Earlier this week, the world marked International Day to End Fistula. Edith Sifuna , a programme officer in the CPN Programme discusses the condition and how the response to COVID-19 is an opportunity to create awareness about obstetric  fistula.

In May 2020, the World Health Organisation (WHO) declared Obstetric fistula as preventable and can largely be avoided by delaying the age of first pregnancy; the cessation of harmful traditional practices; and timely access to obstetric care. The fight to end fistula, one of the most serious and tragic injuries that can occur during childbirth, could be threatened by the current COVID-19 pandemic. Due to the pandemic, it is expected that 13 million more child marriages could take place by 2030 that would have otherwise as a result of economic pressure. As we marked this year’s International Day to End Fistula under the theme; “End gender inequality! End health Inequalities! End Fistula Now!” it is important that the international community comes up significantly to raise awareness and intensify actions towards ending Obstetric Fistula.

At the beginning of 2020, the World Health Organisation (WHO) confirmed COVID-19 as a public health emergency of international concern. The virus has put a strain on health systems worldwide. Countries including Uganda have put guidelines and directives in place to curb its spread. While these have indeed worked to stop the spread of the virus, they have adverse effects on  public health systems, particularly maternal health.

In the midst of all these efforts, there is a danger that may take many women’s lives or inflict permanent physical and social injury. This seldom talked about danger is obstetric fistula. Obstetric Fistula has been placed among the most neglected components of maternal health during COVID-19 yet it is likely to have a devastating impact on the wellbeing of both women and girls of ages 15 to 49 years. Obstetric Fistula occurs as a result of prolonged obstructed labour, which is usually associated with delays in seeking and receiving appropriate emergency obstetric care. This leads to a hole developing  either between the rectum and vagina or bladder and vagina leading to odour, infertility and chronic infection.

In Uganda, apart from the low quality health care, fistula cases have been on the increase due to different cultural practices such as child marriages for economic gains by the parents/guardians, child prostitution resulting into early unplanned pregnancies, and traditional practices like female genital mutilation. These have highly exposed women within the reproductive age to complications at delivery as their bodies are not biologically ready to support a pregnancy, increasing chances of complicated child deliveries. This has been coupled with high poverty rates, especially among women, which deters access to quality health care services.  

According to a Uganda Demographic and Health Survey (UDHS) report, a reduction in fistula prevalence from three per cent in 2006 to two per cent in 2011 was reported. Notably, 62 per cent of the affected women received treatment. Despite the treatment and efforts to curb the disease, it still affects the health, social, economic and psychological wellbeing of women, gradually affecting their productivity as individuals and the family.

In addition to the effects already mentioned, fistula also leads to inability to hold urine for a long time, persistent abdominal pains, failure to give birth again, low sex drive and discrimination from family, society and premployment.

Despite the fact that Fistula can be prevented and treated, the survivors continue to suffer from shame, rejection, isolation, trauma and stigma from partners and communities even after treatment and recovery. Gender based violence has also been noted to increase as men opt to find other women who are free from fistula. Domestic violence also stems from the economic strain on the family in the form of costs for surgeries to repair the damage, and purchase of recovery materials and equipment like adult pampers and medicines. With this, most Fistula cases go untreated as women are afraid to admit to the condition or too poor to afford the treatment. As women continue staying safe at home, they are likely to give birth at home assisted by traditional birth attendants or while they are trying to access healthcare facilities. These circumstances can lead to obstructed labour.

“COVID19 has increased the effects of fistula due to restricted movement, patients with fistula repairs were not able to access hospitals to have their repairs done as only emergency cases were being handled while others were stranded as they could not go back home after treatment. Fistula cases have increased due to failure to access hospitals early for delivery or antenatal care resulting in obstructed labour complications such as bladder injuries, fistula and morbidity. It was really absurd that a lady lost her baby as she could not reach the nearby health facility in Bussi and receive treatment as a result of restricted movement and she is now suffering from effects of birth complications and fistula. If this woman had accessed healthcare services on time, her baby would have been saved and complications avoided. With the current trend, there will be many cases of women suffering from fistula, childbirth complications and morbidity. It is therefore important that women are given easy access to hospitals despite COVID-19 and the restrictions. Proper structures for management of complications due to obstructed labour should also be put in place. It is important to strengthen community structures to identify, monitor and refer women for treatment.” A Fistula Surgeon!

