TWO STEPS FORWARD, FOUR STEPS BACKWARD; THE IMPACT OF COVID-19 PANDEMIC ON MATERNAL HEALTH CARE RIGHTS IN UGANDA
By Muwanguzi Robert (Ph. D), Ayeranga Godfrey and Miyienda Pauline
The outbreak of the Coronavirus (COVID-19) saw Uganda adopt strict measures such as a nation-wide lockdown, ban of private and public transport and curfew. Such drastic measures largely ignored the maternal, sexual and reproductive concerns of vulnerable Ugandan women, especially pregnant women in need of continuous access to Maternal Health Care services (MHSs) leading to an increase in maternal and newborn / unborn deaths.
This paper seeks to analyze the impact of COVID-19 on access to maternal health rights in Uganda, and the long-term effects of the government’s response towards COVID-19 on maternal health care in Uganda. To assess the impact of COVID-19 on maternal health care rights in Uganda, the authors anchored this study on an analysis of reports from government bodies, inter-governmental agencies, media outlets and academic publications. There is evidence that the outbreak of COVID-19 coupled with government instituted measures and restrictions, led to delays by pregnant women and other women with unique needs, in accessing maternal health care services, due to reduced or unavailable access to health care facilities.
The findings of this paper predict an increase in maternal morbidity emanating from COVID-19 related government measures and a subsequent regression in previous gains made by the Ugandan government in improving maternal health care services, standards and facilities.
The outbreak of the deadly Corona Virus (COVID-19) saw Uganda adopting strict measures aimed at containing its spread. Uganda introduced measures like the nation-wide lockdown, curfew and restrictions on use of private and public transport. These rigorous measures ignored the vulnerability concerns of Ugandan women, regarding their sexual and reproductive well-being, and the special needs of pregnant women in need of continuous access to Maternal Health Care services (MHCs).
This paper seeks to analyze the impact of COVID-19 related measures on access to maternal health care services and the enjoyment of maternal health care rights in Uganda. The study is pursued through a desk-top review of existing literature from governmental and inter-governmental agencies, media outlets, and academicians.
The health of a woman during pregnancy and at childbirth was not a focus for policymaking, research and programming until 1985, when a seminal paper provocatively entitled “Maternal health – a neglected tragedy: Where is the M in MCH (Maternal and Child Health)?” was published by Alan Rosenfield and Deborah Maine. In the paper, the authors called upon multi-lateral agencies, particularly the World Bank, to prioritize the essential and worthy maternity care, considerably reduce maternal morbidity and mortality and prenatal mortality as well as encourage contraceptive practice. In the same year, the first International Decade for Women culminated into the widely cited WHO estimates that approximately 500,000 women died annually from obstetric complications.
Another seminal paper, “Too Far to Walk: Maternal Mortality in Context” published in 1994 laid out the three principal delays in health seeking behavior among resource poor women which triggered policy makers to address these pragmatic challenges faced by women. The global UN conferences of 1994 International Conference on Population and Development, and the Fourth International Conference on Women in 1995gave strong affirmations of the basic human right for women to have access to quality and comprehensive maternal and reproductive health care. Since then, maternal health became a global concern as the lives of millions of women in the reproductive age can be saved through maternal health care services.
In as far as this paper is concerned, the term “Maternal health” refers to the health of women during pregnancy, childbirth and the postnatal or postpartum period. Maternal health consists of family planning, pre-conception, antenatal, delivery, prenatal, and postnatal care services.
1.3 A SYNOPSIS ON THE COVID-19 PANDEMIC
On 31 December 2019, the Wuhan Municipal Health Commission in Wuhan City in China reported a cluster of 27 pneumonia cases with a common reported link to Wuhan’s Huainan Seafood Wholesale Market, a wholesale fish and live animal market. However, on 9 January 2020 China found that the novel Corona Virus (SARS-CoV-2, the virus causing COVID-19) was the causative agent for 15 of the 59 cases of pneumonia. By 20th January 2020, there were reports of confirmed similar cases in Thailand, Japan and South Korea; later to spread out globally with devastating human effect.
Uganda reported her first COVID-19 case on 21 March 2020 and eight more cases by 23rd March, emanating from Ugandans who had travelled back from Dubai. This later led to a number of drastic measures from the government to wit, the suspension of both public and private with a requirement that anyone planning to move to access health care services, had to contact their Resident District Commissioners (RDC) for permission. On 30 March, the President declared a nationwide curfew from 7 pm to 6:30 am to curb the spread of the disease.
