Women are waiting at Doctors Without Borders' Ayilo hospital. Uganda, 2014. © Isabel Corthier
In Choloma, Doctors Without Borders team works at a mother and child clinic, offering family planning, ante- and postnatal consultations, psychosocial support to victims of violence, including victims of sexual violence, as well as assisting deliveries. Honduras, 2019. © Christina Simons/MSF
Travel bans, lockdowns, and movement restrictions compound the dangers
Travel bans and movement restrictions imposed to limit the spread of the coronavirus have had unintended consequences on all aspects of sexual and reproductive care. Doctors Without Borders' maternity hospital in Khost, eastern Afghanistan, saw a 40 percent drop in patients in early June. The facility typically delivers an average of 2,000 babies per month and treats sick newborns in its 22-bed neonatal unit, filling tremendous needs in an area with few high-quality, free health care services. Keeping the hospital open has been a struggle as staff have fallen ill and open midwife and gynecologist positions have gone unfilled due to international travel restrictions. (By the end of the month, the hospital was only able to accept women with complications who needed lifesaving emergency care.)
As challenging as it is to keep activities running, the drop in patient numbers is scary. Women in this area have faced difficulties getting transportation. Many are likely delivering at home with traditional birth attendants who have had no formal training, in an environment that may not be safe. “It’s very worrisome,” says Severine Caluwaerts, sexual and reproductive health advisor for the project. “We know some of those women are delivering at smaller community health centers that have built up capacity recently, which is good,” says Caluwaerts, but she warns that there are not nearly enough local clinics to meet the huge demands. Many of the maternal and neonatal deaths caused by movement restrictions—in Afghanistan and around the world—will likely never be counted, precisely because women never made it to a health facility.
In Kenya, pregnant women have struggled to find transportation to hospitals at night after curfew. At our project in Likoni, Doctors Without Borders has been writing notes for drivers to present to police if they get stopped after leaving the hospital. People were scared following news reports of a driver who was stopped and brutally beaten by police while driving a woman in labor to a health facility after curfew. In Mathare, also in Kenya, the lack of transportation for women at night led Doctors Without Borders ambulances to double their activity in April.
Lockdowns and social distancing measures have also contributed to a disturbing spike in reports of domestic violence, including sexual violence. Staying home is not safe for many women and girls who may be trapped with an abuser. The World Health Organization reports that one in three women experience physical or sexual violence, mostly from an intimate partner. During the COVID-19 pandemic, emerging data from around the world show that domestic violence has intensified, according to UN Women. Tensions can build up in confined spaces, especially with added stress over health concerns, economic insecurity, and fear for the future.
Even as the need for sexual violence care is apparently growing, access to health services is more difficult. In many places, Doctors Without Borders is seeing a disturbing rise in reports alongside reductions in people actually coming for care. In South Africa, a national hotline that receives reports of sexual violence saw a three-fold spike in calls after the country-wide lockdown took effect. “But while there was an increase in reports, there was a decrease in clinic visits,” says Kgaladi Mphahlele, Doctors Without Borders safe abortion care and family planning activities manager in Rustenberg, a platinum mining city with a large migrant community. Across the city and surrounding area, other clinics reported the same. Many callers were likely not able to leave their homes or get transportation to a health facility, Mphahlele says. Doctors Without Borders provides transportation for people who seek treatment for sexual violence, and we have continued to do so throughout the lockdown. We have also started telehealth counseling.
Even in normal times, accessing care for sexual violence can be extremely difficult due to stigma, fear of retribution, and a lack of trust in authorities, among other reasons. Now women and girls face even more hurdles. Only emergency cases are being seen at many health facilities, and only by appointment. Treatment for sexual violence is time-sensitive: rape victims must come within 72 hours in order for post-exposure prophylaxis against HIV to be effective, and within five days for emergency contraception to work. Because sexual violence is a taboo subject, many people do not know about the urgent need for treatment—let alone that this is an essential service.
In Choloma, Honduras, our team is seeing a disturbing pattern. “It’s been reported that gang violence has decreased during [lockdown], but domestic violence has gone up—like it has everywhere,” says Dr. Jennifer Stella, Doctors Without Borders' medical advisor in Choloma. Yet the number of women coming for Doctors Without Borders' sexual violence treatment services has dropped, likely due to restrictions on transportation, she says. “When patients are able to get in touch with the social worker or the psychologist, we send taxis for them, to actually get them to the clinic.”
COVID-19 symptom screening is part of the infection control measures at many health facilities right now but may also present a barrier to care, especially for people seeking treatment for sexual violence. Doctors Without Borders' project in Rustenberg has a carefully considered route to care to protect patient privacy, but this is not the case at many other facilities in the area. “On arrival at many primary health care centers, patients are asked, ‘What are you here for?’ before proceeding to be screened for COVID-19,” says Mphahlele. “For a person to answer, ‘I was raped,’ at the gate is not possible.”
