Maternal, Neonatal, and Child Health Services During COVID-19

Step 1. Determine pregnancy status

The first step in providing maternal and newborn services during the COVID-19 pandemic is to determine pregnancy status. Once a woman discovers she is pregnant, she will either contact a Community Health Worker (CHW) to provide an antenatal care (ANC) assessment or visit a health center facility directly to confirm her pregnancy and receive ANC. Alternatively, pregnancies in the community may be discovered through routine pregnancy surveillance. In this instance, facilities will provide pregnancy and COVID-19 assessments using the surveillance process and tools described in Slide 2. Note that both the woman and CHW should be wearing face masks when in the same room. In the health facility, the waiting area should be a well-ventilated room (or an outside space) in which other outpatients/families are socially distancing and wearing masks.

At the first point of contact between a pregnant woman and a CHW/healthcare provider, the woman will be enrolled in the pregnancy register cohort and local area monitoring system which helps CHWs follow the woman throughout her pregnancy and determine her estimated delivery date. During pregnancy assessment, women should be evaluated for potential SARS-CoV-2 infection, the virus that causes COVID-19, by considering the presence of suggestive symptoms, contact with family members or other persons with diagnosed or presumed COVID-19, and the extent of COVID-19 spread within the community. CHWs should be aware that pregnant women with COVID-19 may have mild symptoms (such as fatigue and headache). Additionally, other serious health conditions (e.g., malaria, dengue, preeclampsia, gestational diabetes) have similar symptoms to COVID-19, and thus CHWs must be vigilant in assessing these possibilities. If a CHW suspects a pregnant woman has COVID-19 either due to symptoms of COVID-19, potential recent contact with family members or other persons with diagnosed or presumed COVID-19, or both, the pregnant woman should be referred for testing.

Points of contact between women and health providers at which COVID-19 may be detected and steps for referral include:

Women without COVID-19 symptoms:

• If a woman does not have symptoms of COVID-19, then she should be referred to a health facility for a routine ANC visit.

Women with COVID-19 symptoms:

• If a CHW discovers during initial assessment that a woman has symptoms suggestive of COVID-19 or recent close contact with someone with COVID-19, the CHW should refer the woman to a COVID-19 testing and treatment center immediately. Women should receive information on home isolation while waiting for the test results, and if test is positive, she should follow the United Nations Population Fund (UNFPA) quarantine guidelines pdf icon[2.5 MB, 58 pages]external icon. All women who test positive for COVID-19 should have contact tracing follow-up in the community.
• If a woman exhibits symptoms of COVID-19 during a health facility assessment, she should be referred to a treatment center for a COVID-19 test as promptly as possible, after conducting assessments for other conditions which can present with similar symptoms.
• If at any point during the initial ANC or pregnancy status assessment a woman exhibits severe symptoms consistent with COVID-19 (specifically, trouble breathing; persistent pain or pressure in the chest; new confusion; inability to wake or stay awake; bluish lips or face; fever > 38.6 °C; or severe cough, nausea, vomiting, or diarrhea), she should immediately be referred to the COVID-19 treatment center for treatment.

Step 2. Continue antenatal care (ANC) visits

The second step in providing maternal and newborn services during the COVID-19 pandemic is to encourage the pregnant woman to continue ANC visits. After a woman receives pregnancy confirmation from a CHW or facility (Step 1), she should receive an initial ANC visit from a CHW or visit to facility. Health providers in facility should provide testing for HIV, tetanus toxoid (TT) immunization, syphilis and Hepatitis B infection testing, blood pressure measurement, urine checks for protein, and assess for other chronic conditions or diseases that can impact pregnancy as appropriate. During this first ANC visit, a CHW or health provider should work with the woman to develop an ANC schedule and check-up plan. Monthly ANC visits are recommended, but the schedule may be adapted depending on context and changed programming/conditions during the COVID-19 pandemic. CHWs and health facilities should educate all women on COVID-19 symptoms, importance of home care, maintaining social distancing, wearing a facemask when meeting with visitors, and maintaining good hygiene at home until delivery unless they experience pregnancy-related complications (including abdominal pain, dizziness, vaginal spotting, or bleeding) and/or severe symptoms consistent with COVID-19.

Women with COVID-19 symptoms:

If these symptoms occur during any ANC visit, CHWs or healthcare workers should refer women to COVID-designated treatment centers for testing and treatment, with contact tracing follow-up as needed. CHWs should also be vigilant to assess for other serious conditions that may cause similar symptoms.

Step 3. Facility-based delivery

The third step in providing maternal and newborn services during the COVID-19 pandemic is facility-based delivery. CHWs should refer all women to a Basic Emergency Obstetric and Newborn Care (BEmONC) or Comprehensive Emergency Obstetric and Newborn Care (CEmONC) facility, as appropriate, for delivery with a skilled healthcare worker, regardless of COVID-19 status. Appropriate handover should be ensured so that the receiving facility understands if the woman has had a confirmed case of COVID-19 diagnosed within the previous 14 days. Facilities should follow the standard operating procedure (UNFPA guidelines pdf icon[2 MB, 22 pages]external icon) for delivery during COVID-19, including appropriate infection prevention and control (IPC) practices. CHWs should identify and record women who deliver at home during their visits to the women’s homes.

Women with COVID-19 symptoms:

Women who test positive for COVID-19 or with symptoms consistent with COVID-19 infection should remain in facility after delivery until COVID-19 symptoms clear. Facilities should consult current UNFPA guidelines for discharge recommendations.

In the event of a COVID-19 outbreak or exposure in the facility, the length of stay in the health facility (e.g. 24 hours) may be shortened to reduce potential COVID-19 exposure of the mother and baby. If maternal or neonatal complications are identified, they should be attended to or referred, as is appropriate.

Step 4. Postpartum/postnatal follow-up care

The fourth step in providing maternal and newborn services during the COVID-19 pandemic is postpartum/postnatal follow-up care. After an uncomplicated delivery, women who have tested negative for COVID-19 should be discharged home.

Patients with symptoms consistent with COVID-19 should come back to the facility only after fever has resolved for 3 or more days without the use of any medications and 7 days have passed since the onset of symptoms, unless there are any medical emergencies, in which case she should come back immediately. If a woman is experiencing COVID-19 symptoms and pregnancy or postpartum complications, she must be seen in an isolated room with no other patients.

Pregnancy and neonatal outcomes should be tracked during postpartum follow-up visits using a postnatal care (PNC) checklist at home within one week of delivery (postpartum surveillance). Breastfeeding should be continued, with assistance from the family to pump breastmilk as needed, regardless of mild COVID-19 symptoms. Women should wear a face mask while breastfeeding or expressing breast milk and wash their hands for at least 20 seconds with soap and water before breastfeeding and after expressing breast milk.

If women return as outpatients to a facility for postnatal care, the waiting area should be a well-ventilated room (or even an outside space) in which other outpatients/families are socially distancing and wearing masks. If severe COVID-19 develops during the postpartum period, women should be referred to designated COVID-19 treatment centers.