COVID-19 Could be Devastating to Reproductive Health in Low and Middle Income Countries

While we’ve heard a lot about how COVID-19 is impacting our access to sexual and reproductive health here in the United States, the devastation to SRHR will be felt the world over. In fact, the progress that has been made in supplying women and girls in low- and middle-income countries with reproductive health services could be significantly rolled back as the pandemic continues. Zara Ahmed with the Guttmacher Institute sits down with us to talk about this world-wide change in access.

While tremendous progress has been made over the years in ensuring sexual and reproductive health care for folks in low- and middle-income countries, there was still much work to be done--even before COVID-19 hit. Maternal health care, maternal mortality, abortion access, and contraception access have all been lacking throughout the developing world. And, as the coronavirus has continued to spread globally, individuals and health systems are continuing to be negatively impacted due to supply chain interruptions, the diversion of healthcare providers into other fields, and broader economic and social limitations.

There are several steps that policymakers can take in order to support sexual and reproductive health care during the COVID-19 crisis. First and foremost, policymakers should define and promote SRHR—including safe, legal abortion, contraception, and maternal and newborn care—as essential. The supply chain must reflect a commitment to reproductive health care treatments and medicines. People must be able to access reproductive health care whenever and however they want it, including though innovative solutions like telehealth services. And finally, policy makers must address the unique needs of already-marginalized and vulnerable communities, as these issues don’t impact everyone equally. Reversing the expanded global gag rule, or at least ensuring this rule doesn’t apply to COVID-based funding, as well as committing to funding UNFPA is a step in the right direction.

Links from this episode

Zara Ahmed on Twitter
Guttmacher on Twitter and Facebook
Episode on Clinic Harassment during the COVID-19 era
Estimates and policy analysis regarding COVID-19 and global SRHR services from Guttmacher
More information on how SRHR may be affected by COVID-19
Guttmacher recommendations for policymakers

Transcript

Jennie: Welcome to RePROs Fight Back, a podcast where we explore all things reproductive health, rights and justice. I'm your host, Jennie Wetter, and I'll be helping you stay informed around issues like birth control, abortion, sex education and LGBTQ issues and much, much more-- giving you the tools you need to take action and fight back. Okay, let's dive in.

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Jennie: Hi repros! I hope everybody is doing well. Things are going pretty good for me right now. Um, you know, I'm still working from home, which I've gotten to a groove. Um, I have learned that my cats are absolute divas and have really taken to getting as much attention as they can on every Zoom call. They can tell the difference if I'm like listening to a podcast or while I'm working or if I'm like on a Zoom call and like they will come running as soon as I'm on a Zoom call to like preen for everybody and get as much camera time as they can. Um, it's pretty funny. They have become quite the center of attention. Let's see, I had also promised to keep everybody up to date on my sourdough journey. So I started watching King Arthur Flour has been doing like baking, uh, tutorials on their Facebook and have had like just a bunch of series of videos and there was one on sourdough that was kind of this kind of hands off recipe. It wasn't quite as involved as some of the others. So I followed it and decided to give it a try and… oh my god, y'all, it was so good. I am so excited. It wasn't perfect, but man those loaves looked beautiful. I will make sure that we share pictures on social media. I was so freaking proud of myself. I was so ready for it to fail. And every step along the way when things were looking good I would get inordinately excited. So like it had to do a rise overnight and I was like prepared for it to like not really do it. You know, I, you know, started that yeast from scratch so I was just ready for it to not do its thing. And I came out in the morning and it was like risen to the lid on the bin I had it in and I was just so excited that it seems to have been a huge success and I will absolutely do it again.

Jennie: So that was like my high point. It was just such a personal exciting thing. Nothing too much else exciting going on. You know, still working from home probably in this for a long haul. You know, I live in D.C. and I don't have a car so you know I start to think about going to work and it just like hits this wall of like how am I going to get there? Like I just can't imagine commuting on Metro-- either the buses or the subway anytime in the near future. So there was like the, I knew it was going to be for a long haul before, but this week really came the accepting of like, okay, you're going to be working from home for quite a while and thinking of like getting things. So, you know, I have a more comfortable chair or ways I can be more comfortable in the chair I'm using to work with and like thinking about what I need to make my working space more conducive to it being my workspace for the next, I don't know, months. So that's where I'm at. But things are good. Um, you know, I'm still thinking of all the people who are struggling. I made sure to go out this week also and donate to the local food bank and to a world central kitchen and again to another local abortion fund or not local, sorry, another abortion fund. So yeah, I think that, you know, I am feeling good helping people that need it right now. So with that, let's turn to this week's episode. You know, we've already talked about how Covid is impacting reproductive health in the U.S. with states trying to ban abortion or even that clinic protesters are still showing up to protest at clinics. And unfortunately, that does not seem to have changed. You're still seeing a lot of clinics with protesters and as orders are starting to be slowly lifted in states, you're seeing a big uptick and harassment at clinics.

