The impact of Covid-19 on the maternal, newborn and child health and nutrition services
Impact in Europe and Central Asia, Albania, Bosnia and Herzegovina, Kosovo, Montenegro and Serbia
Introduction
As the full impact of the COVID-19 pandemic continues to be assessed, a better understanding of health system disruption and the consequences for maternal and child health in the Europe and Central Asia (ECA) region would be valuable to guide programme planning and priority setting by global health stakeholders. The objective of this mixed-method analysis is to systematically review available country-specific data and gather feedback from key respondents to develop insights about the current situation and what is urgently needed and would be most beneficial to improve maternal, newborn and child health and nutrition (MNCHN) services despite the rapidly evolving and challenging situation.
Recommendations
Europe and Central Asia
Overall recommended targeted actions to safeguard essential maternal and newborn services include:
- The pandemic has highlighted the importance of investing in resilient health systems that can respond to crises while maintaining essential services. Governments, health organizations, and communities must work together to address the impacts of COVID-19 on maternal and child healthcare services.
- Strengthen the primary healthcare to make it ready to deliver essential services during the pandemic: Invest in the primary healthcare infrastructure and healthcare workforce. Increase the number of healthcare providers in underserved areas and provide ongoing education to ensure high-quality healthcare services for children.
- Foster national leadership and greater transparency with advocates to promote COVID-19 immunization.
- Increase community engagement to address the main drivers of vaccine hesitancy in vulnerable communities and increase coverage of COVID-19 immunization.
- Strengthen the capacities and use of the health information system to ensure that real-time data can be used for decision making.
- Explore new models of care: Upgrade digital infrastructure, provide telemedicine, and develop parents’ application to ensure information sharing and connections with caregivers.
- Improve multidisciplinary collaboration: Foster collaboration between healthcare providers, social workers, educators and other stakeholders to address the social determinants of health that affect children
Albania
Maintaining the delivery of essential MNCHN services during a global pandemic and other emergencies requires a strong and resilient health system. Several key areas will be critical to restore, rebuild, and strengthen in order to improve health outcomes. Recommendations for Albania focus on the importance of contingency planning, a strong healthy workforce, ensuring an adequate supply of essential resources, establishing reliable information systems and other technologies, and relying on committed leadership and governance.
While we now better understand the virus and have the vaccines, diagnostic tools, treatments and other public health and social measures to end the acute phase of the pandemic, we must remain vigilant for the evolution and spread of new variants and redouble efforts to guard against the already stressed health systems and health workers being overwhelmed by new waves of COVID-19.
The pandemic has reinforced the need for countries and partners to be proactive and to react quickly in the face of a public health emergency.
Human resources
- Ensure the allocation of human resources, supplies and infrastructure required to prioritize infection prevention and control programmes.
- Enhance forecasting resources and planning for the future. All commodities must be available, and with sufficient reserve stockpiles, at all operating health facilities. This will ensure that care does not lapse during the critical childbirth and postnatal window in line with modelling results.
- Revisit human resource planning including midterm and long-term workforce planning strategies, through the analysis and determination of how to prepare for future staffing requirements.
- Address the exposure of the healthcare workforce to COVID-19 infection, and ensure an adequate supply of personal protective equipment and disinfectants.
- Manage workforce availability by applying shifts and efficient scheduling of patient visits. Support the health workforce’s mental health and safety from being infected by non-compliant patients.
Service delivery
- Ensure the inclusion of MNCHN services as essential services in national emergency preparedness and response planning.
- Reinforce basic infection, prevention and control measures, insist on respecting social distancing, especially by symptomatic patients. Employ measures to discourage patients with COVID-19 symptoms from visiting out-patient facilities during a two-week self-isolation period.
- Complement centre-based services with telemedicine, and plan and mobilize parents for immunization catch-up campaigns.
- Plan and schedule appointments with caregivers and children to avoid crowding; encourage visits of just one caregiver per child.
- Address long waiting lists in public facilities that prompt patients to use expensive private services instead. Bring services in public facilities to the level of private ones.
- Streamline the testing process to reduce waiting time and ensure compliance with self-isolating measures of those who test positive.
- Schedule antenatal care visits in order to reduce waiting time and encourage such visits in public health facilities.
Risk communication and community engagement
- Anticipate and address caregiver resistance/ concerns with respect to infant immunization.