With all efforts geared towards COVID-19, it is easy to overlook conditions such as fistula. It is therefore necessary that a comprehensive and holistic fistula care and prevention approach is put in place to restore and preserve the confidence and dignity of victims. This can only be realised if the Government and different stakeholders create awareness about prevention and treatment of obstetric fistula in this era, integrating this into the current guidelines. As women continue staying safe at home, they are likely to give birth at home, from Traditional Birth Attendants or along the way while trying to access health care facilities and may be faced with obstructed labour. Health services have become overloaded and maternal health care services somehow neglected as all efforts are geared towards COVID-19.

It is imperative that there is timely access to comprehensive safe delivery services and emergency obstetric care through bridging the unmet need for maternal health care to prevent women from suffering as they perform their natural maternal function. Maternal mortality is a major challenge in Uganda and any set back in the health system will increase the rate at which women die hence the need to come up with quick and effective medical interventions and guidelines for women to easily access health care services to minimize preventable complications due to delay to access health services and information.

In the current COVID-19 situation, it is important that sexual and reproductive health services such as timely obstetric care and treatment for fistula patients are easily accessible. Information on the same should also be available, not to mention the need to strengthen patient referral and follow up mechanisms.

We must therefore stand together to prevent childbirth complications such as Obstetric Fistula. We can do this by providing comprehensive and universal quality maternal health care services and information, and prioritising women with existing fistula conditions in the face of COVID-19. This is because Obstetric Fistula is a serious and potentially tragic condition. A multi-sectoral approach to raising awareness and intensifying actions towards ending it would therefore restore hope, joy and self-esteem among women as they continue performing their maternal right during the COVID-19 pandemic.

We were honored to present Recommendations for the National Health Insurance Bill to the Parliamentary Committee on Health which is currently compiling a report from stakeholder consultations.
The recommendations were derived from a Right to Health analysis made in regards to this Bill.

By the Campaigns, Partnerships and Networks (CPN) Programme – CEHURD

The COVID-19 pandemic in Uganda brings about a worrying situation which will undoubtedly check the quality and ability of our health systems. The pandemic is expected to majorly impact the accessibility and availability of sexual and reproductive health and rights for all Ugandans. The Center for Health Human Rights and Development (CEHURD) is one of the many civil society organisations that are advocating for the advancement of the right to health for the vulnerable communities. This can be achieved by strengthening systems and channels of healthcare service delivery through research, documentation, lobby, advocacy, strategic partnerships and collaborations with respective stakeholders and voices from the rights holders.

In the face of the global pandemic, we commend the Government of Uganda and the Ministry of Health for the different efforts and measures put in place to contain the virus which, among others, include washing hands regularly with soap and water; stopping public gatherings; avoiding touching the eyes, nose and mouth; and closing borders. 

While a lot of effort has been put up in the fight against COVID19, we are concerned that other health matters such as maternal health, mental health and sexual and reproductive health and rights have not been given similar attention. 

The Presidential national address of 21st March 2020, restricted the use of public transport and only allowed private cars. It should be noted that the majority of Ugandans depend on public transport for movement. The additional measures passed by the President in his national address speech on 30th March 2020 that came with a ban of all privately owned cars on the road and required anyone planning to move and access health care services to contact their Resident District Commissioners (RDC) for either permission to move in a private car or access transport to a health center only worsened the situation. Such measures could not adequately address the needs of women seeking sexual and reproductive health services such as antenatal services and family planning services. Further still, during his address on 19th April, 2020, he allowed pregnant women to move to hospital by any available means without seeking permission for the RDCs. Therefore, The Government should ensure that the healthcare system is strengthened and well equipped to handle and respond to all emergencies.

It is the responsibility of all people, civil society organisations and all sectors to contain the infection, reduce transmission and stop the impacts of COVID-19 on sexual and reproductive health. It is our duty to protect and serve the vulnerable, especially the economically constrained who lack access to healthcare. The most vulnerable include women and girls, expectant mothers, adolescent girls and boys, elderly and those with existing chronic conditions like people living with HIV/Aids, cancer patients, diabetics and the hypertensive.

