Dr Natalia Kanem, executive director of the UN Population Fund (UNFPA), warned that the coronavirus outbreak has “severely disrupted” access to sexual and reproductive health (SRH) and gender-based violence (GBV) services “at a time when women and girls need these services most”.

Among the risk groups she identified are pregnant women who need antenatal care but are unsure whether to attend a clinic, and women in abusive relationships trapped at home during the lockdown.

Data available on the impact of COVID-19 on pregnant women is currently limited, with no suggestion of increased susceptibility or of vertical (mother-child) transmission.

However, aid organisations working in so-called "weak health systems" – defined by a high maternal mortality ratio (MMR) – are drawing lessons from the 2014-16 Ebola epidemic in Liberia, Guinea and Sierra Leone. A huge surge in MMR was recorded during and after the outbreak, as women stayed away from medical facilities due to quarantine restrictions or misconceptions about virus transmission, and were forced instead into riskier home births.

In 2015, the UNFPA projected the outbreak would cause 120,000 preventable maternal deaths – more than 10 times the number killed by the disease itself (which totalled roughly 11,310). In addition, vaccination programmes against TB, measles and yellow fever lost ground, as new mothers declined to attend postnatal appointments, with attendance levels failing to recover once the epidemic had passed.

Kanem states that preparedness will be key in dealing with the pandemic’s knock-on effects. The UNFPA is pressing for the full maintenance of sexual and reproductive health services during the COVID-19 outbreak, which should include antenatal and postnatal care, access to modern contraception and emergency contraception, and safe abortion and post-abortion care "to the full extent of the law" in all areas where services are likely to be impacted. The organization is currently working to pre-position emergency reproductive health kits in areas likely to be affected.

It is also calling for priority testing of pregnant women with COVID-19 symptoms, isolation of pregnancy wards from confirmed COVID-19 cases, an elevation of care for any pregnant women with respiratory illnesses, and extra care for all women in delivery, in case breathing complications should arise.

Another chief area of concern is the medical frontline, where women make up an estimated 70% of the world’s global health and social sector workforce. In many cases, their safety is being compromised through contact with high-risk environments and a lack of personal protective equipment (PPE). Adequate psychological support is also essential at a time of high stress for health workers, says the UNFPA.

Away from a clinical setting, the pandemic is widely predicted to exacerbate existing financial inequality between men and women. Globally, women are more likely to hold precarious or vulnerable jobs, which are often the first to be lost during financial shocks. Meanwhile, single parents who need to work and earn money may be prevented from adhering to social distancing measures.

At a time when nations across the world are implementing "stay at home" measures, the UNFPA warned that women are more likely to shoulder higher proportions of the domestic burden during lockdown. Rising tensions due to economic losses could lead to a spike in domestic violence behind closed doors – during a period when counselling and support services may be stripped back to a minimum. The organization also warned of a potential rise in female-genital mutilation, as well as early, child or forced marriages at this time of restricted movement, poor visibility and weakened protection systems.

Often in a pandemic, resources are funnelled away from sexual and reproductive health services towards targets perceived to be more pressing. The UNFPA has vowed to fight this tendency.

"Safe pregnancies and childbirth depend on functioning and accessible health systems," it says.

The organization is already providing support to China, Iran and the Philippines in the form of hygiene items for the vulnerable and PPE for health workers and midwives. In Moldova, it has launched an online dashboard for the health system that shows the caseload grouped according to location, sex, age and pregnancy status.

But in order to avoid the sort of catastrophic collateral effects seen in west Africa during the Ebola outbreak, the UNFPA acknowledges the need to do much more. Priorities include ensuring continued access to family planning care, bolstering supply chains at a time of closed borders and weakened productivity, and targeted information campaigns about the transmission of COVID-19.

After the Ebola outbreak, maternal mortality rates in Sierra Leone soared, back to the grim high points observed in the 1991–2002 civil war. The country stepped back in time – and is still fighting to recover. In 2015, one health worker said he feared the impact would be “everlasting”.

“We think the collateral damage of the epidemic is higher than the damage caused by the epidemic itself,” said gynaecologist Séverine Caluwaerts of the Institute of Tropical Medicine in Antwerp at the time.

The race is on to ensure the same is not true for women when the full effects of COVID-19 become clear.

The evidence suggests that men might be more vulnerable to the virus itself – but women will shoulder the lion’s share of the health impact.
Image: Reuters/Dinuka Liyanawatte