Impact of the COVID-19 pandemic on access to and delivery of maternal and child healthcare services in low-and middle-income countries: a systematic review of the literature

Abstract

Background:

The COVID-19 pandemic has had a multifaceted impact on maternal and child services and adversely influenced pregnancy outcomes. This systematic review aims to determine the impact of the COVID-19 pandemic on access to and delivery of maternal and child healthcare services in low- and middle-income countries.

Methods:

The review was reported following Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. A primary search of electronic databases was performed using a combination of search terms related to the following areas of interest: “impact’ AND ‘COVID-19’ AND ‘maternal and child health services’ AND ‘low- and middle-income countries. A narrative synthesis approach was used to analyse and integrate the results.

Results:

Overall, 45 unique studies conducted across 28 low- and middle-income countries met the inclusion criteria for the review. The findings suggest the number of family planning visits, antenatal and postnatal care visits, consultations for sick children, paediatric emergency visits and child immunisation levels decreased compared to the pre-pandemic levels in the majority of included studies. An analytical framework including four main categories was developed based on the concepts that emerged from included studies: the anxiety of not knowing (1), overwhelmed healthcare systems (2), challenges perceived by healthcare professionals (3) and difficulties perceived by service users (4).

Conclusion:

The COVID-19 pandemic disrupted family planning services, antenatal and postnatal care coverage, and emergency and routine child services. Generalised conclusions are tentative due to the heterogeneity and inconsistent quality of the included studies. Future research is recommended to define the pandemic’s impact on women and children worldwide and prepare healthcare systems for future resurgences of COVID-19 and potential challenges beyond.

Systematic review registration:

PROSPERO (CRD42021285178).

Introduction

The coronavirus disease (COVID-19) pandemic has had a profound impact on the world, causing not only considerable disruptions to daily life but it has tragically resulted in a significant number of deaths worldwide. According to the World Health Organization (WHO), as of June 5, 2023, there have been more than 767 million confirmed cases of COVID-19, including more than 6.9 million deaths globally (1). Countries around the world have responded to the COVID-19 outbreaks with a range of measures aimed at controlling the spread of the virus and protecting their populations (2). The specific actions taken included imposing lockdowns, movement restrictions, mass testing, contact tracing, mask mandates and hygiene practises (3). Countries have collaborated with each other in sharing data, research and resources and implemented travel restrictions, border closures and mandatory quarantine measures (3).

The COVID-19 restrictions have had a multifaceted impact on healthcare access and delivery. Firstly, routine healthcare services, including non-urgent medical procedures, routine screenings and preventive care, were disrupted due to the re-organisation of the healthcare system to meet the needs of patients diagnosed with COVID-19 (4–6). Secondly, access to healthcare facilities was limited as a result of restrictions on movement and transportation challenges (7, 8). It was also noted that patients tend to avoid seeking healthcare due to fear of contracting COVID-19 in healthcare settings (9). Thirdly, COVID-19 has disproportionately affected healthcare delivery for vulnerable populations and exacerbated existing health disparities (10–12). A WHO survey has recently disclosed that disruptions to healthcare services were predictably greater in low- and middle-income countries (LMICs) than in high-income countries (HICs) (13). Finally, the existing studies have described that outbreaks and responses to them may cause unintentional indirect health ramifications. For instance, the overall use of healthcare services, deliveries in health facilities and malaria admissions decreased by 18% (14), 80% (15) and 40% (15), respectively, during the West African Ebola virus outbreak. It was also estimated that mortality rates from the Ebola virus were comparable to deaths from non-Ebola conditions (16–18). There are concerns that these trends are repeated during the COVID-19 pandemic.

