ALERT – Action Leveraging Evidence to reduce perinatal Mortality and morbidity in Sub-Saharan Africa

Phillip Wanduru (Karolinska Institute, Sweden and Makerere University, Uganda), Regine Unkels (Karolinska Institute, Sweden) and Lenka Benova (Institute of Tropical Medicine, Belgium)

In 2020, COVID-19 infections did not develop in most African countries at the same speed as the rest of the world, for reasons not fully known.  However, we think that Africa’s rapid and rigorous response at the outset of the pandemic played a key role.  Countries like Uganda, Rwanda, and South Africa implemented some of the strictest lock-down measures. Unfortunately, when imposed onto a poor population they came with other consequences including a rise in hunger and absolute poverty, more deaths due to infectious diseases, among other negatives. This situation has changed in 2021. Many African countries have experienced an unprecedented rise in COVID-19 infections and deaths.  For instance, in June 2021 alone, Uganda’s COVID-19 related deaths were five-times more than deaths during the entire pandemic in the country. More so, by September 2021, less than 1% of Uganda’s population were fully vaccinated. In Africa those that are fully vaccinated are around 3%, which is way below the 10% vaccination rate by end of 2022. As a group of maternal and newborn researchers, we were concerned in 2020 about what was termed the “indirect effects” of COVID-19. These are effects that result from pandemic control restrictions like lockdowns, curfews, unavailability of health workers for maternal and newborn healthcare, among others. Now we see a double pandemic of “direct” and “indirect effects” of the COVID-19 infections.

How has the surge of COVID-19 infections affected maternal and newborn care in hospitals?

In this blog, we reflect on some of the ways in which the COVID-19 pandemic affected maternal and newborn care in hospitals in Uganda during the peak of the second wave in May to July 2021. From our colleagues in the three other sub-Saharan African countries in the ALERT project, we understand that many of the challenges are similar. Since the problems are too numerous to list, in this blog we concentrate on the three most important ones: accessing hospital care, human resource gaps and supplies and equipment.  

Many pregnant women were unable to access hospitals. This was been driven by three factors. First, lack of transport to get to hospital due to restrictions on public transport on which women are heavily dependent considering the lack of reliable ambulance services in Uganda, as in most places in Sub-Saharan Africa. Second, women, their families and communities had a widespread fear of contracting COVD-19 in hospitals. This has turned away many pregnant women from seeking care at health facilities. The fear to go to the hospital was nourished by the COVID-19 treatment units which were dealing with unprecedented numbers of COVID-19 cases and related deaths, further scaring women away from seeking maternity care. Third, some maternity units were re-purposed due to overwhelming COVID-19 case numbers in the hospital or amongst staff. Worse still, mothers who overcame these barriers and reached the hospital sometimes failed to get care. For example, in June 2021 at two hospitals in Uganda, some women, tested positive for COVID-19.  On hearing this, other women in labor ran out of the unit. The hospital administration closed and first disinfected the ward. Such events are a disruption to continued provision of maternity care.

With regards to human resources, the scarcity of health workers is critical. There was a high COVID-19 infection rate among nurse-midwives and medical doctors and many were unable to work.  This worsened the already pre-existing human resource problem. For example, in Iganga hospital, a high-volume maternity unit in Uganda, 8 out of 18 nurse-midwives in a single month (June 2021) tested positive for COVID-19 and were out of work. Consequently, women who got to the hospital probably did not get quality or adequate care, particularly in case of obstetric emergencies, which is the core function of hospitals.  Movement restrictions are also limiting the ability of health workers to get to their places of work and deliver services.

We also learnt that hospitals frequently ran out of personal protective equipment (PPE). Priority was given to health staff managing COVID-19 patients, not to those on maternity or other wards. Maternity staff had to privately purchase or re-use their facemasks. It is not difficult to imagine how much this is demoralizing health workers, and especially nurses and midwives whose salaries are already far too low to reflect their importance to functional maternity services.

Our reflections on the situation and way forward

The remarkable strides made in maternal and newborn care in Africa in the past 3 decades are at risk of being lost if the pandemic continues to be managed through restrictive lock-downs only. A level of normality and feeling of safety is necessary for health systems to function in a way that encourages women and their babies to access health care even amidst a pandemic. Some of the ways that can be explored to make maternity units safer may include; re-designing client flow, scheduled appointments where possible, tele-medicine, and self-care models among others. In an article published in BMJ global health, we highlight innovations that have already been adopted to suit COVID-19 context in Africa. However, it is important that these innovations are modified as the pandemic situation changes and more knowledge becomes available.

More urgently, Ministries of Health and other partners need to ensure prioritizing protection of the already constrained health workers from COVID-19 infections. Continued exposure of health workers to COVID-19 infection poses a big threat to the health system, even beyond maternal and newborn care. Commendable work has been done already in prioritizing the few vaccines for health workers.   However, we now know that even vaccinated people can get infected and/or re-infected. Therefore, there is need for provision of sufficient PPE in hospitals and all healthcare settings in general.

In Uganda, with a maternal mortality ratio of 336 per 100,000 live births and a perinatal mortality rate 38 per 1,000 live births, the ALERT project team is working toward improving quality of care at birth and thus to ultimately reduce these deaths. However, to achieve this, women and babies must be able to come to hospitals without delay and fear, and good quality care from health workers, and sufficient supplies must be available regardless the situation.