Esther Lutula stopped going for prenatal checkups shortly after the current Ebola outbreak was declared in eastern Congo. Midway into her pregnancy, the 26-year-old feared being put into isolation simply for having a fever, a common misconception.

“That’s why I’m waiting until the disease is no longer widespread,” she told The Associated Press from her home in Bunia, the capital of Ituri province and epicenter of the outbreak declared on May 15.

But that could be a deadly mistake.

Maternal mortality across Ituri soon doubled as news of the outbreak spread, with an average of about six women dying per week due to childbirth complication, according to Noemi Dalmonte, deputy country representative of the United Nations Population Fund in Congo.

While there was an average of 3.1 maternal deaths weekly this year before the outbreak, that jumped to 5.8 deaths from May 25 to July 19. Among those, the deaths outside health centers have also jumped from 9.1% to 17.4% within the same period, UNFPA data shows.

As Congo battles the fastest-growing Ebola outbreak on record, with more than 1,600 confirmed deaths, health and aid workers are warning of a shadow crisis as pregnant women avoid hospitals and the country's already high maternal mortality rate climbs even more.

While it’s common for Africans to avoid health centers during public health emergencies because of safety concerns, “with Ebola, it is stronger because Ebola has a lot of rumors," Dalmonte said in an interview.

With some wary residents questioning whether Ebola even exists, and health workers in one of Congo’s most remote and volatile regions struggling to respond to the outbreak with few supplies, pregnant women have less care than ever.

Congo is one of the world's most dangerous places to give birth
Congo's has among the world's highest rates of both childbirths per woman and deaths around childbirth.

Women in the vast central African nation have almost six children on average. At least 19,000 women died from pregnancy complications in Congo in 2023, according to the latest U.N. data, tied with India and second only to Nigeria globally.

Now health workers in Ituri say they are seeing a decline in hospital visits as people worry about the risk of infection. This type of Ebola has no approved treatment or vaccine.

Women in need of care also fear being caught up in violence. Ebola treatment centers have been attacked by residents fueled by misinformation or anger over strict outbreak measures.

At the Bénédicte Clinic in Bunia, the number of women registered for prenatal care has dropped from 60 each month to around 10, said Dr. Sonny Mwembo, the medical director.

Even now, weeks into efforts to battle misinformation, some residents hold mistaken views of the outbreak.

“Right now, if you feel sick and go to the hospital, they say it’s Ebola and they put you in quarantine right away. That’s what scares people,” said Elodie Yabiri, a Bunia resident who is heavily pregnant.

Yabiri said she’s avoiding hospitals as much as she can.

As long as she still feels her unborn child moving, she believes everything is still okay.

Limited health care pivots to Ebola instead

The outbreak has strained Congo’s already overstretched healthcare system, complicating access for the pregnant women who still come for prenatal care or birth.

Health facilities in the five affected provinces are redirecting staff and supplies to the response, reducing access to essential maternal care services, according to aid groups.

At least 44 health infected workers have died. Many other health workers have walked off their jobs, protesting the lack of payment. At least 12 attacks have been recorded against health facilities and teams since the outbreak was declared in mid-May.

“We are doing everything we can to make the public understand how dangerous this disease is. We are working day and night without being paid,” said Dr. Ghislain Maneba, an epidemiologist and community investigator in Ituri's Rwampara health zone.

All women are at higher risk in this outbreak

Ebola is rare but highly contagious and severe, often fatal. It spreads in the human population through contact with bodily fluids such as vomit, blood or semen, and with contaminated surfaces and materials such as bedding and clothing.

Women are usually the primary caregivers when a loved one becomes ill. Many are among frontline health workers in this outbreak as well.

Associated Press journalists covering the outbreak have seen pregnant health workers among the responders.

“It is very important that they know how to protect themselves, that they have the right information,” Dalmonte said.

Pregnant women with Ebola are at an increased risk of problems including miscarriage, the U.S. Centers for Disease Control and Prevention has said in its clinical guidance.

Meanwhile, pregnant women who delay care and avoid health facilities “could die not from Ebola itself but because the care that would have saved them was no longer accessible, trusted or safe,” Dalmonte said.