Characteristics of included publications and key informants
A total of 1158 citations were returned from peer-reviewed databases, with 140 additional studies identified in reference lists (Figure 1). Following full-text screening, 103 publications met the inclusion criteria (Table 2), comprising of 20 peer-reviewed publications (19,20,29–38,21–28), 82 grey literature publications (39,40,49–58,41,59–68,42,69–78,43,79–88,44,89–98,45,99–108,46,109–118,47,119,120,48), and one dataset (15). The peer-reviewed papers included 15 empirical studies and five reviews; and the grey literature included 31 non-peer reviewed articles published in an academic journal (e.g., editorials, comment, letters to editor), three pre-print studies, two magazine articles, one non-peer reviewed review, 28 reports/briefs from humanitarian actors, 13 news articles and four presentations shared by key informants. The included dataset was retrieved from the UNICEF dashboard (15) which reported data from 26 countries, of which 23 are part of the World Bank fragile and conflict affected states list (16).
Overview of included publications by setting and type of publication
Fragile and conflict-affected setting (FCAS)
Low- and middle-income country (LMIC)
Key informants in the study (n=39) represented donor staff (n=3), academics (n=2) and humanitarian agencies (n=34). Key informants reported findings from the following 12 fragile and conflict affected states: Afghanistan, Colombia, DRC, Iraq, Nigeria, Somalia, South Sudan, Syria, Venezuela, Yemen, Zimbabwe, and Bangladesh (Cox’s Bazaar) (Figure 2).
The research findings are presented by the pandemic’s impact on funding for MNCHN, disruptions to these health and nutrition services, impact on MNCHN outcomes, and reported adaptation strategies for these services during the pandemic.
Impacts of funding for MNCH and nutrition
We identified significant impacts on funding for MNCHN in FCAS. There was a clear political priority placed on COVID-19 activities in many countries from the start of the pandemic. Decisions about funding diversions away from MNCHN and towards COVID-19 specific case management activities were driven by governments, donors and stakeholders (52,69). Respondents highlighted that in many cases governments explicitly requested MNCHN activities to be deprioritised or prevented them from occurring in favour of COVID-19 activities.
Increase in cost of continuing the same activities
COVID-19 has led to significantly increased costs of maintaining existing activities for MNCHN. Data from Nigeria that considered the changes in expenditure pre- and during the pandemic found that the cost of giving birth doubled or tripled depending on the route of delivery, with personal protective equipment (PPE) accounting for a large proportion of the cost increase and COVID-19 Polymerase Chain Reaction (PCR) testing that, in many cases, was passed on to women and families (24,65). These findings were echoed by interview respondents who also cited increased requirements for consumables such as PPE and service modifications for infection prevention control (IPC). More money was also required for human resources to maintain existing services. This is because a significant number of existing staff with underlying medical risk factors had to be moved away from frontline roles and contexts with difficult medical evacuation, and with staff having to self-isolate or quarantine.
Diversion of funding from MNCHN activities to COVID-19 related activities
The diversion of focus towards the pandemic has led to redirection of funds away from MNCHN services according to literature and interview respondants (61,116). Reallocations occurred early in the pandemic, with respondents describing a lack of available funds for the initial COVID-19 response from emergency preparedness, which resulted in use of available funds from MNCHN. The primary use for the diverted funds reported was for IPC activities such as procurement of PPE, strengthening of water, sanitation and hygiene (WASH) services and to build additional inpatient capacity for isolation facilities. It was noted that even once additional funding did become available, it was frequently for COVID-19 specific measures only, and less so for maintaining essential services, including MNCHN services. In many cases additional human resources and supplies were also only available for COVID-19 related activities.
