By Davide De Beni & Federica Maurizio
BANGKOK – Last month, Sheuly rushed into a Dhaka hospital in need of emergency treatment. The 25-year-old Bangladeshi woman had just given birth at home – thinking it a safer setting than the hospital during a pandemic. But as she began to suffer from post-partum hemorrhage – one of the leading causes of maternal death worldwide – avoiding exposure to COVID-19 was the furthest thing from her mind. The same was true of Majufa Akter, the midwife who sprang into action and saved Sheuly’s life, despite not having yet received adequate personal protective equipment (PPE).
Giving birth is an intense moment in a woman’s life under any circumstances. Doing so during a pandemic imbues the experience with a new form of stress. Mothers do not know whether to go to hospitals – where they fear exposure to the coronavirus, personnel shortages, or separation from their partners – or to give birth at home, where medical complications often become far riskier. This is just one example of how the imperative of managing the COVID-19 pandemic is complicating the delivery of essential health services – and leaving women, in particular, highly vulnerable.
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Around the world, when health systems are overstretched, services for women are often among the first to suffer, resulting in increased maternal and child morbidity and mortality. To illustrate the risks, we have modeled the pandemic’s possible impact on three key sexual and reproductive health (SRH) services: births assisted by skilled health-care providers, including midwives; births taking place in health facilities; and access to contraception.
While reduced access to SRH services is a problem in many parts of the world, including developed countries like the United States, we focused our analysis on 14 countries in the Asia-Pacific region that are particularly vulnerable: Afghanistan, Bangladesh, Bhutan, Cambodia, India, Indonesia, Laos, Myanmar, Nepal, Pakistan, Papua New Guinea, the Philippines, the Solomon Islands and Timor-Leste. All already have high maternal mortality ratios – more than 100 deaths per 100,000 live births, which often reflect lower use of health services, such as giving birth in medical facilities or with the help of skilled birth attendants.
The best-case scenario, according to our model, is a 20% decline in use of the three key services. That would lead to a 17% increase in maternal mortality ratio, equivalent to 25,493 additional deaths this year alone. The worst-case scenario – a 50% decline in use of services – would produce a 43% increase in maternal mortality, or 68,422 additional deaths. Of these additional maternal deaths, a considerable proportion would be attributable to the increase in fertility resulting from reduced access to contraceptive services.
In fact, reduced access to contraception and family planning services further exacerbates risks. Border closures and other supply-chain disruptions could reduce the available supply of contraceptives, which are often out of stock even in normal times. Movement restrictions could prevent women from getting to pharmacies or clinics, particularly if family planning is not deemed “essential.” And fear of exposure to the coronavirus could stop women who have access from pursuing services.
Together, these factors could cause the unmet need for family-planning services to spike in 2020, increasing to 22% in our best-case scenario or to 26% in the worst case, from a baseline of 18.9% of women of reproductive age in 2019, as women who previously had access to a modern method of contraception lose that crucial service. That means that the unmet need for family planning could increase by up to 40% in 2020 alone. The result would be thousands of unintended pregnancies in each of the 14 countries, and a higher risk of adverse health outcomes for millions of women and newborns.
And yet these figures are just the beginning: the COVID-19 crisis will almost certainly last beyond the end of this year. The costs – for economies, health systems, and women’s wellbeing – will continue to mount. Recent progress toward more effective and inclusive health systems and gender equality may be reversed.
Action must be taken to limit the fallout. At the 1994 International Conference on Population and Development in Cairo, the world’s governments committed to providing SRH services to all – a commitment they reiterated at last year’s ICPD25 Nairobi Summit. As countries design economic and public health interventions, they must ensure that they are honoring this commitment.
For example, leaders must ensure that essential health personnel like midwives are not diverted away from their primary task of assisting mothers and newborns, and that all personnel receive the PPE they need. Policymakers must also safeguard access to contraceptives. And, where possible, telemedicine and other innovative approaches to health-care provision should be considered. If this pandemic has shown us one thing, it is the lifesaving potential of technology and connectivity.
United Nations Secretary-General António Guterres has rightly called the COVID-19 crisis the “greatest test” the world has faced since World War II. To pass it, leaders everywhere must recognize that, while the pandemic affects everyone, those who were already marginalized – including women, ethnic minorities, and the poor – are likely to suffer the most. That is why no pandemic-response strategy is complete without a plan to ensure uninterrupted access to essential sexual and reproductive health services for all.
De Beni is a health economics adviser. Federica Maurizio is a sexual and reproductive health and rights analyst at the United Nations Population Fund’s Asia-Pacific office.