The webinar on Universal Health Coverage (UHC) and the Coronavirus Crisis – Challenges and Responses: maintaining essential health services for pregnant women and children while responding to COVID-19 held on 2 July 2020 was the 19th in the webinar series on Social protection responses to COVID-19. It was co-organized by the United Nations Children’s Fund (UNICEF) and the International Health Exchange and Cooperation Centre (IHECC) of the National Health Commission (NHC), and in cooperation with the socialprotection.org platform.
The webinar sought to share China’s health systems delivered essential health services for pregnant women and children at the height of the COVID-19 pandemic, as well as the relevant challenges and responses. It also provided the opportunity to explore further cooperation on the COVID-19 response between China and other countries under the overall South-South cooperation strategic plan of China.
The first session of the webinar was moderated by Ms. Wang Jian, Deputy Director General of IHECC, and the second session was moderated by Dr. Douglas Noble, UNICEF Deputy Representative to China. The panel featured presentations from:
- Dr. Wang Ai-Ling, Director of the Maternal Health Department of the National Center for Women and Children’s Health, China Center for Disease Control and Prevention;
- Dr. Xia Huimin, Director General of Guangzhou Maternal and Child Health Care Center;
- Dr. Cui Ying, Director of Health Communication Center, China Center for Disease Control and Prevention;
- Ms. Qiao Jie, Dean of Peking University Third Hospital.
At the start of the webinar, moderator Ms. Wang Jian emphasized the impact the COVID-19 pandemic has had on humankind and the suffering it has caused despite the implementation of preventive and control measures across the globe. Ms. Wang reiterated that IHECC has been committed to promoting Universal Health Coverage (UHC) both domestically and globally since its establishment in 1982. She also stated that, as a strategic partner of UNICEF China, IHECC has closely monitored the situation of maternal and child health (MCH), especially when the health systems were overwhelmed by the COVID-19 outbreak in China.
Ms. Wang discussed the challenges of maintaining service delivery within the MCH system during the pandemic through strategic planning, tactical optimization, resource mobilization and action coordination. Given that the first COVID-19 outbreak was in China, she shared that there are benefits to exploring how China managed to maintain essential health services for women and children while undertaking preventive measures to tackle the pandemic and control the spread of the virus.
In addition, Ms. Wang described how health authorities in China introduced a series of national policies and technical guidelines on risk evaluation, strategy development, innovative service delivery and comprehensive health education to guarantee access to basic health services during the pandemic, including prenatal care, safe delivery, neonatal and child health care, nutrition, and mental health support. At the same time, nosocomial infection control was prioritized to protect health workers and patients from infection, and guidelines on safe delivery assistance of MCH services for COVID-19 pandemic prevention and control was established.
Finally, Ms. Wang emphasized how the webinar was a great opportunity to share challenges and lessons learned from China’s response to COVID-19. She was also eager to learn valuable practices from colleagues in other organizations and representatives from other countries. Lastly, she highlighted the importance of collaboration and cooperation in tackling the persisting challenges of the COVID-19 pandemic.
How China's MCH system provided services during the COVID-19 pandemic
Dr. Wang Ai-Ling shared how China’s MCH system has provided services during the COVID-19 pandemic. In the first part of the presentation, Dr. Wang provided a summary and analysis of the overall situation of MCH during the COVID-19 outbreak from the perspective of a health provider. In this context, the outbreak placed greater pressure on MCH hospitals, with more prevention and control requirements in place and adjustments to diagnostic and treatment procedures. Due to the prevention and control requirements, the need for personal protective equipment (PPE) for patients and staff greatly increased, and some hospitals had an inadequate supply of masks and protective clothing in early February. Fortunately, the situation has improved, and the supply of PPE has increased.
Dr. Wang emphasized the critical need for the delivery of MCH services without delay, even in the event of an outbreak. Thus, hospitals needed to be prepared, including the training of medical staff and the transformation of the medical facilities. In early February, the NHC’s Department of Women and Children’s Health published national policies and technical guidelines on the prevention and management COVID-19. Particularly, it was recommended that services be provided through different channels and platforms. In response to the physical and psychological needs of pregnant women during the COVID-19 outbreak, health facilities were required to providing additional support on antenatal care and mental health, which were carried out through various channels, such as online consultation through WeChat and other social media applications, hotline services, and online multimedia content. Simultaneously, targeted services were provided to pregnant women and newborns during the different stages of the comprehensive screening, assessment and treatment of pregnant women (see slide below).
