BERLIN — Last month, Rael, an expectant mother in Kenya’s central Meru region, went into labor. With the help of a neighbor, she successfully delivered the baby. However, the placenta remained inside her womb.
She called a driver to take her to the hospital that evening, but confusion over who was allowed to travel during Kenya’s dusk-to-dawn coronavirus curfew meant the vehicle did not arrive until the next morning. By the time she reached the hospital, Rael was dead.
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She was enrolled in Child.org’s Team Mum, a network of support groups for pregnant women in Meru County. Martina Gant, who runs the project, said Rael’s death was the most devastating of the many effects that have befallen group members after Kenya hastily implemented movement restrictions to slow the spread of the new coronavirus.
“Women have been too afraid to move during curfew,” Gant said. “There have been hideous cases of brutality toward people trying to support women with access to skilled care.” Gant now warns of a higher newborn death toll than is common and likely long-term ramifications that have yet to emerge.
With lockdown measures beginning to ease, activists across the global south are finally able to begin gauging the impact of the restrictions on maternal health, even as they move quickly to prevent any long-term damage.
Burden on strained resources
As governments rushed to get measures in place to curb the spread of the coronavirus, considerations about the broader ramifications of those restrictions were often overlooked.
“It’s important to design country-specific solutions, which requires getting country-specific information on what’s going on.”— Dorit Stein, health financing associate, Palladium
Analysts from Health Policy Plus, or HP+ — a project run by Palladium to strengthen global health interventions — underscored the particular risk in low- and middle-income settings with strained health services in a recent blog post. They wrote that limiting travel, failing to adequately prepare health facilities, and disrupting the services of community health workers, or CHWs, threatened to further exacerbate the limited access to care.
Dorit Stein, health financing associate at Palladium and co-author of the post, told Devex that those concerns spurred the analysts to model the potential impact of COVID-19 on mothers and newborns in four countries — India, Indonesia, Nigeria, and Pakistan — based on outcomes during West Africa’s Ebola outbreak between 2014 and 2016.
Acknowledging that the two emergencies are far from identical, Stein said the analysis might still offer a window into a possible scenario if the four countries saw the same relative reductions in family planning, antenatal care visits, and facility-based delivery that occurred during the earlier outbreak.
She described what emerged from their model as “surprising”: an additional 31,980 maternal deaths, 395,440 newborn deaths, and 338,760 stillbirths over the next year just in those four countries. Together, that would correspond to a 31% increase in mortality.
Stein emphasized that policy changes and context-specific interventions within communities and health facilities could produce different outcomes.
“It’s important to design country-specific solutions, which requires getting country-specific information on what’s going on to have a better sense of the key reasons for potential shifts or reductions in service,” she said.
Among the potential interventions, she cited more home visits from properly protected CHWs and, within facilities, the proper training and supplies to isolate women and protect them if they sought care. Overriding all of this is the need to properly communicate any changes to communities so they feel safe utilizing whatever services are available.
Reports of unnecessary deaths, such as Rael’s in Meru, seem to indicate that the HP+ team’s concerns were warranted.
Training health workers to reach women
On March 31, Ugandan President Yoweri Museveni announced that lockdown measures were going into effect in two hours’ time. They were among the most restrictive on the continent, with a dusk-to-dawn curfew and prohibitions against both public and private transportation without official authorization.
“That very night, people were in a panic,” said Primah Kwagala, CEO of the Women’s Probono Initiative, which uses legal tools to challenge inequality. “Women who were pregnant and needed to go to the hospital, who needed emergency obstetric care services — they shouldn’t need to ask for permission to go and do that.”
It would take nearly two weeks for the president to clarify that pregnant women were allowed to take transportation to facilities and to seek care during the curfew. By that point, Kwagala’s organization had documented the death of 11 expectant mothers while trying to access services.
In India, the government issued guidelines ahead of the country’s strict lockdown — which is still ongoing — for delivering essential health services. But that information did not reach everyone who needed it, particularly in poorer communities, said Dr. Aparna Hegde, founder of the NGO ARMMAN, which uses technology to improve maternal and child health. Women were calling her organization after being turned away from facilities that had been converted into COVID-19 units, unsure of where to go.
To fill the information gap, ARMMAN is now running a daily antenatal and pediatric clinic, linking women to doctors, finding services for them, and even calling ambulances.
“In the COVID world, social distancing is going to become the norm. Digital programs are going to be the way forward.”— Dr. Aparna Hegde, founder, ARMMAN
“We’ve saved lives,” Hegde said. “Women don’t know where else to turn.”
As restrictions begin to ease, activists are taking stock of the situation, identifying persistent barriers to care while planning strategies to mitigate the potential long-term impact on women’s willingness to seek medical services when the pandemic is finally brought under control — if it ever is.
They have reason to be worried. A retrospective study in Guinea, one of the countries hit hardest by the West African Ebola outbreak, found that demand for essential maternal and child health services not only failed to recover after the outbreak but that targeted interventions would be needed if it were ever going to.
There are worrying signals that many countries could face the same outcome. Kwagala said some Ugandan communities now appear to be turning to low-skilled, traditional birth attendants, which could undo the long-standing campaign to encourage women to deliver in medical facilities. In Kenya, Gant said maternal health campaigns have been set aside as resources are redirected toward the COVID-19 response.
Hegde said governments and organizations should look to technology for new strategies, even as they continue to emphasize in-person CHW programs so that people without access to technology are not neglected.
Child.org, like ARMMAN, is already experimenting with new approaches to leverage its networks and encourage women to continue seeking antenatal care and delivering in health facilities. This includes a partnership with Mama Tips to send updates via text message to keep mothers abreast of the latest developments and aware of the services that are still available to them.
“In the COVID world, social distancing is going to become the norm,” Hegde said. “Digital programs are going to be the way forward.”