Desperately needed supplies out of reach
Shortages of personal protective equipment (PPE) have been a major concern since the start of the COVID-19 outbreak, and this adds another barrier to health care for women and girls. In Mathare, Kenya, Doctors Without Borders teams have seen private health facilities where women usually receive sexual and reproductive health services shut down due to a lack of PPE. In Zimbabwe, where Doctors Without Borders supports a government-run cervical cancer program, services were greatly reduced, in part due to a lack of PPE. The number of screenings dropped from more than 400 in March to around 50 in April.
Supply chain breaks affect much more than PPE. The impact of these disruptions is being felt all over the world, but especially in low- and middle-income countries. In April, the UN Population Fund, the agency dedicated to family planning, reported likely stockouts of critical products in 46 countries over the following six months—including contraceptives, medication abortion pills, and maternal health medicines like oxytocin, an essential drug that prevents and stops bleeding during childbirth. Manufacturers are seeing shipping charges spike due to reduced numbers of flights and staff. If these costs are then passed on to the buyer, sexual and reproductive health could become even harder to access for poor women. If authorities don’t do more to ensure that essential medical supplies are accessible to those who need them, the result will be even more maternal deaths.
There have been a series of reports by news media and by major manufacturers about the domino effect of the supply chain breakdown resulting in shortages of family planning products. Manufacturing halts in countries like China, India, and Thailand earlier this year meant that regular orders of everything from condoms to mifepristone—an abortion medication—could not be filled. Now, factories face a long list of backorders. Shipments of products have gotten stuck at airports and seaports, so now shipping and customs clearance services also face long backlogs. Supply deliveries are further delayed along transportation routes due to curfews, lockdowns, and checkpoints.
Doctors Without Borders' programs have also been impacted by supply issues. Our teams have been able to mitigate the worst effects by having essential stocks pre-positioned—or placed in strategic locations close to our projects. This is something we do to prepare for emergencies. Nonetheless, many of our programs worldwide, including our sexual and reproductive health projects, have been affected by a lack of medicines and PPE. The impact varies from project to project: at one of our programs for Rohingya refugees in Cox’s Bazar, Bangladesh, major shortages in medications, as well as staff, forced our team to limit antenatal care services only to women in their third trimester. In other places, Doctors Without Borders is able to temporarily support health facilities with critical items.
At our project in Arauca, Colombia, Doctors Without Borders is providing women with long-term supplies of contraception. In order to help avert an increase in unwanted pregnancies and potential unsafe abortions after the lockdown period, the team is recommending that women take several months’ worth of contraception pills or consider using longer acting contraceptive methods. The same strategy is being used in many Doctors Without Borders projects that have adequate supplies.
Misinformation can be deadly
Another challenge facing women and girls is the thicket of rumors and misinformation about the coronavirus itself. Especially in places where there is already a lack of trust in authorities and in the safety of health facilities, fear can be a powerful barrier to care. Clear information and guidance from trusted sources are critical. This is yet another lesson from the West Africa Ebola crisis: the fear surrounding infectious disease outbreaks can be more deadly than the virus itself as people avoid going to hospitals and health centers, or delay seeking care until it is too late.
In normal times, nearly all Doctors Without Borders projects rely on health promoters in the communities and facilities where we work to give people clear guidance on what to do if they have a health issue. These health promoters, who are often members of the local communities themselves, play a critical role in connecting people to sexual and reproductive health care. Early on, many of these outreach teams transitioned to a focus on preventing the spread of the coronavirus—telling people what symptoms to look for, how to prevent the spread of infection, and where to go in order to get treatment. Since then, some teams, including in Rustenburg, South Africa, have added back important messaging on sexual and reproductive health services.
Many of these health promotion teams have had to change how they work. It’s risky to meet with large crowds of people during an outbreak, so in Arua, Uganda, health promotion teams are working with community leaders. “We are still very active in the community,” says Marielle D. Celicourt-Toussaint, activity manager for Doctors Without Borders' sexual and gender-based violence program in Arua. “We modified the health promotion method to maximize our village health team, including the youth group leaders, the block leaders, the religious leaders, and the chairperson as well. So what we do, it's the old telephone line—we meet one on one or one on two, since we need to keep social distancing. And we raise awareness with these leaders, who in turn inform other leaders or other community members.”
