Childbirth in the Pandemic How COVID-19 Is Indirectly Killing Mothers and Babies

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Traditional birth attendant Emily Owino, left, cuts with a razor blade the umbilical cord of newborn daughter Shaniz Joy Juma after she was delivered by her mother Veronica Atieno, center, in Emily's one-room house during a dusk-to-dawn curfew, in the Kibera slum of Nairobi, Kenya in the early hours of Friday, May 29, 2020. Kenya already had one of the worst maternal mortality rates in the world, and though data are not yet available on the effects of the curfew aimed at curbing the spread of the coronavirus, experts believe the number of women and babies who die in childbirth has increased significantly since it was imposed mid-March. (AP Photo/Brian Inganga)

Since the beginning of the pandemic, the rate of death among women and infants during or shortly after birth has risen considerably. The virus has caused shortages in hospitals, and led many women to avoid seeking help.

By Anne Backhaus und Sonja Peteranderl

For our Global Societies project, reporters around the world will be writing about societal problems, sustainability and development in Asia, Africa, Latin America and Europe. The series will include features, analyses, photo essays, videos and podcasts looking behind the curtain of globalization. The project is generously funded by the Bill & Melinda Gates Foundation.

It’s shortly before midnight on May 29 when Brian Inganga gets the call. “You have to hurry,” the midwife tells him. The 31-year-old photographer immediately jumps on a motorcycle taxi and heads to Kibera, a slum in Nairobi, the capital city of Kenya. Inganga is anxious, not only because the slum is “dark and dangerous,” as he puts it, but because it’s after curfew and “the police are extremely aggressive at night.”

The midwife picks him up on a street corner and leads him through the narrow alleyways to her small shack. On the floor of a tiny room inside lies Veronica Atieno, 23. Her contractions are strong.

In the hours that follow, Inganga takes photos as the mother gives birth to her daughter, Shaniz Joy Juma. There are no doctors or medical supplies present, just a wooden spoon for the mother to bite on and an herbal mixture from the midwife for the pain. “It was a shocking experience,” says the photographer over the phone, as he relates the story behind the photos. “Our women can’t go to the hospital to give birth. They lie on the filthy ground and are deeply afraid.”

Brian Inganga wanted to document such a birth because he is worried. He grew up in Kibera himself and knows what it means to live in a slum. “Poverty and danger,” he says. “And now, everything has become even more difficult. The corona crisis is a threat to women. Many have become pregnant against their will because it is almost possible to find contraception, or they were abused at a young age. And women giving birth face great dangers and have no one to turn to.”

Even before the pandemic, Kenya had one of the highest maternal mortality rates in the world. Although there is hardly any data available yet for 2020, experts and aid organizations believe that the number of women and babies who die during or shortly after birth has risen significantly – not just in Kenya, but around the world.

study by Johns Hopkins University, based on mathematical modeling for 118 countries, forecast a worst-case scenario with the additional deaths of 1 million infants and 56,700 mothers in 2020 because of the pandemic. “It is currently difficult to get precise numbers,” says Rebekka Frick, a 43-year-old health expert with Save the Children. “The true effect of the pandemic on the mortality rates of mothers and infants will only become clear in a few years.”

“We are more than concerned. That is in part due to reports that we have received from countries like Kenya and Bangladesh, but also due to our knowledge of developments that other epidemics have triggered.”

In the first published study on the influence of the lockdown on births, an international team of scientists analyzed data from nine hospitals in Nepal. They found that the country’s lockdown led to a reduction of hospital births of almost 50 percent. Stillbirths and infant deaths rose over the same period by roughly the same amount.

Similar numbers are expected for many other countries. “We are more than concerned,” says Frick. “That is in part due to reports that we have received from countries like Kenya and Bangladesh, but also due to our knowledge of developments that other epidemics have triggered.”

Seven Dead Infants in a Single Night

In some countries in Africa, medical professionals are already sounding the alarm. In Central Hospital, located in the Zimbabwean capital of Harare, seven babies died during childbirth on a single night in late July. A doctor tweeted a photo of the infants, lined up next to each other and wrapped in cloth.

Doctors in South Africa told the BBC that the maternity ward in the Dora Nginza Hospital in Port Elizabeth is completely overwhelmed. “Several mothers and infants have died” and hospital personnel are “deeply traumatized.”

In both countries, the deaths were partly blamed on severe staff shortages. The majority of health-care workers must focus on treating COVID-19 patients or have been infected themselves. Others are on strike out of fear for their health – due to shortages of protective equipment like masks and gloves. Disinfectant and medicines are also in short supply due to delivery problems. Pregnant women are often forced to wait for days for urgent operations and they frequently cannot be helped in emergency situations or during birth.

“The consequences of the pandemic are catastrophic,” says Emma Ingaiza, 32, who works for an NGO called Shining Hope for Communities in Kenya. She has been working almost constantly since the beginning of the corona crisis, helping people in need, including many pregnant women.

