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Protecting hard-won gains for mothers and newborns in low-income and middle-income countries in the face of COVID-19: call for a service safety net
  1. Wendy Jane Graham1,
  2. Bosede Afolabi2,
  3. Lenka Benova3,
  4. Oona Maeve Renee Campbell1,
  5. Veronique Filippi4,
  6. Annettee Nakimuli5,
  7. Loveday Penn-Kekana1,
  8. Gaurav Sharma6,
  9. Uduak Okomo7,
  10. Sandra Valongueiro8,
  11. Peter Waiswa9,
  12. Carine Ronsmans4
  1. 1Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, UK
  2. 2Department of Obstetrics and Gynaecology, College of Medicine, University of Lagos, Akoka, Lagos, Nigeria
  3. 3Department of Public Health, Institute of Tropical Medicine, Antwerpen, Belgium
  4. 4Infectious Disease Epidemiology, London School of Hygiene & Tropical Medicine, London, UK
  5. 5Obstetrics and Gynecology, Makerere University and Mulago National Referral Hospital, Kampala, Uganda
  6. 6Independent Consultant, Kathmandu, Nepal
  7. 7Vaccines and Immunity Theme, MRC Unit-Gambia, Banjul, Gambia
  8. 8Postgraduate Program of Public Health, Universidade Federal de Pernambuco, Recife, Brazil
  9. 9School of Public Health, Makerere University, Kampala, Uganda
  1. Correspondence to Professor Wendy Jane Graham; Wendy.Graham{at}

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Summary box

  • The adverse impact of COVID-19 on maternal and newborn services in low-income and middle-income countries risks undermining improvements in health outcomes and care achieved over the last three decades.

  • Alarming declines in the use of services and in the quality of care in health facilities are being reported from sources on the ground, captured rapidly and in real time using e-communication tools.

  • Local solutions to the direct and indirect challenges brought to maternal and newborn health services by COVID-19 must be captured effectively and shared efficiently to support health workers and managers.

  • Providing adequate funding to maintain essential services alongside urgent action plans for COVID-19 is essential to enable rapid adaptation and modifications to service delivery in response to different transmission scenarios and stages of the pandemic.

There are an estimated 5. 4 million largely preventable maternal and perinatal deaths each year.1–3 Improving the survival and well-being of mothers and newborns is indisputably a global priority. This is as true today as ever and as the world grapples with the COVID-19 pandemic. For maternal and newborn health (MNH), a critical question today is not only the extent to which pregnant or postpartum women and newborns are vulnerable to COVID-19-infection4 but also the degree to which the safety of giving birth and accessing treatment for complications in health facilities is being compromised by the direct and indirect effects of the virus, thereby reversing hard progress in MNH over the last 30 years. We know that infectious disease outbreaks can devastate provision of such care, for example, during the Ebola outbreak in West Africa.5 In this commentary, we use insights from those on the ground in low-income and middle-income countries (LMICs) to highlight both the impact of COVID-19 on facility births and the innovative local solutions being adopted to mitigate these effects. We consider how in-country responses to the pandemic might also provide an opportunity to finally tackle key weaknesses in facilities, including low staffing, overcrowding, poor infection prevention and control (IPC), and disrespectful care.

In 2006, the Lancet Maternal Survival Series presented convincing evidence for what is now accepted global strategy: that women should be encouraged and enabled to give birth where labour and childbirth can be managed by a skilled attendant in a safe environment, primarily in health facilities.6 The series offered various options for scaling up and mobilising financial resources. The proportion of births in health facilities increased dramatically over the next decade.7 In 2016, the second Maternal Health Series celebrated this success but also drew attention to the poor quality of maternity services, from inadequacies in water and sanitation infrastructure to shortages of trained staff, poor IPC, limited access to surgical interventions and essential drugs, and disrespectful and abusive care to women in labour.8 What was clear long before COVID-19 is that some facilities are unsafe for the physical and mental well-being of women and newborns and that the most marginalised women often receive the poorest quality of care.9

How the pandemic will affect women and newborns is uncertain, as there are many information gaps. For MNH, these fall into three main areas: (1) the epidemiology of COVID-19 infection during and after pregnancy and for the newborn; (2) the clinical management of suspected cases in pregnant or postpartum women and newborns, given the uncertainties in diagnosis and management of COVID-19 in the absence of widespread testing; and (3) the upheaval that the pandemic may be causing in the demand and supply for already-fragile MNH services in LMICs. Here we focus on the third area—the disruption in services—which may well pose the greatest challenge to protecting women and newborns, especially in LMICs.10 11

