Earlier this year, seven stillborn babies were delivered in one night in one facility in Harare, Zimbabwe. In June, a laboring woman in India was denied care by eight different facilities over the course of 15 hours. At their most vulnerable hour, pregnant women and their infants are dying, not from COVID-19, but from the consequences of crumbling health care systems and the secondary effects of the pandemic.
Epidemics, natural disasters, and other crises have shown us, time and again, that we need to rethink how we design, develop, and deliver essential services around the world for higher quality care for the most vulnerable and greater health system resilience.
Today, pregnant women, new mothers, newborns, and young children face a potentially deadly paradox: Receiving essential medical care may put them at risk for COVID-19, but they could also be endangering their health if they do not receive care. If they do decide to seek care, they often face health care systems in danger of collapsing under the strain of a pandemic. This is especially true in low- and middle-income countries where maternal and newborn mortality remains unacceptably high.
Women either are choosing to forgo care when they need it or have been unable to access it — even from within the walls of health facilities, as occurred in Harare. In Kenya, there have been reports of a staggering 50% drop in births at hospitals and clinics; in parts of India, facility-based births are down 40%.
We recently spoke with a public health expert in Tanzania who said an entire birth facility was repurposed for COVID-19 care, with no clear plans for accommodating women who would have given birth there. We’ve also heard from nurse midwives in India who have said that fear of the coronavirus is causing some workers to refuse to provide care, even when they have personal protective equipment on hand.
In many of these countries, COVID-19 preys on the same health system failings that generally lead to poor outcomes for mothers and their babies. It’s not uncommon in low-resource settings for three women to share a bed in a busy maternity ward. Nearly 1 in 6 clinics and hospitals worldwide lack hand-washing facilities in the areas where patients receive care or near toilets. A lack of essential resources like these leaves women in a breeding ground for any infection — not just COVID-19 — and reflects a complete lack of respect for a woman’s privacy.
Put together, the consequences of dramatically reduced access to care within already weak health care systems is proving deadly.
A recent study’s most conservative estimate indicates that the reduction in care services could lead to more than 12,000 additional maternal deaths and more than 250,000 additional newborn and child deaths — far more than the number estimated to die from COVID-19. The estimate is based on data from Ebola and other outbreaks in the past two decades; the fallout from Ebola erased nearly 20 years of progress in maternal and newborn health.
Our urgent response to this crisis must go beyond calls to get “back to normal.” Normal isn’t good enough. This health system disruption is an opportunity to redesign essential services for women, infants, and children for better quality care that is person-centered — where women are respected, informed, and engaged in decision-making. These systems need to be more able to withstand the next inevitable disruption.
Opportunities for innovation are everywhere, from the waiting room to the prenatal clinic, labor and delivery, and the postpartum unit.
Innovation can leverage existing platforms and approaches, like exploring and adapting telemedicine, and using mobile technology to link patients to providers and less experienced providers to remote experts. Medical hotlines have been used successfully to provide referrals and help disseminate timely information that can be customized to the month of a woman’s pregnancy or the age of her child; in some areas, these systems are being adapted for COVID-19.
Alternative care models that provide virtual or home-based care for eligible pregnant women, with flexible schedules based on an individual woman’s medical history and preferences, can help desaturate busy clinics and improve system efficiency. Delivery units could be redesigned for increased patient spacing by making use of underused areas or by developing methods to alert women and providers to where services are overutilized or underutilized.
Innovation in at-home and community-based care — delivered locally through community health workers, potentially using mobile technology — can help ensure women are better connected to care throughout their pregnancies and afterward. We have yet to test the full capacity and potential of community-based primary care that is linked to higher levels and supports and decreased COVID-19 risk.
Issues with PPE bring up the clear opportunity to strengthen supply chains. Gloves, gowns, masks, soap, and water should all be part of basic care. Investment in and focus on stable supply chains for these critical supplies will help address evolving COVID-19 needs, ensure future preparedness, and deliver essential, quality care.
Overnight, COVID-19 has laser-focused our global health efforts on fighting the virus and its consequences. Exposure can be reduced in one of two ways: either by limiting access to care or by redesigning the way we deliver care. If we don’t act now, hundreds of thousands of women, infants, and children will likely die; hundreds of thousands of women, infants, and children will also die when the next inevitable crisis hits, and the next.
It’s up to us all — including funders, global and local development organizations, researchers and academic institutions, program implementers, the tech sector, and policy and advocacy organizations — to seize this opportunity. We must invest our time, energy, and resources into designing solutions that can mitigate the consequences of the pandemic, build resilient systems, and catalyze lasting change — change that finally welcomes newborns and new moms alike with the high-quality care they deserve.
About the authors
Dilys Walker
Dilys Walker is a professor of obstetrics and gynecology and leads the Global Maternal and Newborn Child Health Research Group at the Institute for Global Health Sciences and the Bixby Center for Global Reproductive Health at the University of California, San Francisco.
Carolyn Smith Hughes
Carolyn Smith Hughes is a program manager and research analyst at the Global Maternal and Newborn Child Health Research Group at the Institute for Global Health Sciences at the University of California, San Francisco.