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COVID‐19 and obstetric practice: A critical review of the Nigerian situation

Abstract Objective To review what is known about COVID‐19 and highlight gaps in the context of Nigerian obstetric practice. Research data on COVID‐19 are understandably sparse in Africa. Nigeria, like most African countries, is battling a disease she is poorly equipped to fight. Methods The current available literature on COVID‐19 was reviewed in relation to obstetric practice in the Nigerian context, gaps were identified, and recommendations were made to improve the handling of the COVID‐19 pandemic in Nigerian obstetric practice. Results In and out of hospital, both the obstetrician and the obstetric patient are constantly being put at risk of exposure to the coronavirus because testing and preventive measures are either ineffective or non‐existent. Conclusion The pandemic has exposed the gross inadequacies in Nigeria’s healthcare system and is therefore a wake‐up call to the need for a complete overhaul of infrastructure and services. The government will do well to increase the budget allocation for health from the current paltry 4.14% to the recommended 15% of the total budget. The Nigerian obstetrician stands a high risk of exposure due to inadequate preventive measures, and testing and diagnostic challenges.


| INTRODUCTION
The outbreak of a completely unique 2019 coronavirus disease , previously referred to as 2019-nCoV, was first reported in Wuhan, Hubei province, China, on December 31, 2019. 1 With a case fatality rate (CFR) of 2%, the disease had quickly spread to over 20 countries in the world, including the USA and Europe by January 30, 2020. It was then declared a Public Health Emergency of International Concern. 2 Table 1, Fig. 2). 8 The study of this disease is new and rapidly evolving globally, and there is a paucity of research data on COVID-19 in Africa. In light of this background, there is an urgent need to review what is known so far about the disease and highlight gaps in the context of the African continent, especially the peculiarity of the Nigerian situation. The aim of the present study was to review the current available literature on COVID-19 in relation to obstetric practice in the Nigerian context, identify gaps, and make recommendations.

| COVID-19 AND HEALTHCARE IN NIGERIA
Expectedly, health workers in Nigeria have been hit by the pandemic.
Currently, over 800 Nigerian healthcare workers are infected with the virus. 9 As at June 22, 2020, 910 medical doctors had been quarantined for the disease, with 239 of them testing positive for the virus.
Ten Nigerian doctors have died from COVID-19, the first being an obstetrician, who died at Lagos University Teaching Hospital (LUTH), Idi-Araba, Lagos, on April 15, 2020, after exposure to a patient with COVID-19 in his private clinic. 10 The above situation gives a peek into the COVID-19 pandemic as it affects medical doctors and, by extension, healthcare workers in Nigeria.

| COVID-19 and pregnancy
A major concern for the obstetrician is the effect of COVID-19 on the pregnant patient and her unborn baby. There is currently no evidence that pregnant women are at higher risk of the disease compared to the general population; therefore, there is also no evidence of intrauterine fetal infection and currently no data suggesting an increased risk of congenital malformation, miscarriage, or early pregnancy loss in association with  This is reassuring, especially so for the obstetrician in Nigeria, where the baseline maternal and perinatal morbidity and mortality are already high.
However, malaria fever is endemic in Nigeria and is the commonest cause of fever in pregnant women. This underscores the diagnostic challenge of the disease in the obstetric patient, as many infections and infestations in pregnancy and the puerperium, including but not limited to respiratory and urinary tract infections, malaria, inflammatory conditions such as asthma, puerperal sepsis, pulmonary embolism, and peripartum cardiomyopathy share cardinal symptoms with COVID-19. 12

| COVID-19 testing in Nigeria
The diagnostic dilemma of COVID-19 in the obstetric patient is compounded by the fact that testing in Nigeria is not only limited, but also restricted. The few rapid diagnostic tests with high sensitivity and specificity are only available in high-resource countries. 13 Testing in Nigeria is currently limited to suspected cases of COVID-19, defined by WHO as "a patient with acute respiratory illness (fever and at least one sign/symptom of respiratory disease (e.g., cough, shortness of breath)), AND with no other etiology that fully explains the clinical presentation AND a history of travel to or residence in a country/ area or territory reporting local transmission of COVID-19 disease during the 14 days prior to symptom onset; OR a patient with any F I G U R E 1 World distribution of COVID-19 as of June 26, 2020, 12:00pm ET (source: www.cdc.gov).
T A B L E 1 Distribution of confirmed cases, active cases, discharged and deaths, and tests done in Nigeria as of June 26, 2020 (based on data from the NCDC).