1.4 THE LINK BETWEEN MATERNAL HEALTH AND HUMAN RIGHTS
Human rights are simply entitlements accruing to all human beings by virtue of their inherent dignity. The respect of dignity of human life is central to the realization of human rights. In as far as maternal health is concerned, dignity is conceived within the realms of:- dignity in respect of person, dignity in relation to an individual as connected with their community and respect of dignity ensured by government and health care institutions.
Maternal health care rights are rooted in the rights of life, health, equality and non-discrimination in-order to attain the highest attainable standard of health.  The right to life comprises of reproductive rights, including maternal health. Maternal health without discrimination and respect of dignity enables women to claim their full set of human rights in order to live the healthiest lives possible.
1.5 LEGAL FRAMEWORK GOVERNING THE RIGHT TO MATERNAL HEALTH CARE IN UGANDA
1.5.1 International Legal Framework: The Soft Law
The Universal Declaration of Human Rights (UDHR) provides that everyone has the right to an adequate standard of living necessary for the enjoyment of their health and well-being. This provision includes the right to medical care, such as maternal health care.
The Programme of Action of the International Conference on Population and Development which was adopted in 1994 in Cairo, Egypt requires states to develop policies and programs aiming at advancing the enjoyment of reproductive health rights by all people, which definitely includes maternal health care rights.
The Beijing Declaration and Platform for Action calls upon governments to increase women’s access to affordable, appropriate quality health care, information and related services by providing more accessible, affordable and available primary health-care services of high quality, this includes sexual and reproductive health care, which comprises of family planning services and information, maternal and emergency obstetric care.
The previous Millennium Development Goal 5 was focused on the improvement of maternal health, as it set the targets of reducing maternal mortality by 75% and achieving universal access to reproductive health by 2015. The United Nations Sustainable Development Goals (SDGs) Goals 3 and 5 speak directly to the issues of good health and well-being, and gender equality respectively.
1.5.2 International Legal Framework: The Hard Law
Uganda is a party to several international and regional human rights instruments like; the International Covenant on Economic, Social and Cultural Rights (ICESCR), the Convention on the Elimination of All Forms of Discrimination against Women (CEDAW),and the Convention on the Rights of the Child (CRC), which all recognize the right to health, that includes the right of access to maternal health care.
The ICESCR recognizes that every individual has the right to enjoy the highest attainable standard of health, not forgetting physical and mental health. The Committee on Economic, Social and Cultural Rights (CESCR) has noted that the right to health encompasses sexual and reproductive health, which includes maternal health care. It compels member states to adopt steps aimed at the full enjoyment of this right, while undertaking medical services to the sick and reducing infant mortality. In addition, Article 10(2) requires states to ensure that mothers are accorded special protection for a reasonable period both before and after child birth while recognizing the right to paid leave or leave with adequate social security benefits to working mothers during such times.
The CEDAW requires states to ensure that all persons have access to health services without discrimination counting maternal health care services, this obliges states to ensure that women have access to appropriate services during pregnancy and post-natal. It also protects the other rights related to pregnancy such as maternity leave, and maternity education, which enhance access to maternal health care with time. CEDAW has recognized health care as a basic human right, which comprises of reproductive health.
Lastly, the CRC governing children’s rights guarantees all children the right to the enjoyment of the highest attainable standard of health. It calls upon states to reduce infant and child morality and ensure that mothers have access to appropriate pre-natal and post-natal health care.
1.5.3 International Legal Framework: The Regional Laws
The African Charter on Human and Peoples’ Rights (African Charter) guarantees the right of everyone to the best attainable state of physical and mental health, including the right to maternal health care and obliges states to provide medical care to its nationals whenever they are sickincluding women in need of maternal health care.
The Protocol to the African Charter on Human and Peoples’ Rights on the Rights of Women in Africa (Maputo), guarantees women’s rights to sexual and reproductive health requiring states to respect, protect and promote this right. The African Commission has recognized that sexual and reproductive health is a key component of women’s right to health.
1.5.4 National Legal Framework and Policy
1). The 1995 Constitution
The right to maternal health care is not expressly stipulated under the 1995 Constitution. However, the Constitution contains National Objectives and Directives of State Policy (NODSPs) plus substantive constitutional provisions seeking to promote and protect the right to health, which in turn helps to achieve the right to maternal health care in Uganda. The NODSPs compel the government to ensure that all Ugandans have access to health care services and basic medical services, including maternal health care services and recognize the role Ugandan women play in society.