The scale of the COVID-19 pandemic has significantly affected maternal and child services and adversely influenced pregnancy outcomes. A recent systematic review and meta-analysis suggested that maternal mortality, stillbirth, ruptured ectopic pregnancy, and maternal depression increased during the pandemic (19). Other studies report a rise in iatrogenic preterm birth and caesarean delivery amongst infected mothers (20, 21). Furthermore, a number of reports express concerns that the indirect impact of the pandemic might be similar to the direct influence of the virus, specifically in low-income settings (20, 22). A modelling study involving 118 LMICs estimated that the reductions in coverage by maternal and child services might lead to more than a million additional child deaths (23). Another study estimated that a COVID-19-focused approach may have led to 30% additional maternal and child deaths across four different LMICs (24). However, the current understanding of the COVID-19 effects on maternal and child healthcare services is mainly based on pooled estimates of data gathered globally or across HICs, and the number of studies drawing together results from multiple LMICs remains limited (9, 25). Therefore, this systematic review aims to determine the impact of the COVID-19 pandemic on access to and delivery of maternal and child healthcare services in LMICs.

Methods

The protocol for this review was registered on PROSPERO (CRD42021285178) in advance. This study was reported following the Preferred Reporting Items for Systematic Review and Meta-Analyses (PRISMA) guidelines (26).

Search strategy

The following five electronic databases were searched: Scopus, Pubmed, Embase, Web of Science, and The Cochrane Central Register of Controlled Trials on October 15, 2021 and updated on June 29, 2023. Search terms combined three overlapping areas with keywords such as ‘impact’ AND ‘COVID-19’ AND ‘maternal and child health services’ AND ‘LMICs’ (see Supplementary Files 1, 2). Publication bias was reduced by searching conference records and unpublished literature using Google Scholar, OpenGrey, EThOS, the British Library Catalogue and Copac theses. In addition, backward and forward citation tracking was adopted to include studies and review records.

Selection criteria

Studies were eligible if they evaluated the impact of the COVID-19 outbreak on access to and delivery of maternal and child healthcare services in LMICs as defined by World Bank criteria (27). Studies were excluded if they met one of the following conditions: (1) non-research-based articles, such as conference abstracts, commentaries, opinion pieces, book chapters and editorials; (2) are not written using the Latin alphabet, Russian or Kazakh; (3) abstract is not available; (4) or full text is not available.

Identification and data extraction

Titles and abstracts of identified records were exported to EndNote X8 and screened by AK to exclude irrelevant studies and duplicates. A random sub-sample of 20% of titles and abstracts were screened by a second reviewer (MAO) to ensure the accuracy of selection. Full text articles were inspected again (AK, MAO, MJN and ASS) for relevance according to the inclusion criteria.

Data from included studies were extracted into a spreadsheet by MJN and a random sub-sample of 40% was reviewed by AK and MAO. Discrepancies were addressed by involving a fourth reviewer (ASS). The level of agreement between AK and MAO was 75%, and between AK and ASS was 80%.

Quality assessment

The methodological quality of the included records was assessed depending on their design. The 14-item Quality Assessment Tool for Observational Cohort and Cross-Sectional Studies (28) was applied in accordance with nine criteria, as five criteria were not applicable. The 12-item Quality Assessment Tool was utilised for Pre-Post (Before-After) Studies With No Control Group (29), the 9-item Quality Assessment Tool was used for Case Series Studies (28), the 7-item Quality Assessment Tool was applied for Mixed-Methods Studies (30) and the 10-item Critical Appraisal Skills Programme (CASP) checklist was adopted for qualitative studies (31) (see Supplementary File 3). AK completed a full quality assessment. MAO ensured the accuracy at this stage by independently assessing 20% of records.

Data synthesis

A narrative synthesis approach developed by Popay and colleagues (32) was applied to explain and integrate the results.

Firstly, the preliminary synthesis of quantitative data was conducted in order to describe patterns across the included studies grouped by four indicators: impact on maternity service use, impact on maternity service provision, impact on postnatal care and impact on utilisation of child health services. Textual descriptions of studies and tabulation were used as specific tools. A formal meta-analysis was not performed due to considerable heterogeneity in settings and outcome measures.