The following recommendations are designed to improve children’s healthcare services:
- Strengthening healthcare systems: Improving access to essential healthcare services such as immunization, and investing in the healthcare infrastructure and human resources.
- Increasing community engagement: Engaging parents, caregivers, and community organizations in the planning and delivery of children’s healthcare services, and promoting public awareness of the importance of children’s health.
- Ensuring equity: Addressing health disparities among different groups of children, including those living in poverty, in rural areas, and from minority populations.
By implementing these recommendations, healthcare systems can improve the quality and accessibility of healthcare services for children, ensuring that every child has the opportunity to grow up healthy and thrive.
Bosnia and Herzegovina
Maintaining the delivery of essential MNCHN services during a global pandemic and other emergencies requires a strong and resilient health system. Several key areas will be critical to restore, rebuild, and strengthen in order to improve health outcomes. Recommendations for Bosnia and Herzegovina focus on the importance of sound leadership to guide a unified national response, a reliable up-to-date information system, and ensuring equitable access as the critical elements needed to strengthen the COVID-19 response in the country.
Technical leadership/international guidance as a foundation
- Maintain close WHO and UNICEF partnerships in order to promptly roll out timely guidelines and respond appropriately to concerns expressed by local providers and patients (e.g., guidance about breastfeeding).
- Actively engage with and maintain an active network of MNCHN constituencies, which draws together academic experts, healthcare professional associations and international agencies, for the rapid exchange of information and continued communication to address emerging issues or problems. Maintain a platform for exchange that precludes fragmented and conflicting or inconsistent messaging from organizations, which could lead to inefficient and stalled policymaking.
Information systems to guide the way
- Strengthen information systems for health system monitoring in order to improve the readiness and preparedness of facilities to respond not only to the current situation but also to future outbreaks of similar scope and impact.
- Establish and reinforce for course correction robust mechanisms of data collection, prompt review, and decision-making.
- It is critical to ensure that equivalent data are uniformly collected and updated consistently, given the regional and cantonal structure of Bosnia and Herzegovina; a greater degree of standardization will allow comparisons and adjustments to be made, both within and across health facilities, to improve resource allocation and preparedness planning.
- Information systems allow trends to be tracked for the mitigation of future disruptions under similar circumstances. Planning is required now for the long-term continuity of essential health services thus avoiding severe disruptions impacting mothers and children.
Service delivery
- Plan and conduct immunization catch-up campaigns that are aggressive and well-resourced while preparedness planning should ensure that clinic closures do not occur during future waves of the pandemic.
- Vaccination must be prioritized as an essential public health service and immediately restored and maintained with adapted strategies if needed.
- Focus on reaching communities that still lag behind or have yet to receive healthcare services.
- Plan and conduct mass vaccination campaigns as a key line of defence and forcefully prioritize immunization for those at highest risk of infections and those who are in danger of experiencing life-threatening complications.
The following recommendations relate to relates to the mental health crisis that is emerging due to the pandemic
- Bolster mental health services for those hospitalized, at home in insolation, or working in a demanding clinical environment on an urgent basis.
- Protect the mental health of overburdened frontline workers and draft a centralized plan to provide expanded psychological support services. A healthy workforce is one of the most critical components of a robust and well-functioning health system, and one of the most conspicuous threats weakening this asset is the mental and psychological strain caused by stress as the death toll rises.
- Ensure key services reach vulnerable groups, creating demand for COVID-19 vaccines, and develop a feasible plan for timely mental health support to avoid dire outcomes as the pandemic continues.
Risk communication and community engagement
- Develop careful messaging to alleviate fear and mistrust and to create demand for services, especially in migrant and refugee reception centres and other settings housing vulnerable groups.
- Plan and conduct an effective behaviour change campaign to combat misinformation and to increase uptake of the five available types of COVID-19 vaccine among eligible adults, which currently has waned.
Overall, these are recommendations to improve children’s healthcare services
- Strengthening healthcare systems: Improving access to essential healthcare services such as immunization, and investing in the healthcare infrastructure and human resources.
- Promoting early childhood development: Providing early childhood education, nutrition, and care services to support healthy development and prevent health problems later in life.
- Addressing social determinants of health: Addressing social and economic factors, such as poverty, housing, and education, that can have a significant impact on children’s health outcomes.
