TUNIS — Malek has been nursing for three weeks, but she still can't believe her eyes. "This birth is a small miracle," she says. "I was very afraid of the coronavirus and that something would happen to the baby."

The young mother says the anguish and confinement made her see the virus everywhere, even though she delivered her child in a private clinic where all precautions were taken. As her obstetrician, Faouzi Ariane, explains: "My facility has the strictest hygiene rules. It was especially important to manage the apprehensions of new parents."

For him, the coronavirus has not changed the well-established routine of gynecological procedures. But that's not been the case for all pregnant women. A survey conducted by the Tawhida Ben Cheikh Group and the Tunisian Association of Midwives (ATSF) found that during confinement, 10% of Tunisian women gave birth at home — far more than the usual 0.1%.

"Each birth has its own story," says Jamila, a midwife in Menzel Bourguiba, near Bizerte. "Some women had no means of transport, others were in an emergency and physically unable to move."

The anguish and confinement made her see the virus everywhere.

Jamila was even more concerned about the quality of the support she could provide to patients when she lacked the minimum equipment required.

"The equipment went first and foremost to the medical professionals dedicated to the care of COVID-19," she says. "We were able to rely on civil society to provide masks, gloves and gowns. I didn't want to be a danger to a mother-to-be, but I also wanted to protect myself because I'm in a hospital environment where no one is safe from infection."

The midwife also noted a lack of respect for patient triage and access routes in some hospitals.

"Curfews and widespread confinement, as well as the fear of contamination, create additional difficulties for women, especially during childbirth or in reproductive health emergencies," says the Tawhida Ben Cheikh Group, named after the first Tunisian woman gynecologist who pioneered family planning in the early 1960s. "There is a real risk of an increase in home deliveries and underground abortions, with the complications that can result."

There are approximately 2,200 practicing midwives in Tunisia. Together they oversee 210,000 births and nearly 1 million prenatal visits per year while dealing with the challenges of the country's reproductive health sector. From the beginning of the pandemic, maternal and neonatal health consultants as well as contraception and abortion service providers have faced obstacles.

A health worker seen at Tunis's Charles-Nicolle hospital on May 11 — Photo: Jdidi Wassim/SOPA/ZUMA

The results of the study on pregnant women are indisputable: The deterioration of sexual and reproductive health (SRH) service delivery in frontline settings is a cause for concern, as is the closure of some centers of the National Office for Family and Population (ONFP). This is due to a lack of adequate information on the virus and on protection procedures, as well as the poor dissemination of guidelines and codes of conduct. These shortcomings are at the root of the complications encountered in accessing essential sexual and reproductive health services.

Dr. Amira Yaacoubi denounces this attempt to reduce women's right to health and self-determination. "Under the pretext of the pandemic, three family planning centers have closed," she says.

Women's health is threatened by increased domestic violence, morbidity and unsafe abortions.

A midwife from Douz adds that it's also a question of inequalities between territories. She notes, for example, that the United Nations Development Program has been warning since 2012 of the persistence of maternal mortality in southern Tunisia.

"Access to healthcare is not easy. Populations are scattered and means of transport are not always available," says Dr. Hédia Belhaj, president of the Tawhida Ben Cheikh group, who is particularly concerned about the decline in family planning.

She initiated an appeal, signed by some 50 associations and 70 personalities, urging the Ministry of Health to resume frontline services, including prenatal and postnatal consultations, contraception and medical abortions.

Women's health is threatened by increased domestic violence, morbidity and unsafe abortions. Pregnant women face challenges accessing services to monitor their pregnancy and identify any potential risks. The coronavirus pandemic has only exacerbated these issues.

Dr. Belhaj attributes the deterioration in sexual and reproductive health, which began long before the pandemic, to a lack of leadership from the ONPF and government support. She also highlights the emergence of a conservatism that often conveys erroneous or ideological messages.

"Not only is contraceptive use declining due to a shortage of contraceptives, but also many women are denied abortions for non-medical reasons," she says.

*This article was translated and published with permission of the author.

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