“It took a while for the COVID funds to really come. So we had to use the existing funds to support the program during the adaptation and the later phases as well.” – Multilateral organisation, Bangladesh
Planned funding and MNCHN activities which did not materialise
Interviewees highlighted how the focus on COVID-19 meant that some other MNCH activities that were planned for 2020/2021 did not take place. These included trainings, quality improvement initiatives and entire MNCH programs in some cases. Examples cited included trainings, vaccination activities, HIV and TB, prevention of mother to child transmission (PMTCT), ANC and family planning (FP).
“In many cases funds which had been expected before the pandemic for certain activities did not materialise and planned programs didn’t open. In Yemen we scaled back antenatal and delivery care in an area in the knowledge that another actor had received funding and would start delivering these services; however in the end this actor was not able to open the expected services, citing funding issues... Women were then not receiving these services and we were unable to meet the demand, frequently turning women away in labour. Home deliveries likely increased, and we saw increasing number[s] of neonatal tetanus, probably as a result” - NGO, Yemen
Disruptions to MNCH and nutrition services
Both the demand (service uptake) and supply (service provision) sides of essential MNCHN services in FCAS have been overwhelmingly affected by the pandemic. Factors affecting the demand side identified in literature and interviews included stigma, the fear of infection, interruption of service provision, real or perceived linkage of COVID-19 measures to punitive restrictions on movement and liberty (in particular for migrants and refugees), distance from health facility, difficulties with transportation, increased financial burden and fear of being quarantined following a positive test result (15,23,28,93,110,114,115,117). Factors affecting supply side according to literature and interviews included reduced staffing due to MNCHN staff being diverted to COVID-19, staff infected with or scared of contracting the virus at work leading to absences; stock outs and supply issues including PPE and routine medications; and overall deprioritisation of MNCHN (19,55,93,115).
Within MNCHN services, interviews and literature also highlighted a reduction in the quality of care. For example, one online survey across 60 LMICs which includes some FCAS reports that due to understaffing, the rapid change of guidelines or unclear communication and challenges with the supply chain, the quality of maternal and newborn health services is perceived to be deteriorating (55). Inadequate staffing levels and diversions of resources to COVID-19 were reported by interviewees as further factors contributing to reduced quality of care.
Sexual, Reproductive, Maternal and Newborn Health
The literature review and interviews highlighted reduced and even complete suspension of the provision of maternity services due to COVID-19 (102). A key informant in an NGO reported that outpatient services were significantly reduced in many countries, often to half the normal activity. Interviewees highlighted that ANC services were reduced in many settings to reduce crowding and COVID-19 transmission and, in many cases, women were permitted only one ANC visit. PNC provision was reduced in Zimbabwe, Afghanistan, Venezuela, Bangladesh and South Sudan, with key informants in Bangladesh and Somalia reporting a complete suspension of newborn care (91). Suspensions of outreach activities were common (38). Interviewees described reduction in services that would normally have relied on outreach/mobile strategies as entry-points, including for reproductive health and sexual and gender-based violence (SGBV) interventions.
“... In the camp, you have a really big component that's outreach activities. And this was seriously impacted by COVID-19. Outreach activities [were] almost zero for SRH, it almost disappeared completely... I didn't realize at first that it was the most important activity for SRH and SGBV.” - International NGO, Bangladesh
Reduction in service uptake was also reported, including in ANC and facility delivery (28,105,110,117). In Cox’s Bazar, ANC consultations for adolescents fell by 65% between January and May 2020 (105). In Afghanistan, facility-based deliveries decreased by half (93). Increased home deliveries with traditional birth attendants (TBAs) were reported in several countries including Nigeria and Bangladesh (54,110).
“All other services including antenatal care were disrupted...in theory, the services were not stopped. But people stopped coming to the consultations. People stopped themselves obtaining services. And it was mainly because of the fear...They had the fear that maybe they go to COVID-19 from the hospital, from the healthcare providers...” - Multilateral organisation, Afghanistan
“The bigger concern was we had a huge reduction in the number of patients. So we went from... 2000 deliveries on average to, in July , we had... 900 deliveries... I still don't know where all these people started to go.” - International NGO, Afghanistan
According to key informants, unclear communication and lack of adaptation of COVID-19 messaging for pregnant women also led to confusion about going to health facilities to deliver or not as COVID-19 messaging was advising people to avoid attending them.
