BY KATHERINE GAMBIR, RESEARCH ADVISOR AT THE WOMEN’S REFUGEE COMMISSION
“There are several things in this unpeaceful world today,” Fatama* told the Women's Refugee Commission (WRC) in June 2019. “If you are giving birth frequently and if something happens, which [child] will you carry, which one will you pack, and which one will you leave? I have had a contraceptive in my body now for five years, and I am begging God to continue giving me rest [from childbirth].”
We met Fatama, a woman in her early 20s living in a camp for internally displaced persons (IDPs), during our trip last summer to document contraceptive service delivery for displaced and conflict-affected women and girls in Borno State, Nigeria.
An estimated 1.7 million women and girls of reproductive age have been forcibly displaced in northeastern Nigeria due to a violent insurgency led by fundamentalist extremists, including Boko Haram. Women and girls do not stop needing – or wanting – contraceptives during a crisis. Women and girls affected by the insurgency in Borno State reported wanting to delay or space pregnancies. In fact, they said that they had higher demand for contraceptives after displacement.
Women and girls displaced by conflict or crisis have the right to choose whether and when they have children and to avoid the consequences of unintended pregnancies. This holds true especially now, during the COVID-19 crisis.
Rise in Gender-Based Violence Increases Need for Comprehensive Contraceptive Services
Gender-based violence (GBV) has increased by 25% globally due to COVID-19, which means women and girls are at heightened risk of sexually transmitted infections (STIs), unintended pregnancies, and unsafe abortions. They need uninterrupted care and access to contraceptives that protect them from these adverse health outcomes and to prevent disability, morbidity, and mortality.
In the IDP camps in Borno State, WRC found that short-acting contraceptive methods, such as oral contraceptive pills and male condoms, were widely available, but emergency contraception (EC) was much less available. EC is the only method of pregnancy prevention that can be taken after unprotected sex. It is especially important in contexts of sexual violence because it prevents the traumatic consequences of rape-related pregnancies.
Long-acting contraceptive methods, such as implants and IUDs, were also less available. Increasing access to information and availability of long-acting contraceptives is essential so women have the option of preventing pregnancies for an extended period without the need to return to the health facility monthly or every few months. At the same time, male condoms, and female condoms should continue to be made available to provide dual protection against unwanted pregnancies and STIs.
COVID-19 Restricts Access to Contraceptive Services
Our case study found that women and girls desperately want to use contraceptives; however, huge barriers remain, especially for adolescent girls and unmarried women who face elevated levels of community stigma and ostracization for accessing services. Women reported leaving the IDP camps to access contraceptive services without being seen. If movement is restricted due to COVID-19, women may not be willing to risk ostracization for contraception.
It is important to sustain the availability of all methods, including EC and long-acting methods, and to inform the community through radio and other means about where these services are available. In settings where women and girls face restricted movement, strategies such as remote counseling and pharmacy or community health worker distribution of EC and three-month supplies of ongoing contraceptives should be considered.
Disrupted Contraceptive Supply Chains During COVID-19 Will Lead to Unsafe Abortions
Recent reports show that supply chains for contraceptive commodities have been negatively impacted by the coronavirus pandemic, which will result in unintended pregnancies and lead to women and girls seeking abortion care. Although abortion in Nigeria is legal only when the woman’s life is endangered, women and girls told us abortions in other instances do occur. Women, mostly girls, resort to unsafe and clandestine abortion methods, such as using herbs or detergents or drinking dissolved eyeliner. Some women reported accessing misoprostol, a safe abortion drug, at the pharmacy. However, with the supply chain disrupted by the pandemic, misoprostol will likely become less available and unsafe abortion methods may be women’s and girls’ only option to end their pregnancies.
COVID-19 Strains Health Systems
COVID-19 is putting a huge strain on health services even in countries with sophisticated health systems. Of the seven health facilities we visited in Borno State that offered contraceptive services, four did not have a functioning water supply, three did not have electricity, and only two had the minimum infection prevention supplies. These facilities would not meet the minimal water, sanitation, hygiene, and waste management guidance necessary to protect women and health providers from COVID-19. Health facilities delivering contraceptive services must be bolstered to ensure women and girls are receiving, safe, effective, and quality services.
Given the likelihood of barriers to contraceptives, as well as other contraceptive service delivery challenges during the pandemic, it is imperative that governments, UN agencies, and international nongovernmental organizations take immediate and proactive action. They must prioritize contraceptive service delivery if Fatama is to get her desire for a continued break from childbirth. If we do not act now to ensure the continuity of contraceptive services, morbidity and mortality resulting from unintended pregnancies during the COVID-19 pandemic will surely increase. We must not let this happen.
* Name has been changed to protect her identity.