An expert's point of view on a current event.

The Coronavirus Is Cutting Off Africa’s Abortion Access

The collapse of medical supply chains has been a catastrophe for women in developing countries. Lockdowns have made matters worse.

A woman practicing illegal abortion shows her working medical tools in her living room in Antananarivo, Madagascar, on July 25, 2019.
A woman practicing illegal abortion shows her working medical tools in her living room in Antananarivo, Madagascar, on July 25, 2019. GIANLUIGI GUERCIA/AFP via Getty Images

When Shali Iminza, 27, missed her period in March, the married mother of three felt her stomach sink with dread. Iminza, whose first name has been changed for privacy reasons, works as a farmer in western Kenya, and her husband is a motorcycle taxi driver. Together, they barely make enough money to feed their family. “Sometimes we eat three times [per day], sometimes two,” Iminza told Foreign Policy and Type Investigations over the phone. “Things are very expensive, and to get money nowadays, it’s hard.”

When Shali Iminza, 27, missed her period in March, the married mother of three felt her stomach sink with dread. Iminza, whose first name has been changed for privacy reasons, works as a farmer in western Kenya, and her husband is a motorcycle taxi driver. Together, they barely make enough money to feed their family. “Sometimes we eat three times [per day], sometimes two,” Iminza told Foreign Policy and Type Investigations over the phone. “Things are very expensive, and to get money nowadays, it’s hard.”

Unable to care for another child, Iminza visited a local health clinic, walking more than 3 miles to save money on the taxi fare. When she arrived, the doctor informed Iminza that the pills she would need to terminate her pregnancy were unavailable because of shortages caused by the novel coronavirus. “I’m very angry because the more the days are going, the pregnancy is now growing, so I don’t know what to do,” said Iminza, her voice trembling from stress.

COVID-19 has created delays and disruptions in every step of the supply chain that brings critical safe abortion medication and contraceptives from Asia to East Africa—halting factory production, delaying air and sea shipments, complicating customs approvals, and restricting in-country transport from seaports and airports to hospitals, pharmacies, and health care clinics. Lockdowns and curfews have added to the crisis, preventing women from traveling to clinics to get critical family planning and reproductive health care, and blocking service providers from conducting outreach in hard-to-access rural areas.

The outcome could be disastrous for women and girls, according to experts, who expect to see a rise in unintended pregnancies and unsafe abortions in a region where thousands of women already die each year due to restrictive abortion laws and lack of access to reproductive health care and family planning supplies.

[Mapping the Coronavirus Outbreak: Get daily updates on the pandemic.]

The reproductive health organization Marie Stopes Kenya, which normally operates 20 centers and 15 mobile outreach teams, has been forced to temporarily suspend its outreach programs because of Kenya’s curfew and restrictions on movements and group gatherings. In just one day, the organization says it received around 300 WhatsApp messages from women and girls inquiring if the clinics were still open and what their operating hours were.

Marie Stopes Kenya estimates that if service provision continues to be severely restricted from April through December, a worst-case scenario, the organization could be prevented from averting nearly 100,000 unintended pregnancies, 65,000 unsafe abortions, and 500 maternal deaths. “It can be just as deadly as COVID-19 itself if we turned away and closed our doors,” said Sophie Hodder, Marie Stopes Kenya’s country director.

This spring, DKT International, one of the world’s largest providers of contraception and safe abortion products and services, ran extremely low on its stock of medical abortion pills for its Kenya program when thousands of packs got stuck at the New Delhi airport for nearly six weeks due to air cargo delays. “RE: Kenya shipment, 20,000 packs of MA KARE [the abortion pill mifepristone oral] lying at Airport : Will have to wait till airport opens as it cannot be moved anywhere now,” an email from an Indian pharmaceutical manufacturer to DKT Kenya read.

DKT International had read the warning signs earlier in the year. In January, the organization experienced shipping delays in batches of condoms from Thailand. In February, one of DKT’s India programs ran out of medical abortion pills because the active pharmaceutical ingredient in the pills came from China, the epicenter of the COVID-19 epidemic at the time.

DKT International rushed to place emergency orders of contraceptives and medical abortion pills from Asian manufacturers. Luckily, it managed to accumulate enough buffer stock to fill all incoming orders in East Africa while the medical abortion pills were held up in the Indian airport. DKT Kenya just received its long-awaited shipment of MA-Kare through Kenya’s main airport last week. But the organization says the delays pushed them to the brink. “If there had been another month of delays, we would have likely run out of stock,” said Lauren Archer, DKT Kenya’s country director.

As manufacturing in Asian countries hit hard by COVID-19 stalled in the early months of this year, factories temporarily stopped producing critical raw materials for products such as condoms and intrauterine devices and medications including emergency contraception pills and medical abortion pills. The manufacturing shutdowns created temporary delays in filling orders and resulted in backlogs in supplying key reproductive health medications and commodities to countries around the world.

Severe lockdowns and restrictions on pharmaceutical exports in countries like India compounded the manufacturing delays. Even as some nations have recommenced production of critical commodities and medications, many of these goods still cannot leave their countries of origin.

India has gradually lifted its restrictions on shipping certain medications and medical devices, but further emails from Indian manufacturers to DKT Kenya revealed a threefold increase in freight charges due to limited airline staff and flights for medications permitted to leave the country. This has squeezed organizations like DKT International, whose operating margins are being eaten up by rising prices. “My main message is to ring the alarm bells to the reproductive health community,” said Chris Purdy, DKT International’s president and CEO, in a global reproductive health webinar on March 27.

