The governments of Kenya, Mozambique, Uganda, and Zimbabwe all issued national-level policy guidance related to RMNCH service continuity (Table 1). Policies were formally issued in March (Mozambique), April (Kenya, Uganda), and June (Zimbabwe) of 2020. In Kenya, dozens of COVID-19 policy guidelines were issued by the MOH to cover various operational aspects of the health, transportation, and business sectors, and are available via a Kenyan government website . Of these, three were directly applicable to RMNCH service delivery and thus included in this analysis. Mozambique issued two directives via circulars which were directly related to the analysis, one on maternal health and one on immunization, and a third circular was issued in February 2021 to broadly address mitigation measures for the health sector. In Uganda and Zimbabwe, respectively, guidelines were consolidated into one policy document.
The analysis grouped policy recommendations into two (overlapping) aims: continuing services and preventing COVID-19 transmission during provision of these services. Summarized findings from the four countries are presented in Fig. 2, in which recommendations related to continuity of services or prevention of transmission are divided by service areas (FP, ANC, intra- and postpartum care, and immunization). In brief, telemedicine and multi-month dispensing were recommended for FP and, in some cases, for ANC; all four countries specifically promoted immediate breastfeeding of newborns, with infection prevention and control (IPC) measures for the immediate postpartum period; and triaging and separating pregnant women infected or suspected to be infected with COVID-19 were described during the intrapartum period. Outreach services such as mass immunization campaigns were canceled for immunization services, and information, education, and communication (IEC) campaigns on the continuing importance of childhood vaccination were recommended in all four countries.
The key policy aspects supporting continuation of FP services included multimonth dispensing (generally for oral contraceptives, skin patch contraceptives, depot medroxyprogesterone acetate subcutaneous [DMPA-SC] in places where that method is available, and condoms) and telemedicine (in the form of consultations, reminders, or links to community health workers). Multimonth dispensing of short-term FP methods was described in Kenya, Uganda, and Zimbabwe (Table 2). In both Kenya and Zimbabwe, DMPA-SC was specifically mentioned, but not in Uganda or Mozambique. To prevent COVID-19 transmission, Kenya, Uganda, and Zimbabwe suspended outreach FP events or services and maintained other community-based distribution approaches. In policy guidelines for facility-based services, Kenya recommended immediately suspending group FP counseling. In Kenya, surgical voluntary sterilization methods including bilateral tubal ligation and vasectomy were suspended or postponed; in contrast, Mozambique, Uganda, and Zimbabwe policy guidelines specifically called for maintaining services for all contraceptive methods.
In June 2020 Maintaining essential health services: operational guidance for the COVID-19 context, WHO makes recommendations on maintaining essential RMNCH services, including FP. All four countries included guidance which aligned with WHO’s recommendation of multimonth dispensing of FP (Table 3). Other WHO recommendations, such as making alternative contraceptive methods available in case a woman’s regular method is not available, were not mentioned in Mozambique and Uganda, but related messages were seen in Kenya and Zimbabwe. WHO’s recommendation on relaxing requirements for initial prescriptions for contraceptive methods was not mentioned in any of the four countries’ policy guidance. Only Uganda policy guidelines mentioned expanding availability of FP services to pharmacies and trained drug shops, as recommended by WHO.
For continuation of ANC services, multimonth dispensing of ANC-related supplements and medications was not prominent. This approach was specified in policy guidelines in Kenya, but not mentioned in other country policy guidelines (Table 4). Telemedicine was addressed in Kenya in two ways: health care providers were advised to schedule phone-based ANC consultations as possible, and community health volunteers (CHVs) were provided messages that could be delivered via phone to pregnant women. In Mozambique, pregnant women with minor complaints were told to call the health care provider rather than coming to the health facility (“minor complaints” was not defined). Nothing about telemedicine for ANC was mentioned in Uganda’s policy guidelines. The current recommended schedule for ANC visits (eight visits for Kenya, Uganda, and Zimbabwe and four for Mozambique) was not changed, but in Kenya and Zimbabwe, it was recommended that some of these visits be phone consults rather than in-person visits to the health facility. Uganda guidelines did not mention the ANC visit schedule. Almost every reviewed country’s guidelines detailed physical distancing to be maintained during ANC consultations and mandated mask wearing; however, in the Kenyan RMNFP guidelines, distancing and masks are not specifically mentioned, but “IPC measures” were prescribed.
A number of policy recommendations for ANC services by WHO  were also addressed in country policy guidance, while others were not (Table 5). WHO’s recommendations for prioritizing ANC services for third trimester clients and women with high-risk pregnancies were not mentioned in any reviewed country policy guidance, nor was discussion of adapting birth preparedness/complication readiness plans to COVID-19 health services, or booking ANC visits. Planning to provide all ANC services in a single service visit was similarly not included in any country policy guideline. Multimonth dispensing was mentioned only in Kenyan policy guidance, and this was limited to micronutrient supplements; insecticide treated nets (ITNs) were mentioned. The WHO recommendation most seen in country policies was that of using digital platforms for counseling and screening in ANC; related recommendations were seen in all country policy guidelines except Uganda’s.
