PANDEMIC. The scale of the health emergency led to restrictions and closures in
reproductive health services for months. Artwork by Leila Arenas
With health systems focused on containing the virus, women have experienced severe hardships when trying to access reproductive health services, such as perinatal care, contraceptive methods and safe abortion services. The monitoring carried out in nine countries in the region is showing that these limitations have led to an increase in maternal deaths. Just in Peru, 433 expectant mothers passed away between January and December of 2020, a number not seen in a decade. This year, more than 90 deaths have been registered up to March 9th. If we continue on this path, specialists asked warn, the indicators could be even worse than those reported during the first few months of the pandemic.
March 25th, 2021
In Peru, a 25-year-old first-time expectant mother stopped receiving prenatal care in March of last year. She was in her seventh month of pregnancy and the uncertainty of not knowing the state of her baby triggered an anxiety crisis. In Ecuador, a young woman from Quito needed an appointment in order to have access to a contraceptive method and, despite her best efforts, she was not able to get a single date. In Colombia, a woman requiring an abortion, was referred to a healthcare service that was 12 hours away from her home and she was denied the use of an ambulance or any other means of transportation.
In Latin America, we have multiple testimonials that reveal how the emergency associated to the novel coronavirus has infringed upon the rights of women to access reproductive health services in a timely fashion, despite the fact that they are considered essential by the World Health Organization (WHO) and by the Inter-American Commission on Human Rights (IACHR). This has led to serious consequences for women’s, teenagers’ and girls’ health; which have gone unnoticed.
The “Reproductive Health is Vital” report that was undertaken by the Latin American Consortium against Unsafe Abortions (Clacai in Spanish) between March and August of 2020, proved that there was an upward trend in indicators of maternal deaths in the region compared to the previous year, as a consequence of the restriction in reproductive health services during the pandemic. This initiative – signed by more than 80 organizations in Latin America – gathered data in Argentina, Brazil, Bolivia, Chile, Colombia (the only one not reporting an increase in the official numbers), Ecuador, Peru, Uruguay and El Salvador – giving us a glimpse of the fact that the effects of the pandemic on the reproductive health of women is even greater than the number of deaths directly related to Covid-19.
“THE “REPRODUCTIVE HEALTH IS VITAL” MONITORING COLLECTED DATA IN ARGENTINA, BRAZIL, BOLIVIA, CHILE, COLOMBIA, ECUADOR, PERU, URUGUAY AND EL SALVADOR.”
The numbers from Peru stand out. During 2020, the Ministry of Health (Minsa) recorded 433 maternal deaths, which represent a 42% increase compared to the previous period. “These numbers tell us of a ten-year regression in the efforts to lower the number of maternal deaths”, regrets Margarita Pérez, dean of the College of Obstetricians of Peru. “The greatest concern comes from the fact that we have had 92 deaths up until March 9th of 2021, which proves that we did not learn anything during the first wave and, if we continue on this path, we could finish the year with numbers that are worse than those from last year”, she added.
According to the WHO, 88% to 98% of maternal deaths are avoidable. Deaths from causes associated to pregnancy are not events of nature where health systems are powerless to respond, and strategies to reduce these are not a mystery. Avoiding most of these deaths is technically, economically and politically feasible. Therefore, aside from being a resounding violation of the right to life, maternal deaths are a reliable indicator when measuring the inequalities, the development level, the quality and the access to health services and social support.
In Peru, maternal deaths have historically been associated with direct causes, which correspond to pregnancy-related issues such as hypertensive disorder, obstetric hemorrhage and other less common issues such as sepsis. During 2019, at least 62.3% of the pregnant women who died was because of issues such as these. But during the next year the scales tipped and the number of deaths due to indirect causes went from 37.7% to 43.7%.
Image above: REGRESSION. In Peru, the number of maternal deaths grew to a level not seen in a
decade, according to information from Minsa. Artwork by Leila Arenas
“The pandemic forced prioritization of Covid areas. Other services, such as prenatal care, became invisible”, the dean of the College of Obstetricians of Peru affirms. “The causes of maternal death, both direct and indirect, can be prevented through adequate checkups, to identify complications and provide a timely referral to higher level medical facilities. But in this context, it has not been possible,” she added.
Covid-19 was at the top of the list of indirect causes of death in expectant mothers, at 15.3%, and it replaced cerebrovascular disease, which fell from 7.8% to 4.6%. Minsa’s numbers reveal that, at the very least, 63 expectant mothers or post-partum women died because of the novel coronavirus during the past year. According to the Pan American Health Organization (PAHO), Peru became the Latin American country with the highest number of infected expectant mothers per million inhabitants. The epidemiological report, from January 15th of 2021, reports that 40,648 pregnant women tested positive for Covid-19, representing 49% of the infected women in the region.
