Child Mortality and Maternal Health in the COVID-19 Environment

Preamble

Pakistan has one of the highest child mortality and maternal mortality rate in South Asia.  While the full extent of COVID-19’s impact on the child and maternal health, including child mortality, is still unknown, the United Nations warns that the disruption of life-saving health services could result in children’s death from treatable and preventable diseases and put the lives of mothers in danger. Therefore, it is the need of the hour to fully understand the repercussions COVID-19 will have on child mortality and maternal health in Pakistan and highlight possible policy options to avert these challenges.

Research Questions

1. What are the Challenges related to child and maternal health emerging from COVID-19?

2. What are the guidelines and safe practices for COVID-19?

3. What is the burden of the pandemic on children and how that can be reduced?

4. What are the viable policy options for sustainable child and maternal health in Pakistan?

Introduction

The social and economic impacts of COVID-19 will negatively affect child and maternal health as they are quite likely to become neglected in the wake of the current pandemic. Furthermore, being a developing country with a fragile health delivery system, Pakistan is amongst the top countries predicted to experience a surge in child mortality rate due to COVID-19.  Iqbal Institute of policy studies conducted a webinar on the implications of COVID-19 on child mortality and maternal health in Pakistan. The webinar critically assessed the impact of COVID-19 on child and maternal health, particularly child mortality, and identified opportunities available during the current pandemic.

Challenges Related to Child and Maternal Health Emerging from COVID-19

Ms. Iram Kamran shared findings of a study conducted in Rahim Yar Khan, southern Punjab to assess the impact of Covid-19 on the reproductive health of poor women. It was found that the lady health workers were unable to visit women and provide family planning services. Moreover, the unavailability of contraceptives at health facilities forced women to switch from modern to unreliable traditional methods. Besides, the impact of Covid-19 on maternal health services prevented women from availing antenatal and natal services due to lockdown related restriction on mobility, financial constraints, and non-willingness of hospitals to admit delivery cases. Due to Covid-19 lockdown, antenatal, postnatal, birth spacing and delivery services, all got severely disrupted. This resulted in an increased number of unwanted pregnancies in addition to unsafe abortions, rise in maternal and child mortality, and a massive drop in contraceptive rate (CPR).

As of July 15, Pakistan has recorded 257,944 positive Covid-19 cases out of which 8732 are children between the ages of 1 and 10. Fortunately, the mortality rate is extremely low for this age group, i.e., about 0.1 %. However, the disruption of health services has negatively affected child and reproductive health.  Out of the total Covid-19 cases, 29% of confirmed cases are females, and 8.3% are children under 18 years. No official data regarding pregnant women is available, but it is estimated that about 5000 are Covid positive. In terms of the effect of Covid-19 on pregnancies, currently, there is no difference between the clinical manifestations of Covid-19 among pregnant, postpartum, and non-pregnant women or adults of reproductive age. Also, there is no evidence that pregnant or postpartum women are at higher risk of severe illness. Furthermore, there are no confirmed cases of prenatal transmission. Children are not the face of this pandemic, but they risk being among its biggest victims. Though the direct impact of covid-19 on children and adolescents is extremely limited, the indirect effects on child survival stemming from strained health systems, household income loss, and disruption to care-seeking and preventive interventions like vaccination may be substantial.

Dr. Attiya Abroo explained the effects of Covid-19 on Reproductive, Maternal, Newborn, Child, and Adolescent Health (RMNCAH) services. Lockdown with restriction of public transportation affected the mobility of the health workers to reach their duty stations and community health workers to reach out to their catchment population. At the start of Covid-19, the Ministry of National Health Services Regulation and Coordination developed the National Covid-19 Response Plan. Later with the support of UN agencies, Pakistan Preparedness and Response Plan (PPRP) was developed. Initially, PPRP did not include specific activities on the provision of essential health services. Recently the 9th pillar of PPRP has been developed on essential health services including RMNCAH services. Innovative approaches towards RMNCAH services have been introduced to mitigate the impacts of Covid-19 on healthcare delivery systems. Telemedicine services for RMNCAH services, including family planning helplines, are being established in each province. Moreover, a pool of telehealth providers is being established, and contact information for remote consultation on all health issues is being disseminated.

