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Knauss S, Andriamiadana G, Leitheiser R, Rampanjato Z, Bärnighausen T, Emmrich JV. Effect of the COVID-19 Lockdown on Mobile Payments for Maternal Health: Regression Discontinuity Analysis. JMIR Public Health Surveill 2024; 10:e49205. [PMID: 39078698 PMCID: PMC11322714 DOI: 10.2196/49205] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2023] [Revised: 01/24/2024] [Accepted: 05/03/2024] [Indexed: 07/31/2024] Open
Abstract
BACKGROUND The COVID-19 pandemic resulted in the unprecedented popularity of digital financial services for contactless payments and government cash transfer programs to mitigate the economic effects of the pandemic. The effect of the pandemic on the use of digital financial services for health in low- and middle-income countries, however, is poorly understood. OBJECTIVE This study aimed to assess the effect of the first COVID-19 lockdown on the use of a mobile maternal health wallet, with a particular focus on delineating the age-dependent differential effects, and draw conclusions on the effect of lockdown measures on the use of digital health services. METHODS We analyzed 819,840 person-days of health wallet use data from 3416 women who used health care at 25 public sector primary care facilities and 4 hospitals in Antananarivo, Madagascar, between January 1 and August 27, 2020. We collected data on savings, payments, and voucher use at the point of care. To estimate the effects of the first COVID-19 lockdown in Madagascar, we used regression discontinuity analysis around the starting day of the first COVID-19 lockdown on March 23, 2020. We determined the bandwidth using a data-driven method for unbiased bandwidth selection and used modified Poisson regression for binary variables to estimate risk ratios as lockdown effect sizes. RESULTS We recorded 3719 saving events, 1572 payment events, and 3144 use events of electronic vouchers. The first COVID-19 lockdown in Madagascar reduced mobile money savings by 58.5% (P<.001), payments by 45.8% (P<.001), and voucher use by 49.6% (P<.001). Voucher use recovered to the extrapolated prelockdown counterfactual after 214 days, while savings and payments did not cross the extrapolated prelockdown counterfactual. The recovery duration after the lockdown differed by age group. Women aged >30 years recovered substantially faster, returning to prelockdown rates after 34, 226, and 77 days for savings, payments, and voucher use, respectively. Younger women aged <25 years did not return to baseline values. The results remained robust in sensitivity analyses using ±20 days of the optimal bandwidth. CONCLUSIONS The COVID-19 lockdown greatly reduced the use of mobile money in the health sector, affecting savings, payments, and voucher use. Savings were the most significantly reduced, implying that the lockdown affected women's expectations of future health care use. Declines in payments and voucher use indicated decreased actual health care use caused by the lockdown. These effects are crucial since many maternal and child health care services cannot be delayed, as the potential benefits will be lost or diminished. To mitigate the adverse impacts of lockdowns on maternal health service use, digital health services could be leveraged to provide access to telemedicine and enhance user communication with clear information on available health care access options and adherence to safety protocols.
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Affiliation(s)
- Samuel Knauss
- Global Digital Last Mile Health Research Lab, Charité Center for Global Health, Charité - Universitätsmedizin Berlin, Germany, Berlin, Germany
- Heidelberg Institute of Global Health, Medical Faculty and University Hospital, University of Heidelberg, Heidelberg, Germany
| | - Gracia Andriamiadana
- Wolfson Institute of Population Health, Queen Mary University of London, London, United Kingdom
| | - Roxane Leitheiser
- Global Digital Last Mile Health Research Lab, Charité Center for Global Health, Charité - Universitätsmedizin Berlin, Germany, Berlin, Germany
| | | | - Till Bärnighausen
- Heidelberg Institute of Global Health, Medical Faculty and University Hospital, University of Heidelberg, Heidelberg, Germany
- Harvard Center for Population and Development Studies, Harvard University, Cambridge, MA, United States
- Africa Health Research Institute, Mtubatuba, South Africa
| | - Julius Valentin Emmrich
- Global Digital Last Mile Health Research Lab, Charité Center for Global Health, Charité - Universitätsmedizin Berlin, Germany, Berlin, Germany
- Heidelberg Institute of Global Health, Medical Faculty and University Hospital, University of Heidelberg, Heidelberg, Germany
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Shukla VV, Weaver LJ, Singh A, Rahman AKMF, Nakhmani A, Travers CP, Sinkey R, Arora N, Ambalavanan N, Carlo WA. Social Distancing During the COVID-19 Pandemic and Neonatal Mortality in the US. JAMA Netw Open 2024; 7:e2422995. [PMID: 39023889 PMCID: PMC11258585 DOI: 10.1001/jamanetworkopen.2024.22995] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/03/2024] [Accepted: 05/14/2024] [Indexed: 07/20/2024] Open
Abstract
