Volume 8, Issue 6, June – 2023 International Journal of Innovative Science and Research Technology

ISSN No:-2456-2165

Pregnancy and Newborn Related Complications:

Implication of COVID-19 Pandemic on the
Reduction of Antenatal Care in Bangladesh
Md. Jarif Mahbub
Institute of Nutrition and Food Science (INFS), University of Dhaka
Dhaka-1000, Bangladesh

Abstract:- Antenatal care (ANC) has long been purpose of ANC is to reduce the risk of any sort of health
considered a very crucial component of the successive complications of both mother and fetus and to ensure a
care of a pregnant mother during gestation. It reduces the healthy beginning for the newborn (Banta, 2003).
risk of both maternal and neonatal complications and
gives assurance to a healthy beginning for the infant. The An efficacious ANC can be achieved through ANC
ANC situation of Bangladesh is quite poor comparing contacts. ANC contacts refer to the routine check-up of
that of the developed nations. The scenario has been pregnant women by health care professionals. So that health
further worsened due to the outbreak of the COVID-19 care providers can suggest treatment or medication if there are
pandemic. In Bangladesh, the number of ANC contacts any kind of complications. Moreover, they can provide basic
has been reduced by 20-25% in this pandemic situation. knowledge about pregnancy to women. If a mother keeps
There is a lot of research evidence about the relationship proper knowledge collaborating with skilled health care
between an increased rate of maternal and child personnel, she will be able to understand whether she is at risk
mortality and a reduced number of ANC contacts. or not. Besides, she will be informed of how to prevent
Besides, the quality of ANC is not up to the mark in diseases or health risks associated with pregnancy. On the
Bangladesh. Since the status of a country’s future other hand, it will let her know the condition of the fetus and
generation comprehensively depends on the obstetric learn about crucial pregnancy-related information.
population, no compromise should be allowed regarding Consequently, health care providers can take the necessary
ANC even in this COVID-19 pandemic. The obstetric steps or advise mothers if any complications occur (Banta,
population must need special and distinctive 2003; WHO, 2016). But current COVID-19 pandemic has
considerations in such a pandemic situation because of woefully affected ANC like all other aspects.
their diacritic physiological and psychological needs. An
efficient and collaborative strategic approach must be The novel human coronavirus disease (COVID-19) was
taken by obstetric care providing facilities and the first identified and reported in Wuhan, the capital of Hubei
government to mitigate the adverse effects of decreased Province in the People's Republic of China (Velavan &
ANC contacts. Such a strategic approach may include Meyer, 2020). Gradually, this disease spread throughout the
enhancing health communication, strengthening the globe and the WHO declared it a global pandemic (WHO,
community-based ANC, increasing the collaboration n.d.). Considering phylogenetic analysis, the International
between primary healthcare services and ANC services, Committee on Taxonomy of Viruses officially named the
provision of telemedicine, mobilizing social resources, etc. virus acute respiratory syndrome coronavirus 2 (SARS-CoV-
COVID-19 has shown the shaky structure of the 2) (Gorbalenya et al., 2020). As this disease follows mainly
healthcare system of Bangladesh once again. So, a human-to-human transmission, most of the countries have
potential reformation in the healthcare system is highly called for either lockdown or strict social distancing. Along
needed. with preventive measures like lockdown, social distancing,
etc., scientists of many countries have been working hard to
Keywords:- Antenatal Care, COVID-19, Healthcare System, develop an effective vaccine against SARS-CoV-2. There are
Maternal Health, Child Mortality. a number of vaccines developed in the meantime and most of
them are under trial (Craven, 2020). Very recently, the UK
I. INTRODUCTION has approved the Pfizer/BioNTech coronavirus vaccine on
December 2, 2020, being the first country to approve any
Antenatal care (ANC) the care delivered by skilled vaccine against SARS-CoV-2. This epoch-making decision
healthcare providers to pregnant women to ensure the may pave the way for mass vaccination (Roberts, 2020). Until
optimum health conditions for both mother and newborn mass vaccination, nothing but preventive measures have to be
during gestation. ANC covers the time started from carried out. This lockdown and social or physical distancing
conception till successful parturition. According to the WHO, can have a latent potential to demotivate pregnant women,
there are three components of ANC: a) risk identification; b) especially in developing countries like Bangladesh to
prevention and management of pregnancy-related or schedule ANC contacts.