Jennie: So just, you know, kind of keep those people in your thoughts and you know, go back and listen to my episode on clinic harassment to hear what you can do to support, uh, those clinics. But this week we're going to talk about something that we haven't really focused on and that is Covid and the low- and middle-income countries and what that is going to do for access to reproductive health. And it's kind of terrifying for looking at the numbers is what this is going to mean for people trying to access care around the world. So with that, I'm really excited to interview Zara Ahmed with the Guttmacher Institute to talk to her all about what is happening. So with that, stay tuned to the interview.

Jennie: Hi Zara. Thanks so much for being here today.

Zara: Hi Jennie. Thanks so much for having me.

Jennie: I thought today would be a good time to talk about how Covid-19 is going to impact low- and middle-income countries. But I thought before we get there, we should probably talk about what it looks like to access reproductive healthcare now, um, before Covid really hit. Yeah, that's a great question. Over the last few decades, tremendous progress has been made on sexual and reproductive health and rights. But let's be real. Things were still pretty bad for a lot of people. And because I'm from Guttmacher, I want to dive in on some stuff. Before the pandemic, there were already almost 220 million women around the world in low- and middle-income countries who wanted to prevent a pregnancy but were not using a modern form of contraception. 220 million. That's far more than the entire population of Western Europe. It's crazy that of 206 million pregnancies in 2017 in low- and middle-income countries, almost half… 43%…are unintended. So they either occur too soon or are not wanted at all and of the 127 million women who give birth every year in developing countries, many do not receive essential maternal and newborn care. Barely 60% received the minimum of four antenatal visits and barely two thirds give birth in a health facility. That's shocking. There's a huge gap in access and then unfortunately because of those gaps an estimated 300,000 women in developing countries will die from pregnancy related causes and almost 3 million babies will die in the first month of life alone. Clearly there's so much more to be done. And then on the abortion side there were nearly 60 million abortions every year and almost half of them are unsafe and it's a huge driver of maternal mortality and disability counting for about 10% of more maternal mortality worldwide. And almost all of that is in developing countries. So clearly there was huge work for us to do before the pandemic in terms of access and equity in services, but also understanding ideological attacks. As an FYI, we're going to be putting out updates to all of these numbers related to contraception, unintended pregnancy and global abortion rates over the next couple of months. And the numbers continue to be truly shocking.

Jennie: Yeah, it's always shocking and another good thing to point out is this constitutes real progress like a lot has improved in the last decade, but still there's such a long way to go.

Zara: Absolutely. So we can be proud as a global community and of the healthcare providers and everyone involved, but we have to recognize that even before the pandemic things are still pretty bad.

Jennie: So now that Covid hit, what are some of the challenges low- and middle-income countries will be facing?

Zara: Let's talk about these challenges and break them into two levels. The health system and the individual. So at the health system level we see shortages of medications such as contraceptives, antiretrovirals for HIV/AIDS and antibiotics to treat STIs due to disruptions in the supply chain. Overall in China, which is the second largest export or pharmaceutical products in the world, they've already shut down several drug manufacturing plants, which has in turn delays at Indian factories that produced generic medicines. As we've seen healthcare providers from all disciplines are being diverted to help address the epidemic while unfortunately also being at most risk of acquiring the disease. This is creating a shortage of clinicians who can provide sexual and reproductive health services and also increasing wait times for patients in need in places that already have a limited number of providers like most low- and middle-income countries. This is putting extreme strain on capacity to serve patients, especially for nonemergency care, and these impacts are being compounded by the diversion of financial resources away from sexual and reproductive health. Enter the Covid19 response. Similarly, there's this huge need is we're seeing for precautionary equipment training protocols. All of these draw resources and time and energy away from sexual and reproductive health and unfortunately the burden of this isn't being distributed equally across the healthcare system as certain facilities or geographic areas or clinics that serve certain populations are being more impacted by the outbreak and they need to take more intensive action now turning to the individual in addition to barriers like waiting times and supply shortages, many people seeking sexual and reproductive health care maybe stymied by the broader economic and social hurdles they're facing. First people have a reasonable fear of taking public transportation in the midst of this epidemic. And in many countries, we're seeing a suspension of transit services. So this is a major obstacle for people seeking care, especially if they don't have a car like many low income people. Second, many people already think barriers to care if they can't afford or find childcare. And so in this situation it's much worse. So school and daycare closures have eliminated many childcare options and childcare workers themselves might become sick and many parents may not feel comfortable bringing a child to a health care appointment and exposing them to the virus. And lastly, and more generally because Covid 19 has led to so many workplaces having to close, there've been huge ramifications for employee's income and access to insurance. So particularly in countries that don't guarantee paid sick leave like the U.S. and many in the developing world, people with low incomes may be unable to afford sexual and reproductive health care. That is a lot of compounding problems on top of each other.