How do we know whether services are disrupted? The COVID-19 pandemic has halted many routine and periodic data capture systems. Population-based surveys, such as the demographic and health surveys, have been delayed or deferred indefinitely, and routine information sources are not being maintained because of overload on reporting owing to COVID-19 cases, the need to divert resources to infection surveillance, and safety fears for data collectors and interviewees. Where does this leave us? Social media, rapid online surveys and communities of practice are providing a channel for hearing voices on the ground. Some would reject the use of these ‘anecdotes’, but we argue instead for the capture, synthesis and sharing of this experiential knowledge, with appropriate safeguards for validation and confidentiality.

What do these voices say? Table 1 gives examples of reports received during a recent online survey and webinar organised by the authors.12 13 Collectively, these voices, hailing from over 60 LMICs, suggest two main trends: declining use of services and deteriorating quality, in some cases dramatically so. The fall in use is being seen across a range of MNH services, including facility delivery, antenatal care (ANC) attendance, and use of newborn preventive and curative care, and echoes concerns in other areas such as child immunisation (figure 1). These patterns are emerging at early stages of the pandemic, and they may become more marked as transmission accelerates. A recent modelling of the consequences of declining use, of varying degrees and duration, of maternity services estimated an 8.3%–38.6% increase in maternal deaths per month across 118 LMICs.14

Table 1

Reports on maternity and newborn services in the face of COVID-19: use, quality and solutions

Figure 1

Many women face obstacles to seeking care in health facilities for themselves or their newborn baby (photo credit: Pieter ten Hoopen 2016; license for unrestricted use held by London School of Hygiene & Tropical Medicine (OMR Campbell and WJ Graham)).

The catalogue of problems highlighted in table 1 poses a huge dilemma for MNH care. Will deterioration of facility-based care shift the balance of risk to women and newborns from benefit to harm, so challenging the strategic recommendation for facility deliveries? If so, what choices are there for pregnant women and service providers? Should we revisit risk screening approaches and strengthen ANC so that women at lower risk can be advised to give birth in primary care facilities or in separate midwifery units? How can quality be maintained or improved? Once again, responses are emerging from reports on the ground; the final column in table 1 summarises some local solutions to context-specific problems from our online survey and webinar. Collectively, these local adaptations and responses may protect delivery services from further deterioration and so shield women and newborns. Moreover, beyond this immediate protective strategy, it is crucial to optimise on any wider health systems strengthening which may emerge out of the COVID-19 responses in LMICs,15 including addressing chronic constraints, such as the shortages and poor working environments of health workers.

The authors call on national governments in LMICs and the international community of agencies and donors grappling with the COVID-19 pandemic to preserve hard-won but fragile gains in MNH and in services and to protect frontline workers in health facilities who are key drivers of this progress and whose voices we have tried to capture.

We have three main asks of these stakeholders:

  1. Maintain routine and essential services for MNH, alongside developing urgent action plans for COVID-19, to prevent further spread of the virus and to care for those infected, and to track policy shifts and innovation and key coverage indicators prospectively.

  2. Rapidly establish better ways of both identifying and sharing experiential local knowledge from the frontline on solutions to emerging challenges in MNH service provision and ways of realistically evaluating these adaptations.

  3. Provide adequate funding for facilities both to enable rapid adaptations and modifications to service delivery in response to different COVID-19 transmission scenarios and stages of the pandemic, and to support sustainable improvements.

These actions are geared towards effectively putting a safety net around MNH services in the face of adversity, so increasing the likelihood of emerging from the COVID-19 pandemic with less adverse impact and more lasting benefits for women and newborns.


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  • Twitter @profwendygraham, @lenkabenova

  • Contributors WJG initiated the paper and, with CR, OMRC and VF, created the initial outline and wrote the first draft. LB, LP-K, BA, AN, UO, GS, SV and PW provided access to reports from countries. All authors contributed to the revisions to the drafts and approved the final version.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

  • Patient consent for publication Not required.

  • Provenance and peer review Not commissioned; internally peer reviewed.

  • Data availability statement All data relevant to the study are included in the article or uploaded as supplementary information.