Saturday, August 01, 2020

The Pandemic and Women

Natalia Kanem, executive director of the UN Population Fund, is among experts warning about disrupted health services and a surge in gender-based violence.  Fears are increasing about the effect of the pandemic on women's and girls' sexual and reproductive health and their access to care. 

Natalia Kanem told The Lancet that she was concerned about the effect COVID-19 was having on women and girls. “In a word, it is devastating. There are many women in situations of desperation right now and all this tallies up to devastating health and social consequences for that woman, for that girl, for that family, for that community”, she said. “We were doing okay, we still needed to accelerate progress, but now here you have a situation where we could actually go backward. It's unacceptable.”

 Clare Wenham, assistant professor of global health policy at the London School of Economics, London, UK, said we can look to lessons from the west Africa Ebola virus disease outbreak, which showed that the biggest threat to women's and girls' lives was not the virus itself, but the shutdown of routine health services and fear of infection that prevented them from going to health facilities that remained open.

 Many countries implemented tough lockdowns and travel restrictions in a bid to slow transmission. In doing so, some governments did not heed WHO's advice, and instead forced sexual and reproductive health services to close because these services were not classified as essential. These services include abortion or even, as Human Rights Watch has reported in Brazil, contraception. This decision not only denied women and girls access to time-sensitive—and potentially life-saving—services, but also further distanced them from already difficult-to-access sexual and reproductive health care. Vinoj Manning, chief executive officer of the Ipas Development Foundation, an organisation that is focused on the delivery of comprehensive abortion care, said that while the Indian government classified reproductive health as an essential service—albeit, 3 weeks into lockdown after protest from doctors—the policy did not trickle down to the ground level. The effects of travel restrictions, closure of health services, economic hardship, and gender-based violence are already evident.

UNFPA predicts there could be up to 7 million unintended pregnancies worldwide because of the crisis, with potentially thousands of deaths from unsafe abortion and complicated births due to inadequate access to emergency care. 

Kanem added that she was particularly concerned about “the skyrocketing of gender-based violence”, which she said was a “pandemic within a pandemic and it's very much on my mind”.

 Marie Stopes International (MSI), which works in 37 countries, predicts that the closure of their services would result in up to 9·5 million vulnerable women and girls losing access to contraception and safe abortion services in 2020. That disruption could result in as many as 2·7 million unsafe abortions and 11 000 pregnancy-related deaths. 

For example, countrywide lockdowns in Nepal and India forced clinics operated by MSI—the largest provider of family planning services in India outside of the public sector—to close. The governments of Nepal and India both ordered tough national lockdowns for several months and because of mobility restrictions, neither providers nor clients could reach MSI clinics, forcing the clinics to close. MSI Nepal's contact centre had a huge increase in the number of calls from women seeking abortion services since the start of lockdown. In India, millions of women living in hard-to-reach areas have been unable to access contraceptive services.

The Foundation for Reproductive Health Services India estimates that the disruption caused from lockdowns could leave up to 26 million couples in India unable to access contraception, leading to an additional 2·3 million unintended pregnancies and over 800 000 unsafe abortions, which is the third leading cause of maternal deaths in India.

The Indian public health-care system is on the brink of collapse. “Public health-care facilities have been repurposed for COVID-19. Facilities which offered services for women had to be repurposed too and accredited social health activists [community health workers] have been allocated to COVID-19 prevention, identification, and treatment instead of offering family planning services”, Vinoj Manning said.

Additionally, many private clinics had to shut down because of transport shortages, provider unavailability, and a lack of personal protective equipment. Almost three-quarters of abortions in India are medical abortions, for pregnancies up to 7 weeks. Research from Ipas has found that the closure of pharmacists, the disruption of the supply chain, and travel restrictions had prevented millions of women from accessing medical abortions during lockdown.

There are now many women who are now in their second trimester of an unwanted pregnancy and who, if given the opportunity, would like to terminate it. A major barrier is that many women do not know that abortion is legal up to 20 weeks, except in cases of rape, incest, or when the mother is a minor, when abortion can be done up to 24 weeks.

 “India is not good at providing second trimester abortion even though it's legal; it's not that available even in normal times. Now is the time to look at that cohort of women who require a different sort of service. How do we best handle that? We need a specialised effort.” Manning said that this effort would require the public and private sectors to work together to close the gap, improve the referral system, and raise awareness.

There is also concern that the disruption in global supply chains for contraception could result in more sexually transmitted infections, including HIV. “The adolescent girl was already at the highest risk of contracting HIV, so am I worried? I am absolutely concerned”, Kanem said. “The risk of sexually transmitted infections, in particular HIV, going in the wrong direction could be catastrophic.”

There is also growing anxiety about the increase in gender-based violence, with international and national organisations warning of a dramatic surge in cases of violence against girls and women. In Colombia, for example, reports of gender-based violence during lockdown increased by 175% compared with the same period last year, according to Plan International. “Gender-based violence has distinguished the pandemic [from other crises] because of the lack of movement and people being trapped in abusive situations”, Kanem said. “The hotlines, the shelters, the counselling that is required has been increasing dramatically. It has happened in developed and developing countries.”

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