Part II: Roadblocks to health care for women during COVID-19 in East Africa

Two women passengers ride on a boda-boda motorcycle taxi in Uganda, March 23, 2010. Photo by Daryona via Wikimedia Commons CC BY 2.0.

Editor's note: This story is part of a two-part series on women and health care during COVID-19 in East Africa. Read Part I here

Throughout East Africa, midwives and other skilled health care providers safely assist pregnant women during childbirth to reduce the risk of maternal and child mortality. 

Yet, COVID-19 measures such as travel bans and nightly curfews have created potentially dangerous physical barriers between pregnant women and skilled health care providers during childbirth.      

The ongoing COVID-19 pandemic presents a valid and ongoing threat to unencumbered access to comprehensive maternal health care.

During the pandemic, many pregnant women have been unable to access health care facilities on time — or at all — during childbirth. Under nightly curfews, transport providers have either been unable or unwilling to ferry pregnant women in labor to health facilities for fear of harassment by security agencies.

By mid-April 2020 in Kenya, about one month after COVID-19 measures were put in place, at least five women and three babies died during and immediately following childbirth. 

Three pregnant women died in Makueni County due to challenges in access to public health facilities during curfew hours. One of the three women was turned away in the middle of the night by two local midwives, and a boda-boda (“motorcycle”) rider who refused to transport her and her husband to the hospital for fear of an altercation with police for breaking curfew. 

The mother of six in Makueni died the following day at the hospital while awaiting a blood transfusion. Fear of harassment by police among boda-boda riders partially stems from recent incidents of violence against transport service providers. 

In February 2020 in Kenya, a boda-boda rider was shot dead by a police officer after rushing a child to the hospital who had almost drowned. In March 2020, a boda-boda rider was beaten to death by police officers while returning home after rushing a pregnant woman to the hospital.

Kenya Television Network reported infant mortality rates rose due to fears of “beating the curfew hours”:

In Uganda, at least 11 pregnant women died owing to delays in accessing health care facilities during labor. 

This followed a government-issued transport ban and curfew to restrict movement to only those with permits. While pregnant women were later exempted from this ban, the challenges in accessing health facilities persisted due to limitations in accessing ambulance services or any other form of public transportation during curfew hours.

Zimbabwe faced the same situation. Nurses reported a reduction in the number of pregnant women going to health facilities for delivery and other maternity services. Pregnant women also shared their challenges in accessing public transportation due to the ongoing national lockdown, and fears of facing brutality from police officers. 

During COVID-19, governments must review, establish and implement measures to ensure that pregnant women and girls are able to access well-equipped and properly staffed health care facilities.

State obligations under international human rights law

Under international human rights law instruments, including the African Charter on Human and Peoples’ Rights and the Maputo Protocol, ratified by 43 of the 55 African States protecting and promoting the rights of women in Africa, states must develop and implement measures to ensure physical access to health care facilities, goods and services. 

These measures should essentially strive to reduce the number of steps taken by a person — in this case being pregnant women — to access health care. This includes an obligation to adopt special and particularized measures to guarantee physical accessibility for vulnerable and marginalized groups, such as persons with disabilities, populations stemming from low socio-economic backgrounds and those from rural and remote areas. 

Special measures should also be in place to ensure physical access to health care during emergencies, such as conflict or a pandemic.     

A woman passenger rides on a boda-boda motorcycle tax in Uganda, March 23, 2010. Photo by Daryona via Wikimedia Commons CC BY 2.0.

‘Wheels for life’

Access to ambulance services remains inadequate in many African states, but some authorities have undoubtedly taken measures to ensure access to transportation to health care facilities during the pandemic. 

Wheels for Life, an initiative between the Government of Kenya’s Ministry of Health, AMREF, and Bolt, is a good example of a public-private partnership that ensures that women in labor can access free taxi transportation from their homes to health facilities by dialing 1196 — a toll-free number. 

This taxi service operates during curfew hours between 9 p.m. and 4 a.m. daily in Kenya, amended on 6 June 2020 from 7 p.m. and 5 a.m.  However, this initiative only serves residents within Nairobi, the capital, excluding pregnant women living in all other areas of Kenya — especially those in rural areas. Also, these taxi drivers may only operate in affluent neighborhoods due to perceived fears of insecurity in lower-income areas.

To be more inclusive, authorities could partner with reputable taxi companies or individual taxi operators, including boda-boda taxis, to operate throughout Kenya, with a focus on rural areas where motor vehicles often struggle to access remote homesteads due to a lack of sufficient roads. 

This also applies to numerous low-income settlements located in urban and peri-urban areas where larger vehicles cannot navigate narrow alleyways.

Trusted boda-boda operators, however, can easily navigate the narrow or bush-ridden paths located in hard-to-reach locations to rescue people in need.

The transport providers selected to partner with governments should have a good knowledge of the areas where they will operate and must be well-known to community members, as well as local security structures, who can avail safe entry and exit out of the so-called “unsafe” locations. 

Importantly, all transport measures adopted by governments, including any special measures, should always prioritize the safety and security of pregnant women during transit to health care facilities.

Maternal mortality rates are likely to rise during the ongoing pandemic, similar to the increase in maternal and new-born mortality noted during the 2014-2016 Ebola pandemic in West Africa. 

Therefore, East African governments must take all measures to protect the lives of pregnant women before, during and after childbirth. These measures will also contribute to reducing child-mortality during and following childbirth.

Lydia Muthiani and Nelly Warega are human rights lawyers living and working in Kenya. They specialize in the advancement of women’s and girls’ rights, and are part of Utu Wetu, a collective of human rights experts particularly working on women’s rights. 

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