Effect of the COVID-19 pandemic on health facility delivery in Ethiopia; results from PMA Ethiopia's longitudinal panel

Impact of COVID-19 on Maternal Health Service Uptake and Perinatal Outcomes in Sub-Saharan Africa: A Systematic Review

Coronavirus 2019 (COVID-19) is a major global public health threat that has impeded health infrastructures in low- and middle-income countries. This systematic review examines the impact of COVID-19 on maternal health service uptake and perinatal outcomes in Sub-Saharan Africa. We searched four databases in August 2020 and updated the search on 22 December 2023: PubMed/MEDLINE, CINAHL, Maternity and Infant Care, and EMBASE. Data extraction was performed using a standardised Joana Briggs Institute data extraction format for the eligibility of articles, and any discrepancies were solved through discussion and consensus. This systematic review includes 36 studies that met the inclusion criteria. Antenatal care attendance and institutional childbirth significantly decreased during the COVID-19 pandemic, and home births increased. Fear of contracting the virus, a lack of transport, a shortage of logistic supplies, a lack of personal protective equipment, lockdown policies, economic and food security, stigmatisation of sick persons, long waiting times in the hospital, and health system weakness were barriers to accessing maternity care. The findings of this review showed a significant decrease in antenatal care attendance and institutional birth during the COVID-19 pandemic. Based on our findings, we recommend that stakeholders ensure the availability of essential medical supplies in the hospital.

COVID-19 related barriers to institutional childbirth during the early phase of the pandemic in rural Arsi zone, Ethiopia, 2022: A qualitative study

Introduction

Global, national, and local studies revealed that the COVID-19 pandemic has significantly reduced institutional childbirth. However, it is not well understood how the COVID-19 epidemic affected institutional childbirth service utilization. Therefore, this study aimed to evaluate COVID-19 related impediments to institutional childbirth service uptake during the early phase of the COVID-19 pandemic (March 20/2020-June 20/2020) in the rural Arsi zone of Ethiopia.

Methods

A community-based Phenomenological study was conducted from January 10-25/2022, among mothers who gave birth in the Arsi zone during the early phase of the COVID-19 epidemic (March 20/2020-June 20/2020) in Ethiopia. Data was collected by the primary author and a university graduated Midwives with experience in qualitative data collection. Eight focus group discussions and six in-depth interviews were conducted among mothers who gave birth in selected rural areas of the Arsi zone during the early phase of the COVID-19 pandemic. Nine key informant interviews were also conducted among Midwives, Maternity Ward Heads, and Community Health Extension Workers. Data was transcribed, translated, and analyzed thematically using Atlas Ti.7 version.

Results

Four major themes and eleven sub-themes emerged regarding the barriers to institutional childbirth during the early phase of COVID-19 pandemic. The COVID-19 related fear was a reason for avoiding institutional childbirth for almost all participants. COVID-19 restrictions such as transportation bans, market bans and public transport price doubling were also critical concerns to seeking institutional childbirth. Perceived Poor quality of institutional childbirth care during the curfew was also an impeding factor. Poor communication, incomplete care components and absenteeism were mentioned under this theme. Unbalanced mass media tragedies and rumors of unknown sources were COVID -19 related infodemics found affecting the practice of institutional childbirth.

Conclusions

COVID-19 related fears, COVID-19 restrictions, Perceived Poor quality of care during the COVID-19 pandemic and the COVID-19 Infodemic were the main reasons for reduced institutional childbirth service utilization during the early phase of the COVID-19 pandemic in Ethiopia. Therefore, strategies must be designed proactively to maintain essential maternal health services, particularly institutional childbirth, during pandemics like COVID-19 and similar future epidemics.

