Women lose access to family planning services due to lockdown

Having already given birth to three children, Jessica Ekirapa, 38 years-old, embarked on family planning to ensure she does not get any more children.

She got an implant that would take three years. Unfortunately, she ended up with heavy menstrual periods, high blood pressure, and high sugar levels as a result of the family planning implant. It was unbearable.

Luckily when a family planning method is chosen it is monitored for side effects. If they are severe the healthcare provider changes from one method to another, until a suitable one is found.

With Ekirapa reacting to the implant, her doctor at Katego Family Planning Clinic in Wakiso district removed it. She eventually settled for having a coil (intrauterine device or IUD) inserted.

But on the day she was to have the coil inserted, a lockdown to contain the spread of COVID-19 was announced. Ekirapa could not make it to the clinic.

To avoid unwanted pregnancy she has decided to either abstain from intimacy or use condoms. This is a dilemma most women are facing. Even those who use short-term family methods such as pills and condoms cannot restock.

As COVID-19 sweeps across the world, women, and girls are facing a unique challenge in accessing reproductive healthcare services during this time.

"The majority use public transport to go to the clinics for family planning services, but are now unable to move," says Dr. Kenneth Buyinza Clinic services manager Reproductive Health Uganda (RHU).

There have also been reports of mistreatment of frontline workers including those in health by security agents tasked with enforcing the lockdown.  Some health personnel who are classified as essential workers have failed to access stickers for their vehicles that prove they are authorized to move to their work stations.

This is happening even though the Uganda Medical Association (UMA) agreed that antenatal care, treatment of chronic conditions, and primary healthcare services like immunization would continue through the lockdown.

Health workers are classified as essential workers who have failed to access movement stickers to reach their work stations.

‘‘There are no movement permits for our workers, even though the ministry of health was given 2000 stickers for the sector," 'says Buyinza disappointedly.

Escalating situation

RHU, a member of the International Planned Parenthood Federation (IPPF), is one of the key providers of family planning services in Uganda but has been forced to suspend some of its services.

"We run 19 family planning clinics across different sub-regions of the country, but have decided to close three of our busiest ones in Kampala due to the lockdown," says Dr. Buyinza regrettably.

The closed clinics serve the neediest of the population in Kampala, providing reproductive health services for mothers and immunization for infants.

Also suspended were the RHU outreaches across the country. Among the government guidelines issued to contain the spread of COVID-19 was the suspension of gatherings.

‘'We suspended all our outreaches. We cannot observe the four-metre social distancing with the large clientele we have, we need a huge playground to be compliant which is not possible,'' says Buyinza.

Also suspended were operations of Village Health Teams (VHTs).

‘'Their work involves home visits to distribute family planning items and educate locals on sexual and reproductive health. The challenge is we do not know who they interact with before the home visits, so we suspended the activities,'' says Buyinza.

RHU has, however, kept its 16 regional clinics open to offer remote technical assistance to both private and public health facilities.

‘'We provide these facilities with family planning supplies because it is much easier for us to get the commodities and channel it to them. However, the closure of services in Kampala affects upcountry clinics when they are running low on supplies. ‘We are unable to deliver because our vehicles and staff have not been cleared,' he explains.

"We cannot deliver because we use pick-ups. When returning it is difficult to prove they were carrying family planning items,'' he adds.

Dr. Buyinza says the lockdown directives have been misinterpreted. "There is hooliganism; we cannot put the lives of our staff at risk,' he says.

"Clinics are running without support, but we are unable to respond. We have people in the field, but as a coordinator, I'm stuck home. I cannot monitor service delivery,' he adds.

The reduction in uptake of family planning services is manifesting itself through the reduced number of clients RHU clinics are receiving.

‘'Weekly return of clients is low. But even if it is five clients daily, it's better than keeping the clinics closed,'' says Buyinza.

The upcountry clinics are open from 8:00 am to 5:00 pm to ensure the RHU staff can get home before the curfew starts at 7:00 pm.

Consequences

In Uganda, 39% of women use family planning, but not all they use long-term methods such as implants or the coil that may last two years or more, says Buyinza.

He says most women use short-term methods that take at most three months.

Some are using pills that may have run out and may need a refill. Some men have run out of condoms. Buyinza, says there is now a growing unmet need for reproductive health services across the country.

The situation puts women in the line of picking unwanted pregnancies, says Buyinza.

Why we should worry

Uganda's fertility and population growth rate is among the highest in the world at an average of five children per woman, according to the 2016 Uganda Demographic and Health survey.

However, 336 mothers die of pregnancy-related complications per 100,000 live births. Buyinza says when faced with limitations in accessing family planning services, the result will be a significant increase in unwanted pregnancies and unplanned childbirth which has a direct impact on population growth.

‘'For a better quality of life, women and men should have children by choice. If we keep having children who are unplanned for as a country, It will have a bearing on the overall quality of life,'' he says.

Uganda's family planning goal

Uganda chose to scale up the use of modern family planning methods to ensure that every Ugandan woman can choose when and how many children to have.

Uganda is committed to reduce the unmet need for family planning to 10% and increase modern contraceptive prevalence rate to 50% by 2020, according to the ministry of health.

Improving access to family planning is a crucial part of Uganda's commitment to reduce maternal mortality and improve economic wellbeing.

Why it is crucial

Family planning saves lives. The risks of illnesses and death of women and children are affected by the number of pregnancies and their timing, according to RHU.

Mothers below 18 or above 34, those with more than three children, as well as those whose with less than two years gap between children, or those who fall in all the categories are at greater risk of complication, said RHU in a report.

In 2014, Uganda launched the family planning costed implementation plan to increase the use of modern contraception. Reaching this goal is expected to lead to 9,549 mother's lives saved as of 2015-2020.

According to RHU, unintended pregnancies carry associated healthcare costs, including the cost of antenatal, delivery, and postpartum care for the mother and routine healthcare for the child.

But if family planning goals are achieved, Uganda would save sh868 billion in maternal and infant healthcare services by 2020 an additional sh88billion more than if the family planning goals are not achieved.

Solution

"If the clinics can open at least once a week to clients, we can walk there so that we can access family planning services," says Ekirapa.

‘'Alternatively, we can ride bicycles. Some mothers had babies recently and want to start on family planning methods, but they are now stuck,'' she adds.

There should be an arrangement that enables all health workers to open facilities and give services, implores Dr. Buyinza.

Dr. Natalia Kanem the United Nations Population Fund (UNFPA) Executive Director said in a statement that as is with most crises, the COVID-19 pandemic has severely disrupted access to life-saving sexual and reproductive health services at a time when women and girls need these services most.

UNFPPA embarked on working with its partners to prioritise the needs of women in line with their goal to end unmet need for family planning and end preventable maternal death by 2030.

With $187.5 million (sh690 billion), the UNFPA COVID-19 response will among others, ensure access to sexual and reproductive health services as well as ensuring that pregnant women can get antenatal care safely as the world battles COVID-19.