Jennie: Absolutely. You know, it's a perfect storm, honestly, of structural factors. History, previous on equal access and then the pandemic. So what could all this mean for people?

Zara: We were really curious about that at Guttmacher. So our team went ahead and estimated how sexual and reproductive health outcomes could change if there was only, for example, a modest, let's say 10% decline in access to care. So we modeled this out for 132 low and middle income countries around the world. And those countries together represent over 1.6 billion women of reproductive age. The implications are totally staggering in terms of the needs left, unmet, unintended pregnancies, unsafe abortions, maternal and newborn deaths. So specifically over the course of a single year, a 10% decrease in sexual and reproductive health services in low and middle income countries would lead to 49 million more women with an unmet need for modern contraception, 15 million more unintended pregnancies, 168,000 more newborn deaths, 28,000 more maternal deaths, and we could see 3 million more unsafe abortions and a thousand more maternal deaths if just 10% of safe abortions are compromised. These estimates are shocking, but the reality could be much worse and more than 10% of services are compromised or disrupted. And in addition to scale of this impact would be many times greater in specific countries or regions or populations as the virus. And the lack of an effective response has and will hit certain populations and areas harder. And again, this is on top of the vast preexisting need. If you want to find out more about this, you can look up our paper on this cause its research was led by a team…. So I really encourage people to check it out.

Jennie: Yeah, we'll absolutely include it in our show notes. I just remember those numbers being so striking. You know, it's something that you and I fight for all the time, is that to address the need that already existed and to see such a big setback is pretty devastating.

Zara: Absolutely. I mean we started out talking about nearly 200 million women, 220 million women in need of care and contraception. That was already a huge bite. And now we're talking about these massive disruptions and you know, these are, these are lasting consequences. These are not just one-off things that happen. The thought that we don't really have and there's no easy answer, just makes it so much harder.

Jennie: So what can we learn from other crises that have happened and how can we apply it to protecting SRHR now?

Zara: Yeah. So I'm going to talk about two examples. So let's talk about Ebola and then we'll talk about my personal experience in Haiti with Ebola in Sierra Leone, which is one of the countries most effected by Eola and which saw decreases in maternal and newborn care due to disrupted services. The general fear of seeking treatment during the two years of the outbreak contributed to about 3,600 maternal and neonatal deaths. That's almost the same number of deaths as totally caused by Ebola in that country. So the secondary impact can be huge. Moving into Haiti, I moved to Haiti in 2014 about four years after the devastating earthquake and I was there for two years. And over those two years I saw how progress remained fragile. For example, although there were significant and improvements in both rural and urban settings across a range of health indicators, there remained a great shortfall in the resources required for basic infrastructure and services in the country. There was slow and limited progress in restoring physical health infrastructure in that case or rebuilding back to the health workforce needed for many programs. The financial resources that were made available in the immediate aftermath of the earthquake, just as we're seeing with Covid, were needed for just simply maintaining key programs such as human resources or commodities, but they weren't enough funding to address these ongoing needs. So while we may be able to avert some immediate consequences, again, we're left with this huge unmet need that persists in terms of lessons learned and Haiti, what we saw was that as the focus of the response naturally shifted from addressing short term crisis needs to longer term needs, there were new challenges and priorities that emerged. However, the link between immediate problems. So in the case of Haiti, cholera and structural issues, again, weak water and sanitation systems, is clear and we realized that the two need to be addressed in tandem. So in this case of Covid, we see that the immediate problem of access to reproductive health services and the structural issues of the vast economic, social and gender inequality issues need to be addressed together. Failure to consider the long-term context and the immediate aftermath of the emergency might jeopardize the hard won public health gains that we've made with sexual and reproductive health over the last few years. However, I think that we can take heart from the examples of Haiti and affected countries as they've made substantial progress in their overall health indicators in the 10 years since the earthquake and the five years since Ebola. And they might serve as a model for other countries trying to recover from disasters like Covid 19.