Pregnancy outcomes before and during COVID-19 pandemic in Tamale Metropolis, Ghana: A retrospective cohort study

BACKGROUND

The COVID-19 pandemic affected expectant mothers seeking maternal health services in most developing countries. Access and utilization of maternal health services including antenatal care (ANC) attendance and skilled delivery declined drastically resulting in adverse pregnancy outcomes. This study assessed pregnancy outcomes before and during COVID-19 pandemic in Tamale Metropolis, Ghana.

METHODS/DESIGN

A retrospective cohort study design was employed. A random sampling technique was used to select 450 women who delivered before or during the COVID-19 pandemic in Tamale Metropolis, Ghana. The respondents were interviewed using structured questionnaire at their homes. In this study, the data collected were socio-demographics characteristics, ANC attendance, before or during pandemic delivery, place of delivery and birth outcomes. Chi-square test and bivariate logistic regression analyses were performed under significant level of 0.05 to determine factors associated with the outcome variables.

RESULT

Of the 450 respondents, 51.8% were between 26 and 30 years of age. More than half (52.2%) of the respondents had no formal education and 93.3% were married. The majority (60.4%) of the respondents described their residence as urban setting. About 31.6% of the women delivered before the pandemic. The COVID-19 pandemic influenced place of delivery. The proportion of women who attended at least one ANC visit (84.5% before vs 70.5% during), and delivered at a hospital (76.8% before vs 72.4% during) were higher before the pandemic. More women were likely to deliver at home during COVID-19 (OR: 2.38, 95%CI: 1.52-3.74, p<0.001). Similarly, there was statistically significance difference between before and during COVID-19 delivery on at least one ANC attendance (OR: 2.72, 95%CI: 1.58-1.67, p<0.001). Women who delivered during COVID-19 were about twice more likely to develop complications (OR: 1.72, 95%CI: 1.03-2.87, p = 0.04).

CONCLUSION

ANC attendance and health facility delivery decreased while pregnancy complications increased during COVID-19. During disease outbreaks, outreach engagement strategies should be devised to increase access and utilization of maternal health services for marginalized and underserved populations. The capacity of health workers should be strengthened through skills training to manage adverse birth outcomes.

Needs and unmet needs for support services for recently pregnant intimate partner violence survivors in Ethiopia during the COVID-19 pandemic

BACKGROUND

Globally, 2-14% of women experience intimate partner violence (IPV) during pregnancy. Timely response to IPV is critical to mitigate related adverse health outcomes. Barriers to accessing limited IPV support services are pervasive in low- and middle-income countries (LMICs), such as Ethiopia; key barriers include mistrust, stigmatization, and self-blame, and discourage women from disclosing their experiences. Infection control measures for COVID-19 have the potential to further disrupt access to IPV services.

METHODS

In-depth qualitative interviews were undertaken from October-November 2020 with 24 women who experienced IPV during recent pregnancy to understand the needs and unmet needs of IPV survivors in Ethiopia amid the COVID-19 pandemic. Trained qualitative interviewers used a structured note-taking tool to allow probing of experiences, while permitting rapid analysis for timely results. Inductive thematic analysis identified emergent themes, which were organized into matrices for synthesis.

RESULTS

Qualitative themes center around knowledge of IPV services; experiences of women in seeking services; challenges in accessing services; the impact of COVID-19 on resource access; and persistent unmet needs of IPV survivors. Notably, few women discussed the violence they experienced as unique to pregnancy, with most referring to IPV over an extended period, both prior to and during COVID-19 restrictions. The majority of IPV survivors in our study heavily relied on their informal network of family and friends for protection and assistance in resolving the violence. Though formal IPV services remained open throughout the pandemic, restrictions resulted in the perception that services were not available, and this perception discouraged survivors from seeking help. Survivors further identified lack of integrated and tailored services as enduring unmet needs.

CONCLUSIONS

Results reveal a persistent low awareness and utilization of formal IPV support and urge future policy efforts to address unmet needs through expansion of services by reducing socio-cultural barriers. COVID-19 impacted access to both formal and informal support systems, highlighting needs for adaptable, remote service delivery and upstream violence prevention. Public health interventions must strengthen linkages between formal and informal resources to fill the unmet needs of IPV survivors in receiving medical, psychosocial, and legal support in their home communities.