Dr. Wang explained that low-risk pregnant women were advised to adjust their schedule for antenatal care visits and consult their doctors on how to protect themselves and conduct health monitoring at home. For pregnant women with complications, suggestions were provided on how to conduct antenatal care visits as scheduled, and under what situations they should go to the hospital. In order to ensure timely detection and treatment of pregnant women infected with COVID-19, a service provision system for screening, diagnosis and treatment of pregnant women confirmed with COVID-19 was established within the existing MCH system.
For pregnant women and infants confirmed with COVID-19, Dr. Wang indicated that all cases followed the newly developed national management protocol on treatment and follow-up. Expert groups composed of obstetricians, paediatricians, and physicians specialized in respiratory, infectious diseases, intensive care and other relevant fields were also established across the country. These experts participated in the management of near-miss pregnancies with COVID-19 infection. Furthermore, newborns of mothers confirmed with COVID-19 were required to undergo isolation with specialized newborn care instructions, and newborns with severe health conditions were referred to designated hospitals for further treatment.
Dr. Wang concluded her presentation by emphasizing three key points on how China's MCH system provided services during the COVID-19 pandemic:
- Timely development and distribution of national policies and technical guidelines on COVID-19 prevention and management for pregnant women and children;
- Optimization of the operation of the MCH service system to adapt to the changing situation during the outbreak; and
- Strengthening the provision of MCH services through different channels and platforms.
Experiences in MCH service delivery during the COVID-19 pandemic
Dr. Xia Huimin shared the Guangzhou Women and Children’s Medical Center (GWCMC)’s experiences of delivering MCH services during the COVID-19 pandemic. GWCMC is one of the biggest MCH hospitals In the region of Guangzhou, and it was appointed as a paediatrics treatment centre for COVID-19. Between January 19 and June 16, 2020, GWCMC handled 24 confirmed pediatric cases of COVID-19. Through analyzing these cases, several epidemiological and clinical characteristics of pediatric patients confirmed with COVID-19 were detected:
- The viral excretion from the gastrointestinal tract lasted longer than the respiratory tract;
- CT scan presents more definite signs of pneumonia compared to chest X-ray, especially in asymptomatic or mild cases; and
- Most patients from familial clusters presented mild symptoms, and some were asymptomatic.
From these scientific findings, the medical team at GWCMC developed the comprehensive strategy, clinical pathway and treatment protocol (see slide below) to provide the best possible treatment for all the children.
Dr. Xia mentioned that in addition to educating visitors on the importance of social distancing and hand washing, the hospital systematically organized training sessions to ensure hospital staff followed protocols. Moreover, the hospital ensured the supply of PPE as part of their infection prevention and control strategy to protect hospital staff. Dr. Xia also demonstrated the impact of COVID-19 on the volume of medical services provided in GWCMC’s outpatient and inpatient departments, which dropped to 29.12 per cent between January and May 2020 compared to 50.95 per cent of the same period in 2019, with a particular impact on pediatric services.
During his presentation, Dr. Xia discussed the impact of COVID-19 on immunization services, an issue of great concern. Compared to the same period in 2019, there has been a 38.97 reduction in vaccinations provided by GWCMC, particularly during February and March 2020. In other words, many children did not receive their routine vaccinations in a timely manner during the COVID-19 outbreak. As this is a critical issue, GWCMC put in place a strategy to reopen facilities and services during April and May 2020 to allow children to receive the delayed doses.
Dr. Xia stated that another critical issue was the efficient identification, screening and classification of high-risk pregnant women. The hospital-community priority strategy was established, with a three-tier network to facilitate the screening of pregnant women through obstetric hospitals, community health centres and township hospitals. It also provided guidance on the management of high-risk pregnancy (see slide below).
