NEW YORK — Like many other health care providers, women’s health nonprofit WINGS in Antigua, Guatemala, was not prepared for the coronavirus pandemic in March. They shuttered the clinic and substituted telemedicine for mobile van units, dropping their number of monthly average patients from 1,000 to just a few hundred.
The importance placed on maternal health before the pandemic and whether there will be a second wave of COVID-19 are among the factors that will determine how quickly and effectively countries can rebuild their services, experts tell Devex.
The low-cost clinic reopened earlier this month with limited hours, after securing personal protective equipment and touchless thermometers. The demand for family planning services was clear: Their patient load surged past pre-pandemic levels, resulting in WINGS setting up a new office space to accommodate patients.
“We are definitely now ready. The main concern right now is safety. This is going to be a process. And hopefully we have the capacity to go to the places we used to go, to the communities we used to serve,” said Rodrigo Barillas, WINGS executive director.
Service disruptions to sexual and reproductive health during the COVID-19 pandemic have been widespread worldwide, according to anecdotal evidence. Several organizations are working to produce comprehensive data analysis on the crisis’ impact on women’s health care.
The Guttmacher Institute has estimated that the pandemic could result in a 10% decline in use of short- and long-term acting reversible contraceptives, impacting 48,558,000 additional women with an unmet need for contraception, and leading to 15,401,000 new unintended pregnancies.
‘The most disruptive interruption’
Analysis of new gaps in sexual and reproductive health care is still anecdotal, but accounts from direct service providers reveal a drop in these services, even when governments classify them as essential, according to Ashley Wolfington, the acting COVID-19 task team coordinator of the Inter-Agency Working Group on Reproductive Health in Crisis, or IAWG.
“It is the most disruptive interruption any of us have ever seen in terms of a public health emergency, on top of that many organizations that are active in IAWG are working in countries where they are also affected by crisis, or countries where they are providing services for a large number of displaced people,” Wolfington told Devex.
IAWG hosted digital discussions with nearly 300 sexual and reproductive health care providers in crisis settings in May. The discussions showed that the pandemic has sidelined SRH, diverting women’s health resources to other services. Marginalized populations, such as gender-based violence survivors, have become harder to reach, and logistical problems such as lack of public transport and internet access have made it more difficult for women to receive standard care, according to Wolfington.
“We are all struggling to adapt to the pandemic,” Wolfington said. “Sexual health is being sidelined and not prioritized and that is playing out in a number of different ways.”
IAWG has published programmatic guidance for sexual and reproductive health during the pandemic.
“The need for contraceptives continues through a pandemic, despite disruption of supply chains and other factors. There is research to show a small decline in this could result in a large increase in additional unintended pregnancies,” said Bergen Cooper, director of policy research at U.S. nonprofit Center for Health and Gender Equity.
Confusion and practical hurdles
There has been confusion in South Africa over whether women should go to health clinics if they have an issue unrelated to COVID-19, according to Dr. Tlaleng Mofokeng, a doctor at a private women’s health clinic in Johannesburg, and a commissioner at the national Commission for Gender Equality.
“What tended to happen is that people were staying away,” Mofokeng said, noting that her private office had an easier time quickly adapting to social distancing protocols than public clinics.
Health supplies are another concern for Mofokeng. There are shortages of injectable contraceptives in South African public clinics, reducing many women’s birth control choices to external condoms. Reliance on condoms carries added risk for women if their male partners do not use them, Mofokeng said.
“We know in terms of negotiation for safer sex, the power dynamics are very much imbalanced. Not only then does a woman now have to worry about an unwanted pregnancy, but there is the added stress of having an STI [sexually transmitted infection] transmission,” Mofokeng said.
“Even if sexual and reproductive health services have resumed, the services are not consistent, and caseloads have dropped.”— Vinoj Manning, CEO, Ipas Development Foundation
And some health care providers have told women who are pregnant but considering an abortion to come back in a few weeks, raising the chance of a second trimester abortion.
“The question is whether you can get the procedure done safely or not, and unfortunately people are going to fall into the hands of untrained people who are trying to pretend like they are doctors masquerading to people,” Mofokeng continued.
Abortions have become harder to access in many low-income countries, and facilities are also experiencing shortages of contraceptives, according to Anu Kumar, president and CEO of Ipas, an international NGO that works for safe abortion access.
In India, the first three months of public lockdowns compromised abortion access for an estimated 1.85 million people, according to Ipas, even though the government designates abortion as an essential service. Travel restrictions, suspension of public transportation, and conversion of public health facilities to COVID-19 treatment centers have all impeded care.
“Even if sexual and reproductive health services have resumed, the services are not consistent, and caseloads have dropped,” Vinoj Manning, CEO at the Ipas Development Foundation, wrote in an email to Devex.
Rebuilding for a new normal
Most IUDs are manufactured in India, which is still under lockdown, adding another layer to new SRH supply chain disruptions like delayed shipments, according to John Skibiak, director of the Reproductive Health Supplies Coalition. China, another major producer of contraceptive implants, has resumed production.
Supply chains will likely again become stronger as India and other countries ease lockdown restrictions, but Skibiak said new ways forward might still be helpful to accommodate the pandemic’s impacts.
“In the short term, I think we are going to need to adapt the supply chains. We're going to need to adapt the systems to a different reality,” Skibiak said. “As we build for the post-COVID world, we will be building more supply chains that may involve more automated delivery or telemedicine and more ways of dealing with these realities.”
Participants in IAWG’s webinars from countries such as Burkina Faso also discussed the importance of regularly using telemedicine and formalizing it as part of government protocols and policy, according to Wolfington.
In Guatemala, WINGS expects that patient loads will soon level off, especially as the organization continues to expand their work through mobile units in remote locations.
New protocol measures involve reducing the number of health workers who travel in cars from five to two at a time. Confirmed COVID-19 cases have continued to climb in Guatemala over the last few months, reaching more than 600 new cases a day this week.
“It is educating our nurses in new safety protocols and PPE, getting used to that,” Barillas said. “We definitely feel optimistic, but we are really trying to keep an eye on everything as much as we can. But so far, so good.”