African governments could face lawsuits arising from maternal deaths caused by COVID-19 restrictions, human rights lawyers have warned today.

As part of a major global investigation, openDemocracy today reveals “alarming” evidence of deaths and unsafe births across Africa during the pandemic, in circumstances that contravene World Health Organization (WHO) guidelines and national laws.

In some cases, COVID-19 transport bans prevented women from getting to hospital in time during emergencies, while other health workers fearing coronavirus infection shunned or refused to treat pregnant women in emergencies.

“You can be sure, cases are going to be filed,” Nelly Warega, a lawyer in Nairobi, Kenya with the Women’s Link Worldwide NGO, told openDemocracy. She said governments were required by the African Union’s Maputo Protocol to ensure their pandemic emergency measures protected women’s rights.

The Kenyan government is already being sued over forced quarantine during COVID-19. As part of that case, filed on 2 July by Women’s Link Worldwide and twelve other petitioners, the government has been asked to provide, as a matter of urgency, information about aspects of its pandemic response that some of the petitioners claim endangered pregnant women’s lives.

Women’s Link Worldwide said in its affidavit that the Kenyan government has failed to provide “clear and comprehensive” information in response to what was “reported by a number of media outlets that women and girls in Kenya are failing to access health care facilities” because of COVID-19 curfews.

Pregnant women who need medical attention have been staying at home “because they don’t know if they can go to hospitals or must stay at home,” added lawyer Nerima Were, who represents a number of the other petitioners, including the Kenya Legal and Ethical Issues Network on HIV/Aids.

These problems are not unique to Kenya. While tracking the impact of COVID-19 restrictions on women giving birth around the world, openDemocracy has identified reports in 45 countries of how women’s access to timely, high-quality and respectful maternity care has been hindered during the pandemic.

In Ethiopia, Kenya, Sierra Leone, Uganda and Zimbabwe, openDemocracy has compiled reports of women dying, resorting to dangerous home births or missing antenatal care after governments banned or restricted transport.

In Latin America, pregnant women in labour and distress have been refused entry to overstretched hospitals, while some maternity hospitals were rededicated to the COVID-19 response without notifying their patients in advance.

Melissa Upreti, a human rights lawyer and member of a UN working group on tackling discrimination against women, called openDemocracy’s findings “shocking and disturbing”. She said: “Denying women services they need is discrimination from a legal standpoint. We have a very strong case to make… that governments are violating their own laws and policies.”

Ready for COVID-19 – but mothers dead

In Lacor, northern Uganda, staff at St Mary’s Hospital describe their facility as well prepared to take “any number of coronavirus patients”. Gynaecologist Sande Ojara says: “We have prepared our ICU and isolation ward. All staff have been trained. We do internal drills for all departments.”

Since 2000, when 224 patients including 13 staff members died from a local Ebola outbreak, this hospital has been on alert for highly infectious diseases. It is a large private facility backed by Italian charities.

As of early July, there have been no COVID deaths across Uganda, despite more than 1,000 confirmed infections.

But Ojara told openDemocracy that he attributes at least three patient deaths at his hospital to government COVID-19 measures. Three women died during childbirth, he says, “simply because of a delay in transportation”.

In April, the government imposed a ban on all public and private passenger transport, in an effort to contain the spread of the virus. This ban has now been partially lifted, but public transport remains heavily restricted. Passenger cars are only permitted if they are half-empty and motorcycle taxis are still banned.

As a result, women were unable to reach hospitals during obstetric emergencies. Some died as a result, while others gave birth by the roadside or in other unsanitary public places.

“Most of them now deliver at home,” one midwife in eastern Uganda told openDemocracy, about the pregnant women in her area.

She warned that this is dangerous for both women and babies, and described how, during the lockdown, two anaemic mothers arrived as emergency cases at her health centre after their unattended home births had resulted in excessive bleeding. (Both were referred for treatment at a hospital and survived.)

Uganda’s restrictions on movement did not apply to the “transporting of sick people including obstetric emergencies,” Uganda’s maternal and child health commissioner Jesca Nsungwa Sabiiti told openDemocracy. But she said that “this was not well understood by both the population and the police who were arresting people.”

The regulations added further complications. People travelling in a medical emergency needed written permission from a local representative of the president, which many found a “futile pain” in practice.

Warega from Women’s Link Worldwide says that African countries could be held accountable for their failings under domestic laws, and at the African Court on Human and Peoples’ Rights for violating the African Union's Maputo Protocol on women’s rights.

“I wish we didn't have to go down that route,” adds Warega. She told openDemocracy that women’s rights advocates have tried to reach out to governments and share information and offer guidance. If governments don’t respond to this, Werega says, rights advocates may be “forced to go to court”.

Sabiiti, the Ugandan health commissioner, acknowledges that women must not become “invisible or forgotten victims of this pandemic”.

But, she added, suing the government for maternal deaths would require overlooking how “readiness for a pandemic of this nature is a new thing to Uganda and even more developed countries.”

Equipment shortages and rising infections

The number of confirmed coronavirus infections on the continent is currently rising, and this is creating another obstacle for women in obstetric emergencies: the shortage of protective equipment for health care workers.

Most hospitals are not as well equipped as St Mary’s Hospital in Lacor. “The COVID capacity-building efforts have concentrated on Kampala and ports of entry and little has been done elsewhere around the country,” warned the local health rights NGO CEHURD in a report published in April.

“We are not receiving any equipment,” said the midwife in eastern Uganda. She said that COVID-19 restrictions had, in fact, halted the supply of regular medical equipment such as “cotton and gauze, which are essential for births”.

Health workers’ fear of infection is also an issue. Tracy Namagala, who gave birth in late May at a government health centre in eastern Uganda, told openDemocracy: “The health workers are afraid of us! They are very cautious and keep some distance away. You have to be visibly badly off for them to come close.”

Namagala said she went to the hospital with her mother, her planned birth companion, but staff refused to let them in because they didn’t have masks. She was eventually admitted, but her mother was turned away.

When Namagala had problems during labour, her mother was allowed into the ward, and was asked by overwhelmed staff to hand them supplies.

Namagala says the health workers seemed to avoid her until she was in serious medical trouble. “The midwife told me the baby was coming out legs first [a breech birth] and called the doctor, but he wasn’t around,” she recalls. To avoid a high-risk breech birth, doctors usually perform a C-section.

Instead, the midwife gave her an episiotomy (cut her vaginal opening) – without pain relief. Namagala thinks this would not have been necessary if she had been attended to earlier.

UN development goals off track

openDemocracy has identified cases in at least 45 countries of pregnant women who have been denied services or treated in ways that defy World Health Organization childbirth guidance during the pandemic.

Women, doctors and maternal health advocates around the world told openDemocracy about forcible separation from newborns; being forced to give birth “alone”; pain medication being withheld; and procedures including C-sections being performed not because they were medically necessary but because of “misguided” policies to get women out of hospitals faster.

Before COVID-19, most of the African continent was already off track for meeting UN development goals to dramatically reduce maternal and infant deaths by 2030. Sabiiti, the Ugandan health commissioner, now warns that the pandemic is “likely to delay their attainment” even further.

“We cannot lose sight of maternal and child health goals [during the pandemic] because the consequences could be catastrophic,” Emily Carter from Johns Hopkins University in the US told openDemocracy. She recently co-authored an article in The Lancet which predicted that lockdowns and other pandemic restrictions would kill tens of thousands of women around the world.