Research supports most maternal deaths as attributable to one of the following three delays: 1) A delay in seeking health care after the sudden onset of labor, 2) a delay in reaching a health facility, and 3) a delay in being assisted once the health facility is reached (Onambele et al., 2022). While delays in accessing maternal health care are a perennial issue in some countries, these delays can be even further impacted by overlapping crises as was the case for Afghanistan where a mid-pandemic political turnover in 2021 led to withdrawn health care funding which compounded the negative impact on what was already one of the world’s lowest maternal mortality rates at 620 deaths per 100,000 live births (Tharwani et al., 2022). In fact, 75% of the countries who registered a high maternal mortality rate in 2008 were at war, and while the morality of diverting health care funding during overlapping crises remains an interesting philosophical argument, there’s little argument that pandemics, much like wartime, create competition that can strain the distribution of resources, services, supplies, and personnel (Onambele et al., 2022). The isolated impacts of COVID-19 on each country’s maternal mortality rate are likely a reflection of the impact of COVID lockdown measures on the three delays that become more prevalent during crises, the ability of health care institutions and patients to prevent and circumvent the “three delays”, overall effectiveness in preventing COVID transmission, population density, and geographic size. Although many countries and their citizens experienced region-specific barriers to accessing maternal health care during COVID-19 pandemic that may only be applicable to the given population, examining their unique approaches responses to maternal health care challenges during times of disaster and institutional strain offers an opportunity for both retrospection and improved emergency preparedness as it pertains to mitigating loss of life for new and expectant mothers and infants and loss of resources.

Clinical Characteristics of COVID in Maternal Health Cases 

Non-obstetric causes of maternal mortality (i.e., causes not directly related to pregnancy and childbirth) commonly include severe hemorrhage, infection, high blood pressure and unsafe abortion, and account for a majority of all maternal deaths but become an even bigger issue in the context of pandemics and within endemic regions (WHO, 2023). On the African continent, malaria is the number one non-obstetric cause of maternal mortality, and the prevalence of plasmodium falciparum, the deadliest parasitic causative agent of malaria in Africa, is seasonally high in young women (e.g., in Mali, 42.2% in the rainy season vs. 11.5% in the dry season) (Onambele et al., 2022). Globally, COVID-19 is an especially difficult non-obstetric complication. A Latin American study showed that for women who experienced COVID-associated maternal death, 60.3% of COVID cases were detected in the third trimester and 76.9% experienced preterm delivery (Maza-Arnedo, 2022). Unvaccinated pregnant women may especially struggle with receiving an accurate prognosis, succumb to a less predictable course of COVID disease, and face an increased likelihood of pre-term births and other pregnancy complications (Atak, 2022). Among unvaccinated mothers in Turkey, the COVID-associated maternal mortality rate (156.3 deaths per 100,000) was 19.9% higher than the overall maternal mortality rate (128.0 deaths per 100,000), suggesting COVID testing prior to the third trimester and maternal health vaccinations as a means by which to reduce maternal mortality (Atak, 2022).

Concerns of Maternal Healthcare Patients

Given the political upheaval in Afghanistan during COVID and its impacts on gender equality, especially as it pertains to access to health care and health care employment, it may come as no surprise that 40% of Afghan women identified safety as a primary concern when seeking medical assistance. However, while accessible maternal health care in Afghanistan is a perennial issue, during COVID, the concern for personal safety while seeking health care became a shared phenomenon among women across the globe, even among those in countries with low maternal mortality rates (Tharwani et al., 2022). One Italian study acknowledges the increased prevalence of negative emotional experiences during the pandemic as a potential driver of low quality pregnancy experiences and poor maternal health outcomes. Basic emotions related to childbirth expectations among a pre-pandemic and a mid-pandemic cohort of mothers were significantly different based on chi-square tests that evaluated joy (pre-pandemic, 63%; mid-pandemic, 17%, p < 0.00001), anticipation (26.5%; 14.0%, p < 0.01), surprise (10.5%; 2.5%, p < 0.01), trust (7.0%; 0.5%, p < 0.001), fear (7.5%; 49.0%, p < 0.0001), and sadness (0.5%; 10.5%, p < 0.0001). In both cohorts, differences in negative physical sensations (16.5%; 13.5%, p < 0.7) and positive physical sensations (3.5%; 1.0%, p < 2.8) were not significantly different; however, more positive psychological constructs of awareness (7.0%; 0.5%, p < 0.001), closeness (49.5%; 0.5%, p < 0.0001), empathy (5.5%; 1.0%, p < 0.05), love (13.0%; 3.0%, p <  0.001), safety (38.0%; 7.5%, p < 0.0001) and serenity (25.5%; 1.0, p < 0.0001) were overwhelmingly present in the pre-pandemic cohort, whereas negative psychological constructs of anxiety (3.0%; 32.5%, p < 0.0001), danger (0%; 26.0%, p < 0.00001), loneliness (1.0%; 53.5%, p < 0.0001), restriction (19.0%; 41.99%, (p < 0.00001), self-doubt (1.0% vs 9.0%, p < 0.001), and worry (1.0% vs 19.5%, p < 0.0001) were more prevalent in the mid-pandemic cohort of mothers (Rusconi et al., 2023).

