But when Zimbabwe went into lockdown in March to try to curb the spread of the novel coronavirus, many of her patients disappeared.
Shoniwa, an experienced nurse working for Marie Stopes International, one of the world’s largest family planning organizations, said it’s not because they no longer need her services. Some are afraid to visit the clinic because they don’t want to catch the virus. Others, she said, have reported being turned away at checkpoints by security forces or fear upsetting local leaders who have instructed residents to stay at home.
As coronavirus lockdowns continue to restrict movement around the world, Shoniwa and others working on family planning initiatives in developing countries have found female patients facing an uncomfortable paradox: The measures intended to keep them safe from the pandemic could have dangerous long-term impacts on their health.
Marie Stopes warned last month that disruptions in service in 37 countries where the organization works could prevent 9.5 million women from accessing contraceptives and safe abortion. The organization projected that such disruptions could lead to up to 3 million unplanned pregnancies, 2.7 million unsafe abortions and thousands of pregnancy-related deaths. A recent United Nations Population Fund study suggested that if the pandemic continues to disrupt care in more than 100 low- and middle-income countries over the next six months, 47 million women could lose access to contraceptives, leading to 7 million unplanned pregnancies.
Although it’s too soon to determine what long-term consequences the pandemic could have on women’s health-care access globally, experts pointing to the lessons of past outbreaks say the impact could be substantial, even as some countries begin to roll back their social-control measures.
If Zimbabwean women continue to face obstacles seeking care, “we are going to be in very big trouble and have very big problems,” Shoniwa said. Already women are missing out on crucial care to replace expired long-term contraceptives or pick up new supplies, she said. Callers flooding the Marie Stopes hotline are almost all asking the same questions: When and where can we get services?
In a male-dominated society like Zimbabwe, Shoniwa said, many women face pressure from their husbands to have sex, even if they have run out of contraceptives. Those pressures have only intensified in quarantine.
“Men have not got any other activities. They can’t watch soccer, they can’t go to social places where they used to,” she said. “They are spending most of their time at home and what is the activity that is happening there?”
Anushka Kalyanpur, a gender specialist at humanitarian organization CARE, said she is alarmed to have seen a reduced focus on programming for gender-based violence and access to sexual and reproductive health resources.
Even before the coronavirus, there were “so many barriers to accessing those services,” in marginalized communities around the world, she said. “With further restrictions on mobility, that’s even more concerning.”
Abebe Shibru, country director for Marie Stopes Zimbabwe, said that while his organization applauds government efforts to fight the virus, he is concerned that disruptions to health care could cause unplanned pregnancies that will lead to unsafe underground abortions. Zimbabwe already faces high maternal mortality and teenage pregnancy rates. The coronavirus restrictions, he said, should not come “at the expense of women’s health.”
Zimbabwean health officials did not immediately respond to a request for comment.
Marie Stopes has also expressed concern over family planning access under lockdown measures in countries around the world, including in Uganda, Kenya, India and Nepal. In some places, there have already been shortages of oral and emergency contraceptives, the organization said.
Even health workers who have not yet seen a dramatic impact on their ability to provide care say they fear supply chain shortages and dragged out lockdowns could eventually disrupt some of their programs.
In Gambia, the Bundung Maternal and Child Health Hospital continues to provide essential health services to women.
But Marie Bass Gomez, a senior nursing officer who leads the hospital’s reproductive and child health clinic, said the hospital had to cancel a program it normally hosts for pregnant patients’ husbands, in which health workers teach men about childbirth and contraceptive options.
Gomez said at least a dozen men used to participate in the meetings each week.
The cancellation “will definitely have an impact because we are in a culture where childbirth and delivery is termed a women’s responsibility. Men do not get involved,” she said. The outreach program, she said, “has changed their way of thinking.”
In those workshops, men are also encouraged to donate blood to help their wives and other women who may require donations if they experience complications during childbirth. Now Gomez fears that fewer people visiting the hospital could lead to a decrease in donations.
“When people are worrying about what to eat, the last thing they will think of is giving out blood,” she said.
In refugee settlements housing Rohingya refugees in Bangladesh, aid workers are taking extra precautions to try to keep the virus out of the crowded camps. Ram Das, the deputy country director for CARE’s Bangladesh programs, said that his team has seen a dramatic drop in visitors to their general health centers since the crisis began.
“Less people are coming to these centers because of these fears of gathering and there’s a lot of messaging around not to crowd places,” he said.
Instead, his team is using outreach programs to find people who need care and also raise awareness about the coronavirus.
A tight lockdown implemented in Paraguay in early March has led to a decrease in women seeking health services, even though clinics are still open, said Sandra Recalde, a midwife who leads the Paraguayan Ministry of Public Health’s obstetrics division. Although health workers are trying to reach women and hand out extra contraceptive supplies to keep people stocked for longer, some people are still afraid to seek treatment, she said.
In Paraguay’s delivery wards, health workers are also worried about catching the virus. The country has confirmed fewer than 500 cases of the virus, but fear of contagion remains omnipresent.
Still, she said, health workers providing essential care are finding ways to confront the fear.
“The spaces where women give birth in health clinics have become places of compassion, love and, yes, fear,” she said. “There is fear among the staff and health workers … but all that fear subsides when they see women having their babies and knowing that they are healthy.”