Bangladesh has suffered in numerous ways at the hands of the notorious and on-going COVID-19 pandemic. From the first week of March, the country sought to ban all mass gatherings, including a notable 100th-anniversary celebration event of the birth of the founder of Bangladesh, Sheikh Mujibur Rahman. In addition, a national lockdown was enacted, hoping to contain community transmission between March 26th to April 4th which went on to be extended to May 30th.
Despite such measures, the ripples streaming through Bangladeshi society have been complex and unprecedented. The pandemic has exposed the insufficiency of a fragmented healthcare system, reaching widely into one of the world’s most densely populated countries. Though this exposure has happened in concert with other more developed countries such as Italy, the UK and the USA who are suffering a similar unrelenting challenge, the complications in Bangladesh appear starker, especially given the pre-existing healthcare divide emanating from urban and rural disparities.
Importantly, critical maternal health services have been stretched thin. This short blog touches upon trends in maternal health during COVID-19 lockdowns, using data gathered from Bangladesh's Ministry of Health and Family Welfare and Directorate General of Family planning. In addition, I explore connected factors pertaining to maternal mental health using new research from mothers enrolled on the BRISC trial in Bangladesh.
Obtaining timely antenatal care (ANC) is a vital aspect to maternal health. It allows medical professionals to track the progression of a pregnancy and enables any worrying symptoms or stagnation in the growth of a foetus to be picked up early. ANC outlines the assessment of the individual needs of a pregnant woman and covers screening tests and education on self-help during pregnancy.
In Bangladesh, ANC visits in April 2020 were 50% lower than in April 2019 (Ainul et al., 2020).As the country slowly recovers, from July 2020 the ANC figures remained around 25% lower than in July 2019 (Ainul et al., 2020). Dhaka and its surrounding districts such as Rajbari and Chandpur, along with eastern districts in Sylhet division suffered more serious disruptions in ANC services, whilst the greatest disruption of a 71% decline occurred in Sherpur in Northern Bangladesh. Improvements in the first ANC visit have been encouraging, however, disruption to the fourth ANC visit nationwide continued into July (Ainul et al., 2020). Why is the fourth ANC visit so pertinent? As it happens, studies show that implementation of policies geared towards provision of at least four ANC appointments can serve as an effective intervention to link mothers to appropriate skilled birth attendants and health facilities for safe motherhood (Ryan et al., 2019).
Post-natal care (PNC) allows the avoidance of maternal and neonatal death. Examining a mother and child post-partum allows for any excessive blood loss or infection following delivery to be picked up. Any worrying issues in the neonate can be identified, examples including neonatal jaundice, sepsis and congenital malformations that require urgent review. In addition, PNC visits provide a safe space for issues pertaining to post-partum depression and post-partum psychosis to explored.
Sadly, PNC declined in a similar fashion to ANC visits. PNC visits were 40% lower in April 2020 than in April 2019 (Ainul et al., 2020). Figures for PNC visits are recovering at a steady rate, yet in July they remained lower than the year prior. One third of districts have documented declines in the first PNC visit, as much as 40% even in July (Ainul et al., 2020). This could indicate longer lasting impacts of COVID-19 on initial PNC visits.
Unsurprisingly, institutional delivery, i.e. any delivery that takes place at a medical facility staffed by a skilled delivery assistant, dipped through March and April. There has been slight recovery but figured remained 10% lower in June 2020 than in the previous year (Ainul et al., 2020). In Dhaka at least, there has been rapid recovery following the end of lockdown.
COVID-19 related disruptions stem from the obvious restriction of mobility of patients as well as service providers. During the lockdown, community-based immunisations and family planning programmes were suspended. Essential community health workers services were cancelled due to movement restrictions (Ahmed et al., 2020). City-wide lockdowns involved the closure of public transport, thus impeding the flow of medical supplies. Supplies from China did little to suffice the needs to the population (Chowdhury, 2020). The lack of PPE and safety equipment made it even harder for co-ordination between service providers to continually reassess the situation and be prepared for continual challenges to patient management and referral. These facts help to explain the logistical difficulties in healthcare provision.
The closure of small clinics that would enable low-cost healthcare access to more deprived regions have excluded much of the population from seeking medical attention (Ahmed et al., 2020). Intertwining with this is the fear of infection and stigmatisation. Indeed, the first COVID-19 suicide case was a tragic story of man hanging himself because of the intense prejudice he suffered in his village (Mamun & Griffiths, 2020). The case is a mere glimpse into the psychological stress being endured by such communities (Bhuiyan et al., 2020). It seems the fear of infection is as contagious as the virus itself, as is the rampant spread of misinformation.
The effects on maternal mental health are quickly emerging. A survey looking at the effects of the immediate stay-at-home lockdown reveal that maternal mental health deteriorated (Hamadani et al., 2020). The median GAD-7 score measured in this survey of 2424 mothers was 3. This is consistent with mild anxiety with the majority saying their anxiety had increased since the onset of lockdown. The same study depicted women experiencing a concerning increase in the prevalence of intimate partner violence, in particular emotional (being insulted, humiliated, intimated and threatened) and physical violence (being pushed, having their hair pulled, kicked, dragged or threatened with a weapon).