Government therefore, has a role and duty to protect and preserve its people by providing for access to and availability of health care services to the population equitably during this pandemic of COVID-19.

Limited access to reproductive health services

In the face of COVID-19 and the government’s response to it, accessing healthcare services has become a privilege reserved for only a few. Women now have to trek long distances to access the health facilities. This puts the lives of especially expectant mothers at risk, not to mention the babies since there is a possibility of giving birth along the way or resorting to traditional birth attendants since they are within the communities.  The media has reported women giving birth either in institutional quarantine centres or by the road side as they walk long distances to the hospitals. This will definitely see a rise in the number of maternal and child deaths due to lack of access to health facilities. 

Government and other stakeholders should therefore establish alternative, well-coordinated and safe means of transport to allow women access to the much needed healthcare. This coordinated response should be able to address emergencies and avoid the three delays in health according to World Health Organisation guidelines (delay in decision to seek care, delay in reaching care and delay in receiving adequate health care) for both the mothers and the babies to survive. In addition to this, the Government and Ministry of Health should closely work with civil society organizations such as CEHURD to sensitise masses on the referral medical services during COVID-19 lockdown and their right to quality healthcare.

Another challenge that may be faced by expecting women and their families during this current situation is being infected with the Coronavirus as their condition puts them at high risk. This risk is likely to affect their mental health and may lead to unexpected complications during or after child birth. The fear of not being able to get quality and timely healthcare services and information, inadequacy of supplies, absence of healthcare providers and commodities to respond to emergencies and offer specialised services as they are also in panic and fear for their lives, only compounds the problem. Most of the countries that have been supplying healthcare commodities either through donations or imports have been severely hit by the pandemic. This means that there is an anticipated shortage in supply of essential maternal health commodities such as misoprostol, oxytocin, magnesium sulphate and other necessary commodities. This has created a condition of uncertainty for expectant mothers about their lives.

In addition to the expectant women, over three million Ugandans are living with HIV and need to access ARVS mainly on a monthly basis. The lockdown affects those that were due for accessing care. Failure to access ARVs will affect their health, creating a state of ill health. Providing practical ways and allowing people living with HIV/Aids (PLHA) to access their medication freely despite the pandemic will ease the burden on the health care system after the lockdown. .

Health workers and support healthcare providers (Village health teams and Health unit management committees) should be trained and supported to provide health care during the prevailing pandemic. At the same time, they should have access to resources and systems necessary to safely and effectively contain the spread of the virus while giving healthcare to others. This can be done by availing them with reliable and up to date information, safety and protective gear and emergency services such that they are efficient and ready to take care of the expectant mothers, PLHA and other illnesses with confidence and professionalism.

Limited access to family planning services

The lockdown is likely to expose many men, women, boys and girls of reproductive age to a lot of sexual activity.  The chances of accessing and using protection and contraceptives during the lockdown are minimal. Unprotected sex will only expose them to risks of unwanted pregnancies, infection of HIV and STIs and resultant unsafe abortions. 

Already, Uganda is reporting very high rates of unmet needs to family planning. Twenty Eight per cent unmet need is a high number. Although the President committed to having this reduced to 10% by 2022 during the International Conference on Population and Development, the factors enabling this reduction must be in place. We are aware that some women and girls were accessing this service in hiding and the lockdown makes it extremely difficult for them to leave their homes to access the same.

Therefore, effective measures should be put in place to ensure access to and availability of contraceptives and family planning services during the era of COVID-19. Measures including putting up alternative service delivery points, empowering Village Health teams to continue providing services like condoms, and allowing free movement of health service providers to be in position to give the necessary services. . 

Young people’s access to services and information about their sexual and reproductive health needs/ challenges

According to the Presidential directives, schools and learning institutions were shut down. This leaves many young people at home with no access to information about their sexuality or even means to get to the next youth friendly centre for this information and services. It should be noted that the National Sexuality Education Framework for the out of school has never been finalised and nor were the parenting guidelines disseminated and implemented by the Ministry of Gender, Labour and Social Development.