Secondly, the experiences of service users and healthcare professionals regarding access to and delivery of maternal and child healthcare services during the pandemic were analysed using the Framework Method following the guidelines developed by Gale and colleagues (33). This method includes seven distinct stages: transcription, familiarisation with the data, coding, developing a working analytical framework, applying the analytical framework, charting the data into framework matrix, and interpreting the data. As the review collated data from published studies, the initial stage of transcription was not applicable. The familiarisation stage included reading and rereading the studies included in the review. Further, data from the results sections of included studies were coded and preliminary concepts were defined inductively. Similar concepts were grouped into categories and sub-categories independently by the first author (AK) and were discussed with the other researchers (MAO and ASS) to ensure the range and depth of the coding. The defined categories and sub-categories were then organised into the working analytical framework, which was applied to the results sections of the included studies by systematically coding in a line-by-line manner. Once appropriate codes and categories were assigned, data was charted into the framework matrix by listing illustrative quotations by category and sub-category from each study.

Results

The original search yielded 2,492 articles through database searching, 11 through other sources and 1,132 through search update. Overall, 945 articles were removed as duplicates and 2,485 articles were excluded for not meeting the inclusion criteria. The full texts of the remaining 205 papers were examined, 45 of which were included to the review. The detailed selection process is presented in the PRISMA flow diagram below (Figure 1).

Figure 1

Overview of included studies

Studies were published between 2020 and 2023 solely in English. Overall, 14 studies reported data from four low-income countries (34–47), 21 studies were focused on 13 lower-middle income countries (48–68), seven studies were conducted in five upper-middle income countries (69–75) and three were multi-centred (76–78). Out of 45 included studies, 11 studies were cross-sectional (41, 45, 48, 51, 55–57, 65, 69, 70, 76), 14 were pre-post studies (34, 38, 49, 50, 52, 53, 56, 62, 64, 72–75, 77), nine were time-series (35, 37, 39, 43, 58, 59, 67, 71, 78), five were mixed methods (36, 42, 47, 61, 63) and six were qualitative (40, 44, 46, 54, 60, 68). The included studies’ characteristics are summarised in Table 1.

The results of the current review will be presented in two parts. Firstly, the impact on access to and delivery of maternal and child healthcare services will be presented in accordance with four groups of indicators. In the second part, the experiences of service users and healthcare professionals regarding the pandemic’s impact on access to and delivery of maternal and child healthcare services will be introduced.

Impact on maternity service use and provision

Family planning services

In nine studies (34, 38, 41, 47, 49, 58, 67, 76, 77), the analysis showed interruptions in family planning services (76), a decrease in attendance of family planning visits (77), in the overall number of such visits (34, 41, 47, 49, 58, 67) and family planning acceptance rate (38) compared to the pre-COVID-19 levels. Although some authors observed a reduction in the number of new contraceptive acceptors (45) and difficulties accessing contraceptives (73), Tilahun and colleagues reported an increased contraceptive acceptance rate in Ethiopia (42). Three studies declared impaired abortion care during the pandemic in Ethiopia and India (38, 45, 66).

Antenatal and postnatal care coverage

Twenty-seven studies reported on antenatal care coverage during the pandemic using various metrics (34, 36–38, 42, 43, 47, 49–51, 56, 58, 59, 61–63, 65, 67, 70–78). Albeit no changes were made to the standard antenatal care protocol in the majority of settings, increased interruptions in antenatal care (76) and a decrease in antenatal care coverage (42), antenatal recruitment rate and prenatal visit completion rate (59), antenatal care registrations (62), number/proportion of antenatal care visits (34, 36–38, 47, 49, 56, 58, 61, 65, 67, 71, 72, 74, 75) and attendance (50, 51, 70, 77, 78) was noticed in most cases as compared to the pre-pandemic period. However, Pillay and colleagues (73) observed no difference in the number of first antenatal care visits in South Africa and Lydon and colleagues (43) detected an increased number of first antenatal visits and no difference in the number of fourth antenatal visits in Mozambique. No difficulties in accessing antenatal care were declared in one study originated from India (63). Due to the restrictions imposed during the COVID-19 pandemic, authors noticed a declining trend in the number of first routine laboratory tests (58), first and second trimester sonography (58, 66) and pregnant women receiving the second dose of tetanus toxoid vaccine during pregnancy (49). Furthermore, as per Burt and colleagues (37), the number of attendances for prevention of mother-to-child transmission of HIV dropped than stabilised in Uganda. A surge in the number of high-risk pregnancies was described in one study (56).

