'Maintain sexual and reproductive health services during pandemic'
Previous experience from Ebola epidemic in Liberia has already proven that discontinuing heath services unrelated to epidemic response resulted in more deaths than the epidemic itself. Most of the reproductive health services are time sensitive and further delay or denial in seeking services can increase the morbidity and mortality and ultimately poor reproductive outcomes in the long run.
A novel coronavirus (SARS-CoV-2) that causes COVID-19 has spread rapidly since emerging in late 2019, from Wuhan China. The World Health Organization declared the disease a global pandemic in March 2020.
Governments across the world have had to quickly adapt and respond to interrupt transmission of the virus and provide care to the infected ones. Like many countries, Nepal also announced nationwide lockdown on March 24 to combat its spread. To comply with lockdown most of the health institutions curtailed their regular services only to provide emergency care.
Previous experience from Ebola epidemic in Liberia has already proven that discontinuing health services unrelated to epidemic response resulted in more deaths than the epidemic itself. So it is important to maintain continuity of healthcare services to ensure that there is no further increase in morbidity and mortality due to other health conditions and to protect the health system from swamping at this time of pandemic.
Among the essential health services, the most affected is reproductive health in state of crisis. The limited access to obstetric care, safe abortion care and family planning services lead to poor health outcomes among women. There are more chances of unwanted pregnancies, unsafe abortions, physical and sexual violence, and psychological stress and depression because of confinement, economic issues, limited decision making power and reduced access to the healthcare facilities.
Many health institutions halted the outpatient department and non-urgent surgeries across the country, affecting the reproductive health services due to lockdown.
The health management information system reports from different health institutions nationwide suggest a significant decrease in reproductive health services. Reportedly many hospitals and clinics refused to provide services for non-Covid reasons, leading to poor outcomes and a negative psychological impact among women. With the increase in number of Covid cases, many public hospitals were converted to Covid hospitals which further limited the reproductive health services. The impacts of these conversions lead to disruption and loss of confidence in those services and increased hesitancy in seeking services elsewhere.
Most of the reproductive health services are time-sensitive and further delay or denial in seeking services can increase the morbidity and mortality and ultimately poor reproductive outcomes in the long run. According to UNFPA, “The pandemic is deepening inequalities, and millions more women and girls now risk losing the ability to plan their families and protect their bodies and their health. Women’s reproductive health and rights must be safeguarded at all cost, the services must continue, the supplies must be delivered, and the vulnerable must be protected and supported.” It is estimated that 47 million women in 114 low and middle income countries may not be able to access modern contraceptives and 7 million unintended pregnancies are expected to occur if the pandemic prevails for 6 months and major health services get disrupted. If lockdown continues, for every 3 months, up to 2 million women may be unable to use modern contraceptives.
Approach from Koshi Hospital
Koshi Hospital, a tertiary care hospital in eastern Nepal responded to the COVID-19 crisis early on. With the help of provincial government, it mapped out and identified existing facilities with possibility of transforming abandoned public building into a Covid-19 hospital well ahead of time. The lesson learnt from elsewhere were utilised; strategies were planned for separating Covid-19 from non-Covid-19 patients. After serious discussion with doctors and staff, decision was taken for the continuation of all essential services including reproductive health services. A dedicated hospital was set up by renovating an unused old office building of National Trading Center to manage Covid-19 patients to prevent the transmission of the viral infection to others. Support from the provincial government made this happen in just 10 days.
Setting up a separate Covid-19 Hospital enabled Koshi Hospital to manage the sudden surge in cases, starting up with 31 cases, more than 50 per cent of the nation’s total cases on March 27 while the geographical distance of the Covid Hospital ensured in maintaining client trust in accessing uninterrupted essential health services at the hospital. The main hospital block continues to provide other essential healthcare and services such as 24/7 emergency service and acute care, including emergency obstetric services. Reproductive, maternal, new-born and child health services all duly following physical distance norms, hand hygiene facilities and appropriate protection measures for the health workforce have been continued without a day’s disruption. A separate helpline service has also been started for clients who need urgent consultation and can’t visit the hospital physically.
