Estimated reading time – 6 minutes
After 15 months of researching COVID-19 and maternal health, I wanted to reflect on the type of research which has been done, and our roles as researchers in advancing women’s and maternal health during the pandemic, and in general. These reflections are a result of many conversations and exchanges with colleagues, and I draw on global lessons, bringing comparative perspectives and examples from the research conducted by the dedicated team at ITM together with our partners, including an online survey of maternal/newborn health providers globally and in-depth study of seven referral hospital maternity wards in Uganda, Tanzania, Nigeria and Guinea.
With the occurrence and spread of SARS-CoV-2 in early 2020 globally, two main streams of work emerged. The first was looking at what we call the direct effects of SARS-CoV-2 on maternal health – for example, the infectious nature of the virus, severity of infection in pregnant women, extent of vertical transmission, effect on levels of maternal mortality, prematurity/stillbirths, etc. These were key issues related to the virus and lots of excellent work was done by clinicians and researchers, predominantly those who were operating in systems with excellent data infrastructures, for example in the UK and Brazil. Yet, we learned very quickly that assessing these biological questions is next to impossible in settings where many births occur in home settings (and therefore we miss a large part of the denominator – the women and their pregnancies) or where integration of SARS-CoV-2 testing in clinical work and in routine data systems was a challenge. From the onset therefore, we relied on high-income country data to answer these questions. Many of these answers started emerging during the period of March, April and May 2020 and put us somewhat – and perhaps complacently - at ease.
At the same time, there was a related but separate stream of work going on highlighting the expected and emerging indirect effects of the COVID-19 pandemic on maternal health. What we mean here are the effects of the COVID-19 pandemic on women’s use of health care (which declined in many settings, partly due to fear of infection in health facilities), on the provision of care/its availability (health workers were not sufficiently protected or were not able to reach their workplace, they were reassigned to COVID wards, some facilities were closed), and the massive effect of country-level policies on the health of women and their babies – such as lockdowns, large-scale migration, and inability to move on roads to reach essential services such as emergency obstetric care. The first type of studies to attempt to capture this effect were modelling studies  &  (again, mostly from high-income country researchers), which painted a very bleak picture and warned us that the indirect effects will be much more detrimental to the health of women and babies than the direct effects of the virus itself. From the fewer, but rich and contextualised signals we were beginning to hear from various countries, we also realised that not only was the provision and use of healthcare declining, but the need for care was increasing at the same time. This was for various reasons, such as increase in poverty due to loss of employment, declining mental health, for example among postnatal women in lockdown, rise in unwanted pregnancies, closure of school-based sexual and reproductive health services, and the immense increase in violence against women, mainly happening in their own homes.
A third type of research was published on experiences of continuing to provide care during COVID-19, the difficulties, the adaptations which took place in order to continue clinical care. The results of these studies are much more “fuzzy”, more difficult to summarise in a traditional systematic review, because they are affected by the complex realities in each country and women’s lives. What they did show us, however, was that the real effect of COVID-19 on pregnant, birthing, postpartum women and their babies was really a result of a three-way interaction between the virus itself, the socio-economic context of peoples’ lives, and the health system.
Within this body of literature, two examples are particularly meaningful. First, the effect of COVID-19 on health workers, which is revealing as it cast health workers in two opposing perspectives: health workers as villains and vectors of disease, versus health workers as heroes and saints of the fight against the pandemic. Research in many settings has shown us that health workers involved in caring for women, mothers, and newborns were particularly forgotten during COVID-19, for instance in terms of ensuring personal protective equipment (PPE), ability to benefit from being considered front-line health workers. Health workers reported having to spend their own money to buy PPE, to buy mobile data in order to participate in virtual meetings, sleeping in the health facilities in order to avoid delays associated with lack of public transport, having very difficult conversations with their own families when they volunteered to provide care to women with SARS-CoV-2. In our survey we hear their voices very clearly; they are extremely upset about changes to care which they see as unnecessary and compromising their ability to connect with patients and support them along the continuum of care they way they believe is needed and to which women are entitled. We also clearly see differences between the experience of doctors versus nurses and midwives, accentuated along the lines of hierarchy and gender in the workforce.