Although three studies highlighted reduced postnatal care (45, 67, 78), it was not universal as postnatal care coverage surged in Ethiopia (42).

Virtual care protocols

Despite the active promotion of virtual services during the pandemic, only one study from Cameroon reported an increase in the use of telemedicine services (57). According to Goyal and colleagues, just 3.6% of pregnant women living in India exploited teleconsultations amongst more than a thousand respondents (66).

Impact on institutional delivery

Included studies showed mixed results concerning institutional deliveries that comprise normal vaginal deliveries and caesarean sections. Even though eight studies highlighted a reduction in the number/proportion of institutional deliveries (36, 49–51, 56, 61, 62, 67, 71), six reports (38, 43, 63, 73–75) observed growth and two studies (34, 42) did not find any changes with respect to this indicator. The results varied depending on the setting in three multi-centred studies (64, 77, 78), making it difficult to provide a generalised conclusion. Home delivery rate rose based on the results of two studies originated from Mozambique and India (36, 62) and reduced in Ghana (48).

Birth outcomes

The impact of the COVID-19 pandemic on birth outcomes was reported in eight studies. Maternal mortality rates increased (64, 73, 75) and remained unaffected (37, 51) in three cases and two cases, respectively. A growth in stillbirth levels was observed in two studies (38, 63), and a decline was reported in one instance (51). Diverse results were obtained concerning the risk of adverse birth outcomes and obstetric complications (43, 64, 72).

Impact on child service use and provision

Despite the fact that the rate of neonatal admissions increased in Uganda (37), its overall number declined in Ethiopia, Ghana and Guinea (34, 48, 64) as compared to the pre-pandemic period. Furthermore, a decrease in the number of consultations for sick children and emergency visits was observed in four different countries – Cameroon (57), Mexico (71), Ethiopia (34, 35) and South Africa (69). In the context of the COVID-19 pandemic, the level of early neonatal deaths increased in Uganda, Zimbabwe, Guinea and South Africa (37, 51, 64, 73). The majority of studies reported a fall in child immunisation levels (37, 38, 49, 71, 73, 75, 77–79). However, three studies highlighted that the number of children receiving scheduled vaccination increased in Ethiopia (38, 42) and India (62) and no changes with respect to this indicator were found in two studies from Ethiopia and Mozambique (39, 41).

Experiences of service users and healthcare professionals

Identified concepts relevant to service users’ and healthcare professionals’ experiences regarding the impact of the COVID-19 pandemic on access to and delivery of maternal and child healthcare services were grouped into four main framework categories: the anxiety of not knowing (1), overwhelmed healthcare systems (2), challenges perceived by healthcare professionals (3) and difficulties perceived by service users (4). The respective sub-categories within each of these categories are reported in the section below. Illustrative quotations within each category are presented in Table 2.

The anxiety of not knowing

The anxiety of not knowing about COVID-19, particularly in the early stages of the pandemic, was a common and understandable response to the rapidly evolving situation. According to the participants, limited knowledge about the disease, misconceptions and stigma, and fear of contagion contributed to this anxiety.

Limited knowledge

Considering that COVID-19 was a completely new disease and there was little information available, participants demonstrated only basic and rather limited knowledge about its causes, symptoms, transmission and potential consequences (36, 46, 47). It was noted that COVID-19 is “a very dangerous disease” (46), which “can be transmitted through air/breathing, shaking hands, kissing, contact with others” (47). The essential measures, such as wearing a mask (36, 47), washing hands (36) and social distancing (36) were mentioned as helping to protect yourself and others from the disease.