“We did see a drop in service utilization. And I think that was probably for a number of reasons. One was….the lack of clarity in in terms of messaging, so should people stay at home or should people still come to the clinic.” – International NGO, South Sudan
Downscaling and closure of consultations, reduced preventive and curative care, vaccination and nutrition programmes related to child health was seen (20,21,30,39,43). Interviews and literature findings noted a decline in utilisation of outpatient and inpatient child health services (15,23,35,72,93). Save the Children examined the impact of COVID-19 on child health in 37 countries and found that more than one third of respondents faced barriers to accessing healthcare including the closure of health facilities, long queues, and shortage of medications (104).
Routine immunisation was disrupted across many settings due to early recommendations from scientific advisory groups for emergencies to suspend all preventative mass vaccination campaigns, which placed children, especially those suffering from malnutrition, at increased risk (15,31,68,72,79,102). Additional reasons cited in the literature for vaccine disruption include delivery systems affected by the pandemic, healthcare services being stretched, social distancing measures, and caregivers becoming fearful of visiting health centres (27,58,93,118). Several interview respondents attributed the reduction or suspension in vaccination coverage to factors including supply chain issues, suspension of outreach activities to prevent COVID-19 spread and consequences of stopping other services (e.g., ANC) which normally would be used as an opportunity for comprehensive care provision, including vaccination.
Past epidemics indicate that this type of situation could result in a decline of vaccinated children and in the surge of new epidemics of childhood vaccine preventable diseases (32,50). Despite the declaration of wild polio eradication in Africa in 2020, vaccine-derived polio transmission has increased and is now reported in a number of countries including Niger (31). In Afghanistan, polio vaccination was stopped and there was a rise in polio cases, particularly in polio free areas (63,71,75).
“We are already seeing increases in vaccine-preventable diseases, for example Diphtheria, tetanus pertussis, and measles outbreaks. Polio campaigns were also suspended and Vaccine derived Polio cases are also occurring due to low vaccination coverage.” – NGO, setting anonymised on request
Concerns have been raised over the effects of neglecting malaria control programmes including net distribution, seasonal malaria chemoprevention, and treatment, especially for children, since this age group has the highest burden of malaria, accounting for 70% of global malaria deaths (26,47,95,120).
Nutrition services were suspended in several FCAS, including nutrition centres, food distributions and treatment for child wasting (15,44,80). Reasons for reduced nutrition activities cited in interviews and the literature included a link to reduction or suspension of community outreach activities, measures to prevent gatherings and prevent transmission of COVID-19, and diversion of nutrition staff to COVID-19 (72,93).
“We were told that you cannot go into the community because you can potentially take COVID in and out to the community... So we had to stop that...And because some of the programs, the nutritional programs such as dinners for kids were shut down... that is a problem because a lot of kids didn't have anything to eat except for what was given in those diners.” - NGO, Venezuela
“When the COVID-19 started... I would say nutrition really suffered, because… they are reassigning… all the nutrition staff to work on COVID-19 related activities. So, we noted that... all the upstream work that we do to do with policy guidelines... things were not moving, everything had to come to a standstill for like five months.” - Multilateral organisation, Somalia
Reports from several countries refer to the difficulties that populations have been facing in accessing and ensuring food supplies. Reduced income, limited resources for quality diets, food insecurity, higher prices in food, limitation of health care services and interruption of humanitarian responses are leading to undernutrition (37,44,49,82,90,104,106,108,109,113). Interview respondents noted a reduction in uptake of nutrition services during the pandemic despite needs increasing in some contexts, especially for child nutrition interventions.
