Continuing maternal and child health (MCH) services during COVID-19: activities, challenges and the lessons learnt

The Family Health Bureau (FHB) is the national focal point on maternal and child health (MCH) in Sri Lanka. It has spearheaded several initiatives in responding to the COVID-19 pandemic through an integrated approach via maternal and child health networks. Preparedness and response activities were carried out through advocacy, capacity building, strengthening supplies and communication at the national, provincial, district and grass root level.


Introduction
The Family Health Bureau (FHB) is the national focal point on maternal and child health (MCH) in Sri Lanka. It has spearheaded several initiatives in responding to the COVID-19 pandemic through an integrated approach via maternal and child health networks. Preparedness and response activities were carried out through advocacy, capacity building, strengthening supplies and communication at the national, provincial, district and grass root level.

• Preparedness and response
When the World Health Organization (WHO) declared COVID-19 as a public health emergency, Sri Lanka had reported only one case. The FHB initiated discussions with all relevant stakeholders including the higher officials of the Ministry of Health led by Deputy Director General of Public Health Services (II), Directorates of MCH, Epidemiology, Health Promotion and Mental Health, Professional Colleges of different specialties (e.g. obstetrics and gynaecology, paediatrics, psychiatry and microbiology) and experts from the Ministry of Education to reach consensus, obtain technical guidance and work on directives on ensuring optimum service delivery during the pandemic.

• Technical guidance and logistic support
Evidence-based interim guidelines on the continuation of essential services related to MCH in both curative and preventive sectors were formulated (1-4) and circulated. Instructions were issued to relevant regional level health staff on provision of domiciliary care, field clinic care, referral criteria for specialized care, protective measures, managing logistics and creating community awareness through several guidelines at different time periods based on the evolving disease situation in the country. High risk approach was adopted in prioritizing groups to receive maternal care due to limitations in human and other resources because of the pandemic. Different service provision strategies were recommended for low risk and high-risk areas. The latter categorization was based on risk of COVID-19 exposure in the community. A checklist on MCH activities was prepared and circulated among the medical officers of MCH (MOMCH) to supervise activities at district level.
Two hospitals were modified to manage pregnant mothers and newborns who would become COVID-19 positive (Colombo East Base Hospital) and suspected cases (Colombo East Teaching Hospital) with the support of ministry officials. Optimization of care in these hospitals was ensured by providing trained competent human resources and logistics such as facilities for providing newborn intensive care. Site visits were carried out to assess the ground situation of providing curative care for pregnant mothers either suspected or confirmed of COVID-19. This was done in collaboration with experts in clinical specialties to identify the service gaps and further strengthen the service delivery in both curative and preventive sectors.
Measures were taken with the Inspector General of Police (IGP) allowing pregnant mothers to use their Mothers Record (H512A) as a curfew pass whenever they need to seek medical assistance. Newborn screening for identification of congenital hypothyroidism was continued with the support of the district field staff with the disruption to routine postal services. 'COVID-19 Handbook for MCH Field Staff' was developed to provide guidance on carrying out field visits and field clinics by public health midwives (PHM), supervising public health midwives (SPHMs) and public health nursing sisters (PHNS).

• Procurement of essential equipment
Procurement and provision of personal protective equipment (PPE) for PHMs was carried out to ensure safety of the health staff as well as the clients. For females in the reproductive age residing in lockdown areas and quarantine centres, 'dignity kits' with sanitary products and 'maternity kits' for pregnant/postpartum mothers were distributed with donor assistance. PHMs were provided with necessary equipment and specific home delivery kits with the assistance of the Medical Supplies Division of the Ministry of Health. Hand sanitizers, face masks, protective face shields and other protective gear including aprons and gowns were procured through government agencies and non-governmental organizations and distributed among districts on priority basis. The FHB facilitated donations of PPE and several essential newborn care items from several agencies. Collaborative efforts have been initiated with UN organizations to ensure uninterrupted provision of nutrition commodities, logistic support to resume growth assessment and material to safeguard nutrition under five children. Family planning program was strengthened by continuous supply of contraceptive commodities across the country.
• Creating awareness and empowering the community A brief need assessment was conducted among youth (n=37) representing youth from different categories over the phone. Youth identified the need for introducing income generating options for the period (27%) and promoting home gardening and healthy cooking through "Yowun Piyasa" social media (32%). As a response, linkage on self-employment options was provided and online discussions with resource persons of that field were arranged for them. Social media posts were created on effectively utilizing leisure time, healthy lifestyle, engaging in creative activities, healthy sleep and prevention of mobile phone addiction with the involvement of youth. Leisure time activities such as creative decorations, healthy cooking and home gardening prepared by the youth were shared. Further details of mental health support centres were disseminated through social media targeting youth.
As a result of mobility restriction and physical distancing to prevent COVID-19, many people had more time to spend with their families. Positive inspirational posts and videos to create awareness among the general public aiming reinforcement of family harmony and well-being were prepared and published in social media. However, there were several incidents of gender-based violence reported over the time period. Therefore, there was a demand created for gender-based violence care centres in hospitals (Mithuru Piyasa/ Natpu Nilayam) and temporary shelters for survivors. As such, supplementary guidelines were developed and disseminated requesting the relevant staff to adhere.
The FHB was involved in re-establishing MCH services following the release of curfew and other restrictions. A guideline on preparedness of schools for reopening was formulated and submitted to the Ministry of Education with the aim of prevention of COVID-19. Further guidelines on preparedness for restarting youth training institutions and higher educational institutions was developed with the involvement of relevant ministries. Furthermore, FHB intends to conduct research activities on resilience of healthcare workers during this pandemic situation.

• Surveillance, monitoring & evaluation
A desk review of the maternal deaths reported during the lockdown period (n=13) was carried out to evaluate the implications of the restrictions on care pathways of the index cases. It was concluded that there was a substantial increase in the reporting of maternal deaths during the period under study compared to the number of deaths reported in the first two months of the year 2020. Furthermore, five out of thirteen cases were directly or indirectly related to the COVID-19 epidemic situation in the country, which resulted in delay in receiving optimal care for the index case. Hence, recommendations were formulated to streamline service delivery. Details of the foeto-infant deaths reported during the first quarter of 2020 are being collected for comparison, review and meaningful practice change.
Monitoring of the services was carried out by establishing a linkage with peripheral MCH teams via conducting online meetings. Platforms were created to link with the peripheral staff every week online and through the use of social media enabling the grassroot level workers to be directly linked with the centre. Furthermore, a mechanism was established to continue the national MCH reviews online.

Challenges and way forward
Provision of MCH services has been an uphill battle due to the unique and novel situation created by COVID-19 in the country. It has been a learning experience to all the sectors involved.
Undivided attention must be given to the clinical, public health and social impact of the pandemic both short and long term, as it would negatively affect the pregnant women and the families in several ways. There is a threat that this may set back already well-established MCH health care and wellbeing of the families in years to come. Thus, all those who are involved in the provision of MCH care in the country must be ready to sustain these services through continuous advocacy, capacity building and research. The COVID-19 pandemic provides us an opportunity to re-evaluate the gaps in our service provision. In a country with low maternal and infant mortality indices, multi-sectoral and intra-sectoral collaboration within the crisis and beyond must be strengthened to ensure that MCH care is not neglected.
Regardless of the many challenges, dedication and commitment of the entire public health network to safeguard the country's mothers, children and families during a public health emergency has been exemplary and is truly commendable.