This leaves parents ill-equipped to provide accurate and age appropriate information about their sexual and reproductive health and rights.  For some of these students, they are spending more time with their abusers who also double as their relatives or guardians. This is likely to cause an increase in rape, defilement, incest, teenage pregnancies rates and unsafe abortions and with inability to report these violations or even access services like PrEP and emergency contraceptives.  

Gender based violence

With the lockdown and the shutdown of learning institutions, a lot of violence either mental, physical or sexual has been inflicted against women, girls and boys. There is a need to protect these against any forms of violence that may be as a result of idleness and poverty both at home and in public places like markets.

In Uganda, the majority of homesteads are women headed providing food, education to children, health care and all the basic necessities yet relying on daily incomes from small businesses.  Therefore, if violated and not given access to their sources of income, many families and children may end up suffering from hunger, illnesses, domestic violation and no education in addition to other effects of the COVID-19 pandemic. 

Failure to access food and the quality of food being given out by the Government

With the presence of the COVID-19 in Uganda, a country where the biggest population survives on daily income through informal work, many have become financially constrained during this time. As part of the Government interventions during this pandemic, is to provide free food to such people living on a daily income and those in hospitals. However, the food has not reached most parts of the country and even those who have been able to access it have raised major concerns about its quality.

During this pandemic, being healthy by consuming nutritious foods is paramount thus local food systems should be properly coordinated and managed  to allow for access to safe and clean food and water. As communities are washing hands regularly and maintaining proper hygiene and sanitation to curb the spread of COVID-19, it is important that there is constant supply of and access to clean and safe water. Regulations on price hikes for essential commodities like sanitisers, soap, sugar and food stuffs should be implemented.

Recommendation

It is therefore important that as Government continues to manage COVID-19 crisis, emphasis  be put on essential medical services mainly addressing maternal health. This can be done by stocking and providing healthcare facilities and workers with the maternal life saving commodities (misoprostol, magnesium sulphate, oxytocin and other alternatives) to handle emergencies but also providing protective gears for the health workers to take care of the women during childbirth not putting their lives at risk of acquiring the Coronavirus.

MoH supports the Blood bank to stock blood sufficient enough to serve those mothers who may suffer from hemorrhage while giving birth during this crisis of COVID-19. This is because due to the social distancing, few people may be able to come out and donate blood yet a lot is going out and less is coming in to support women while giving birth.

Health workers and health care facilities should be fully provided for and stocked with adequate essential commodities to address the needs of women and the general public in case of any emergency while controlling the spread of the Coronavirus.

The referral system should be effective and efficient that in case of any emergency the women are referred as soon as possible for specialized services to control deaths while giving birth during the era of COVID-19 in Uganda. Every life matters.

Government collaborates with the private sector to support women with basic health commodities that can be used during child delivery but also after giving birth to maintain proper hygiene for the health care provider, woman and the newborn.

Different institutions to work hand in with the Ministry of Health to create awareness about the effect of COVID-19 pandemic to different parts of the country on the economic, social and health status of the entire country.

Alternative means of ensuring that young people have access to reproductive health and rights information and services should be put in place. The different stakeholders to circulate correct information on SRHR on their various online platforms as this will go along in preventing young people from being misled with myths and misconceptions about their health and reproduction.

Separate toll free lines should be put in place for the public to report non COVID19 related emergencies that require immediate attention and response.

That the Uganda police and all other security agencies stop the violation of human rights specifically women through beating them as they enforce the presidential directives. Every human being should be treated with respect and dignity irrespective of their gender and income status.

All these recommendations should be in addition to the Ministry of Health guidelines, Presidential directives and the WHO guidelines to control the spread of COVID-19 within the country and globally.

A version of this article was originally published in the Daily Monitor.

As the Mental Health Awareness Week winds up, one of our programme officers, Miriam Kyomugisha, shares what she has observed in regard to mental health during COVID-19.

