Healthcare utilization and maternal and child mortality during the COVID-19 pandemic in 18 low- and middle-income countries: An interrupted time-series analysis with mathematical modeling of administrative data

BACKGROUND

The Coronavirus Disease 2019 (COVID-19) pandemic has had wide-reaching direct and indirect impacts on population health. In low- and middle-income countries, these impacts can halt progress toward reducing maternal and child mortality. This study estimates changes in health services utilization during the pandemic and the associated consequences for maternal, neonatal, and child mortality.

METHODS AND FINDINGS

Data on service utilization from January 2018 to June 2021 were extracted from health management information systems of 18 low- and lower-middle-income countries (Afghanistan, Bangladesh, Cameroon, Democratic Republic of the Congo (DRC), Ethiopia, Ghana, Guinea, Haiti, Kenya, Liberia, Madagascar, Malawi, Mali, Nigeria, Senegal, Sierra Leone, Somalia, and Uganda). An interrupted time-series design was used to estimate the percent change in the volumes of outpatient consultations and maternal and child health services delivered during the pandemic compared to projected volumes based on prepandemic trends. The Lives Saved Tool mathematical model was used to project the impact of the service utilization disruptions on child and maternal mortality. In addition, the estimated monthly disruptions were also correlated to the monthly number of COVID-19 deaths officially reported, time since the start of the pandemic, and relative severity of mobility restrictions. Across the 18 countries, we estimate an average decline in OPD volume of 13.1% and average declines of 2.6% to 4.6% for maternal and child services. We projected that decreases in essential health service utilization between March 2020 and June 2021 were associated with 113,962 excess deaths (110,686 children under 5, and 3,276 mothers), representing 3.6% and 1.5% increases in child and maternal mortality, respectively. This excess mortality is associated with the decline in utilization of the essential health services included in the analysis, but the utilization shortfalls vary substantially between countries, health services, and over time. The largest disruptions, associated with 27.5% of the excess deaths, occurred during the second quarter of 2020, regardless of whether countries reported the highest rate of COVID-19-related mortality during the same months. There is a significant relationship between the magnitude of service disruptions and the stringency of mobility restrictions. The study is limited by the extent to which administrative data, which varies in quality across countries, can accurately capture the changes in service coverage in the population.

CONCLUSIONS

Declines in healthcare utilization during the COVID-19 pandemic amplified the pandemic's harmful impacts on health outcomes and threaten to reverse gains in reducing maternal and child mortality. As efforts and resource allocation toward prevention and treatment of COVID-19 continue, essential health services must be maintained, particularly in low- and middle-income countries.

THE INTERGENERATIONAL MORTALITY TRADE-OFF OF COVID-19 LOCKDOWN POLICIES

In lower-income countries, the economic contractions that accompany lockdowns to contain COVID-19 transmission can increase child mortality, counteracting the mortality reductions achieved by the lockdown. To formalize and quantify this effect, we build a macrosusceptible-infected-recovered model that features heterogeneous agents and a country-group-specific relationship between economic downturns and child mortality and calibrate it to data for 85 countries across all income levels. We find that in some low-income countries, a lockdown can produce net increases in mortality. The optimal lockdown that maximizes the present value of aggregate social welfare is shorter and milder in poorer countries than in rich ones.

Factors associated with the adoption of a digital health service by patent proprietary medicine vendors (PPMVs) in Lagos, Nigeria

Background

Patent proprietary medicine vendors (PPMVs) are the first point of care for low-income Nigerian households. They are likely to have an important role in a digital care pathway established for low-income Nigerian women and children. Yet, little is known about what drives the adoption of digital platforms by PPMVs.

Methods

This study explores factors associated with the adoption of a digital service, NaijaCare, created to enable PPMVs to increase the range and quality of products and services they offer. A structured, quantitative, face-to-face survey was conducted among 248 PPMVs in Lagos in February and March 2020. Multivariate analysis was conducted to identify factors associated with the adoption of NaijaCare.