Guidelines and Safe Practices for COVID-19

Professor Mamoona Mushtaq shed light on the guidelines and safe practices for COVID-19. She explained that individual responses to viral infections are different for different women. There have been case reports of women with severe COVID-19 symptoms at the time of birth who have required ventilation and extracorporeal membrane oxygenation. Therefore, the continued provision of antenatal and postnatal services is essential for maternal health. Care for pregnant and postnatal women is a critical service that must not be disrupted. Women should be advised to attend routine antenatal care unless they are in self-isolation with symptoms of cough or fever. Hospitals should rapidly seek to adopt teleconferencing and videoconferencing capability and consider what appointments can be conducted remotely. Electronic record systems should be used if possible.

In terms of intrapartum services, women should be permitted to have a support person present with them in their labour and during birth. Additional restrictions, such as limiting the number of birth attendants, restricting visitors to antenatal or postnatal wards, and preventing swapping and postnatal visitors should be put in place. For women with Covid-19, if an ambulance is required, the call handler should be informed that the woman is currently in self-isolation. Also, women should be asked to alert a maternity staff member before entering the hospital. The staff providing care should take personal protective equipment (PPE) precautions as per health protection guidelines. Isolation rooms should ideally have an antechamber for putting on and removing staff PPE equipment and adjacent bathrooms. Only essential staff should enter the room.  Entry for patients and the public at the first point of contact should have a system to identify potential cases. This should be employed before a patient takes a seat in the maternity waiting area, ensuring early recognition and infection control. Some situations where overlap between pregnancy and COVID-19 symptoms may cause confusion (e.g., fever with ruptured membranes). In cases of uncertainty, staff should seek additional advice and treat patients as COVID-19 positive until additional information is available.

There is an estimated incubation period of 0-14 days. Infected women may start developing symptoms later during an admission. Health professionals should be aware of this possibility, particularly those who regularly measure patient vital signs (e.g., Nurses).  In the event of new-onset of respiratory symptoms or unexplained fever of or above 37.8 degrees following admission, the woman should be isolated and appropriate infection control precautions should be initiated in line with Infection Prevention and Control Guidance. When confirmed or suspected COVID-19 patient is admitted to the delivery unit, a multi-disciplinary team should be informed. This team should include Consultant obstetrician, Consultant anaesthetist, Nurse-in-charge, Consultant neonatologist, Neonatal nurse in charge and Infection control team.  Efforts should be made to minimise the number of staff members entering the room, as there is evidence of household clustering and household co-infection. Furthermore, neonatal care literature from China has advised separation of the infected mother and her baby for 14 days. The mother should wear a mask while breastfeeding and handling the baby. Infected women may start developing symptoms later during an admission. Health professionals should be aware of this possibility, particularly those who regularly measure patient vital signs (e.g., Nurses).

The Burden of the Pandemic on Children

Brig. Shahid Aziz deliberated upon the burden of Covid-19 on children in Pakistan. Majority of the children each year die of vaccine-preventable diseases such as pneumonia, diarrhoea, measles, tetanus, pertussis, and TB. According to UNICEF, in the year 2018, 91,000 Children in Pakistan died of pneumonia while 53, 300 children died of diarrhoea. Furthermore, in 2018, an estimated 19.4 million infants worldwide were not reached with routine immunisation services. Alarmingly, around 60% of these children lived in 10 countries such as Pakistan, India, and Indonesia. Vaccination and routine immunisation are vital for preventing millions of deaths worldwide. To date, the eradication of smallpox has spared the global community of some 40 million deaths. Polio is also on the verge of eradication in the world, but in two countries, namely Pakistan and Afghanistan, Polio cases are still widespread.

About 58% of children in Pakistan remain unimmunised. The main reasons for this undercover include economic challenges, weak healthcare system, logistics obstacles, parental attitudes, and religious & community perception. There are certain ways to improve vaccine uptake like making birth registration mandatory, linking immunisation with NIC, giving incentives to parents through cash programs like Benazir income support, and broadcasting routine vaccination advertisements along with Covid-19 prevention messages. There is a great hidden burden of interrupted vaccination. Recurrent untreated infections lead to malnutrition which can result in neonatal and infant mortality. We must focus on parenting during the lockdown. Children have limited understanding of COVID-19. Good parenting measures would include educating children about the situation in age-appropriate ways, acknowledging their distress, and answering their questions with honesty. Furthermore, the NGOs and volunteer organisations should work with the government in monitoring delayed & interrupted vaccination during Covid-19 pandemic. They must advocate for policies to encourage and facilitate telemedicine.