Importance Neonatal mortality is a major public health concern that was potentially impacted by the COVID-19 pandemic. To prepare for future health crises, it is important to investigate whether COVID-19 pandemic-related interventions were associated with changes in neonatal mortality. Objective To investigate whether social distancing during the pandemic was associated with a higher neonatal mortality rate. Design, Setting, and Participants This cohort study examined maternal-linked birth and infant death records from the National Center for Health Statistics, a population-level US database, from 2016 through 2020. The mortality rates were correlated using machine learning-based autoregressive integrated moving average (ARIMA) models with the social distancing index (SDI). The reference period was January 2016 through February 2020, and the pandemic period was March through December 2020. Statistical analysis was performed from March 2023 to May 2024. Exposures SDI, computed from 6 mobility metrics. Main Outcomes and Measures The primary outcome was neonatal mortality rate, defined as death at age less than 28 days. Results The study included 18 011 173 births, of which 15 136 596 were from the reference period (7 753 555 [51.22%] male; 11 643 094 [76.92%] with maternal age of 20 to 34 years) and 2 874 577 were from the pandemic period (1 472 539 [51.23%] male; 2 190 158 [76.19%] with maternal age of 20 to 34 years). Through ARIMA-adjusted analyses, accounting for the declining mortality trend in the reference period, the mortality rates during the pandemic period did not significantly differ from the expected rates. SDI did not exhibit significant correlations with neonatal mortality (unadjusted: correlation coefficient [CC], 0.14 [95% CI, -0.53 to 0.70]; ARIMA adjusted: CC, 0.29 [95% CI, -0.41 to 0.77]), early neonatal mortality (unadjusted: CC, 0.33 [95% CI, -0.37 to 0.79]; ARIMA adjusted: CC, 0.45 [95% CI, -0.24 to 0.84]), and infant mortality (unadjusted: CC, -0.09 [95% CI, -0.68 to 0.57]; ARIMA adjusted: CC, 0.35 [95% CI, -0.35 to 0.80]). However, lag analyses found that SDI was associated with higher neonatal and early neonatal mortality rates with a 2-month lag period, but not with infant mortality rate. SDI was also associated with increases in 22-to-27 weeks' and 28-to-32 weeks' preterm delivery with a 1-month lag period. Conclusions and Relevance In this population-level study of National Center for Health Statistics databases, neonatal, early neonatal, and infant mortality rates did not increase during the initial COVID-19 pandemic period. However, associations were observed between the pandemic period social distancing measures and higher rates of neonatal and early neonatal mortality, as well as preterm birth rate with a lag period, suggesting the importance of monitoring infant health outcomes following pandemic-related population behavior changes.
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Affiliation(s)
- Vivek V. Shukla
- Division of Neonatology, Department of Pediatrics, University of Alabama at Birmingham
| | - Lucinda J. Weaver
- Division of Neonatology, Department of Pediatrics, University of Alabama at Birmingham
| | - Avinash Singh
- Department of Electrical and Computer Engineering, University of Alabama at Birmingham
| | | | - Arie Nakhmani
- Department of Electrical and Computer Engineering, University of Alabama at Birmingham
| | - Colm P. Travers
- Division of Neonatology, Department of Pediatrics, University of Alabama at Birmingham
| | - Rachel Sinkey
- Division of Maternal and Fetal Medicine, Department of Obstetrics and Gynecology, University of Alabama at Birmingham
| | - Nitin Arora
- Division of Neonatology, Department of Pediatrics, University of Alabama at Birmingham
| | | | - Waldemar A. Carlo
- Division of Neonatology, Department of Pediatrics, University of Alabama at Birmingham
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Alie MS, Girma D, Negesse Y, Adugna A, Abebe GF. Impact of COVID-19 on individual mental health and maternal health services in Ethiopia: systematic review and meta-analysis. Front Public Health 2024; 12:1407269. [PMID: 38979045 PMCID: PMC11228260 DOI: 10.3389/fpubh.2024.1407269] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2024] [Accepted: 05/23/2024] [Indexed: 07/10/2024] Open
Abstract
Background The COVID-19 pandemic has caused a major outbreak in the 21st century and has led to significant mental health hazards worldwide. To address this issue, a systematic review has been conducted to analyze existing literature on the impact of COVID-19 on the psychological well-being of the general population, as well as the associated risk factors. Methods A comprehensive search was carried out on PubMed, Embase, Medline, Web of Science, and Scopus databases, covering all available literature up until February 20, 2024. This search was conducted in accordance with the PRISMA guidelines, ensuring a systematic approach. The selection of articles was based on predetermined eligibility criteria, ensuring the inclusion of appropriate and suitable research. In the final analysis, a total of 15 articles focusing on depression and anxiety, 11 articles on stress, and 7 articles on psychological problems were included. These articles specifically examined the outcome variables within the context of English language and specific areas. For the meta-analysis on maternal health services, 11 articles were included for family planning, 25 articles for postnatal care services, 16 articles for institutional delivery, and 14 articles for safe abortion services. These articles