With the outbreak of COVID-19, people’s mental wellbeing was bound to be affected. When the news first broke in Uganda, there was general panic. I remember the day before lockdown, I was heading to work and offered a workmate a lift but I could see vivid fear in his eyes and speech since he was a public transport user. As the news of the global death scale spread there was a lot of anxiety and from the WhatsApp work group chat. Many people were scared to sleep, some said they couldn’t feel their legs. One of my family members claimed he was beginning to feel as though he had the symptoms because of following the news on different TV stations. That indicates the psychological trauma that the news of COVID-19 spread to even people who did not have mental disorders per se. The paranoia of contracting the disease spread like a wild fire.One of the popular memes that has circulated the internet during this period has been one that talks about fear, anxiety and worry killing people even before the virus.

Given the different reactions cited above about COVID -19, one cannot help but wonder about what is happening with the people suffering mental illness already.

One of the measures the Government had to put in place to curb the spread of the virus was a quarantine period which was communicated in the presidential address in April 2020. This quarantine came with restriction of movement of people, lockdown and curfew. Now, most mental disorders do not go well with isolation or being alone. One of the most popular treatments for most mental disorders is being surrounded by loved ones, being busy and basically, avoiding situations that might lead you to be depressed, as this usually escalates the illness. In this lockdown, people have been holed down in their houses, alone, leading to increased levels of depression resulting from all the loneliness.

As a result of the lockdown, there are reports of suicidal attempts caused by depression and loneliness.This is as a result of patients lacking the support and love they would otherwise receive if they had other people. An example that comes to mind is of a young woman in her early 20’s who suffers from PTSD (Post-Traumatic Stress Disorder) after being raped several times. She attempted suicide and was rushed to Nakasero hospital.One of the causes of the attempt was depression caused by the fact that she was alone and dealing with the psychological pain. Also, for disorders like bi polar which is characterized by extreme highs and lows, it is hard for the sufferers to even reach out for a phone and call for help during the low periods and that has been challenging too. Another area in which mental health has been affected is the cancellation of group therapy sessions where most of the patients usually benefit from because as humans, we find it easier to identify and heal with people going through the same thing as we are. These have not been favored by the need for social distancing and the transport restrictions and also the fact that hospitals are concentrating on COVID-19 patients thus leaving the mental health patients hanging.

The COVID-19 restrictions have also limited access to mental health care. I know of a patient with a bipolar disorder who has significantly deteriorated with the lockdown. Her counselor who prefers to treat people in their home setting could not access her because of the transport restrictions. We tried to get her to Butabika National Mental Referral Hospital, a renowned facility that specializes in mental health but we were told they were not admitting patients because of the COVID-19 scare. We also tried a private mental facility in Najjera whose administration explained that they were not admitting for the same reason. What was most baffling was the fact that they were not willing to even first test the patient, they simply turned us away.We luckily got help from a friend who gave me contacts of psychiatrists at different hospitals including Nakasero Hospital which has a reputable psychiatric ward. When I called in to ask about admission, I was told that I would have to pay two million Uganda shillings as initial deposit before admission. Unfortunately, we could not afford it at the time. We resorted to getting some medication to contain her condition as we await the end of the lockdown.

Despite the numerous measures advanced in the COVID-19 response, mental health has not been prioritized. In the medical emergencies that the government has addressed, mental health is not mentioned anywhere but that’s not new. According to the international journal of mental health systems, mental health Services are still significantly underfunded (with only 1% of the health expenditure going to mental health), and skewed towards urban areas. Per 100,000 population, there were 1.83 beds in mental hospitals, 1.4 beds in community based psychiatric inpatient units, and 0.42 beds in forensic facilities. The total personnel working in mental health facilities were 310 (1.13 per 100,000 population). Only 0.8% of the medical doctors and 4% of the nurses had specialized in psychiatry.

Also, important to note is that with people having a lot of time on their hands and not much to do, they have taken to social media, which is one of the leading causes of depression as it promotes false impressions of people living better lives than you are. It basically leads to comparison and its no news that some people have done drastic things like suicide resulting from social media influence.

In conclusion, our society’s failure to take mental health very seriously during this period will most likely lead to increased mental health issues. There should have been publications and sensitisation on how to deal with the same as key issues during this time. Also people who help to treat mental health illnesses should have been facilitated to reach their patients. I also think a safe space for people dealing with mental health issues should have been put in place to enable easy, accessible and affordable mental health care.