Dr. Amna Amjad, Public Health Professional, stated that the mortality rate among children due to Covid-19 is extremely low, but the secondary impacts of the virus are quite severe. The suspension of life-saving interventions such as immunisation drives can be lethal for children. The disruption of essential immunisation services is expected to cause long-lasting impacts on child health. Polio vaccinations have been suspended worldwide while measles vaccines have been delayed in 24 countries. Due to household income loss, children are at higher risk of malnutrition.  It is recommended that the government scale up Covid-19 response and prevention measures and strengthen essential health delivery systems. Furthermore, the front-line health care provider must be equipped with protective gear, masks, and sanitisers.

Viable Policy Options for Sustainable Child and Maternal Health in Pakistan

Pakistan can take many concrete steps to ensure sustainable maternal and child health (MCH) in Pakistan. Improved deployment of the healthcare workforce, prioritization of pro-poor policies for health financing and integration of various health information systems, decentralization of government services to improve responsiveness and quality of health services, and controlling the quality of drugs and medical devices are some of the ways which can ensure future progress in maternal and child health. Lastly, the provinces need to revise their health budget to allocate more funds to high-priority MCH issues.

Key takeaways

1. Though the direct impact of Covid-19 on children and adolescents is extremely limited, the indirect effects on child survival stemming from strained health systems is substantial.

2. Owing to economic challenges, weak healthcare systems, parental attitudes, and religious perception, about 58% of children in Pakistan remain unimmunised. Under this environment, family planning becomes more important to avoid the indirect adverse impact on infant and maternal health.

3. On average, a patient with any ailment remains a burden on the health system for about ten days.  However, a pregnant woman requires medical assistance for a period of 1 to 1.5 years (pregnancy plus infant care). This is the biggest challenge for maternal health, and infant mortality as timely and adequate health services may not be available. Therefore, family planning (birth spacing) is the most effective way to avoid additional burden on the health system, thus ensuring infant and maternal health.

4. Due to Covid-19, the disruption of family planning services and the unavailability of contraceptives at health facilities are forcing women to switch from modern to unreliable traditional methods of birth control.

5. Currently, there is no difference between the clinical manifestations of Covid-19 among pregnant, postpartum, and non-pregnant women or adults of reproductive age.

6. Majority of the children each year die of vaccine-preventable diseases such as pneumonia, diarrhoea, measles, tetanus, pertussis, and TB. In 2018, an estimated 19.4 million infants worldwide were not reached with routine immunisation services.

7. There are certain ways to improve vaccine uptake like making birth registration mandatory, linking immunisation with NIC, giving incentives to parents through cash programs, and broadcasting routine vaccination advertisements along with Covid-19 prevention messages.

8. Furthermore, the NGOs and volunteer organisations should work with the government in monitoring delayed & interrupted vaccination during Covid 19 pandemic. They must advocate for policies to encourage & facilitate telemedicine.

9. Hospitals should rapidly seek to adopt teleconferencing and videoconferencing capability and consider what appointments can be conducted remotely. Electronic record systems should be used if possible.

10. Neonatal care literature from China has advised separate isolation of the infected mother and her baby for 14 days. Also, the mother should wear a mask while breastfeeding and handling the baby.

11. With the support of UN agencies, Pakistan Preparedness and Response Plan (PPRP) was developed. Recently the 9th pillar of PPRP has been developed on essential health services including RMNCAH services. Innovative approaches such as telemedicine services have been introduced to mitigate the impacts of Covid-19 on healthcare delivery systems.

Bibliography

Iqbal Institute of Policy Studies. (2020). Child Mortality and Maternal Health in the COVID-19 Environment. Islamabad: IIPS. Available at https://www.facebook.com/144287616215098/videos/308450430342102