Impact of COVID-19 on maternal and child health
Authors: Brenda Sequeira Dmello, Natasha Housseine, Thomas van den Akker, Jos van Roosmalen, Nanna Maaløe
Journal: The Lancet Global Health (2020)

Previous infectious outbreaks taught us how over-concentrating resources on one vertical programme can aggravate the epidemic of lives lost during childbirth. We applaud Timothy Roberton and colleagues1Roberton T Carter ED Chou VB et al.Early estimates of the indirect effects of the COVID-19 pandemic on maternal and child mortality in low-income and middle-income countries: a modelling study.Lancet Glob Health. 2020; 8: e901-e908Google Scholar for raising the alarm on how history is repeating itself in this COVID-19 pandemic. Workforce reductions (as staff are quarantined, ill, or reallocated), interrupted supply chains, and decreases in service use are contributing to rising deaths.1Roberton T Carter ED Chou VB et al.Early estimates of the indirect effects of the COVID-19 pandemic on maternal and child mortality in low-income and middle-income countries: a modelling study.Lancet Glob Health. 2020; 8: e901-e908Google Scholar We draw attention to additional concerns and the increased clinical complexity of maternity care in COVID-19 times, particularly in countries with fragile health systems and the highest maternal and child mortality. Interim guidance released by WHO emphasises fewer clinic visits, early discharge, COVID-19 screening upon admission, and quarantining of suspects until proven negative.2WHOClinical Management of COVID-19—interim guidance.https://www.who.int/publications-detail/clinical-management-of-covid-19Date: 27 May. 2020Date accessed: June 3, 2020Google Scholar, 3WHOMaintaining essential health services: operational guidance for the COVID-19 context—interim guidance.https://www.who.int/publications-detail/10665–332240Date: 1 June. 2020Date accessed: June 3, 2020Google Scholar However, the response is undermined by low testing capacity, delays in obtaining results, constraints in infrastructure, and staffing shortages. Notably, because COVID-19 symptoms mimic obstetric emergencies, triaging women with concomitant complications might be delayed.2WHOClinical Management of COVID-19—interim guidance.https://www.who.int/publications-detail/clinical-management-of-covid-19Date: 27 May. 2020Date accessed: June 3, 2020Google Scholar Moreover, the vertical COVID-19 response leaves women even more vulnerable to delays, neglect in isolation, and substandard management of life-threatening complications. WHO urges context-adaptation of their guidance and continuation of essential health services. However, low-income and middle-income countries (LMICs) often do not adapt guidance, because it is a complex and resource-consuming process when non-contextualised recommendations are far from achievable.4Maaløe N Meguid T Housseine N Tersbøl P Nielsen K Lessons from the local adaption of intrapartum clinical guidelines, United Republic of Tanzania.Bull World Health Organ. 2019; 97: 365-370Google Scholar In LMICs, health services offered are predominantly essential, and little can be discontinued without catastrophic consequences. We are concerned that this vertical COVID-19 response counteracts years of advocacy and arduously achieved health-system improvements for maternity care, with poor interim practice becoming institutionalised into a new, even lower "low normal". To fulfil the complex demands of COVID-19 management while continuing essential reproductive health services, the number of maternity staff needs to be increased, capacitated, and provided with personal protective equipment, essential medicines, and access to integrated, relevant, and realistic guidelines on respectful maternity and COVID-19 services (appendix). If we manage to integrate the COVID-19 response into essential care, health services everywhere even have a chance to become better, with improved hygiene measures as a new normal, and the WHO daily statistics on COVID-19 deaths could be expanded to include deaths from all causes, including maternal and perinatal mortality. Such an integrated response at regional, national, and international levels, within and beyond maternal health, could trigger long-term strengthening of fragile health-care systems. If we fail and let one disease over-influence care and further debilitate frail health systems, unacceptable suffering and premature deaths will follow. We declare no competing interests. We would like to recognise the brave health-care providers serving on the frontlines, from whom we have learned. Also, thanks to Tarek Meguid for valuable inputs to this correspondence. Download .pdf (.17 MB) Help with pdf files Supplementary appendix Early estimates of the indirect effects of the COVID-19 pandemic on maternal and child mortality in low-income and middle-income countries: a modelling studyOur estimates are based on tentative assumptions and represent a wide range of outcomes. Nonetheless, they show that, if routine health care is disrupted and access to food is decreased (as a result of unavoidable shocks, health system collapse, or intentional choices made in responding to the pandemic), the increase in child and maternal deaths will be devastating. We hope these numbers add context as policy makers establish guidelines and allocate resources in the days and months to come. Full-Text PDF Open AccessImpact of COVID-19 on maternal and child healthThe study by Timothy Roberton and colleagues (July, 2020),1 which modelled the indirect effects of COVID-19 on maternal and child mortality in low-income and middle-income countries (LMICs), highlights potential consequences of disruptions to routine health care and decreased access to food. While the total projected impact is shocking, the analysis omitted modelling disruptions in breastfeeding practices because the authors "assumed only a marginal reduction in these activities."1 The COVID-19 pandemic is already indirectly threatening breastfeeding practices (early initiation and exclusive and continued breastfeeding). Full-Text PDF Open AccessImpact of COVID-19 on maternal and child healthTimothy Roberton and colleagues1 estimate the indirect effects of COVID-19 on maternal and child mortality in low-income and middle-income countries (LMICs) with use of the Lives Saved Tool (LiST), suggesting that reduced provision and use of reproductive, maternal, newborn, and child health-care services might substantially increase maternal and child deaths. Although we commend their efforts, we are concerned that omission of stillbirths from their analyses has resulted in a considerable underestimate of this impact. Full-Text PDF Open AccessImpact of COVID-19 on maternal and child health – Authors' replyWe thank our colleagues for raising crucial issues in response to our analysis of the indirect effects of the COVID-19 pandemic disruptions to essential health services in resource-limited settings.1 Full-Text PDF Open Access