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The Changing Aspects of Motherhood in Face of the COVID-19 Pandemic in Low- and Middle-Income Countries

The Changing Aspects of Motherhood in Face of the COVID-19 Pandemic in Low- and Middle-Income... Purpose To advocate perspectives to strengthen existing healthcare systems to prioritize maternal health services amidst and beyond the COVID-19 pandemic in low- and middle income countries. Description COVID-19 directly affects pregnant women causing more severe disease and adverse pregnancy outcomes. The indirect effects due to the monumental COVID-19 response are much worse, increasing maternal and neonatal mortality. Assessment Amidst COVID-19, governments must balance effective COVID-19 response measures while continuing deliv - ery of essential health services. Using the World Health Organization’s operational guidelines as a base, countries must conduct contextualized analyses to tailor their operations. Evidence based information on different services and comparative cost-benefits will help decisions on trade-offs. Situational analyses identifying extent and reasons for service disruptions and estimates of impacts using modelling techniques will guide prioritization of services. Ensuring adequate supplies, maintaining core interventions, expanding non-physician workforce and deploying telehealth are some adaptive measures to optimize care. Beyond the COVID-19 pandemic, governments must reinvest in maternal and child health by building more resilient maternal health services supported by political commitmentand multisectoral engagement, and with assistance from international partners. Conclusions Multi-sectoral investments providing high-quality care that ensures continuity and available to all segments of the population are needed. A robust primary healthcare system linked to specialist care and accessible to all segments of the population including marginalized subgroups is of paramount importance. Systematic approaches to digital health care solutions to bridge gaps in service is imperative. Future pandemic preparedness programs must include action plans for resilient maternal health services. Keyword Maternal and child health · Covid 19 · Pandemic · Pregnant women · Preparedness Significance Statement What is Already Know on this Subject? * Jennifer Prince Kingsley The direct effects of COVID-19 on pregnant women include jennypk@uab.edu more severe disease and increased risk of adverse pregnancy Paul Kingsley Vijay outcomes such as preterm births. The indirect effects from paulkvijay@gmail.com barriers to health services are more severe exacerbating Jacob Kumaresan maternal/neonatal morbidity and mortality particularly in jacobkumaresan@yahoo.com low- and middle-income countries, with vulnerable sub- Nalini Sathiakumar groups affected the most. nalini@uab.edu What this Study Adds? Department of Epidemiology, University of Alabama at Birmingham, Birmingham, USA We advocate perspectives to strengthen existing healthcare Clinic Qualitas, Johor Bahru, Malaysia systems to prioritize maternal health services amidst and Former WHO Executive Director, New York, USA Vol.:(0123456789) 1 3 Maternal and Child Health Journal beyond the COVID-19 pandemic. Multi-sectoral investments 1.5 times more likely to be admitted to the intensive care unit providing high-quality care that ensures continuity and avail- and to receive mechanical ventilation, but the risk of death able to all segments of the population are needed. was similar (0.2% for both). Data from the CDC COVID- NET on hospitalized pregnant women (n = 598) from 13 US states during March to August 2020 with laboratory- Introduction confirmed COVID-19 found that severe illness occurred among symptomatic pregnant women (n = 272) including Since December 2019, the world is reeling from a pandemic intensive care admissions (16%), mechanical ventilation of titanic proportions due to Corona Virus Disease 2019 (8%) and death (1%) compared to 0% of these characteristics (COVID-19) caused by severe acute respiratory syndrome among asymptomatic pregnant women (n = 326) (Delahoy coronavirus 2 (SARS-CoV-2) (WHO 2020a). As of Octo- et al. 2020). Compared to asymptomatic pregnant women, ber 2020, COVID-19 has infected almost 35 million people symptomatic pregnant women had higher occurrences of and has caused more than 1,000,000 deaths globally (JHU pregnancy loss (5% vs. 0.9%) and newborn death (1.5% vs. 2020). Eo ff rts to stem the COVID-19 pandemic has exposed 0%). A cohort of 1,009 pregnant women going into labor at every country’s existing social, economic, geographic and one of 45 hospitals in Spain during March to May 2020 and health care access inequalities on an unprecedented scale. who were screened for SARS-Co-V-2 was followed up until The weak health infrastructures coupled with endemic dis- six weeks post-partum; 246 tested positive and 763 tested eases and malnutrition in low- and middle-income countries negative (Perez et al. 2020). Compared to the COVID-19 (LMICs) has further deepened such inequities. negative women, COVID-19 positive women had a signifi- cant two-fold increase in preterm births, 1.7-fold increase in premature rupture of membranes at term and 4.6-fold COVID‑19 and Pregnancy increase in neonatal intensive care unit (NICU) admissions. Prematurity and respiratory distress were the main causes Direct Eec ff ts of admission to the NICU. Few other studies, based on small numbers of subjects, The World Health Organization (WHO) classifies pregnant provide additional information. Chen et al. (2020) found women as an important subgroup of the population that are no evidence of a vertical transmission based on data on six most vulnerable in the event of a pandemic or a disaster, pregnant women with COVID-19 pneumonia in the third taking a relatively high share of the disease and associated trimester. Compared to controls, third trimester placentas emergencies (WHO 2002). Viral disease pandemics in the in 16 women positive for SARS-CoV-2 were found to show past such as the Severe Acute Respiratory Syndrome (SARS) features of maternal vascular mal-perfusion (Shanes