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New study from Nepal confirms the direct effect of the COVID-19 pandemic on care around the time of birth.

By Mary Kinney & Ashish KC

A new study from Nepal confirms that the COVID-19 outbreak and response have severely affected maternal and newborn health. The study, published The Lancet Global Health, of 21,763 women across nine hospitals shows reduced coverage of health facility births by half and widening inequalities, with significant increases in stillbirth by 40% and neonatal mortality rates by three-fold. At the start of the pandemic, our leaders warned not only about the dangers of the pandemic but also the indirect impact of the pandemic on health systems, economies and societies. These indirect effects would adversely affect the most vulnerable and marginalized in the world, including women and their babies around the time of birth.

Even before COVID-19, the day of birth was the most dangerous day for babies in nearly every country, rich and poor alike. Maternal and newborn deaths and stillbirths are sensitive markers of a health systems strength because the health system needs to be able to respond to an emergency within minutes; the referral system needs to be functional; and women must access quality care before, during and after pregnancy in order to screen, identify and treat risk factors.  Jugmati Tharu, a woman from marginalized community from the rural municipality in Mid-western Nepal who delivered in one of the study hospital just before the lockdown says “I was quite afraid because I had heavy bleeding before the labour in middle of night. We could not get ambulance, and had to hire a private vehicle in a high cost. I was hopeless about my life, what would I think about the baby.”

The actual indirect impact of the pandemic and the related responses, e.g. “lockdowns”, have been challenging to measure. Many national data systems that monitor coverage and mortality trends have been compromised due to overwhelmed systems linked to the pandemic, especially in settings where these systems were already weak. There has been mounting antidotal evidence that the COVID-19 pandemic has led to fewer women giving birth in health facilities, poorer quality of care at facilities, and increasing deaths of women and their babies during pregnancy, childbirth and shortly after. Additionally, modeled estimates have indicated the implications for maternal and neonatal health will be significant.

The alarming outcomes from this new study demonstrate the fragility of health systems, especially in low-and middle income settings. It also raises questions on policies regarding strict lockdowns in LMIC during the COVID-19 outbreak. Sushila Bhatta, vice-mayor of Dhangadi Sub-Metropolitan municipality agrees that “During the lockdown has led to substantial decrease in the number of women delivering in health facilities. In our municipality, women fear of going to hospital and most have delivered in home without skilled provided. The other reason for home birth is unavailability of ambulance. We have now procured three ambulances to improve the referral to health”

Pandemic shutdowns threaten lives now, and also jeopardise progress made in the last two decades for women’s and children’s health, potentially derailing on-track status to achieve SDGs especially for maternal and newborn survival, and to build stronger health systems afterwards. Some places and practices seem to be more resilient, and understanding and sharing such learning is urgently needed to mitigate effects especially for the poorest families.