Impact of COVID-19 pandemic on utilization of essential maternal healthcare services in Ethiopia: A systematic review and meta-analysis

BACKGROUND

The COVID-19 pandemic has a significant challenge for countries to maintain the provision of essential maternity services. Many women could experience difficulties in accessing maternal healthcare due to transport problems, anxiety, and fear of infection. A reduction in the utilization of maternity services has been suggested as a possible cause of worsened maternal health outcomes. Thus, this study aimed to determine the impact of the COVID-19 pandemic on the utilization of maternal healthcare services in Ethiopia.

METHODS

Searching of articles was conducted from PubMed, Science Direct, Cochrane Library, Web of Science, Scopus, and Google scholar. The quality of studies was evaluated using the Newcastle-Ottawa scale. Inspection of the Funnel plot and Egger's test were used to evaluate the evidence of publication bias. Heterogeneity was evaluated using Cochran's Q statistic and quantified by I2. A random-effects model was used to determine pooled estimates using STATA 14.

RESULTS

After reviewing 41,188 articles, 21 studies were included in this systematic review and meta-analysis. The pooled reduction was 26.62% (95% CI: 13.86, 39.37) for family planning, 19.30% (95% CI: 15.85, 22.76) for antenatal care, 12.82% (95% CI: 7.29, 18.34) for institutional delivery, 17.82% (95% CI: 8.32, 27.32) for postnatal care, and 19.39% (95% CI: 11.29, 27.49) for abortion care. This study also demonstrated that maternal perception of poor quality of care and fear of infection, lack of transport, cultural events, diversion of resources, lack of essential drugs, and lack of personal protective equipment and sanitizer were identified as the main challenges faced during the pandemic.

CONCLUSION

This study revealed that the utilization of maternal healthcare services in Ethiopia significantly decreased during the COVID-19 pandemic. Government measures, health facility-related barriers, and maternal-related factors were identified as challenges faced during the pandemic. Thus, service providers, policy-makers, and other relevant stakeholders should prioritize maternity care as an essential core healthcare service. Besides, increasing awareness of women through mass media, and making maternity services more accessible and equitable would likely increase the utilization of maternal healthcare services.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42021293681.

An integrative literature review on the impact of COVID-19 on maternal and child health in Africa

Africa has the highest rates of maternal deaths globally which have been linked to poorly functioning health care systems. The pandemic revealed already known weaknesses in the health systems in Africa, such as workforce shortages, lack of equipment and resources. The aim of this paper is to review the published literature on the impact of the COVID-19 pandemic on maternal and child health in Africa. The integrative review process delineated by Whittemore and Knafl (2005) was used to meet the study aims. The literature search of Ovid Medline, CINAHL, PubMed, WHO, Google and Google scholar, Africa journals online, MIDIRS was limited to publications between March 2020 and May 2022. All the studies went through the PRISMA stages, and 179 full text papers screened for eligibility, 36 papers met inclusion criteria. Of the studies, 6 were qualitative, 25 quantitative studies, and 5 mixed methods. Thematic analysis according to the methods of Braun and Clark (2006) were used to synthesize the data. From the search the six themes that emerged include: effects of lockdown measures, COVID concerns and psychological stress, reduced attendance at antenatal care, childhood vaccination, reduced facility-based births, and increase maternal and child mortality. A review of the literature revealed the following policy issues: The need for government to develop robust response mechanism to public health emergencies that negatively affect maternal and child health issues and devise health policies to mitigate negative effects of lockdown. In times of pandemic there is need to maintain special access for both antenatal care and child delivery services and limit a shift to use of untrained birth attendants to reduce maternal and neonatal deaths. These could be achieved by soliciting investments from various sectors to provide high-quality care that ensures sustainability to all layers of the population.

