Disruptions in maternal health service use during the COVID-19 pandemic in 2020: experiences from 37 health facilities in low-income and middle-income countries.

The COVID-19 pandemic has heterogeneously affected use of basic health services worldwide, with disruptions in some countries beginning in the early stages of the emergency in March 2020. These disruptions have occurred on both the supply and demand sides of healthcare, and have often been related to resource shortages to provide care and lower patient turnout associated with mobility restrictions and fear of contracting COVID-19 at facilities. In this paper, we assess the impact of the COVID-19 pandemic on the use of maternal health services using a time series modelling approach developed to monitor health service use during the pandemic using routinely collected health information systems data. We focus on data from 37 non-governmental organisation-supported health facilities in Haiti, Lesotho, Liberia, Malawi, Mexico and Sierra Leone. Overall, our analyses indicate significant declines in first antenatal care visits in Haiti (18% drop) and Sierra Leone (32% drop) and facility-based deliveries in all countries except Malawi from March to December 2020. Different strategies were adopted to maintain continuity of maternal health services, including communication campaigns, continuity of community health worker services, human resource capacity building to ensure compliance with international and national guidelines for front-line health workers, adapting spaces for safe distancing and ensuring the availability of personal protective equipment. We employ a local lens, providing prepandemic context and reporting results and strategies by country, to highlight the importance of developing context-specific interventions to design effective mitigation strategies.

Strategies for Success: Simple Education Interventions to Equip Nursing Students in Rural Liberia.

Severe shortages of skilled health workforce remain a major barrier to universal health coverage in low income countries including Liberia where nurses and midwives form more than 50% of the health workforce. According to the 2018 Service Availability and Readiness Assessment (SARA) report, Liberia has 10.7 core healthcare workers per 10,000 people, far below the WHO benchmark of 23/10,000 people. High quality training for nurses and midwives is one of the most important strategies to addressing these health workforce shortages. Since 2015, William V.S Tubman University (TU) faculty and Partners in Health (PIH) have partnered in nursing and midwifery education to address nursing and midwifery workforce shortages in Southeast Liberia. In our collaboration we have sought to not only increase the quantity of graduate nurses and midwives but also improve the quality of the training to ensure they are equipped to serve the population. TU strives to produce highly competent generic nurses who will excel in their clinical practice and future specialized training. By applying the theory of deliberate practice, learners are allowed to practice and self-evaluate repeatedly until they attain proficiency. Simulation training was adopted early in the training of nurses and midwives at TU to ensure students are well-prepared for real-life patient care. TU also established a preceptorship program to ensure that students receive skilled mentorship during clinical rotations. Internship for graduating senior Nursing/Midwifery students, where they focus on enhancing psychomotor and assessment skills, professional communication, safety and organization, medication administration and documentation, ensures successful integration into clinical practice after graduation. This progression of the student nurse or midwife from the exposure in the skills lab during pre-clinical modules, to individual preceptorship during clinical rotations to a structured internship experience with an intensive pre-internship "boot camp" have been the major innovations that have helped our partnership flourish. The foundation of these interventions is strong and sustained investment in nursing and midwifery faculty both at the university and the health facilities.

Facing COVID-19 in Liberia: Adaptations of the Resilient and Responsive Health Systems Initiative.

The 5-year Resilient and Responsive Health Systems (RRHS)-Liberia Initiative, funded by PEPFAR via HRSA, launched in 2017 and was designed to support the implementation of Liberia's National Health Workforce Program as a means to improving HIV-related health outcomes. The COVID-19 pandemic, arrived in Liberia just five years after Ebola and during RRHS-Liberia's fourth year, impacted educational programs and threatened the project's continued work. This paper presents the challenges that the COVID-19 pandemic posed to the RRHS partners, as well as adaptations they made to maintain progress towards project goals: 1) contributing to Liberia's 95-95-95 HIV targets via direct service delivery, and 2) building a resilient and responsive health workforce in Liberia via instruction and training. Direct health service impacts included decreased patient volumes and understaffing; adaptations included development of and trainings on safety protocols, provision of telehealth services, and community health worker involvement. Instruction and training impacts included suspension of in-person teaching and learning; adaptations included utilization of multiple online learning and virtual conferencing tools, and increasing clinical didactics in lieu of bedside mentorship. The RRHS team recommends that these adaptations be continued with significant investment in technology, IT support, and training, as well as close coordination among partner institutions. Ultimately, the RRHS Liberia consortium and its partners made significant strides in response to ensuring ongoing education during the pandemic, an experience that will inform continued service delivery, teaching, and learning in Liberia.