were carefully selected for the final pooled analysis. Result According to a recent systematic review, anxiety, depression, stress, and psychological distress have been prevalent in Ethiopia during the COVID-19 pandemic, with rates of 40, 41, 23, and 41%, respectively. The review also identified various sociodemographic factors that have impacted the country's response to the pandemic, including female gender, age, marital status, incarceration, low income, and lack of social support. Furthermore, the review found that maternal health services have experienced significant reductions during the pandemic. Conclusion The COVID-19 pandemic has led to a significant increase in psychological distress, which in some cases, is severe enough to require clinical treatment. It is crucial to prioritize efforts to address the negative impact of COVID-19 on mental health as a global public health priority. Additionally, it is important to pay attention to maternal health services during COVID-19 mitigation programs.
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Affiliation(s)
- Melsew Setegn Alie
- Department of Public Health, School of Public Health, College of Medicine and Health Science, Mizan-Tepi University, Mizan-Aman, Ethiopia
| | - Desalegn Girma
- Department of Midwifery, College of Medicine and Health Science, Mizan-Tepi University, Mizan-Aman, Ethiopia
| | - Yilkal Negesse
- Department of Public Health, College of Medicine and Health Science, Debre Markos University, Debre Markos, Gojjam, Ethiopia
| | - Amanuel Adugna
- Department of Midwifery, College of Medicine and Health Science, Mizan-Tepi University, Mizan-Aman, Ethiopia
| | - Gossa Fetene Abebe
- Department of Midwifery, College of Medicine and Health Science, Mizan-Tepi University, Mizan-Aman, Ethiopia
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Bayu Abdi H, Beyen TK, Regesu AH, Worke MD, Wami GA, Husen BA, Damtew BS. COVID-19 related barriers to institutional childbirth during the early phase of the pandemic in rural Arsi zone, Ethiopia, 2022: A qualitative study. Heliyon 2024; 10:e32051. [PMID: 38882262 PMCID: PMC11176848 DOI: 10.1016/j.heliyon.2024.e32051] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2024] [Revised: 05/27/2024] [Accepted: 05/28/2024] [Indexed: 06/18/2024] Open
Abstract
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.
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Affiliation(s)
- Hinsermu Bayu Abdi
- Department of Midwifery, College of Health Sciences, Arsi University, Asella, Ethiopia
| | - Teresa Kisi Beyen
- Department of Public Health, College of Health Sciences, Arsi University, Asella, Ethiopia
| | | | - Mulugeta Dile Worke
- Department of Midwifery, College of Health Sciences, Debra Tabor University, Debra Tabor, Ethiopia
| | - Girma Alemu Wami
- Department of Public Health, College of Health Sciences, Arsi University, Asella, Ethiopia
| | - Beker Ahmed Husen
- Department of Midwifery, College of Health Sciences, Arsi University, Asella, Ethiopia
| | - Beyene Sisay Damtew
- Department of Midwifery, College of Health Sciences, Arsi University, Asella, Ethiopia
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Pons-Duran C, Bekele D, Haneuse S, Hunegnaw BM, Alemu K, Kassa M, Berhan Y, Goddard FGB, Taddesse L, Chan GJ. Antenatal care coverage in a low-resource setting: Estimations from the Birhan Cohort. PLOS GLOBAL PUBLIC HEALTH 2023; 3:e0001912. [PMID: 37967078 PMCID: PMC10651002 DOI: 10.1371/journal.pgph.0001912] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/18/2023] [Accepted: 10/11/2023] [Indexed: 11/17/2023]
Abstract
Antenatal care (ANC) coverage estimates commonly rely on self-reported data, which may carry biases. Leveraging prospectively collected longitudinal data from the Birhan field site and its pregnancy and birth cohort, the Birhan Cohort, this study aimed to estimate the coverage of ANC, minimizing assumptions and biases due to self-reported information and describing retention patterns in ANC in rural Amhara, Ethiopia. The study population were women enrolled and followed during pregnancy between December 2018 and April 2020. ANC visits were measured by prospective facility chart abstraction and self-report at enrollment. The primary study outcomes were the total number of ANC visits attended during pregnancy and the coverage of at least one, four, or eight ANC visits. Additionally, we estimated ANC retention patterns. We included 2069 women, of which 150 (7.2%) women enrolled <13 weeks of gestation with complete prospective facility reporting. Among these 150 women, ANC coverage of at least one visit was 97.3%, whereas coverage of four visits or more was 34.0%. Among all women, coverage of one ANC visit was 92.3%, while coverage of four or more visits was 28.8%. No women were found to have attended eight or more ANC visits. On retention in care, 70.3% of participants who had an ANC visit between weeks 28 and <36 of gestation did not return for a subsequent visit. Despite the high proportion of pregnant women who accessed ANC at least once in our study area, the coverage of four visits remains low. Further efforts are needed to enhance access to more ANC visits, retain women in care, and adhere to the most recent Ethiopian National ANC guideline of at least eight ANC visits. It is essential to identify the factors that lead a large proportion of women to discontinue ANC follow-up.