- Ensuring equity: Addressing health disparities among different groups of children, including those living in poverty, in rural areas, and from minority populations.
Kosovo*
Maintaining the delivery of essential MNCHN services during a global pandemic will require a strong and resilient health system. Several key areas will be critical to restore, rebuild, and strengthen in order to improve health outcomes. Recommendations for Kosovo focus on rebuilding and maintaining adequate stockpiles of key resources needed to deliver highquality clinical care, ensuring that widening human resource gaps are addressed, and fostering demand for health services including COVID-19 immunization with diminished barriers to access to promote greater equity.
Building health system resilience
- Ensure key areas are addressed to not only improve recovery from this crisis but foster resilience to face future crises.
- First, ensure that adequate stockpiles of drugs, supplies, and commodities are available and maintained at operational facilities, in order to continue the delivery of essential service for mothers and children.
- Second, maintain a robust up-to-date information system to support the decision-making process. Data collected should include service utilization as inputs, morbidity and mortality as outputs, and resource mapping. Reporting mechanisms should appropriately represent the municipalities, regional branches, and central offices to improve the use and flow of key information and ultimately improve the health of the population.
Effective leadership
- Maintain key partners such as WHO and UNICEF who can contribute by offering technical leadership or guidance as clinical and epidemiology insights are quickly emerging. Address demand during critical periods from childbirth to postnatal, as the quality and consistency of care in the public sector is gradually improved.
Human resources as a precious asset:
- Address the current need of both primary health care providers and advanced specialists, in order to avoid further burnout and risk of health system collapse when demand rapidly increases. Additional training programmes, increasing incentives, and task-shifting may offer some short-term options, and a holistic strategy must be adopted to address this worsening crisis
- Support professional development based upon updated clinical guidelines and protocols and supportive supervision, with the aim to improve the quality of care of existing providers.
- Consider immediate action to offset the pandemic’s profound impact on mental health, as health care workers report more symptoms of anxiety and depression. Expanded mental health resources are needed for frontline workers and the vulnerable populations they serve, which may require additional triage or referral options. Stakeholder buy-in is the critical first step and working with health professional societies or NGOs to both assess the most urgent needs and plan for implementation are also critical. The impact on minorities and vulnerable population subgroups must also be explored as they may require outreach or customized efforts to deliver mental health support
Service delivery
- Strengthen existing public programmes, such as the Home Visiting programme for maternal and child health, to reach marginalized groups. These populations face a high level of poverty and are reluctant or unable to access public health services. The success of a coordinated national response to COVID-19 will ultimately be tied to reaching these most vulnerable mothers and children to ensure that they can safely access key preventive and emergency medical services.
- Organize outreach activities for COVID-19 and childhood immunizations and connect them to available safety net measures already in place. Innovative strategies to target these missed opportunities should address associated maternal and child factors or obstacles that lead to delays in seeking care, reaching care, and receiving adequate high-quality care after arrival.
Risk communication and community engagement
- Develop programmes to efficiently create demand as immunization to fight COVID-19 is being rapidly rolled out to reach the general population. Providing vital information about the vaccine in clear and concise language and endorsed by reliable authorities is essential to combat vaccine hesitancy and misinformation that may be more prevalent in vulnerable communities.
- Use promotional materials about COVID-19 and childhood vaccines to communicate technical information, logistics details about where or how to seek care, and advocacy, and share these across multiple media platforms. Older populations, for example, who bear the greatest risk of serious COVID-19 complications and mortality, are most familiar with the print media including daily newspapers as a reputable source.
- Given the shift to online media, alternative approaches must be piloted while also promoting media literacy for all population age groups. The ability to understand what is accurate and informed news from trusted authorities is essential as the country strives to vaccinate the population and measures that modified service delivery can be lifted and rebuilding can continue.
Further recommendations to improve children’s health care services:
- Strengthening primary healthcare: Invest in primary healthcare services, including well-child check-ups, immunization, and preventive care, to ensure that children receive the care they need from an early age.
- Improving health literacy: Increase public awareness of children’s health issues, and promote education and health literacy among parents, caregivers, and healthcare providers to improve health outcomes.
- Investing in the healthcare workforce: Increase the number of healthcare providers, especially in underserved areas, and provide ongoing training and education to ensure high-quality care for children.