et al. in 2002–2003 which originated in the Guangdong province 2020). Newborns (n = 10) born to mothers with COVID- of China and the Middle Eastern Respiratory Syndrome 19 exhibited adverse perinatal outcomes such as fetal dis- (MERS) in 2012 which originated in Saudi Arabia (also tress, respiratory distress, thrombocytopenia accompanied caused by coronaviruses) were associated with adverse preg- by abnormal liver function, and one died (Zhu et al. 2020). nancy outcomes. SARS was associated spontaneous mis- Groß et al. (2020) isolated SARS-CoV-2 from one of two carriages, preterm deliveries, intrauterine growth retarda- nursing mothers with COVID-19. Further longitudinal data tion (IUGR), intensive care hospitalization, and a maternal from larger study sizes would be required to confirm the mortality of 30% (Maxwell et al. 2017). MERS had similar findings from the above studies. adverse pregnancy outcomes with a maternal mortality of The CDC recommends that pregnant women should be 27% and a neonatal mortality of 27% (Alfaraj et al. 2019). aware of their potential risk for severe COVID-19 illness and There was no evidence of an intrauterine transmission of emphasizes that they take all necessary precautions to avoid either SARS-CoV or MERS-CoV (Schwatz et al. 2020). exposure to COVID-19; potential barriers to adherence to Pregnant women are known to be at an increased risk COVID-19 prevention measures should be addressed (CDC for more severe illness from respiratory infections due to 2020a). Although breast feeding has not been shown con- their immunologic and physiologic changes that occur dur- clusively to transmit the virus, the CDC recommends breast ing pregnancy (Rasmussen et al. 2011). Using COVID-19 feeding of infants if the mother is asymptomatic in view of surveillance data from January to June 2020, the Centers for the benefits of breast milk. Disease Control and Prevention (CDC) compared data on pregnant (n = 8207) and nonpregnant (n = 83,205) women Indirect Eec ff ts who tested positive for SARS-Co-V-2 (Ellington et al. 2020). Compared to nonpregnant women, pregnant women were Governments around the world have responded to the more likely to be hospitalized (31.5% vs. 5.8%), and to be COVID-19 crisis by implementing monumental measures to 1 3 Maternal and Child Health Journal prevent transmission of infection and to treat infected cases. continue to provide maternal health services despite lack Such response measures have impacted maternal and neona- of supplies such as PPEs (Awasthi, 2020); scarcity of tal health negatively and exacerbated the existing inequali- resources pose additional burden on these workers who ties within societies. Prior to the COVID-19 pandemic, high- work in an atmosphere of fear and anxiety of contracting quality and timely maternal health services were unavailable the disease. Several frontline workers and support per- or inaccessible to large proportions of women in LMICs of sonnel have been infected with COVID-19 (Nguyen et al. very low to low socioeconomic status and those living in 2020). rural areas (Bong et al. 2020). The COVID-19 response has further compromised these services. Lockdowns/Quarantine Disruption of Maternal Health Services Most LMICs implemented rigorous strategies to limit the With the draconian measures required for COVID-19 con- spread of infection via national lockdowns (stay-at-home or tainment, countries are facing major challenges to maintain movement control order) along with suspension of public the provision and continuity of essential services for preg- transportation. In most LMICs, the poorest families may nant women and newborns. High-income countries (HICs) typically share a single-room dwelling with eight to 10 focused on testing, hospitalization and intensive care, can- family members, use a public bathroom and have limited celling “non-essential” services such as elective surgeries, access to public water supply (Madhav et al. 2017). Thus, restructuring maternity and other wards to treat COVID-19 “social distancing” and hand hygiene practices may not be patients and switching to virtual care when possible (Hart an option and family members have a high likelihood of et  al. 2020). In LMICs with fewer resources and limited contracting and spreading infection, with pregnant women intensive care capacity, governments downscaled or closed and their newborns being particularly vulnerable. Further, regular maternal health services. As per the WHO, essen- lockdowns/suspended transportation measures have reduced tial services have been disrupted, ranging from 24 to 64% access to care especially among vulnerable groups most in (WHO 2020b). Further, women with high-risk pregnancies need of care. Further, fear of contracting COVID-19 may have limited access to specially trained providers at second- cause delays in seeking care. During the Ebola epidemic ary or tertiary care facilities, negatively impacting maternal in West Africa in 2014–2016, pregnant women had fewer and neonatal morbidity and mortality (Kapur et al. 2015); or no antenatal care visits and delivered at home for fear common causes of high-risk pregnancies include obstructed of contracting the infection (Sochas et al. 2017). Lack of labor, post-partum hemorrhage, sepsis and maternal non- access to care is particularly life-threatening for high-risk communicable diseases (NCDs) such as hyperglycemia in pregnancies and obstetric emergencies. Mental disorders, pregnancy, hypertensive disorders of pregnancy, anemia intimate partner violence (IPV) and poverty are other prob- etc. An analysis of data collected from national surveys in lems associated with lockdown measures and consequent 132 LMICs in Africa, Asia, Eastern and Southern Europe, economic losses. Mental disorders— Worldwide, about Latin America, and Caribbean reports that an additional 1.7 10% of pregnant women and 13% of women in the post- million pregnant women and 2.6 million newborns would partum period develop a mental disorder with LMICs hav- experience major complications and not receive the care they ing a higher occurrence of 15.6% and 19.8%, respectively need during the COVID-19 