COVID-19 has disrupted health care services globally. A new survey of health workers across 62 countries finds it caused disruptions in newborn care as well, putting small and sick newborns at increased risk of death.
Prior to COVID-19, the world lost an estimated 2.4 million newborns per year. Health experts point out increased intensive care, including interventions such as kangaroo mother care or KMC, which involves early, prolonged skin-to-skin contact between mothers and small, vulnerable newborns with a birth weight of less than 2,000 grams (70.5 ounces) soon after birth, as well as exclusive breastfeeding, can help reduce this mortality rate.
However, the new survey, covering 1,120 health care professionals carried out between July and October 2020 published in BMJ Global Health, finds that implementation of these critical interventions was delayed, or not followed, for a number of reasons.
“There's this instinctive feeling that if the baby's really tiny and vulnerable, and you don't know if the mother's got COVID or not, you should play it safe … but actually, by so-called playing it safe, you’re actually putting them at risk.”— Joy Lawn, director, The Centre for Maternal, Adolescent, Reproductive, & Child Health, LSHTM
These include health worker hesitancy due to their own fear of infection, as well as fear of COVID-19 transmission between mothers and newborns due to lack of COVID-19 testing or delays in the results of those tests for mothers; lack of proper guidelines on newborn care during COVID-19; as well as the diversion of health care staff and facilities, such as oxygen tanks from newborn wards to COVID-19 wards.
The survey doesn’t provide information on newborn mortality rates as a result of newborn care disruptions, and more data is needed on how newborn deaths have changed during the COVID-19 pandemic. But an observational study in Nepal in 2020 showed linkages between newborn care disruptions and mortality.
A separate modeling study published in The Lancet’s EClinicalMedicine also showed that practicing KMC significantly outweighs the risks of newborns dying from COVID-19 in health facilities. In a scenario where KMC was fully practiced amid an assumption of 100% mother-to-child COVID-19 transmission, 125,680 newborns’ lives were saved versus 1,950 lost due to COVID-19. However, a reduction of KMC coverage of up to 20% in a span of one year could result in 25,000 additional neonatal deaths.
A question of what is safe?
Only 36.2% of 807 health care personnel who responded to the survey said routine testing for SARS-CoV-2—the virus causing COVID-19—was available for all women giving birth upon admission. Where testing was available, delays in the release of the test result led health care personnel to delay the implementation of interventions such as KMC.
While the survey was done in the third and fourth quarter of 2020, most of the hospital settings covered in the survey still don’t have regular testing, said professor Joy Lawn, director of The Centre for Maternal, Adolescent, Reproductive, & Child Health, at the London School of Hygiene & Tropical Medicine.
She said almost none of the 65 hospitals in Malawi, Kenya, and Nigeria that she and teams part of the Newborn Essential Solutions and Technologies or NEST 360° network, provide support to have regular COVID-19 testing.
“So that is partly what's driving fear,” she told Devex. “If you're a [health care] worker … even if you're wearing a mask, and the mother’s wearing a mask, but you have no information about who's ... positive or not … you do feel more fearful, because the unknown makes you more fearful.”
Mothers’ test results greatly affected the implementation of KMC: 79.2% of 664 respondents proceeded to practice KMC for mothers with negative test results, but only 36.1% of 543 respondents practiced KMC for mothers suspected with COVID-19, and 32.4% of 519 respondents practiced the intervention for mothers who tested positive for COVID-19.
But Lawn said keeping babies from their mothers can put them further at risk of mortality.
“I think there's this instinctive feeling that if the baby's really tiny and vulnerable, and you don't know if the mother's got COVID or not, you should play it safe … but actually, by so-called playing it safe, you’re actually putting them at risk,” she added.
A newborn agenda
Not all personnel received institutional guidelines on how to care for small and sick newborns during the COVID-19 pandemic, with only 23.1% reported having access to such guidelines. Most were gathering information from the Internet, colleagues or public health authorities.
This is not very surprising given how little guidance was available on newborn care prior to the pandemic. The World Health Organization only produced norms and standards for newborn care in September 2020, Lawn said.
“I like to say that newborn care is still newborn on the global agenda,” Lawn said. “So many of these [health care] workers, their countries are still … just starting to produce newborn care guidelines.”
In some settings, neonatal inpatient care was also reduced, with 18.9% of those surveyed reported staff were reassigned to cover for COVID-19 and other related duties, while 14.6% said areas dedicated for newborn care were reallocated to COVID-19.
Families were also requesting early discharge from the hospital out of fear for mothers and babies contracting COVID-19, and 73.3% reported families were reluctant to do follow-up care for their newborns for similar reasons.
But this heightens the risk of newborns dying. A lot of the newborns discussed in the survey were “extremely” preterm babies — less than 32 weeks old and therefore require clinical care.
“If you're born two months preterm in many countries, you would stay in hospital for a month. So if you're taken home on day three, you know, a lot of those babies will die at home … They're not stable enough to go home, they can still get worse, get an infection, have respiratory complications … they don't have a suck reflex, they'll need help with feeding,” Lawn said.