Rafaela de Silva de Jesús died one week after giving birth to her only daughter. Hers was the first maternal death because of the novel coronavirus officially recorded in Brazil. The young woman of 28 was a resident of the state of Bahía, a woman of African descent and a schoolteacher in a school in the interior part of the state. Her dream was to become a mother and, after five years of fertility treatments, she was able to conceive Alice. Unfortunately, her husband provided transportation services for a wedding, where more than 280 guests were in attendance, and the couple contracted the virus.
Days after giving birth, Rafaela exhibited symptoms associated with Covid-19 and had to be hospitalized. However, the hospital in her city did not have an Intensive Care Unit (ICU). She died before she could be transferred to another health center. This happened in March of 2020. What came after turned Brazil into the epicenter of the pandemic in Latin America, given the mortality rate per 100,000 inhabitants. A fact that is reflected in the maternal deaths indicators: only in the first semester of 2020, the death of 926 expectant mothers had already been recorded, of those 124 were because of the novel coronavirus, as reported by Anis – Institute for Bioethics, Human Rights and Gender, the organization in charge of monitoring in this country.
Maternal and neonatal morbidity & mortality
The table shows the percentage increase in maternal and neonatal morbidity & mortality in 2020 compared to 2019. Certainly, Covid-19 has brought about an unprecedented crisis. Nevertheless, the Ebola epidemic in Sierra Leone, between 2014 and 2015, had already left us with some lessons that health authorities could have applied during this pandemic. The African country’s health crisis, as well as the experiences with Zika and N1H1 influenza, have all proven that extreme restrictions to sexual and reproductive health services lead to an increase in maternal and neonatal deaths. We had four years to rectify the decisions made at the time, so as to safeguard women’s rights. But it was not done.
The scale of the current health emergency has led to closures or restrictions in primary care centers’ schedules, where most reproductive health services are provided; there has been a reduction in medical staff because of reassignment to Covid-19 care; bio-security measures in order to access care were insisted upon and there was ample denial of some rights that had been recently gained, such as having a companion during birth and unnecessary c-sections, overruling the calls by the United Nations Office of the High Commissioner for Human Rights to attend not only the medical dimensions of the pandemic, but also aspects related to human rights and the consequences of gender gap.
Lorena*, a 39-year-old woman living in a rural area of Quito, is an example. She realized she was pregnant towards the end of April of 2020. She was facing a complicated situation: she was out of work, she had to provide for her 13-year-old daughter and her partner lacked the resources to support her. A few weeks later she suffered a miscarriage. There was some minor bleeding and a lot of pain, but she was afraid to leave home, because Ecuador was in one of the most severe stages of the pandemic. Even so, the discomfort forced her to go to a health center, where she was denied treatment because she was not considered to be “in serious condition”. A few days later, she went to the maternity center in her area. There she was told to get an appointment over the phone and, even though she tried to do so repeatedly, she was not able to get them to give her a date. Finally, she got a family member to loan her some money to go to a private service, where they ascertained that the miscarriage had been incomplete and that she had an infection.
Image above: LESSONS. The Ebola pandemic had already shown that extreme restrictions in reproductive
health services leads to serious problems for women’s health. Artwork by Leila Arenas
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Before, during and after giving birth
Peru decreed a health emergency on the 16th of March of 2020. Since then, confinement measures and other restrictions to reduce the spread of the virus have been implemented. This included limiting access to reproductive health services, which moved these services away from the most vulnerable sectors.
For over three months, outpatient visits were suspended in the 8,000 smaller health posts and centers around the country. A decision that left a great number of expectant mothers without care, given that 80% of prenatal checkups are performed in those facilities and at least 15% end up being high risk cases that must be referred to a hospital. Currently, they are providing services, although not at 100% capacity due to the absence of personnel.
Sandra*, a pregnant woman who received care at the Hospital Sabogal from EsSalud, in El Callao, had her last checkup in February of 2020. Back then, she was informed that her baby had a choroid plexus cyst on his head, while it does not usually jeopardize the fetus’ life, she did need a follow-up ultrasound. But once the quarantine started, all her scheduled check-ups and tests were canceled. Every time she called the hospital, she was told: “Once the quarantine is over, everything will go back to normal”.
