOKO, Sierra Leone — When Fatmata Kabia walked into the Ebola isolation center, her chances of survival were almost zero.
Not because her symptoms were particularly bad — though they were. Not because the disease had already killed most of her family — though it had. Kabia, 21, appeared doomed for another reason: She was pregnant.
Few diseases are less understood than the Ebola virus, which has claimed more than 7,900 lives across West Africa. But one thing is clear: Pregnant Ebola patients rarely survive. And their babies never do.
Even as doctors watched a succession of Ebola-stricken pregnant women die or lose their babies in recent months, they weren’t entirely sure why it was happening. Perhaps the mothers’ immune systems were weakened, making them more susceptible to the incapacitating fever that accompanies the disease, or maybe the virus pooled in fetal fluid. Some of the babies died early in pregnancy, others closer to term.
“There have been no neonatal survivors” is how Denise Jamieson, an obstetrician with the Division of Reproductive Health at the Centers for Disease Control and Prevention, put it flatly.
Kabia didn’t know that. She knew only that some time after the disease crossed the border from Guinea to Sierra Leone, it had arrived in her town, called Lunsar. Then it snaked into her home, where her mother, father and brother tested positive. And then she tested positive.
A few weeks later, when she walked out of the Port Loko Ebola isolation center — her test results negative, her baby growing in her belly — the epidemiologists had already started talking about her.
But Kabia faced six more months of pregnancy, six more months of potential battle with the disease. This time, though, it would be her baby’s fight, waged inside her.
“I’m just not sure what will happen,” she said.
Kabia is a small woman with big eyes and a wide smile. She rests her hands on her stomach when she sits and taps her sandal-clad feet on the ground. Sometimes, talking about the baby makes her nervous, like she’s waiting for the results of her Ebola test all over again.
She had become pregnant in August just as the disease started spreading rapidly across Sierra Leone. Kabia had already miscarried once, years before Ebola. She was so worried when she became pregnant this time that she didn’t tell her husband. One day, he pointed to her belly and asked: was she? Kabia told him, and they celebrated. He died a few weeks later.
When she came down with the disease, already one month and three weeks pregnant, everything was working against her. Maternity wards had started closing amid fears that pregnant women with the virus would infect anyone who attempted to assist their deliveries. Ebola is transmitted through bodily fluids, which gush during childbirth.
An ambulance took her to a hospital overflowing with suspected patients and filled with dirty mattresses. It wasn’t even an Ebola treatment facility — just a place to keep suspected patients while centers were built. Often, dead bodies lay on the floor for hours. By the time she was admitted, her parents, brother and sister had died. Her husband would soon succumb, too.
“Based on what I learned about the disease, I was expecting her to die,” said Matilda N’glanda, the head nurse.
Then, remarkably, Kabia’s health started to improve. “It was the drugs and God,” Kabia said.
She was released in mid-October, with a certificate declaring her a survivor. It was supposed to mean the end of her battle with Ebola. But Kabia had a bad feeling about the baby.
Two weeks later, she touched herself between her legs and saw that her fingers were red. She tried to stay composed, to drag herself to a clinic, even though she knew she might be refused treatment.
“I worried I was going to lose it,” she said.
Although the research is in the early stages, many obstetricians have suggested that Ebola might pool in a woman’s placenta even after it has disappeared from the rest of her body. The same is true of other diseases, such as malaria. In other words, Kabia could test negative for Ebola but her baby could still have it.
“The blood might be negative, but it can survive in other body compartments,” said Jamieson, the CDC specialist.
Some doctors and nurses have begun testing the fetuses of the miscarried infants of Ebola victims. The research isn’t formal, and it’s still in an early stage, but the results have been startling. Grazia Caleo, an epidemiologist for Doctors Without Borders, remembers the first fetus she tested last year.
“It was the highest viral load we’ve ever seen. Just off the charts,” she said.
Since she was a little girl, Kabia had dreamed of being a mother. She hadn’t finished high school, but she imagined her child would go to college.