| Attitude and perception of Nigerians towards COVID-19
There are cases in Nigeria of patients hiding their travel history from their managing doctors. The implication of this is that such patients who would hitherto have fulfilled the COVID-19 suspected case definition criteria, and tested in line with the country's testing protocol, would most probably be admitted and managed for other benign conditions without a suspicion of COVID-19. This portends grave danger for not only the doctors but also for all other healthcare workers and patients who would come into contact with such patients.
There are also reports of persons absconding after testing positive for the coronavirus, all with a view to avoid being taken to an isolation center. Quarantine measures are being flouted, as there are cases of persons with a travel history to high-risk countries refusing to go into the stipulated 14 days of isolation upon return from such countries. These people pose a risk to other members of the community, who, after exposure to such contacts, may present asymptomatically to the hospital, further propagating the spread of the virus.

| Obstetric practice in Nigeria during the COVID-19 pandemic
The Society of Gynaecology and Obstetrics of Nigeria (SOGON) has issued a practice guidance aimed at preventing the spread of coronavirus while delivering obstetric care during the pandemic. 17 The guidance recommends that duty rosters be reorganized to limit hospital contact of medical personnel. This has been difficult to implement in many obstetric units across the country due to a gross shortage of manpower predating the COVID-19 pandemic. There are 39 qualified medical doctors per 100 000 people (0.4 per 1000) in Nigeria. 18 The implication of this is that aside from the elderly practitioners, especially those aged 60 years or above, who are strongly advised to work from home, all or most of the other cadres of doctors in obstetric units across the country still report for duty daily. On a positive note, the Nigerian government has recently made significant efforts in increasing the supply of PPE kits to hospital units across the country. Even though these kits are still grossly inadequate, the government has taken a step in the right direction. The government has also provided group life insurance for health workers and has commenced payments of special COVID-19 hazard allowances to healthcare workers in the country.

| COVID-19 PREVENTIVE MEASURES IN NIGERIA: THE CURRENT SITUATION
The Nigerian government declared a two-week lockdown on March 30, 2020, which was extended for another 2 weeks on April 13, 2020. 25 This had severe economic consequences on families, mostly so because the majority of Nigerians are either unemployed or work in the informal sector, depending on daily earnings for sustenance. 23,25 Further, nearly one-half of Nigeria's population live below the poverty line. 25 Expectedly, therefore, many Nigerians did not obey the "stay at home" orders.

| CONCLUSION
The obstetrician in Nigeria has not only an underequipped and underfunded healthcare system to contend with, but also stringent working conditions and poor physical infrastructure, with little or no motivation, and barely being provided with appropriate PPE to work with during this pandemic. In and out of hospital, both the obstetrician and the obstetric patient are constantly being put at risk of exposure to the coronavirus because preventive measures are either ineffective or non-existent. It is a constant battle to deliver a healthy baby to a happy and satisfied mother. Even more, it is an uphill battle for the obstetrician to stay alive and uninfected in the process.

| RECOMMENDATIONS
Prevention remains the cornerstone in the fight against COVID-19.
Intense and continuous public health education on the need to strictly adhere to preventive measures, including the use of face masks/ shields, social distancing, frequent hand washing, and use of alcoholbased hand sanitizers, is recommended.
There is an urgent need to increase the country's capacity for testing and decentralize it in order to improve access to tests. Secondary and tertiary hospitals will need to seek alternative sources of funding to establish their own testing centers instead of waiting on the government.
Rapid test kits should be made available and used to screen all women in labor. Women in labor often hyperventilate and scream/shout, thereby aerosolizing the viral droplets in asymptomatic cases. This increases the risk of infection to the obstetrician and other staff in the labor room.
Local manufacturers should be incentivized by the government to produce PPE that meets safety standards using locally available materials and appropriate technology. This will also help to provide jobs and boost the economy. The pandemic has exposed the gross inadequacies in Nigeria's healthcare system and is therefore a wakeup call to the need for a complete overhaul of infrastructure and services. The government will do well to increase the budget allocation for health from the current paltry 4.14% to the recommended 15% of the total budget. Private sector investment in the health sector should be encouraged. A revamped and functioning health system through public-private partnership will reduce the need for overseas medical tourism and loss of valuable foreign exchange.
The government should provide palliatives for the citizens in terms of tax waivers, suspension of utility bills and mortgage payments, soft loans for small and medium scale enterprises, and incentives and improved working conditions for healthcare workers. The telecommunications industry can help to facilitate the use of telemedicine for outpatient consultations by their subscribers. Most importantly, as citizens of the world, we must remember that we are in this together, sink or swim.

AUTHOR CONTRIBUTIONS
IO conceptualized and designed the study; IO and UA developed and wrote the manuscript; OB, KT, EO, and IJ assisted with manuscript review. All the authors have read and agreed to the final manuscript.