"One of the most profound impact of COVID-19 has been on the lives of women and girls. The lockdown and quarantine measures imposed to curb the spread of virus have put millions of women around the world out of reach of birth control options and other sexual and reproductive health (SRH) services"
The
COVID-19 public health emergency has already become a crisis of global
proportions as countries imposed national emergency, restrictions on travel,
including stop-movement orders. This pandemic has placed unprecedented
pressures on our health and social systems. Frontline service providers and
systems, such as health, policing and social welfare, are overwhelmed by a
plethora of activities related to preparedness and response of the COVID-19
pandemic. The major efforts of the entire health system and workforce are directed
towards containing the spread of the disease and often the resources are
diverted from the routine health services. In doing so, there is a risk that
essential health services which communities expect from the health system,
would be compromised. The health seeking of many essential services has been
deferred because of lockdown and physical distancing requirements coupled by fear
of COVID-19 exposure on venturing out of the house. Nepal has been under lockdown
since March 24 and stays to continue till date. With no clear plan about going
back to the normal life, the end to the lockdown is still not clear. This are public
concerns whether this lockdown would be extended indefinitely.
One of the most profound impact of COVID-19
has been on the lives of women and girls. The lockdown and quarantine measures imposed
to curb the spread of virus have put millions of women around the world out of
reach of birth control options and other sexual and reproductive health (SRH) services.
Confined to the home with their partners, they are much at risk to face
unwanted or unplanned pregnancies. Because of COVID-19 related travel bans and
closure of many clinics and health facilities, women are less able to access
critical SRH services such as maternal health care, contraceptives and family
planning, abortion, screening and treatment of STIs & other reproductive
morbidities including other routine services. For women using long acting
reversible contraceptives such as implants and intra-uterine devices, there
might be a need for replacement, re-insertion or switching to another method
due to side effects, complications or completion of duration. Even for those
using short-term methods such as oral contraceptive pills and condoms, going
out to procure a contraceptive is relatively difficult. In both cases, as the
services are unavailable, more women are likely to experience unplanned
pregnancies. Some women may opt for an abortion and many of these could turn
out to be unsafe as the crisis could push women to take abortion drugs without
supervision or seek help from people who lack training. Women also face greater
exposure and vulnerability to gender-based violence and other harmful practices
as they have been obliged to spend long hours at home with abusers, and with
limited options for seeking help and support. This is especially problematic
for women and girls from hard-to-reach areas including marginalized groups and those
with disability.
Even in places where health services are
available, many women refrain from visiting health facilities as they fear being
beaten by security forces and accused of defying the lockdown. Although
government has long ago declared that the people seeking essential services
would be allowed to commute freely, there is no public transportation
available. On the other hand, due to shyness and fear of stigmatization women often
might not be in a state to openly disclose the reasons to the security forces
who impede their movement on the way to health centers. Nonetheless, many women
prefer to seek family planning, abortion or other reproductive health services clandestinely
from the health centers which are typically away from their residence.
Meanwhile, outreach services, the key to reaching rural women and those
furthest behind, have largely been suspended to avoid crowds and to prevent the
risk of virus transmission from one community to another. The COVID-19 pandemic
has also led to disruptions in supply chains across sectors, including with
contraceptives and essential medical supplies. The impact of such disruptions are
being manifested through stock-outs at health facility levels and community
based distribution points followed by increased times for delivery of
contraceptives.
Why should it matter?
A recent estimate from a Guttmacher
institute revealed that even a 10% decline in contraceptive use in low and
middle income countries due to reduced access would result in an additional 49
million women with an unmet need for modern contraceptives and an additional 15
million unintended pregnancies over the course of a year. The institute has also
predicted that even a modest decline of 10% coverage of pregnancy related and
newborn health care would have disastrous implication for the lives of women
and their newborns. An additional 1.7 million women who give birth and 2.6
million newborns would experience major health complications but would not
receive the care they need resulting in an additional 28,000 maternal deaths
and 168,000 newborn deaths. Similarly, the estimates say that if 10% of safe
abortions become unsafe because women cannot access safe abortion services amid
lockdowns and clinic closures, there would be an increase of three million
unsafe abortions and one thousand more maternal deaths in the low and middle
income countries. On the other hand, the United Nations Population Fund estimates
that 23 million women in 114 low and middle income countries may not be able to
access modern contraceptives and 600,000 unintended pregnancies are expected to
occur if the lockdown carries on for three months with medium disruptions to
health services. In the same period, 31 million additional cases of
gender-based violence can be expected to occur. It is therefore clear that the
consequences could be severely catastrophic for women and their families if
critical sexual and reproductive health services are reduced or suspended
during the pandemic. The access to reproductive health services is almost
always time sensitive and potentially life-saving and shouldn’t be deferred or
placed on hold given any circumstances including a COVID-19 lockdown.
What can be done?
It is not logical to protect the people
from COVID-19 and yet expose them to other fatalities against which government
and other partners have made substantial investments over several years. So, the
answer is clear and obvious; despite the lockdown and travel bans, it is imperative
that the critical sexual and reproductive health services should be continued
and made accessible to everyone without having to face barriers of any kind. However,
the most indispensable question is How? The COVID-19 pandemic has been a severe
stress-test for all of us. The existing health system is overstretched and
preoccupied with preparedness and response activities such that its capacity to
deliver the essential health services has been severely undermined. Despite
these challenges, the health system should not depart itself from exploring innovative
models and approaches of care. Given that the stringent lockdown and travel
restriction measures are currently in place, asking women to visit health
centers for the services they need might not be both practical and ethical, for
many reasons. It is therefore imperative for a health system to adopt
alternative models of outreach services in order to cater women at places near
to their doorstep.