Article 21(4) requires parliament to pass legislations that seek to enforce policies and programs aimed at reducing societal imbalance emanating from the existing societal inequalities. Through such legislation, gender inequality will be limited, thereby increasing access to maternal health care for all Ugandan women as gender inequality is one of the major causes of the high maternal mortality rate in Uganda.
Article 33 recognizes a variety of women’s rights and obliges the government to protect women’s rights including those emanating from their maternal functions in society, thereby recognizing maternal health related rights and recognizing the unique status of women in society since it is them that bear children not men. The Constitution also guarantees the protection of other human rights not expressly laid out in the Constitution,not forgetting the right to maternal health care.
2). National Health Policies
The 2010 National Health Policy is the primary policy regulating government planning aimed at ensuring that Ugandans obtain a good standard of health. The policy proposes the minimum health care package that seeks to introduce the most cost-effective priority healthcare interventions and services, aimed at addressing the high disease burden with minimum health package in maternal and child health. The 2004 National Adolescent sexual and reproductive health policy seeks to ensure that adolescents have access to good quality and cheap health services and information,eradicating gender violence and inequality and guaranteeing the protection of adolescents’ right to health. This policy is in line with the state’s duties under the African Youth Charter which requires states to ensure that the adolescents have access to youth friendly health services, and formulate a youth policy.
The Second National Development Plan is the main state framework governing the government’s planning process. The plan seeks to promote the use of health care facilities and skilled birth attendanceso as to reduce maternal mortality rate through increasing access to skilled birth attendants, emergency obstetric care, antenatal care, post-natal care and provision of universal access to family planning.
1.6 THE STATE OF MATERNAL HEALTH CARE IN UGANDA PRIOR TO OUTBREAK OF COVID-19
In comparison to many African countries, Uganda has progressively improved its performance on the metrics of maternal and neonatal mortality. According to the Uganda Bureau of Statistics, as of end of 2019, the infant mortality rate stood at 43 deaths per 1,000 live births down from 54 deaths per 1, 000 live births in 2011; the under-five mortality rate was at 64 deaths per 1,000 live births down from 90 deaths per 1,000 live births in 2011; 73% of births were delivered in a health facility an increase from 57% in 2011; 60% of pregnant women attended antenatal care (ANC) visits for at least four (4 )or more times as recommenced during their entire pregnancy an increase from 48% in 2011; and the percentage of child births attended to by a skilled health professional had increased over the years, from 39% in 2001 to now 73%.
Despite the above gains, the country has been slow in realizing SDG 5 targets of fully improving all dimensions of maternal health. Uganda’s MMR is still one of the highest in the world as one woman out of every 49 die of a maternal complication. At least one woman out of every 49 die of a maternal complications related to pregnancy or delivery.According to the last conducted Uganda Demographic Health Survey of 2011, it was revealed that maternal mortality is the leading cause of death among Uganda’s women of childbearing age with over 80% of all maternal deaths being as a result of: severe bleeding (mostly bleeding after childbirth), infections (usually after childbirth), high blood pressure during pregnancy (pre-eclampsia and eclampsia) and unsafe abortion among others. There are also concerns about the affordability of maternal health care services since “out of pocket expenditure in the health sector contributes to up to 70% ranging from informal “under the-table” payments to health workers to buying prescribed medication from private health facilities, a feature of many nominally free health services”; a practice that tends deny and discourage would be patients in accessing health care services and resulting into death of patients.
It is therefore evident that although the country was not at its best before the pandemic outbreak, there had been progress in maternal health care standards.
1.7 IMPACT OF THE COVID-19 PANDEMIC ON MATERNAL RIGHTS IN UGANDA
According to the International Planned Parenthood Federation, the COVID-19 pandemic is a health crisis in the sexual and reproductive healthcare, since millions of females have needs that can’t wait, but are facing accessibility challenges to health care facilities and contraceptives. It is estimated that up to 47 million women in 114 low and middle income countries may not be able to access modern contraceptives, 7 million unintended pregnancies were expected to occur as the lockdown carried on for extra months and an additional 2 million women could fail to access modern contraceptives.