pandemic (Riley et al. 2020). (WHO 2015a). As depression and anxiety have escalated with the COVID-19 pandemic, the looming mental health Diversion of Resources crisis is expected to emerge as a major public health problem (Topalidou et al. 2020). IPV - Estimates from the United Governments have diverted health care resources to Nations Population Fund indicate that every three months COVID-19 response efforts at the expense of several of quarantine will result in a 20% increase in IPV through- essential services including maternal and child health ser- out the world with at least 15 million additional cases of vices; these resources include budgets, personnel, medica- IPV (Stanley 2020). Social isolation is the major risk factor tions, personal protective equipment (PPEs), infection con- followed by unemployment and anxiety. IPV victims are at trol supplies (disinfectants, sanitizers) etc. In most LMICs, risk of unwanted pregnancies and associated complications with most health care workers diverted to COVID-19 care, (Kaur 2020). Poverty− COVID-19 is pushing almost 70 mil- local midwives and community health workers (CHWs) lion people into poverty (Mahler et al. 2020). Poverty is have been the backbone in maintaining routine mater- associated with increased risks for preterm labor and deliv- nal health services. In India, Accredited Social Health ery, IUGR and neonatal death. The early child health con- Activists (ASHA) workers instituted by the government’s sequences of poverty often sets a newborn on a life-course Ministry of Health for the National Rural Health Program of health disparities (Larson et al. 2007). 1 3 Maternal and Child Health Journal Maternal and Neonatal Mortality deaths/1000 live births (WHO 2015b). The global progress towards these targets is lagging. Failure to prioritize mater- During the ongoing COVID-19 crisis, women in LMICs nal health during the COVID-19 pandemic would reverse are more likely to deliver at home without a skilled birth the gains made in MMR and NMR during the past decade. attendant leading to deaths from treatable and preventable The impact would be enormous for LMICs and marginalized conditions. In the case of the Ebola epidemic in West Africa, populations within them. maternal and neonatal deaths and stillbirths indirectly caused Policymakers in LMICs face the major dilemma of bal- by the epidemic outnumbered direct Ebola-related deaths ancing effective COVID-19 response measures with con- (4000 vs. 3600) (Sochas et al. 2017); indirect causes were tinued delivery of essential health services because of their primarily due to disruption or shutdown of maternal health low-resilience health systems. These efforts will require services. A similar scenario is observed for the COVID-19 sufficient financial and technical resources. International pandemic; the indirect effects of COVID-19 response are funding partners have stepped up to provide some sup- of great concern. A study done across in 118 LMICs using port, necessitating LMICs to maximize their resources. the Lives Saved Tool (LiST) estimated that COVID-related In implementing action plans, the WHO’s operational maternal health service coverage reduction of 9.8%–18.5% planning guidelines for maintaining essential services at over six months would result in 12,200 additional mater- national, regional and local levels during the COVID-19 nal deaths (Robertson et al. 2020). Coverage reductions of pandemic will form the base (WHO 2020c). As resources 39.3%–51.9% over 6 months, considered a more serious sce- and disease burdens differ by country, decision makers in nario, would result in 56,700 additional maternal deaths. each country must conduct contextualized analysis to tailor The additional deaths represent an 8.3 to 38.6% increase in operations to prioritize eessential services with trade-offs on maternal deaths per month. strategy of other services of a lesser priority to ensure that Countries with the expected highest numbers of births limited resources provide maximum benefit for the popula- beginning nine months since the beginning of the COVID-19 tion. Evidence-based information on different services and pandemic include India (20.1 million), China (13.5 million), comparative cost-benefits will guide these decisions; global Nigeria (6.4 million), Pakistan (5 million) and Indonesia (4 development partners play a major role in providing techni- million); these countries had high maternal and neonatal cal assistance in this process. mortality rates prior to the pandemic (Stein, et al, 2020). If essential maternal and neonatal services decline consistently Identifying Extent and Reasons for Service Disruptions in LMICs, it is estimated that an additional 31,980 mater- and Impacts nal deaths, 395,440 newborn deaths and 338,760 stillbirths would occur, corresponding to a 31% increase in mortality An initial step would be a situational analysis with quantita- in these indicators. tive and qualitative components conducted among stakehold- ers including local experts and community members. The extent and reasons for service disruptions in the continuum Perspectives to Maintain and Strengthen of maternal health services from antenatal care, delivery and Maternal Health Services postnatal/neonatal care must be ascertained. Projection mod- elling tools are valuable in providing quantitative estimates Amidst the COVID‑19 Pandemic of impacts of service disruptions on maternal and neonatal morbidity and mortality. In evaluating the impact of disrup- Maternal and neonatal mortality rates are key indicators tion of specific services, comparative analysis of COVID- of the health and infrastructure of a country and govern- specific health benefits may be weighed against the greater ments across the world have strived to improve the health of health benefits of continuing such services. Health impacts pregnant women and newborns. In 2015, the United Nations on frontline health workers, who are critical resources in the (UN) reviewed the Millennium Development Goal (MDG) health care system, will provide the basis to ensure adequate 5 to reduce global maternal mortality ratio (MMR) by 