Misconceptions and stigma

COVID-19 has not only been a health crisis but also a social and psychological challenge, leading to the rapid spread of misinformation (40, 42, 46, 47, 54, 61, 68). Misconceptions ranged from false information about its origin to conspiracy theories about its existence. In particular, participants believed that the virus “attacks animals” (46) and implied that it “may not be real” (47). Furthermore, it was reported that people diagnosed with COVID-19 or who had recovered from the virus were being victimised (54) and experienced discrimination as people tend to “badmouth” (54), “refrain from meeting them” (40) and “not go near them” (61). However, participants also highlighted that public awareness campaigns focusing on disseminating accurate information helped to address misconceptions and reduce stigma across different communities (42).

Fear of contagion

COVID-19 demonstrated rapid community transmission, resulting in widespread outbreaks across countries and continents. The exponential growth in cases has instilled fear of contagion in many individuals and communities (36, 40, 42, 44, 46, 47, 54, 60, 61, 68). Participants shared that healthcare facilities were considered as potential sources of COVID-19 transmission (36, 40, 42, 44, 47, 60); therefore, they tend to postpone or avoid general healthcare visits and antenatal care due to the “fear of acquiring the disease” (47). Participants also highlighted having anxious thoughts about the requirement to wash hands frequently (68) and the fear of testing positive for COVID-19 (40). Nevertheless, some participants underlined that “fear has slowly decreased” (68) when lockdowns were lifted (47).

Overwhelmed healthcare services

During the COVID-19 pandemic, healthcare services in LMICs faced overwhelming issues due to the rapid and widespread transmission of the virus. A number of contributing factors were discussed, including insufficient staffing levels, disrupted flows of commodities, decreased quality of care, limited access due to transportation issues and patient flow fluctuations.

Insufficient staffing levels

Healthcare staff during the pandemic have been reassigned to the COVID-19 units (40, 44), leaving maternity and child services with fewer resources. Furthermore, participants highlighted that the pandemic had exacerbated the pre-existing “chronic shortage” (68) of healthcare staff, which resulted in longer waiting times (36, 54, 61). The increased risk of exposure to the virus amongst healthcare staff has also led to a significant reduction of available workforce, and there were cases where no healthcare workers were able to attend patients (54, 60).

Disrupted flow of commodities

Restrictions on travel, border closures, and lockdown measures during the COVID-19 pandemic disrupted the global chain of pharmaceuticals and essential goods (40, 42, 44, 60). Participants emphasised that they faced “a serious shortage of essential drugs and supplies” (40) and a limited supply of vaccines (42). Nevertheless, one participant noted incoming cargo planes continued to operate during the COVID-19 pandemic, maintaining the flow of essential commodities (44).

Decreased quality of care

Concerns regarding the quality of care were expressed by both service users and healthcare professionals (40, 42, 46, 60, 61, 63, 68). Service users experienced delays or cancellations of services (46), faced challenges in accessing healthcare facilities (42) and expressed concerns about infection control measures (61). Healthcare providers, in turn, highlighted that COVID-19 restrictions resulted in reduced personalised attention and care as “frequent conversations and patting on the back or holding hands” (68) were not possible. The availability of crucial services, such as ultrasound check-ups and laboratory services was limited (63). The preference of service users (mothers) to be discharged earlier after giving birth was also observed by healthcare providers, which undermined the quality of postnatal care (68). Moreover, healthcare professionals noted that the number of stillbirths and caesarian sections increased, whereas the proportion of skilled deliveries decreased in comparison to the pre-pandemic levels (42). According to participants, service users tend to miss their immunisation appointments due to safety concerns (42).

