Case Report: Maternal Health and Healthcare System Resilience in the Context of the COVID-19 Pandemic and Sustainable Development Goals

This report details the case of a pregnant patient with severe COVID-19 in a district general hospital in Sri Lanka. The case highlights the critical intersection of healthcare delivery with several Sustainable Development Goals (SDGs), primarily SDG 3 (Good Health and Well-being), SDG 5 (Gender Equality), and SDG 10 (Reduced Inequalities).

Patient Presentation and Initial Assessment

The case concerns a 44-year-old, obese (BMI 33 kg/m²), South Asian mother in her 37th week of gestation, presenting with severe respiratory symptoms during the COVID-19 pandemic. Her admission underscores the heightened vulnerability of pregnant women, a key demographic for achieving SDG 3, Target 3.1 (reduce global maternal mortality).

Initial Vitals and Clinical Findings

• Respiratory Rate: 24/minute
• Oxygen Saturation: 93% on air
• Pulse Rate: 110/minute
• Blood Pressure: 145/88 mmHg
• Key Symptoms: Worsening cough, shortness of breath, mild pedal edema.
• Risk Factors: Pregnancy, obesity, immobility, and confirmed contact with a COVID-19 patient.

Diagnostic Process and Systemic Challenges

The diagnostic journey illustrates significant challenges related to healthcare infrastructure, directly impacting the ability to provide universal health coverage as outlined in SDG 3, Target 3.8, and highlighting the disparities addressed by SDG 10 (Reduced Inequalities).

Investigation Limitations

1. Initial COVID-19 Testing: Two successive Rapid Antigen Tests (RAT) were negative, demonstrating the limitations of available point-of-care diagnostics.
2. Definitive Testing Delay: A PCR test, the gold standard, was not available on-site and had to be sent to a tertiary care center, delaying definitive diagnosis and management. This points to a critical gap in the capacity for early warning and management of global health risks (SDG 3, Target 3.d).
3. Equipment and Facility Shortages: The hospital faced significant infrastructural constraints:
   • The portable X-ray machine was out of order.
   • Computed Tomography (CT) facilities were unavailable.
   • Essential laboratory tests such as D-dimer levels were unavailable.

Despite these resource limitations, a high index of clinical suspicion led to the eventual diagnosis of severe COVID-19, preeclampsia, and high risk of thromboembolism.

Treatment, Management, and Inter-Institutional Collaboration

The patient’s management required a robust, multidisciplinary response, showcasing the importance of strong health institutions (SDG 16) in achieving positive health outcomes.

Therapeutic Interventions

1. Initial Management: The patient was admitted to a high-dependency unit and commenced on high-flow nasal oxygen, broad-spectrum antibiotics, and prophylactic anticoagulants.
2. Escalation of Care: As her condition worsened, a multidisciplinary team (obstetrician, physician, anesthetist) escalated care to include therapeutic anticoagulation, BiPAP therapy, and intravenous dexamethasone.
3. Emergency Caesarean Section: A critical decision was made to perform an emergency caesarean section. This intervention was vital to protect the lives of both mother and child, directly aligning with SDG 3, Target 3.1 (maternal mortality) and Target 3.2 (end preventable deaths of newborns).
4. Tertiary Care Transfer: The patient was transferred to a tertiary center for intensive care, including mechanical ventilation and advanced therapies like tocilizumab. This highlights the necessity of a functional referral system within a national health framework to achieve SDG 3.

Outcome and Follow-Up: A Success for SDG 3

The successful outcome for both the mother and her baby represents a significant achievement in the face of considerable systemic challenges.

Patient and Neonatal Outcomes

• Maternal Outcome: The patient was successfully weaned off ventilation, discharged from the hospital on day 15, and made a full recovery with no residual symptoms at the 1-year follow-up. This successful management of a high-risk pregnancy contributes to the goals of SDG 3 and SDG 5 by ensuring the health and well-being of women.
• Neonatal Outcome: A healthy 2.8 kg baby was delivered who tested negative for COVID-19, fulfilling the objective of SDG 3, Target 3.2.

This case demonstrates that despite the inequalities in healthcare resources (SDG 10), dedicated clinical management and collaborative institutional action (SDG 16) can lead to the successful preservation of life, upholding the fundamental principles of SDG 3: Good Health and Well-being.

1. Which SDGs are addressed or connected to the issues highlighted in the article?

SDG 3: Good Health and Well-being

• The entire article is a medical case report focusing on the diagnosis, treatment, and successful outcome of a pregnant patient with severe COVID-19. It directly addresses health challenges, including managing infectious diseases during a pandemic, maternal health complications (preeclampsia), and the provision of critical and emergency care.

SDG 5: Gender Equality

• The article centers on a pregnant woman, highlighting specific health risks and needs associated with maternal health. Ensuring access to quality maternal and emergency obstetric care, as detailed in the case, is a key component of women’s health and well-being, which is integral to gender equality.

SDG 9: Industry, Innovation, and Infrastructure

• The article highlights significant challenges related to healthcare infrastructure. The district general hospital lacked essential diagnostic equipment, such as a functional portable X-ray, CT facilities, and in-house PCR testing capabilities. This points directly to issues of infrastructure quality and reliability in healthcare settings.

2. What specific targets under those SDGs can be identified based on the article’s content?

SDG 3: Good Health and Well-being

1. Target 3.1: By 2030, reduce the global maternal mortality ratio to less than 70 per 100,000 live births.

   The patient was in her 37th week of pregnancy and presented with severe, life-threatening complications (severe COVID-19, preeclampsia). The successful management, including an emergency caesarean section and intensive care, which led to her survival, directly relates to efforts to prevent maternal mortality.

