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We read with interest the article by Blanchet et al on Protecting essential health services in low-income and middle-income countries and humanitarian settings while responding to the COVID-19 pandemic. We concur with this paper’s message that essential health services in maternal and newborn health must be prioritised and protected during the pandemic, and welcome the priority list of 120 essential services which has been co-produced with context-specific expertise from Afghanistan, Ethiopia, Pakistan and Zanzibar. This list was based on the Disease Control Priorities, 3rd edition, Highest Priority Package (DCP3 HPP) which listed 108 key interventions thought most important to achieve essential universal health coverage(1).
However, we were dismayed not to find a separate category of interventions to provide essential elements of postnatal care to women. Several components of this care are listed under other categories (e.g. safe blood transfusion to treat postpartum haemorrhage, management of maternal sepsis, manual removal of the placenta). However, the list does not distinguish which of these components relate directly to postnatal care and therefore conflates these components with other aspects of care within the broader obstetric continuum. There is additionally a lack of representation of key conditions that occur frequently and primarily in the postnatal period (e.g. lactational mastitis and postnatal depression), which exists within the WHO essential interv...
However, we were dismayed not to find a separate category of interventions to provide essential elements of postnatal care to women. Several components of this care are listed under other categories (e.g. safe blood transfusion to treat postpartum haemorrhage, management of maternal sepsis, manual removal of the placenta). However, the list does not distinguish which of these components relate directly to postnatal care and therefore conflates these components with other aspects of care within the broader obstetric continuum. There is additionally a lack of representation of key conditions that occur frequently and primarily in the postnatal period (e.g. lactational mastitis and postnatal depression), which exists within the WHO essential interventions list but was not included in the DCP3 HPP(2). Furthermore, several essential services that are listed by Blanchet et al, e.g. contraception, maternal wellbeing, and vaccinations, do not appear to be contextualised to postnatal care where they would be most critical to be provided. The spectrum of newborn conditions and interventions was captured on this list much more holistically, with its own category.
We highlight this important omission as the postnatal period presents a high risk of complications leading to maternal morbidity and mortality - particularly in LMICs and humanitarian settings. The largest burden of maternal deaths occurs during labour, delivery and the immediate postnatal period (first 24-hour period after the expulsion of the placenta), followed by the extended postnatal period (up to 42 days after the end of the pregnancy)(3). Between 20% and 44% of maternal deaths in sub-Saharan Africa, for example, are estimated to occur in the postnatal period(4)(5). Yet, the Countdown to 2030 report showed that postnatal services to have the lowest median national coverage of interventions on the continuum of maternal healthcare (6). The most important causes of postnatal deaths among women are haemorrhage, sepsis, hypertensive diseases of pregnancy, and indirect causes such as postnatal depression, HIV and malaria. The vast majority of these deaths are preventable with timely access to good quality care.
The WHO currently recommends a package of routine postnatal care interventions(7)(8).This package of critical elements enables health providers to detect and manage conditions with a very high risk of maternal mortality and morbidity (such as late-onset eclampsia, and postpartum haemorrhage and sepsis), monitor physical and mental wellbeing of postpartum women, and provide supportive care in order to initiate and sustain breastfeeding, education on newborn care and warning signs, and ensure continuity of care such as access to postpartum contraception. We stress here that these interventions comprise a package, and are not a list of one-off, unrelated, solely clinical care components. It is a holistic package of observations, diagnoses, treatments, and nutritional, physical and mental support components which are essential to be provided to every woman postnatally to support her and her newborn. The timescale of provision of this package begins at birth and last for a minimum of six weeks. Its elements can be provided by a range of health professionals and allied health personnel in joint cooperation within a functioning system on various levels, including in health facilities, on an outpatient level, and in the community.
Given that the largest burden of maternal ill-health occurs in the postnatal period, we call for inclusion of postnatal care services for women as a separate category within the essential list of services during the COVID-19 pandemic. We understand that the list presented by Blanchet et al was based on the DCP3 HPP. However, to make progress in reducing maternal mortality and morbidity in limited-resource settings during this unprecedented crisis, we must use such pre-existing “laundry lists” of individual interventions critically. Entanglement with other aspects of the obstetric continuum can result in postnatal care being pushed or missed off the global maternal and newborn health agenda. To harness the maximal value of the comprehensive package of essential services in maternal care we must ensure it is coordinated and inclusive across the entire obstetric continuum and not a scattering of elements here or there. Postnatal care for women is already a neglected service, we cannot afford for it to fall further off the agenda especially during the COVID-19 pandemic.
1. Jamison DT, Alwan A, Mock CN, Nugent R, Watkins D, Adeyi O et al. Universal health coverage and intersectoral action for health: key messages from Disease Control Priorities, 3rd edition. The Lancet. 2018 Mar 17;391(10125):1108-1120. https://doi.org/10.1016/S0140-6736(17)32906-9
2. The Partnership for Maternal, Newborn & Child Health. 2011. A Global Review of the Key Interventions Related to Reproductive, Maternal, Newborn and Child Health (RMNCH). Geneva, Switzerland: PMNCH
3. World Health Organization. Trends in maternal mortality: 1990 to 2015: estimates by WHO, UNICEF, UNFPA, World Bank Group and the United Nations Population Division. 2015
4. Merdad L, Ali MM. Timing of maternal death: Levels, trends, and ecological correlates using sibling data from 34 sub-Saharan African countries. PLoS One. 2018 17;13(1): e0189416.
5. Alliance for Maternal and Newborn Health Improvement (AMANHI) mortality study group. Population-based rates, timing, and causes of maternal deaths, stillbirths, and neonatal deaths in south Asia and sub-Saharan Africa: a multi-country prospective cohort study. Lancet Glob Health. 2018 Dec;6(12):e1297-e1308.
6. Boerma T, Requejo J, Victora CG, Amouzou A, George A, Agyepong I, et al. Countdown to 2030: tracking progress towards universal coverage for reproductive, maternal, newborn, and child health. Vol. 391, The Lancet. Lancet Publishing Group; 2018. p. 1538–48.
7. WHO. 2015. Pregnancy, Childbirth, Postpartum and Newborn Care: A guide for essential practice. Third Edition. 2015. Geneva, Switzerland.
8. WHO. WHO recommendations on postnatal care of the mother and newborn. 2013. Geneva, Switzerland.