75% resources to minimize their exposures. Stratifying all analy- and found that only few countries had achieved this target. ses by population subgroups will help in identifying vulner- In the same year, the UN Summit for Sustainable Develop- able groups for the purpose of ensuring inclusive services ment, adopted 17 Sustainable Development Goals (SDGs) that reduce inequities. for 2030: SDG 3 targets reducing the global MMR to no more than 70 maternal deaths/100,000 live births, with a Adaptation of Strategies to Optimize Services supplementary national target that no country should have an MMR greater than 140/100,000 live births, and reducing National governance should prioritize maternal and neo- the neonatal mortality rate (NMR) to no more than 12 infant natal services, issue specific and practical guidance on 1 3 Maternal and Child Health Journal the maintenance of services and monitor the continuity period. Implementing appropriate policies will be chal- and access to services. Prioritizing maternal and neona- lenging and will require political commitment and mul- tal services as “essential” will enable all pregnant women tisectoral engagement. In addressing the historic under- including those with suspected or confirmed COVID-19 investment in maternal and child health, LMICs must to continue antenatal care visits, deliver in a functional build new partnerships and expand international funding facility with a skilled birth attendant and have access to partners. Investments that will generate the greatest ben- post-natal and neonatal care. Health care systems must be efit should be prioritized based on evidence-based data. well-equipped to provide emergency antenatal, natal and The consequences of poor maternal and child health with postnatal care. It is crucial to include targeted plans for vul- adverse trajectories extending to adulthood and to the next nerable subgroups of the population who are most at high generation (eg. maternal malnutrition leads to childhood risk for both the direct and the indirect effects of COVID-19. stunting and low educational attainment in adulthood, low Some approaches include: (1) Provision of adequate supplies birthweight predisposing to NCDs in adult life etc.) must including PPEs and disinfectants, and ensuring continuity factor in these decisions. A robust primary healthcare of essential medications. (2) Maintaining core maternal and system linked to specialist care and accessible to all seg- child interventions that are known to prevent deaths. Some ments of the population including marginalized subgroups examples are: parenteral administration of uterotonics, anti- is paramount to optimizing maternal and neonatal health. biotics, anticonvulsants and clean birth environments pre- Developing systematic approaches to digital health care vent 60% of additional maternal deaths; coverage of antibiot- solutions to bridge gaps in service is imperative. Action ics for neonatal sepsis and pneumonia and oral rehydration plans for resilient maternal health services should be inte- for diarrhea prevent 41% of additional neonatal deaths (Rob- gral in future pandemic preparedness programs. ertson et al. 2020). (3) Mobilizing CHWs to provide educa- tion, triaging and referrals for COVID-19 supported with sufficient funding, technical support and more personnel. (4) COVID-dedicated clinics and wards for the care of pregnant Conclusions women who are COVID-19 positive with separate entrances and restricted access to visitors (CDC 2020b). (5) Deploy- As aptly summed up by Henrietta Fore, UNICEF Exec- ing telehealth and other digital tools. In LMICs, cell phone utive Director, “Millions of mothers all over the world penetration is about 90% in recent years and mobile inter- embarked on a journey of parenthood in the world as it net connectivity is around 40% (Feroz et al. 2020). LMICs was. They now must prepare to bring a life into the world have used mHealth extensively for education and prevention as it has become—a world where expecting mothers are measures for COVID-19. For vulnerable subgroups with no afraid to go to health centers for fear of getting infected, access to cell phones, alternative strategies such as cam- or missing out on emergency care due to strained health paigns should be considered. Use of mobile phone-based services and lockdowns. It is hard to imagine how much telehealth measures to replace in-person consults provide the coronavirus pandemic has recast motherhood” (Africa scope for innovation and experimentation for maintaining News 2020). While it is necessary to focus on the current continuity of services and referrals. (6) Mental health ser- crisis, maternal health must be protected through research, vices should be a part of the agenda with stepping up of advocacy and practice. The pandemic gives us the unique services to tackle the increased demands and integrated into opportunity to reassess and address the disparities in primary healthcare. (7) Transparent communications with our society. Being vigilant and sensitive to the changing the public and strong community engagement to maintain needs is crucial to maintain continuity of care for pregnant people’s trust in the system to facilitate their seeking care women and to provide for the next generation coming into when appropriate, and adhering to public health advice. the world in such tumultuous times. Beyond the COVID‑19 Pandemic Authors Contribution JPK designed the review and drafted the article. PKV contributed to the revision and re-drafting of the article. JK and Beyond COVID-19, LMIC governments will look at new NS reviewed it for intellectual content and approved the version to be ways to develop innovative programs and strategies to published. reduce the vast inequalities and build more resilient and inclusive societies. It is clear that a focus on maternal and Funding None. child health will promote later resilience. 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The Changing Aspects of Motherhood in Face of the COVID-19 Pandemic in Low- and Middle-Income Countries

Maternal and Child Health JournalNov 26, 2020

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Pubmed Central
