More than a year after the start of the global coronavirus pandemic, and the release of openDemocracy’s investigation into childbirth during COVID-19, we know that there have been too many violations of women’s pregnancy and childbirth rights during this crisis, including outright suspensions of services.
Too often, the response of governments and health facilities to the spreading pandemic quickly abandoned evidence-based, respectful care practices, without adequately considering alternatives – including via midwives and community-based care models – that could enhance infection prevention while also protecting such practices.
But there is also good news. Around the world, women, healthcare providers and (some) decision makers have imagined and implemented solutions in response to these problems. These innovations, crafted in a time of crisis, hold very valuable lessons.
At the level of healthcare providers and facilities, damaging top-down changes that suspended rights and services were mitigated in some contexts by rapid adaptations to uphold respectful care in the face of COVID-19 challenges.
After a six-month openDemocracy investigation, major aid donors and NGOs have said they will investigate anti-LGBT ‘conversion therapy’ at health facilities run by groups they fund.
But unlike the other aid donors, US aid agency PEPFAR has not responded at all.
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In Croatia, for example, staff at the small Čakovec General Hospital – which serves a population north of the capital Zagreb with a high proportion of Roma women – resisted banning birth companions at a time when 90% of the country’s hospitals did so. Instead, they decided to procure COVID-19 rapid antigen tests for both the expectant mother and her companion, to ensure that women could have birth companions and remain with their babies at all times – a correct and best practice for optimal health outcomes.
In the Netherlands and in Mexico, midwives used hotels and newly established ‘maternity homes’, respectively, for birth and postpartum care for healthy women with low-risk pregnancies. This minimised their exposure to COVID-19 and also ensured their autonomy during birth.
Digital and telehealth alternatives enabled women to talk to doctors and other healthcare professionals via virtual consultations (UK), and facilitated self-care through YouTube videos (Japan) and online group birth preparation classes (mostly in high-income countries).
However, this shift to online methods also exacerbated inequalities. One doctor in India noted that “the use of the phone, SMS and WhatsApp is a success for telemedicine, but only 30% of the people have a smartphone.”
For women facing intersecting barriers to accessing healthcare, it was community-based health workers, especially midwives, who stepped in and stepped up.
In Mexico, groups of midwives in the states of Chiapas, San Luis Potosí and Oaxaca coordinated ‘care brigades’ to visit women in remote, predominantly Indigenous communities. In Alaska, Indigenous women have approved the return to traditional practices of being supported by a midwife to give birth at home, where they can speak their native language and have family nearby. Before the pandemic, they were often encouraged – or even required – to travel hundreds of miles south to give birth.
In Croatia, Slavojka Aresnović, a midwife working on the island of Korčula, accompanied pregnant and birthing women on their precarious 100-kilometre ambulance journey over bumpy roads to the nearest hospital – which is in Dubrovnik on the mainland.
Community-based maternity care
With COVID-19 far from over and growing disparities and inequities in health outcomes around the world, what can we learn from the solutions crafted during the pandemic about restructuring and improving the ways that maternity care is delivered?
Countries around the world have long abandoned community midwifery services in favour of centralised care, but the pandemic has shown how dangerous it is to rely on a single form of care delivery during emergencies. It is past time to reinstate community-based models of care, including community midwifery services. Diversity in the who, where and how of healthcare delivery allows for adaptation during crises.