Prenatal care in Peru dropped by about 40% during March and August of 2020. The same thing happened in Bolivia. And in Ecuador, where expectant mothers were left adrift due to the restrictions in services. In person visits were only granted for high risk pregnancies. “I only had two checkups before giving birth”, says Ana*, a 29-year-old Ecuadorian woman of African descent. “I had an appointment in April and I didn’t go because I was afraid of catching the virus, but I was never told to reschedule”.
“OTHER EPIDEMICS HAVE ALREADY SHOWN US THAT RESTRICTING REPRODUCTIVE HEALTHCARE SERVICES INCREASES MATERNAL AND NEONATAL DEATHS”
Marlene*, who was in her sixth month of pregnancy at the time of the interview, had not been able to schedule a single prenatal checkup, due to the lack of availability in the Quito hospitals. This Venezuelan migrant was suffering from abdomen pain, but the closest health center did not have an obstetrics area. She had to travel to try to get access to a medical check-up. She was not even given the option of a telemedicine appointment. In the end, she had to go to emergency services and she had to pay for an ultrasound in a private clinic, despite her precarious economic situation.
Childbirth care
The table shows the drop in hospital-based care for childbirth (in red) in three countries and the change in the number of home births (in gold) in 2020, as compared to 2019.
It is also noteworthy to mention that Peru has registered a 40% increase in home births, according to data gathered by the Center for Promotion and Defense of Sexual and Reproductive Rights (Promsex), an organization that was part of the Clacai report. To that effect, Margarita Pérez, dean of the College of Obstetricians, stated that the fear of catching the virus and the restricted mobility led more than 6,268 women to give birth at home. Even more staggering, the registered number of workplace deliveries was seven times higher than that of the previous year.
These births, called unplanned extra-institutional births, often present complications, that are later reflected in the number of deaths of expectant mothers. In Peru, the extra-institutional maternal deaths, that happened at home or on the way to a health center, represented 24.5% in 2020. Even though the Minsa report does not show a significant variation in this percentage compared to the previous period, the dean of the College of Obstetricians does not hesitate to say that there may be some under-reporting, due to the number of deliveries that happened at home since the beginning of the pandemic.
“These deliveries outside of medical institutions –explained Pérez– happen because we have many hospitals that have had to expand their attention to handle Covid-19 cases, at the expense of obstetrics services. Without mentioning the 40% reduction in the number of obstetricians, that had to work remotely because of advanced age or because of a preexisting condition”.
Bolivia, requires a negative Covid test in order to receive medical care when going into childbirth. This requirement, with a cost that is not covered by the State, has led to an increase in unplanned extra-institutional high risk births. It has even led to some women to deliver right outside the doors of health centers, faced with the impossibility of getting 150 dollars for a test to confirm that they do not have the virus, as disclosed by Católicas por el Derecho a Decidir, the organization in charge of the monitoring in this country.
In Cochabamba, for example, a case of a woman who took nine hours to find a hospital where she could be admitted was reported, which happened because she did not have a Covid test. Marina* left her house at 8 in the evening and gave birth at 5:20 in the morning, in a car that was parked in front of a health center, with the help of her sister-in-law. After giving birth, the medical staff went to the car to provide care, but they made her sign a document saying that the child had been born inside the institution and not in the vehicle.
Argentina, on the other hand, instituted guidelines to provide access to prenatal care during the pandemic, that could be considered best practices to bear in mind for the second or third waves of the pandemic, as voiced by the Latin American Justice and Gender Team (ELA), the organization in charge of local monitoring. In this case, the staff gave a medical report to each expectant mother on their first checkup and the records were immediately updated, so that the could go to any health center. They were assured that results would be sent via email and follow-ups were done through telemedicine.
Colombia also applied measures that turned out to be positive, such as limiting wait times in healthcare services, speeding up turns and using telemedicine to follow up on checkups for low risk pregnancies. Meanwhile, Uruguay, Brazil, Chile and El Salvador established triage by telephone in order to identify whether an in-person visit was required or not. In the last country, telephone counseling for contraceptive services was implemented, as reported by the Citizen Group for the Decriminalization of Abortion.
Image above: HIGH RISK. In several countries of the region the number of unplanned extra-institutional birth
grew during the pandemic. These usually present complications. Artwork by Leila Arenas.
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Confined without contraception
The pandemic also entailed interruption in access to contraceptives for many women, due to the difficulties that presented themselves when picking them up from health centers or the lack of inventory. In Chile, to cite a case, checkups and care for contraceptive issues dropped by 43% between March and August of 2020. Nor was there free provision of condoms, and faulty lots of contraceptives were reported to have been distributed throughout the public health system, these had to be recalled. As a matter of fact, about 140 women inevitably became pregnant because of the defective contraceptives, according the report of the Legal Termination of Pregnancy Movement (MILES).
