By Sarita Santoshini, Foreign Policy
On a hot afternoon in April, while the rest of her village stayed home under lockdown, community health worker Urmila Patel walked to a pharmacy to purchase a pregnancy test for a neighbor. As one of India’s almost 900,000 accredited social health workers, Patel usually focuses on maternal and newborn health. For hundreds of millions of Indians, these workers—locals who are given basic health care training by the government—are their primary source of information and services related to family planning.
When the Indian government went into overdrive in its fight against the coronavirus, community health workers like Patel, who lives in Maharashtra state, were drafted to the front lines and ordered to mostly replace their usual rounds with coronavirus monitoring. Since before India’s lockdown began on March 25, Patel has been going door to door daily to offer coronavirus education and screen residents of Surul village for symptoms, referring them to local health centers if needed. But even as the need for reproductive health services mounts under lockdown, India’s shift in resources has left families empty-handed.
“I continue to distribute contraceptives while carrying out the coronavirus survey, but it isn’t enough. I can no longer provide the kind of support that I once did,” Patel said.
In mid-March, local health officials provided Patel with just four packets of contraceptive pills and a single box of 90 condoms for her rounds—covering 200 households in total. She has not received any restocks since. Even before March, supplies had been running low due to coronavirus-related interruptions in supply chains, leaving her neighbor and many others in the village with no birth control.
When Patel returned with the pregnancy test, it proved her neighbor Geetanjali Waidende’s worst fears: She was pregnant. With two young children and virtually no income, Waidende couldn’t afford another child. But she was already too far along to qualify for a medical abortion, and with surgical abortion halted during the lockdown, her options were few. “I have no choice in the matter now, I have to keep the child,” she said, sounding worried. “How am I going to take care of this third one? I am scared.”
With the lockdown entering week eight, health experts fear irreparable harm has been done to India’s already struggling family planning efforts.With the lockdown entering week eight, health experts fear irreparable harm has been done to India’s already struggling family planning efforts. Many women are no longer receiving potentially life-saving services that can help them make informed choices about delaying, preventing, and spacing pregnancies. “Sexual and reproductive rights were in crisis [globally] even before the pandemic hit. The pandemic just makes these injustices more visible,” said Seema Jalan, the executive director of the Universal Access Project. The coming year may well bring a baby boom few can afford, along with a dangerous increase in unsafe abortions. In a country of about 357 million reproductive-age women, any diminution in family planning services could be catastrophic.
The Guttmacher Institute, a research group that supports abortion rights, estimates that even a 10 percent decline in use of reversible contraceptive methods in low- and middle-income countries due to reduced access would result in an additional 49 million women with an unmet need for contraceptives and an additional 15 million unintended pregnancies over the course of a year. With a population of over 1.2 billion, India is likely to soon become the most populous country in the world, and this growth poses a significant challenge to health care access, especially that of women. Over 200 million women around the globe contend with an unmet need for family planning; more than one in five of these women reside in India.
“All the work that has gone into the development and well-being of women and children, I think the pandemic has pushed us back by 50 years,” said Shamala Dupte, the director of medical at Family Planning Association of India. It was only when India extended the lockdown after the initial 21-day period that family planning and abortion services were added to the list of essential services. Even after that, access has been uneven. The Family Planning Association and other organizations that have managed to keep open their clinics say only the smallest fraction of patients are now able to come in.
In spite of being the first country in the world to start a large-scale family planning program, in 1952, India has long struggled to increase contraceptive use nationwide, stymied by stigma and inadequate women’s rights. The most widely accepted form of contraception remains tubal ligation or female sterilization (used by 36 percent of married Indian couples), despite evidence it is among the most invasive and dangerous family planning methods. Recent years have seen a huge demand among women for more modern contraceptive methods, but the pandemic threatens to unmake much of that progress.
“In a community where women know about contraception and how to prevent pregnancy, all of a sudden they find two major things: one is that money is drying up because jobs are lost, and second, they cannot move anywhere. Suddenly they’re living in a police state,” said Sharad Iyengar, the executive director of Action Research and Training for Health, a nonprofit public health organization working with rural women from tribal communities in the northwestern Indian state of Rajasthan.