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© Springer Science+Business Media, LLC, part of Springer Nature 2020
ISSN
1092-7875
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1573-6628
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10.1007/s10995-020-03044-9
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Abstract

Purpose To advocate perspectives to strengthen existing healthcare systems to prioritize maternal health services amidst and beyond the COVID-19 pandemic in low- and middle income countries. Description COVID-19 directly affects pregnant women causing more severe disease and adverse pregnancy outcomes. The indirect effects due to the monumental COVID-19 response are much worse, increasing maternal and neonatal mortality. Assessment Amidst COVID-19, governments must balance effective COVID-19 response measures while continuing deliv - ery of essential health services. Using the World Health Organization’s operational guidelines as a base, countries must conduct contextualized analyses to tailor their operations. Evidence based information on different services and comparative cost-benefits will help decisions on trade-offs. Situational analyses identifying extent and reasons for service disruptions and estimates of impacts using modelling techniques will guide prioritization of services. Ensuring adequate supplies, maintaining core interventions, expanding non-physician workforce and deploying telehealth are some adaptive measures to optimize care. Beyond the COVID-19 pandemic, governments must reinvest in maternal and child health by building more resilient maternal health services supported by political commitmentand multisectoral engagement, and with assistance from international partners. Conclusions Multi-sectoral investments providing high-quality care that ensures continuity and available to all segments of the population are needed. A robust primary healthcare system linked to specialist care and accessible to all segments of the population including marginalized subgroups is of paramount importance. Systematic approaches to digital health care solutions to bridge gaps in service is imperative. Future pandemic preparedness programs must include action plans for resilient maternal health services. Keyword Maternal and child health · Covid 19 · Pandemic · Pregnant women · Preparedness Significance Statement What is Already Know on this Subject? * Jennifer Prince Kingsley The direct effects of COVID-19 on pregnant women include jennypk@uab.edu more severe disease and increased risk of adverse pregnancy Paul Kingsley Vijay outcomes such as preterm births. The indirect effects from paulkvijay@gmail.com barriers to health services are more severe exacerbating Jacob Kumaresan maternal/neonatal morbidity and mortality particularly in jacobkumaresan@yahoo.com low- and middle-income countries, with vulnerable sub- Nalini Sathiakumar groups affected the most. nalini@uab.edu What this Study Adds? Department of Epidemiology, University of Alabama at Birmingham, Birmingham, USA We advocate perspectives to strengthen existing healthcare Clinic Qualitas, Johor Bahru, Malaysia systems to prioritize maternal health services amidst and Former WHO Executive Director, New York, USA Vol.:(0123456789) 1 3 Maternal and Child Health Journal beyond the COVID-19 pandemic. Multi-sectoral investments 1.5 times more likely to be admitted to the intensive care unit providing high-quality care that ensures continuity and avail- and to receive mechanical ventilation, but the risk of death able to all segments of the population are needed. was similar (0.2% for both). Data from the CDC COVID- NET on hospitalized pregnant women (n = 598) from 13 US states during March to August 2020 with laboratory- Introduction confirmed COVID-19 found that severe illness occurred among symptomatic pregnant women (n = 272) including Since December 2019, the world is reeling from a pandemic intensive care admissions (16%), mechanical ventilation of titanic proportions due to Corona Virus Disease 2019 (8%) and death (1%) compared to 0% of these characteristics (COVID-19) caused by severe acute respiratory syndrome among asymptomatic pregnant women (n = 326) (Delahoy coronavirus 2 (SARS-CoV-2) (WHO 2020a). As of Octo- et al. 2020). Compared to asymptomatic pregnant women, ber 2020, COVID-19 has infected almost 35 million people symptomatic pregnant women had higher occurrences of and has caused more than 1,000,000 deaths globally (JHU pregnancy loss (5% vs. 0.9%) and newborn death (1.5% vs. 2020). Eo ff rts to stem the COVID-19 pandemic has exposed 0%). A cohort of 1,009 pregnant women going into labor at every country’s existing social, economic, geographic and one of 45 hospitals in Spain during March to May 2020 and health care access inequalities on an unprecedented scale. who were screened for SARS-Co-V-2 was followed up until The weak health infrastructures coupled with endemic dis- six weeks post-partum; 246 tested positive and 763 tested eases and malnutrition in low- and middle-income countries negative (Perez et al. 2020). Compared to the COVID-19 (LMICs) has further deepened such inequities. negative women, COVID-19 positive women had a signifi- cant two-fold increase in preterm births, 1.7-fold increase in premature rupture of membranes at term and 4.6-fold COVID‑19 and Pregnancy increase in neonatal intensive care unit (NICU) admissions. Prematurity and respiratory distress were the main causes Direct Eec ff ts of admission to the NICU. Few other studies, based on small numbers of subjects, The World Health Organization (WHO) classifies pregnant provide additional information. Chen et al. (2020) found women as an important subgroup of the population that are no evidence of a vertical transmission based on data on six most vulnerable in the event of a pandemic or a disaster, pregnant women with COVID-19 pneumonia in the third taking a relatively high share of the disease and associated trimester. Compared to controls, third trimester placentas emergencies (WHO 2002). Viral disease pandemics in the in 16 women positive for SARS-CoV-2 were found to