Impact of COVID-19 on maternal and child health.

Previous 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 colleagues 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. 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.

Interim guidance released by WHO emphasises fewer clinic visits, early discharge, COVID-19 screening upon admission, and quarantining of suspects until proven negative.2, 3 However, the response is undermined by low testing capacity, delays in obtaining results, constraints in infrastructure, and staffing shortages. Notably, because COVID-19 symptoms mimic obstetric emergencies, triaging women with concomitant complications might be delayed. Moreover, the vertical COVID-19 response leaves women even more vulnerable to delays, neglect in isolation, and substandard management of life-threatening complications. WHO urges context-adaptation of their guidance and continuation of essential health services. However, low-income and middle-income countries (LMICs) often do not adapt guidance, because it is a complex and resource-consuming process when non-contextualised recommendations are far from achievable. In LMICs, health services offered are predominantly essential, and little can be discontinued without catastrophic consequences.

We are concerned that this vertical COVID-19 response counteracts years of advocacy and arduously achieved health-system improvements for maternity care, with poor interim practice becoming institutionalised into a new, even lower “low normal”. To fulfil the complex demands of COVID-19 management while continuing essential reproductive health services, the number of maternity staff needs to be increased, capacitated, and provided with personal protective equipment, essential medicines, and access to integrated, relevant, and realistic guidelines on respectful maternity and COVID-19 services (appendix).

If we manage to integrate the COVID-19 response into essential care, health services everywhere even have a chance to become better, with improved hygiene measures as a new normal, and the WHO daily statistics on COVID-19 deaths could be expanded to include deaths from all causes, including maternal and perinatal mortality. Such an integrated response at regional, national, and international levels, within and beyond maternal health, could trigger long-term strengthening of fragile health-care systems. If we fail and let one disease over-influence care and further debilitate frail health systems, unacceptable suffering and premature deaths will follow.