Pregnancy is generally a time of happiness and expectation, however, when experienced during a pandemic that has recast motherhood, it can also be a time of anxiety and stress. It is important for us to understand the full impact of Covid-19 on maternal health, as new mothers and their babies stand to face the harsh consequences of lockdowns and global containment measures.

According to Unicef, an estimated 116 million babies will be born under the shadow of the Covid-19 pandemic. In the nine months since the onset of the pandemic, the countries with the highest numbers of forecast births are expected to be India (20.1 million), China (13.5 million), Nigeria (6.4 million), Pakistan (five million) and Indonesia (four million). This list predominantly includes low middle income countries where maternal and infant mortality rates were already unacceptably high even in the pre-pandemic scenario.

Case reports thus far have suggested that pregnant women are not at a higher risk of developing Covid-19 complications and that transmission to the foetus during pregnancy is unlikely. However, the US Centers for Disease Control and Prevention (CDC) continues to urge precaution as pregnant women are often more susceptible to infection due to pregnancy associated changes in their immune system. Clinically, this is good news for maternal health, but this early data should be interpreted with caution and countries still need to ensure steady access to stable antenatal, delivery and postnatal services.

As the swift spread of Covid-19 continues on uninterrupted, forcing many developing countries with fewer resources and limited intensive care capacity to implement and enforce stringent lockdowns, they risk witnessing an increase in levels of neonatal and maternal morbidity and mortality with Covid-19 conditions in parallel.

The Covid-19 response is impacting the availability of essential health services, especially health services for pregnant women and newborns that cannot be delayed or shifted to other settings. Even before the emergence of Covid-19, high-quality and timely maternal healthcare services were deficient, inaccessible, or unaffordable for millions of women. Now, restrictions on travel and gatherings, health facilities with limited infection prevention supplies and unreliable infection control practices, and disrupted community health worker routines threaten to exacerbate the limitations when it comes to access to care, thus negatively impact women’s health.

From a retrospective analysis of the 2014 Ebola epidemic in West Africa, we saw that the use of reproductive and maternal healthcare services plummeted so much that maternal and neonatal deaths and stillbirths indirectly caused by the epidemic outnumbered direct Ebola-related deaths. Many women stopped going to the facilities altogether due to fear of infection and increased financial and physical barriers. Whereas, others were denied care if they were suspected of having Ebola as many facilities were poorly equipped to provide healthcare to infected women.

The effect that Covid-19 will have on use of maternal healthcare services is still uncertain and much depends on whether the efforts of low- and middle-income countries to prevent further spread of the virus are effective.

Based on the estimates of relative reductions in the uptake of family planning, antenatal care, and facility-based delivery services seen during the Ebola epidemic, scientists have deduced the indirect impact of the Covid-19 pandemic on the health of new mothers and newborns in India, Indonesia, Nigeria, and Pakistan over the next 12 months. These four countries remain the most populous low- and middle- income countries in the world — accounting for almost one third of the world’s population— and continuously struggle with poor maternal and newborn health outcomes.

Significant increases in maternal and newborn deaths and stillbirths would occur across these four countries over the next year if health service use continues to decline compared to what would be otherwise prevalent if these countries maintained adequate use of maternal and reproductive health services.

While these worrisome estimates suggest a significant impact, countries can learn from and adopt successful examples of maintaining high-quality maternal and reproductive healthcare during public health emergencies. Ministries of health and partners need to collaborate and develop their own context-specific solutions. As governments prepare their systems to deal with the influx of Covid-19 patients, they must also act urgently to ensure mothers and newborns are still able to get the routine and emergency care they need.

A few recommendations for consideration include:

• Helping women and their newborns get adequate and timely antenatal,skilled deliver, postnatal, reproductive and Covid-19 related care asand when needed

• Ensuring funds for the Covid-19 response go toward efforts to ensurecontinuity of care with adequate funding for infection prevention andcontrol supplies, equipment and vaccination, once it becomesavailable, for healthcare workers

• Health workers serving to deliver health services to mothers andbabies in their communities should be involved in policy responsediscussions and need to have access to up-to-date, evidence-basedinformation that can be delivered through peer-to-peer networks andmessaging applications

• Ensure proper infection prevention and control measures are in placeimmediately before and after childbirth

• Referral mechanisms and transportation must remain intact to dealwith obstetric emergencies and hospitals need to be able to properlyscreen, isolate, and care for infected pregnant women.

• Train, protect and equip healthcare workers to attend home births ininstances where health facilities may be closed.

• Guarantee proper allocation of resources to lifesaving services andsupplies for maternal and child health, both during and after thepandemic.

While it is imperative to focus on weathering the current crisis, those of us who work in maternal health must make a concerted effort to protect it through research, advocacy, and practice in the near future. The pandemic has given us the unique opportunity to reassess the cracks in our society, and with vision and hard work, address deep-seated inequities. We must work together in this crisis and beyond to ensure that maternal and child health is not neglected now or later.