“Separated during the first hours”—Postnatal care for women and newborns during the COVID-19 pandemic: A mixed-methods cross-sectional study from a global online survey of maternal and newborn healthcare providers

**Background:** The postnatal period (first 42 days after birth) is critical for maternal and newborn health, yet postnatal care (PNC) coverage has historically been among the lowest on the continuum of maternal and child healthcare globally. The COVID-19 pandemic introduced additional disruptions through lockdowns, staff shortages, and infection control measures. While WHO recommended PNC as an essential service during the pandemic, evidence from early 2020 suggested considerable collateral damage. This study aimed to fill knowledge gaps using data collected after the early pandemic phase (July–December 2020).

**Methods:** A global online survey of maternal and newborn healthcare providers was conducted using a questionnaire available in 11 languages. Of 1,405 total responses, 424 respondents from 61 countries answered at least one of four questions on PNC in an optional module (95.7% of optional module respondents). Respondents included midwives (27%), obstetricians/gynaecologists (27%), medical doctors (14%), nurses (13%), nurse-midwives (8%), and neonatologists/paediatricians (8%). Nearly half (46%) were from high-income countries, 42% from middle-income countries, and 12% from low-income countries. Quantitative data were analyzed using descriptive statistics stratified by country income level; qualitative open-text responses were analyzed using content analysis with deductive and inductive coding.

**Key Results:** The most commonly reported adaptation was earlier discharge after birth, reported by 59% (n=183/310) of respondents consistently across all income groups. Tightened visiting rules were widespread: 55% (n=219/397) reported reducing the number of visitors, 42% (n=168/397) banned visitors altogether, and 38% (n=150/397) shortened visiting hours. Complete banning of visitors was reported by 64% (n=115/180) in high-income countries versus 6% (n=3/49) in low-income countries. A quarter (26%) of respondents reported that mothers with suspected/confirmed COVID-19 were routinely separated from their newborns, rising to 30% (n=36/120) in high-income countries. Reduced breastfeeding support was reported by 40% (n=38/95) in high-income countries versus 7% (n=3/41) in low-income countries. Reduced provision of postnatal family planning counselling was reported by 34% (n=14/41) in low-income countries versus 16% (n=15/95) in high-income countries. Reduced frequency of routine postnatal monitoring before discharge was reported by 45% (n=21/47) in low-income countries versus 11% (n=13/120) in high-income countries. Telemedicine for PNC was reported by 40% (n=62/155) in high-income countries versus 8% (n=4/49) in low-income countries. Home-based PNC visits were reportedly reduced or stopped for 17% (n=63/369) overall, though some settings increased home visits. Almost 60% (n=183/310) reported earlier discharge, and 27% (n=99/369) perceived a reduction in outpatient PNC attendance. Reduced bed availability due to social distancing was reported by 37% (n=18/49) in low-income countries. Creation of COVID-19 isolation rooms reducing postnatal ward space was reported by 22% (n=39/180) in high-income and 19% (n=32/168) in middle-income countries versus 14% (n=7/49) in low-income countries.

**Clinical Implications:** The documented disruptions to PNC content and quality are concerning because PNC coverage was already sub-optimal pre-pandemic. Separation of mothers and newborns, reduced breastfeeding support, and absence of skin-to-skin contact contradict evidence that benefits of these practices far outweigh COVID-19 infection risks. Early discharge without adequate follow-up threatens maternal and newborn safety, particularly in low-income countries where 90% of maternal deaths occur. The findings highlight that disruptions persisted beyond the initial pandemic phase despite available WHO guidance. Depriving women of companionship and support violates respectful maternity care recommendations and may erode trust in health systems. Positive adaptations included spaced appointments, telemedicine (mainly in high-income countries), and home visits where infrastructure existed. The authors emphasize that context-specific mitigation strategies are needed, and that protecting essential PNC services is imperative to prevent losing progress in maternal and newborn health.