Causal loop diagrams can highlight and visualize complex behaviors, pinpointing vital leverage points for effective interventions in response to public health crises. Additionally, their use promotes a mutual understanding among policymakers, managers, and service providers about the depth of the crisis and the resulting response.

We used a causal loop diagram to visualize how the COVID-19 pandemic and its response disrupted maternal health services in Islamabad, Pakistan.

We argue that given the complexity of the response to the COVID-19 pandemic and the pre-existing vulnerabilities of Pakistan's maternal health system, systems thinking approaches, such as causal loop diagrams, should have been at the center of the pandemic preparedness and response to consider and prevent unintended consequences.

On February 26, 2020, Pakistan reported its first travel-associated confirmed case of COVID-19 in Islamabad. Shortly after, on March 23, 2020, the Government of Pakistan declared a nationwide lockdown, encompassing Islamabad and Rawalpindi. The absence of full-fledged isolation centers in Islamabad led to the implementation of a home-based isolation strategy, accompanied by a 2-week cordoning of the entire area.1 The suspension of outpatient services by provincial governments worsened the already precarious access to health services, necessitating the intervention of the Supreme Court of Pakistan to mandate the resumption of these services across all hospitals.2

Even before the emergence of the COVID-19 pandemic, Pakistan's health system grappled with barriers that disproportionately impacted marginalized groups and women. These challenges were fueled by inadequate quality of care and a dearth of essential commodities and services.3 Notably, the maternal mortality ratio remained alarmingly high, surpassing regional benchmarks.4 The structure of Pakistani society is characterized by 2 main institutionalized systems of inequality: class and gender. As a result, even during “normal” times, educated women are over 3 times more likely to be attended by skilled birth …