Jennie: Yeah, it's nice to have examples to look back on to see what worked or what didn't work to be able to think about how we move forward now.

Zara: Absolutely. And there's a saying in recovery, which is build back better. And I think that's really what we want to focus in on. We can simply just go back to the way things were in December of 2019 clearly there was this huge unmet need. It was vastly unequal in terms of access. We don't want to go back to that. This is a chance for transformation and to do something different and innovative that actually gets at the heart of the problem.

Jennie: So what motivates you to do this work?

Zara: So sexual and reproductive health and rights is personal, I think for everyone. And everyone brings their own history to this work. So I want to tell you a bit about my own family and own history, and I'll talk about my two grandmothers on my mom's side. My grandmother's mother died when she was little. My grandmother got married young and then had seven children in less than 10 years with one of the children dying as an infant. In that we see maternal mortality, child mortality, lack of adequate birth spacing, and a lack of birth control. And this was for a family with very little money or education. My own grandfather had to drop out of school in second grade to start doing odd jobs to support his family, my grandparents and their six surviving children. My mom's the youngest in a one room apartment and not one bedroom, one room with a shared community bathroom. Now my grandparents love their children and they worked incredibly hard to support them, but it wasn't easy. On my dad's side, my grandmother got married at 16 and had her first child at 17, quickly followed by three more and again, she loved her children, but she didn't have any control over her reproductive destiny. She also cared for her nieces and nephews after her sister in law died in childbirth. Moving forward to my own parents, they were lucky enough to have access to education and to excel. My dad became a doctor and my mom worked in business and they moved to England. They decided to wait five years after they got married to have children because they really want to just solidify their partnership. They knew they only wanted two children so that they could provide for them. And that's what they did. That's a total transformation in a single generation, both in terms of education and an ability to shape their family as they wanted. So I think about this a lot about how if a few things had gone differently, I would perhaps already be a grandmother in my mid-thirties. I feel incredibly lucky to have so much freedom to make my own choices and to craft my own life. But I know that so many people don't have that. I truly want everyone to have the ability to pursue their dreams, whether it's a big family or small, many kids, a few or none, a partnership or not, higher education or career, whatever they want. That's what motivates me.

Jennie: Yeah, absolutely. And I think it seems so basic.

Zara: I think that's where I get tripped up with when we're talking about all of this. Like all of this is not happening in a vacuum. There are a lot of U.S. policy attacks around reproductive health and rights, and that's where you know this simple basic thing of being able to control your destiny. When you see something powerful like the U.S. government enacting policies that interferes in that. That really gives me part of my passion to fight back too. Ideology doesn't have any place in people's individual lives. It's so sad and disheartening to see global reproductive health used as a domestic political football in the U.S. That's not what this should be about. Conversations should be between healthcare providers and patients or between family members and should be about science and medicine and ambition and preference. It should not be about the constraints imposed by governments or by politicians quite frankly.

Jennie: So with all of this, what steps can policymakers and should policy makers and partners be taking right now?

Zara: Yeah, there's a lot to do and it's so overwhelming. So I want to really focus in on a few key recommendations for policymakers to take and they have to be done quickly because this is a potential global catastrophe. First and foremost, they have to define and promote sexual and reproductive healthcare, including safe abortion, contraception, and maternal and newborn care as essential. That's the heart of the matter. From that alongside private sector actors, they must support the supply chain to make sexual and reproductive health medicines and supplies more accessible. Next, we have to make contraception available to people when they want it, where they want it and how they want it. That means things like using telemedicine to get, uh, people to have access to a healthcare provider, to get a prescription or even making contraception available without a prescription. Next, you have to adopt innovative models of care. There's so many things that we've said could never be done right, like telehealth or sexual and reproductive health services. And here we are doing it, so we must adopt it, not just now, but in the long-term. And finally, and this is really, really important, they must address the unique needs of marginalized and vulnerable populations. Again, this is not going to hit everybody the same and there's so many groups that are going to need special attention. And so these recommendations apply to policy makers and partners in all countries. And it's not just for programs within their own borders, but also if they're so lucky in the work that they do with partner governments overseas. And then in terms of the U.S. we specifically want to see the U.S. reverse the global gag rule or at least ensure that it doesn't apply to covert supplemental funding. And really critically we need to scale up support, uh, financial, technical, and programmatic to UNFPA.

