Licensed under CC BY 4.0 International License which permits use, distribution and reproduction in any medium, provided the original work is properly cited.J. Lumbini. Med. Coll. Vol 8, No 1, Jan-Jun 2020 ___________________________________________________________________________________ Submitted: 22 May, 2020 Accepted: 24 May, 2020 Published: 28 May, 2020 a - Assistant Professor, Department of Obstetrics and Gynaecology, b - Lumbini Medical College Teaching Hospital, Palpa, Nepal. Corresponding Author: Shreyashi Aryal e-mail: shreyashiaryal@gmail.com ORCID: https://orcid.org/0000-0002-6832-3530 How to cite this article: Aryal S, Shrestha D. Motherhood in Nepal during COVID-19 Pandemic: Are We Heading from Safe to Unsafe? Journal of Lumbini Medical College.2020;8(1):2 pages. DOI: https://doi. org/10.22502/jlmc.v8i1.351 Epub: 2020 May 28._______________________________________________________ Perspectivehttps://doi.org/10.22502/jlmc.v8i1.351 Shreyashi Aryal,a,b Deepak Shrestha a,b Motherhood in Nepal during COVID-19 Pandemic: Are We Heading from Safe to Unsafe? Safe Motherhood Program (SMP) has been one of the successful ongoing maternal health programs in Nepal. It is the major reason for Nepal being able to reduce its Maternal Mortality Ratio (MMR) significantly falling from 539 to 281 deaths per 100000 live births over the decades.[1] SMP has nine components out of which three components mainly deal with pregnancy and puerperium; birth preparedness plan, rural ultrasound program and the “Aama and New born Program”. The latter one is one of the key components of SMP which includes incentives, free delivery services and free sick newborn care. Financial incentives are provided for transport and completion of four antenatal visits, and for health care workers attending deliveries.[2] However, with the corona virus disease (COVID-19) pandemic, this program might not be enough to ascertain a safe motherhood for Nepalese women. This program aims to reduce the three delays leading to maternal morbidity and mortality namely, delay in reaching care, seeking care and receiving care. But with a nationwide lockdown, the chances of these delays have increased even more. Pregnant women are being requested to delay regular antenatal checkups to minimize transmission through hospitals. This means missing prenatal vitamins, immunization and chances to diagnose high risk pregnancies. With 80% antenatal coverage and only 59% institutional deliveries, Nepal still has high MMR compared to some other countries in Southeast Asia.[3,4] Reduced antenatal visits may lead to missed chances of diagnosing pregnancy complications in time. There is a possibility of delay in seeking care when pregnant mothers are unsure when to visit the hospitals because of the uncertainty of availability of their services during the pandemic. For women hailing from remote areas, the travel ban during the lockdown causes a delay in reaching care. In the present scenario, halt in local transportation, scarce ambulance services, and geographical remoteness in the mountainous country Nepal, leaves a pregnant woman with the only option of delivering at home. Without aseptic measures, home delivery is not risk free. Few fortunate ones who reach the health care center might already have developed complications. When they reach late to the hospital, free delivery services are futile in preventing complications. With inadequate Personal Protective Equipment (PPE) and limited workforce, there is an expected delay in receiving care to some extent. Rural ultrasound program which is a part of SMP might also be affected because of inadequate PPE for health care workers in the rural locations. Easy availability of blood transfusion services is another component of SMP but during the lockdown, this access is also not easy. In the absence of blood products, obstetric emergencies are difficult to manage optimally. With all these delays enhanced due to the effects of the pandemic, MMR is predicted to increase, thereby threatening the most appraised outcome of the SMP. Maternal mental health is altogether an unaddressed issue in safe motherhood. With incidences of depression and domestic abuse Aryal S, et al. Motherhood in Nepal during COVID-19 Pandemic: Are We Heading from Safe to Unsafe? jlmc.edu.npJ. Lumbini. Med. Coll. Vol 8, No 1, Jan-Jun 2020 increasing during this time, safe pregnancy cannot be guaranteed. Alternative methods for antenatal and postnatal care like awareness through social media, videoconferencing and telemedicine can be some effective options. Teaching women to take their own fundal height through online classes is one of the methods to detect early growth restrictions,[5] but keeping in mind the unavailability of internet access and literacy level of women in rural areas, this might not be the feasible option either. Mobilizing Female Community Health Volunteers, while maintaining the norms of physical distancing, should be continued for both antenatal and postnatal period to detect danger signs. Continuing postpartum care including contraception is another important aspect to prevent morbidities. With recommendations for early discharge and difficulty in follow up, postpartum complications can be expected to rise. Policies to increase access to institutional delivery addressing the barriers to the three delays need to be formulated and implemented. With increasing number of COVID-19 positive cases, pregnant women are also likely to get infected. When medical resources are diverted for COVID-19 cases, high risk pregnancies will definitely get suboptimal treatment but even healthy pregnancies might resort to becoming complicated. Obstetric preparedness has to be a priority at this point. Nepal witnessed its first COVID-19 mortality and the deceased was a new mother in her first week of puerperium. Preliminary reports suggest that a delay in reaching health care due to unavailability of transportation was the reason of untimely demise of this 29-year-old new mother.[6] SMP has to be tailored to fit this pandemic so that maternal mortality remains low. The government has risen up to the challenge to reduce MMR successfully in the past. At this point if we let the pandemic increase MMR, it will be a slip hard to recover from. Conflict of interest: Authors declare that no competing interest exists. Funding: No funds were available for the study. REFERENCES: 1. Bhandari A, Gordon M, Shakya G. Reducing maternal mortality in Nepal. 2011;118 Suppl 2:26-30. PMID: 21951499 DOI: https://doi. org/10.1111/j.1471-0528.2011.03109.x 2. Safe motherhood program. Government of Nepal. Ministry of Health and Population. Available from: https://www.mohp.gov.np/eng/ program/reproductive-maternal-health/safe- motherhood-programme 3. Ministry of Health - MOH/Nepal, New ERA/ Nepal, and ICF. 2017. Nepal Demographic and Health Survey 2016. Kathmandu, Nepal: MOH/ Nepal, New ERA, and ICF. Available from: http://dhsprogram.com/pubs/pdf/FR336/FR336. pdf 4. Bhandari TR. Maternal and child health situation in southeast Asia. N J Obstet Gynaecol. 2012;7:5–10. DOI: https://doi.org/10.3126/njog. v7i1.8825 5. Bergman E, Axelsson O, Kieler H, Sonesson C, Petzold M. Relative growth estimated from selfadministered symphysis fundal measurements. Acta Obstet Gynecol Scand. 2011;90(2):179-85. PMID: 21241264 DOI: https://doi.org/10.1111/ j.1600-0412.2010.01026.x 6. Poudel A. Nepal reports its first Covid-19 death. The Kathmandu Post. 2020 May 16. Available from: https://tkpo.st/2TeY3lU