Results

Women comprise the majority (67%) of medicine vendors in Lagos. Most medicine vendors (64%) had gotten health training on the job. About a quarter (27%) of medicine vendors reported seeking business advice on the internet. Medicine vendors who had obtained on-the-job training had a 12.31 times higher odds ratio ( p < 0.01) of adopting the digital service. Medicine vendors who sought business advice on the internet had a 6.48 times higher odds ratio ( p < 0.001) of adopting NaijaCare.

Conclusion

The study findings suggest that PPMVs’ use of the digital service was driven by their desire to increase business profits. Digital care pathways targeting low-income households should be aligned with the business interests of informal providers.

How many infants may have died in low-income and middle-income countries in 2020 due to the economic contraction accompanying the COVID-19 pandemic? Mortality projections based on forecasted declines in economic growth

OBJECTIVES

While COVID-19 has a relatively small direct impact on infant mortality, the pandemic is expected to indirectly increase mortality of this vulnerable group in low-income and middle-income countries through its effects on the economy and health system performance. Previous studies projected indirect mortality by modelling how hypothesised disruptions in health services will affect health outcomes. We provide alternative projections, relying on modelling the relationship between aggregate income shocks and mortality.

DESIGN

We construct a sample of 5.2 million births by pooling retrospective birth histories reported by women in Demographic and Health Surveys conducted in 83 low-income and middle-income countries between 1985 and 2018. We employ regression models with country-specific fixed-effects and flexible time trends to estimate the impact of gross domestic product per capita on infant mortality rate. We then use growth projections by the International Monetary Fund to predict the effect of the economic downturn in 2020 on infant mortality.

RESULTS

We estimate 267 208 (95% CI 112 000 to 422 415) excess infant deaths in 128 countries, corresponding to a 6.8% (95% CI 2.8% to 10.7%) increase in the total number of infant deaths expected in 2020.

CONCLUSIONS

The findings underscore the vulnerability of infants to the negative income shocks such as those imposed by the COVID-19 pandemic. While efforts towards prevention and treatment of COVID-19 remain paramount, the global community should also strengthen social safety nets and assure continuity of essential health services.

Disruptions in maternal and child health service utilization during COVID-19: analysis from eight sub-Saharan African countries

The coronavirus-19 pandemic and its secondary effects threaten the continuity of essential health services delivery, which may lead to worsened population health and a protracted public health crisis. We quantify such disruptions, focusing on maternal and child health, in eight sub-Saharan countries. Service volumes are extracted from administrative systems for 63 954 facilities in eight countries: Cameroon, Democratic Republic of Congo, Liberia, Malawi, Mali, Nigeria, Sierra Leone and Somalia. Using an interrupted time series design and an ordinary least squares regression model with facility-level fixed effects, we analyze data from January 2018 to February 2020 to predict what service utilization levels would have been in March-July 2020 in the absence of the pandemic, accounting for both secular trends and seasonality. Estimates of disruption are derived by comparing the predicted and observed service utilization levels during the pandemic period. All countries experienced service disruptions for at least 1 month, but the magnitude and duration of the disruptions vary. Outpatient consultations and child vaccinations were the most commonly affected services and fell by the largest margins. We estimate a cumulative shortfall of 5 149 491 outpatient consultations and 328 961 third-dose pentavalent vaccinations during the 5 months in these eight countries. Decreases in maternal health service utilization are less generalized, although significant declines in institutional deliveries, antenatal care and postnatal care were detected in some countries. There is a need to better understand the factors determining the magnitude and duration of such disruptions in order to design interventions that would respond to the shortfall in care. Service delivery modifications need to be both highly contextualized and integrated as a core component of future epidemic response and planning.