In the last two months of lockdown (till May 24), the obstetrics and gynaecology department served more than 2,820 women in the outpatient department while 847 were admitted in the hospital for further care and management. Out of 746 deliveries in the hospital, 195 cases were of caesarian section and 9 cases of other life-saving surgeries. As many as 33 women received safe abortion services. Family planning counselling and services continued. 72 new users were added while continued services were provided to old users. 55 women received care for post abortion services as most of them had consumed unsupervised medical abortion pills directly from the pharmacy. There were 41 cases of gender-based violence which includes 29 cases of sexual assault. There were 14 cycles of immunisation service, and a total of 979 children were immunised as per schedule. Beyond directly benefitting women, these services helped in maintaining client and community trust as well as in improving the reproductive health outcomes in these testing times.
Across the globe, the pandemic has made us realise that reproductive health services always get affected. It may be due to the non-inclusion of reproductive health into pandemic preparedness and response, and limited understanding and sensitivity of women health issues at policy level. It is important to note that almost all the women health issues are time-sensitive and absence or disruption of services may lead to increased morbidity and mortality.
In countries like Nepal where the access and availability of reproductive health services are already limited due to geography and other issues, non-availability and refusal of reproductive health services may lead to serious consequences. Inter-Agency Standing Committee for reproductive health has issued multiple field guidance documents on maintaining sexual and reproductive health in Covid-19 situation. Incorporating these guidelines in national protocol could be a possible solution for delivering reproductive health services in current scenario.
First, the infection prevention and control strategies like regular hand washing, use of hand sanitisers, social distancing and respiratory hygiene should be emphasised and strictly applicable to women, their family members and community to curb the risk of infection. The special mention on taking nutritious diet and guidance on how to use locally available food for nutrition should be emphasised.
Second, possible ways for service provision of consultation and follow up for women should be explored. The three-tier government structure could be effectively used for service delivery, encouraging the local government to take the lead. They can mobilise the local health workers and Female Community Health Volunteer (FCHV) to reach these women directly to assess their needs and provide or arrange required services. Alternately, telephone, text messaging, digital applications, social media application, and telemedicine facilities should be used to full strength. The ward committees and their elected representatives can directly monitor and coordinate with the health institution for specific services and timely referral to avert untoward consequences.
Third, packaging of the message in COVID and its impact on women should be loud, consistent and clear. The information should reach to women, family members, community, and health care providers in a way that is understandable and action-oriented. These messages should reaffirm that the women and community should seek realtime care and receive essential reproductive health services to avert morbidity and mortality.
Finally, the provision of Minimal Initial Service Package (MISP) at all the health facilities for the continuation of sexual and reproductive health services is very important. The risks of adverse outcomes from other complications outweigh the risk of corona infection among women. The continuous availability of all crucial healthcare services is urgent for improved outcomes. This includes obstetric care, safe abortion services, post-abortion care, family planning provisions, services for victims of gender-based violence, and newborn care. Appropriate triaging of women, provision of isolation for suspected cases and availability of personal protective equipment for staff as per WHO protocol can help in ensuring smooth services.
To conclude, in the confusing state of COVID induced crisis, the reproductive health issues need not be undermined, while focusing on corona prevention measures. It is a well-understood fact that when healthcare facilities are feared, they are avoided. Given the time-sensitivity of reproductive health services, any act of service limitation, denial or difficult access to existing services may disrupt the trust and confidence of these women increasing the preventable morbidities and death. Clear and consistent messaging by government and existing health services is urgent so that women and their families seek early advice to make timely decisions. This is particularly important for women from marginalised communities, low-income families, women in quarantine and isolation, and areas of reduced transportation facilities.
The management of all components of reproductive health is difficult in this pandemic but not impossible if proper strategies are used keeping social distancing, accessible and functional hand hygiene stations, triaging, proper messaging, optimal service provision, necessary protection for the health care staff. While ensuring all these, proper disinfection and waste disposal by mobilising adequate resources for outbreak response are warranted.
Dr Sangeeta Mishra is an obstetrician and gynaecologist as well as a public health expert, currently working as Medical Superintendent at Koshi Hospital, Biratnagar