Given the unlikelihood of mother to child transmission, the COVID-19 pandemic should have had minimal impact on childbirth, but the lockdown imposed to curb the virus in the past three months has indirectly led to a rise in maternal deaths in Nepal.
Lack of transportation has meant that pregnant women and mothers have not been able to get pre- and ante-natal care. There has been a sharp rise in home deliveries, and when complicated maternal cases do arrive at hospitals, it is sometimes too late.
Although Nepal’s maternal mortality rate has come down dramatically over the past 20 years, the lockdown has worsened an already substandard maternal healthcare system especially in rural areas.
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Srijana Khanal is five months pregnant and had recently visited Patan Hospital for her first dose of the Tetanus-Diptheria (TD) vaccine. She waited for three hours before giving up. She was too hungry and none of the teashops or restaurants close by were open because of the lockdown.
“I went back the next day but it was even more crowded so I went to a private hospital and got the shot,” she says, adding that because of her pregnancy and the pandemic, she has become paranoid of strangers touching her, even unintentionally.
Gita Thapa is seven months pregnant. She has not been able to go to a hospital in Kathmandu for her second dose of the TD vaccine due to the continued restrictions on movement.
“I was expecting the lockdown to open but instead, the coronavirus infection is spreading even more,” says Thapa. “I don’t own a vehicle to go by myself, and I’m also scared of going to hospitals due to the higher risk of coronavirus there.”
Two doses of TD vaccine are recommended for all pregnant women at intervals of a month each after the second trimester. The vaccine is essential not only to the health of the newborn child, but also to meeting the targets set by UN Sustainable Development Goal 3, which Nepal has committed to.
However, more than three months into the lockdown, pregnant women across the country are having a hard time visiting health facilities for regular check-ups, thereby losing access to essential supplies of iron, calcium, folic acid pills, and recommended vaccine shots.
Kusum Kafle of Jhapa is four months pregnant but has not been able to go for a check-up and find out about the condition of her baby. She has had to buy iron pills otherwise free-of-cost during normal times. “Health wise, I’m fine, but without regular check-ups, I’m afraid for my baby,” she says.
Health facilities across the country, already under-equipped and dealing with the pressures of the COVID-19 outbreak, are now running out of their stock of essential prenatal medication. Their efforts to provide check-ups and consultations to pregnant women are hindered by the restrictions placed to prevent the spread of COVID-19.
Shanta Khanal, who works as a female health volunteer in Arjundhara of Jhapa district, says she has not been able to supply patients with essential medicines due to the lockdown. “But I still provide consultations to pregnant women in my community,” she adds.
Pawan Sharma at the Patan Academy of Health Sciences (PAHS) advises expecting mothers not to visit the hospital unless required and to get necessary consultations via phone or online platforms.
“If a woman is experiencing a normal pregnancy, I recommend that they stay put at home with a balanced diet and basic exercise,” says Sharma who has been providing consultations to expecting mothers via PAHS’ Viber service. “Visit nearby health clinics for blood pressure check-ups and iron pills. And if one must visit a hospital, masks, sanitiser, and physical distancing are a must.”
Jogendra Gautam, director of the Paropakar Maternity Hospital in Kathmandu says, “We recommend pregnant women to visit the hospital only in the case of emergency or for the TD vaccine. Otherwise, we have set up a toll-free number for telephone consultations.”
Traffic restrictions and the continued ban on public transport have rendered pregnant women immobile, causing a spike in deaths caused during childbirth. UN estimates show that roughly, a woman dies in childbirth every two minutes around the world – a bulk of these deaths in developing countries.
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However, Nepal is considered to be a success story in improving survival rates for childbirth. Between 1990 and 2015, Nepal reduced its maternal mortality ratio from 901 deaths per 100,000 live births to 258. It had gone down further since, but there has been a spike in maternal and neonatal mortality across the country that threatens to undo the progress.
The situation is worse in remote areas where hospitals are few and far between, and communities are plagued by regressive patriarchal values, coupled with a lack of awareness about reproductive healthcare.
Bayalpata Hospital in Achham district recently persuaded a patient who lived 7 hours away to stay at the hospital for her childbirth. She gave birth to healthy twins. However, such positive outcomes are rare during the lockdown.
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“Delays in getting the pregnant women to hospitals has been a major reason for maternal mortality in the mountains of Nepal and this is exactly where the lockdown has hit the hardest,” says Bikash Gauchan, healthcare director at Bayalpata.
There have been at least 30 reported maternal deaths nationwide in the past two months, and this is much lower than the average because fewer mothers are doing institutional delivery because of the fear of coronavirus.
“Maternal deaths have gone up dramatically during the lockdown, most of them cases of excessive bleeding, ruptured uteruses, and infections directly linked with (the) inability to access birthing facilities due to the lockdown,” says Punya Paudel at the Family Welfare Division.
Although the Ministry of Health and Population has come up with interim guidelines to alleviate the detrimental effects of COVID-19 on reproductive healthcare, but public health experts fear the mass movement of returning migrant workers across the country will continue to impact many pregnant women among them.
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With additional reporting by Sonia Awale