The SARS-CoV-2 pandemic scenario in Africa - What should be done to address pregnant women needs? A commentary.

Charles M’poca Charles ^1,2,*† ; Emefa Modey Amoah ^3†; Kadidiatou Raissa Kourouma⁴; Luis Guilhermo Bahamondes² ; José Guilherme Cecatti² ; Nafissa Bique Osman ^5,6,; Philip Govule ⁷; Abdou Karim Diallo⁸; Jahit Sacarlal ⁹ ; Rodolfo de Carvalho Pacagnella ².

¹ Provincial Health Administration - DPS Manica, Manica Province, Mozambique.

² University of Campinas, School of Medicine, Department of Obstetrics and Gynecology, 101 Alexander Fleming st, Campinas, São Paulo, Zip code: 13083-970, Brazil.

³ University of Ghana, Department of Population Family and Reproductive Health, Accra, Ghana.

⁴ National Institute of Public Health of Côte d’Ivoire, Abidjan, Côte d’Ivoire.

⁵ Eduardo Mondlane University, Faculty of Medicine, Department of Obstetrics and Gynecology, 706 Salvador Allende st, Maputo, Mozambique.

⁶ Maputo Central Hospital, Department of Obstetrics and Gynecology, Agostinho Neto st, Maputo, Mozambique.

⁷ University of Ghana, School of Public Health, Department of Epidemiology and Disease control, Accra, Ghana.

⁸ Clinique Gynécologique et Obstétricale de l’Hôpital Aristide Le Dantec, Dakar, Senegal.

⁹ Eduardo Mondlane University, Faculty of Medicine, Department of Microbiology, 706 Salvador Allende st, Maputo, Mozambique.

† Co-First authorship

*Corresponding author:

Charles M’poca Charles, Provincial Health Administration - DPS Manica, Manica Province, Mozambique.

Email: cmpoca@gmail.com

Phone number: +258 825483741 / +55 19 98198-7713

Shortened running title: The SARS-CoV-2 pandemic in Africa & pregnant women.

Keywords: SARS-CoV-2, COVID-19, Africa, Low and middle-income countries, network, severe maternal morbidity.

The SARS-Cov-2 (COVID-19) virus causes an infectious and multisystem disease first diagnosed in China in December 2019.¹Having evolved rapidly with an exponential increase in the number of cases and deaths worldwide, COVID-19 was declared a pandemic by the WHO in mid-March 2020. Although in most Sub-Saharan African countries the pandemic is in its initial phase, as of 8 September 2020, the cumulative total cases of COVID-19 in the African Region exceeded one million and it is now at 1 315 073 confirmed cases with 31 725 deaths.²

The advent of the pandemic has exhibited the weaknesses of health systems in different settings, testing capacity and strategy being more evident in low and middle-income countries (LMICs).³The growing number of COVID-19 cases has forced many countries to reorganise existing health services and reassign available healthcare professionals to combat COVID-19. In this regard, a number of service delivery points were closed due to the lack of healthcare providers.

In response to the COVID-19 pandemic, many countries enforced lockdown restrictions that closed down schools, businesses, restaurants, markets, religious gatherings, and limited mass gatherings and border entry. The lockdowns in some contexts, led to the disruption or suspension of many essential health services including sexual and reproductive health (SRH) services, thus placing women of reproductive age under conditions of greater vulnerability and at risk of suffering devastating effects from COVID-19.^{4, 5}

In LMIC countries, the disruption in SRH services such as family planning, prevention and treatment of sexual transmitted infection (STI), safe abortion services, antenatal and postnatal consultations pose risks to women of reproductive age. The disruptions were generally associated with low coverage of the health network, weak diagnostic capacity for SARS-CoV-2 detection, shortage of trained healthcare personnel and reduced demand for services in the available health facilities due to stigma and fear of acquiring SARS-COV-2 infection.

This situation has the potential to contribute negatively to the incidence of high risk pregnancy, near miss, maternal and perinatal deaths in these LMIC countries, with the consequent compromise of objective 3.1 of the WHO Sustainable Development Goals, 2030 agenda.⁶

Although information on the clinical course of the disease and the consequences on maternal and perinatal health are still scarce, there is evidence that SARS-CoV-2 infection during pregnancy is associated with an increased risk of perinatal complications, including foetal distress, premature birth, perinatal death ⁷ and increased rate of admission to the intensive care unit and need for mechanical ventilation. ^{8, 9}

The risk of maternal and perinatal complications may be increased in pregnant women with underlying medical conditions, black pregnant women, and pregnant women from a disadvantaged social class and, in contexts with limited access to adequate healthcare services for COVID-19 management. ^{10, 11}

Although, the impact of COVID-19 on pregnant women was considered a secondary priority (12), studies involving pregnant women with respiratory diseases caused by other respiratory viruses in addition to recent data from studies of pregnant women with SARS-CoV-2 infection in middle and high-income countries, highlight the need to pay special attention to this group of women, especially in settings where healthcare services are strained.

While global maternal deaths gradually declined between 2000 and 2017, disparities in patterns of mortality still exist with Sub-Saharan Africa region alone accounting for approximately 66% of deaths in the continent.¹³ Due to the increasing number of reported maternal death cases related to the COVID-19, mostly from LMIC, and deficiencies in reporting cases in those countries, the need for prospective monitoring of COVID-19 cases among pregnant women in the context of LMIC is needed now more than ever.

As SARS COV-2 is a novel virus, knowledge of its impact on sexual and reproductive health (SRH) is now emerging. ¹⁴Therefore, to understand the dynamics of SARS-CoV-2 infection in its broad spectrum in the obstetric population of LMIC countries and to minimize the effects of the pandemic on maternal and perinatal health, it is essential to join forces among African researchers to generate evidence to better elucidate the magnitude of the problem. For this, the adoption of interinstitutional and multinational strategies is essential to optimize the allocation of scarce resources to fight the pandemic.

In response to the SARS-COV-2 pandemic in sub Saharan Africa, domestic and regional level efforts have been undertaken by various partners in multiple sectors.^{15, 16} A critical component to complement these strategies is the setting up of multi-centre collaborative networks of African researchers to undertake surveillance studies of conditions related to maternal and neonatal morbidity associated with COVID-19 and interinstitutional support for the creation and implementation of care protocols. The building of a collaborative network to study the impact of COVID-19 on the obstetric population in Africa (African Network for fighting COVID-19 in pregnancy- ANCOVID-19) would enable a broad understanding of the pattern of disease evolution in different countries and different contexts, enabling a better understanding of the role of context-specific determinants in the evolution of infection by SARS-CoV-2 and strengthen measure to ensure access to essential reproductive health services during pandemics, lockdowns and easing of restrictions.

Likewise, the implementation of robust surveillance systems and support to weaker systems by the stronger partnerships may favour the collection of standardised information on related maternal and perinatal morbidity. Continuous monitoring of the impact of the disease on maternal and perinatal health including strategies for remote monitoring of pregnant women through telephone calls and/or digital tools where available coupled with the sharing of clinical information will contribute to a better understanding of the dynamics of infection in this population and the moment of greatest vulnerability for the maternal and newborn health.

Thus, we call on all researchers in Africa to join in a continental effort to combat COVID-19 and reduce its impacts on maternal and perinatal health in Africa. This would encourage the provision of routine maternal and newborn services during and post pandemic in Sub-Saharan Africa.