In June in New Delhi, the husband of Neelam Kumari Gautam transported his young wife in the back of a rickshaw to eight hospitals in the span of 15 hours. Despite her cries of pain, each hospital turned them away, and Neelam died in childbirth.
Covid-19 had shut the doors, taken over the hospital beds, and monopolised the attention of doctors and nurses.
We do not know how many African women have suffered a similar fate during the nine months the pandemic has raged. We do know, however, that reductions in the use of maternal and child health services due to the pandemic are a tragedy of yet unforeseen proportions.
Until risk management and mitigation strategies are put in place at all levels of the health system, the indirect impacts of Covid-19 on women and children will be overwhelming.
While there is a need for further investigations to estimate the exact burden, there is ample evidence that women and children are in danger.
Prior to Covid-19, many low and middle-income countries had reported high rates of women dying during pregnancy or childbirth and premature death among newborns and children. In countries like Sierra Leone, 1 in 17 women were still dying from preventable causes such as bleeding, hypertensive disorders, and infections.
Countries adopted aggressive strategies to improve access to quality maternal and child health services.
Now, the partial or total disruption of healthcare services caused by Covid-19 has exacerbated the unmet health needs of women and children.
A new report from the United Nations finds that health checks for children and immunization services have been disrupted in at least 71 countries; antenatal and post-natal care check-ups disrupted in at least 66 and 62 countries, respectively.
A number of factors have conspired to prevent pregnant women, and new mother and babies from getting the care they need: transport restrictions; avoidance of health centers for fear of infection; suspension or closure of services; fewer healthcare workers; a massive redirection of health resources to fighting the pandemic; and greater financial difficulties.
On the flip side, dramatically restricted access to contraception may lead to up to 7 million unintended pregnancies worldwide—and increased numbers of unsafe abortions and of home deliveries that result in more maternal and infant deaths. Decreased access to vaccination will increase child deaths.
The reduced access to maternal care and immunization services during the pandemic also limits the opportunities for health providers to detect danger signs and risk factors in pregnant women.
Conditions that could have been treated such as high blood pressure will become life-threatening emergencies.
These trends have already been set in motion. Countries must act now to limit the damage and to build resilient health systems that can recover lost ground and improve maternal and child health.
Re-imagining health services
It is imperative to adopt proactive measures for women and children to ensure access to quality services. This will require a threefold shift in public health programming.
Make structural changes to health systems:
In the short term, systematic screening of pregnancy danger signs should be integrated into ongoing Covid-19 services such as testing. Every Covid-19 health visit is also an opportunity for targeted education on family planning, safe pregnancy and childbirth.
Traditionally, maternal health and child services take place at health facilities. But especially during the pandemic, these facilities are not up to the task. In Tanzania, a major maternity hospital was converted into a Covid-19 hospital.
Decentralization of health services from primary health facilities to communities—including schools and churches—could maximize the chance for early identification of danger signs.
Recent studies demonstrated that community health workers (CHWs) reduce maternal, foetal, and new-born deaths.
In Rwanda, CHWs implement preventive and lifesaving practices for women and children. In Kenya, Malawi and Nigeria, CHWs play various roles from women’s education to provision of long-acting reversible contraceptives and assisting deliveries.
This effort led to dramatic improvement in maternal and newborn outcomes. "Task-shifting,” or training CHWs to provide more advanced services such as normal deliveries is a strategy that works.
Such structural adaptations will require major amendments in national policies and guidelines and remarkable investments in training.
Revisit health financing and resource allocation:
Maternal and child health services require a functional health system in its entirety, including capacity for diagnostics, service delivery, and supplies.
Yet health system financing is typically delivered to siloed specialty programs such as HIV/AIDS, Malaria, and COVID-19. At national and global levels, such priorities have secured funding, while less attention is paid to the overall health system.
Therefore, to mitigate overwhelming maternal deaths, two changes are needed. First, maternal and child health need their own dedicated funding to provide essential supplies and to train all health workers in lifesaving techniques such as emergency obstetrics and neonatal care.
However, a strategy that speeds recover and build resilience should also include more funding for overall health system strengthening.
Build practical solidarity for human resources for health
Solidarity among low- and middle-income countries is essential to securing the health of women and children. For example, maternal mortality is higher in Africa than in any other world region and Africa suffers more than 22% of the global burden of disease. Yet many African countries still rely on less than 1 doctor per 5000 people.
Meanwhile, the ongoing efforts of individual countries to increase their human resources are painfully slow. There is an urgent need for countries across the region to coordinate in the training and strategic deployment of a skilled health workforce, including nurse-midwives and physicians. Further, countries should develop a system to recruit nurse-midwives and physicians from the region.
To be sure, African countries have invested remarkable efforts in elaborating strategies to contain the pandemic and maintain essential health services. A number of experts including the UN secretary-general, António Guterres, highlighted the impact of Covid-19 on women's health and rights.
Countries prioritize care for women with complicated conditions. WHO has established the quality maternal and newborn, and published guidelines to maintain essential health services. However, efforts have been limited primarily to policies and epidemiologic surveillance.
There is a need for proactive strategies and intentional investments to minimize poor health outcomes among women and children during and after COVID-19.
The writer is the deputy chief medical officer at Partners In Health, assistant professor of global health at the University of Global Health Equity, Lecturer at Harvard University and Aspen New Voices Fellow.