India is hardly unique. Around the globe, countries that long relied on community health workers for critical family planning services have seen services disappear overnight. In Zimbabwe, the restriction of movement and suspension of community mobilization has meant that one of the country’s largest family planning providers, Marie Stopes, has seen almost a 70 percent reduction in the number of women that it is able to reach and support. Reproductive Health Uganda, which said it reaches almost 70 percent of its clients through community outreach programs, has had to similarly suspend much of its work amid the outbreak. “Right now, everything, from political will to resources, has been diverted towards COVID-19 at the expense of women. In the context of the African continent, this means the government is likely to face another catastrophe in the form of increased maternal mortality,” said Abebe Shibru, the Marie Stopes Zimbabwe country director. Both countries are ramping up alternative tactics—for example, offering telephone counseling services, issuing public service announcements, or planning to offer alternatives to the most commonplace forms of contraception, such as injectables that women could take home and administer themselves.
But their work is cut out for them. Research from the Ebola crisis shows the sharp impact on maternal services that a pandemic can have.Research from the Ebola crisis shows the sharp impact on maternal services that a pandemic can have. In Sierra Leone, an estimated 3,600 maternal deaths, neonatal deaths, and stillbirths were traced back to “disrupted services and fear of seeking treatment during the outbreak,” according to the Guttmacher Institute. That figure was on par with deaths caused by Ebola itself.
Family planning efforts have been worsened by shocks to the global supply chain of contraceptives. Major suppliers of condoms and IUDs located in India and Malaysia have reported production and shipping restrictions. According to the latest update by the United Nations Population Fund (UNFPA), as many as 46 countries face stock-out risks of at least one form of contraceptive in the next six months. Both Zimbabwe and Uganda are staring at a potential shortage in contraceptives due to delay and complications in shipping clearances. Shibru said Marie Stopes Zimbabwe’s supplies would run out in two or three weeks if the expected consignments did not arrive. In Uganda, there is already a shortage of implants and emergency contraceptives.
In Nepal, Tika Kumari Ghimire, an outreach worker with Marie Stopes, continues to receive calls, as she is the only family planning service provider for many women, and government facilities report an unavailability of supplies and confusion over lockdown rules. Last week, she trekked to a health post about an hour and a half away—having to first convince the staff there that providing family planning services during the lockdown wasn’t prohibited—to provide a contraceptive implant to a client.
Even in India, supply chains have been affected as pharmaceutical factories faced disruption in both production and distribution during lockdown; India’s import of pharmaceutical ingredients from China was also impacted during this period. According to a front-line worker in Uttar Pradesh, supplies have already run out of Chhaya, a popular weekly oral contraceptive pill introduced by the government.
For accredited social health workers in India, this has been an overwhelming time. As some of the only workers allowed to move freely, many fear contracting the coronavirus themselves due to a lack of safety gear.As some of the only workers allowed to move freely, many fear contracting the coronavirus themselves due to a lack of safety gear. Rampant misinformation regarding the cause, spread, and treatment of COVID-19 has created more visceral threats in the form of physical attacks and harassment. As voluntary workers who do not receive a fixed salary (paid, instead, on a performance-based incentive system based on how many of their patients get IUDs or deliver in health centers, for instance), they are also demanding fair compensation.
Over everything lies the shadow of international funding. A U.S. policy formally known as the Mexico City policy, but often called the “global gag rule,” has prevented billions of dollars of U.S. global health aid from reaching health care providers. The United States also defunded the UNFPA for a third consecutive year in 2019. “For marginalized populations that have already lost their access to health care because of the impacts of the Global Gag Rule, there is no recourse; and their lives and livelihoods will be further jeopardized in the context of the COVID-19 pandemic,” Jalan of the Universal Access Project stressed. “In the U.S., Congress has a role to play: it can and should move to permanently end the Global Gag Rule and restore full funding to UNFPA. When the crisis eases, we cannot go back to business as usual; and when the next one hits, we must be better prepared.”
For now, service providers hope that donors and governments will quickly realize the importance of safeguarding reproductive and sexual health rights in these extraordinary times. “We cannot stop the impact. The impact has been made. Unintended pregnancies are going to increase, and we have seen gender-based violence increasing,” said Simon Richard Mugenyi, the advocacy and communications manager at Reproductive Health Uganda. “We can only decrease the magnitude of the impact now, and that’s what we are trying to do.”
In India, the health worker Patel is distressed that the challenges for women of reproductive age as well as female health workers will exacerbate further. “The response to any epidemic or disaster situation is always so gendered, disproportionately affecting women and girls. This time is the same,” said Dupte of the Family Planning Association of India. “But at least after so many years of advocacy, family planning has come to the forefront. The efforts need to continue.”
Sarita Santoshini is an Indian journalist.