concurrent diseases; c) health education and health promotion
(World Health Organization [WHO], 2016). The main

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ISSN No:-2456-2165
ANC has the potential ability to minimize the risk of all has decreased in 2017-18. This percentage was 40% in
both maternal and child mortality and morbidity. It also 2007 and in 2017-18, it has become 8%.
ensures positive maternal and neonatal outcomes. (Banta,
2003; WHO, 2016). Many studies have found that ANC is Bangladesh Multiple Indicator Cluster Survey 2019
effective to diminish maternal mortality and morbidity (MICS 2019) reported that the percentages of women (age
(Bloom et al., 1999, Carroli et al.; 2001; Prual et al., 2000). 15-49) who have had ANC contacts at least one time by
Multiple studies have indicated a positive association between skilled health personnel, at least four times by any provider,
increased ANC contact and reduced probabilities of neonatal at least eight times by any provider are 75.2, 36.9 and 4.9
death (Kuhnt & Vollmer, 2017; Pervin et al. 2012; Roy & respectively (Bangladesh Bureau of Statistics [BBS], 2019).
Haque, 2018; Tekelab et al., 2019; Wondemagegn et al.,
2018). A study conducted in Bangladesh found that women Table 1: Coverage of Antenatal Care Contacts (2007-2018)
who had proper ANC experienced 18% lower odds of early Number of BDHS BDHS BDHS BDHS
neonatal mortality than women who did not have ANC (Roy ANC visits 2007 2011 2014 2017-18
& Haque, 2018). Another study revealed that women having None 39.6 32.1 21.4 8.0
less than or equal to one ANC contact faced two times more 1 15.8 15.3 17.9 13.1
perinatal mortality than women having more than three ANC 2 13.0 14.4 16.2 16.4
contacts (Pervin et al., 2012). At least one ANC contact 3 10.9 12.5 13.2 15.5
provided by a proficient health service provider can decrease 4 or more 20.6 25.5 31.2 47.0
neonatal death by 39% in the sub-Saharan African countries
(Tekelab et al., 2019). A cohort study conducted in rural According to the BDHS 2017-18 definition of quality
Bangladesh discovered an association between decreased ANC, only 18% of women were able to receive quality ANC.
cases of preterm births and an increased number of ANC It means four out of every five mothers of Bangladesh lack
contacts (Pervin et al., 2020). quality ANC. The indicators of quality ANC comprises
receiving four or more ANC contacts, of which at least one is
Because of such vitality of ANC, WHO recommends at from a medically trained health personnel and having basic
least eight ANC contacts (previously a minimum of four ANC services of ANC, including measurements of weight, blood
contacts) throughout gestation in order to reduce perinatal pressure, blood and urine tests, and information on signs of
mortality and enhance the mother’s experience of care. The possible maternal and fetal complications (NIPORT, 2019a).
terms ‘ANC contact’ and ‘ANC visit’ are identical. The term
‘ANC visit’ is still used vastly because this term was used in There are some determining factors regarding the
every previous WHO recommendations. But now, in the latest quality and frequency of ANC in Bangladesh. Several types
recommendation, the WHO experts prefer the word ‘contact’ of research have been conducted to identify the factors and to
to ‘visit’ as it connotes an active connection between pregnant measure to what extent they are associated with ANC. Urban
women and health service providers. (WHO, 2016). women are more likely to have quality ANC than rural
women. It is found that urban women are more concerned
Based on experimental pieces of evidence, it is about ANC and have more accessibility towards ANC than
confirmed that ANC contacts should be followed mandatorily. rural women (Ali et al., 2018; Jahan & Jahan, 2016).
But in today’s COVID-19 pandemic situation, we notice a Maternal education plays a vital role in receiving ANC. The
sudden decrease in practicing ANC contacts. The ostensible more educated a woman, the more she is likely to get proper
complications seem to be quite alarming. This article will try ANC. Uneducated or less educated mothers are not aware of
to find the impact of the COVID-19 pandemic on the having enough ANC (Ali et al., 2018; Jahan & Jahan, 2016).
reduction in ANC and also find some possible ways which A study showed that women empowerment is also associated
can enhance the chance of achieving a quality ANC in such a with the utilization of ANC after measuring the education
pandemic situation. follow. level and participation of women in decision making.
