Impact of COVID-19 on maternal and child health - Authors' reply.

We 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.

We agree with Jenny Busch-Hallen and colleagues and acknowledge both the importance and well established benefits of breastfeeding for the mother–child dyad. The Lives Saved Tool (LiST) includes the effect of exclusive and continued breastfeeding to reduce child morbidity, mortality, and undernutrition on the basis of available evidence. Our health-systems framework did not lend itself to readily model how breastfeeding prevalence, at a societal or household level, might change because of a worsening pandemic. Guidance from WHO does strongly recommend skin-to-skin, kangaroo mother care, and especially continued breastfeeding practices because the life-saving benefits far outweigh any potential risks for transmission in cases of suspected or confirmed COVID-19. We fully support efforts to highlight the central role of breastfeeding as a valuable and essential global health intervention.

Similarly, we share the concerns expressed by Elizabeth McClure and colleagues about the untold burden of stillbirths in the context of the evolving pandemic. Disruption of essential services might lead to disproportionately greater perinatal losses in areas with high maternal and neonatal mortality. To address the pressing need to understand better this burden, UNICEF and WHO convened an interagency technical working group to expand upon earlier UN Inter-agency Group for Child Mortality Estimation work and to examine the impact of the COVID-19 pandemic on stillbirths. Collaborative exchanges like these are required to thoughtfully move the dialogue forward. Our shared goal is to understand valuable opportunities to intervene and develop evidence-based strategies for action.

Considerations presented by Brenda Sequeira Dmello and colleagues underscore how devastating and far-reaching the consequences of disruption might be in the context of fragile health-care systems. Timely adaptation of global recommendations is crucial to mitigate adverse health outcomes, but standardised guidance is not available to help policy makers or programme managers contextualise the recommendations to their own settings. This “complex and resource-consuming process” indeed becomes frustrating and daunting because collected data are sparse and the way forward for successful implementation remains unclear. Coordinated efforts joining together invested partners who are able to draft programmatic guidance (eg, coalition for sexual and reproductive health and rights in humanitarian settings) fill an urgent need for effective prioritisation and action.

Future LiST analyses are planned to explore the effect of potential strategies to maintain essential health services and therefore mitigate the impact of COVID-19 on maternal and child health.