After leaving the treatment center, she had even grander ambitions. “It will become a doctor,” she said. “Because that’s who saved me.”
It was the only hope she could hold on to.
She used to work selling kitchen utensils. But her job disappeared when she got sick. Her days were monotonous and lonely.
Kabia’s landlord kicked her out of her home. There was no one left in her family to pay rent, and survivors were stigmatized by people who believed, wrongly, that they are contagious. She moved into a friend’s apartment, and they shared a bed. That’s where she noticed the bleeding.
It seemed like it might be the end for her baby, like the disease was trying to prove that she wasn’t an exception to any rule. But the clinic gave her an injection and some drugs.
In a day, the bleeding stopped. She regained strength. The baby again appeared to be as healthy as she was.
“I felt better — small, small,” she said of the pace of her recovery.
Everyone who knew Kabia saw the bleeding as a sign of how tenuous her situation was. Still, weeks have passed since then, her pregnancy is entering its fifth month, and the fetus appears healthy.
“Of course I worry about her,” said Freeman Taylor, who leads a group of volunteers who work with survivors. “All the time.”
A world away, in Atlanta, doctors and scientists at the CDC are trying to create a registry of Ebola survivors, each of their cases documented in as much detail as possible. The hope is that patterns will emerge and anomalies can be studied. The world’s understanding of the disease will improve.
One of the scientists who recently returned from working on the Ebola outbreak in Port Loko is Sara Jamieson. The epidemiologist met Kabia and took a picture of her, which she keeps on her phone.
“I immediately thought of what it meant for her and the child,” Jamieson said. “Will she be able to carry the child to term? If so, will it be born healthy?”
For scientists, this Ebola outbreak is more than just a horrible tragedy. It’s a once-in-a-lifetime research opportunity that could help prevent, or contain, the next epidemic. The last study on pregnant Ebola patients was conducted in 1995, during an outbreak in Kikwit, Zaire, where a total of 315 people came down with the disease, just a handful of them expectant mothers. This outbreak has infected more than 20,000 people.
If the right cases are documented and researched, it could change the foundations of our knowledge about the disease. If Kabia and her baby survive, it could mean that we have to reevaluate much of what we know about the intersection of Ebola and obstetrics.
“It would give a lot of people a lot of hope,” said Denise Jamieson, who is no relation to Sara.
At the beginning of the HIV outbreak, nearly half of all pregnant HIV patients passed the virus on to their babies. It took years, but scientists learned that by using anti-retroviral drugs, they could cut the mother-to-child transmission rate to less than 5 percent.
For now, in every recorded case, mothers with Ebola pass the disease to their children.
In November, Kabia returned to the holding center where she had been treated, just to visit.
There were fewer patients because a formal treatment unit had finally opened nearby. But everything else looked familiar to Kabia: the dirt driveway, the white plastic barrier between patients and the outside world, the nurses in head-to-toe protective gear.
“I see her and I feel good,” Taylor said. “She’s the answer to my prayers.”
Another pregnant woman, Meratu Koroma, was at the center. But at the stage when Kabia’s health had improved, Koroma’s had deteriorated. She could barely walk and was sitting on a slab of concrete in the shadow of a tent. She moaned and spat on the ground. She told Taylor she hadn’t received any oral rehydration salts for days.
“They’re still not taking care of pregnant women,” Taylor said.
In another courtyard of the hospital complex, away from the Ebola ward, about 25 mothers had gathered with their newborns for a class on child care. The women had never contracted Ebola and the infants were healthy, clinging to their mothers as they were rocked. A nurse instructed the parents on when their babies should be immunized and how they should be bathed.
Kabia walked somberly past the group. She was no longer like Koroma, fighting for her life. But she wasn’t yet in the circle of mothers. There was no guarantee she would be.
She sat in the shade, nervously tapping her feet on the ground.
“I think my baby will be safe,” she said.