Natalia Kanem, executive director of the UN Population Fund, is among experts warning about disrupted health services and a surge in gender-based violence. Sophie Cousins reports. As the COVID-19 pandemic accelerates, fears are increasing about the effect of the pandemic on women's and girls' sexual and reproductive health and their access to care. In response to COVID-19, in March, WHO issued interim guidance for maintaining essential services during an outbreak, which included advice to prioritise services related to reproductive health and make efforts to avert maternal and child mortality and morbidity. As the pandemic spread, 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. Although numerous countries have now eased restrictions, the effects of travel restrictions, closure of health services, economic hardship, and gender-based violence are already evident. With the pandemic growing in many places, governments have to make difficult decisions about how best to protect the health of their citizens. Natalia Kanem, executive director of the UN Population Fund (UNFPA), 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.” 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”. Similarly, 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. Most states in India are now out of lockdown and MSI has, in some areas, been able to reopen its clinics. Working with local governments, many clinics in Nepal have also been able to reopen. But for many women and girls, the damage has already been done. The Foundation for Reproductive Health Services India, an affiliate of MSI, 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. 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. Now, as the country continues to record tens of thousands of COVID-19 cases every day, the 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”, he 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. “It has been a huge challenge. But the biggest challenge now is: how do we recover? This period of time will be very important.” Manning refers to the number of 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.” As the pandemic continues, experts are encouraging countries to look at ways of mitigating the effects on access to sexual and reproductive health services. 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. She said that Ebola virus disease illustrated the need for “simple steps” to facilitate access to health care. “This can include moving sexual and reproductive health services and care out of hospitals or into the community, or the free distribution [of contraception] at pharmacies or other places where women are not scared to go”, she said. Kanem agreed, adding “We're at a point where people are avoiding health systems for fear of COVID-19, so the role of the midwife, the role of the community health worker, the ability of someone to receive contraception of their choice close to their places where they reside is absolutely essential.” In Australia, telehealth services have been an effective way of providing abortion services. At the beginning of the pandemic, the Australian Government expanded telehealth services, which could be billed to the public health system, Medicare. Telehealth consultations for early medical abortion have increased by 25% since the pandemic began, indicating that telehealth services can improve access when distance and out-of-pocket costs are barriers. Moreover, use of telehealth services removes fear of infection and can ease pressure on struggling health systems. In late March, 2020, the UK moved to temporarily allow early medical abortions at home, as in Australia, a decision, however, that was quickly reversed by the government. The policy was soon reinstated. Kathryn Church, director of global evidence at MSI, said that other countries needed to follow the UK's decision, which had also increased the medical abortion permitted gestation period to 10 weeks. “In the UK, abortion at home via telemedicine was rapidly implemented meaning that women and girls have still been able to access safe services, but we have not seen equivalent rapid policy change in other countries, and also many countries lack the infrastructure required to make telemedicine work”, she said. “Health systems need to find ways to continue to deliver health services safely, by adapting their service settings, or implementing telemedicine models where feasible.” Other countries that have tried to enable access to medical abortion outside of health facilities include South Africa, where telehealth services are in place for remote consultations including the dispensing of medical abortion pills, and Ethiopia, where the government has approved a pilot scheme for nurses to provide medical abortion in homes in Addis Ababa. In Nepal, changes in national guidelines stipulate that medical abortions can be delivered outside of health-care facilities, and in India, the government has issued telemedicine guidelines that do not rule out medical abortion. While there is no end in sight for the pandemic, there is hope that the deep existing inequalities COVID-19 has further brought to the foreground will encourage more action in the future. “If anything, the fact of the disparities which [COVID-19] has unveiled should spur us on to be more ambitious than we were before”, Kanem said. For the Human Rights Watch report on access to contraception in Brazil see https://www.hrw.org/news/2020/06/12/brazil-protect-sexual-reproductive-rights-pandemic