Educated mothers who participate in the decision-making of
II. ANTENATAL CARE SITUATION IN family affairs are more amenable to achieve complete ANC
BANGLADESH than uneducated, less educated, and genuflected women
(Hossain & Hoque, 2015). Women who earn money are more
Table 1 shows the number of ANC contacts and the likely to have quality ANC than typical housewives
percentage of women (age 15-49) fallen in each class of (Chakraborty et al., 2003). Husband’s education is also
ANC contacts, according to Bangladesh Health and related to ANC. An educated and conscious husband is
Demographic Survey 2007, 2011, 2014, 2017-18 (National always aware of his wife’s healthcare (Ali et al., 2018).
Institute of Population Research and Training [NIPORT], Husband’s occupation also determines the quality and
2009, 2013, 2016, 2019a). It is noticeable that the percentage frequency of ANC. A study revealed that service holders and
of women who have had four or more ANC contacts has businessmen are more conscious about their wives' care than
increased by a great extent in 2017-18. The percentages of that of farmers and day laborers (Chakraborty et al., 2003).
women who have had four or more ANC contacts in 2007 The high socio-economic status of the family is positively
and 2017-18 are 21% and 47% respectively. Even so about associated with an increased ANC (Ali et al., 2018; Shajahan
half of the women have had less than three ANC contacts. et al., 2013; Islam & Masud, 2018). Exposure to mass media
The percentage of women who have had no ANC contacts at (e.g. television, newspapers, radio, etc.) is an important factor
regarding ANC. Women having access to mass media are

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Volume 8, Issue 6, June – 2023 International Journal of Innovative Science and Research Technology
ISSN No:-2456-2165
more prone to schedule ANC contacts. But in rural 2020). These findings carry evidence that how robustly
Bangladesh, the proportion of women who have television or COVID-19 has affected the maternal healthcare services of
read newspapers regularly is very low (Ali et al., 2018; Bangladesh. A modelling study estimated that low- and
Shajahan et al., 2013). With the increase in the number of middle-income countries might face an additional 60%
living children, mothers are demotivated to schedule ANC maternal deaths and 41% child deaths in the COVID-19
contacts (Shajahan et al., 2013). The above-cited studies pandemic due to potential obstruction in health systems and
show us that rural residence, illiteracy, and ignorance of both reduced access to food (Robertson et al., 2020). Bangladesh is
husbands and wives, poverty, less exposure to mass media, not out of this scenario.
increased number of offspring, etc. are negatively associated
with quality and complete ANC in Bangladesh. It can be assumed that expecting mothers are reluctant to
schedule ANC contacts in this pandemic situation because of
III. COVID-19 PANDEMIC AND ANTENATAL the fear of being affected by SARS-CoV-2. The first-ever
CARE IN BANGLADESH reported study of the United Kingdom about pregnant
women’s perceptions of COVID-19 found that a significant
At the time of writing this article, there were a number number of pregnant women were in fear of being affected by
of 68,165,877 confirmed cases of COVID-19 and 1,557,385 the virus and they thought that the disease could be
confirmed deaths recorded worldwide (WHO, n.d.). transmitted to their baby (Karavadra et al., 2020). On the other
Bangladesh is a developing nation. This country is also facing hand, the magnitude of the pandemic is now trending all over
the invasion of COVID-19 like the rest of the world. The the mass media. Moreover, there is a great number of people
Government of Bangladesh has to follow preventive who can be COVID-19 positive but show no symptoms.