show past such as the Severe Acute Respiratory Syndrome (SARS) features of maternal vascular mal-perfusion (Shanes et al. in 2002–2003 which originated in the Guangdong province 2020). Newborns (n = 10) born to mothers with COVID- of China and the Middle Eastern Respiratory Syndrome 19 exhibited adverse perinatal outcomes such as fetal dis- (MERS) in 2012 which originated in Saudi Arabia (also tress, respiratory distress, thrombocytopenia accompanied caused by coronaviruses) were associated with adverse preg- by abnormal liver function, and one died (Zhu et al. 2020). nancy outcomes. SARS was associated spontaneous mis- Groß et al. (2020) isolated SARS-CoV-2 from one of two carriages, preterm deliveries, intrauterine growth retarda- nursing mothers with COVID-19. Further longitudinal data tion (IUGR), intensive care hospitalization, and a maternal from larger study sizes would be required to confirm the mortality of 30% (Maxwell et al. 2017). MERS had similar findings from the above studies. adverse pregnancy outcomes with a maternal mortality of The CDC recommends that pregnant women should be 27% and a neonatal mortality of 27% (Alfaraj et al. 2019). aware of their potential risk for severe COVID-19 illness and There was no evidence of an intrauterine transmission of emphasizes that they take all necessary precautions to avoid either SARS-CoV or MERS-CoV (Schwatz et al. 2020). exposure to COVID-19; potential barriers to adherence to Pregnant women are known to be at an increased risk COVID-19 prevention measures should be addressed (CDC for more severe illness from respiratory infections due to 2020a). Although breast feeding has not been shown con- their immunologic and physiologic changes that occur dur- clusively to transmit the virus, the CDC recommends breast ing pregnancy (Rasmussen et al. 2011). Using COVID-19 feeding of infants if the mother is asymptomatic in view of surveillance data from January to June 2020, the Centers for the benefits of breast milk. Disease Control and Prevention (CDC) compared data on pregnant (n = 8207) and nonpregnant (n = 83,205) women Indirect Eec ff ts who tested positive for SARS-Co-V-2 (Ellington et al. 2020). Compared to nonpregnant women, pregnant women were Governments around the world have responded to the more likely to be hospitalized (31.5% vs. 5.8%), and to be COVID-19 crisis by implementing monumental measures to 1 3 Maternal and Child Health Journal prevent transmission of infection and to treat infected cases. continue to provide maternal health services despite lack Such response measures have impacted maternal and neona- of supplies such as PPEs (Awasthi, 2020); scarcity of tal health negatively and exacerbated the existing inequali- resources pose additional burden on these workers who ties within societies. Prior to the COVID-19 pandemic, high- work in an atmosphere of fear and anxiety of contracting quality and timely maternal health services were unavailable the disease. Several frontline workers and support per- or inaccessible to large proportions of women in LMICs of sonnel have been infected with COVID-19 (Nguyen et al. very low to low socioeconomic status and those living in 2020). rural areas (Bong et al. 2020). The COVID-19 response has further compromised these services. Lockdowns/Quarantine Disruption of Maternal Health Services Most LMICs implemented rigorous strategies to limit the With the draconian measures required for COVID-19 con- spread of infection via national lockdowns (stay-at-home or tainment, countries are facing major challenges to maintain movement control order) along with suspension of public the provision and continuity of essential services for preg- transportation. In most LMICs, the poorest families may nant women and newborns. High-income countries (HICs) typically share a single-room dwelling with eight to 10 focused on testing, hospitalization and intensive care, can- family members, use a public bathroom and have limited celling “non-essential” services such as elective surgeries, access to public water supply (Madhav et al. 2017). Thus, restructuring maternity and other wards to treat COVID-19 “social distancing” and hand hygiene practices may not be patients and switching to virtual care when possible (Hart an option and family members have a high likelihood of et  al. 2020). In LMICs with fewer resources and limited contracting and spreading infection, with pregnant women intensive care capacity, governments downscaled or closed and their newborns being particularly vulnerable. Further, regular maternal health services. As per the WHO, essen- lockdowns/suspended transportation measures have reduced tial services have been disrupted, ranging from 24 to 64% access to care especially among vulnerable groups most in (WHO 2020b). Further, women with high-risk pregnancies need of care. Further, fear of contracting COVID-19 may have limited access to specially trained providers at second- cause delays in seeking care. During the Ebola epidemic ary or tertiary care facilities, negatively impacting maternal in West Africa in 2014–2016, pregnant women had fewer and neonatal morbidity and mortality (Kapur et al. 2015); or no antenatal care visits and delivered at home for fear common causes of high-risk pregnancies include obstructed of contracting the infection (Sochas et al. 2017). Lack of labor, post-partum hemorrhage, sepsis and maternal non- access to care is particularly life-threatening for high-risk communicable diseases (NCDs) such as hyperglycemia in pregnancies and obstetric emergencies. Mental disorders, pregnancy, hypertensive disorders of pregnancy, anemia intimate partner violence (IPV) and poverty are other prob- etc. An analysis of data collected from national surveys in lems associated with lockdown measures and consequent 132 LMICs in Africa, Asia, Eastern and Southern Europe, economic losses. Mental disorders— Worldwide, about Latin America, and Caribbean reports that an additional 1.7 10% of pregnant women and 13% of women in the post- million pregnant women and 2.6 million newborns would partum period develop a mental disorder with LMICs hav- experience major complications