To increase the availability of services and respond to questions regarding COVID-19 among their patients, the GWCMC launched an online platform with an appointed panel of specialist and experts on January 29, 2020. The platform provided online maternal and pediatric services, including nutrition and dietary counselling for infants, psychological health support for mothers and physical exercise guidance for pregnant women, and blood glucose monitoring at home.
In his closing remarks, Dr. Xia highlighted six takeaways of the GWCMC on what facilitated the delivery of MCH services during the COVID-19 outbreak:
- Central government support and mobilization for COVID-19 treatment;
- Ongoing hospital capacity building for COVID-19 prevention and control;
- Healthcare training specific to the demands of the pandemic and the related tasks;
- Enhancement of MCH service provision through monitoring, health education, and telemedicine;
- A bench-to-bedside collaborative mechanism to provide strong scientific and technological support; and
- Coordinated societal efforts to combat the COVID-19 pandemic.
Information dissemination and risk communication during the COVID-19 pandemic
Dr. Cui Ying shared China’s experiences in information dissemination and risk communication during the COVID-19 outbreak from the perspective of the China Center for Disease Control and Prevention (China CDC).
In terms of needs assessment and monitoring, the first component of the risk communication strategy, Dr. Cui underscored the importance of prompt action to understand the needs and concerns of the public. As part of the needs assessment and monitoring, the China CDC communicated with the public primarily through three channels (see slide below):
- The health hotline (#12320) was used to collect questions from the public and for daily monitoring data analysis. The number of inquiries peaked on February 26, 2020.
- The China CDC’s official social media platforms, including Weibo and WeChat, were also used to collect common questions from the public;
- Big data analytics was used to assess keywords searched online to understand public concerns and hot topics.
Based on the analysis of big data, Dr. Cui indicated that there was no significant difference in hot topics among the high-, medium- and low-risk areas in the early phase of the outbreak. Moreover, the public’s demand for information changed in the different phases of the COVID-19 outbreak. The public inquired about clinical symptoms of COVID-19 in the early phase, asked about how to prevent and deal with suspected cases of COVID-19 during the mid-phase, and posed questions about precautions at work during the re-opening phase.
The second component is the demand-oriented aspect of the risk communication strategy. This meant interacting with the public in an accurate and timely manner to respond to public needs, and also actively disseminating information and knowledge to improve prevention and control measures. The China CDC coordinated efforts with experts by establishing a mechanism and expert team to ensure that accurate knowledge was disseminated to the public. Moreover, a cooperative closed-loop approach starting with evaluation, then moving to generation, adaptation, communication, and redevelopment was put in place.
The third critical part of the risk communication strategy pertains to accuracy and the work of China CDC to communicate complex knowledge and scientific information in a mode and language that would be easy to understand and digest by the public. In ensuring the health of pregnant women and children, China CDC cooperated with UNICEF and produced various popular science videos, posters and images for different audiences. These products have also been translations into English, Italian, Russian and other languages, and shared with countries like Cambodia, Indonesia, Democratic People's Republic of Korea, Lao People’s Democratic Republic, Malaysia, and Thailand.
The fourth component of the risk communication strategy focused on strengthening engagement with partners, including through South-South cooperation, in close connection with the National Health Commission and with the Ministry of Foreign Affairs and the Ministry of Education and cooperate with big platforms such as Baidu, Ali and Tencent, etc.
In the fifth component of the strategy, the feedback mechanism used three different methods and channels:
- Public - to understand the needs and impact of risk communication;
- Experts - for a timely interpretation of COVID-19 prevention and control measures;
- Media - to disseminate information on multiple platforms and amplify risk communication.
Dr. Cui highlighted that during the 100 days from January to April, 248 public health communication products were published, with almost 200 million views on Weibo and WeChat. Furthermore, to measure the risk communication impact, online surveys were launched in March and April through the China CDC’s official WeChat platform to learn about changes in public perception and behaviour. The results from the online surveys found that over 90 per cent of the respondents wore a mask all the time when they were outdoors. Dr. Cui shared results from another survey examining the change in awareness and behaviours among the caregivers of children. A total of 1,325 guardians of children under five were surveyed, and 95.8 per cent responded that the popular science information on prevention and control of COVID-19 released by CDC as helpful. The survey also showed that respondents who reported changing their behaviours, such as using hand sanitizer or disinfectant wipes in hospital, wearing masks, washing hands and changing clothes when they got home, had increased.
