Peering inside a red Nissan hatchback that had pulled up to the gate of an Ebola treatment center here, a guard saw an older woman holding a tiny newborn, a young woman sprawled in the back seat and a man in his 60s crouched in the rear, gripping her clothing so she did not slide off. The woman, the couple told aid workers who quickly gathered Saturday afternoon, was their daughter. She had been sick for a week and was bleeding profusely after giving birth prematurely about two hours before. Her boyfriend, the baby’s father, had recently been treated for Ebola, they added.

 

Workers asked the couple to wait outside the gate, where a masked man with a chlorine sprayer soaked the ground around them. Before sending the car to the triage area, a doctor opened a back door and saw no movement. Realizing he needed protective gear, he went to suit up, then examined the woman and pronounced her dead.

 

For her child, there were no clear protocols. No one touched the tiny girl, aside from the grandparents holding her. No one at the center had any experience in dealing with babies in the Ebola crisis, nor could they fully evaluate the dangers. They were caregivers, after all, at a place of last resort. In a country devastated by a terrible disease, where the fear of it is pervasive, what do you do with a vulnerable infant?

 

“Every time somebody’s sick, people say Ebola,” John Yarkpawolo, 66, the baby’s grandfather, said later. “People are afraid.”

 

His wife, Annie Yarkpawolo, 64, a trained midwife, had sensed trouble when she received a phone call two nights earlier at her home in Gbarnga, she recalled. Emmanuel Dormeyan, the longtime boyfriend of her oldest daughter, Diana Flomo, 36, said he was bringing her from their home in Monrovia, more than four hours away.

 

“What happened?” Mrs. Yarkpawolo remembered asking. Mr. Dormeyan told her, “Your daughter can’t hear me, can hardly understand, can’t eat for a week,” she said.

 

The next morning, he dropped off Ms. Flomo, who was eight months pregnant and sold market goods in Monrovia. A day later, she suddenly gave birth and began hemorrhaging. While tending to her daughter, Mrs. Yarkpawolo tied plastic bags around her wrists and shoes, her usual protection during deliveries.

 

“She were bleeding, bleeding, water running,” she recalled. She and her husband, a social studies teacher, had no car, but found the young driver of the red Nissan willing to take them to nearby C. B. Dunbar maternity center.

 

There they waited for perhaps an hour and a half before a doctor became available. He offered no help, they said, but urged them to go to Phebe Hospital, also in Gbarnga. The family traveled on to Phebe, and again they waited. “She gave up,” Mrs. Yarkpawolo said of her daughter. She was not admitted. A doctor eventually sent the family a half-hour away to the Ebola treatment center, newly opened by the American charity International Medical Corps.

 

Many health workers in Liberia and its virus-ravaged neighbors have contracted Ebola while attending to births and being exposed to blood and other body fluids, provoking fears of providing maternity care. Turning pregnant women away was such a common occurrence that Yekeh Gayflor, the guard at the treatment center, sized up the situation as soon as the Nissan pulled up. “We didn’t need to ask questions,” he said.

 

It was not clear whether Ms. Flomo had even had Ebola; her family did not mention a fever, which typically accompanies the disease, and her symptoms could be explained by other maladies common in the region. But the center did not have equipment to test for Ebola after death, such as by swabbing her mouth. If she did have it, her baby could have been infected.

 

There is little research, but doctors speculate that Ebola can be transmitted from mother to baby in utero or during exposure to fluids while passing through the birth canal. A high proportion of pregnant women with Ebola miscarry and die. In outbreak areas, one study noted, every pregnant woman who is hemorrhaging should be viewed as a suspected victim of Ebola.

 

The International Medical Corps unit had never had a case like this in its three weeks of existence, and none of its doctors or nurses had treated Ebola before working here. “M.S.F. will know,” Sean Casey, the team leader at the center, said, using the French abbreviation for Doctors Without Borders. He called Dr. Anja Wolz, an Ebola treatment veteran based elsewhere in Liberia, who had offered to give advice on tough cases. “The baby’s not ever eaten,” Mr. Casey told Dr. Wolz.

 

Dr. Wolz suggested that the baby not be admitted; if she was not infected, she could be exposed to the deadly virus. If the grandmother had symptoms and required admission, she suggested, perhaps a nurse could be found to care for the newborn, using protective gear just in case. She told Mr. Casey that she thought the baby had very little chance of survival.

 

How to feed the baby and give her a chance? Staff members found a can of powdered baby formula. They boiled water and filled a bottle, and Mr. Casey translated the French instructions for how much powder to add. But the directions were intended for babies of at least two weeks of age, and this was an hours-old preemie. The aid workers guessed at the right volume and walked down the driveway to the grandparents. But the baby was not sucking. Someone brought a small syringe, and the grandmother dripped the formula into the infant’s mouth.

 

Afterward, a nurse, Audrey Rangel, asked screening questions and found that neither grandparent showed any symptoms of Ebola. Their driver had left, so the charity sent them home with the baby in an ambulance, but notified a religious leader on the local county’s Ebola task force to help smooth their return and avoid stigmatization. The couple were given gloves for handling the baby, a list of instructions written on a piece of notebook paper in English and a thermometer for monitoring their own temperatures in case they had contracted Ebola. They would also get a bucket and chlorine and instructions on how to clean the house where Ms. Flomo had given birth. Later, they were placed under quarantine by local officials, which made them worry about how they would get food during the 21-day period.

 

“This is new for all of us,” Mr. Casey said later, at once frustrated that the clinic could not do more and mindful that, as an Ebola unit rather than a hospital, it was not set up to do so. “It still wasn’t the right solution,” he said, “but it was the best we could do.”

 

He sat down with the unit’s program coordinator, who grabbed a notebook and wrote “Hmm?” on top, then listed questions for which the unit needed to develop answers.

1. “Are there admission criteria for infants? Other children who can’t communicate symptoms?”

2. “What is the protocol for a child that cannot eat/care for themselves?

3. “What food for <2 wks. baby.”

Another question: how to coordinate with local contact-tracing efforts to help stop the spread of Ebola among people at risk from confirmed patients?

 

At the grandparents’ house the next day, the baby’s face was cocooned in sheets. Her father, Mr. Dormeyan, had come from Monrovia to meet her and named her Diana, just like her mother. He wanted his daughter tested for Ebola, he said, and was desperate to know how Ms. Flomo had died, a question that might never be answered. “I want to know what’s the cause,” he said.

 

Her mother was grieving. When one of Mrs. Yarkpawolo’s sisters came down a dirt path past banana palms to the yard outside the family’s modest home in a neighborhood of Gbarnga called Millionaire Quarter, the two women keened and rocked. “My oldest daughter has died,” Mrs. Yarkpawolo cried.

 

Diana was still being fed through the syringe and seemed to be doing well. But on Tuesday night she cried and did not sleep. On Wednesday morning, the formula seemed to stick in her throat. She vomited and breathed hard for a while, the grandparents reported. 

 

Then she died.

 

A county burial team sprayed the small body and the room she had been in with diluted bleach. Mr. Yarkpawolo traveled with the group to the Ebola treatment center, past a health promotion road sign that said, “No woman should die while giving life.” He wanted to make sure his granddaughter would be placed near his daughter, who had been interred three days before.

 

The smell of chlorine hung in the air. In a blizzard of spades, four men quickly filled the small hole, then tapped a marker — “In Loving Memory of Diana Dormeyan,” it said in handwritten letters — into the soft earth. Mr. Yarkpawolo wiped his face. “Thank you, man,” he said to a worker. “O.K., Pop,” the man replied.

 

By SHERI FINKOCT

Newyork Times