Keeping vital health services running in the COVID-19 crises.
UK Med’s Health Advisor and ITC Coordinator in Bangladesh, Melanie Johnson reports on her work improving sexual and reproductive health (SRH) in the Rohingya Refugee Camps, Cox’s Bazar.
The months since the initial surge in COVID-19 cases have been a whirlwind of work for many UK-Med members. In the UK and around the world, the struggle to balance responding to the COVID-19 pandemic with keeping essential health services running has been abundantly clear.
When resources are under pressure, sexual and reproductive health services (SRH) are often one of the first areas to suffer. As part of our response to the pandemic, UK-Med and UK-EMT members have undertaken work to support SRH services to make sure the Rohingya refugee families have access to vital reproductive healthcare.
As UK-Med’s Infection Treatment Centre (ITC) Coordinator working with the International Organisation for Migration (IOM), I supported the SRH team to adapt maternal health strategy to the COVID-19 context and to create safe spaces within the (ITC’s) for maternal care and midwife IPC training. This work has been developed brilliantly by Maureen, a qualified midwife on Team Two.
The scale of response needed:
Of the 3.1million babies born every year in Bangladesh, just under half occur in a healthcare facility. with a maternal mortality rate of 196 per 100,000 (Mahmood et al, 2019).
Concerningly these numbers still do not accurately reflect the difficult maternal health situation in Cox’s Bazar, even less so within the Rohingya camp setting.
It was clear that the scale of response needed, combined with the inability for staff to return from leave in other countries, had left many areas under-resourced, with national staff working full pelt to fill the gaps.
Assessing the impact of the pandemic:
Working alongside Dr Tasnuba Mithila, (SRH Health Officer IOM), it was apparent that SRH services had declined. Inability to meet in large groups meant antenatal clinics (ANCs) and postnatal clinic (PNC) sessions had been cancelled and uptake when they re-opened was limited.
This was echoed in the Primary Health Centre (PHC) birth figures which were soon at around half the expected number.
In normal times primary health facilities were considered an emergency alternative to home birthing. Now rumour and fear were preventing women from attending medical centres. Many were worried about becoming infected or being tested and taken away to isolation facilities against their wishes. With limitations imposed on visits from community health workers it was clear Community Engagement would be crucial for SRH services to continue.
Creating safe delivery facilities within Infection Treatment Centres:
Our first priority was to ensure each ITC could accommodate a space for safe deliveries. We allocated spaces and staff and worked on IPC regulations and maternal patient flows.
Two of our three ITC’s could facilitate maternal wards inside the red zone. This was an obvious compromise since, should a woman present late-stage without known COVID-19 status, we were potentially placing her at risk of exposure. To mitigate these risks we designed stringent IPC protocols and measures.
We trained midwives working within the ITC’s and PHC’s, who had previously not been prioritised due to capacity. Dr Tasnuba turned around a week of intensive training sessions as well as assuring PPE provision to these centres, improving safety for both mothers and staff going forwards.
Our second team, has shifted focus to educating the community about the benefits of visiting the antenatal, postnatal, pre-assessment clinics and hospitals for the support and care that they need leading up to, during and after their babies have been born. This enables teams to identify COVID-19 patients as they attend the clinics’ services.
The team are also working with the Health Outreach Team, going into the community to counsel beneficiaries on SRH services and refer them to IOM clinics as needed.
In summary, our take-away points for camp-setting SRH response within the Covid-19 context would be:
- Don’t make SRH a last option. More than just maternal care, omitting family planning, sexual and gender based violence (SGBV) and other SRH services from a response stores up problems as does the cessation of any primary care or non-infectious disease service.
- Remember ALL SRH staff. Those outside the ITC’s were arguably at more risk than those within in a community transmission scenario due to lower levels of training and facilities planning.
- Community engagement is critical: making it clear to service users that services are still available and will be provided in a safe and considered way.
- Advocacy – where possible, the best option is always to deliver in an appropriate specialist centre rather than an ITC. Our Rohingya maternal population were no more of a coronavirus risk to staff in national delivery centres than any other patient. It is up to us as clinicians and coordinators to advocate for this whenever possible.
Mahmood, I. , Bergbower, H. , Mahmood, A. and Goodman, A. (2019) Maternal Health Care in Cox’s Bazar, Bangladesh: A Survey of Midwifery Experience at Hope Foundation and a Review of the Literature. Open Journal of Obstetrics and Gynecology, 9, 1624-1637. doi: 10.4236/ojog.2019.912158