Effect of COVID-19 on maternal and neonatal services – Authors' reply
Authors: Ashish KC, Mary V Kinney, Joy E Lawn
Journal: The Lancet Global Health (2020)

We thank Asma Khalil and colleagues, Jogender Kumar, and Deepak Jha and colleagues for their feedback in response to our analysis on the indirect effects of the COVID-19 pandemic lockdown in Nepal on intrapartum care and outcomes (preterm births, stillbirths, and neonatal mortality).1KC A Gurung R Kinney MV et al.Effect of the COVID-19 pandemic response on intrapartum care, stillbirth, and neonatal mortality outcomes in Nepal: a prospective observational study.Lancet Glob Health. 2020; 8: e1273-e1281Summary Full Text Full Text PDF PubMed Scopus (272) Google Scholar As noted by Khalil and colleagues, our study underestimated the true burden of stillbirths because the data are facility-based and we excluded women who did not have a fetal heart sound at admission and women with an antepartum stillbirth occurring before admission. Although we included stillbirths that occurred after admission, the data were not disaggregated by time of stillbirth. In Nepal, gestational age estimation is commonly based on the last menstrual period, with few women having ultrasonography-dated pregnancy. We are doing additional research now on antenatal care and associated factors. We agree with Kumar that our study provides new evidence on the indirect effect of lockdown during the pandemic and appreciate the list of queries requiring further investigation. We particularly agree that health worker to patient ratio is crucial and further investigation is underway using a subset of the sample. Further research will be needed to unpack what is needed to prevent deaths during the pandemic. Jha and colleagues contribute complementary data from Nepal's health management information system, showing a 32·6% decline in the national institutional delivery rate, which is a major disruption even if less than what was shown in our study (52·4%). Although limitations of health management information systems (eg, timeliness,2Mate KS Bennett B Mphatswe W Barker P Rollins N Challenges for routine health system data management in a large public programme to prevent mother-to-child HIV transmission in South Africa.PLoS One. 2009; 4e5483Crossref PubMed Scopus (152) Google Scholar accuracy of reporting3Day LT Gore-Langton GR Rahman AE et al.Labour and delivery ward register data availability, quality, and utility—Every Newborn—birth indicators research tracking in hospitals (EN-BIRTH) study baseline analysis in three countries.BMC Health Serv Res. 2020; 20: 737Crossref PubMed Scopus (21) Google Scholar) can be an issue, we highly value the need to invest in better routine systems to enable tracking of coverage and quality of care at a national level and especially during pandemics. Our prospective observational study was limited to the facilities that were participating in the SUSTAIN and REFINE studies, but these do account for 11·2% of national births in Nepal. We acknowledge that these results might differ over a longer study period, once the hard lockdown was eased, but we note that disruptions are ongoing. We hope that our results will be useful in guiding policy makers to help protect women and their newborn infants during the pandemic, to highlight issues that will be important to address after the pandemic, and to build a stronger health system in Nepal. Additionally, there is a pressing need for community mobilisation4KC NP KC A Sharma N et al.Community participation and mobilization in community-based maternal, newborn and child health programmes in Nepal.J Nepal Health Res Counc. 2011; 9: 101-106PubMed Google Scholar and inclusive participation5Shannon G Jansen M Williams K et al.Gender equality in science, medicine, and global health: where are we at and why does it matter?.Lancet. 2019; 393: 560-569Summary Full Text Full Text PDF PubMed Scopus (227) Google Scholar in programming and evidence generation for mothers and neonates. Disparities have widened during this pandemic and hard-won progress towards the Every Newborn Action Plan and Sustainable Development Goals are now at risk, especially for the poorest people. We declare no competing interests. Effect of the COVID-19 pandemic response on intrapartum care, stillbirth, and neonatal mortality outcomes in Nepal: a prospective observational studyInstitutional childbirth reduced by more than half during lockdown, with increases in institutional stillbirth rate and neonatal mortality, and decreases in quality of care. Some behaviours improved, notably hand hygiene and keeping the baby skin-to-skin with their mother. An urgent need exists to protect access to high quality intrapartum care and prevent excess deaths for the most vulnerable health system users during this pandemic period. Full-Text PDF Open AccessEffect of COVID-19 on maternal and neonatal servicesGlobally, the COVID-19 pandemic has badly affected almost all sectors, including health. Ashish KC and colleagues1 showed that, in Nepal, institutional birth rates declined by almost 50% and that institutional neonatal mortality increased by more than 200% in selected referral hospitals between January and May, 2020. However, convincing explanations for such a drastic change in maternal and neonatal health services are yet to be explored. Here we aim to provide possible reasons for such a decline in maternal and neonatal health services and provide perspectives on the potential ways to improve them. Full-Text PDF Open AccessEffect of COVID-19 on maternal and neonatal servicesSimilar to the observations made by Ashish KC and colleagues1 in Nepal, we previously reported an increase in stillbirths associated with the COVID-19 pandemic in the UK, from 2·38 per 1000 births (between Oct 1, 2019, and Jan 31, 2020) to 9·31 per 1000 births (between Feb 1 and June 14, 2020), but unrelated to clinical severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection.2 This observation has been sustained, with the number of stillbirths remaining high in July, 2020 (14·2 per 1000 births). Full-Text PDF Open AccessEffect of COVID-19 on maternal and neonatal servicesI congratulate Ashish KC and colleagues1 for their efforts to highlight the lesser-known effects of COVID-19. The pandemic abruptly disrupted efforts towards almost all Sustainable Development Goals and, in many cases, turned back decades of progress.2 The increased stillbirths and neonatal mortality during COVID-19 will also be a major setback for the Every Newborn action plan by WHO.1,3 The study by KC and colleagues focused on hospital deliveries and the effect at the community level is likely to be worse. Full-Text PDF Open Access