2. Target 3.2: By 2030, end preventable deaths of newborns and children under 5 years of age.

   An emergency caesarean section was performed to deliver the baby. The article notes that a “2.8-kg single live fetus was delivered” and that the baby was “healthy and did not acquire the infection.” This successful outcome for the newborn addresses the goal of preventing neonatal deaths.

3. Target 3.3: By 2030, end the epidemics of AIDS, tuberculosis, malaria and neglected tropical diseases and combat hepatitis, water-borne diseases and other communicable diseases.

   The case is centered on the management of COVID-19, a major communicable disease pandemic. The article details the diagnostic process (RAT, PCR) and treatment protocols (dexamethasone, tocilizumab) used to combat the virus in a high-risk patient.

4. Target 3.8: Achieve universal health coverage, including financial risk protection, access to quality essential health-care services and access to safe, effective, quality and affordable essential medicines and vaccines for all.

   The patient received extensive and complex care, including admission to a high-dependency unit, high-flow oxygen therapy, multiple medications (Co-amoxiclav, enoxaparin, dexamethasone), an emergency caesarean section, and transfer to a tertiary care center for intensive care. This demonstrates access to quality essential healthcare services. However, the initial lack of diagnostic tools at the district hospital also highlights gaps in universal access to comprehensive services at all levels of care.

5. Target 3.d: Strengthen the capacity of all countries, in particular developing countries, for early warning, risk reduction and management of national and global health risks.

   The article illustrates a country’s health system responding to the COVID-19 pandemic. It shows the process of diagnosis, multidisciplinary team collaboration (obstetrician, physician, anesthetist), and a tiered referral system (transfer from a district hospital to a tertiary care center). The challenges faced, such as equipment failure and unavailability of tests, also reflect the existing capacity and areas needing strengthening.

SDG 5: Gender Equality

1. Target 5.6: Ensure universal access to sexual and reproductive health and reproductive rights.

   Maternal healthcare is a critical component of sexual and reproductive health. The article details the provision of specialized care for a pregnant woman, including fetal assessment, management of pregnancy-related complications like preeclampsia, and performing an emergency caesarean section to ensure the health of both mother and child. This represents the delivery of essential reproductive health services.

SDG 9: Industry, Innovation, and Infrastructure

1. Target 9.1: Develop quality, reliable, sustainable and resilient infrastructure… to support economic development and human well-being.

   The article explicitly mentions infrastructure deficits that impacted patient care. It states, “The portable X-ray was out of order, and computed tomography (CT) facilities were unavailable.” Furthermore, “a PCR test for COVID-19 was sent to the closest tertiary care center, as it was not available at our hospital.” These points directly illustrate a lack of reliable and quality health infrastructure at the district hospital level.

3. Are there any indicators mentioned or implied in the article that can be used to measure progress towards the identified targets?

For Target 3.1 (Maternal Mortality)

• Indicator 3.1.1: Maternal mortality ratio. The article provides a case of maternal survival despite life-threatening illness (severe COVID-19 ARDS, preeclampsia), which is a positive data point contributing to a lower maternal mortality ratio. The detailed account of the successful emergency obstetric care serves as a qualitative indicator of the health system’s ability to prevent maternal death.

For Target 3.2 (Neonatal Mortality)

• Indicator 3.2.1: Under-5 mortality rate & Indicator 3.2.2: Neonatal mortality rate. The article provides a direct data point for this by stating the baby was delivered alive, was healthy, and tested negative for COVID-19. This successful birth outcome is a measure of preventing neonatal mortality.

For Target 3.3 (Communicable Diseases)

• Indicator 3.3.1: Number of new HIV infections per 1,000 uninfected population… While not the specific diseases listed, the principle applies to “other communicable diseases.” The article implies indicators for pandemic management through:
  • Diagnostic testing: Use of RAT and PCR tests to confirm a COVID-19 case.
  • Treatment and outcome: Successful treatment and recovery of a severe COVID-19 patient.

For Target 3.8 (Universal Health Coverage)

• Indicator 3.8.1: Coverage of essential health services. The article provides a narrative indicator of service coverage. The patient received:
  • Emergency and intensive care (HDU, ICU).
  • Advanced respiratory support (high-flow nasal oxygen, BiPAP, intubation).
  • Access to essential medicines (antibiotics, anticoagulants, steroids).
  • Surgical services (emergency caesarean section).

  However, it also indicates gaps in coverage, as certain diagnostic services (PCR, CT, specific blood tests like D-dimer) were not available at the initial point of care.

For Target 3.d (Health System Capacity)

• Indicator 3.d.1: International Health Regulations (IHR) capacity and health emergency preparedness. The article serves as a case study for this indicator by describing:
  • Surveillance and response: The hospital’s protocol for suspected COVID-19 cases based on symptoms and contact history.
  • Laboratory capacity: The availability of RATs locally but the need to send PCR tests to a tertiary center indicates a tiered but limited lab capacity.
  • Human resources: The mention of a “multidisciplinary team discussion” indicates the availability of specialized personnel.
  • Points of entry/referral system: The successful transfer of the patient to a higher-level facility for intensive care demonstrates a functional referral pathway.

For Target 9.1 (Infrastructure)

• While there isn’t a direct numerical SDG indicator, the article provides qualitative evidence related to infrastructure quality and reliability. The statements “The portable X-ray was out of order” and “computed tomography (CT) facilities were unavailable” are direct indicators of infrastructure failure and gaps in a critical public service facility (a district hospital).

4. Table of SDGs, Targets, and Indicators

Source: jmedicalcasereports.biomedcentral.com