June 22, 2021

Policy Brief: Maternal, neonatal lessons from the first and second waves of COVID-19 in South Africa

As with all health programs in South Africa and many around the world, COVID-19 had a significant impact on the delivery of reproductive, maternal, and neonatal services in 2020.


In 2018, the Clinton Health Access Initiative (CHAI), the government of South Africa, and a consortium of partners launched an integrated sexual, reproductive, maternal, and newborn health project, underpinned by a locally led quality improvement approach. The project has ambitious goals to significantly and sustainably reduce maternal and neonatal mortality and institutional stillbirths in the provinces of Mopane (Limpopo), Ehlanzeni (Mpumalanga), Nelson Mandela Bay, and Sarah Baartman (Eastern Cape).

The project aims to strengthen facility and district capacity to undertake routine monitoring and improve health outcomes. This approach has enabled local health workers to target and strengthen quality of services tied to leading mortality drivers including management of pre-eclampsia, haemorrhage (tied to provision of safe caesarean section), preterm births, and birth asphyxia.

Then, the pandemic hit. As with all health programs in South Africa and many around the world, COVID-19 had a significant impact on the delivery of reproductive, maternal, and neonatal services in 2020 (Pillay et al, 2021).

In South Africa the first wave began at the end of March and the second wave began in December. The consortium continued to support the government to implement the quality improvement project, switching from in-person meetings to digital platforms like Zoom and WhatsApp. The learnings and recommendations in this brief were drawn from these interactions.

In preparation of a third wave, CHAI and partners prepared a brief highlighting the key lessons learned on the ground to date. This brief was subsequently endorsed by the South African National Department of Heath and, in May 2021, shared with facilities throughout the country. The aim of the document was to identify areas for health systems strengthening and help mitigate any direct or indirect effects on reproductive, maternal, and newborn services caused by the latest COVID-19 crisis.

With cases of COVID-19 infections in South Africa doubling over the past two weeks, and with no sign of the rise slowing, it is hoped that the lessons shared here may help with the response to the latest wave, as well as be useful to stakeholders in other countries facing similar challenges.

Lessons from the first two waves of COVID-19 infections

  • National maternal mortality rates increased by 24 percent in 2020 due to
    • COVID-19 infections in pregnant women;
    • Disruption of maternal and newborn health services;
    • Diversion of health workers from routine services to respond to COVID-19 coupled with absenteeism as workers became sick or died.
  • Neonatal deaths increased by 5 percent, while late neonatal deaths[1] increased by 16 percent in 2020. Overall perinatal mortality increased by 3.4 percent.
  • Women accessing contraceptive services decreased by 5 percent during the two waves.
  • Health services in metropolitan areas were stretched due to COVID-19 infections, which reduced staff and service availability for non-COVID-19 needs.
  • Rural areas in some provinces were already suffering from staff shortages before the pandemic. Many became overwhelmed by the sudden increase in patients as women migrated back to their ancestral homes.
  • Staff shortages in both metropolitan and rural areas were exacerbated by staff becoming ill due to COVID-19 or needing to quarantine due to possible exposure.

Recommendations to prepare for the next wave

In May 2021, CHAI and partners developed the following recommendations to be implemented by district and facility management, unless otherwise indicated. The recommendations may be adjusted for other countries’ use, depending on the healthcare system structure in those settings.

  • Healthcare managers should prioritize vaccinating their staff. This will help prevent absenteeism due to illness, which exacerbates the already overburdened health workforce. This will also improve morale, as staff members may avoid the negative impact that illness or death of colleagues can have on their mental and emotional well-being.
  • Health facility managers should ensure better human resource planning to avoid diversion of key personnel from essential services in emergencies.
  • Health facility process flows and infrastructure should be reviewed immediately to ensure social distancing is being effectively implemented. All Infection Prevention and Control protocols should be reviewed and updated in line with the government’s COVID-19 guidelines.
  • Health facility managers should implement robust stock management practices that regularly replenish personal protective equipment (PPE) in health centers.
  • Health authorities should communicate with the communities they serve, especially pregnant women, the importance of the following:
    • Starting antenatal care early and attending appointments regularly and safely in the context of COVID-19 is essential to protect the health of women and infants. Communication should be done using radio, television, and community and religious gatherings as well as social media. Consider the use of influencers such as local celebrities and community leaders.
    • Health workers should advise pregnant women to plan for their deliveries at health facilities. They should provide specific guidance, including packing ‘get-up-and-go bags’, arranging for transportation to the facility, etc.
    • Health workers should communicate that reproductive health services remain open and able to serve women who need contraception or counselling.
  • Healthcare workers should stay up-to-date on directives from the Ministerial Advisory Committee about the importance of vaccinating pregnant women against COVID-19 and communicate the options available to their patients.
  • All health workers should have access to and be familiar with the South African Framework and Guidelines for Maternal and Neonatal Care during a Crisis, which contains the most recent guidance on the prevention and management of COVID-19.
  • Provincial health information directorates should conduct data clean-ups and facility audits immediately as data quality may have been affected by staff absenteeism.


Pillay Y, Pienaar S, Barron P, Zondi T. (2021) Impact of COVID-19 on routine primary healthcare services in South Africa. S Afr Med J. Published online 17 May 2021. https://doi.org/10.7196/SAMJ.2021.v111i8.15786

SAMRC. The impact of Covid-19 on pregnancy in 2020 compared with 2019: interim fact sheet

[1] The neonatal period begins at birth and ends 28 days after birth. Late neonatal mortality refers to infants who die between seven and 28 days after birth.
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