Management of RMNCAH services in the context of COVID-19

Maternal, newborn, child and adolescent health (RMNCAH) services are essential services and must continue during epidemics. The objective is to maintain safe access to care while preventing infection transmission to mothers, newborns, families, and healthcare workers.

Women attending services are generally healthy but may:

• Fear acquiring infection at facilities

• Delay seeking care

• Experience anxiety and misinformation

Healthcare workers may likewise fear occupational exposure. Therefore maternity services must combine continuity of care + strict IPC.

CORE SERVICE PRINCIPLES

Health facilities shall:

1. Maintain maternity care as priority essential service

2. Apply strict infection prevention measures

3. Minimize crowding and waiting time

4. Encourage mask use during visits

5. Separate suspected/confirmed patients

6. Communicate patient infection status during handover

7. Provide side rooms where possible

8. Give special attention to mothers with comorbidities

1. STANDARD INFECTION CONTROL PRECAUTIONS (SICP)

Basic precautions applied to all patients regardless of diagnosis.

Sources of infection

• Blood

• Body fluids (excluding sweat)

• Secretions/excretions

• Non-intact skin

• Mucous membranes

• Contaminated equipment/environment

Measures

• Hand hygiene

• PPE according to risk

• Equipment disinfection

• Environmental cleaning

• Respiratory hygiene

• Waste management

2. TRANSMISSION-BASED PRECAUTIONS (TBP)

Applied when SICP alone is insufficient.

For COVID-19 the TBP categories include:

• Droplet precautions

• Contact precautions

• Airborne precautions (during aerosol procedures)

Hierarchy of Facility Control Measures

1. Early recognition/reporting

2. Early triage

3. Separation of cases

4. Education of staff and patients

5. Restrict ill visitors

6. Sick staff remain at home

7. Dedicated PPE donning/doffing areas

8. Minimal staff entry

9. Remove non-essential equipment

10. Clean areas after each use

A. MIDWIFERY CARE

Midwives are essential frontline providers.

Key Policies

• Continuity of care models encouraged

• Limit number of caregivers

• Maintain respectful maternity care

• Do not redeploy midwives away from maternity services

• Provide full PPE access

• Maintain safe working environment

B. ANTENATAL CARE (ANC)

General Considerations

Current evidence shows:

• Pregnancy does NOT necessarily increase severe disease risk

• Vertical transmission remains uncommon

• Virus rarely detected in amniotic fluid or breast milk

All pregnant women — including infected — have the right to quality care.

Service Delivery Strategy

• Continue routine ANC

• Collaborate with community health workers

• Continue immunization and family planning

• Provide GBV screening and support

Clinic Decongestion

Low-risk mothers:

• Extended appointment spacing (≈2 months)

• Home follow-ups via CHW

• Remote consultation when possible

Essential ANC Package

• Malaria prevention (SP)

• Iron + folate

• Deworming

• LLINs

• Danger sign education

C. CARE DURING PREGNANCY

Contact Schedule

• Reduce physical visits

• Use virtual contacts

• Combine services in single visit

Screening

Every contact:

1. Obstetric danger signs

2. COVID-19 symptoms

3. Malaria screening

Education

Provide counseling on:

• Labor signs

• Birth preparedness

• Complication readiness

• Address myths

Gender-Based Violence Support

Healthcare provider must:

• Listen without judgement

• Validate experiences

• Provide referrals

• Provide post-rape care if required

D. INTRAPARTUM CARE (LABOUR & DELIVERY)

Labor Room Preparedness

• Adequate PPE stock

• Chlorine 0.5% cleaning

• Strict hand hygiene

• Routine screening at entry

For All Women

• Do not delay obstetric emergency care

• Encourage facility delivery

• Apply respectful maternity care

Suspected/Confirmed Infection

If labor not advanced

Transfer to designated facility if possible.

If delivery imminent

• Isolate mother

• Treat newborn as high risk

• Mother wears mask

• Staff use PPE

• Dedicated staff only

Mode of Delivery

Based on obstetric indication ONLY(COVID-19 alone is NOT indication for C-section)

Monitoring

Moderate-severe disease → hourly fluid balance chart

Neonatal Resuscitation

Use separate equipment for exposed newborn.

Caesarean Section

• Full PPE

• Prefer spinal anesthesia

• Rapid sequence induction if general anesthesia needed

E. BREASTFEEDING

Mother and baby should NOT be separated.

Safe Breastfeeding Measures

• Mask during feeding

• Hand hygiene before/after contact

• Surface disinfection

If mother too ill

• Express breast milk

• Feed via cup/spoon

• Clean expressing equipment

Breast milk substitutes should NOT be promoted.

REFERRAL DURING LABOUR

During transport:

• Staff in PPE

• Mother wears mask

• Gentle ventilation if BMV required

• Avoid circuit disconnection

• Prepare emergency drugs

EXPECTING NORMAL DELIVERY

• Prefer isolation room

• Use partograph

• Prepare vacuum extraction if maternal distress

• Start early skin-to-skin and breastfeeding

CAESAREAN DELIVERY PRECAUTIONS

• Informed consent

• Masked patient

• Full PPE staff

• Aerosol-minimizing anesthesia

F. POSTNATAL CARE

All mothers screened at first contact.

Care must be individualized.

Discharge Timing

Additional Counseling

• Hand hygiene

• Symptom monitoring

• Seek care early

• Follow-up calls every 3 days if possible

Ambulatory Postnatal Contacts

Minimum contacts:

• Day 1

• Day 5

• Day 10

Prioritize in-person for:

• Psychosocial risk

• Operative birth

• Premature baby

• Complications

Follow-up

• CHW home visits

• Phone consultations

• Routine baby visit at 6 weeks

KEY SAFETY MESSAGE

Even during pandemics: Delaying maternity care causes more maternal and neonatal deaths than infection itself.