In the meantime, the “Access and attention in sexual and reproductive health services in Ecuador during the Covid-19 pandemic” online survey registered that, out of 244 people who were interviewed by the Surkuna organization, at least 37.68% said that there was a lack of available contraceptive methods in health centers, another 31.8% indicated that they had been denied care or been told to go to a different facility and almost 26% did not know where to go or who to call in the context of the health emergency in order to get contraceptive methods.
“When I went to get my pills with my ID, they didn’t want to give them to me,” Eugenia*, a young woman from Quito, reported. “Just because I was living in a different place during the pandemic. I insisted and managed to get enough for three months, but it was as if it were a favor to me. I even presented a grievance. I went back in June and again they refused to provide them, because we were already in a yellow light situation and I could, supposedly, move around. But I lived with my grandmother, who is part of the at-risk population. I tried to change address. I wasn’t able to do it and had to suspend my treatment”, she remarked to the Surkuna Support and Protection of Human Rights Center, in charge of the monitoring in Ecuador.
“OTHER EPIDEMICS HAVE ALREADY SHOWN US THAT RESTRICTING REPRODUCTIVE HEALTHCARE SERVICES INCREASES MATERNAL AND NEONATAL DEATHS”
A study by the Guttmacher Institute (2020) attempted to show, from very early on, the impact that a 10% reduction in the provision of reversible forms of contraception would bring to low and middle income countries and the results were not too encouraging. Their assessment concluded that there would be at least 49 million additional women with unmet modern contraception needs and 15 million unwanted pregnancies.
Long-lasting methods were not even considered as a viable option for women in the region, because surgical contraception was suspended during the pandemic, unless they were done after a c-section. In Argentina, the National Unwanted Teenage Pregnancy Prevention Plan (ENIA) also reported a 40% reduction in the use of long-lasting contraceptives in the first four months of the year.
However, some countries did implement practices to promote access, that could be replicated in this second wave. Uruguay, for example, extended the expiration dates of their treatment ID cards so that the beneficiaries could receive their supplies during the health emergency, without needing to take care of administrative procedures for renewal. Furthermore, Argentina, designed contact-less pick up points, expanded the three-month limit for supplies, activated issuance of electronic prescriptions, and like Colombia, implemented home deliveries.
Truncated path to abortion
Mandatory social distancing placed women in the region in a more vulnerable situation. Many found themselves confined together with their aggressors and were exposed to abuse, without the possibility of seeking refuge in another place or being able to leave to ask for help. In Argentina, Brazil, Bolivia, Chile, Colombia and Uruguay legal abortion is an option in case of rape. But, during the pandemic, getting access to this procedure was almost impossible for women, teenage girls and girls.
Given the context, women were more prone to become victims of misleading services, carried out by untrained persons, and using unsafe practices. More than a few were scammed into buying counterfeit medicine being sold online. The Safe Abortion Information hotline, in Peru, registered a 400% increase in calls from women looking for reliable counseling. While the “I Decide” collective helped 2,063 users in April, three times as much as before the emergency. This same thing happened to other hotlines that provide information about safe abortion in other countries, like Argentina, Ecuador and Chile.
The existing barriers in the region when it comes to access to safe abortion – except for some states like Mexico, Uruguay and, as of the end of 2020, Argentina, where legislation provides for legal termination of pregnancy – relegate women to clandestine and risky practices. During the pandemic, things were no different. In Brazil, where abortion is legal in case of rape or life-threatening risk, the public health system reported 1,040 pregnancy terminations between January and July of 2020. Yet in that same period, 83,099 hospitalizations were recorded, all due to complications because of abortions that were carried out outside the health care network.
The data do not give a full account of the magnitude of the problem, because it does not consider that there is under-reporting of women who do not make it to health services in Brazil, as pointed out by the Anis organization. Bom Jesus do Norte city, in the state of Espíritu Santo, for example, reported the case of a 28 year old woman, who died because of abortion complications. Flavia* tried to terminate her pregnancy with a syringe, catheter and potassium permanganate; a very unsafe technique. The woman died after wounding her uterus, the wound led to heavy bleeding and, as a consequence, cardiac arrest.
