A worrying drop in antenatal and follow-up visits during lockdown

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The COVID-19 pandemic is seen as the cause of patients defaulting on chronic medical and not seeking care. New data points to fears of contracting COVID-19 at congested health facilities as the primary reason for people not seeking needed care and defaulting on their chronic medication, including antiretrovirals (ARVs) for the treatment of HIV, reports Spotlight.

ARVs are but one example of how the COVID-19 pandemic is impacting non-COVID-healthcare in South Africa. According to data from the National Income Dynamics Study – Coronavirus Rapid Mobile Survey (NIDS-CRAM) that was released last week Wednesday, access to medication and services has been affected across the board.

“We find it particularly concerning that 11% of our sample of public sector expectant mothers or mothers with infants have run out of ARTs (antiretroviral treatment). Overwhelmingly, fears of contracting the voronavirus is the most important reason cited for not seeking care,” noted the NIDS-CRAM study authors.

The new data is based on interviews with around 7,000 participants already involved in previous NIDS surveys, using 50 call-centre agents, from the 7th of May to the 27th of June. The researchers used the well-established MomConnect SMS-based platform to garner an additional 3 140 responses between 24 and 30 June. The survey looked at three key issues to examine the impact of the pandemic described as “the largest social and economic shock in our lifetime” – employment, hunger and access to healthcare.

The researchers will continue to follow up with respondents and will release data in further waves as the pandemic progresses in South Africa. While the data has its limitations, including a small sample size, Principal investigator Dr Nic Spaull wrote that “we can say with some confidence that this is the most representative survey of South African individuals and households in 2020 that currently exists”.

The survey found that one in 10 HIV positive new and pregnant mothers ran out of ARTs in May and June. A total of 1 610 mothers reported needing ART, but 175 (11%) said they ran out of medication. When asked why they ran out of ART, 40% “selected ‘Afraid of getting the coronavirus’ as their reason”, noted the authors. “This fraction is very concerning as interruption in ART risks the health of the mother, as well as increasing the risk of transmission to the baby, whether vertical [during gestation or delivery] or through breastfeeding.”

The study authors suggested that these estimates are likely “conservative” and that the situation in the general population is likely to be worse because “we focus on high-stakes types of health demand”.

“Given the risk of ART interruptions for pregnant and breastfeeding mothers, we would expect this patient group to be less likely to run out of ART than other patients,” explained the authors.

Additionally, the data suggests that many pregnant women are skipping important antenatal visits, largely due to fear. One in six mothers and pregnant women reported at least a two-month gap in visits to their designated clinic or hospital. “Of those who did not go to the clinic, 37% cited coronavirus fears as the reason why they did not consult,” noted the survey.

Professor of vaccinology at the University of the Witwatersrand, Shabir Madhi, said this could have a severe impact on the country’s immunisation programme. “We’ve seen a 25% reduction in childhood immunisation over the past few months. This places the entire immunisation programme in a vulnerable position. We would be extremely fortunate if we don’t experience outbreaks of highly contagious preventable diseases like measles, which happened in the Democratic Republic of the Congo during the Ebola outbreak. Because then, children will start dying – not from COVID-19 – but from preventable diseases,” he said.

The survey further found that only 78% of people in need of healthcare for acute conditions actually sought help and visited a healthcare facility, meaning 22% chose to stay at home despite their symptoms.

“Although this is a relatively small number of respondents (133 individuals) their stated reasons for not seeking care are nevertheless interesting to unpack further. It is worrying that for those respondents who did not seek care for their acute health needs, COVID-19 and lockdown-related fears were mentioned as the number one reason,” noted the survey’s overview.

Significantly, the survey suggests that access to medication has been severely, and negatively, impacted by the pandemic. Almost a quarter (23%) of respondents reported that they were unable to access medication, condoms or contraception in the preceding four weeks. Patients taking medicines for chronic conditions such as HIV, TB or diabetes seem to be even worse-off.

“Of the 1 524 respondents with a chronic condition, 705 (39%) reported that they could not access medicine, condoms or contraception,” according to the survey. While the majority (40%) of mothers who ran out of ART cited COVID-19 fears as their reason, 21% reported that there was no ART available at facilities.

This data is supported by reports of ARV stock-outs received by the Treatment Action Campaign (TAC).

Spotlight quotes TAC’s acting manager for Gauteng, Tshepo Maboe, as saying that access to ART has been affected by both stock-outs and COVID-related facility closures. He said that a number of people living with HIV going to clinics to refill their ART scripts have been turned away and “told that the facility is only dealing with emergencies”.

Maboe said that many patients have resorted to sharing pills so as not to default. According to a Gauteng Health memo dated 7 April: “Patients stable on chronic medication… who are in possession of a six-month repeatable prescription, should be issued a two-month supply of treatment at a time, wherever possible.” However, Maboe said that, in reality, many patients living with HIV have been given a treatment supply for just one week, and, in some cases, not at all.

Maboe criticised the government for seemingly having no plan for unplanned facility closures and medication stock-outs. “If a clinic is closed due to COVID, there should be a contingency plan or something to mitigate the situation. If I am an operations manager at a clinic and there are stock-outs, there need to always be a plan, maybe to contact the nearest facility informing them that these patients would be coming and need medication. We have had so many cases like this since the start of lockdown. Access to HIV medication is not a priority for the department,” he said.

