Samira Aboubaker, PSBI Community of Practice Technical Lead & Former Senior Medical Officer, Department of Maternal, Newborn, Child and Adolescent Health and Development, World Health Organization Organization
To date, Europe and North America have been most strongly hit by the COVID-19 pandemic. However, the global MNCH community is watching closely and preparing for the steadily worsening situation in low- and middle-income countries (LMICs). In a recent webinar, global leaders and technical experts summarized what we know (and what we don’t yet know yet) about COVID-19 in mothers, newborns, and children; shared guidelines and recommendations on COVID-19 and newborns; and discussed the indirect effects of COVID-19 on newborn health. Slides and a link to the recording can be found here.
What we know and don’t
From research published in China, we know that children ages 0-19 years have both a lower prevalence of COVID-19 and milder COVID-19 disease than older people. Why this is the case is yet uncertain and the subject of much ongoing investigation. Despite the lower prevalence and milder disease among children, there is concern that infants (1-11 months) might not be presenting with respiratory illness, but with other atypical symptoms. Additionally, there is limited information about the conditions that increase severe disease in children, and there is no information focused on malnourished children. What we know is changing daily, but we cannot let down our guard thinking that children do not have or transmit COVID-19.
Even less is known about how newborns are affected, but the good news is that data being collected in hospital settings seem to indicate that most babies born to mothers with COVID-19 have mild or no disease, and there is no evidence that COVID-19 is transmitted through placenta, vaginal secretions, or breastmilk. Likely, newborns with disease are acquiring it from symptomatic mothers.1 There is, however, no information about preterm or small for gestational age newborns, or about the risk of transmission from skin-to-skin contact, kangaroo mother care (KMC), or breastfeeding.
Initial evidence indicates that risk of COVID-19 disease is similar for pregnant and non-pregnant women. Importantly, for future guidance on screening pregnant women for COVID-19 in facilities, evidence from New York City facilities indicates that most of the women admitted for delivery who tested positive for COVD-19 were asymptomatic. Ideally, all pregnant women being admitted for delivery should be tested for COVID-19. Given the lack of widespread rapid testing and its cost, masks and other personal protective equipment (PPE) must be used with ALL presenting patients. Not only are sufficient and appropriate PPE crucial to ensuring that both families and health workers feel safe and appropriately protected, they will also help reduce the chances of declines in service utilization due to fear of transmission.
Guidelines for COVID-19 and newborns
The WHO has developed a suite of guidelines for COVID-19 management, and is working to harmonize those guidelines with other key partners such as the US Centers for Disease Control and Prevention (CDC) and to update them as new information becomes available. In developing the guidelines, experts have carefully weighed the risks and benefits of interventions such as breastfeeding and KMC which help all babies, particularly low birthweight and preterm, to survive. The current recommendation is to continue to provide these life-saving interventions if the mother is positive for COVID-19 unless she is very sick and unable to do it. In addition, facilities should ensure mothers have access to their sick newborn, birth companions should be allowed for COVID-19 positive mothers, and cesarean delivery should be reserved for medically justified cases. With all these recommendations, the importance of appropriate precautions (i.e. handwashing and distancing) and PPE was emphasized. For the most up-to-date advice on questions related to breastfeeding and skin-to-skin contact, click here.
More broadly, services need to be strengthened in both health facilities and communities to ensure women, newborns and children are not put at greater risk resulting from interrupted services. The global MNCH community must continue to support local capacity strengthening of pediatricians, community health workers, and other frontline health workers, and advocate for distribution of sufficient and appropriate PPE to all LMIC health workers.
Indirect impacts far exceed direct impacts
Steady progress has been made in reducing neonatal mortality worldwide, but global coverage of essential interventions is only mediocre and the impact of the COVID-19 crisis on newborn care in facilities and in the community threatens to dismantle this progress. The impact of the ongoing economic shock will hit women, children, and other vulnerable groups hardest, and there is a risk of a major decrease (and delayed initiation) in MNCH service utilization. Modelling based on the Lives Saved Tool (LiST) predicts up to 1.2 million additional child and maternal deaths as a result of reduced coverage of family planning, antenatal, childbirth care, postnatal care, vaccinations, early child preventive, and curative care over 6 months in 118 LMIC.
To continue to support mothers, newborns, and children to survive and thrive, high coverage of key effective interventions such as treatment for possible severe bacterial infection (PSBI) is critical. Despite ever-evolving and growing evidence on COVID-19 and newborns, one message is clear – the importance of maintaining essential services cannot be understated. The overarching message is to ensure that mothers, newborns, and children continue to receive all the beneficial interventions while remaining as safe as possible. By balancing the benefits and risks, the guidelines for maintaining health system interventions during COVID-19 will minimize any negative effects of discontinuing effective interventions.
Other indirect effects such as the impact on mental health, domestic violence, and anxiety; impact in humanitarian settings; impact of restrictions and infection prevention and controls on children; and impact of reorganizing health services are less known and need further investigation.
WHO’s COVID-19: Operational Guidance for Maintaining Essential Health Services during an Outbreak seeks to support countries to mitigate these indirect effects, but innovative delivery approaches and strategies for monitoring and reviewing them are necessary ensure protection of frontline health workers and support women, newborns, and children to safely access the interventions proven to help them survive and thrive.
This blog was made possible by the support of the American People through the United States Agency for International Development (USAID) under the terms of the Coordinating Implementation Research to Communicate Learning and Evidence (CIRCLE) contract AID-OAA-M-16-00006. CIRCLE is implemented by Social Solutions International, Inc. The information provided in this blog is not official U.S. Government information and does not represent the views or positions of USAID or the U.S. Government.
- Cochrane Fertility and Pregnancy Group. Perinatal outcomes in COVID 19 infection data sheet. https://cgf.cochrane.org/news/covid-19-coronavirus-disease-fertility-and-pregnancy Accessed 25April2020 & Internal review of 14 studies of 33 mother-infant pairs from China and Turkey as of 25 April 2020