- Encouraging multidisciplinary collaboration: Foster collaboration between healthcare providers, social workers, educators, and other stakeholders to address the social determinants of health that affect children.
- Promoting family-centred care: Emphasize the importance of family-centred care, which involves families and caregivers in all aspects of their children’s healthcare, to improve outcomes and patient satisfaction.
- Advocating for children’s health: Advocate for policies and programmes that prioritize children’s health, including funding for research and development of new treatments, and expansion of healthcare services.
By implementing these recommendations, healthcare systems can improve the quality and accessibility of healthcare services for children, ensuring that every child has the opportunity to grow up healthy and thrive.
Montenegro
To maintain delivery of essential MNCHN services during a global pandemic will require a strong and resilient health system. Several key areas are critical to restore, rebuild, and strengthen in order to improve health outcomes. Recommendations for Montenegro focus on strengthening the health information systems to support key functions such as surveillance and monitoring, building a robust and diverse workforce to deliver care and improve population-level health, and promoting a strong uniform voice of leadership to reinforce evidence-based recommendations and carry out a strategic plan to rebuild public trust and ensure preparedness planning for the future.
Strong leadership and technical guidance as a foundation
- Address inconsistencies in practice or implementation, to match the aligned national policies with guidance from global authorities such as WHO and UNICEF during the pandemic. Adhere to recommendations such as mask wearing and distancing.
- Advocate for, and emphasize continued adherence to public health best practices paired with an efficient strategy for COVID-19 immunization. There is a need for targeted interventions to improve access for the elderly and other high-risk groups at the community level, including minority communities.
- Strengthen contingency planning to address future waves or pandemics.
- Maintain close partnership with international organizations, for example WHO and UNICEF, in conducting a series of public surveys assessing vaccine attitudes, knowledge, and acceptance. As trends of vaccine acceptance continue to improve, messaging to clinicians and the public must promote continued vigilance and commitment to infection prevention and control and immunization as key interventions.
- Disseminate information from WHO and UNICEF, promoting restoration and continuity of services including childhood immunization, to guide national plans in the context of COVID-19 and address barriers to demand. Lingering concerns or fear of COVID-19 infection from health facilities reduced utilization of public health centres as mothers preferred to seek care at private clinics, expecting better quality of care and reduced wait-times or smaller crowds.
Service delivery
- Improve health communication across multiple platforms about precautions put in place for safe delivery of care in order to boost confidence in public sector services.
- Invest in telemedicine in the public sector and communicate to the general public the telemedicine options in addition to traditional ways of delivering healthcare services.
Health information systems to guide and plan for the future
- Build a robust health information platform that collates accurate metrics to assess and improve the decision-making process across various sectors. Develop a reliable platform to collect updated data about epidemiological trends, available resources (e.g., medications and equipment, human resources, supplies of essential commodities), and processes such as standardized reporting that would facilitate tracking and monitoring of progress or detection of emerging issues.
- Follow vaccine-preventable diseases and anticipate potential outbreaks. Although the focus of surveillance departments shifted to the COVID-19 response, the country’s dependence on tourism and international visitors heightens concerns about the risk of outbreaks such as measles due to low vaccination coverage. It is critical to quickly rebuild surveillance and conduct catch up measles vaccination.
- Support an integrated public health strategy that encompasses primary, secondary, and tertiary prevention efforts, with a focus on both leading risk factors and contributors to the burden of disease, as well as current patterns about where care is being sought and the quality of the interventions being delivered. With this critical contextual information, updated data about the delivery of health services can guide efforts to shape demand and improve the care being delivered.
Human resources as a precious asset
- Ensure the availability of skilled health professionals including doctors and nurses is evenly distributed across the municipalities. Address the human resource gaps by increasing training or task shifting, including for the efficient rollout of the COVID-19 vaccine. Engaging the private sector as a partner may improve rates of immunization by increasing the workforce that could be mobilized.
- Increase the uptake of COVID-19 vaccines among healthcare workers through improved messaging and risk communication. Historically low participation in influenza immunization among healthcare workers foreshadowed lagging interest, but protection of frontline workers is essential to mitigate the toll of the pandemic.
Risk communication and community engagement
- Ensure consistent messaging about the mitigation of risk and continued care-seeking, and sustain or increase demand for COVID-19 immunization.