Regarding Uganda, COVID-19 measures came at a time when it was still grappling with challenges connected implementing a multiplicity of healthcare strategies. For many vulnerable women, the requirement to seek RDC permission, it presented challenges for especially far flung, poor and illiterate women. It was evident that when government required such women to seek for permission from an RDC, to whom she had to provide explanations, it is as good as saying “do not seek maternal health services”. The curfew imposed in Uganda limited women’s ability to travel and access health services when in labour. For instance, it was documented that maternal and new-born death as a result of the lockdown and banned transportation made it difficult for women to reach health facilities in time. For instance, eight babies reportedly died in Namuyingo District, between May and July 2020 as their mothers had arrived late at the hospital facilities.
Deaths resulting from maternal health care complications increased during the initial months of the lockdown. The Ministry of Health reported an increase in maternal deaths, from 92 (January / February) to 115 (March) and 96 (April). In another documented report, seven women in labour and two babies died because they were forced to walk to hospital to give birth due to the ban on private transport in place since March 30 2020. One of the victims, was Scovia Nakawooya’s unborn child who died inside her as she struggled to reach a hospital on foot and died at the medical centre the next morning at the BMC Medical Centre, after suffering a premature separation of the placenta from the uterus. There was also a quite similar but different case in Pallisa District of a 35-year-old expectant mother (named Perepata Atim) and her unborn baby who died after failing to secure an ambulance to take her to hospital to receive urgent medical attention.
Although there was an eventual lift on the ban on public and private transport, the high charges levied on public transport could further lead to poor pregnant mothers, in rural areas resorting to walking to the health facilities which may lead to risks associated with walking long distances to health facilities and in some cases failures/ delays in reaching the health facilities. A relevant example of the above scenario was in Namuyingo District, where some poor pregnant mothers shunned hospitals and resorted to using Traditional Birth Attendants, with dire consequences.
The pandemic also affected the level of utilisation of delivery professionals in health facilities since they were far off, which increased the risk of maternal and new-born mortality occurrences. It has also been reported that a lack of access to contraception services also increased the risk of unwanted pregnancies, with a possible child boom soon which all worsen the existing population pressures. In Mbarara and Kapchorwa Districts, there was a sharp decline in access to contraceptives by patients as Medical suppliers of contraceptives stated that the restrictions on travel made it difficult to ship in emergency contraceptives.
The lockdown brought about the physical and psychological harassment of pregnant women and other women seeking family planning services. The ugliest aspect of harassment has been the physical attack on beating of pregnant women. For example in Kampala’s Rubaga Division, a seven-months pregnant woman, Mercy Nakate was beaten on 27th March by a group of policemen and members of Local Defence Units (LDU) conducting foot patrols, as she was accused of disobeying presidential guidelines on non-movement and non-congregation as it was claimed that she and other people had sought shelter from rain in a makeshift structure used by residents. While others ran away when the patrol team came in and started beating them; she was left behind due to her condition, and was she was hit and kicked despite her cries for mercy.
1.8 CONCLUSION AND RECOMMENDATIONS
While Uganda already started relaxing lockdown and curfew measures, the impact of the measures continues to accelerate. For the poorest and most vulnerable women, the COVID-19 measures represent a fundamental threat to the realization of their maternal health rights. The existing problems with Uganda’s maternal health care system were exacerbated by the government measures instituted to curb the spread of the COVID-19 pandemic. The impact of the COVID-19 pandemic has undoubtedly brought about a worrying situation, that has tested the country’s health system to handle maternal health needs / emergencies. It can be concluded that there is evidence that the outbreak of COVID-19 coupled with government instituted measures and restrictions, led to delays by pregnant women in accessing maternal health care services, due to the restricted access to private and public transportation.
The following recommendations can be made on how future responses to pandemics can be balanced with maternal health care services: –
It is recommended that health facilities should create comprehensive databases of women seeking MHSs for health personnel to travel and access vulnerable women when similar strict measures are instituted. In line with the National Disaster Management Policy, 2010, the Ministry of Health should fast-track the development of a national emergency response strategy, in order to ensure that when future pandemics break out, health facilities are able to respond to MHC needs. Part of this strategy could include the creation of an efficient ambulance system at sub-county level that should respond to emergency calls related to maternal health care needs, especially in times where transport is suspended, lockdowns and curfews are instituted. Other health emergencies strategies could be creating fully facilitated / trained Village Health Teams (VHTs), Traditional Birth Attendants (TBAs) and door-to-door delivery services.
Through a multi-stakeholder approach, government should ensure that MHSs are inevitably available to those that need them, whether the country is in a health crisis or not. This could potentially be done through decentralized health response system made available using local government structures strengthening community-led communications and patient tracing.
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