This month, in Foreign Affairs, Melinda Gates published “The Pandemic’s Toll on Women.” The article described the ripple effects of COVID-19, including the virus impact on the health system. Epidemics, she wrote, “not only overwhelm immune systems but also overwhelm health systems. And because the parts of those systems devoted to caring for women are often the most fragile and underfunded, they collapse first and fastest.”
For a deeper dive, The Optimist spoke with three experts on women’s health care—particularly as it’s delivered in low- and middle-income countries:
- Violaine Mitchell is director of the foundation’s Health Funds and Partnerships team.
- Lester Coutinho is deputy director, of the foundation’s Family Planning program
- Jeffrey Smith is an obstetrician/gynecologist and deputy director of Implementation Research and Demonstration for Scale of the foundation’s MNCH team.
COVID-19 is killing more men than women, so it may seem odd to some people to talk about women’s health care during a pandemic. Why is it important?
LESTER COUTINHO: I'll start us off by noting that inequities of every kind will get heightened during this pandemic, and hence inequities based on gender will likely get worse. The impact on women needs to be understood in relation to the intersectionality with other inequities. Women will be worse off now than in “normal” times. This will be especially true for women's access to health care, to food and nutrition, and will likely increase gender-based violence, especially in the domestic space. Even though we are talking about women here we need to acknowledge that outside of the developed world we know very little about access to health care for persons of other gender identities, who may also face challenges in accessing health care during the pandemic.
JEFF SMITH: I think that’s right. Pandemics like COVID-19 overwhelm health systems, and in particular, they overwhelm women’s health care services. Those often get de-prioritized during emergencies.
For example, I think there is a prevailing sentiment in many places that facility-based birth is really still "optional." One would never say to a man having a heart attack "Well, you're having a heart attack, we have two options here. You can see if you can manage it by yourself at home, or you can come into the facility and try and get care."
That would never really be considered an option, but during a pandemic, there is a sense that, "Okay, childbirth. Well, you could either come into the facility, or you could stay home.” But it shouldn’t be an option! Women should always be able to come in for delivery and for better care in the hands of a skilled provider. Or, if that's really challenging, have a skilled provider go to the home of the woman.
I also think a critical message has got to be that maternal and newborn health services in facilities must not only be maintained, but they must be strengthened during this time. I think that has to be quite intentional.
I think this is actually the moment to re-envision health care services.
Director, Health Funds and Partnerships
Bill & Melinda Gates Foundation
For example, in many countries, nurse midwives are trained as both nurses and midwives, which means those nurses have the potential of being diverted from the labor unit. A nurse can be pulled from the labor unit and has to go work on the adult COVID-19 ward, because she's a nurse as much as she is a midwife, and so there is the real potential for understaffing or de-staffing of the maternity unit in favor of other parts of the hospital. The option of just reducing maternal health services should never be part of the solution for the pandemic.
VIO MITCHELL: There were many learnings from [the West African] Ebola [outbreak in 2014]. One was that health workers fought the disease more effectively when they set up separate Ebola treatment centers away from main health care facilities, and I think that this will prove to be the same with COVID-19.
Another lesson was the importance of engaging with the community, building trust, and shaping services in ways that fit their lives.
I think this is actually the moment to re-envision health care services. We have this disjointed system in many parts of the world where Monday is your vaccination day, Tuesday is your antenatal care (or ANC) day, Wednesday is your nutrition day, Thursday is potentially your family planning day or your tuberculosis screening, and it’s highly inefficient.
I'll take immunization as an example: Mothers will be told to be there at 8:00 in the morning. More than 100 or 200 women will be crammed in rooms, probably with not enough benches, with their children, and they will wait.
They will wait until the health worker feels that there are enough people, and then there will be some sort of lecture about health. Then they [the health workers] will collect and fill out the patients’ immunization cards. Then people will actually start to get some services, perhaps.
It's four or five hours in a small room where you've assembled several hundred people. It isn’t respectful of people's time and patience and money. And it’s not wise during an outbreak of an infectious respiratory virus.
When it comes to caring for women, how do health systems need to adapt now?
VIO MITCHELL: On the problem I just mentioned, rather than have hundreds of women come in all day, more places could schedule smaller groups for smaller windows of time. The guidelines have been very rigid. Women shouldn’t need to wait all day to see a health worker.
Here’s another idea: It's not going to work everywhere, but there is a definite way that we could actually make sure that when a woman shows up at a clinic, she's being provided a number of different services—and not just whatever service that’s scheduled for that particular day of the week: She's being asked about family planning, she would be screened for TB, and it would be a one-stop service. It might not work all the time, but this is our opportunity to change those things.
There's some really interesting work coming out of India, right now. I think that out of the darkness of COVID-19 is a way to completely rethink how we provide basic care and build trust in communities, and moreover, protect the health care workers who need to deliver those services.
[NOTE: An example of this: In India’s Bihar state, thousands of health workers donned PPE in April and went door-to-door gathering information about where COVID-19 had spread. Within four weeks, they’d surveyed nearly 2 million homes for the virus covering 104 million people. But not only that; they also used the survey as an opportunity to counsel women and couples about family planning, and screen expectant mothers for possible risks.]
LESTER COUTINHO: I agree. The WHO [World Health Organization] has recommended whenever women visit a clinic, providers need to leverage the visit as an opportunity to offer her additional services she may need but may not ask for.
Women will quite often come in for childcare, but nobody is asking her about reproductive health care and other health care services she may need—or, some women come in for reproductive health, and nobody is asking them about other health issues, including violence or abuse at home or in communities.