Further recommendations to improve children’s healthcare services
- Encouraging multidisciplinary collaboration: Foster collaboration between healthcare providers, social workers, educators and other stakeholders to address the social determinants of health that affect children.
- Promoting family-centred care: Emphasize the importance of family-centred care, which involves families and caregivers in all aspects of their children’s healthcare, to improve outcomes and patient satisfaction.
- Advocating for children’s health: Advocate for policies and programmes that prioritize children’s health, including funding for and expansion of healthcare services.
By implementing these recommendations, healthcare systems can improve the quality and accessibility of healthcare services for children, ensuring that every child has the opportunity to grow up healthy and thrive.
Serbia
To maintain delivery of essential MNCHN services during a global pandemic will require a strong and resilient health system. Several key areas will be critical to restore, rebuild, and strengthen in order to improve health outcomes. Recommendations for Serbia focus on strengthening the health information system to serve as a robust, reliable, and up-to-date resource, fostering transparency in leadership and governance, and rebuilding public trust in health programmes and institutions.
Leadership and sound governance to lead the way
- Anticipate and address the decline in public trust by placing greater emphasis on transparency and accountability. Maintain Serbia’s remarkable success in procuring adequate supplies of COVID-19 vaccines.
- Make procurement data regarding pandemic-related medical and non-medical purchases available to the public. Address uncertainty and government mistrust in order to increase vaccination rates for COVID-19.
- Provide clear and updated guidance while maintaining linkages with reputable global partners such as WHO and UNICEF as insight emerges or clinical recommendations evolve.
- Engage in-country stakeholders to lead implementation and local dissemination to reach wider audiences.
- Disseminate tailored messages (e.g. breastfeeding policy in the health facility setting) and global guidance through online training and innovative platforms, especially if service delivery is modified.
- Training of clinical staff, recruitment of volunteers to support campaigns, and patient follow-up may need revised approaches.
Information systems to guide the way
- Ensuring a well-functioning and accurate health information system. Serbia must commit adequate resources to strengthen, bolster, or expand the capabilities of the health information system as the consequences of misrepresentation can be serious when data are critical to inform strategic planning and decision-making in real time.
- Ensure access and use of a centralized and coordinated platform to collate uniform indicators for analysis of and planning national efforts. Ensure consistency, completeness and representation of aggregated data.
Risk communication and community engagement
- Address the spread of misinformation and disinformation about COVID-19, the vaccine, government measures, etc., propagated via online platforms Ensure transparency to fight a sense of growing mistrust and disconnect between the public as healthcare consumers and the state represented by government leaders, political parties, and stateled institutions.
- Consider launching a strong health education campaign relying on trusted community advocates or vaccine champions, to address any doubts and misconceptions about immunization against COVID-19, and the intent or motives of political figures.
- Develop a comprehensive health education strategy based on established social and behaviour change communication principles, to reach two key populations: healthcare workers and the public.
- Raise awareness among healthcare workers as a key high-risk population to create demand for utilization of the available vaccine supply. Immunization as a critical occupational health tool, as essential as infection prevention and control, must be emphasized among clinicians to improve stalled coverage.
- Address concerns about side effects, safety profile, effectiveness, development of the vaccine, etc., to combat apathy or inaction and to restore public trust in this key public health intervention.
- Reach frontline healthcare workers to enlist them to serve as powerful advocates and as sentinel messengers who share important health information or provide vital patient education.
- Engage young community leaders or activists, in addition to trusted and familiar medical authorities, as valuable allies to advocate for individual risk mitigation and to raise awareness about the risks and greater benefits of protection with the COVID-19 vaccine.
- Promote care-seeking, which has been affected by the pandemic, during key periods such as childbirth and for routine childhood immunizations, aimed at improving utilization of the state-run healthcare system.
- Tackle areas such as health information and bolster key resources with greater accountability, to strengthen the system and improve public health in Serbia.
Highlights
Overall, changes in mortality in the ECA region due to service disruption have been mild. Data suggests that swift action to restore services was effective and able to limit any negative and unintended consequences of the global pandemic. One key element, related to disruptions in service, has been the degree to which healthcare workers were affected by this pandemic. Importantly, guidance at the global, regional and national levels was critical to ensure that stakeholders are engaged and action is coordinated. At the same time, plans of action are dependent upon the country context factoring in health system.