Assessing the performance of the Caregiver Reported Early Development Instruments (CREDI) in rural India

Although many education and health programs aim to improve early childhood development, it is challenging to assess developmental levels of infants and small children through large household surveys. The Caregiver Reported Early Development Instruments (CREDI) has been proposed as an adaptable, practical, and low‐cost instrument for measuring the developmental status of children under 3 years of age at scale, as it is relatively short and collected by caregiver report. This study employed the CREDI to measure the development of a sample of 994 children ages 22–35 months in rural India and compared the results to those obtained using the Bayley Scales of Infant and Toddler Development (Bayley‐III), a reliable and widely used instrument, albeit one not always suited to large‐scale data collection efforts given its length, cost, and complexity of administration. The CREDI validation exercise showed that caregivers can provide assessments in keeping with the more interactive (hence more time‐consuming and training‐intensive) Bayley‐III instrument. Noteworthy, there was no indication that concordance of the instruments differed by education of the caregiver. This is important as it points to alternate feasible tools to measure child development outcomes through large‐scale surveys.

Physical activity and sedentary time in a rural adult population in Malawi compared with an age-matched US urban population

Objectives

This study was designed to assess patterns of objectively measured physical activity (PA) and sedentary behaviour in a sample of adults in a rural setting from a low-income Sub-Saharan African country (Malawi). The patterns of PA and sedentary behaviour in Malawi were compared with US data collected and analysed using the same methodology.

Methods

The Malawi PA data were collected as part of a survey experiment on the measurement of agricultural labor conducted under the World Bank Living Standards Measurement Study program. ActiGraph accelerometers (model GT3X) were worn on the right hip in a household-based sample of 414 working-age adults (15-85 years).

Results

Mean total and 95% CIs for PA by category in min/day for Malawi adults were: sedentary 387.6 (377.4-397.8), low-light 222.1 (214.7-229.5), high-light 136.3 (132.7-139.9), moderate 71.6 (68.8-74.5), vigorous 1.1 (0.5-1.8) and moderate-to-vigorous physical activity (MVPA) 72.8 (69.7-75.9). Mean of PA and sedentary behavior (min/day) summed across age and sex groups are compared between Malawi and US samples: sedentary behaviour, 387.6 vs 525.8 (p<0.001); low-light, 222.1 vs 217.0 (p=ns); high-light, 136.3 vs 45.6 (p<0.001); moderate, 71.6 vs 28.0 (p<0.001); vigorous, 1.1 vs 2.5 (p<0.001); MVPA, 72.8 vs 30.5 (p<0.001). Compared with the USA, Malawi participants averaged consistently less sedentary time/day and more minutes/day in all intensity levels of PA, except for low-light and vigorous PA.

Conclusion

Overall, levels of MVPA and high-light activity in adults in Malawi were substantially higher and sedentary time was substantially lower than those observed in US samples using near identical data collection, scoring and analysis.

Improving Supply Chain for Essential Drugs in Low-Income Countries: Results from a Large Scale Randomized Experiment in Zambia

Despite increased investments in procurement of essential medicines, their availability at health facilities remains extremely low in many low- and middle-income countries. The lack of a well-functioning supply chain for essential medicines is often the cause of this poor availability. Using a randomized trial conducted in 439 health facilities and 24 districts in Zambia, this study helps understand the optimal supply chain structure for essential medicines distribution in the public sector in low-income countries. It shows that a more direct distribution system where clinics order and receive medicines supply directly from the central agency through a cross-docking arrangement significantly reduces the duration and frequency of stockouts compared to a traditional three-level drug distribution system. As an example, the frequency of stockouts for first line pediatric malaria medicines reduced from 47.9% to 13.3% and the number of days of stockout in a quarter reduced from 27 days to 5 days. The direct flow of demand and order information from health facilities to the central supply agency reduces the problem of diffuse accountability that exists in multi-tiered distribution systems. It also shifts the locus of decision making for complex supply chain functions such as scarce stock allocation and adjustment of health facility order quantities to levels in the system where staff competency is aligned with what the function needs. Even when supply chain system redesign such as the one evaluated in this paper are demonstrated to be technically robust using rigorous evidence, they often require navigating a complex political economy within the overall health system and its actors.

