Impact of the COVID-19 pandemic on utilisation of facility-based essential maternal and child health services from March to August 2020 compared with pre-pandemic March-August 2019: a mixed-methods study in North Shewa Zone, Ethiopia

BMJ Open, Volume 12, No. 6, Year 2022

Interpretation

Introduction Health systems are often weakened by public health emergencies that make it harder to access health services. We aimed to assess maternal, newborn and child health (MNCH) service utilisation during the first 6 months of the COVID-19 pandemic compared with prior to the pandemic. Methods We conducted a mixed study design in eight health facilities that are part of the Birhan field site in Amhara, Ethiopia and compared the trend of service utilisation in the first 6 months of COVID-19 with the corresponding time and data points of the preceding year. Result New family planning visits (43.2 to 28.5/month, p=0.014) and sick under 5 child visits (225.0 to 139.8/month, p=0.007) declined over the first 6 months of the pandemic compared with the same period in the preceding year. Antenatal (208.9 to 181.7/month, p=0.433) and postnatal care (26.6 to 19.8/month, p=0.155) visits, facility delivery rates (90.7 to 84.2/month, p=0.776), and family planning visits (313.3 to 273.4/month, p=0.415) declined, although this did not reach statistical significance. Routine immunisation visits (37.0 to 36.8/month, p=0.982) for children were maintained. Interviews with healthcare providers and clients highlighted several barriers to service utilisation during COVID-19, including fear of disease transmission, economic hardship, and transport service disruptions and restrictions. Enablers of service utilisation included communities’ decreased fear of COVID-19 and awareness-raising activities. Conclusion We observed a decline in essential MNCH services particularly in sick children and new family planning visits. To improve the resiliency of fragile health systems, resources are needed to continuously monitor service utilisation and clients’ evolving concerns during public health emergencies. We conducted the study in eight health facilities in the Birhan North Shewa Zone, Amhara Region, Ethiopia. The field site was established in June 2018. The Birhan field site is a community-based continuous follow-up study of health and demographic conditions that provides up-to-date information on the catchment population and establishes a population frame to nest studies. We selected all catchment health facilities for this study, including five health centres, two primary hospitals (one public and one private) and one referral hospital. These facilities provide essential MNCH services for both the rural majority population and urban population within the field site catchment and non-catchment areas. The health centres provide antenatal care (ANC), postnatal care (PNC), delivery, abortion, routine immunisation (RI), integrated management of neonatal and childhood illness (IMNCI), and family planning (FP). Each health centre also has a minimum of five service extension health posts, mainly for FP and RI in each kebele (the lowest administration unit in Ethiopia), and each health post sends monthly activity reports to health centres. Two public hospitals (one primary and one referral) and one private general hospital also provide the aforementioned essential MNCH services, except for RI, which is given mainly in health centres and catchment health posts. Mixed phenomenological qualitative and facility-based cross-sectional study designs were employed. For the quantitative part of the study, a facility-based cross-sectional survey was conducted to assess the impact of COVID-19 on essential MNCH service provision or utilisation and provider-side barriers to service provision and utilisation in the Birhan field site catchment health facilities. We interviewed 91 MNCH HCPs (doctors, nurses, midwives and clinical officers available at the time of data collection) with uniformly structured questionnaires about their perception of client flow and possible barriers for respective sections. Twelve out of 91 HCPs were working in two MNCH departments and were interviewed twice. In addition to this, we extracted retrospective, healthcare utilisation time-series data from each facility using monthly facility reports and medical registers. Retrospective facilities’ service statistics were collected over an 18-month period from March 2019 to August 2020 using Computer Assisted Field Editing. We extracted data from the uniformly structured questionnaires, entered it into the Open Data Kit (ODK), and collected and uploaded the data to the ODK aggregate. The monthly facility reports and medical registers data were collected separately. The health centres’ monthly reports include services given in the health posts that are extension sites for the health centre, but the facility registers are exclusively for services given in the health centres. In addition to the cross-sectional study, we implemented a phenomenological qualitative design using in-depth interviews to assess client and provider-side barriers and enablers to service provision/utilisation in the Birhan field site catchment health facilities. We sampled and conducted in-depth interviews until we reached theoretical saturation. For this section of the study, we interviewed 10 facility or department heads, and 9 mothers (delivered at home or facility and had ANC or missed ANC follow-up). An interview guide with open-ended questions was translated from English to Amharic and was used to elicit the qualitative information from informants. We conducted in-person interviews with facility or department heads, women who visited facilities during COVID-19, and women who delivered at the facilities and phone interviews with women who missed an ANC follow-up or delivered at home. With the permission of the respondents, we recorded all interviews and transcribed all records into English for further analysis. To ensure the safety of the data collectors and participants, data collectors wore masks and practised physical distancing during training and data collection from 2 to 20 November 2020. The extracted data were exported to Stata V.17.0 for analysis and the average MNCH service utilisation was calculated each month to quantify the changes pre-COVID-19 (March–August 2019) and during the COVID-19 (March–August 2020) pandemic. To control for potential seasonal fluctuations in service utilisation, March–August 2019 and March–August 2020 were considered pre-COVID-19 and COVID-19 periods, respectively. Across all health facilities, we had 48 paired months of observations (6 months for each of 8 facilities) for all essential MNCH variables except for RI, which was only administered at the five health centres (and corresponding extension health posts), resulting in 30 paired months. Errors were found in some cases where medical records were misplaced and data for some months were missing or partially filled. To avoid the effect of missing and partially filled values, analogous months’ data from the same facility were excluded from the data analysis. Finally, we compared visits for each MNCH service in the pre-COVID-19 and COVID-19 period using a two-tailed independent sample t-test. We repeated the analysis for the initial 2 months (March–April 2020) of the pandemic and the analogous period (March–April 2019) to examine changes in service utilisation at the onset of the COVID-19 pandemic. We used a significance level of α=0.05 for all statistical tests. In addition to the quantitative metrics listed above, English language transcript data were entered in Dedoose software for qualitative data analysis. After familiarisation with the data, the content of the data was coded line by line for thematic analysis following a framework theory approach to describe and interpret health providers’ and communities’ perceptions of barriers and enablers to MNCH service provision. The framework approach involves using some pre-assigned themes to initially categorise data while also adjusting and iterating the coding scheme to accommodate newly emergent themes, subthemes, and categories through inductive interpretation.9 Coded data were examined for potential relationships and themes were also assessed across relevant participant demographic categories to understand different user perspectives. Findings were described under pre-assigned and newly emerged themes. As in-person meetings were restricted by local authorities during protocol development and data collection due to COVID-19 pandemic, we were not permitted to involve clients or the public in study design or reporting and dissemination plans of our research.

