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The only thing more terrifying than the spread of Ebola is when the hemorrhagic fever spreads to pregnant women. It’s not just a likely death sentence for the mother and fetus. It also can ravage entire public health systems meant to bring children safely into the world.

Part of the gripping story of Thomas Eric Duncan, the first person with Ebola diagnosed in the U.S., includes a detail about how he likely contracted the disease. According to reports, he probably became infected four days before flying to the U.S. after helping a friend and neighbor who was dying from Ebola.

Because of intense interest in how Duncan got to the U.S. and whether doctors in Dallas handled the diagnosis in a timely fashion, the most poignant detail in the story has been mostly glossed over: The source case, a 19-year-old woman named Marthalene Williams, was seven months pregnant. A few hours after the prolonged exposure to Duncan, Williams and her fetus died of overwhelming Ebola infection.

Little is known about the effect of Ebola on pregnancy, but what we do know seems particularly grim. Only one study, a 1999 report from an outbreak in the Democratic Republic of the Congo in 1995, has examined the condition. Belgian and local researchers reported on the outcomes of 15 pregnant women who were among the 105 women who developed the disease. Of these, 14 (96 percent) died. As did their fetuses, including those of the four women who were in their last trimester. 

The cause of death for many was bleeding—not a surprise given the intense blood vessel richness of the placenta and the pregnant uterus. Combining that dense mat of small arteries and veins with a disease that is among the hemorrhagic fevers is asking for trouble, even with a young and healthy group of patients. Indeed, all 15 women in the study had severe bleeding and, in addition to the death of the mother, many miscarried before perishing.

The extremely high death rate is surely alarming. By comparison, the overall death rate in those earlier years, before the utility of supportive care with IV fluids was fully appreciated, was 77 percent—a statistically trivial difference. A recent 2014 review by the Centers for Disease Control and Prevention (CDC) of risk to obstetricians from Ebola viruses also considered the issue and leaned on the same 1999 data, repeating the same sad news and adding the equally grim fate of the fetuses.

Now with a death rate of about 55 percent for the more than 7,000 cases diagnosed to date, the survival differences, if present, will stand out more sharply and significantly. It is uncertain, however, whether pregnancy is a condition recorded by local health authorities, who are busy with a thousand other tasks. In other words, we may never know the exact increment of increased risk for pregnant women who contract the infection.

But a second risk to pregnant women has emerged. A recent flurry of attention has been aimed at the collateral problems to anyone with a medical condition in Ebola-strapped countries, including those without infection: the deleterious impact of packed hospitals, filled beds, and overwhelmed, frightened doctors and nurses. This lack of predictable prenatal care may have a larger public health impact than the deaths of so many during this frightening, historic epidemic. This is a testament to both the remarkably salutary effect of prenatal care, even at its bare-bones most simple, and the fragile, now- tottering health care systems of the three countries who may lose an entire generation should the disease not be stopped.

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