Impact of COVID-19 on maternal and child health
Authors: Jenny Busch-Hallen, Dylan Walters, Sarah Rowe, Archana Chowdhury, Mandana Arabi
Journal: The Lancet Global Health (2020)

The study by Timothy Roberton and colleagues (July, 2020),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 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."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 The COVID-19 pandemic is already indirectly threatening breastfeeding practices (early initiation and exclusive and continued breastfeeding). Universal breastfeeding could prevent 823 000 child deaths per year,2Rollins NC Bhandari N Hajeebhoy N et al.Why invest, and what it will take to improve breastfeeding practices?.Lancet. 2016; 387: 491-504Google Scholar yet additional examination as part of COVID-19 impact modelling is needed. During the COVID-19 pandemic, reductions in breastfeeding prevalence will plausibly occur due to limitations in the provision and use of health services and disruptions to the enabling environment. Limitations in the availability of skilled health workers and increased reluctance by women to use the health system could lead to lower coverage of antenatal care, postnatal care, and facility and community-based lactation support and counselling. Anecdotal evidence suggests that some health facilities are inappropriately separating newborn babies from mothers and discouraging breastfeeding because of unfounded fears of transmission of COVID-19 through breastmilk. These situations might result in a decline in early initiation of breastfeeding after birth—missing the child's first natural vaccine (colostrum)—and, in turn, exclusive breastfeeding. The enabling household environment for breastfeeding can be compromised by the potential increased demand for child caregiving during lockdowns and school closures. The societal enabling environment can be threatened by formula manufacturers that exploit fears of contagion through coercive marketing practices in violation of the International Code of Marketing of Breast-Milk Substitutes.3WHOInternational Code of Marketing of Breast-Milk Substitutes.https://www.who.int/nutrition/netcode/resolutions/en/Date: 1981Date accessed: June 5, 2020Google Scholar Although some determinants of breastfeeding could be positively affected by the pandemic, we hypothesise that there are negative social, economic, corporate, and health-system forces affecting the mother's decision to breastfeed that should be considered. We estimated, using the Alive & Thrive cost of not breastfeeding tool,4Walters D Mathisen R Linh PTH The global cost of not breastfeeding: a new tool and results.Health Policy Plan. 2019; 34: 407-417Google Scholar that a hypothetical effect of small (5%), moderate (10%), medium (25%), or severe (50%) relative reductions in the prevalence of breastfeeding due to COVID-19 disruptions would result in 16 469 (small reduction), 32 139 (moderate reduction), 75 455 (medium reduction), and up to 138 398 (severe reduction) child deaths across 129 LMICs over a 1-year period, plus additional morbidity (appendix). This analysis highlights the need for continued support from governments to promote and protect breastfeeding, in line with the Global Breastfeeding Collective's call to action during COVID-19.5WHOThe Global Breastfeeding Collective.https://www.who.int/nutrition/topics/global-breastfeeding-collective/en/Date: 2020Date accessed: June 5, 2020Google Scholar We encourage authors publishing on the estimated indirect impacts of COVID-19 pandemic to consider the substantial morbidity and mortality repercussions from pandemic-related disruptions to breastfeeding. We declare no competing interests. Download .pdf (.08 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 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 AccessImpact of COVID-19 on maternal and child healthPrevious 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 colleagues1 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.1 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. Full-Text PDF Open Access