Indirect effects of COVID-19 on maternal, neonatal, child, sexual and reproductive health services in Kampala, Uganda

  • BMJ Global Health, Volume 6, No. 8, Year 2021

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Study Justification:
– The study aimed to assess the impact of the COVID-19 lockdown on maternal, neonatal, child, sexual, and reproductive health services in Kampala, Uganda.
– The study was conducted to understand how movement restrictions and limited access to services during the pandemic affected health outcomes in these areas.
– The findings of the study can provide valuable insights for policymakers and healthcare providers to improve future pandemic responses and protect maternal and child health.
Highlights:
– The study found that during the lockdown period, there was a significant decrease in antenatal clinic attendances and vaccination services.
– Pregnancy complications and adverse fetal and infant outcomes increased during the lockdown and immediately after.
– Maternal mortality remained stable, but neonatal death rates rose.
– Attendance for prevention of mother-to-child transmission of HIV dropped but then stabilized.
– The number of children treated for pneumonia, diarrhea, and malaria decreased during the lockdown.
– Decreased vaccination clinic attendance left a cohort of infants unprotected against vaccine-preventable diseases.
Recommendations:
– Future pandemic responses should consider the impacts of movement restrictions on access to preventative services for maternal and child health.
– Measures should be taken to ensure continued access to antenatal care, vaccination services, and treatment for common childhood illnesses during lockdown periods.
– Efforts should be made to address delayed care-seeking behavior and ensure timely care for pregnancy complications and adverse outcomes.
– Strategies should be implemented to increase vaccination clinic attendance and protect infants from vaccine-preventable diseases during and after lockdowns.
Key Role Players:
– Ministry of Health: Responsible for policy-making and coordination of healthcare services.
– Healthcare Providers: Including doctors, nurses, midwives, and other healthcare professionals involved in maternal, neonatal, child, sexual, and reproductive health services.
– Community Health Workers: Involved in outreach and education programs to promote access to healthcare services.
– NGOs and International Organizations: Providing support and resources for maternal and child health programs.
Cost Items for Planning Recommendations:
– Staffing: Budget for additional healthcare professionals, including doctors, nurses, and midwives, to ensure adequate coverage and access to services.
– Training: Budget for training programs to enhance healthcare providers’ skills in managing pregnancy complications, neonatal care, and vaccination services.
– Equipment and Supplies: Budget for necessary medical equipment, vaccines, medications, and other supplies needed for maternal, neonatal, child, sexual, and reproductive health services.
– Outreach and Education: Budget for community health worker programs, awareness campaigns, and educational materials to promote access to services and address delayed care-seeking behavior.
– Monitoring and Evaluation: Budget for data collection, analysis, and monitoring of health outcomes to assess the effectiveness of interventions and make necessary adjustments.

The strength of evidence for this abstract is 7 out of 10.
The evidence in the abstract is based on an observational study using routinely collected data. While the study provides descriptive statistics and interrupted time series analysis, it does not mention a control group or randomization, which limits the ability to establish causality. To improve the strength of the evidence, future studies could consider incorporating a control group and randomization to better assess the impact of COVID-19 on maternal, neonatal, child, sexual, and reproductive health services. Additionally, the study could benefit from a larger sample size and multi-site data collection to enhance generalizability.

Background COVID-19 impacted global maternal, neonatal and child health outcomes. We hypothesised that the early, strict lockdown that restricted individuals’ movements in Uganda limited access to services. Methods An observational study, using routinely collected data from Electronic Medical Records, was carried out, in Kawempe district, Kampala. An interrupted time series analysis assessed the impact on maternal, neonatal, child, sexual and reproductive health services from July 2019 to December 2020. Descriptive statistics summarised the main outcomes before (July 2019-March 2020), during (April 2020-June 2020) and after the national lockdown (July 2020-December 2020). Results Between 1 July 2019 and 31 December 2020, there were 14 401 antenatal clinic, 33 499 deliveries, 111 658 childhood service and 57 174 sexual health attendances. All antenatal and vaccination services ceased in lockdown for 4 weeks. During the 3-month lockdown, the number of antenatal attendances significantly decreased and remain below pre-COVID levels (370 fewer/month). Attendances for prevention of mother-to-child transmission of HIV dropped then stabilised. Increases during lockdown and immediately postlockdown included the number of women treated for high blood pressure, eclampsia and pre-eclampsia (218 more/month), adverse pregnancy outcomes (stillbirths, low-birth-weight and premature infant births), the rate of neonatal unit admissions, neonatal deaths and abortions. Maternal mortality remained stable. Immunisation clinic attendance declined while neonatal death rate rose (from 39 to 49/1000 livebirths). The number of children treated for pneumonia, diarrhoea and malaria decreased during lockdown. Conclusion The Ugandan response to COVID-19 negatively impacted maternal, child and neonatal health, with an increase seen in pregnancy complications and fetal and infant outcomes, likely due to delayed care-seeking behaviour. Decreased vaccination clinic attendance leaves a cohort of infants unprotected, affecting all vaccine-preventable diseases. Future pandemic responses must consider impacts of movement restrictions and access to preventative services to protect maternal and child health.

