About 1·8 billion people live in fragile contexts worldwide,
1
including 168 million individuals in need of humanitarian assistance. Approximately
a quarter of those in fragile contexts are women and girls of reproductive age.
2
Experience from past epidemics in these settings has showed that discontinuing health-care
services deemed unrelated to the epidemic response resulted in more deaths than did
the epidemic itself.
3
Issues related to sexual and reproductive health are among the leading causes of mortality
and morbidity among women of childbearing age, with countries affected by fragility
and crisis accounting for 61% of maternal deaths worldwide.
4
Poor health outcomes will surge from the absence or disruption of lifesaving services,
including emergency obstetric and newborn care, contraception to prevent unwanted
pregnancies, and the management of abortion complications. Gender-based violence and
sexual exploitation and abuse might increase during outbreaks because of confinement,
increased exposure to perpetrators at home, economic precarity, and reduced access
to protection services. The care for children and others confined at home further
reduces women's ability to properly care for themselves.
5
In the context of the pandemic preparedness and response, members of the Inter-Agency
Working Group for Reproductive Health in Crises have issued various field guidance
documents on sexual and reproductive health and coronavirus disease 2019 (COVID-19).
Building on the overarching need for humanitarian actors to coordinate and plan to
ensure that sexual and reproductive health is integrated into the pandemic preparedness
and response,
6
there are four prongs on how to mitigate the impact of COVID-19 on mortality and morbidity
due to sexual and reproductive health conditions in crisis and in fragile settings.
First, with the understanding that the risks of adverse outcomes from medical complications
outweigh the potential risks of COVID-19 transmission at health facilities, the availability
of all crucial services and supplies as defined by the Minimum Initial Services Package
for sexual and reproductive health should continue.
6
These services include intrapartum care for all births and emergency obstetric and
newborn care (caesarean sections should only be performed when medically indicated
as a COVID-19 positive status is not an indication for a caesarean section
7
), post-abortion care, safe abortion care to the full extent of the law, contraception,
clinical care for rape survivors, and prevention and treatment for HIV and other sexually
transmitted infections. Early and exclusive breastfeeding and skin-to-skin contact
for neonates should be promoted, and mother and neonate should not be separated unless
one or both are critically ill in cases of suspected or confirmed COVID-19 infections.
7
Second, comprehensive sexual and reproductive health services should continue as long
as the system is not overstretched with COVID-19 case management. For relevant consultations
and follow-up, remote approaches should be considered where feasible (eg, telephone,
digital applications, text messaging). In addition to the Minimum Initial Service
Package, these comprehensive services—ie, all antenatal care, postnatal care, newborn
care, breastfeeding support, and cervical cancer screening, as well as care for individuals
experiencing intimate partner violence—should remain available to all individuals
who need them, including adolescents.
Third, clear, consistent, and updated public health information crafted with representatives
of the targeted audiences should reach the community and health-care workers. This
information should reaffirm that medical complications outweigh the potential risk
of transmission at health facilities and that community members should continue to
seek and receive care during childbirth and for all other essential sexual and reproductive
health needs or emergencies resulting from other diseases, trauma, or violence. The
community should understand that any changes in routine services are for patients'
benefit to ensure support to the COVID-19 response, avert undue exposure to the risk
of contracting the virus in a health facility during the outbreak, or both. However,
the coordination and planning to re-establish such comprehensive services should occur
as soon as the situation stabilises.
Fourth, COVID-19 infection prevention and control precautions, including hand hygiene,
physical distancing, and respiratory etiquette should apply to patients (and accompanying
family members if their presence is necessary). Additionally, staff should be protected
with adequate personal protective equipment. Facilities also need to establish a patient
flow that incorporates triage before entrance into the facility, and an isolation
area and separate consultation room for suspected or confirmed cases.
To minimise preventable deaths, crucial health-care services, including sexual and
reproductive health services, should remain accessible during public health emergencies,
even when resources from already fragile health systems are often redirected for outbreak
response. The COVID-19 pandemic will magnify the risks inherent to resource reshuffling
at the expense of other services; however, sexual and reproductive health cannot be
viewed as a luxury.
8
On March 31, 2020, the United Nations Secretary-General highlighted in relation to
COVID-19 that “we are only as strong as the weakest health system in our interconnected
world”.
9
To echo this statement, we have offered guidance on sexual and reproductive health
and COVID-19, and we call on health authorities to prioritise these lifesaving services
in humanitarian and fragile settings. Such interventions should be considered as indispensable
components of health services that do not strain, but strengthen health systems during
COVID-19 preparedness and response efforts. The collective health of women, girls,
and the wider community depends on these services.