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Affiliation(s)
- Clara Pons-Duran
- Department of Epidemiology, Harvard T. H. Chan School of Public Health, Boston, Massachusetts, United States of America
| | - Delayehu Bekele
- Department of Epidemiology, Harvard T. H. Chan School of Public Health, Boston, Massachusetts, United States of America
- Department of Obstetrics and Gynecology, St. Paul’s Hospital Millennium Medical College, Addis Ababa, Ethiopia
| | - Sebastien Haneuse
- Department of Biostatistics, Harvard T. H. Chan School of Public Health, Boston, Massachusetts, United States of America
| | - Bezawit Mesfin Hunegnaw
- Department of Pediatrics and Child Health, St. Paul’s Hospital Millennium Medical College, Addis Ababa, Ethiopia
| | - Kassahun Alemu
- HaSET Maternal and Child Health Research Program, Addis Ababa, Ethiopia
- Department of Epidemiology and Biostatistics, Institute of Public Health, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia
| | | | - Yifru Berhan
- St. Paul’s Hospital Millennium Medical College, Addis Ababa, Ethiopia
| | - Frederick G. B. Goddard
- Department of Epidemiology, Harvard T. H. Chan School of Public Health, Boston, Massachusetts, United States of America
| | - Lisanu Taddesse
- HaSET Maternal and Child Health Research Program, Addis Ababa, Ethiopia
| | - Grace J. Chan
- Department of Epidemiology, Harvard T. H. Chan School of Public Health, Boston, Massachusetts, United States of America
- Department of Pediatrics and Child Health, St. Paul’s Hospital Millennium Medical College, Addis Ababa, Ethiopia
- Department of Pediatrics, Boston Children’s Hospital, Harvard Medical School, Boston, Massachusetts, United States of America
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Singh T, Kaur R, Kant S, Mani K, Yadav K, Gupta SK. Effect of COVID-19 pandemic on utilization of maternal healthcare services in a rural area of Haryana - A record-based comparative study. J Family Med Prim Care 2023; 12:2640-2644. [PMID: 38186835 PMCID: PMC10771182 DOI: 10.4103/jfmpc.jfmpc_99_23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2023] [Revised: 07/06/2023] [Accepted: 07/07/2023] [Indexed: 01/09/2024] Open
Abstract
Background The COVID-19 pandemic posed a challenge for the public health system, as all the health facilities and manpower were diverted for the delivery of COVID-19-related services. This affected the provision of routine health services, including maternal healthcare services. There is a paucity of data from rural and primary healthcare settings, as the earlier studies were either modelling-based or from tertiary care centres. Materials and Methods This record-based study was conducted in 12 subcentres in the district Faridabad of Haryana. Data of pregnant women registered during 1 April to 30 September in the years 2017-2020 were retrieved. The utilization of maternal healthcare services among women registered during 1 April 2020 to 30 September 2020 was compared with those registered in the same period during the preceding 3 years (2017-2019). Results There was a significant decline in utilization of maternal healthcare services. Services like minimum four antenatal visits declined from 67.8% to 48.3% (P < 0.0001), at least 100 iron-folic acid tablets (45.4-20.9%; P < 0.001), and examination at each visit (90.8-72.3%; P < 0.001). The proportion of pregnant women who received full antenatal care decreased from 26.0% to 10.7% (P < 0.001). There was a significant increase in delivery in private health facilities (40.9-49.9%) and delivery by caesarean section (21.6-27.3%; P = 0.002). Conclusion COVID-19 pandemic had an adverse effect on utilization of maternal healthcare services. Effective planning and coordination between different levels of government health facilities and primary care providers, including family physicians, can ensure uninterrupted provision of essential services during similar emergencies in future.