“There was definitely a reduction in the number of children that were enrolled in supplementary feeding and therapeutic feeding programs. And this was... for a number of reasons. One of them being that you know, people were reluctant to come to the clinics.” - Multilateral organisation, Global
Data collection activities
Several respondents reported disruption or suspension in routine data collection, monitoring and evaluation and measurement activities in MNCHN. This was due to deprioritisation of MNCHN measurement activities, inadequate staffing, and difficulty in carrying out activities based in the community due to lack of PPE, movement restrictions and other COVID-19 prevention measures which leads to reduced quantity and quality of data. Multiple community measurement activities were suspended, including mortality surveys, (e.g., Standardised Monitoring and Assessment of Relief and Transitions (SMART) surveys) and nutrition surveys, as well as community surveillance, have also been impacted. As a result, there has been a significant reduction in the visibility of community level deaths of women and children during the pandemic.
“I think everyone, even governments, are facing data collection gaps. Data collection and data quality was in a bad state before COVID-19 in many countries. And now with COVID-19, it's just worsening...we don't know how many people are affected. [...] You know, in some countries, community health workers are very strong data collectors. But with COVID-19, they might not even go to the villages where they would normally go.” - Multilateral organisation, global
MNCH and nutrition outcomes
Findings from interviews and published literature point to increased morbidity and mortality associated with MNCHN across several settings related to the disruptions to funding and services, threatening years of advocacy and improvements (5,42,55).
Sexual, Reproductive, Maternal and Newborn Health outcomes
Increasingly late presentations were reported across settings which resulted in poorer health and mortality outcomes. Women are reported as arriving late at heath facilities and more frequently presenting with serious complications (such as eclampsia) as ANC services are neglected.(53,110) Interview respondents also reported women presenting with more severe maternal morbidity and complications linked to reduced pregnancy care and other COVID-19 related impacts, such as iron deficiency anaemia, secondary to increased levels of malnutrition.
“I think one thing that we did see was an increase in late presentations and there was a subtle increase in maternal mortality cases in our clinic over the summer. That speaks to a presentation of patients not coming in for routine, preventative care in their pregnancy, and then having problems later on...” - International NGO, Bangladesh
Estimations looking at the indirect mortality from COVID-19 disruptions in LMICs, indicate that over six months of disruptions would result in an increase of 8.3%-38.6% in maternal deaths per month across 118 countries (25). Another publication estimated that, over a year in LMICs, a 10% decline in coverage of maternal and newborn health services would mean an additional 1.7 million women who give birth and almost 2.6 million newborns that would experience major complications without receiving the needed obstetric and newborn care. This would result in additional 28,000 maternal deaths and 168,000 newborn deaths (62). Data from the four most populous LMICs (including Nigeria) could see a 31% increase in maternal and newborn deaths and still births as a result of reduced FP, ANC and facility based deliveries in the next 12 months (99,110).
Authors caution that these numbers are an underestimation, especially in rural, low resource and FCAS where the most vulnerable pregnant women are (60). Specific estimations for selected FCAS indicate that the impact of a large service disruption in 2020-21 would lead to between a 1% to 11% increase in maternal mortality; and that between 10,700 and 725,900 fewer women would be left without access to facility-based deliveries across several FCAS, such as in Yemen, South Sudan and Central African Republic (CAR) (96–98,100,101,103,111).
Several interview respondents also highlighted an increase in maternal mortality across a range of humanitarian settings, citing inability to access care, reduced care-seeking behaviour, reduced ANC and potential COVID-19 infection itself as attributing factors.