Transportation-related issues

A number of transportation-related issues impacting access to healthcare facilities became a significant challenge for many people across LMICs (40, 44, 47, 54, 61, 63, 68). Participants emphasised that public transportation systems reduced or suspended their operating services during the pandemic, which resulted in “late admission of women at 41 to 42 weeks of pregnancy” (68), absence of transportation options for patients from remote areas (47, 63) and cases where “delivery happened at home” (61). Notably, service users also “were staying at hospital unnecessarily” (47) due to the limitations of transportation services. Although seeking medical care was amongst the essential activities allowed during lockdowns, restrictions on movement worsened access to healthcare facilities (44). Furthermore, participants shared that “transport fares had been hiked” (44), leading to financial constraints and making it difficult for them to afford transportation (40, 44).

Challenges perceived by healthcare professionals

Healthcare professionals experienced numerous challenges during the COVID-19 pandemic as they played a critical role in caring for patients and managing healthcare systems during a global health crisis. Some of the key challenges highlighted by participants included emotional toll, shortage of personal protective equipment and lack of service users’ compliance.

Emotional toll

Healthcare professionals had to cope with significant emotional stress and mental health challenges due to witnessing the suffering of patients (68) and fear for their own health and that of their families (40, 68). Participants also reported experiencing harassment and discrimination from members of the public who perceived them as “a vehicle for COVID transmission in the community” (68). Such hostile attitude towards healthcare professionals endangered their job motivation and commitment (42, 68).

Shortage of personal protective equipment

During the pandemic, there were widespread shortages of personal protective equipment (40, 42, 68), leading healthcare professionals to resort to buying it by themselves “at extortionist prices “(68) or relying on donations from philanthropic agencies (68). Inadequate access to protective equipment increased fear and risks of infection (42), which forced healthcare professionals to “compromise the routine antenatal care service” (40) by not performing physical or laboratory examinations.

Lack of service users’ compliance

Healthcare professionals encountered issues with service users’ compliance in following recommended health guidelines (36, 68). In particular, some individuals demonstrated aggressive behaviour by threatening “to physically assault the personnel if they attempted to stop the visitors from entering the hospital” (68) or were reluctant to wear masks or practise social distancing (36, 68).

Difficulties perceived by service users

Participants of the study shared difficulties that affected their healthcare experiences and overall well-being. Reduced/lost income and food insecurity, increased out-of-pocket expenditure and healthcare professionals’ unprofessional behaviour were reported as major ones.

Reduced/lost income and food insecurity

The economic impact of the COVID-19 pandemic on LMICs has been significant and exacerbated existing vulnerabilities. Many businesses had to shut down or reduce operations, resulting in widespread job losses and furloughs. Participants noticed that “many of the caregivers lost their jobs” (46) and they are struggling “because there is no income at all” (60). Loss of livelihoods, food price inflation, and disruptions to agricultural activities made it challenging to meet basic food needs (44, 46, 54, 60, 61). Participants admitted that “it was better to buy food than to pay” (60) for healthcare services.

Increased Out-of-pocket expenditure

Participants highlighted that increased out-of-pocket expenditure for healthcare services during the pandemic had considerable implications for individuals and families with limited financial resources (54, 63, 68). High healthcare costs resulted in avoided medical care and heightened health risks (54, 68).

Healthcare providers’ unprofessional behaviour

Service users admitted to facing numerous cases of healthcare providers’ unprofessional behaviour. Unprofessional behaviour involved a lack of empathy and compassion for patients and their families during such challenging times (42). Patients described their experience as “completely discouraging” (40) and “not pleasing” (54) because healthcare professionals were “abusive and rude” (54). Inappropriate adherence to infection control measures, such as using “the same glove for different clients” (40) and reluctance to physically examine patients (61) and attend calls (68) was also mentioned as examples of unprofessional behaviour.