Intrapartum and postpartum care
Most of the elements described for intra- and postpartum care were related to continuity of services (Table 6). Policy guidance described whether birth companions could be present during birth (not allowed in Kenya, Mozambique and Zimbabwe; not mentioned in Uganda). All four countries’ policy guidelines encouraged immediate breastfeeding by all women, using precautions, including the mother wearing a mask and washing hands and breasts before breastfeeding. Zimbabwe was the only country that issued policy guidance about maternity waiting homes, specifying that they should be kept open. Postpartum FP was mentioned in policy guidance only in Kenya, which clarified that postpartum FP should be offered at all health facilities during the pandemic. PNC services, typically provided at either health facilities or via a home visit, were mentioned in all four countries’ policy guidance. In Kenya, the 2- and 6-week PNC visits were preserved and occur at a health facility, with recommendations on where a woman should seek care based on her risk category. Kenya’s guidance for CHVs included details of what could be discussed by phone regarding PNC. In Zimbabwe and Mozambique, policy guidelines specified that PNC visits should be provided with no modifications during the COVID-19 pandemic, whereas in Uganda, home PNC visits were to be suspended. Due to the nature of intrapartum care being necessarily facility-based, policy guidance to prevent COVID-19 transmission in intrapartum care from all countries focused on triage procedures during admission to maternity services or during intrapartum care, including screening women in labor for symptoms of or possible exposure to COVID-19 (all four countries), separate entry areas for those not yet screened (Uganda and Zimbabwe), and psychological support for women with COVID-19 (Zimbabwe).
When comparing WHO’s guidance  to country policy guidance, only Zimbabwe’s policy guidelines mentioned that maternity waiting homes should be kept open (Table 7). WHO guidance promotes birth companions, subject to screening for COVID-19, while policy guidelines in Kenya, Mozambique and Zimbabwe stated that birth companions would not be allowed in birthing areas (not mentioned in Uganda). In line with WHO recommendations, all four countries specifically promoted immediate breastfeeding of newborns, with prevention measures that included washing hands and breasts, and each mother wearing a mask; however, none of the country policy guidelines mentioned skin-to-skin placement of the newborns, which was mentioned in the WHO recommendations. The only country policy guidance which mentioned safe transport of a pregnant women to the health facility, as was recommended by WHO, was Uganda, which described contacting boda boda motorcyclists for transport to facilities, including creating rosters and securing emergency travel permits for riders. Regarding cesarean deliveries, WHO recommends keeping the decision to conduct a cesarean delivery separate from COVID-19 exposure, infection, or transmission status. In Kenya and Mozambique, policy guidance stated to conduct cesarean deliveries as per pre-existing protocols, whereas in Uganda, the policy guidance specified that in the case of elective cesarean deliveries, a decision to delay could be made on a case-by-case basis. In Zimbabwe, the guidance appeared to contradict WHO recommendations, in that the guidelines named different levels of care and indicated that a delay of cesarean delivery may be possible for women suspected of having COVID-19 infection. WHO’s recommendation to provide PNC within 24 h was not specified in any of the four countries’ policy guidance. In Kenya, the guidelines specified that PNC follow-up visits should be made at 2 and 6 weeks, and for women with high-risk births, the determination should be made on a case-by-case basis. In Zimbabwe, follow-up of the new mother at home was advised to take place 7 days after delivery. Multiple recommendations from WHO on PNC were not mentioned in country policy guidelines, including using digital platforms for PNC, providing all relevant PNC services in a single visit, multimonth dispensing of supplements and medicines related to PNC, and updating PNC complication readiness plans to take into account changes to service provision.
Continuation of services featured prominently in the policy guidance recommendations for immunization (Table 8). One of the most significant considerations was maintaining or canceling outreach services. Zimbabwe was the only country whose guidance recommended continuing outreach services for immunization, specifying that outreaches should be smaller, held more frequently, and conducted outdoors. Outreach immunization services in Kenya were canceled in April 2020 guidelines; this temporary suspension was continued in an update to the guidelines issued in July 2020. According to policy guidelines of both Mozambique and Uganda, campaigns should be halted and immunization only offered at health facilities; Kenya guidance also recognized immunization as an essential service to be provided at the facility level. Immunization schedules are defined by both national and international guidance and changes in schedules are not advised in any country guidance. In Zimbabwe and Uganda, the policy mentioned “mop-up” campaigns to reach children who missed their appointments due to COVID-19. Mozambique, Uganda, and Zimbabwe policy guidelines all specified that communication campaigns should be used to promote the importance of childhood immunization and explain access to childhood immunization during COVID-19.
WHO’s guidance  called for regular evaluation of evidence and surveillance data to inform how immunization services could continue to be offered, suggesting modifications that may help reduce risk of transmission within immunization services (Table 9). All country policy guidelines included some elements, such as improving IPC, while others were not seen in any country guidance (such as limiting the duration of visit to the health facility during immunization services).