Jennie: Those all seem like really smart recommendations and you know, funding UNFPA was important and repealing the global gag rule was really important before and now and they just seem so much more important in the light of this crisis.

Zara: Absolutely. I think that we always knew that these groups like UNFPA were at the heart of service delivery and how essential they are. And this is just shone a spotlight on the good work that they do and how critical they are to so many millions of people around the world.

Jennie: So we always like to kind of wrap up with, you know, we've talked about all these things that need to be done and what's happening, um, what’s something that listeners can do. So what actions can listeners take right now?

Zara: So first keep being interested in this issue. I think it's really easy to look away from these issues and just to focus on our immediate needs. This is a long, complicated fight and we all need to balance staying engaged but also taking care of ourselves. So please keep listening to the podcast while you engage in whatever self-care you need. Second, people just stay informed. So again, definitely keep listening to this podcast, but you can also get the latest updates on global, federal, and state developments on sexual reproductive health by signing up for the Guttmacher emails at guttmacher.org. Follow us on Twitter for all your breaking updates, latest data. Next, keep advocating. Now this means within your own organizations and communities, but also with your family and friends. For example, I had a great conversation last weekend with my parents about the global fight for access to safe abortion and I gave them talking points to use with people they know who are anti-choice. There's also talked about the difference between real actual clinics that provide abortion services and so-called crisis pregnancy centers, which are of course a scam. Uh, and lastly it was really listen to others and pay attention to whose voices you're hearing. Think about people who you aren't hearing from. I am really concerned about how little attention is being paid to people in marginalized and multi-marginalized communities, sexual and reproductive health and rights and Covid affect everyone, including people who are unhoused, the LGBTQ community, people with disabilities, immigrants and others. So rarely, unfortunately, are these people at the table when it comes to raising up the challenges that they face and developing solutions most critically now during this crisis and far beyond, we need everybody engaged in this fight. It simply can't be the same people who have largely been white, straight, upper middle-class women who've been the most vocal. We need everybody to come together and get on board with an agenda that prioritizes rights, access and justice for all.

Jennie: Okay. So one thing I've been adding since so many of us are working from home or under state home orders is what is bringing you joy right now or making you happy? It doesn't have to be work related.

Zara: Um, what's bringing me joy? Anybody who's Zoomed with me has seen the jungle that I live in… like a hundred plants in my apartment and I'm experimenting with things like growing flowers, hydroponically. I'm growing lots of vegetables and herbs and just caring for something and seeing it change and evolve over time is lovely. And also just using truly fresh herbs makes everything you cook tastes so much better. So highly recommend. And I will happily grow seedlings for anybody who wants them.

Jennie” Oh, that's so fun. So while I've been home and I've been, um, I planted a jade plant, I don't know, a long time ago and it's been growing kind of oddly. So I've been starting to like really prune it and try to get it to be fuller and watching it, uh, bounce back and look better. Uh, while I've been home has been a lot of fun and making me happy.

Zara: That's great. Yeah, plants are crazy resilient and it's really nice to see and appreciate.

Jennie: Okay. Well Zara, thanks so much for chatting with me today.

Zara: Thanks so much for having me. Jennie.

Jennie: Thanks for listening everybody. I hope you enjoyed this week's episode. I think, you know, it was our give us a lot to think about and a lot of those numbers are again, just so start and I hope you heard my cats in the background Cinder was, um, in my face while I was recording the whole time and had to make sure to say hello to everybody. So enjoy. I'm not sure for sure if you were able to hear it, but uh, Zara could, so we'll see. And with that, you know, always feel free to reach out. We'll see you on our next episode of RePROS Fight Back. For more information, including show notes from this episode and previous episodes, please visit our website at reprosfightback.com. You can also find us on Facebook and Twitter at RePROS Fight Back, or on Instagram at reprosfb. If you like our show, please help others find it by sharing it with your friends and subscribing, rating and reviewing us on iTunes. Thanks for listening.

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