AI Digest

Study Justification:

The study aimed to assess the impact of the COVID-19 pandemic on the utilization of essential maternal and child health services in North Shewa Zone, Ethiopia. Public health emergencies often weaken health systems and make it harder for people to access healthcare services. By understanding the changes in service utilization during the pandemic, policymakers and healthcare providers can identify areas of concern and develop strategies to improve the resiliency of the health system.

Highlights:

– New family planning visits and sick under 5 child visits declined significantly during the first 6 months of the pandemic compared to the same period in the previous year.
– Antenatal and postnatal care visits, facility delivery rates, and family planning visits also declined, although not statistically significant.
– Routine immunization visits for children were maintained.
– Barriers to service utilization during COVID-19 included fear of disease transmission, economic hardship, and transport service disruptions and restrictions.
– Enablers of service utilization included decreased fear of COVID-19 among communities and awareness-raising activities.

Recommendations:

– Continuous monitoring of service utilization and clients’ evolving concerns during public health emergencies.
– Allocation of resources to address the decline in essential maternal and child health services, particularly for sick children and new family planning visits.
– Development of strategies to address the identified barriers to service utilization, such as improving transportation services and addressing economic hardships.
– Strengthening awareness-raising activities to promote the importance of accessing healthcare services during the pandemic.

Key Role Players:

– Ministry of Health: Responsible for policy development and resource allocation.
– Healthcare providers: Involved in delivering essential maternal and child health services and implementing strategies to improve service utilization.
– Community leaders and organizations: Engaged in raising awareness and addressing community concerns.
– Non-governmental organizations (NGOs): Provide support and resources to improve service delivery and address barriers to utilization.

Cost Items for Planning Recommendations:

– Transportation services: Budget for improving transportation services to ensure access to healthcare facilities.
– Awareness-raising activities: Allocate funds for community engagement and education campaigns.
– Healthcare workforce: Consider budgeting for additional healthcare providers to meet the increased demand for services.
– Infrastructure and equipment: Allocate resources for improving healthcare facilities and ensuring the availability of necessary equipment and supplies.
– Data collection and monitoring: Budget for the implementation of systems to continuously monitor service utilization and clients’ concerns.

Strength of Evidence

The strength of evidence for this abstract is 7 out of 10.
The evidence in the abstract is moderately strong, but there are some areas for improvement. The study design is mixed-methods, which provides a comprehensive approach to understanding the impact of the COVID-19 pandemic on maternal and child health services. The quantitative data collected from facility reports and medical registers allows for a comparison of service utilization before and during the pandemic. The statistical analysis using t-tests provides some evidence of changes in service utilization. The qualitative data collected through interviews with healthcare providers and clients adds depth to the findings and helps identify barriers and enablers to service utilization. However, there are a few limitations to consider. The sample size for the qualitative interviews is relatively small, which may limit the generalizability of the findings. Additionally, there are errors and missing data in some of the medical records, which could introduce bias into the analysis. To improve the strength of the evidence, it would be beneficial to increase the sample size for the qualitative interviews to ensure a more representative sample. Additionally, efforts should be made to address the errors and missing data in the medical records to ensure the accuracy of the analysis.