techniques (e.g. lockdown, strict social distancing, etc.) to Many studies have been published regarding this phenomenon
quell the spread of the virus until mass vaccination. The (Bai et al., 2020; Mizumoto et al., 2020). A Japan-based study
lockdown, described as general holiday by the government, found 18% of the COVID-19 patients were asymptomatic
continued from March 26 to May 31. Then some restrictions (Mizumoto et al., 2020). These reasons legitimate the fear of
were eased for offices and public transports, and offices were pregnant women about COVID-19. Significant financial
reopened (Shawon, 2020). But the educational institutes are constraints are seen in families which principally depend on
still under general holiday and remained closed. In daily wage-earning due to lockdown condition. A newspaper
Bangladesh, the first case of COVID-19 was reported on report mentioned that many head family-income earners have
March 8, 2020. The number of daily COVID-19-detection lost their jobs in this pandemic situation in Bangladesh (Nur,
tests was very low in the first six or seven weeks, then the 2020). Not only males, but also many females who used to
number of tests was comparatively increased gradually. A work in garments factories, or as housemaids, lost their job
total number of 485,965 people had been affected and 6,967 due to COVID-19. An article from Maternal Health Task
had died by December 10, 2020, in Bangladesh (Ministry of Force (Harvard Chan School Center of Excellence in Maternal
Health and Family Welfare, n.d.). The number of tests is still and Child Health) Blog confirmed that most of the low- and
very low compared to other countries, so it is questionable middle-income countries do not have the capability to provide
whether the confirmed cases represent the actual situation. monetary relief to needy citizens. The stay-at-home situation,
that is why, is like a curse for many poor and underprivileged
Antenatal care, an indispensable matter for every (Kotlar, 2020). Therefore, it can be said that because of the
pregnant woman, is going through a drastic change in the COVID-19 pandemic, newly impoverished families have
COVID-19 situation in Bangladesh. Not a great number of emerged, and poor families have become poorer. For this
evidence data are available but several newspaper reports reason, many families nowadays cannot afford nutritious
(Maswood, 2020) and research briefs (Ainul et al., 2020) from foods for mothers and children. Hence, maternal and child
nongovernmental research organizations confirmed maternal malnutrition is on the rise. Maternal malnutrition can lead to
healthcare disruptions in this pandemic. According to the maternal death, stillbirth, neonatal death, preterm birth, low
research brief of the Population Council (Ainul et al., 2020), birth weight, etc. (Black et al., 2008; Jammeh et al., 2011;
antenatal care (ANC), postnatal care (PNC) and delivery Singh et al., 2009). As described earlier, all types of
services are facing considerable declines. The number of institutional delivery services reduced during this pandemic.
ANC visits in June 2020 and July 2020 was 20-25% lower This reduction occurred due to the maladjustment between
than that of June 2019 and July 2019. Similar trends followed service providers and authorities along with emerging income
for PNC. All types of institutional delivery services—normal reduction and poverty among service-recipients. To cut the
delivery, active management of the third stage of labor extra burden of cost for transport and delivery, many women
(AMTSL), and caesarian section were 10-15% lower in June are willing to give birth at home with the help of unqualified
2020 and July 2020 than that in 2019. A rapid needs traditional birth attendants. Postpartum hemorrhage (PPH)
assessment conducted by CARE International found that 71% and eclampsia are responsible for 54% of maternal deaths in
of the pregnant respondents had missed their regular ANC Bangladesh (NIPORT, 2019b). Thus, titular ANC and at-
check-ups due to the unavailability of healthcare services and home delivery during COVID-19 can cause increased
local transportation (CARE International, 2020). Director for maternal and perinatal death in Bangladesh. As said
Maternal and Child Health of Directorate General of Family beforehand, less ANC is associated with poverty. On the other
Planning confessed to a newspaper that COVID-19 had hand, pregnant women of such low socioeconomic status
brutally shattered the maternal health care. They were also cannot afford to get quality ANC provided by experienced,
afraid of a surge in the maternal mortality rate (Maswood, private practitioners due to poor economic conditions. So,

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Volume 8, Issue 6, June – 2023 International Journal of Innovative Science and Research Technology
ISSN No:-2456-2165
they are heavily dependent upon government facilities like (NIPORT, 2019b). These rates are quite high. If the ANC
Union Health and Family Welfare Center, Upazilla Health contacts are likely to diminish, there is a very strong
Complex, District Hospitals, Medical College Hospitals, etc. possibility of increasing these rates. This can be alarming.