“...during my first three months of being in Yemen, I had no maternal deaths... then when COVID hit, we had so many more maternal deaths. Sometimes, it's hard for us to say exactly whether it was because of COVID-19 because we didn't actually test everybody. [...] It could have been due to COVID. It could have been that people were a lot more afraid of coming to the hospitals, because obviously that was like, I think, a common narrative around the world.” - International NGO, Yemen
A report from Save the Children warns that 60 million children will need humanitarian assistance in 2021 to survive, which accounts for half of all children in need globally (73). A modelling study that considers the excess mortality due to disruptions in essential maternal and child services and access to food reported estimates 253,500 to 1,157,000 additional child deaths in a year in the least and most severe scenarios respectively (25). This translates to a 9.8% – 44.7% increase in deaths in under-fives per month across 118 countries LMICs and to a 12% - 18% increase in selected FCAS (25,96–98,100,101,103,111).
Interview respondents highlighted increased child morbidity and mortality with children frequently arriving at health facilities late and with severe disease. Key attributing factors included reduction in child health provision facilities, reduced outreach activities, reduced health seeking behaviour and worsening malnutrition.
“...In Yemen, there were a lot of children arriving in a very bad state. In White Nile the team asked because the number in the hospital was very low. And that was because the activities - the screening activities at community level stopped with the pandemic.” - International NGO, Yemen and Sudan
There is a strong argument to continue routine vaccinations, ensuring appropriate use of PPE, hygiene and physical distancing measures are put in place (45). A modelling study estimated that routine childhood immunisations in selected African countries should be continued as the deaths prevented by this activity outweigh the risk of COVID-19 deaths related with the visits to vaccination clinics (34). However, catch-up programmes in some FCAS were restarted to address the impact of early programme disruptions (78,91).
Several settings reported rises in severe acute malnutrition admissions, ranging from increases of 10% up to 70% (72,76,86,93,108,117). Several interviews reported increased malnutrition, with women and children being most at risk, particularly in settings that were already experiencing high levels of food insecurity and malnutrition before COVID-19. Women’s nutrition was also affected with at least a quarter of a million pregnant and lactating women, in Southern Yemen, in need of malnutrition treatment (86,89). In a modelling study looking at the indirect mortality from COVID-19 in LMICs including FCAS, the authors estimate that 18-23% of additional deaths in children under-five will be caused by the increased prevalence of wasting (25).
Adaptation strategies for MNCH and nutrition services
The literature search and key informant interviews reported a range of adaptation strategies for MNCHN implemented, most of them with the primary objective of reducing transmission of COVID-19.
Factors enabling successful adaptations of MNCHN services included preparedness, coordination and collaboration between actors, good communication, provision of adequate amount of supplies and support from the local population (74,80).
Barriers to adaptations include lack of flexible funding, challenges with global supply chains, and capacity to rapidly implement new ways of working (77). There were concerns from some key informants about whether the priority placed on reducing transmission of COVID-19 compared to other essential services was proportionate to the threat given the seriousness of other factors affecting MNCHN in FCAS. Acceptability of adaptations by the local population was a further challenge faced by several actors. For example, lack of acceptance of one adaptation preventing hospital visitors led to reduced service uptake.
“...The first thing we did was to stop with all the caretakers to enter the hospital, you need to think that in that area, I mean the patient, they are always coming with the mother-in-law... And this was a big, huge thing. And challenge, because also, we need to have a lot of meetings with the elderly, with the community to also make them understand, we need to reduce the flow of the people coming inside and going outside.” – International NGO, Afghanistan
“People started losing trust in our facilities because they came and they didn’t get treated, because there wasn’t anything, which is very unusual... I think that had a very, very huge impact on the perception of the community of what we do.” – International NGO, DRC
Adaptations to funding
There were some accounts of positive adaptations in relation to funding MNCHN services in FCAS. One study highlighted that the pandemic has diversified the funding sources which could be a solution to strengthen reproductive, maternal and child health programmes (116).
Several interview respondents reported additional funding being made available from both international internal organisation funding and from donors. Strengthening WASH including IPC was a major reported use for the funding to increase availability and quality of WASH in health facilities and improve communication and education on WASH which had a positive effect beyond the avoidance of COVID-19 infections. Various actors and funders highlighted that funding was not earmarked for the pandemic and could be used for other activities such as MNCHN services.