and not receive the care they ing a higher occurrence of 15.6% and 19.8%, respectively need during the COVID-19 pandemic (Riley et al. 2020). (WHO 2015a). As depression and anxiety have escalated with the COVID-19 pandemic, the looming mental health Diversion of Resources crisis is expected to emerge as a major public health problem (Topalidou et al. 2020). IPV - Estimates from the United Governments have diverted health care resources to Nations Population Fund indicate that every three months COVID-19 response efforts at the expense of several of quarantine will result in a 20% increase in IPV through- essential services including maternal and child health ser- out the world with at least 15 million additional cases of vices; these resources include budgets, personnel, medica- IPV (Stanley 2020). Social isolation is the major risk factor tions, personal protective equipment (PPEs), infection con- followed by unemployment and anxiety. IPV victims are at trol supplies (disinfectants, sanitizers) etc. In most LMICs, risk of unwanted pregnancies and associated complications with most health care workers diverted to COVID-19 care, (Kaur 2020). Poverty− COVID-19 is pushing almost 70 mil- local midwives and community health workers (CHWs) lion people into poverty (Mahler et al. 2020). Poverty is have been the backbone in maintaining routine mater- associated with increased risks for preterm labor and deliv- nal health services. In India, Accredited Social Health ery, IUGR and neonatal death. The early child health con- Activists (ASHA) workers instituted by the government’s sequences of poverty often sets a newborn on a life-course Ministry of Health for the National Rural Health Program of health disparities (Larson et al. 2007). 1 3 Maternal and Child Health Journal Maternal and Neonatal Mortality deaths/1000 live births (WHO 2015b). The global progress towards these targets is lagging. Failure to prioritize mater- During the ongoing COVID-19 crisis, women in LMICs nal health during the COVID-19 pandemic would reverse are more likely to deliver at home without a skilled birth the gains made in MMR and NMR during the past decade. attendant leading to deaths from treatable and preventable The impact would be enormous for LMICs and marginalized conditions. In the case of the Ebola epidemic in West Africa, populations within them. maternal and neonatal deaths and stillbirths indirectly caused Policymakers in LMICs face the major dilemma of bal- by the epidemic outnumbered direct Ebola-related deaths ancing effective COVID-19 response measures with con- (4000 vs. 3600) (Sochas et al. 2017); indirect causes were tinued delivery of essential health services because of their primarily due to disruption or shutdown of maternal health low-resilience health systems. These efforts will require services. A similar scenario is observed for the COVID-19 sufficient financial and technical resources. International pandemic; the indirect effects of COVID-19 response are funding partners have stepped up to provide some sup- of great concern. A study done across in 118 LMICs using port, necessitating LMICs to maximize their resources. the Lives Saved Tool (LiST) estimated that COVID-related In implementing action plans, the WHO’s operational maternal health service coverage reduction of 9.8%–18.5% planning guidelines for maintaining essential services at over six months would result in 12,200 additional mater- national, regional and local levels during the COVID-19 nal deaths (Robertson et al. 2020). Coverage reductions of pandemic will form the base (WHO 2020c). As resources 39.3%–51.9% over 6 months, considered a more serious sce- and disease burdens differ by country, decision makers in nario, would result in 56,700 additional maternal deaths. each country must conduct contextualized analysis to tailor The additional deaths represent an 8.3 to 38.6% increase in operations to prioritize eessential services with trade-offs on maternal deaths per month. strategy of other services of a lesser priority to ensure that Countries with the expected highest numbers of births limited resources provide maximum benefit for the popula- beginning nine months since the beginning of the COVID-19 tion. Evidence-based information on different services and pandemic include India (20.1 million), China (13.5 million), comparative cost-benefits will guide these decisions; global Nigeria (6.4 million), Pakistan (5 million) and Indonesia (4 development partners play a major role in providing techni- million); these countries had high maternal and neonatal cal assistance in this process. mortality rates prior to the pandemic (Stein, et al, 2020). If essential maternal and neonatal services decline consistently Identifying Extent and Reasons for Service Disruptions in LMICs, it is estimated that an additional 31,980 mater- and Impacts nal deaths, 395,440 newborn deaths and 338,760 stillbirths would occur, corresponding to a 31% increase in mortality An initial step would be a situational analysis with quantita- in these indicators. tive and qualitative components conducted among stakehold- ers including local experts and community members. The extent and reasons for service disruptions in the continuum Perspectives to Maintain and Strengthen of maternal health services from antenatal care, delivery and Maternal Health Services postnatal/neonatal care must be ascertained. Projection mod- elling tools are valuable in providing quantitative estimates Amidst the COVID‑19 Pandemic of impacts of service disruptions on maternal and neonatal morbidity and mortality. In evaluating the impact of disrup- Maternal and neonatal mortality rates are key indicators tion of specific services, comparative analysis of COVID- of the health and infrastructure of a country and govern- specific health benefits may be weighed against the greater ments across the world have strived to improve the health of health benefits of continuing such services. Health impacts pregnant women and newborns. In 2015, the United Nations on frontline health workers, who are critical resources in the (UN) reviewed the Millennium Development Goal (MDG) health