which provide cost-free or low-cost services. Though there Bangladesh has targeted to achieve a maternal mortality ratio
are a lot of public health care facilities in both rural and urban of 70 per 100,00 live births and a neonatal mortality rate of 12
areas of Bangladesh, the quality of their service is not up to per 1,000 live births regarding Sustainable Development
the mark, very poor actually (Chowdhury et al., 2009; Mansur Goals (SDG)-Agenda 2030 (Government of the People's
et al., 2014). The primary health care services have collapsed Republic of Bangladesh [GoB], n.d.). SDG Tracker, a
due to the lockdown and unwillingness of health care government website regarding SDG achievement status,
providers to provide service in this pandemic (Islam et al., shows that in 2019 maternal mortality ratio was 165 per
2020). For such reasons, poor women are likely to miss the 100,000 live births and the neonatal mortality rate was about
privilege of getting cost-free or low-cost ANC services. 16 per 1,000 live births and there was a reducing trend in
Comparing the present condition with the dimension of access these rates (GoB, n.d.). But COVID-19 has changed the whole
by Penchasky and Thomas (1981), it can be declared that low- scenario. Now it may be very difficult for developing
quality health care resource settings combined with reduced countries like Bangladesh to achieve the SDG goals by the
accessibility due to lockdown can lead to a maternal health deadline.
care catastrophe (Huq & Biswas, 2020). It was described
beforehand that access to mass media (newspapers, Some effective strategies have to be identified in order to
televisions, etc.) is positively associated with ANC. Women’s increase the extent and the quality of ANC during such
exposure to mass media has been very poor from the very pandemic situations. A probable efficient set of strategies is
past. It is not difficult to assume that this exposure is more given below:
reduced in such a pandemic situation when most of the
underprivileged people have been just trying to get rid of  Enhancing Health Communications
starvation with their very limited resources. So, the ANC The government and non-government agencies can take
awareness programs on television, newspaper releases have necessary steps to build up awareness among women about
not caught their eyes. Domestic violence is an important the inevitability of ANC contacts even in such epidemic
concern in this pandemic situation. Domestic violence has situations. Effective communication between mass people and
been existing for a long since and is likely to be increased due healthcare authorities of the government can be established in
to work-from-home or stay-at-home situation. Child or several ways. The government can promulgate the effect of
women abusers nowadays mostly stay at home and this having and not having ANC through electronic (e.g., Radio,
pushes the risk of increased abuse or violence (Evans et al., Television) and print media (e.g., Newspapers), cellular SMS,
2020). According to WHO, one of every three women is audio message through automated phone calls, etc. Social
either sexually or physically abused. Intimate partner violence media can play an important role here because it has become a
(IPV) is the most common among women (WHO, 2013). A part and parcel of everyday life. Social media releases, videos,
rapid needs assessment conducted in Bangladesh by CARE etc. containing pregnancy-related knowledge, more
International found that 35% of the participants had been specifically ANC-related information, can be an effective
physically abused by their husbands and all of them low-resource strategy.
confirmed that psychological or mental pressure had increased
in the lockdown (CARE International, 2020). A newspaper  Strengthening Community-based Antenatal Care
report suspected that domestic violence might increase in The government can set up necessary home visits by
Bangladesh during the COVID-19 pandemic (Jahid, 2020). Family Welfare Visitors (FWV) with the help of non-
IPV is responsible for delayed ANC, deterioration of maternal governmental organizations (NGOs). These home visits
mental health, preterm birth, low birth weight, small for should be cost-free, and this will help poor and unprivileged
gestational age, perinatal death, etc. (Alhusen et al., 2015; pregnant women. These home visits should give priority to
Huth-Bocks et al., 2002). rural areas, urban slum areas, poverty-ridden areas, and areas
having most of the confirmed cases of the infected disease.
Royston et al (1989) found that 99% of the total This visit should include weight and blood pressure
maternal deaths across the globe occurred in less developed or measurement along with a thorough check-up of complication
developing countries. At present, the rate is 94% (WHO, sign-symptoms. Urine and blood samples can also be
2019). The rate has not significantly changed from as it was in collected, and the report can be provided over SMS or cellular
the late 1980s. Most of these deaths could be restrained. A calling. The whole procedure should be performed by
quality ANC can play a vital role in preventing such deaths maintaining all sorts of health protocols (e.g., FWVs must
(Banta, 2003; WHO, 2016, 2019). During the Ebola virus wear Personal Protection Equipment). If such home visits are
epidemic, the number of women attending antenatal care not feasible due to the shortage of healthcare personnel or the
reduced by 18% in Sierra Leone. 34% and 24% increase were risk of transmission of the virus, another strategy can be
observed in maternal mortality ratio and stillbirth rate followed. All the expecting mothers of a certain locality can
respectively (Jones et al., 2016). In Bangladesh, the congregate in a particular place maintaining physical distance
probability of death within the first month of life (neonatal and all other health protocols. One or two (according to
mortality) is 26% (BBS, 2019). 13% of the total adult female necessity and availability) health service providers can give
deaths occur due to maternal causes. In Bangladesh, the them advice about various aspects of pregnancy and maternal
maternal mortality ratio is 196 per 100,000 live births

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care. Then the necessary check-ups of the pregnant mothers why mobilization of social resources matters so profoundly
can be done one after another. for the welfare of impoverished families. Policies should be
developed regarding how the socio-economic status of
 Modification in recommended routine ANC contacts that impoverished people can be improved. It can be achieved
include in-person services (Zangmo et al., 2020) either by providing monetary or food reliefs or creating
Instead of the latest WHO recommendation of eight employment opportunities for them.