Impacts of the COVID-19 pandemic on access to HIV and reproductive health care among women living with HIV (WLHIV) in Western Kenya: A mixed methods analysis

Introduction

The COVID-19 pandemic has impacted access to health services. Our objective was to understand the pandemic's impact on access to HIV, pregnancy, and family planning (FP) care among women living with HIV (WLHIV).

Methods

Data were collected after June 2020, when questions about the pandemic were added to two ongoing mixed methods studies using telephone surveys and in-depth interviews among WLHIV in western Kenya. The Chaguo Langu (CL) study includes primarily non-pregnant WLHIV receiving HIV care at 55 facilities supported by AMPATH and the Opt4Mamas study includes pregnant WLHIV receiving antenatal care at five facilities supported by FACES. Our outcomes were self-reported increased difficulty refilling medication, accessing care, and managing FP during the pandemic. We summarized descriptive data and utilized multivariable logistic regression to evaluate predictors of difficulty refilling medication and accessing care. We qualitatively analyzed the interviews using inductive coding with thematic analysis.

Results

We analyzed 1,402 surveys and 15 in-depth interviews. Many (32%) CL participants reported greater difficulty refilling medications and a minority (14%) reported greater difficulty accessing HIV care during the pandemic. Most (99%) Opt4Mamas participants reported no difficulty refilling medications or accessing HIV/pregnancy care. Among the CL participants, older women were less likely (aOR = 0.95, 95% CI: 0.92-0.98) and women with more children were more likely (aOR = 1.13, 95% CI: 1.00-1.28) to report difficulty refilling medications. Only 2% of CL participants reported greater difficulty managing FP and most (95%) reported no change in likelihood of using FP or desire to get pregnant. Qualitative analysis revealed three major themes: (1) adverse organizational/economic implications of the pandemic, (2) increased importance of pregnancy prevention during the pandemic, and (3) fear of contracting COVID-19.

Discussion

The two unique participant groups included in our study encountered overlapping problems during the COVID-19 epidemic. Access to HIV services and antiretrovirals was interrupted for a large proportion of non-pregnant WLHIV in western Kenya, but access to pregnancy/family planning care was less affected in our cohort. Innovative solutions are needed to ensure HIV and reproductive health outcomes do not worsen during the ongoing pandemic.

Effects of the COVID-19 pandemic on maternal and perinatal health service utilisation and outcomes in Mozambique: an interrupted time series analysis

OBJECTIVES

To measure the effects of the COVID-19 pandemic on maternal and perinatal health services and outcomes in Mozambique.

DESIGN

This is an observational study analysing routine service delivery data using interrupted time series analysis. We used 43 months of district-level panel data with April 2020 as the point of interruption, adjusting for seasonality and population growth to analyse service utilisation outcomes.

SETTING

The 222 public health facilities in Nampula Province, Mozambique, from January 2018 to July 2021.

OUTCOME MEASURES

The change in the number of antenatal care (ANC) visits and facility deliveries, and the change in the rate of adverse birth outcomes at pandemic onset and over time compared with expected levels and trends, respectively.

RESULTS

There were no significant disruptions to ANC at pandemic onset. Following this, there was a significant monthly increase of 29.8 (18.2-41.4) first ANC visits and 11.3 (5.5-17.2) ANC visits within the first trimester per district above prepandemic trends. There was no significant change in the number of fourth ANC visits completed. At the onset of COVID-19, districts experienced a significant decrease of 71.1 (-110.5 to -31.7) facility deliveries, but the rate then increased significantly above prepandemic trends. There was no significant increase in any adverse birth outcomes during the pandemic. Conversely, districts observed a significant monthly decrease of 5.3 uterine rupture cases (-9.9 to -0.6) and 19.2 stillbirths (-33.83 to -4.58) per 100 000 facility deliveries below prepandemic trends. There was a significant drop of 23.5 cases of neonatal sepsis/100 000 facility deliveries per district at pandemic onset.

