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COVID-19 and sexual and reproductive health and rights

Associate Professor Linda Bennett discusses the impact of COVID-19, and responses to it, on sexual and reproductive rights and health in Indonesia.
Hi everyone. I’m Linda Bennett and I’m from the Nossal Institute for Global Health at the University of Melbourne. Today I’m here to talk to you about COVID-19 and its impact on sexual and reproductive health and rights.
To give an example what’s happening currently I’m going to talk about the Indonesian experience and demonstrate how government and community responses there are affecting people’s sexual and reproductive health and rights. And because learners in this course are a global audience, I’m just going to begin by giving you a few facts about Indonesia and its COVID-19 experience. The Republic of Indonesia is the fourth largest nation in the world and it’s home to 270 million people It’s situated in Southeast Asia and is now classified as a low middle-income country. Indonesia’s Human Development Index is currently 0.707 and the average life expectancy at birth is 71.5 years.
On April 13th this year, Indonesia’s current president Joko Widodo declared the spread of COVID-19 to be a national disaster. From this point onwards, the government diverted key health system resources such as health workers and health facilities to focus on the COVID-19 response. And introduced social distancing and quarantine. To date, Indonesia is experiencing amongst the highest documented rates of COVID-19 related fatalities in Southeast Asia as well as very high rates of health worker fatalities. In June this year, a collaborative project between Atmajaya University in Jakarta and the Nossal Institute for Global Health in Melbourne began documenting the nature of COVID-19 impacts on social and reproductive health in two Indonesian cities.
Over two months we’ve interviewed 18 people including health and community workers who are all engaged in sexual and reproductive health provision. To ascertain how their routine services they offer have been affected by COVID-19. So this presentation draws on their experiences as well as relevant secondary data
So the immediate and long-term impacts of COVID-19 on sexual reproductive health are really best understood as a combination of supply and demand side factors. And on the supply side, or the health system side, the reallocation of health workers to the COVID-19 response has had a range of impacts in different geographical locations with the impacts being the most severe in regions where health worker to population ratio was already very low. Clinics providing sexual reproductive health services in both public and private sectors have experienced dramatically reduced opening hours. Some have closed and some are offering emergency services only which does not include sexual and reproductive health services. In some locations, clinics have reduced opening hours to one day a week.
In other locations, they may have closed altogether. In many clinics, routine STI and HIV testing installed and this is also the case for mobile testing clinics Routine screening for cervical breast cancer has also stopped and clinic closures occurred in instances where the clinics are located in larger facilities that have been redeployed to the COVID-19 response. As a consequence of the reduced availability of services and health care workers, there’s been a higher demand for services in the private sector. This has increased the cost of those services, making them completely unaccessible to lower-income families. Consequently, the impact of reduced access to sexual reproductive health care is falling disproportionately on those with low or no income.
Now let’s talk about the consumer or demand side issues. The health seeking behaviour of the population has also been shaped by their responses and concerns in relation to COVID-19. The biggest factor is loss of income resulting from the economic down turn caused by COVID-19. This is affecting people’s ability to access sexual reproductive health services and to travel to access them. Fear of contracting COVID-19 at health services and during travel to clinic is also reducing people’s willingness to access those services. Another barrier is the lack of information regarding which clinics are open, during what hours, and what services are being offered.
So the health information efforts of the Indonesian government during the pandemic have been firmly focused on messaging related to managing COVID-19 itself, whereas information about how other services have been reorganized has not been communicated to the public. Reduced mobility, particularly for people who have no independent means of transport has also impacted on access to services. Some community-level responses have also involved strict lockdowns and this has meant people are further restricted to accessing sexual and reproductive health services within their immediate neighbourhood. So the combined consequences of the supply and demand sides of COVID-19 are going to affect sexual and reproductive health of Indonesians in both the short and long term.
So just to comment on what we think these impacts will be, we have to note that we can’t reliably measure them during the time of crisis. However, there’s been some convincing attempts to model the impact of COVID-19 on the reduction of women’s access to sexual and reproductive health services in low and middle-income countries. The modelling exercises indicate that with just a 10 percent decline in women’s access to sexual reproductive health services and contraception that there’s likely to be enormous negative impacts on the health including the escalation of maternal mortality rates. So in Indonesia, the impacts that we’ve already seen and expect to continue, include the following.
Constrained access to modern contraceptive methods and particularly long acting methods, leading to greater unmet need for contraception, reduced contraceptive choice and subsequent increased of unintended pregnancies. With increased rates of unintended pregnancy, comes the subsequent need to access safe abortion Currently, abortion is only legal in Indonesia where a woman’s life is deemed to be at risk. Thus, we can expect maternal morbidity and mortality resulting from unsafe abortion to escalate. With reduced access to health facilities, we can also expect a continued rise in home births and higher rates of maternal and newborn mortality under those conditions.
For women who do manage to deliver in facilities shortages of emerging obstetric staff are also expected to lead to higher rates of maternal and newborn death. So women’s reduced mobility and the stalling of outreach care has also led to a decline in the number of women receiving pre and postnatal care and this also impacts on breastfeeding support and postpartum contraceptive counselling. Due to the stalling of routine HIV and STI testing, and the counselling the goes through that testing we can expect a rise in undiagnosed and untreated STIs including HIV. In the long term, untreated STIs are also likely to increase infertility. Interruption of cancer screening programs will also result in a rise of undiagnosed reproductive cancers.
And in the longer term, poorer survival rates resulting from late diagnosis and treatment. Reduced access to counselling related to sexual and reproductive health will also have a negative impact on both the mental well-being of the population and the health issues they’re seeking to resolve via counselling. So from this brief case study, we can see that the broader health impacts of COVID-19 can be colossal And should not be neglected in government responses to the epidemic We can also see how countries with lower health system capacity prior to COVID-19, are far more vulnerable to experiencing severe broader health impacts.
To design appropriate responses for maintaining adequate sexual and reproductive health services during a pandemic, it’s crucial to identify who was the most vulnerable in relation to sexual reproductive health, which is the focus o f the next step. Thanks very much.

Sexual and reproductive health services are an essential area of health care the world over, and the interruption of these services during times of crises has far reaching impacts. In this mini lecture, Associate Professor Linda Bennett explores exactly how the COVID-19 pandemic, and government and community responses to it, have disrupted people’s access to essential sexual and reproductive health care in Indonesia.

The case study describes how the reduction in available services and health care workers has led to the interruption of specific types of care including access to: long acting contraceptives, pre and postnatal care, safe abortion, STI and HIV testing, cervical and breast cancer screening, HPV vaccination, and sexual and reproductive health education and counselling. Changes to the health seeking behaviour of Indonesians, which have been shaped by the pandemic and particularly the economic effects of the pandemic, are also explained as barriers to accessing sexual and reproductive health care. Finally, this mini lecture describes and predicts the broader health impacts resulting from reduced access to sexual and reproductive health care for Indonesians during the COVID-19 pandemic, which include significant increases in unintended pregnancies, unsafe abortion, and maternal and newborn mortality. The case study provides a simple analytical framework for thinking about how supply and demand side factors related to health care can combine to constrain access to essential services during pandemics. This framework is easily adaptable for learners interested in analysing the impact of COVID-19 on sexual and reproductive health in their own country contexts.

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COVID-19: Global Health Perspectives

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