This was a single-site observational study, which utilised retrospectively collected data, based on KNRH. This is a large, urban hospital with over 21 000 deliveries per annum, 200 antenatal clinic visits and 100 child admissions to hospital per day.24 The hospital provides preventative and curative care during pregnancy and intrapartum, newborn and postnatal care, a paediatric ward and vaccination services at a standard indicative of care in urban Uganda. After the initial lockdown period (4 weeks without outpatient services), measures to reduce the number of women attending ANC included reducing the number of appointments per day from 150 to 90 for ANC and all women <26 weeks gestation being sent away to return after 30 weeks. For infants, the vaccination clinic remained operating routinely. During the initial phases of lockdown (April and May 2020), 35/60 doctors were reassigned to acute care at COVID-19 centres in anticipation of a large number of COVID-19 cases, but 53 nurses were recruited at the same time with result-based financing support raising the number of nurse/midwifes on site from 184 to 237 after April 2020. Patients were not involved directly in the formation of this study. We have involved women in a separate, dedicated qualitative study about their experiences of ANC during the pandemic.25 Data were retrospectively collected in January 2021, by hospital staff with access to the Electronic Medical Records (EMR) system. This system is part of the Uganda Ministry of Health (MoH) eHealth Policy, Strategy and Implementation Plan and utilises the District Health Information Software 2 (DHIS2).26 The DHIS2 indicators for which data were collected are detailed in the available data set27 and were taken from health management information system data, which is reported to the MoH, covering pregnancy preventative services, pregnancy curative services, childbirth, care of the newborn, postnatal care, preventative childcare, curative childcare, preventative services for women of reproductive age, curative services for women of reproductive age and unavailability of medicines and commodities. Monthly totals were gathered for the period from July 2019 to December 2020. In accordance with the Sex and Gender Equity in Research guidelines, pregnancy, childbirth and sexual health-related indicators are reported for those of the female sex, and no segregation is made between male and female sex or gender for childcare indicators as this was not part of the reporting data.28 Neonatal mortality was calculated as the sum of immediate neonatal deaths and deaths from neonatal sepsis 0–7 days, neonatal sepsis 8–28 days, neonatal pneumonia, neonatal meningitis, neonatal jaundice, premature baby (as condition that requires management) and other neonatal conditions. Data were input into Microsoft Excel and exported to R V.4.0.4 (R Foundation for Statistical Computing, Vienna, Austria) for further analysis purposes. We calculated the number of attendances per month for each indicator and then analysed the aggregated data at the month level as a proportion of antenatal, labour and delivery, child health or sexual and reproductive health services attendance. For each indicator, the data were divided into pre-COVID (July 2019—March 2020), lockdown (April—June 2020) and post-COVID lockdown (July—December 2020). We used descriptive statistics to summarise demographic and clinical data and present summaries of outcomes before, during and after lockdown (the intervention) as medians and IQRs (online supplemental table 1). To identify suitable regression models for estimating the effects of lockdown, we first graphically plotted the number of events per month over time and assessed for stationarity and autocorrelation using the Durbin-Watson test, graphs of residuals from ordinary least square regression and graphs of auto and partial autocorrelation functions. We then conducted interrupted time series analyses using the generalised least square approach, which allows for inclusion of autoregressive or moving average autocorrelation processes. These models were used to estimate the effects of lockdown on preventative, curative, labour and delivery and child health services at KNRH. The model included a time variable (month), a dummy lockdown variable indicating prelockdown, lockdown and postlockdown and trend variables for the lockdown and postlockdown periods. This approach allows for estimation of the change in levels and trends of the outcomes following the multiple interruptions (start and lifting of lockdown). We use a 5% significance level and 95% CIs. bmjgh-2021-006102supp001.pdf

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Based on the information provided, here are some potential innovations that could be used to improve access to maternal health:

1. Telemedicine: Implementing telemedicine services can allow pregnant women to receive prenatal care and consultations remotely, reducing the need for in-person visits and improving access to healthcare services.

2. Mobile health (mHealth) applications: Developing mobile applications that provide information and resources on maternal health, including prenatal care guidelines, nutrition advice, and appointment reminders, can help women access important information and support throughout their pregnancy.

3. Community health workers: Training and deploying community health workers who can provide basic prenatal care, education, and support to pregnant women in remote or underserved areas can help improve access to maternal health services.

4. Transportation support: Establishing transportation services or subsidies specifically for pregnant women can help overcome barriers related to distance and transportation costs, ensuring that women can access healthcare facilities for prenatal care and delivery.

5. Community-based prenatal care: Implementing community-based prenatal care programs, where women receive care in their own communities rather than having to travel to healthcare facilities, can improve access to maternal health services, particularly in rural or remote areas.

6. Maternal health hotlines: Setting up hotlines staffed by healthcare professionals who can provide guidance, answer questions, and address concerns related to maternal health can help women access information and support when needed.

7. Mobile clinics: Deploying mobile clinics to underserved areas or areas with limited healthcare facilities can provide essential prenatal care services, including check-ups, screenings, and vaccinations, to pregnant women who may otherwise have difficulty accessing care.