Skilled & Unskilled Labor

In Japan, through sponsorship by a program called Konnichiwa Akachan Jigyo, local municipalities conduct home visits to new mothers within 4 months after delivery to help expand post-natal care beyond hospital discharge. However, during the pandemic, the skilled health care workers who support this program cited difficulty in talking face-to-face, providing support for partners of maternal health patients, offering assistance to families, and dealing with their own anxiety in regard to being a potential source of infection (Furudate, 2023). The intensity of COVID lockdowns has meant delays in access to maternal health care that in some countries, led to an increase in deliveries and post-natal care assisted by unskilled people. Studies have linked hemorrhage, one of the leading causes of maternal death, to deliveries assisted by unskilled people, performed at home or in ill-equipped primary health care centers without access to consumables or transfusion (Onambele et al., 2022). In India, 89% of childbirths in 2020 were skilled birth assisted deliveries, and their maternal mortality rate of 97 deaths per 100,000 is well below WHO’s sustainable development goal of 140 deaths per 100,000. In Senegal, their 75% attendance rate for skilled healthcare workers during live births is perhaps reflected in their maternal mortality rate of 261 deaths per 100,000, and Afghanistan’s maternal mortality rate of 620 deaths per 100,000 is at least partially attributable to the fact that only 62% of births were attended by a skilled health care worker (Tharwani et al., 2022; UNICEF, 2020). This perceived tendency for countries with a lower percentage of births attended by a skilled health care worker to have a higher maternal mortality rate led to our research question, “During the first full year of the global COVID-19 pandemic, was there a significant relationship between rates of ob-gyns and midwives per country and lower rates of maternal and infant mortality?”

Methods 

Disease surveillance requires the data collection infrastructure necessary to find new cases and maintain accurate records of pre-existing disease. However, pandemic and wartime conditions may create difficulties with estimation of maternal mortality given the increased potential for deliveries performed outside of healthcare facilities, attended by unskilled people, and deceased new and expectant mothers with undocumented pregnancies (Onambele et al., 2022). The nature of estimate generation during crises means that shifting conditions within the sample population may lead to a larger sampling error where certain sub-populations may not be well-represented. Regardless, measures of certainty (or uncertainly) are usually reflected in the standard error, coefficient of variation (i.e., variability), and confidence interval and offer reassurance regarding how much of an emphasis to place on pandemic-era estimates. Maternal mortality is defined as the death of a woman either while pregnant or within 42 days after the pregnancy’s termination from any cause related to pregnancy, its management, and/or complications from pregnancy or childbirth, with the exception of unintentional or incidental cases (Tharwani et al., 2022). According to WHO guidelines, methods to count stillbirths across countries vary, and thus, when comparing maternal mortality rates globally, excluding stillbirths from counts is considered a best practice in order to ensure reliable data. There is much overlap in global methods to track maternal mortality rates (e.g., demographic surveillance, maternal death surveillance and response systems, health record review studies, prospective cohort studies, confidential inquiries into maternal deaths, reproductive-age mortality surveys, direct or indirect sisterhood methods and mathematical modeling); however, maternal mortality and infant mortality rates utilized for these analyses are primarily modeled estimates from OCED (Organization Economic Co-operation and Development), with national estimates from UNICEF (United Nations International Children's Emergency Fund) utilized where modeled estimates were not available (Onambele et al., 2022). This study proceeded with a correlation analysis to determine if rates of ob-gyns and midwives per country were associated with lower rates of maternal and infant mortality.Pearson's r formula (r=∑(xi−x̄)(yi− ȳ)√ (∑(xi−x̄)2(yi−ȳ)2) ½) for measuring correlation remains remarkably unchanged for a 100-year old index and is the most popular statistical measure of association between variables (Lee Rodgers & Nicewander, 1988). R 4.2.0 was used to analyze these data, and results were interpreted based on a significance level of p <.05. Countries included in the analysis were those with searchable estimates for either maternal or infant mortality rate and either ob-gyns or midwives per 1,000 live births (see Table 2).