Discussion

Main findings

Based on the findings from 45 unique studies conducted across 28 LMICs, the current review suggests that the COVID-19 pandemic disrupted access to and delivery of maternal and child services. In particular, the number of family planning visits, antenatal and postnatal care visits, consultations for sick children, paediatric emergency visits and child immunisation levels decreased as compared to the pre-pandemic levels in the majority of included studies. In contrast, a rise was observed in the number of neonatal admissions and early neonatal deaths. Inconclusive results were acquired concerning the number of institutional deliveries, adverse birth outcomes and obstetric complications.

The analytical framework that comprised four main categories of the anxiety of not knowing (1), overwhelmed healthcare systems (2), challenges perceived by healthcare professionals (3) and difficulties perceived by service users (4) was developed based on the concepts that emerged from included studies. Participants shared that limited knowledge about COVID-19, along with misconceptions and fear of contagion, led to people avoiding seeking healthcare. Unsurprisingly, participants also highlighted that maternity and child healthcare services were disrupted by significant challenges presented during the pandemic, including insufficient staffing levels, disrupted flow of commodities, decreased quality of care and transportation-related issues. On a personal level, healthcare professionals have reported experiencing a profound emotional toll, shortage of personal protective equipment and lack of service users’ compliance in the context of high workload due to the constant demand for healthcare services. Service users, in turn, have reported that issues, such as reduced/lost income and food insecurity, increased out-of-pocket expenditure and healthcare professionals’ unprofessional behaviour affected their ability to receive timely care. Identified main categories and respective sub-categories relevant to service users’ and healthcare professionals’ experiences regarding the impact of the COVID-19 pandemic on access to and delivery of maternal and child healthcare services were closely linked and largely overlapped. For example, healthcare professionals and service users shared the anxiety of not knowing about the novel coronavirus, which may have led to decreased quality of provided care and a lack of patient compliance. Overwhelmed healthcare services, in turn, have contributed to an enormous emotional toll amongst healthcare professionals and may have been a reason for their unprofessional behaviour noted by service users.

Strengths and limitations

To our knowledge, this is the first systematic review aiming to determine the impact of the COVID-19 pandemic on access to and delivery of maternal and child healthcare services in LMICs. A further strength is that the review used a comprehensive approach, searching through studies from all LMICs, which allowed to include data from different countries and cultural backgrounds. However, this approach presented several limitations. Firstly, due to the heterogeneity of included studies, the variety of reported outcomes and their limited quality, it was not possible to conduct a meta-analysis; therefore, the final interpretation of quantitative data was made based on descriptive-analytical procedures. Such considerable heterogeneity also suggests that the findings of the current review should be interpreted with caution. Secondly, although it was possible to extract general concepts relevant to service users’ and healthcare professionals’ experiences regarding the impact of the COVID-19 pandemic on access to and delivery of maternal and child healthcare services, there is not enough evidence to assess whether these apply to all LMICs. There might be regional or clinical characteristics that have not been identified in this review. Finally, the comparability of findings across the included studies may be limited due to wide variability in periods (first wave, lockdown, second wave, etc.) when studies were conducted, local public health messaging to which people were exposed, national-specific circumstances and cultural differences. Also, the majority of studies were focused on African countries, which made it challenging to generalise any conclusions about LMICs.

Comparison with literature from high-income countries

Similar to the findings of the current review, disruptions in the antenatal and postnatal care coverage were observed by numerous studies from HICs. In particular, a decrease in the number of antenatal visits (80–87), prenatal genetic diagnostic procedures (88) and performed obstetric ultrasound scans (89, 90) was reported alongside reduced postnatal care (91) in the United States, United Kingdom, Italy, Belgium and Saudi Arabia. These informal comparisons might suggest that healthcare professionals and patients from both HICs and LMICs perceived similar challenges during the COVID-19 pandemic. However, no change in antenatal care attendance (92, 93) and an increased number of the first-trimester prenatal screenings (94) were determined in the United States and Italy, respectively, highlighting inconsistencies in the obtained results due to wide variability of possible influencing factors. Although the results from LMICs were inconclusive regarding obstetric complications, the data from the United States and Israel suggests a decline in the number of obstetric emergency department visits (95, 96) and obstetric hospitalisations (97). This underlines the need for detailed analyses and the consideration of specific contexts in order to provide firm conclusions.