Abstract

We conducted the study in eight health facilities in the Birhan North Shewa Zone, Amhara Region, Ethiopia. The field site was established in June 2018. The Birhan field site is a community-based continuous follow-up study of health and demographic conditions that provides up-to-date information on the catchment population and establishes a population frame to nest studies. We selected all catchment health facilities for this study, including five health centres, two primary hospitals (one public and one private) and one referral hospital. These facilities provide essential MNCH services for both the rural majority population and urban population within the field site catchment and non-catchment areas. The health centres provide antenatal care (ANC), postnatal care (PNC), delivery, abortion, routine immunisation (RI), integrated management of neonatal and childhood illness (IMNCI), and family planning (FP). Each health centre also has a minimum of five service extension health posts, mainly for FP and RI in each kebele (the lowest administration unit in Ethiopia), and each health post sends monthly activity reports to health centres. Two public hospitals (one primary and one referral) and one private general hospital also provide the aforementioned essential MNCH services, except for RI, which is given mainly in health centres and catchment health posts. Mixed phenomenological qualitative and facility-based cross-sectional study designs were employed. For the quantitative part of the study, a facility-based cross-sectional survey was conducted to assess the impact of COVID-19 on essential MNCH service provision or utilisation and provider-side barriers to service provision and utilisation in the Birhan field site catchment health facilities. We interviewed 91 MNCH HCPs (doctors, nurses, midwives and clinical officers available at the time of data collection) with uniformly structured questionnaires about their perception of client flow and possible barriers for respective sections. Twelve out of 91 HCPs were working in two MNCH departments and were interviewed twice. In addition to this, we extracted retrospective, healthcare utilisation time-series data from each facility using monthly facility reports and medical registers. Retrospective facilities’ service statistics were collected over an 18-month period from March 2019 to August 2020 using Computer Assisted Field Editing. We extracted data from the uniformly structured questionnaires, entered it into the Open Data Kit (ODK), and collected and uploaded the data to the ODK aggregate. The monthly facility reports and medical registers data were collected separately. The health centres’ monthly reports include services given in the health posts that are extension sites for the health centre, but the facility registers are exclusively for services given in the health centres. In addition to the cross-sectional study, we implemented a phenomenological qualitative design using in-depth interviews to assess client and provider-side barriers and enablers to service provision/utilisation in the Birhan field site catchment health facilities. We sampled and conducted in-depth interviews until we reached theoretical saturation. For this section of the study, we interviewed 10 facility or department heads, and 9 mothers (delivered at home or facility and had ANC or missed ANC follow-up). An interview guide with open-ended questions was translated from English to Amharic and was used to elicit the qualitative information from informants. We conducted in-person interviews with facility or department heads, women who visited facilities during COVID-19, and women who delivered at the facilities and phone interviews with women who missed an ANC follow-up or delivered at home. With the permission of the respondents, we recorded all interviews and transcribed all records into English for further analysis. To ensure the safety of the data collectors and participants, data collectors wore masks and practised physical distancing during training and data collection from 2 to 20 November 2020. The extracted data were exported to Stata V.17.0 for analysis and the average MNCH service utilisation was calculated each month to quantify the changes pre-COVID-19 (March–August 2019) and during the COVID-19 (March–August 2020) pandemic. To control for potential seasonal fluctuations in service utilisation, March–August 2019 and March–August 2020 were considered pre-COVID-19 and COVID-19 periods, respectively. Across all health facilities, we had 48 paired months of observations (6 months for each of 8 facilities) for all essential MNCH variables except for RI, which was only administered at the five health centres (and corresponding extension health posts), resulting in 30 paired months. Errors were found in some cases where medical records were misplaced and data for some months were missing or partially filled. To avoid the effect of missing and partially filled values, analogous months’ data from the same facility were excluded from the data analysis. Finally, we compared visits for each MNCH service in the pre-COVID-19 and COVID-19 period using a two-tailed independent sample t-test. We repeated the analysis for the initial 2 months (March–April 2020) of the pandemic and the analogous period (March–April 2019) to examine changes in service utilisation at the onset of the COVID-19 pandemic. We used a significance level of α=0.05 for all statistical tests. In addition to the quantitative metrics listed above, English language transcript data were entered in Dedoose software for qualitative data analysis. After familiarisation with the data, the content of the data was coded line by line for thematic analysis following a framework theory approach to describe and interpret health providers’ and communities’ perceptions of barriers and enablers to MNCH service provision. The framework approach involves using some pre-assigned themes to initially categorise data while also adjusting and iterating the coding scheme to accommodate newly emergent themes, subthemes, and categories through inductive interpretation.9 Coded data were examined for potential relationships and themes were also assessed across relevant participant demographic categories to understand different user perspectives. Findings were described under pre-assigned and newly emerged themes. As in-person meetings were restricted by local authorities during protocol development and data collection due to COVID-19 pandemic, we were not permitted to involve clients or the public in study design or reporting and dissemination plans of our research.