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Affiliation(s)
- Tejbeer Singh
- Centre for Community Medicine, All India Institute of Medical Sciences, New Delhi, Delhi, India
| | - Ravneet Kaur
- Centre for Community Medicine, All India Institute of Medical Sciences, New Delhi, Delhi, India
| | - Shashi Kant
- Centre for Community Medicine, All India Institute of Medical Sciences, New Delhi, Delhi, India
| | - Kalaivani Mani
- Department of Biostatistics, All India Institute of Medical Sciences, New Delhi, Delhi, India
| | - Kapil Yadav
- Centre for Community Medicine, All India Institute of Medical Sciences, New Delhi, Delhi, India
| | - Sanjeev Kumar Gupta
- Centre for Community Medicine, All India Institute of Medical Sciences, New Delhi, Delhi, India
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Mohd Ujang IR, Hamidi N, Ab Hamid J, Awang S, Zulkifli NW, Supadi R, Mohamed NE, Sooryanarayana R. The COVID-19 pandemic and disruptions to maternal and child health services in public primary care Malaysia: a retrospective time-series analysis. BMJ Glob Health 2023; 8:e013397. [PMID: 37949498 PMCID: PMC10649372 DOI: 10.1136/bmjgh-2023-013397] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2023] [Accepted: 10/16/2023] [Indexed: 11/12/2023] Open
Abstract
INTRODUCTION The COVID-19 pandemic has posed significant challenges to healthcare systems worldwide. Maintaining essential health services, including maternal and child health (MCH), while addressing the pandemic is an enormous task. This study aimed to assess the impact of the COVID-19 pandemic on the utilisation of MCH services in Malaysian public primary care. METHODS A retrospective analysis was conducted using national administrative data from 1124 public primary care clinics. Eight indicators were selected to measure service utilisation covering antenatal, postnatal, women's health, child health, and immunisation services. Interrupted time-series analysis was used to evaluate changes in levels and trends of indicators during four different periods: pre-pandemic (January 2019-February 2020), during pandemic and first lockdown (March-May 2020), after the first lockdown was lifted (June-December 2020) and after the second lockdown was implemented (January-June 2021). RESULTS Most indicators showed no significant trend in monthly utilisation prior to the pandemic. The onset of the pandemic and first lockdown implementation were associated with significant decreasing trends in child health (-19.23%), women's health (-10.12%), antenatal care (-8.10%), contraception (-6.50%), postnatal care (-4.85%) and postnatal care 1-week (-3.52%) indicators. These indicators showed varying degrees of recovery after the first lockdown was lifted. The implementation of the second lockdown caused transient reduction ranging from -11.29% to -25.92% in women's health, contraception, child and two postnatal indicators, but no sustained reducing trend was seen afterwards. Two immunisation indicators appeared unaffected throughout the study period. CONCLUSION The COVID-19 pandemic significantly impacted MCH services utilisation in Malaysia. While most MCH services were negatively affected by the lockdown implementation with varying degrees of recovery, infant immunisation showed resilience throughout. This highlights the need for a targeted preparedness plan to ensure the resilience of MCH services in future crises.
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Affiliation(s)
- Izzatur Rahmi Mohd Ujang
- Centre for Healthcare Quality Research, Institute for Health Systems Research, Ministry of Health, Shah Alam, Malaysia
| | - Normaizira Hamidi
- Centre for Healthcare Quality Research, Institute for Health Systems Research, Ministry of Health, Shah Alam, Malaysia
| | - Jabrullah Ab Hamid
- Centre for Health Equity Research, Institute for Health Systems Research, Ministry of Health, Shah Alam, Malaysia
| | - Samsiah Awang
- Centre for Healthcare Quality Research, Institute for Health Systems Research, Ministry of Health, Shah Alam, Malaysia
| | | | - Roslina Supadi
- Centre for Healthcare Quality Research, Institute for Health Systems Research, Ministry of Health, Shah Alam, Malaysia
| | - Nur Ezdiani Mohamed
- Centre for Healthcare Quality Research, Institute for Health Systems Research, Ministry of Health, Shah Alam, Malaysia
| | - Rajini Sooryanarayana
- Family Health Development Division, Ministry of Health Malaysia, Putrajaya, Malaysia
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