The WHO has developed guidelines for ensuring that women are asked, in a subtle but intentional way, about whether they are facing abuse, and gender-based violence at home or in workplaces. While this is a standard of care in many developed countries, there continues to be a lack of attention to providing such care in most developing countries. Just a simple screening tool comprising a few questions can ensure that women are being offered the services they want and need.
I also think it's about the integration of those services within the clinic that becomes particularly important at this time when women’s mobility is likely to be even further constrained.
VIO MITCHELL: We also can’t forget about the health workers.
The majority of our front-line workers are women in most countries. They are also family members. They're caregivers. They are in an extremely vulnerable situation, right now, and they're often the last people that we think about, or not that we think about, but that they're often the recipients of PPE, for example. To me, it goes to the heart of how people are being treated seriously, who is involved in the decision making, who is at the table, and because they are, they're providers and clients, all at the same time.
A moment ago, Jeff mentioned that midwives may be pulled away from delivering babies and into COVID-19 response. Is there a concern this becomes standard practice for health systems during a pandemic? Are they shifting all their resources towards combating the big, new disease—and overlooking that there are other services they have to provide?
JEFF SMITH: Oh, absolutely. And that's why we're seeing reductions in clinical volume at hospitals for deliveries and reduction of antenatal care visits. It's not only a sense of fear among the women, but it's a sense of prioritization among the managers. What messages, implicit or explicit, are they giving to the community about what kind of things need to be cared for, and what kind of things are optional and can be deferred to another time, or ignored all together.
VIO MITCHELL: You know, what we're all talking about is a reinvigorated primary health care system that makes sure that women are referred to the secondary and tertiary levels of care, as they need them. One of my big fears is that primary health care may be a casualty of COVID-19.
I've heard a number of colleagues from countries saying, “We should have invested more in our tertiary systems.” Look how many conversations we're hearing about ventilators…
But I think that we also need to take the opposite lesson: We need to invest in the most basic and essential forms of care.
If we had a really strong functional public primary health care system that was addressing some of the basic needs—that was able to refer women, have proper institutionalized births, etcetera—we would obviously see an impact from COVID-19 [on the maternal mortality rate], of course, but it wouldn’t be as dramatic.
These service disruptions and modifications are going to go on for a while... this is a chance for us to put in alternative models of care... it's definitely not too late.
Deputy Director, Implementation Research and Demonstration for Scale, MNCH
Bill & Melinda Gates Foundation
Let’s talk about family planning. Early estimates also suggest the pandemic will cause 49 million additional women to go without contraceptives. Why is that happening?
LESTER COUTINHO: Well, historically, in times of crisis the behavior that sets in for governments is to be protectionist about ensuring availability of essential medicines for their populations. For contraceptives, the idea that’s taken hold in some countries is, "Let's not export drugs right now because we don't know how long in-country manufacturing capacity may be compromised."
Look at India. They manufacture a lot of the generic contraceptives that women in low- and middle-income countries depend on, but India doesn’t manufacture all of the APIs [Active Pharmaceutical Ingredients] needed for those contraceptives. Most of these are imported from other countries, that are in turn worried about the security of commodities for their citizens. And so, there is likely to be this knock-on effect on the global supply chain which will eventually impact most women in the poorest and most remote communities. Even when countries do eventually begin exporting product it takes a while to fill up the supply chain again particularly in the context of COVID-19 when distribution logistics are also compromised.
Contraceptive supply chains are also impacted within countries where—even if they have the product—the transport of goods from warehouses down the supply chain are compromised due to COVID-19.
Who is responsible for these decisions—and can help make the supply chains flow again?
LESTER COUTINHO: When it comes to API stockpiling, it’s the health ministers, the finance and industry who are making those decisions.
These decision makers are not unaware that somewhere down the line, their decisions are going to hurt someone else in another part of the world, but when they put the policies in place, they are thinking of their own populations. The good news is that at least in some instances when, for instance, an Indian IUD manufacturer along with global NGO made the case to the government of India, the policy makers responded positively.
What about the last mile?
LESTER COUTINHO: There are many lessons to be learned from how the world delivers vaccines. Immunization programs have over time developed a more sophisticated understanding of how to use data visibility and distribution innovations to ensure supply chains work in some of the most difficult places of the world, and so there's a ton that Vio can tell you, about what we've learned and what we can do.
VIO MITCHELL: Yes, certainly with the vaccines, we're very successful in getting vaccines out, but we're still missing a good 10%, 15%, or 20% of kids at times, and so we haven't completely nailed it. That’s why the big focus over the next five years, for Gavi, the Vaccine Alliance, for example, is reaching “zero-dose”, children who have never received any vaccines at all. The zero-dose child can actually be sitting next to a health facility in an urban setting or he/she can be a long way away.
Lester is absolutely right. We need to think creatively about supply chains.
Final question: You’ve proposed a lot of useful ideas. Turning many of them into a reality takes time. But how much time? Is it too late to limit the maternal and child deaths from this particular pandemic?
VIO MITCHELL: No.
LESTER COUTINHO: No.
JEFF SMITH: Absolutely not. I think it is active engagement with governments to ensure that services are available and that women have confidence in them. Unfortunately, this pandemic is going to go on for a while, and these service disruptions and modifications are going to go on for a while. I think, to Vio's point, it's not only not too late, but it is an opportunity for us to try and do things better. This is a chance for us to put in alternative models of care. You know, from adversities, we must seize opportunities, and so it's definitely not too late.