Spotlight says the NIDS-CRAM researchers have made several policy suggestions to mitigate the situation including more effective deployment of community health workers, the distribution of free face masks to the poorest communities, clearer and more concise communication to the public and anchoring messages in hope – a strategy that could counteract the prevailing atmosphere of fear.

According to Madhi one “of the unfortunate things we need to admit that was lacking in the South African response in the early stages, was the involvement of social behavioural scientists”.

Madhi is also director of the SAMRC Vaccines and Infectious Diseases Analytics Research Unit (VIDA). “As a result, we didn’t do a good job when it came to communication,” he said.

One of the NIDS-CRAMS findings was that knowledge “about the three most common COVID-19 symptoms is limited”. The survey also found that only one-in-three respondents reported implementing the most effective preventative measures. Madhi said this communication could have gone some way to mitigate the fear people have been experiencing especially when it comes to accessing healthcare and what “people need to do to remain safe when it comes to health facilities”.

“The absence of this is unfortunate but it is not too late for these social behavioural scientists to be brought on board,” he said.

Professor Francois Venter, from the University of the Witwatersrand Reproductive Health and HIV Institute, has reported that headcounts at Johannesburg clinics have decreased by between 30% and 70% since the pandemic hit South Africa.

Spotlight quotes Venter as saying that the NIDS-CRAM data is “absolutely devastating”. “This data shows catastrophic suffering in South Africa, and we will face a wave of disease and death in our immediate future. Health provision has been devastated, and the social consequences arising from employment loss will simply make things worse. COVID-19 is very serious, however, the lack of a coherent strategy to address and mitigate all the other health issues will mean far more people will die from the consequences of the lockdown than COVID, unless something is done urgently,” he said.

 

Spotlight looks at recent research showing a significant drop in antenatal and follow-up visits to health facilities during South Africa’s COVID-19 lockdown.

Spotlight reports that to help understand these statistics, Tiyese Jeranji spoke to health workers as well as new and expecting mothers about being pregnant during a pandemic.

The National Income Dynamics Study – Coronavirus Rapid Mobile Survey (NIDS-Cram) showed that antenatal and follow-up visits after birth dropped significantly during lockdown. Of the 3,140 women surveyed, 16% reported that they last visited a health facility in April or earlier.

“This represents a two-month gap in care, which is considered to be a risk for this group of women – but would admittedly vary substantially based on the individual’s health,” reads one of a series of papers published with the NIDS-Cram data.

Just more than half (58%) of these respondents reported attending a healthcare facility in June and 24% in May. Fear of contracting COVID-19 was cited by some 40% of the surveyed mothers as being among the reasons for the drop in antenatal and post-natal visits. “Missing these critical visits as found in our study, especially in the last trimester of pregnancy when blood pressure levels may be increasing and pre-eclampsia developing, can lead to longer-term health impacts for both mother and baby,” the paper reads.

Also, of concern is that about 11% of mothers living with HIV ran out of antiretroviral therapy and about 5% of mothers whose children needed care or vaccinations did not seek such care.

Spotlight reports that hospitals like Mowbray Maternity Hospital had to adapt. Sarah Willemse, who has been a midwife at Mowbray Maternity Hospital for more than 28 years, says COVID-19 poses many challenges for the healthcare system, and midwifery is no exception.

“We face the fear of the unknown daily. Limited physical contact creates a unique challenge in the care of a person under investigation (PUI) or positive patient. We now have to adapt our specialty as physical contact forms the cornerstone of care. Many changes had to be made to the maternity ward, including special isolation rooms and patient social distancing. Patients and healthcare workers are now required to wear masks at all times, which makes communicating very challenging. COVID PUIs and positive patients require special equipment which cannot be used on other patients,” says Willemse. She says multiple measures and operating procedures are now in place to ensure the safety of staff and patients.

Karen Wilmot, a virtual midwife, says in the report she has seen an increase in the number of expecting mothers seeking her help and she has supported most of her clients 24/7. “The demand had definitely increased because of the pandemic. It is not just about the fear of being pregnant in the pandemic, but also what kind of support there is when the mother gets to the hospital. I think everybody has fears and decisions are made based on fear,” she says.

Spotlight reports that with a limited number of people allowed in the hospital, most mothers who had planned to have birthing doulas by their side now have to go through the process alone or with only their partners if they are lucky to make it inside. A doula is trained to support expecting mothers emotionally and physically throughout their pregnancy, but is not a medical professional.

“Doulas have been so great at supporting the moms and they have a deep understanding of the hospital system. They understand the birthing environment and they have also become advocates. They understand all things that happen at the hospital. They know how things work and they can manage and understand procedures. (However, because of) the pandemic they are not allowed in hospitals and new moms have to do this alone, with little or no understanding of the hospital system. This has left most moms frustrated, but it is what it is. We have to learn new ways to support mothers,” Wilmot says.

In an effort to put expecting mothers and new moms at ease, the Perinatal Mental Health Project – a non-profit entity based at the University of Cape Town which provides mental health services for pregnant and postnatal women, and trains those who work with mothers to improve the quality of their care – together with other organisations and experts have teamed up to offer support to mothers through an initiative called Messages for Mothers Alliance.

Spotlight reports that one of the messages to mothers is timely, given the NIDS-Cram findings: “Pregnant women should continue attending their planned antenatal visits,” and “wear a cloth mask. When you arrive at the facility, you will be asked questions about COVID-19, have your temperature checked and asked to use hand sanitiser.”

Willemse says such reassurance is key to preventing panic and the spread of misinformation.

 

Full Spotlight report

 

Full Spotlight report

 

CRAM survey

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