Covid-19 came late to Bangladesh, which gave the doctors and midwives working at HOPE Hospital for Women and Children of Bangladesh time to prepare. But even as they learned the procedures for safely donning and doffing full PPE, they didn’t anticipate the flood of patients.

Dr. Iftikher Mahmood, HOPE’s founder, explained that health care providers around the country were refusing to work as the virus appeared. “They’re scared they will be Covid patients,” he said. “They’re trying to stay alive, basically.”

At the same time, Mahmood said, a number of international health care providers working in Bangladesh were sent home.

HOPE quickly became the only 24-hour emergency obstetric health care provider in the Rohingya camps, Mahmood said. Their workload increased to somewhere between double and triple its usual amount.

“That puts a lot of pressure on us,” Mahmood said. But he was sanguine about HOPE for Bangladesh’s ability to meet the needs of maternal health patients. “We don’t get afraid, and we don’t get worried. We try to manage it.”

Maternal health care providers around the world felt the effects of Covid-19. Even as researchers find evidence of increased maternal mortalities, stillbirths, and other indicators of interrupted maternal health care, the organizations that care for some the world’s most vulnerable communities report everything from difficulties procuring PPE – one midwifery organization in Indonesia reported having to use plastic raincoats when gowns ran out – to malnourished mothers and infants.

Pandemic Costs

Dr. Victoria Chou, a researcher at Johns Hopkins Bloomberg School of Public Health and co-author of an early modeling study examining the pandemic’s effects on maternal and child health, said that, in the pandemic’s earlier phases, maternal health services were significantly disrupted by lockdown measures, supply chain interruptions, disruptions in the availability of health care workers, and other measures.

“Country-specific analyses have suggested that there was a disruption that lasted weeks and months, but a lot of those services have been restored,” she said.

At this point, researchers are particularly concerned about food insecurity and other economic consequences of the pandemic – along with mental health concerns.

Like their patients, maternal health care providers that care for vulnerable patients are feeling the economic consequences of the pandemic. Many kept their doors open even when other organizations weren’t able to provide maternal health services.

To help defray the costs of the Covid-19 pandemic – and help on-the-ground organizations continue to provide vital health services – Direct Relief is dispensing $2.5 million in grants to international partners. Nine of those partners focus specifically on reproductive and maternal health.

For example, the Indonesian midwifery group, Bumi Sehat, quickly began burning through the PPE required to safely see patients through their deliveries, said founder Robin Lim. A senior midwife died of Covid-19.

Maternal health organizations have also reported high costs of PPE, staffing and sick leave; economic downturn; and other financial consequences.

“The economy shut down; there were shortages of everything,” said Jane Drichta, executive director of Midwives for Haiti. “We still have a massive PPE shortage, and the thing with PPE is you’ve got to keep buying it.”

Midwives for Haiti, which staffs a government hospital with qualified maternal health providers, didn’t see the upward swing in patients that HOPE for Bangladesh did.

Instead, “there was a lot of stigma…there was a lot of fear, there was a lot of evocation of indigenous knowledge,” Drichta said. “Our census at the hospital went way down, because people were afraid to come in to deliver their babies.”

In lieu of hospital births, women whom Midwives for Haiti would ordinarily have served were relying on traditional birth attendants, called matrons. The organization responded by providing the matrons with education and midwife kits.

The matrons, whom Drichta described delivering babies on dirt floors without electricity in some cases, “are our real eyes and ears out in the villages,” she said. “If they run into a problem, they will call and we can give them advice over the phone.”

Indirect Consequences

Edna Adan, founder of the Edna Adan University Hospital in Somaliland, said that a number of colleagues had come down with Covid-19, further straining the hospital’s resources. She described gloves being washed and reused – fresh, sterile ones are reserved for surgeries.

But her greatest worry is for her patients. Food insecurity was always a concern in Somaliland, where a large number of people earn their incomes by raising animals for export, but when international demand for the animals decreased, women’s health suffered.

“There were always women who were weak and who were anemic, but now we’re seeing an upsurge of malnutrition,” Adan said. For a woman about to give birth, “the only thing we can do is try to give her a blood transfusion…so if she loses blood, she won’t die from it.”

Adan has also seen an increase in the number of babies weighing less than two kilos – about four and a half pounds. “This is something we are seeing repeatedly. This is not something I can attribute to anything other than acute malnutrition and Covid,” she said.

In Bali, where Bumi Sehat has a birthing center, a significant majority of people were dependent on the tourism industry, which has been curtailed by Covid-19. “Lots of people are back in the garden growing food because they don’t have jobs,” Lim said.

Bumi Sehat has been attempting to bolster the local economy – and feed patients – by buying fruits and vegetables from local farmers and giving them to families who need food.

Vital Support

External support has played an essential role in helping these organizations continue to provide uninterrupted maternal health services.

“It really helped to keep our focus on work,” Mahmood said. Without funding, PPE, and other essential resources, “we would be broken as an organization.”

Mahmood described his staff as passionate and dedicated – only one non-clinical staff member opted not to continue their work during the pandemic. “We like to help people,” he said.

And all stressed the importance of continuing to provide these services. Bumi Sehat, for example, had recently opened up a new health center on the Indonesian island of Lombok. Bumi Sehat purchased the land and Direct Relief funded construction of the center.

During the pandemic, the facility stayed open, providing both maternal and community care despite the difficulties.

“People needed a birthing center that was kind and compassionate so badly. And free,” Lim said. “They needed free.”