8. Public-private partnerships: Collaborating with private healthcare providers and organizations to expand access to maternal health services can help fill gaps in healthcare infrastructure and resources, ensuring that more women have access to quality care.

9. Health education campaigns: Conducting targeted health education campaigns to raise awareness about the importance of prenatal care, nutrition, and healthy behaviors during pregnancy can help empower women with knowledge and encourage them to seek timely and appropriate care.

10. Data-driven decision-making: Utilizing electronic medical records and data analytics to identify gaps and trends in maternal health service utilization can inform targeted interventions and resource allocation, ultimately improving access to care for pregnant women.

It’s important to note that these recommendations are based on general principles and may need to be adapted to the specific context and needs of Kampala, Uganda.
AI Innovations Description
Based on the information provided, the study conducted in Kampala, Uganda identified several negative impacts of the COVID-19 pandemic on maternal, neonatal, child, sexual, and reproductive health services. To improve access to maternal health, the following recommendation can be developed into an innovation:

1. Telemedicine and Mobile Health Services: Implementing telemedicine and mobile health services can help overcome barriers to accessing maternal health services during times of restricted movement, such as lockdowns. This innovation would involve providing virtual consultations, remote monitoring of maternal health indicators, and delivering essential information and education through mobile applications or telecommunication platforms.

By leveraging technology, pregnant women can receive antenatal care, postnatal care, and counseling remotely, reducing the need for physical visits to healthcare facilities. This approach can ensure continuity of care, early detection of complications, and timely interventions, even during periods of restricted movement.

Additionally, mobile health services can be used to disseminate important health information, such as pregnancy-related guidelines, nutrition advice, and reminders for vaccination schedules. This can help bridge the gap in access to preventative services and ensure that women and infants receive necessary vaccinations and preventive care.

Implementing telemedicine and mobile health services would require collaboration between healthcare providers, technology companies, and government agencies to establish secure and reliable platforms, train healthcare professionals, and ensure equitable access to digital services, especially for marginalized populations.

Overall, this innovation can improve access to maternal health services by providing remote care, reducing the need for physical visits, and ensuring continuity of care during times of restricted movement, such as the COVID-19 pandemic.
AI Innovations Methodology
Based on the provided information, here are some potential recommendations to improve access to maternal health:

1. Telemedicine and Mobile Health: Implementing telemedicine and mobile health solutions can help overcome barriers to accessing maternal health services, especially in remote or underserved areas. This can include virtual consultations, remote monitoring of vital signs, and mobile apps for education and appointment reminders.

2. Community-Based Care: Strengthening community-based care models can improve access to maternal health services by bringing healthcare closer to women’s homes. This can involve training and empowering community health workers to provide antenatal care, postnatal care, and health education.

3. Transportation Support: Addressing transportation challenges can significantly improve access to maternal health services. Providing transportation vouchers, establishing community transportation networks, or partnering with ride-sharing services can help pregnant women reach healthcare facilities in a timely manner.

4. Health Information Systems: Enhancing health information systems can improve coordination and continuity of care. Implementing electronic medical records, interoperable systems, and data analytics can help identify gaps in service delivery and enable targeted interventions.

To simulate the impact of these recommendations on improving access to maternal health, a methodology could include the following steps:

1. Define Key Indicators: Identify key indicators that reflect access to maternal health services, such as the number of antenatal visits, facility-based deliveries, postnatal care utilization, and maternal mortality rates.

2. Baseline Data Collection: Gather baseline data on the identified indicators before implementing the recommendations. This can involve reviewing existing data sources, conducting surveys, or utilizing electronic medical records.

3. Model Development: Develop a simulation model that incorporates the baseline data and simulates the impact of the recommendations on the identified indicators. The model should consider factors such as population demographics, healthcare infrastructure, and the specific interventions being implemented.

4. Intervention Scenarios: Create different scenarios that represent the implementation of the recommendations. For example, simulate the impact of telemedicine implementation, community-based care expansion, or transportation support programs.

5. Data Analysis: Run the simulation model for each intervention scenario and analyze the results. Compare the indicators between the baseline and intervention scenarios to assess the potential impact on improving access to maternal health.

6. Sensitivity Analysis: Conduct sensitivity analysis to understand the robustness of the results. This involves testing the model with different assumptions and parameters to assess the variability of the outcomes.

7. Interpretation and Recommendations: Interpret the simulation results and provide recommendations based on the findings. Identify the most effective interventions and their potential impact on improving access to maternal health.

It’s important to note that the methodology described above is a general framework and may require customization based on the specific context and available data.


Statistics:
Citations: 42
Identifiers:
DOI: 10.1136/bmjgh-2021-006102
Research Areas:
Community Interventions, COVID, Health System and Policy, Infectious Diseases, Maternal Access, Maternal and Child Health, Noncommunicable Diseases, Quality of Care, Sexual and Reproductive Health, Social Determinants, Technology and Innovations, Workforce
Study Countries:
Uganda
Study Design:
Cohort Study, Cross Sectional Study, randomised-control-trial
Study Approach:
Mixed-methods, Qualitative, Quantitative
Participants Gender:
Male & Female
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