CONCLUSION

Despite pandemic interference, Nampula Province saw no disruptions to ANC, only temporary disruptions to facility deliveries and no increases in adverse birth outcomes. ANC visits surprisingly increased, and the rates of uterine rupture, stillbirth and neonatal sepsis decreased, suggesting that Nampula Province may offer insights about health system resilience.

Impact of the Early Stages of the COVID-19 Pandemic on Coverage of Reproductive, Maternal, and Newborn Health Interventions in Ethiopia: A Natural Experiment

Background

The COVID-19 pandemic and response have the potential to disrupt access and use of reproductive, maternal, and newborn health (RMNH) services. Numerous initiatives aim to gauge the indirect impact of COVID-19 on RMNH.

Methods

We assessed the impact of COVID-19 on RMNH coverage in the early stages of the pandemic using panel survey data from PMA-Ethiopia. Enrolled pregnant women were surveyed 6-weeks post-birth. We compared the odds of service receipt, coverage of RMNCH service indicators, and health outcomes within the cohort of women who gave birth prior to the pandemic and the COVID-19 affected cohort. We calculated impacts nationally and by urbanicity.

Results

This dataset shows little disruption of RMNH services in Ethiopia in the initial months of the pandemic. There were no significant reductions in women seeking health services or the content of services they received for either preventative or curative interventions. In rural areas, a greater proportion of women in the COVID-19 affected cohort sought care for peripartum complications, ANC, PNC, and care for sick newborns. Significant reductions in coverage of BCG vaccination and chlorohexidine use in urban areas were observed in the COVID-19 affected cohort. An increased proportion of women in Addis Ababa reported postpartum family planning in the COVID-19 affected cohort. Despite the lack of evidence of reduced health services, the data suggest increased stillbirths in the COVID-19 affected cohort.

Discussion

The government of Ethiopia's response to control the COVID-19 pandemic and ensure continuity of essential health services appears to have successfully averted most negative impacts on maternal and neonatal care. This analysis cannot address the later effects of the pandemic and may not capture more acute or geographically isolated reductions in coverage. Continued efforts are needed to ensure that essential health services are maintained and even strengthened to prevent indirect loss of life.

COVID-19 and resilience of healthcare systems in ten countries

Declines in health service use during the Coronavirus Disease 2019 (COVID-19) pandemic could have important effects on population health. In this study, we used an interrupted time series design to assess the immediate effect of the pandemic on 31 health services in two low-income (Ethiopia and Haiti), six middle-income (Ghana, Lao People's Democratic Republic, Mexico, Nepal, South Africa and Thailand) and high-income (Chile and South Korea) countries. Despite efforts to maintain health services, disruptions of varying magnitude and duration were found in every country, with no clear patterns by country income group or pandemic intensity. Disruptions in health services often preceded COVID-19 waves. Cancer screenings, TB screening and detection and HIV testing were most affected (26-96% declines). Total outpatient visits declined by 9-40% at national levels and remained lower than predicted by the end of 2020. Maternal health services were disrupted in approximately half of the countries, with declines ranging from 5% to 33%. Child vaccinations were disrupted for shorter periods, but we estimate that catch-up campaigns might not have reached all children missed. By contrast, provision of antiretrovirals for HIV was not affected. By the end of 2020, substantial disruptions remained in half of the countries. Preliminary data for 2021 indicate that disruptions likely persisted. Although a portion of the declines observed might result from decreased needs during lockdowns (from fewer infectious illnesses or injuries), a larger share likely reflects a shortfall of health system resilience. Countries must plan to compensate for missed healthcare during the current pandemic and invest in strategies for better health system resilience for future emergencies.