Access to abortion in the region
The report concluded that abortion services were the most affected services during the pandemic. The table shows a decline in services in 2020 as compared to 2019. Ecuador, Peru, Chile and Uruguay did not provide any flexibility in terms of the necessary requirements to expedite termination of pregnancy because of rape or risk to life. Brazil maintained the requirement of presenting a formal accusation in sexual abuse cases. As a consequence, there was a drop of as much as 86% in Peru in the number of procedures carried out in 2020.
The same thing did not happen in Colombia or Argentina. Both countries promoted the use of remote consultations for patients seeking abortion during the pandemic. Which is a practice that is aligned with the WHO recommendations since 2012, confirming that self-managed abortion is safe if pregnant women have the necessary information about effective treatment protocols, the correct medication and adequate dose; and access to medical follow-ups, if needed.
Teresa*, a young woman from Bogota, experienced this first hand. She got an appointment to get a termination in a clinic in Bogota. But that day, when she arrived at the medical center, she was informed that her temperature was too high and that they could not let her in. On her way back home, a man offered her a pamphlet of a clandestine abortion service. She rejected it and, fortunately, found Oriéntame’s “home abortions through telemedicine” service online.
She scheduled an appointment that same afternoon and had a one hour online consultation with a doctor that told her about the procedure. The next day, a box of misoprostol arrived at her house, this was the medication she used for her treatment. Sometime after, she had a checkup with Oriéntame. “Why isn’t this alternative publicized more?”, Teresa* remarked. “Other women could have access to safe abortion, from their home. By doing so we would not have to run so many risks”.
“IN 2020, ECUADOR, PERU, CHILE AND URUGUAY REGISTERED A DROP OF UP TO 86% IN THE NUMBER OF LEGAL TERMINATIONS OF PREGNANCY PERFORMED”.
This pandemic leads us to ask many questions about the effectiveness of the adopted measures and the intensification of barriers to access reproductive health services. Above all, we question the lack of attention in marginal urban neighborhoods, the impact confinement has had on violence within the home, and how vulnerable populations, such as migrant and indigenous women, have been forgotten.
The indicators for reproductive health in the context of this health emergency make it clear that the States need to guarantee the continued operations of reproductive health services during whatever is left of the pandemic. And, at the same time, they show the need to update legal abortion protocols, to avoid forced pregnancies; a situation that is recognized as a violation of human rights. Especially, when there is a predictable impact on the physical or mental health of the expectant mother.
Image above: ABORTION. During the pandemic, access to termination of pregnancy for victims of rape was
nearly impossible. Artwork by Leila Arenas
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This would avoid repeating cases like the one of a 10 year old girl in the state of Espíritu Santo (Brazil), who became pregnant after being raped by a family member and had to overcome many obstacles in trying to get access to legal abortion. Her family took her to the city’s hospital, but the doctors refused to perform the termination. Furthermore, they didn’t respect the ruling of the local court, that prescribed an abortion. The girl and her mother had to travel more than 1,400 kilometers, to Recife (in the state of Pernambuco), so that she could be cared for in another public health center.
There was a similar case in Ayacucho, Peru, where a 12 year old girl became pregnant because of rape and not receiving the emergency rape kit on time. Her family asked for the implementation of the therapeutic abortion protocol, because of the physical and mental repercussions for the minor. But the hospital staff refused to carry out the termination. As a matter of fact, a priest and a nun went to the health center to try to convince her not to go through with the abortion. At the end of the day, certain declarations ended up undermining the girls accusations, and she was declared as responsible for the rape.
“What this shows us is that we are having serious difficulties guaranteeing the sexual and reproductive rights of women”, maintained Gladys Vía Huerta, coordinator of Católicas con Derecho a Decidir – Peru, who anticipates a peak in girl’ and teenage pregnancies. “Now, we will see an increase in forced pregnancies in girls due to sexual violence, because, given the context, there are very few therapeutic abortions being carried out. As a matter of fact, we are seeing a drop in the care being provided to persons with chronic diseases, because the healthcare system has collapsed, and maternal mortality increased (…) It is particularly unfortunate that many of these deaths could be avoided”.
El informe completo en español está disponible aqui. Cover image: Leila Arenas
This research was carried out and coordinated by researchers Sonia Ariza Navarrete, assistant in the health area of the Center for Studies in State and Society (Cedes) and Agustina Ramón Michel, law professor in the University of Palermo (Argentina), with the support of journalist Mirelis Morales Tovar, and the backing of OjoPúblico publishing house.
The findings are part of the “Reproductive Health is Vital” study, undertaken by the Latin-American Consortium Against Unsafe abortion (Clacai). All the names of the women affected by the pandemic whose cases are mentioned in this report have been changed to maintain their confidentiality.
