In this review, we attempted to locate documents in the form of guidelines, consensus statements, best practice statements and standards of practice indicating directions on how reproductive health service during COVID-19 pandemics. We searched guideline databases, PubMed, EMBASE and Google Scholar and website of international professional associations and organizations working on sexual and reproductive health.
Antenatal care
Antenatal care services are one of the essential services that the WHO recommends being given during pandemics [WHO]. One of the major focus areas of the guidelines and consensus statements is on antenatal care provision during the COVID-19 pandemic.
Pre-triage for ANC
In circumstances where a pregnant mother presents for a face to face care most of the societies including FIGO recommend screening (triage) at the entrance into the health facility (4, 9-13). The MFM guidance advises on even an earlier pre-triage with phone communication while the patient is at home before she visits ANC clinics [MFM guidance]. Some even recommend screening of attendants too.
Mode of ANC provision
The mode of ANC services delivery should be modified, and innovative ways of care provision are recommended with due consideration of individualized care plan (in eight of the reviewed 12 documents)(4, 10-16). In low-risk mothers, Telehealth (voice or video calls) are viable options for delivering prenatal care as well as triaging women before they present to the clinic. Remote access options such as home antenatal service provision by community health care workers are also suggested in WHO, RCOG and SMFM guidelines(4, 9, 12). But face to face care provision is advised in high-risk pregnancies and women with emergency conditions where physical examination and other clinical/laboratory tests might be needed(10, 14).
ANC schedules
There is no clear recommendation in any of the guidelines and consensus statements regarding modifications in the timing of 1st visit, subsequent visits and the total number of ANC visits. But omitting or virtual visits are recommended by the RCOG and RCM(9, 17),while standard schedules are advised in high-risk mothers by the SMFM(12). The RCOG guidance on antenatal care services and ultrasound in the COVID-19 pandemic suggests that local practice should determine re-booking (9). Repeat visits might be scheduled using Telehealth. In three of the guidelines, it is suggested that pregnant mothers present for prenatal visits alone or just with a single screen-negative attendant (9, 10, 13).
The extent of Prenatal care services
There are no recommendations on modifications to the extent of service provision in the standard prenatal care. The only guideline addressing the issue is the RCOG labor, delivery and postnatal guidance in COVID-19 pandemic which states scans and antenatal appointments and other investigations should be provided within a single visit one-stop clinic(9).
Obstetric referral pathways
One of the health service challenges encountered during any pandemics is how to effectively sustain functional referral pathways, especially in low resource settings. The joint RCOG/RCM Guidance for provision of midwife-led settings and home birth in the evolving coronavirus (COVID-19) pandemic states there is good evidence to inform transport for complications and obstetric emergencies. Solutions are likely to be context-specific, dependent on E.g. urban/rural context, and the extent of pressure on the ambulance services(17). The RCOG guidance on labor/delivery and postnatal care states obstetric antenatal referrals can be triaged locally by a consultant with a telephone appointment to discuss a proposed plan of care with the woman (14). It is advised by the WHO that Instituting targeted referral and counter-referral criteria and processes are crucial to keeping the system from becoming overwhelmed labour and delivery(4).
Labor and delivery.
Induction and Elective Cesarean delivery(CD).
There is limited guidance on the induction of labor in the face of the COVID-19 pandemic. The RCOG recommends labor induction in low-risk mothers can be considered at as outpatient department (OPD) to ease the burden on inpatient services(14). The NHS advises that elective procedures (including) be done as planned to avoid burden on emergency services(15).
Place of Delivery.
In institutional deliveries limiting the number of attendants is recommended but with due consideration of making sure that there is always a family member around in emergencies. A single preferably screen negative labor companion is recommended in 2 of the guidelines(10, 15).
The COVID-19 pandemic will strain labor and delivery services if tertiary centers are overwhelmed with the care of non-pregnant patients with COVID-19 infection. Some of maternal health service providers might also be called to provide care in non-obstetric settings. There is also a concern for a healthy woman giving birth in a facility acquiring the COVID-19 infection. Hence some of the guidelines have addressed the issue of the place of birth in the face of COVID-19 pandemic. The International Confederation of Midwives (ICM) and the Royal College of Midwives (RCM) support community birth (home birth) for healthy women and newborn infants if there are appropriate mid-wife staffing and referrals are facilitated in obstetric emergencies (17-19). Where these are not available, it may be necessary to modify available services, seeking at all times to maximize the provision of safe and positive birth experience to all women (19). The NHS Clinical guide for the temporary reorganization of intrapartum maternity care during the coronavirus pandemic has put 4 options of childbirth: homebirth, alongside midwifery-led unit, freestanding midwifery-led unit, and obstetric unit. Freestanding mid-wife led delivery services are forwarded as viable options of childbirth by both NHS and RCOG guidance (15, 19). But this usually requires a response from an ambulance service, which may also currently be stretched. This means transfers from home to the hospital may not be sufficiently quick to ensure the safety of mother and baby (15).
Post-natal care
Modification of postnatal services is recommended with fewer visits and provision of care with telehealth. The telehealth care even can extend into those patients who have undergone surgeries. Generally, earlier discharge of mothers with uncomplicated deliveries is recommended (immediate or less than 24hrs in those after vaginally delivery and after 24hrs in cesarean section (11).
In the presence of community-based health workers home, postnatal care provision is another option suggested by WHO (4). The RCOG postnatal care guidance recommends for most women telephone or home visits may be preferable to community clinic visits to comply with social distancing. Face to face visiting is recommended for women with Known psycho-social vulnerabilities, operative birth, premature/low birthweight baby and other medical or neonatal complications (9). But ACOG advisory commentary suggests that phone call consultations and video conferencing with inspection of photos of wound site can be done in women who have undergone surgery(11).