In her summary, Dr. Cui pointed to four key elements of how the China CDC leveraged risk communication to combat the COVID-19 pandemic:
- Establishment of a monitoring system to accurately gauge the needs of the public;
- Multi-format products, multi-channel communication, and multi-platform interaction to maximize the influence and reach of core public health messages;
- Communication of public health information for pregnant women and children improved the public's awareness of protective measures and promoted changes in behaviours;
- Leveraging the reputation of the China CDC, health communication and an enabling environment for public health communication was created through a series of health communication initiatives during the COVID-19 outbreak.
Treatment experiences of pregnant women confirmed with COVID-19
Ms. Qiao Jie shared findings on the treatment experiences of pregnant women confirmed with COVID-19, while also reiterating the gravity of the pandemic around the world where more than 100,000 new cases are being confirmed each day. Ms. Qiao recalled that in the early stages of the outbreak, despite the large and rapidly rising number of cases of COVID-19 and resulting deaths, there was limited data on the clinical characteristics of pregnant women with the disease. Hence, there was a need to invest in research and publish data on the clinical characteristics of pregnant women confirmed with COVID-19.
From December 8to March 20, 2020, we identified 118 pregnant women confirmed with COVID-19 in Wuhan. 84 women (71 per cent) had positive Polymerase Chain Reaction (PCR) testing for severe SARSCoV-2, and the remaining 34 (29 per cent) had suggestive findings on their chest CT scans. The results showed that pregnant patients represented 0.24 per cent of all 50,005 reported patients confirmed with COVID-19 at the hospitals in Wuhan during this time. Fortunately, 109 of 118 women (92 per cent) were classified as mild cases, and only 9 (8 per cent) exhibited severe symptoms (e.g. hypoxemia). Severe cases of the disease developed among 6 of the 9 women after delivery, and the women who received noninvasive mechanical ventilation did so after delivery.
Sixty-eight of the 118 patients (58 per cent) delivered during the study period, accounting for 0.56 per cent of all 12,195 deliveries in Wuhan during this time. Of these 68 patients, 63 (93 per cent) underwent a cesarean section, and the procedure was performed because of concerns about the effects of COVID-19 in 61 per cent of the patients. A total of 14 deliveries (21 per cent) were premature, out of which 7 were related toCOVID-19 concerns. No babies had neonatal asphyxia. As of March 20, 109 of 116 women (94 per cent) have been discharged, including all women with severe or critical forms of the disease, and there were no deaths.
Based on the study, the results suggest that:
- The risk of having a severe form of the disease among the pregnant population (8 per cent) compared favourably with the general population (15.7 per cent);
- The present data do not suggest an increased risk of a severe form of the disease among pregnant women;
- Escalation of the disease during the postpartum stage are related to pathophysiological changes.
Following the examination of the clinical characteristics of pregnant women, the next question was the management and treatment experience of suspected and confirmed cases among pregnant women. The most important task was to set up different isolation categories and designated hospitals to provide medical services for non-infected or suspected/infected pregnant women. In this regard, it was recommended that every hospital developed an emergency process to prepare for the diagnosis and treatment of suspected cases (see slide below).
Simultaneously, measures were undertaken to protect the medical staff. Staff were provided training and guidance while regularly monitoring their temperatures and reporting symptoms every day.
In terms of the management of infected pregnant women during the first/second/third trimester, Ms. Qiao emphasized the following points:
- The clinical course of COVID-19 is similar between pregnant women and adults of the same age;
- Pregnant women with chronic diseases/maternal complications should receive special attention;
- Gestational weeks and the adverse effects of drugs on pregnant women and fetuses should be seriously evaluated during the treatment;
- No evidence to support the termination of pregnancy without medical indicators;
- Early delivery among pregnant women with severe or critical COVID-19 is recommended , and the best choice is a caesarean section.