Ingaiza has also read reports recently about the unusual number of stillbirths and mothers dying during birth. “Everyone is panicked due to the coronavirus,” she says. “All protective measures and almost all remaining medical personnel are focused on COVID-19. Pregnant women, mothers and babies are suffering as a result.”

In Kenya, she says, some medical facilities where up to 30 children were born every night prior to the coronavirus pandemic have had to close due to a shortage of personnel. Women whose contractions begin in the evening, she says, are afraid to leave their homes due to the brutality with which the police have been enforcing the coronavirus curfew, which has been in place since mid-March. Several people have been beaten by the police, she says, because they were outdoors at night. “Including a man who wanted to drive his pregnant wife to the hospital,” says Brian Inganga. “That kind of thing gets around quickly.”

In many cases, this has meant home births, with a midwife present in the best-case scenario. But midwives have also had trouble keeping up with demand of late. “Sometimes, they are trying to care for three women with strong contractions, but only have a single pair of gloves,” says Inganga, the photographer, who has been in close contact with several midwives in Nairobi for weeks. “What are they supposed to do then?”

Midwives in Germany and other wealthy countries have noticed that the limits on social contact and the resulting forced inactivity during the pandemic have been good for many mothers-to-be. One study found that the drop in premature births and other complications is linked to, among other things, lower stress levels.

But in many other countries around the world — particularly in poorer ones, where there was a shortage of life-saving medical care for mothers and infants even before the coronavirus pandemic — there are concerns about rising maternal and infant mortality rates. The World Health Organization (WHO) defines maternal mortality as a situation when a mother dies during pregnancy or up to 42 days after giving birth. Infant mortality refers to deaths during the first 28 days of life.

For many aid organizations and scientists, numbers from comparable, past epidemics are important indicators for where we stand now. The West African office of the United Nations Population Fund (UNFPA) has issued guidelines based on the lessons learned from the epidemics seen since 2003. During the Ebola epidemic, for example, which wreaked havoc in Guinea, Sierra Leone and Liberia from 2013 to 2016, constraints on medical care led to an alarming rise in maternal mortality.

UNFPA is thus recommending that the new COVID-19 crisis teams established in many countries increase their focus on women’s health issues.

Mothers and Babies Contract the Virus in Hospitals

An additional problem is ensuring that the health checkups that generally take place before and after birth actually happen. “In many countries, women are no longer coming to the hospitals because they are afraid of corona,” says Rebekka Frick of Save the Children. “They hear that many people are dying there, and they want to protect themselves and their babies.”

Hilda Argüello Avendaño, a doctor with Observatorio de Mortalidad Materna, an NGO monitoring maternal mortality, says that in Mexico, too, this fear has led pregnant women with complications to only seek hospital care as a last resort. Eight children, including four newborns, recently got infected with the coronavirus in a hospital in Oaxaca.

“In Mexico, the pandemic has become the primary cause of maternal death,” says Avendaño. Compared to the same period last year, she says, the death rate of mothers has risen by more than 25 percent. By the beginning of August, there were 97 cases of women infected with the coronavirus dying during pregnancy or shortly after giving birth.

In around half of those deaths, existing conditions like obesity, diabetes or high blood pressure played a role. The pandemic, though, has revealed social inequalities in the country: Mothers-to-be who do not have insurance and are forced to rely on free state health care face an especially high risk of dying, say doctors, in part because they receive worse care or because care comes too late.

The decision to forego a visit to the midwife, the doctor or the local clinic doesn’t just have direct consequences for the birth. “Many vaccinations and checkups, both before and after giving birth, are omitted completely,” says Rebekka Frick. “That will have horrific consequences and put great strain on health systems for some time to come.”

Whether measles, tuberculosis or malaria, coronavirus threatens to significantly hamstring efforts to combat other life-threatening diseases around the world. Medical professionals and NGOs are concerned that millions will die in the coming months and years not from of the coronavirus, but from its consequences – or from other, treatable diseases, because, for example, they avoid going to the doctor for a simple vaccination.

Huge Advances in the Last 20 Years

That is particularly tragic given the huge advances many countries have made in recent decades in lowering mortality rates. Since 2000, deaths among children have fallen by 40 percent while maternal mortality has plunged by more than a third. Those reductions in the infant and maternal death rates are an important element in achieving the third goal of the UN’s Sustainable Development Goals: “Good Health and Well-Being.”

For this to occur, however, much more attention must be paid to the health of mothers and infants around the world, and governments must avoid neglecting basic medical treatment alongside the treatment of COVID-19 patients.

In countries like Mexico, there are calls for home births to be better regulated and for them to be state financed. Women in Mexico currently must pay for midwives themselves. Several aid organizations argue in favor of additional mobile intervention teams that could also locate pregnant women in isolated communities in order to provide them with medication and information or, in case of emergency, make it possible for them to be transported to a hospital.

Brian Inganga, the photographer, wants to accompany the small girl whose birth he witnessed with his camera in the coming years. Shaniz Joy Juma is now two-and-a-half months old. “I’d most like to photograph her when she finishes school,” says Inganga. “I hope she doesn’t get sick.”

Der Spiegel

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