These results reflect a combination of predisposing and precipitating factors. In Bangladesh, 55.0% of women in rural areas and 48·7% in urban areas report having experienced physical or sexual violence from their husbands, with the most common reasons cited by women being unprovoked violence or violence provoked by a financial crisis (Bangladesh Demographic and Health Survey, 2007). In contrast, men cited disobedience by their wives as the leading cause. Precipitating factors include the heavy psychosocial stress encompassing losing work, income, occupational identity, and of course loved ones to COVID-19.
So, whilst the macroeconomic cost of stay-at-home orders appear evident in China, Europe, and other middle-income/high-income settings, the same cannot be said for countries like Bangladesh where the situation remains precarious. The declines in critical maternal health care covered here have happened within the context of varying degrees of food insecurity (Islam et al., 2020). In fact, the World Food programme estimates that food insecurity could double worldwide as a direct consequence of the pandemic. In Bangladesh, half the population entered extreme poverty and the lockdown has had deleterious impacts on Bangladeshi women both in terms of mental health and maternal health.
In summary, there is an urgent need for the creation of targeted interventions to rebuild the shaken trust between communities and the health system. The development of standard operating procedures for maternal health continuation for a potential future emergency should include clear instructions regarding family outreach and health worker readiness (Ainul et al., 2020). Alongside dedicated research involving pregnant mothers to acquire accurate outlines of both supply and demand factors in maternal health services during COVID-19, there is a need to emphasise pregnant women's fears and anxieties about visiting faculties.
The use of telemedicine is a possible route to grappling with the mental health crisis, but is of course, limited to the technological capabilities across the region. A national hotline or radio broadcast addressing mental and maternal health could serve as ways of improving effective communication amongst women in Bangladesh. In the face of COVID-19, fortifying the existing relations within the healthcare system could also aid in mitigating the effects of pandemic.
Written By: Sabeera Dar, Maa Charity
More information on Maa Charity at: https://maacharity.org
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References:
Ahmed SAKS, Ajisola M, Azeem K, et al. Impact of the societal response to COVID-19 on access to healthcare for non-COVID-19 health issues in slum communities of Bangladesh, Kenya, Nigeria and Pakistan: results of preCOVID and COVID-19 lockdown stakeholder engagements. BMJ Global Health 2020;5:e003042. doi:10.1136/ bmjgh-2020-003042
AKMI Bhuiyan, N Sakib, AH Pakpour, MD Griffiths, MA Mamun
Chowdhury SI. China to Give Bangladesh Testing Kits, Protective Gears. (2020). Available online at: https://www.newagebd.net/article/102576/china-to-give-bangladesh-testing-kits-protective-gears
COVID-19-related suicides in Bangladesh due to lockdown and economic factors: case study evidence from media reports
5. Hamadani, J.D., Hasan, M.I., Baldi, A.J., Hossain, S.J., Shiraji, S., Bhuiyan, M.S.A., Mehrin, S.F., Fisher, J., Tofail, F., Tipu, S.M.M.U., Grantham-McGregor, S., Biggs, B.-A., Braat, S., Pasricha, S.-R., 2020. Immediate impact of stay-at-home orders to control COVID-19 transmission on socioeconomic conditions, food insecurity, mental health, and intimate partner violence in Bangladeshi women and their families: an interrupted time series. The Lancet Global Health 8, e1380–e1389. https://doi.org/10.1016/s2214-109x(20)30366-1
Int J Ment Health Addict (2020) published online May 15.
Islam, S.M.D.-U., Bodrud-Doza, Md., Khan, R.M., Haque, Md.A., Mamun, M.A., 2020. Exploring COVID-19 stress and its factors in Bangladesh: A perception-based study. Heliyon 6, e04399. https://doi.org/10.1016/j.heliyon.2020.e04399
Mamun, M.A., Griffiths, M.D., 2020. First COVID-19 suicide case in Bangladesh due to fear of COVID-19 and xenophobia: Possible suicide prevention strategies. Asian Journal of Psychiatry 51, 102073. https://doi.org/10.1016/j.ajp.2020.102073
National Institute of Population Research and Training (NIPORT) MaA, and Macro International: Bangladesh Demographic and Health Survey 2007 National Institute of Population Research and Training, Mitra and Associates, and Macro International, Dhaka, Bangladesh and Calverton, Maryland, USA (2009)
Ryan, B.L., Krishnan, R.J., Terry, A. et al. Do four or more antenatal care visits increase skilled birth attendant use and institutional delivery in Bangladesh? A propensity-score matched analysis. BMC Public Health 19, 583 (2019). https://doi.org/10.1186/s12889-019-6945-4
Sigma Ainul, Md. Saddam Hossain, Md. Irfan Hossain, Md. Kamruzzaman Bhuiyan, Sharif M. I. Hossain, Ubaidur Rob, Ashish Bajracharya. Trends in Maternal Health Services in Bangladesh Before, During and After COVID-19 Lockdowns: Evidence from National Routine Service Data. Research Brief. Dhaka: Population Council. September 2020.
World Food Programme, COVID-19 - Potential Impact on the World's Poorest People, April 2020: https://www.wfp.org/publications/covid-19-potential-impact-worlds-poorest-people