On the question of whether there is vertical transmission from mothers to babies, Ms. Qiao shared the findings from recent studies. In one study, the nucleic acid tests of 6 neonatal amniotic fluid, cord blood, breast milk and throat swab samples were all negative. In another study, neonatal pharynx tests from COVID-19 patients were all negative. However, two studies reported that IgM and IgG antibodies from the novel coronavirus were detected in newborns. Since IgM antibodies could not be transmitted from mother to fetus through the placenta, it suggests that there may be an intrauterine transmission. However, considering the accuracy and sensitivity of IgM detection, further clinical studies are needed. Moreover, in another study, a case was reported that Nasopharyngeal swabs were obtained from the neonate on the day of birth, day 2 and day 7. All 3 of the neonate’s nasopharyngeal swabs were positive for SARS-CoV-2 gene targets via RT-PCR testing. The neonatal plasma tested positive on day 4, and the stool was positive on day 7, indicating probable congenital SARS-CoV-2 infection in a neonate born to a woman with active SARS-CoV-2 infection.
Ms. Qiao concluded by emphasizing the 4Es (early identification; early reporting; early isolation; and early treatment) and 4Ps (protection of pregnant women; protection of family members; protection of health workers; and protection of hospitals) as critical in addressing the COVID-19 pandemic.
Opportunities for South-South cooperation and multilateral cooperation
In the final remarks from Dr. Douglas Noble, he highlighted the usefulness of listening to the experiences of the experts, particularly in regard to pediatric patients, pregnant women, health service design and communication for development. But also, how the contributions served as a reminder of the importance of maintaining routine health services despite the COVID-19 pandemic. For example, figures have shown that routine immunization rates have declined. Hence, there is a need for strong communication for development and risk communication to tackle the fears associated with attending clinics.
Furthermore, Dr. Douglas Noble emphasized the role of health service leaders in designing health services that inspire confidence in the public, so that they feel safe to go for antenatal and postnatal care or other health services. UNICEF and WHO recommend that mothers with suspected or confirmed COVID-19 should be encouraged to initiate and continue to breastfeed. This is recommended due to the findings that conclude the benefits of breastfeeding outweigh the potential risks for transmission. That being said, of course, precautions must be taken when breastfeeding under such circumstances. Dr. Douglas Noble also mentioned how COVID-19 had affected other public sectors all over the world. We have seen the closing of schools despite limited evidence that localized transmissions occur between children in schools.
Ultimately, Dr. Douglas Noble stressed the significance of seizing opportunities in South-South Cooperation as people from all over the globe face challenges. UNICEF and partner organizations are ready to continue to work in partnership with countries across the world to share experiences and help countries respond to COVID-19.
In her closing remarks, Ms. Wang Jian reiterated that the pandemic is still taking its toll around the world and that while China has the pandemic under control, it was after extremely painstaking efforts and at an enormous price. Given the impending risk of another outbreak, MCH service providers still have a long and tough way to go. In this context, Ms. Wang emphasized that we must shoulder the responsibility together through closer multilateral cooperation. The Chinese government has prioritized contributions to global MCH governance, and it will do its utmost to build a shared future for mankind.
Ms. Wang Jian also took the opportunity to announce the Belt and Road MCH collaboration platform, established by the International Health Exchange and Cooperation Centre and UNICEF China, will be launched in early August. It is a demand-oriented platform that is integrating best resources from China and abroad, and a catalogue of online and offline services, with the aim to build a long-term communication platform for partners to address challenges, share experiences and learn from each other. Ms. Wang also shared that the training hub of health cooperation for Belt and Road Initiative countries will be launched in August and available at www.brhth.com.
The webinar concluded with an interesting Q&A, accessible here.
This was the nineteenth webinar of the “Social protection responses to COVID-19” webinar series. The series is a joint effort initiated by the IPC-IG, GIZ on behalf of the German Federal Ministry for Economic Cooperation and Development (BMZ), and the Australia Government's Department of Foreign Affairs and Trade (DFAT) in collaboration with the socialprotection.org platform, and in cooperation with partners from different organizations. Join our online community ''Social protection responses to COVID-19 [Task force]'' to learn more about the initiative and future webinars.