ANC contacts, a minimum of four ANC contacts can be
scheduled to reduce the contact with outside people, and  Citizen response
exposure to the clinic or hospital environment. A study has Solidarity network, tools for crowdfunding, innovative
found no disadvantage of having four ANC contacts rather tech tools for skill-time matching ANC volunteering services
than the latest recommendation of eight ANC contacts (Villar can be introduced to the strategic approaches. Constructing
et al., 2001). But all kinds of tests, immunization should be solidarity networks with an aim to reinforce ANC services
done in between these contacts, rather than in different could prove to be beneficial. Spontaneous contribution from
schedules. Unless there would be no use in reducing the inhabitants might bolster the ANC infrastructures in a
number of ANC contacts. particular area. They might be able to assist both monetarily
or with voluntary services. This way, even if support from
 Use of Telehealth, Telemedicine, and Virtual Healthcare governing authorities is inadequate, we might be able to
The meaning and purpose of these terms are quite achieve a sustainable ANC infrastructure.
similar. These words are among the most used words in this
epidemic situation. These technologies have paved the way Devising new strategies and tools for crowdfunding
for connecting the patients and health care providers without ANC services might be of great value. For voluntary services,
in-person contact and from long distance. Expecting mothers a database may be created to record the availability and skills
can have their ANC contacts, that do not comprise any in- of those interested.
person involvements like ultrasonography, biochemical
laboratory tests, through telehealth. These telecommunication  Transparency for health equity
between health care providers and pregnant women can also Mortality and morbidity numbers should be adequately
act as a triage system. If a woman feels she needs to have a documented for transparency. This will expose existing
face-to-face appointment with health care personnel, disparities in socio-economic and health systems
telecommunication between her and an expert, experienced or disproportionately affecting certain communities and thus
reputable health service provider can decide whether she compounding the negative impact of the pandemic on ANC.
needs it or not. Thus, needless visits to clinics, hospitals, or As a result, response measures can be specifically aimed to
any kind of health care centers can be diminished (Osanan et address the unique needs of specific communities that will fill
al., 2020; Zangmo et al., 2020). gaps in institutionalized services.

 Strengthening the Coordination between Primary Health IV. CONCLUSIONS

Care Services and ANC Services
Specialization is needed for pregnant mothers who come COVID-19 has slowed down the pace of the whole
to the primary health care centers with the symptoms of world. This global epidemic has put a great impact on every
COVID-19. Policies and strategies should be developed for corner of our lives. It is very difficult to find an aspect that is
solid coordination between primary health care services and out of its claw. The whole healthcare system of this world is
ANC care. Isolation units can be prepared solely for COVID- going through a reformation. In this reformation process,
19 suspected pregnant women in both primary health care ANC contacts cannot be overlooked. Because ANC is equally
centers and specialized ANC centers. Integrated ANC services important for the survival of both mother and baby. A good
in primary health care should be regarded to support the ANC can ensure a healthy and active future generation and a
clinical, professional, organizational, system, and normative healthy and active generation can be turned into a productive
integration (Afrizal et al., 2020). asset for any country. We should try to find new ways
regarding ANC as we cannot omit this essential care. Every
 Mobilizing Social Resources and Policies hazard teaches us new lessons. This pandemic may be
Most of the people of low- and middle-income countries temporary, but these lessons will help us to combat other
possess a limited amount of resources. COVID-19 has jeopardies in the future.
worsened the previous situation. The economic condition of
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