Impact of the COVID-19 pandemic on intimate partner violence during pregnancy: evidence from a multimethods study of recently pregnant women in Ethiopia

OBJECTIVES

This multimethods study aimed to: (1) compare the prevalence of intimate partner violence (IPV) during pregnancy pre-COVID-19 and during the COVID-19 pandemic using quantitative data and (2) contextualise pregnant women's IPV experiences during the COVID-19 pandemic through supplemental interviews.

DESIGN

Quantitative analyses use data from Performance Monitoring for Action-Ethiopia, a cohort of 2868 pregnant women that collects data at pregnancy, 6 weeks, 6 months and 1-year postpartum. Following 6-week postpartum survey, in-depth semistructured interviews contextualised experiences of IPV during pregnancy with a subset of participants (n=24).

PARTICIPANTS

All pregnant women residing within six regions of Ethiopia, covering 91% of the population, were eligible for the cohort study (n=2868 completed baseline survey). Quantitative analyses were restricted to the 2388 women with complete 6-week survey data (retention=82.7%). A purposive sampling frame was used to select qualitative participants on baseline survey data, with inclusion criteria specifying completion of quantitative 6-week interview after the onset of the COVID-19 pandemic, and indication of IPV experience.

INTERVENTIONS

A State of Emergency in Ethiopia was declared in response to the COVID-19 pandemic approximately halfway through 6-week postpartum interview, enabling a natural experiment (n=1405 pre-COVID-19; n=983 during-COVID-19).

PRIMARY OUTCOME MEASURES

IPV during pregnancy was assessed via the 10-item Revised Conflict and Tactics Scale.

RESULTS

1-in-10 women experienced any IPV during pregnancy prior to COVID-19 (10.5%), and prevalence of IPV during pregnancy increased to 15.1% during the COVID-19 pandemic (aOR=1.51; p=0.02). Stratified by residence, odds of IPV during the pandemic increased for urban women only (aOR=2.09; p=0.03), however, IPV prevalence was higher in rural regions at both time points. Qualitative data reveal COVID-19-related stressors, namely loss of household income and increased time spent within the household, exacerbated IPV.

CONCLUSIONS

These multimethods results highlight the prevalent, severe violence that pregnant Ethiopian women experience, with pandemic-related increases concentrated in urban areas. Integration of IPV response and safety planning across the continuum of care can mitigate impact.

A mixed-methods study of maternal health care utilisation in six referral hospitals in four sub-Saharan African countries before and during the COVID-19 pandemic

INTRODUCTION

In sub-Saharan Africa, referral hospitals are important sources of key maternal health services, especially during a crisis such as the COVID-19 pandemic. This study prospectively assessed the effect of the COVID-19 pandemic on maternal health service utilisation in six large referral hospitals in Guinea, Nigeria, Tanzania and Uganda during the first year of the pandemic.

METHODS

Mixed-methods design combining three data sources: (1) quantitative data based on routine antenatal, childbirth and postnatal care data collected March 2019-February 2021, (2) qualitative data from recurring rounds of semi-structured interviews conducted July 2020-February 2021 with 22 maternity skilled heath personnel exploring their perceptions of service utilisation and (3) timeline data of COVID-19 epidemiology, global, national and hospital-level events. Qualitative and quantitative data were analysed separately, framed based on the timeline analysis and triangulated when reporting.

RESULTS

Three periods including a first wave, slow period and second wave were identified. Maternal health service utilisation was lower during the pandemic compared with the prepandemic year in all but one selected referral hospital. During the pandemic, service utilisation was particularly lower during the waves and higher or stable during the slow period. Fear of being infected in hospitals, lack of transportation, and even when available, high cost of transportation and service closures were key reasons affecting utilisation during the waves. However, community perception that the pandemic was over or insinuation by Government of the same appeared to stabilise use of referral hospitals for childbirth.

CONCLUSION

Utilisation of maternal health services across the continuum of care varied through the different periods and across countries. In crisis situations such as COVID-19, restrictions and service closures need to be implemented with consideration given to alternative options for women to access and use services. Information on measures put in place for safe hospital use should be communicated to women.