Mothers in low- and middle-income countries face substantial challenges in accessing quality care. The COVID-19 pandemic is exacerbating these challenges, disrupting essential maternal and newborn services, with likely impacts on morbidity and mortality beyond what is directly attributable to the virus. In a recent blog published on Medium, modelers estimated that the four most populous low- and middle-income countries (India, Indonesia, Nigeria, and Pakistan) alone could see an additional 766,180 (a 31% increase) maternal and newborn deaths and stillbirths as a result of reduced family planning use, antenatal care visits, and facility-based deliveries in the next 12 months – the indirect impact of the COVID-19 pandemic.
On April 21, a group of MNCH practitioners from Nepal, Bangladesh, Nigeria, Uganda, and Brazil shared their recent experiences – the trends they are seeing, the challenges being encountered, and the solutions being implemented to ensure essential maternal and newborn health services continue to be available and accessible during the COVID-19 crisis. What these experts are reporting anecdotally seems to confirm that while countries are taking actions to mitigate the negative impact on MNCH, more needs to be done to develop, implement, and capture lessons learned from strategies to ensure continuity of care.
Are women still coming to health facilities for antenatal care (ANC) services and delivery?
In all five settings, to different degrees, panelists observed that fewer women are attending antenatal care (ANC) services, and women are arriving at facilities later and with serious complications such as eclampsia that they feel may be related to reluctance to attend ANC, delays in seeking delivery care, difficulties in accessing transportation, and facility-based challenges to provision of maternity services, all related to COVID-19. Most countries are seeing a decrease in numbers of deliveries in facilities, and Dr. Peter Waiswa, from the Makerere University Maternal, Newborn and Child Health Center of excellence in Uganda anecdotally shared,” there are reports that more women are delivering at home with traditional birth attendants (TBAs)”, though there is no indication that anyone is supporting TBAs to adjust their practices during COVID-19.
What challenges are women facing in traveling to health facilities for ANC, labor, delivery, & postnatal care?
COVID-19- related lockdowns, curfews, and public transport shut-downs have exacerbated challenges with accessing transportation services in both rural and urban areas, inhibiting the ability of both pregnant women and providers to get to health facilities. Even when private transportation options are available, many families are struggling to find money to pay for it. As a result, women in labor are waiting for ambulances, which were in short supply before COVID-19, and which are now quickly becoming overwhelmed. The resulting delays are thought to be contributing to later arrivals at referral facilities with worsened conditions. Context-specific solutions such as identification cards for taxi drivers to exempt them from lockdown, purchasing (or renting) ambulances from the private sector to help transport women to facilities, and subsidization of fuel costs are being adopted.
How are MNCH health services and practices being adapted?
Governments and frontline health workers are now also thinking about how to reconfigure and reorganize services to ensure continuity of care during the COVID-19 pandemic. Examples of adapting services include discontinuing group ANC visits, scheduling individual ANC appointments with longer intervals between appointments, and shifting appointments to the afternoons when clinics are typically less crowded. Providers in Brazil are utilizing WhatsApp to reassure women and to encourage them to continue their ANC visits.
Historically, overcrowded maternity services make infection control difficult. Advice hotlines and telemedicine visits are being utilized to facilitate triage and reduce the number of unnecessary facility visits. Health workers are adapting services so that admissions are shorter, and screening women for COVID-19 is widely done, although testing remains limited.
How are health workers coping?
The media attention on COVID-19 crosses all borders, and health workers are watching what is happening in much better-resourced health systems and wondering what will happen to them. Healthcare providers, including community health workers, health extension workers, and ambulance drivers, fear for their own health and are scared about the lack of personal protective equipment (PPE). Health workers posted in rural areas are isolated and unable to travel to see their families. In some settings, provider absenteeism and retention are becoming huge challenges.
Panelists indicated that a large number of healthcare workers are testing positive for COVID-19. To ensure the appropriate actions are taken swiftly, it is critical to understand the reasons for this in each setting. Protocols need to be put in place to ensure the safety of all healthcare workers, community volunteers and transport workers, including receipt of appropriate training and PPE.
How is COVID-19 affecting the provision of respectful maternal and newborn care?
Given the challenges posed by COVID-19, there is a concern in some settings that respectful maternal and newborn care is suffering. For example, in many settings women are no longer allowed birth companions during delivery, in an apparent attempt to reduce exposure to the coronavirus. However, these restrictions seem to overlook the established evidence that birth companions improve birth outcomes. Furthermore, screening of women (for fever, cough or contact with someone exposed to COVID-19) has been widely introduced based on the underlying principle that every patient might be infected, but the increasing stigma associated with COVID-19 leaves many women wanting to hide their potential COVID-19 exposure or travel history. Participants raised the following questions for further exploration: What protections and messages are being put in place to address these issues? Can service contacts be leveraged to screen and refer for other problems which seem to be exacerbated by the COVID-19 pandemic, such as gender-based violence?
How can adaptive learning strategies support the continuity of MNCH services?
Health systems are grappling with COVID-19 on top of other public health challenges, and the need for maternal and child health services to support women and children to survive and thrive remains constant across all countries. It is critical, therefore, to think about what happens to routine services and support rapid adjustments that can be made to those services to minimize the loss of life from reduced care-seeking during the COVID-19 pandemic.
Collaborative efforts involving government, academia, public and private healthcare providers, funders, and beneficiaries are necessary to identify problems as they are developing and make timely adjustments. For this, national, subnational, and facility data systems need to be developed, strengthened, or supplemented to support documentation of the impact of COVID-19 on health services, including transport. By capturing data and sharing lessons learned on how countries are implementing the Guidelines for Maintaining Essential Services during an Outbreak, we can inform progress during this pandemic and improve preparedness for future pandemics.
Finally, a big thank you to the panelists who participated in this forum:
- Dr. Sandra Valongueiro, Brazil
- Dr Keya Farida Yasmin, Bangladesh
- Dr Bea Ambauen-Berger, Bangladesh
- Dr. Abha Shrestha, Nepal
- Dr. Michael Ezeanochie, Nigeria
- Dr. Peter Waiswa, Uganda
- Dr. Seun Aladesanmi, CHAI
The reflections provided and questions raised during the webinar are just a small piece of the dialogue. We encourage everyone to continue the technical exchange and learning by joining the Care-Seeking & Referral Community of Practice.