Next, the signals were loud and clear from the very beginning of COVID-19 that respectful maternity care was among the first casualties of adaptations to suit the virus, rather than the needs of women. A concrete and crushing example of this is the illegal and unnecessary separation of newborns from mothers at birth. Despite strong evidence that such early and continuous contact is absolutely essential to health and wellbeing, we saw separation measures implemented in many countries. The ground work done by women’s and human rights NGOs was critical in this area and is key source of evidence, although not always in the form of peer-reviewed papers. We must also remember that knowledge, signals, evidence, comes in many shapes and forms, and particularly COVID-19 reminds us that the lived experience of women is one of the most important ways through which we “know” about maternal health. We must ensure that we hear women and that we listen.
So, what are some of the key lessons which COVID-19 has taught us about maternal health?
- The existence and needs of pregnant, birthing, postnatal women and health workers who care so deeply about them and for them had been largely forgotten in decision-making. Political decisions, from lockdowns which closed access roads to hospitals, to lack of distribution of PPE to midwives conducting postnatal home visits speaks to both a lack of representation of women’s lives in the various levels of decision-making, but also to a dearth of understanding the complexity and intersectional nature of women’s lives. Pregnant women are never “just” that. They are pregnant and cannot feed their older children, they are breastfeeding and a health-care worker, they have given birth and an undocumented migrant, they are experiencing a miscarriage and unable to take a day off from their supermarket job, they are trying to conceive using IVF while experiencing stress due to home-schooling, they are in labour and the hospital is being bombed…. As a society, we were unable or unwilling to accommodate this complexity in the decisions made during the response to COVID-19, in nearly every country in the world. This is not new of course, but it gives us another impetus to try harder.
- Pregnant women are unlike any other category of people coming to contact with the health system – because the majority of them are not sick. We have here a predominatly healthy population of individuals, being brought into potentially unhealthy environments of health facilities. This was already the case before COVID-19 with overmedicalisation (too many labour inductions, unnecessary caesarean sections), preventable infections in health facilities and others. But COVID-19 has made it all the more obvious when women refused to come to health facilities and be exposed to the risk of SARS-CoV-2, and instead searched for options such as midwife-led hotels, home births, etc. It is up to us how we rise to the challenge in the future, and how we learn from this to reflect what women want and what is the best way of providing maternal care rather than what is the system which works best for clinicians, healthcare managers and insurance companies. After all, the healthcare system is here for the women, not the other way around.
- Third, as maternal health researchers, we cannot escape the fact that health is political. We all knew, for many years, that a global epidemic was very likely coming. We thought it was going to be a pandemic of influenza. And yet, despite the fact that influenza has much more severe biological outcomes on pregnant women compared to SARS-CoV-2, we were grossly underprepared. The political nature of the response to COVID-19 is also why it is so hard to isolate the biological, the direct effect from the indirect effects of the pandemic on maternal and perinatal health outcomes. Have stillbirths increased or decreased? What about maternal deaths? The answer depends not just on the variant, but also on the vulnerability of excluded populations, on the availability of free healthcare and oxygen, on the ability and willingness of local coordinating mechanisms to ask for help and challenge central government decisions which are impeding continued access to and provision of essential services, etc. These seemingly puzzling trends and patterns are, after all, a result of a system which is exacerbating vulnerability, destroying the natural environment for the sake of economic growth, excluding, marginalising, underpaying and undervaluing humans in general and women in particular, including health workers, the majority of whom are women.
This is a short version of a seminar given on May 19 2021 to the Working Party International Safe Motherhood & Reproductive Health. I would like to thank Prof Thomas van den Akker for his kind invitation.
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