“On the one hand... IPC improved, hygiene improved, hand washing improved, I mean, it was much more focus put on that, where you could actually even see a reduction in certain diseases…diarrhoeal diseases, and whatever.” - International NGO, DRC
Infection prevention and control measures
Reorganisation of patient flow, social distancing measures (e.g., reduction of hospital visitors, reduction in access to smaller groups of patients at a time, reduced frequency of facility visits), reduced opening hours and reduction or suspension of out-patients department (OPD) consultations were highlighted in the literature and interviews (19,33,54,85,112,116).
“These are services that are usually very crowded. So they tried to adjust the services too. They had longer hours. They gave women specific times to come to reduce some crowding, where they did have to decrease services, they prioritised women that were in the third trimester of pregnancy.” - Multilateral organisation, global
Interview respondents noted that increased WASH activities were implemented in many contexts, with handwashing and environmental IPC prioritised. Emphasis was placed on training staff in IPC and use of PPE in several settings (67).
Use of technology
Telemedicine was used as an adaptation strategy in a number of FCAS including Zimbabwe, Syria and Nigeria (33,55,85,112). Several interview respondents highlighted that MNCHN service provision was shifted to online modalities, for example mobile phone/WhatsApp calls and messaging. In addition to its use for providing services and information to users, interview respondents noted the use of online technology for staff training (including on COVID-19 measures and for maintaining essential health services) and to adapt data collection in several settings to try and continue the delivery of routine monitoring and evaluation on MNCHN data.
“They can do the consultation remotely, using the tablet, community health workers, you know, bring it to the pregnant woman and then they consult with the midwives. And then for the other thing also that we also try to improve in is using the mobile phone platform [...] - the community can text a message to the health provider or to the community health workers about their problems.” - Governmental agency, Bangladesh
Nevertheless, the impact of limited use of telemedicine services has not been equitable across settings and socioeconomic groups. Some respondents noted that access and proficiency in technology was a challenge for adaptation strategies involving online tools for staff and target populations; and it might not be a realistic solution for some settings (29).
Decentralisation of services
Due to the decrease in demand for facility-based health care, it was crucial to provide MNCHN services at the community level (116). Several interview respondents intended to shift MNCHN services to mobile or outreach services to better reach populations in the community. Examples of how they managed to operationalise this shift included using important community gathering places such as the local mosque to provide health promotion and related services.
“We decided to use a mobile clinic to do outpatient treatment... We just needed to be closer to the population to do this screening and treatment at the community level. We left the hospital and moved to the community to try to treat the malnourished children earlier.” - International NGO, Yemen
Interview respondents described new communication and advocacy activities on maintaining essential services to reassure and continue promotion of usage of MNCHN services, such as institutional deliveries.
“Community messaging has been a key part of what we’ve done. To reassure people that the services are still open and safe to attend. And also information about COVID, how to stay safe, hand washing, guidance, all those kinds of things that we’ve seen in many other contexts globally.” – International NGO, Yemen
Another form of decentralisation of services was using self-care interventions. Several respondents mentioned the shift in global nutrition guidance to using mother/caregiver led mid upper arm circumference (MUAC) measurements to screen for malnutrition at home, with guidance on when to seek health care given to caregivers. This adaptation was also highlighted in the literature (15,74,80).
Interview respondents also described how treatment protocols in some settings were altered to continue essential healthcare whilst reducing contact frequency at facilities. Measures included giving longer durations of medication and food rations and encouraging use of long-acting reversible contraceptives (e.g., intrauterine devices, implants).
However, despite the intention to increase community-based services, the extent to which this has actual been possible has been limited in many settings. This is because of funding constraints, the repurposing of community health workers to COVID-19 related activities, and limitations to community gatherings. In some countries, outreach activities were suspended during the pandemic.