1. Service use is falling, owing to

 Fear of women/babies becoming infected, and bringing illness back to homes, being treated badly, or costs if unable to work and pay for care.

 Fear of being quarantined away from family and support networks in case women test positive.

 Fear of aggravating domestic violence if use of services defies partner.

 Ambulances feared as sources of COVID-19 infection.

 Radio campaigns and messaging urging women to continue attending maternity care services.

 Use of visual aids and pictographs in public places and health facilities to ensure women with low literacy have access to correct information.

 Increased use of Whats App and other social media, with appropriate safeguards for reliability of information, to communicate with women and share information about health workers.

 Huge demands on few hospital transport/ambulances that exist, with ambulances used for COVID-19.

 Confusion over public health messaging about staying at home means women delay to seek care, and some facilities are seeing a marked increase in complicated cases on admission.

 Curfews, permit requirements from a local authority, bans on private vehicles, shutdowns of public transport.

 Childcare responsibilities (school closure) and care for elderly prevent women from seeking care for themselves or their newborns.

 Inability to afford transport/care due to loss of income in lockdown, inability to find someone to accompany them.

 Routine newborn screening/vaccination skipped or postponed

 Poor routine postnatal monitoring: shorter postnatal lengths of stay in facilities, fewer postnatal home visits, lack of postpartum family planning.

 Private sector is no longer taking patients. Women who prepaid for private sector childbirth have now lost all their money. These closures further increase overcrowded public-sector facilities.

 Fewer outpatient appointments given to reduce crowding in waiting rooms, fewer inpatient beds available to introduce physical distancing.

 Some services are intentionally shut as part of a strategy to encourage women to go elsewhere, but women may not be informed of reasons and do not know where to go.

 Community health awareness/outreach services are cancelled.

 Lack of access to safe abortion care for unintended pregnancies.

 Elective procedures, such as caesarean sections and IVF, are being cancelled or postponed.

 Information campaigns as above mentioned previously.

 Negotiating with local police to allow pregnant women to travel to services.

 Travel badges or car stickers for pregnant women.

 Prescribing oral contraceptives to all postpartum women and other women with unmet needs for family planning.

 Increasing time between ANC visits and reducing the number of visits.

 Arranging ANC services so women do not come at busy times, stopping any group care.

 Telemedicine where available, including ANC and virtual Douala services.

 Woman guided to administer their own medication (eg, medical abortion).

2. Overall quality of care is deteriorating, owing to

 High levels of staff absenteeism and resignation.

 Health workers redeployed elsewhere.

 Less skilled/unqualified health workers assigned to maternity care (locum staff, students and interns).

 Stressed, demotivated and tired health workers, with fear of unsafe working environment, including key support workers such as cleaners.

 Badges/permits to allow health workers to travel during lockdown/curfew.

 Telementoring to support (lone) healthcare workers.

 Change in rosters of nurses and doctors to reduce numbers of people per shift and lengthen shifts, with the intention of limiting exposure of all personnel at the same time.

 Active involvement of facility staff in forums to share ideas for adapting services/care and for problem-solving.

 Peer support systems for health workers’ mental health and psychosocial well-being.

 Some advice may become outdated or may be proven dangerous; mechanisms to share updates are not clear and dissemination slow and limited.

 New information coming in rapidly, no systems to digest/disseminate this to health workers.

 Minute-by-minute barrage of fake and real news, causing anxiety and fear.

 Confusion over PPE for different contexts and workers.

 Hospital-produced protocols in every department on managing suspected and confirmed COVID-19 cases.

 Virtual training to strengthen IPC knowledge and practice, for COVID-19 cases, and dissemination of new guidelines.

 Limited availability of COVID-19 test kits; results take 1–2 days.

 Disruption of imports of medicines/commodities, increased costs.

 Lack of PPE is problematic for many health workers in facilities and in communities, and for hospital transport/ambulance drivers.

 Laundry facilities not functional, so how/where to dispose used PPEs without incinerators.

 It takes time to don/doff PPE, delaying urgent care.

 In crowded facilities, shared beds or floor patients, and newborns sharing cots are particularly risky practices in the face of COVID-19.

 Space limitations present challenges for creating separate isolation areas before transfer of suspected case.

 Dedicated referral facilities set up for COVID-19 cases may not have health workers specialised in managing pregnant or postpartum women/newborns; maternity workers will have less specialised expertise for managing COVID-19.

 Lack of dedicated ventilators, dedicated neonatal resuscitaires and clinical space to manage suspected/confirmed COVID-19 cases.

 Poor water supply is even more problematic where hand hygiene and cleaning are key interventions for COVID-19.

 Lack of supplies for hand hygiene and surface cleaning.

 Waste management is a challenge, as are sanitation facilities; separate toilets for COVID-19 cases may not be possible.

 Pain relief options reduced, particularly nitrous oxide.

 Birth companions and visitors not allowed.

 Stillbirth counselling not provided.

 Forced separation of mothers with suspected/confirmed COVID-19 (and those in isolation while waiting for test results) from their newborns, breastfeeding prohibitions, barring parental visits to newborns in neonatal units.

 Women abandoned during the process of labour because staff with PPE can only attend to patients for 2 hours maximum, more difficult communication between women/providers when PPE is worn.

 More labour inductions and elective caesarean sections overall and for suspected/confirmed COVID-19 cases, in part to help manage patient flow with respect to staff availability, and as scheduled delivery in theatre avoids problem of monitoring women in labour with full PPE.

 Some women do not get adequate food while in the hospital as family who normally brings this is prohibited and hospitals are unable to incur the full additional costs of feeding.

 Local fundraising to purchase PPE for maternity ward staff.

 Guidelines for wearing and laundering facility health worker uniforms.

 Improving maternity ward layout consistent with outbreak management, emergency hotlines for PPE shortages.

 Decreasing length of stay and maintaining contact with discharged women by phone.

 Relocating births from hospitals to other adapted locations (eg, hotels).

 Implementing triage systems that provide appropriate detection and isolation of women with COVID-19 symptoms.

 Local women’s group campaigns to ensure women may still have at least one birth companion where appropriate.