Some projects have found creative ways to try to reach people with critical information. In Kasese, Uganda, Doctors Without Borders saw a drop in attendance at the Kasese Adolescent Center, a program that provides contraception and treatment for sexually transmitted infections (STIs), among other services. The center supports mainly teenagers who have no other way to access this care in a culturally conservative area. The team was concerned, knowing that reports of domestic violence, including sexual violence, were on the rise during lockdown. In order to keep the channels of communication open, the Kasese team started a community radio show in collaboration with the Ministry of Health where people can call in with questions. “The main topic we talk about is COVID … and mental health management due to lockdown,” says Alix Jobbe Duval, manager of the center. “We also raise awareness about domestic violence and sexual and gender-based violence.” The team uses the show to remind people that their health facilities are open.
Rosalita, 22, who has two children, receives family planning advice with a Doctors Without Borders health promotion officer in Tondo, Manila. Philippines, 2019.
A push to adapt and innovate
Many Doctors Without Borders projects are adapting to the curbs on face to face care by using some form of telehealth, whether it’s establishing hotlines for people with health concerns or reaching out by phone for counseling sessions. In Arauca, Colombia, the Doctors Without Borders team has been using telehealth for antenatal care (ANC)—regular consultations with pregnant women in the months before they deliver—and post-natal care (PNC) during the weeks after delivery. “We have to balance between the [possible] danger of their coming to the health facilities and getting infected with COVID-19, and the need to follow up on their pregnancies,” says Trapy, the project coordinator. If a patient does not have complications, they are advised not to come for an in-person consultation.
At Doctors Without Borders projects, ANC and PNC services usually involve large crowds of expectant or new mothers waiting for their turn in the consultation room. Infection prevention and control measures during this pandemic have required our teams to adapt. Some projects are reducing the number of ANC visits to the minimum of four prior to delivery, or scheduling women to be seen over several days rather than having everyone come on the same day. Clinicians are also giving women a long-term supply of iron pills to prevent anemia.
At Doctors Without Borders' project for sexual and reproductive health on the island of Samos, Greece—where a camp originally set up for around 650 migrants and refugees now hosts more than 6,000—the team is using telehealth in a different way. After health promotion activities were cancelled due to the risks of spreading the virus, the team started identifying people with medical backgrounds who were living in the camp and wanted to participate in outreach support. There is now a network of around 30 people recruited from this community of migrants and refugees who are actively identifying individuals with health needs. They communicate by phone with the Doctors Without Borders team and connect those patients with care.
Adapting services to make them safer is crucial during the pandemic. But this is also the time for innovation. The COVID-19 pandemic could be an opportunity to fundamentally change aspects of how sexual and reproductive health services are delivered, in order to make them more accessible. “We have to simplify the process and meet women where they are,” says Dr. Manisha Kumar, head of Doctors Without Borders' task force for safe abortion care, “not sit around and wait for them to come to health facilities. Women need to be trusted and empowered to care for themselves.”
A move towards more community-based and self-managed care for some services has already begun at a few Doctors Without Borders projects. In Malawi and Mozambique, Doctors Without Borders runs programs specifically for sex workers who have a difficult time getting the health care they need due to stigma. Doctors Without Borders teams have trained full-time peer workers, all of whom are current or former sex workers, to help provide contraception care, HIV screenings, and other services—and to refer their peers to Doctors Without Borders staff for specialized care. This makes essential health care much more accessible for some of the most vulnerable communities.
The safety and effectiveness of medication abortion—or abortion with pills—has opened up more possibilities for self-managed abortion care. A self-managed abortion is when a woman administers the abortion pills herself at home, with support from those who share accurate information, help her to access quality medicines, and provide other assistance, if needed. Medication abortion is proven to be more than 99 percent safe and more than 95 percent effective. Most women do not need to come to a health facility for an ultrasound or a follow-up visit, which is particularly relevant during a pandemic. The United Kingdom’s Department of Health and Social Care made headlines in late March when it announced that due to the COVID-19 lockdown, they would temporarily support women to access medication abortions at home after a telephone consultation with a health care provider. Doctors Without Borders has also started to explore more self-managed models of safe abortion care.
We know that more women and girls are likely to die due to the secondary impacts of the COVID-19 pandemic than due to the disease itself. Governments, health authorities, and health providers need to act now to eliminate barriers to care and save as many lives as possible. Most immediately, movement restrictions must be adapted to allow for women to access all essential health services when they need them. Health facilities must continue to offer essential health care—including contraception services, safe abortion care, and treatment for sexual violence—to anyone who needs them. Communities need to receive clear communication and guidance to prevent the misinformation and fear that prevents women from accessing the services they need. Supply chain disruptions affecting medical materials, including contraceptives and key sexual and reproductive health medications, must be addressed.
The lives and health of women and girls must be prioritized, during COVID-19 and always.
