COVID-19 and maternal and perinatal outcomes

In their systematic review and meta-analysis, Barbara Chmielewska and colleagues¹ note significant increases in maternal death and stillbirths during the COVID-19 pandemic. They link these outcomes to reduced access to maternal health services, stating that in low-income and middle-income countries (LMICs), remote antenatal care appointments are less feasible because of technological shortcomings in these countries.

As the authors note, the experiences and outcomes in different countries have varied widely during the pandemic and their review only included a few papers from LMICs. For this reason, we find it crucial to share our experiences at our six Partners In Health project sites in Haiti, Lesotho, Liberia, Malawi, Mexico, and Sierra Leone. Since May, 2020, we have continuously monitored health services using the model described by Fulcher and colleagues.² In four sites (Haiti, Liberia, Mexico, and Sierra Leone), we did observe moderate declines in antenatal care and facility-based deliveries, but in most cases services rebounded back to what was expected by mid-2020. In the other sites, we did not observe any significant decline in maternal health services during the pandemic.

Our experience sheds light on health services in LMICs during the pandemic, which are often under-represented in the literature. Importantly, although access to technology might be a barrier at some of our programme sites, many non-technological solutions were implemented to ensure the continuity of maternal health services. First, it is important to note that lockdowns have differed from country to country. Our programme sites in Lesotho, Malawi, and Mexico reported fewer mobility constraints than those in Haiti, Liberia, and Sierra Leone. Second, programmes have adopted home-grown solutions to maintain access to care, and each country produced a different adaptation. Lesotho, Malawi, and Mexico adopted strategies to safely maintain community health worker programmes, which have been previously shown to be a key factor in the uptake of maternal services,³ despite the pandemic restrictions. Sierra Leone focused on communication campaigns to inform the population about COVID-19 infection and the importance of maintaining other health services. Liberia promoted providers“ capacity building on the safe provision of maternal health care during COVID-19 and strengthening their supply chain, whereas Haiti restructured clinic spaces so that pregnant women could still receive care at the same time as distancing at the facility. Importantly, all sites benefited from long-standing and close collaboration between Partners In Health and public health systems to ensure the continuity of essential health services, using lessons learned by the organisation through its experience in other infectious disease outbreaks in the past.

The COVID-19 pandemic has affected every country, but every country has been affected differently. We hope that this Correspondence adds perspective on the effect of the pandemic on maternal health service use in LMICs, and identifies the strategies adopted by sites to maintain services during this health emergency.