Transverse drag of slow light in moving atomic vapor

The Fresnel-Fizeau effect of transverse drag, in which the trajectory of a light beam changes due to the transverse motion of the optical medium, is usually extremely small and hard to detect. We observe transverse drag in a moving hot-vapor cell, utilizing slow light due to electromagnetically induced transparency (EIT). The drag effect is enhanced by a factor 3.6×10⁵, corresponding to the ratio between the light speed in vacuum and the group velocity under EIT conditions. We study the contribution of the thermal atomic motion, which is much faster than the mean medium velocity, and identify the regime where its effect on the transverse drag is negligible.

Using supervised learning to select audit targets in performance-based financing in health: An example from Zambia

Independent verification is a critical component of performance-based financing (PBF) in health care, in which facilities are offered incentives to increase the volume of specific services but the same incentives may lead them to over-report. We examine alternative strategies for targeted sampling of health clinics for independent verification. Specifically, we empirically compare several methods of random sampling and predictive modeling on data from a Zambian PBF pilot that contains reported and verified performance for quantity indicators of 140 clinics. Our results indicate that machine learning methods, particularly Random Forest, outperform other approaches and can increase the cost-effectiveness of verification activities.

Cost-effectiveness of results-based financing, Zambia: a cluster randomized trial

Objective

To evaluate the cost-effectiveness of results-based financing and input-based financing to increase use and quality of maternal and child health services in rural areas of Zambia.

Methods

In a cluster-randomized trial from April 2012 to June 2014, 30 districts were allocated to three groups: results-based financing (increased funding tied to performance on pre-agreed indicators), input-based financing (increased funding not tied to performance) or control (no additional funding), serving populations of 1.33, 1.26 and 1.40 million people, respectively. We assessed incremental financial costs for programme implementation and verification, consumables and supervision. We evaluated coverage and quality effectiveness of maternal and child health services before and after the trial, using data from household and facility surveys, and converted these to quality-adjusted life years (QALYs) gained.

Findings

Coverage and quality of care increased significantly more in results-based financing than control districts: difference in differences for coverage were 12.8% for institutional deliveries, 8.2% postnatal care, 19.5% injectable contraceptives, 3.0% intermittent preventive treatment in pregnancy and 6.1% to 29.4% vaccinations. In input-based financing districts, coverage increased significantly more versus the control for institutional deliveries (17.5%) and postnatal care (13.2%). Compared with control districts, 641 more lives were saved (lower-upper bounds: 580-700) in results-based financing districts and 362 lives (lower-upper bounds: 293-430) in input-based financing districts. The corresponding incremental cost-effectiveness ratios were 809 United States dollars (US$) and US$ 413 per QALY gained, respectively.

Conclusion

Compared with the control, both results-based financing and input-based financing were cost-effective in Zambia.

Maternal depressive symptoms are negatively associated with child growth and development: Evidence from rural India

Maternal depression has been suggested as a risk factor for both poor child growth and development in many low‐ and middle‐income countries, but the validity of many studies is hindered by small sample sizes, varying cut‐offs used in depression diagnostics, and incomplete control of confounding factors. This study examines the association between maternal depressive symptoms (MDSs) and child physical growth and cognitive development in Madhya Pradesh, India, where poverty, malnutrition, and poor mental health coexist. Data were from a baseline household survey (n = 2,934) of a randomized controlled trial assessing an early childhood development programme. Multivariate linear and logistic regression analyses were conducted, adjusting for socio‐economic factors to avoid confounding the association of mental health and child outcomes. MDS (measured using the Center for Epidemiologic Studies Short Depression Scale) was categorized as low, medium, and high in 47%, 42%, and 10% of mothers, respectively. The prevalence of child developmental delay ranged from 16% to 27% for various development domains. Compared with children of mothers with low MDS, those of high MDS mothers had lower height‐for‐age, weight‐for‐age, and weight‐for‐height z‐scores (0.22, 0.21, and 0.15, respectively), a higher rate of stunting and underweight (~1.5 times), and higher rate of developmental delay (partial adjusted odds ratio ranged from 1.3–1.8 for different development domains and fully adjusted odds ratio = 1.4 for fine motor). Our results—that MDS is significantly associated with both child undernutrition and development delay—add to the call for practical interventions to address maternal depression to simultaneously address multiple outcomes for both women and children.