Contraception service.
For women already on contraception:
Telemedicine and self-care family planning methods were recommended consistently. Self-care family planning methods include contraceptive pills, self-injectables, subcutaneous depo shots, condoms, vaginal rings, and fertility awareness methods [WHO, FIGO, RCOG, RCM, SOGC, RANZOG, IPPF, UNFPA, MSI, and FSRH ](3, 20-24).
There are consistent position statements that recommend combined hormonal contraception (CHC) and progesterone-only pills (POP) users to continue 6-12 months without visits and rechecking body mass index (BMI) and blood pressure. Depot medroxyprogesterone acetate (DMPA) users can switch to available progesterone-only pills (POP) to avoid face to face contact(3, 20, 25, 26). For long term contraceptive user’s options of extended use to avoid face to face contact is recommended. Limited evidence shows that the duration of long-acting contraceptive effect is 2 years beyond the Food and Drug Administration(FDA)-approved duration(27). Depending on that evidence many associations and organizations practice recommendations [FIGO, RCOG, RCM, SOGC, RANZOG, IPPF, UNFPA, MSI, and FSRH] advised delaying removal of implants and IUCD during the pandemic crisis unless series side effect happens or wants to get pregnant (3, 20, 23, 26, 28, 29).
New contraception starters:
Telemedicine and self-care family planning with remote assessment and prescription of CHC, POP for 6-12 months and self-injectable contraception were consistently recommended. However, administration of DMPA or insertion of implants or intrauterine devices to be considered where concerns about adherence, individual intolerance of oral contraceptives or use of teratogens make longer-acting reversible contraception the only suitable option. Pre-procedure assessment and information-giving remotely to minimize face-to-face contact time (minimum contact service) with healthcare professionals were recommended [WHO, FIGO, RCOG, RCM, SOGC, RANZOG, IPPF, UNFPA, MSI, and FSRH]. Optimal use of contact points, such as expanding post-partum family planning with special focus on long-acting reversible contraception was recommended [FIGO, RCOG, RCM, FSRH, MSI, and UNFPA].
Emergency contraception (EC):
Remote assessment of requirements and choice of EC. Oral emergency contraception remote prescription or provision without prescription or Cu-IUD provision with minimum face to face contact is recommended [RCOG, RCM, FSRH, BSACP, FIGO].
Safe abortion service.
All records (practice recommendations and position papers or commentaries) consistently recommend screening for COVID-19 symptoms from remote before face to face contact or during remote early medication abortion without face to face contact. There were several recommendations on no-touch/no-test early medication abortion protocol (2, 3, 25, 28, 30). The no-touch protocol depicts pathways to minimize COVID-19 exposure to patients and staff by organizing early medical abortion services to be delivered via video or teleconferencing /telemedicine and delivery of a treatment package(2, 25, 28). The treatment package includes mifepristone, misoprostol, ibuprofen, and self-care family planning. The no-touch/no-test protocol is self-medication abortion in early pregnancy without pre-procedure ultrasound and blood testing. The guideline also indicated that for women in self-isolation because of exposure to COVID-19 no-touch early medication abortion can be arranged similarly at home. If face to face contact care is must for COVID-19 exposed women, the guideline recommends that it should be booked when the isolation period is over unless the gestation is uncertain, and the delay may result in a woman not being able to access abortion in which face to face contact must be arranged with full personal protective measures(25). There is no specific protocol recommended for second-trimester medication abortion (above 12 weeks), but professional association and organizations position papers consistently recommend the utilization of telemedicine for digital patient education and counseling to reduce waiting periods and extent of face to face contact(minimal contact service)(4, 28, 30, 31).
For surgical abortion position papers and practice, recommendations focus on minimum contact procedure by remote digital patient education, counseling, and evaluation. The other focus practice recommendation is increasing safety during the procedure by limiting the number of people in the procedure room, appropriate use of personal protective equipment's and decontaminate area after the procedure as per the recommendation(28, 30, 31). The practice recommendations also include surgical facemask and sanitizer or hand washing for women. Vacuum aspiration, dilatation, and evacuation or dilatation and curettage are not aerosol-generating procedures unless done by general anesthesia(32). Therefore, these procedures don't require full personal protective equipment like N95, but abortion provides should screen all patients before the procedure and use standard precautions. Where possible and feasible it’s also highlighted to perform the procedures under local anesthesia or intravenous sedation or spinal anesthesia to avoid the need for general anesthesia(25, 28, 30, 32). Its recommended consistently that follow up visits is not required in all conditions and were needed to be done remotely by telemedicine.
Gender-Based Violence(GBV).
It is recommended that medical, legal and policy mechanisms for victims of gender-based violence remain in place during the pandemic crisis. Access to clinical care (medical evaluation and management) for rape survivors is recommended to be maintained 24/7 with necessary modifications in referral pathways to increase access[UNFPA, WHO, FIGO, RANZOG, RCOG, RCM, FSRH, and UN Women](3, 4, 31, 33, 34).
Assisted reproductive technology(ART).
Its recommended that assisted reproduction (including diagnostic procedures for infertility) shouldn't be started during the pandemics except in cases of urgent fertility preservation such as in oncology patients, the cryopreservation of gametes, embryos or tissue can still be considered [ESHRE, BFS, FSA, HFEA, and ASRM]. For those already on treatment its recommended to freeze all for later embryo transfer(35-39).