During an outbreak of a disease like COVID-19, priorities and resources shift. How can health care systems adapt to changing circumstances to maintain key health care services?

In an IHI Ubuntu Learning Community call this summer, Suzanne Stalls, Maternal and Newborn Technical Lead for USAID’s MOMENTUM 2A, and Dr. Chibugo Okoli, Deputy Country Director at Jhpiego in Nigeria, discussed work to address the impact of COVID-19 on maternal and newborn health in Nigeria and beyond. Stalls explained, “Hard-earned global health gains are being reversed, with health inequities widening, as resources meant for routine health programming and health service delivery are directed towards the COVID-19 pandemic response.”

During the COVID-19 pandemic, the World Health Organization (WHO) has provided guidance on maintaining essential health services during an outbreak. Early on, the WHO identified “reproductive health, including care during pregnancy and childbirth” as a high-priority category in interim guidance (note that information may have changed since publication). Stalls notes that pandemics exacerbate inequalities for women and girls. This includes the risk of gender-based violence and risk of exposure in the workplace, as women represent 70 percent of the global health and social sector workforce.

Across the globe, providers have made serious changes to continue maternal and newborn health (MNH) services while keeping patients and staff safe during the COVID-19 pandemic. Some of these changes include:

• Screening areas outside of health facilities
• Correct and appropriate use of personal protective equipment (PPE)
• Respiratory and hand hygiene rules
• Disinfection of surfaces between clients
• Separation of those infected with COVID-19 from those who are well
• Redesigned patient flow to minimize contact between clients
• Social distancing (for example, spaced seating) and guidance for masks, self-isolation, and quarantine

To support health workforce capacity, institutions may reallocate staff and increase support for screening stations and telehealth; train all staff about COVID-19, and provide mentoring, job aids, and tools for staff assigned new tasks; or offer mental health support for frontline staff, including enforced rest if possible and virtual support groups.

USAID’s MOMENTUM 2A facilitates countries’ increasing abilities to provide vital services for their citizens with less or no external support. USAID is working with Jhpiego, an international nonprofit affiliated with Johns Hopkins University, to reduce maternal mortality and morbidity (MMM) from indirect causes by applying a quality of care model to improve prevention, detection, and management of indirect causes of MMM associated with pre-eclampsia (a condition during pregnancy involving high blood pressure and other symptoms) and eclampsia (a rare complication of preeclampsia that leads to seizures). Their initiative began with 20 health care facilities in Lagos State and Federal Capital Territory with plans to expand to 100 facilities in October 2020.

The project focuses on high blood pressure, diabetes, anemia, and obesity, which can increase risk for pre-eclampsia/eclampsia and premature cardiovascular disease. A baseline survey of 649 women found limited knowledge of these risk factors. Participating facilities established quality improvement teams that are currently testing interventions such as on-site and virtual training for providers, shared learning across sites, and patient education, including digital support for women’s self-management of risk factors.

Due to the COVID-19 pandemic, Nigeria underwent a five-week lockdown, impacting health care workers, along with pregnant woman and other patients. Providers reduced and rescheduled appointments and faced a disrupted supply chain for materials. Patients experienced confusion about access to services, fear of visiting health facilities, transportation issues, and the spread of misinformation.

In response, early efforts focused on identifying essential services, optimizing both in-person and virtual delivery platforms, triaging patients for COVID-19 exposure and symptoms, and supporting health workforce capacity. Over time, the project team established and strengthened remote learning sessions for facilities, weekly mentoring of health care workers, and virtual support for pregnant women to care for their health needs. The care team used different settings as appropriate to optimize care, such as facility-based care for infected mothers and newborns, telemedicine for triage and counseling, and community-based visits with trained community health workers for some routine care.

Hospitals faced many challenges in trying to maintain MNH services, including limited staff, lack of COVID-19 tests for workers not involved in direct COVID-19 patient care, and insufficient supply of PPE in some facilities. In some areas, limited phone, internet, or data service constrained remote care delivery.

As the teams addressed these challenges, they learned some valuable lessons on how to move forward:

• Flexibility is key. Health systems need to be prepared to adapt to the unexpected. In order to make these adaptions, health care workers need to be equipped with the proper tools and resources.
• There is more than one way to provide and sustain MNH services. Remote mentoring and training, text messages and digital health applications, community-based visits, and facility-based care each serve a purpose.
• Staff support is vital. The need to support the mental health of health care workers should never be underestimated.

To learn more about the project, watch the full Ubuntu Learning Call. (Note that clinical assumptions may have changed as the understanding of COVID-19 has evolved.)

Dieynaba Dieng is a former Project Assistant at IHI.

You may also be interested in:

IHI Africa Forum (4–6 May 2021 | Online)

Supporting New Mothers in the Time of COVID-19

Testing Virtual Ways to Support New Mothers

AHA Maternal and Child Health During COVID-19 resources

California Perinatal Quality Care Collaborative and California Maternal Quality Care Collaborative COVID-19 Resources for Maternal and Infant Health

More COVID-19 Guidance and Resources