Global responses to the COVID-19 pandemic are intersecting with pre-existing pervasive sexual and reproductive health inequities which disproportionately impact vulnerable populations. While COVID-19 has a severe, and in some cases, devastating impact on health systems around the world, studies show that people whose human rights are least protected – including refugees, displaced peoples, conflict-affected populations, indigenous peoples, and those living in low-income settings – are likely to experience unique difficulties in accessing quality sexual and reproductive healthcare during a crisis. Studies of previous health crises, notably the Ebola epidemic in West Africa and the Zika epidemic in South America also indicate that where health systems lack resilience the indirect mortality effects (including maternal and neonatal mortality) of a public health crisis can be as significant as the direct mortality effects. While there appear to be no direct clinical outcomes among pregnant women due to COVID-19, initial projections anticipated that COVID-19 would inevitably cause a disruption of health services, with resources and personnel diverted from SRH to the public health emergency. Disruption of global pharmaceutical and medical supply chains were also predicted, which would cause bottlenecks and reduced commodities (including contraceptives, antenatal supplements, and sterile medical equipment essential for deliveries). Experts also anticipated that COVID-19 would have an impact on health-seeking behaviours, with fears of contracting COVID-19 preventing women from accessing family planning, antenatal care, skilled birth assistance, and other essential reproductive, maternal, and newborn health (RMNH) services.
This report reviews data from six focal countries – Bangladesh, Burkina Faso, Colombia, Democratic Republic of Congo (DRC), Nigeria and Syria in order to assess the impact of COVID-19 on sexual and reproductive health. Overall, across the six focal countries the data available suggests that there has been a reduction in access to family planning counselling and to contraception access and use in some settings – although not all. Family planning has been significantly impacted in Bangladesh (down 50 per cent), as has contraceptive access and use (down 35 per cent). Contraceptive access and use has also been negatively impacted in Colombia due to supply chain disruptions and the DRC due to access barriers. However, contraceptive use has increased in Burkina Faso since the beginning of the pandemic – particularly among nulliparous women (up 39 per cent) – indicating a preference by women to delay a first pregnancy. School closures have contributed to increased rates of child, early and forced marriage (CEFM) and adolescent pregnancy – particularly in the DRC, the northeast of Nigeria, and Syria. Consequently, there has been a rise in demand for safe abortion, which does not appear to be met, particularly in the DRC.
Overall, there appears to be a critical reduction in availability and uptake of antenatal care (ANC) in most of the focal countries, however there is limited data available. There has been a 31 per cent decrease in ANC visits in Bangladesh, and in Colombia, border closures have had a serious impact on Venezuelan migrant and refugee women’s access to ANC. Skilled assisted delivery rates were initially affected in Nigeria and Syria at the beginning of the pandemic, however both have since improved. In Syria, the percentage of births attended by a skilled health professional is now at 95 per cent, which is 4 points higher than it was before the pandemic. In Bangladesh, there was a twothirds reduction in skilled assisted delivery across the country, and it does not appear that this has fully recovered in 2021. Maternal mortality figures are available for some contexts; however, it is not always clear whether the rates reflect all deaths of pregnant women (including those who died from COVID-19), or only deaths caused by pregnancy complications. There has been a significant increase in maternal mortality in Colombia and the DRC, however rates appear to have improved in Burkina Faso compared with pre-pandemic figures.
COVID-19 has caused significant barriers to health access, as well as changes in people’s healthseeking behaviour. Across the six focal countries, one of the dominant barriers to health access during the pandemic has been a diversion of health resources towards the pandemic, and away from SRH services. This has led to a lack of adequate health facilities, shortages of medical equipment including PPE, and an insufficient number of healthcare professionals to meet population needs. In Bangladesh, 19 percent of people felt COVID-19 had reduced their access to healthcare, while 15 percent of people in Colombia felt the same. In Syria, this figure increases to 45 per cent, suggesting that the ongoing conflict has caused very poor resilience of the health system. Shortages of healthcare workers have been particularly pronounced in Nigeria, Burkina Faso and Syria due to illness, burnout, and targeted attacks on health services. Other access barriers that existed prior to COVID-19 have been exacerbated by the pandemic, including travel distance, cost of healthcare and transport to healthcare facilities, and insecurity caused by conflict. The past 18 months have also seen changes in people’s health-seeking behaviour; in many contexts people appear to be avoiding attending health facilities – even for essential care purposes -- due to fears of contracting COVID19. Contraceptive access, ANC visits, safe abortions and skilled assisted deliveries are essential forms of healthcare, and reductions in women seeking out these services is incredibly concerning.
This report also explores the significant gaps in availability of RMNH data in the six focal countries.
Comprehensive and quality data is essential for RMNH and SRH decision-making. Without information on gaps in services, barriers to access, and numbers of people affected, government health ministries and humanitarian health clusters cannot meaningfully respond to the health emergency with targeted strategies and resources. Where data is contradictory and conflicting, such as in Bangladesh and Nigeria, governments and Health Clusters are unable to assess the true scale of the need for response. In contexts where there is no data, this problem is magnified because it can render the issues completely invisible. For example, good data in Burkina Faso on contraceptive access disguises a lack of data on ANC coverage, which can lead to an assumption that ANC coverage must be good if it isn’t reported. Similarly, in Syria where deaths from other causes are being reported, maternal deaths can be rendered invisible.