To help with the crisis, the Swedish International Development Cooperation Agency, Sweden’s government agency responsible for most official development assistance to developing countries, pledged an additional $1.9 million to ensure that DKT International was equipped to handle potential supply shortages and expand access to contraception and safe abortion in countries across East and Southern Africa, including Kenya and Uganda. But if the COVID-19 pandemic continues to linger, providers say, $1.9 million will not be enough to address global supply chain disruptions.

Even after medications and commodities are manufactured and shipped and have reached their destinations, COVID-19 delays slow down the supply chain yet again. In Kenya, the port of Mombasa has been overwhelmed by staff shortages that are hindering the customs and regulatory approval of products. DKT International has received messages from its contacts telling the organization to expect delays as many of the port authority employees have been put in quarantine. Goodlife Pharmacy, a chain of pharmacies across Kenya and Uganda, initially experienced two-week delays getting its cargo from the ports. “When the product is at the port, they don’t have enough people to clear the cargo,” said Amaan Khalfan, the CEO of Goodlife.

Once the products are finally cleared through Kenya’s port, they are loaded onto trucks, which bring them to distribution centers in Kenya and Uganda. But Khalfan’s trucks also experienced delays en route to their final destinations because, during the early weeks of Kenya’s 7 p.m. to 5 a.m. curfew and a total lockdown in Uganda, the company needed to carry additional authorization letters to pass through checkpoints. “Within the city and within the counties, they’re a little unclear about what essential services are,” Khalfan explained. “They say pharmacies are essential service, so people can travel if you’re working with a pharmacy. But what about the product that’s in a truck?”

Truck drivers have come under increased scrutiny in recent days for possibly spreading COVID-19 as they transport essential services across the region, prompting the government of Uganda to institute widespread testing for drivers as well as “relay driving,” in which truckers must drive up to a border, stop, sanitize their vehicle, and pass it to the next driver to minimize cross-border transmission of COVID-19. While important, providers say these safeguards further compound delays in getting contraceptives and safe abortion medication to the women and girls who need them. DKT International already reports experiencing several days’ worth of delays for goods being transported into Uganda from Kenya.

The delays and price hikes mean that medical distributors, hospitals, and health care clinics across Kenya and Uganda are running out of essential medications. Marie Stopes Uganda, which claims to be the largest provider of family planning services and commodities in the country, reported in early April that it has been out of emergency contraception, commonly referred to as the morning after pill, since January of this year and expects to run out of all other abortion and contraceptive supplies by the end of April. “Within the first two months of this year, we found ourselves [selling out of supplies] that we projected to sell in six months,” said Carole Sekimpi, Marie Stopes Uganda’s country director. “The product was due to come in the beginning of February. The COVID conversation started, then it was moved to come in by the second week of March. COVID got even more serious.”

Lockdowns and restrictions on movement have added to the crisis, preventing women from traveling to clinics to get critical reproductive care and commodities and prohibiting health care organizations from conducting outreach in hard-to-access rural areas.

In Kenya, women and girls are facing rising prices due to restrictions on movement. Kenya’s matatus, small buses that are the primary mode of public transportation in the country, have been prohibited from carrying more than a few passengers at a time, prompting them to raise fares to make up the difference. Passengers must also wear masks, an expensive luxury for many Kenyan women barely surviving hand to mouth each day.

Nelly Munyasia, the head of Reproductive Health Network Kenya, said that to spare the travel expenses, women and girls will choose to visit local neighborhood “quacks,” unqualified providers passing themselves off as pharmacists and doctors, rather than traveling to a proper reproductive health clinic that may be located farther away from their homes. These unqualified providers often use coat hangers, bleach, or even crushed glass to try to terminate women’s pregnancies, which can result in the women being permanently maimed or even killed.

“We will definitely start seeing an increase in unsafe abortion cases,” Munyasia said. “We’re looking at probably even deaths related to unsafe abortion. We are looking at girls and women with ruptured uterus. Cases of girls losing their uterus as a result of this.”

Health care workers say they have already begun to see a rise in unwanted pregnancies and are predicting a correlated increase in unsafe abortions by as early as June. Elizabeth Nyambura Mariara, a nurse who runs a health care center in rural Kenya, said she saw only one case of teenage pregnancy in January. In April, she has already seen five cases come through her doors. Though it’s too early to attribute the rise in unintended pregnancies to COVID-19 disruptions, Mariara said she strongly suspects the spike could be related because students in Kenya have been out of school since mid-March—now living at home with little oversight from teachers and too much idle time on their hands. “I [normally] don’t see a lot of students. Now you see 100 percent are students, which is really shocking and alarming,” Mariara said. “[COVID-19 disruptions] are going to harm the wanjiku, the poor women who are in the territories of Kenya,” she added.

In Uganda, 343 women die per 100,000 live births, and unsafe abortions contribute to around 26 percent of these maternal deaths. In Kenya, too, the issue of unsafe abortion was so grave that in 2013, the Health Ministry conducted a study to determine the impact of maternal mortality due to unsafe abortions on the population.

For Iminza, access to safe abortion services could mean the difference between life and death. Iminza is aware of the dangers associated with unsafe abortion: She knows women who have bled to death from the procedure. “I didn’t want to go [to an unlicensed doctor] because I can’t risk my life,” Iminza said. “My children are depending on me.” But as the COVID-19 pandemic rages on, Iminza is running out of options.

This story was produced in partnership with Type Investigations.

Neha Wadekar is a Nairobi-based journalist.

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