care system, will provide the basis to ensure adequate 5 to reduce global maternal mortality ratio (MMR) by 75% resources to minimize their exposures. Stratifying all analy- and found that only few countries had achieved this target. ses by population subgroups will help in identifying vulner- In the same year, the UN Summit for Sustainable Develop- able groups for the purpose of ensuring inclusive services ment, adopted 17 Sustainable Development Goals (SDGs) that reduce inequities. for 2030: SDG 3 targets reducing the global MMR to no more than 70 maternal deaths/100,000 live births, with a Adaptation of Strategies to Optimize Services supplementary national target that no country should have an MMR greater than 140/100,000 live births, and reducing National governance should prioritize maternal and neo- the neonatal mortality rate (NMR) to no more than 12 infant natal services, issue specific and practical guidance on 1 3 Maternal and Child Health Journal the maintenance of services and monitor the continuity period. Implementing appropriate policies will be chal- and access to services. Prioritizing maternal and neona- lenging and will require political commitment and mul- tal services as “essential” will enable all pregnant women tisectoral engagement. In addressing the historic under- including those with suspected or confirmed COVID-19 investment in maternal and child health, LMICs must to continue antenatal care visits, deliver in a functional build new partnerships and expand international funding facility with a skilled birth attendant and have access to partners. Investments that will generate the greatest ben- post-natal and neonatal care. Health care systems must be efit should be prioritized based on evidence-based data. well-equipped to provide emergency antenatal, natal and The consequences of poor maternal and child health with postnatal care. It is crucial to include targeted plans for vul- adverse trajectories extending to adulthood and to the next nerable subgroups of the population who are most at high generation (eg. maternal malnutrition leads to childhood risk for both the direct and the indirect effects of COVID-19. stunting and low educational attainment in adulthood, low Some approaches include: (1) Provision of adequate supplies birthweight predisposing to NCDs in adult life etc.) must including PPEs and disinfectants, and ensuring continuity factor in these decisions. A robust primary healthcare of essential medications. (2) Maintaining core maternal and system linked to specialist care and accessible to all seg- child interventions that are known to prevent deaths. Some ments of the population including marginalized subgroups examples are: parenteral administration of uterotonics, anti- is paramount to optimizing maternal and neonatal health. biotics, anticonvulsants and clean birth environments pre- Developing systematic approaches to digital health care vent 60% of additional maternal deaths; coverage of antibiot- solutions to bridge gaps in service is imperative. Action ics for neonatal sepsis and pneumonia and oral rehydration plans for resilient maternal health services should be inte- for diarrhea prevent 41% of additional neonatal deaths (Rob- gral in future pandemic preparedness programs. ertson et al. 2020). (3) Mobilizing CHWs to provide educa- tion, triaging and referrals for COVID-19 supported with sufficient funding, technical support and more personnel. (4) COVID-dedicated clinics and wards for the care of pregnant Conclusions women who are COVID-19 positive with separate entrances and restricted access to visitors (CDC 2020b). (5) Deploy- As aptly summed up by Henrietta Fore, UNICEF Exec- ing telehealth and other digital tools. In LMICs, cell phone utive Director, “Millions of mothers all over the world penetration is about 90% in recent years and mobile inter- embarked on a journey of parenthood in the world as it net connectivity is around 40% (Feroz et al. 2020). LMICs was. They now must prepare to bring a life into the world have used mHealth extensively for education and prevention as it has become—a world where expecting mothers are measures for COVID-19. For vulnerable subgroups with no afraid to go to health centers for fear of getting infected, access to cell phones, alternative strategies such as cam- or missing out on emergency care due to strained health paigns should be considered. Use of mobile phone-based services and lockdowns. It is hard to imagine how much telehealth measures to replace in-person consults provide the coronavirus pandemic has recast motherhood” (Africa scope for innovation and experimentation for maintaining News 2020). While it is necessary to focus on the current continuity of services and referrals. (6) Mental health ser- crisis, maternal health must be protected through research, vices should be a part of the agenda with stepping up of advocacy and practice. The pandemic gives us the unique services to tackle the increased demands and integrated into opportunity to reassess and address the disparities in primary healthcare. (7) Transparent communications with our society. Being vigilant and sensitive to the changing the public and strong community engagement to maintain needs is crucial to maintain continuity of care for pregnant people’s trust in the system to facilitate their seeking care women and to provide for the next generation coming into when appropriate, and adhering to public health advice. the world in such tumultuous times. Beyond the COVID‑19 Pandemic Authors Contribution JPK designed the review and drafted the article. PKV contributed to the revision and re-drafting of the article. JK and Beyond COVID-19, LMIC governments will look at new NS reviewed it for intellectual content and approved the version to be ways to develop innovative programs and strategies to published. reduce the vast inequalities and build more resilient and inclusive societies. It is clear that a focus on maternal and Funding None. child health will promote later resilience. 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Published: Nov 26, 2020

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