One approach is to revitalize and
reposition the role of visiting service providers who are often found very
effective in increasing the uptake of contraceptives especially the long acting
methods by rural and marginalized women. Visiting service providers in the form
of LARC ANMs, MS ladies or roving ANMs travel to rural health facilities and
communities on regular intervals to cater the contraceptives and maternal health
care needs of the women and girls. Although these cadre of service providers
are currently available in more than fifty districts, mostly remote and
hard-to-reach, activities of the majority have been suspended greatly ever
since the lockdown. It is a stark reality that these cadres are barely utilized
during this period of crisis although the entire health sector is struggling
with health workforce shortages. Where feasible, health system must thus consider
exploring the opportunity for mobilization of visiting providers by
repositioning their role from a family planning service provider to the role as
a provider of comprehensive sexual and reproductive health services. In
addition, taking into account the local availability of human resources and
current pressures on the health system, the local governments and health system
authorities may also decide to mobilize other public health care providers (both
nurses and paramedics) at peripheral levels to offer SRH and other critical
health services in the outreach.
These visiting providers could plan a
fixed service day for each village/ward area and organize comprehensive family
planning, sexual and reproductive health outreach sessions. Such kind of
sessions could be planned on dates and time decided locally based on demands
from the community. The beneficiaries may be called in a small group of 3-4 per
session to ensure adherence to physical distancing. The existing community
networks such as female community health volunteers, local health workers and social
mobilizers/volunteers might be utilized to identify and communicate about
outreach services to women and girls with need for services, and this could
possibly be done through the telephone or local contacts. Furthermore, in
circumstance with special needs such as high-risk pregnant, post-partum mother,
women with disability, and other women with special needs, the outreach services
through home visits can be provisioned and optimized. Such home visits and
outreach services should preferably be linked to temporarily established helpline/hotline
services such that needs for additional support and referrals can be responded
immediately.
Besides, offering family planning
services to postpartum women through infant immunization contacts has been
considered one of promising high-impact practices in family planning. Given the
need for a health system to work efficiently by minimizing the frequency of people
contacts, the opportunities could be explored to cater both, the infant for
immunization and the mother for family planning and/or SRH services during their
solo visit on immunization session.
Ensuring the uninterrupted supply of
contraceptives and birth control pills and other essential commodities is
another critical aspect to safeguard people’s access to sexual and reproductive
health services. In rural communities, where reaching health facilities or
private pharmacies could be a problem due to travel restrictions, different
alternatives could be considered for increasing people’s access to contraceptives.
One approach is to explore whether it would be feasible to make the short-term
contraceptives such as condom and pills available at local grocery stores. Amid
lockdown, the grocery shops remain open each day, even if it is for certain
hours in a day and are often accessible to everyone. Local governments may
appoint a local youth volunteer as runner to fetch contraceptive supplies from district/municipal
store or health facilities up to these distribution points. Movements of such
volunteers should be facilitated locally in coordination with local authorities
and police administration.
It is also critically important to make
the best use of existing digital and tele-health platforms to ensure the
provision of reproductive health information, counseling and services. Digital
platforms worldwide have become a more popular, safer and effective means to
reach client with comprehensive and reliable information and services during
this lockdown period. A number of toll free helpline facilities are currently
available for sexual and reproductive health services in Nepal. For instance, a
Meri Saathi free helpline has been offering information, counseling and
referrals on sexual and reproductive health issues through the dedicated
counselors. Also, there are other hotline services and mobile health platforms
operated by few other NGOs including the Ministry of Health and Population. In
addition, a 24-hour hotline service operated by National Women Commission
offers support to survivors of Gender Based Violence. Such hotline service can
respond promptly during emergencies and offer referral services for women to
receive health services, legal aid, psychosocial support, child support and
safe shelter. Clients requiring any type of information and support services
should therefore be encouraged to utilize these tele-platforms to obtain
comprehensive information, identify a need to visit a health facility/hospital
and to determine whether referral services are needed. A number of mass-media
could be used to inform the public about its availability, to build public
trust that these services are confidential and reliable and to promote the use of
such services.
Having considered all these approaches, the
government and health system must also be thoughtful on few other basic issues.
Firstly, as the public transports have been closed, health care providers may
face difficulties in their commute to outreach sessions, particularly those who
rely on public transports for their movements. Where feasible, the
inter-mediate means of transportation such as bicycle, scooter or other local
means could be provisionally made available to theses providers to enable their
movements to distant or hard-to-reach areas. Secondly, the protection of
visiting service providers is crucially important. Thus, before deployment for
outreach services it is imperative that these nurses and health care providers
are well-informed and orientated on the standard protocols for infection
prevention and control and are aware of the advisories for infection
prevention, personal protection and physical distancing norms. Provision for
the adequate and appropriate personal protective equipment would be equally necessary.
Lastly, the key to successful pandemic response and continuity of essential
health services largely depend on how robustly the governments and health
system apply their efforts and resources and how effectively the coordination
has been sustained with other private and non-government sectors at local level.
For universal access to sexual and
reproductive health services to become a reality, there is an urgent need for
concerted efforts, quick and decisive action. It is the responsibility of
everyone including the public health sector, governments at all three tiers, for-profit
as well as not-for-profit sectors to devise necessary measures to ensure that reproductive
health services remain readily accessible to everyone and ensure the
functioning of community systems to protect the rights and dignity of all women
and girls. While COVID-19 pandemic is inevitable, the devastating impacts of
lockdown on SRH services can be significantly mitigated if the community level
efforts are well-integrated.
This article was published at Online Khabar on 06 May 2020: Please follow the link below
https://english.onlinekhabar.com/ensuring-access-to-sexual-and-reproductive-health-services-amid-lockdown.html
