MATCO was a global study of Maternal health provision during the COVID-19 pandemic. As a part of the MATCO study, we conducted a mixed-methods, longitudinal in-depth case study of preparedness and response to COVID-19 in seven large maternity/newborn hospital wards in large cities in four countries in sub-Saharan Africa (Guinea, Nigeria, Uganda, Tanzania). This study served as a platform for exchange of information and experiences across the contexts studied. We used semi-structured interviews, visual data documentation, and routine health records analysis.

The objective of the MATCO study was two-fold:

1. To understand how health professionals and health facilities prepare and respond to COVID-19 in regard to the care provided to women and their babies during antenatal, intrapartum and postnatal care.
2. More broadly, to document and analyse the effect of the COVID-19 pandemic on the services available to pregnant, labouring and postpartum women and their newborns, as a result of increasing pressures on the health system.

The Hospital Dynamics study within MATCO focused on these objectives from the perspective of tertiary referral hospitals in sub-Saharan Africa. The specific objective was to document the preparedness and response to COVID-19 among large maternity/newborn wards in four countries in sub-Saharan Africa over time.

The importance of maternity wards in tertiary referral hospitals to the COVID-19 response cannot be overstated: they serve large urban populations, take care of the most complicated obstetric cases, provide outpatient and inpatient care to thousands of women and newborns annually, conduct critical research, and train the next generation of health providers, including obstetricians, midwives, nurses, and laboratory technicians. More than half of women in sub-Saharan Africa give birth in health facilities. In urban areas, where two-thirds of the world’s population will live by 2050, the use of health facilities for childbirth is even higher, and progressively concentrated in hospitals. Designed to serve primarily as referral facilities for high-risk women, large tertiary referral hospital maternity wards (“mega-maternities”) often serve as childbirth facilities for large numbers of low-risk women seeking to avoid poor care at lower-level facilities. Most mega-maternities often struggle to serve either group well, and might not be able to provide high-quality, respectful care to women owing to insufficient resources and space to manage high volumes of low-risk births and complications referred from lower-level facilities. Care for women in mega-maternities is also prone to overmedicalisation due to shortages of beds and human resources, particularly midwifery cadres. Yet, women with complications face life-threatening delays in reaching mega-maternities for emergency care as a result of insufficient communication between providers, transport options, and accountability mechanisms

In addition to their importance as teaching hospitals and the location of care for thousands of women, large urban maternities were at the forefront of dealing with the COVID-19 epidemic in sub-Saharan Africa. They were the first to develop protocols, to train staff, to encounter a suspected COVID-19 case among women, and were expected to provide guidance on how to continue providing good quality maternal and newborn care during the epidemic. Driving this study was the bold idea that mega-maternities are an untapped resource for identifying ingenious coping strategies and innovative solutions to improving maternal and perinatal health in urban contexts. Many countries have only one mega-maternity; global linkages are therefore needed to recognize and share locally identified innovations. We used stakeholder knowledge, cross-learning between researchers across the study hospitals, and global networks to harness these solutions. Beyond relevance to the hospitals included in this study, the methods and findings of this study are useful to other settings, primarily in sub-Saharan Africa.