According to the report by the World Health Organization, disruption in the delivery of maternal and child health services was caused by two main reasons: “changes in demand and patient behaviour” and “changes in health-care supply” (98). This corroborates the findings of the current review that patients’ healthcare-seeking behaviour considerably changed due to the fear of contagion and misconceptions about COVID-19. Several studies from HICs support this statement by reporting that patients tend to cancel or ignore their appointments due to the risk of COVID-19 exposure and expressed a preference for shorter hospital stays after giving birth (80, 99–103). Reduced income and food insecurity during the pandemic have also played a significant role in influencing healthcare-seeking behaviour in LMICs. It seems predictable that individuals may prioritise meeting basic needs over seeking healthcare in situations of severe economic hardship, particularly in resource-scarce settings. Such changed maternity care-seeking behaviour determined in the current review might need to be perceived as potentially contributing to poorer birth outcomes. Even though the findings of the review were mixed, it appears reasonable to assume that not attending antenatal care visits, for example, might be associated with poorer pregnancy outcomes.

The alterations in the healthcare-seeking behaviour happened in the context of overwhelmed healthcare systems, leading to challenges to the quality of delivered care. It is important to note that increased use of telemedicine has only rarely been mentioned in studies of LMICs (47) albeit it was extensively discussed across studies conducted in HICs (93, 104–106). This indicates that whilst antenatal and postnatal care has transformed into a hybrid mode in HICs, minimising the pandemics’ impact on maternity and child care, antenatal and postnatal care services in LMICs faced often unavoidable ramifications. The COVID-19 pandemic has once again demonstrated inequalities between societies and regions as the majority of technological benefits were available to financially secure patients from HICs.

Implications for research and practice

In order to generate clear directives for improvements, future research should aim at creating a set of indicators, allowing for direct cross-country comparisons and enabling to evaluate the scale of maternal and child healthcare disruptions during the pandemic. Moreover, future research studies may need to perform a comprehensive analysis of actions undertaken throughout the COVID-19 pandemic, which can be used to develop a healthcare delivery plan for emergency situations. This may help to build resilient healthcare systems in low-resource settings.

By considering the findings of the present review, future healthcare policies might need to prioritise helping LMICs adopt telemedicine into their healthcare systems. This would require a comprehensive approach that involves collaboration between governments, healthcare providers, technology developers and communities as a range of major challenges, such as limited access to reliable internet connectivity, lack of technical resources, electricity outrages, absence of clear regulations governing telemedicine, data privacy concerns, digital illiteracy and cultural resistance to change should be addressed. Supporting healthcare professionals after the COVID-19 pandemic to address the physical, mental and emotional toll they have experienced is also crucial to ensure a sustainable and resilient healthcare workforce. Providing regular counselling sessions, implementing flexible scheduling options, offering opportunities for continuing education and developing resilience-building programmes might help healthcare professionals recover from the impact of the pandemic. Finally, establishing collaboration and sharing experiences amongst countries seems essential to prepare maternal and child health services for future pandemics and improve global health outcomes. Facilitating collaborative research projects, offering cross-border training and knowledge exchange, empowering communities to implement community-led interventions and promoting culturally sensitive approaches may assist in enhancing pandemic preparedness.

Conclusion

The current review has identified that COVID-19 has presented an unparalleled challenge to maternal and child health services in LMICs by disrupting family planning services, antenatal and postnatal care coverage, and emergency and routine child services. However, generalised conclusions are tentative due to the heterogeneity and inconsistent quality of the included studies. Investigating the pandemic’s impact is crucial to mitigate its negative consequences on women and children worldwide and prepare healthcare systems for future resurgences of COVID-19 and potential challenges beyond.

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