Materials

Innovations

Based on the information provided, it is difficult to identify specific innovations for improving access to maternal health. However, some potential recommendations based on the study findings and the identified barriers and enablers could include:

1. Telemedicine and virtual consultations: Implementing telemedicine platforms and virtual consultations can help overcome barriers such as fear of disease transmission and transport service disruptions. This would allow pregnant women to receive antenatal care and postnatal care remotely, reducing the need for in-person visits.

2. Mobile health (mHealth) interventions: Utilize mobile phones and SMS messaging to provide health information, reminders for appointments, and educational materials to pregnant women and new mothers. This can help increase awareness and knowledge about maternal health and encourage utilization of services.

3. Community-based outreach programs: Establish community-based outreach programs to raise awareness about the importance of maternal health services and address misconceptions or fears related to COVID-19. This can be done through community health workers or volunteers who can provide information, support, and referrals to health facilities.

4. Strengthening transportation services: Collaborate with local transportation providers to ensure reliable and safe transportation options for pregnant women to access health facilities. This could involve arranging dedicated transport services or subsidizing transportation costs for pregnant women.

5. Financial support and incentives: Provide financial support or incentives to pregnant women and new mothers to encourage them to seek and utilize maternal health services. This could include cash transfers, vouchers, or subsidies for transportation, medications, or other related expenses.

6. Collaboration with private sector and NGOs: Partner with private sector organizations and non-governmental organizations (NGOs) to expand access to maternal health services. This could involve leveraging existing networks, resources, and expertise to reach underserved populations and improve service delivery.

7. Continuous monitoring and evaluation: Establish systems for continuous monitoring and evaluation of maternal health service utilization during public health emergencies. This would help identify trends, challenges, and opportunities for improvement, allowing for timely interventions and adjustments to service delivery.

It is important to note that these recommendations are general and may need to be adapted to the specific context and needs of the North Shewa Zone in Ethiopia.

AI Innovations Description

The study titled “Impact of the COVID-19 pandemic on utilization of facility-based essential maternal and child health services from March to August 2020 compared with pre-pandemic March-August 2019: a mixed-methods study in North Shewa Zone, Ethiopia” provides valuable insights into the decline in maternal and child health service utilization during the COVID-19 pandemic. Based on the findings and the identified barriers and enablers, the following recommendation can be developed into an innovation to improve access to maternal health:

1. Strengthen community awareness and education: Develop and implement targeted awareness campaigns to educate communities about the importance of maternal health services, dispel myths and misconceptions related to COVID-19 transmission, and address fears and concerns. Utilize various communication channels, including radio, television, social media, and community health workers, to reach a wide audience.

2. Expand telehealth services: Establish and promote telehealth platforms that allow pregnant women to access antenatal care, postnatal care, and counseling remotely. This can include virtual consultations, remote monitoring of vital signs, and provision of health information through mobile applications or text messages. Ensure that these services are accessible to women in both urban and rural areas, taking into account the availability of internet connectivity and mobile phone access.

3. Improve transportation services: Collaborate with local transportation providers and authorities to ensure reliable and safe transportation options for pregnant women to reach health facilities. This can involve setting up dedicated transport services or subsidizing transportation costs for women seeking maternal health services. Additionally, explore innovative solutions such as community-based transportation networks or partnerships with ride-sharing platforms.

4. Strengthen health facility preparedness: Provide necessary resources and support to health facilities to ensure they are adequately prepared to handle maternal health services during public health emergencies. This includes ensuring the availability of personal protective equipment (PPE) for healthcare providers, implementing infection prevention and control measures, and establishing protocols for managing suspected or confirmed COVID-19 cases.

5. Enhance collaboration and coordination: Foster collaboration between healthcare providers, community leaders, and relevant stakeholders to address the challenges faced in accessing maternal health services. This can involve establishing coordination mechanisms, such as task forces or committees, to facilitate information sharing, resource allocation, and joint decision-making.

6. Monitor and evaluate service utilization: Develop a robust monitoring and evaluation system to continuously track and analyze maternal health service utilization during and after the COVID-19 pandemic. This can help identify trends, gaps, and areas for improvement, and inform evidence-based decision-making and resource allocation.

By implementing these recommendations, stakeholders can work towards improving access to maternal health services, ensuring the well-being of pregnant women and their newborns, and strengthening health systems’ resilience during public health emergencies.

AI Innovations Methodology

Based on the provided description, here are some potential recommendations for improving access to maternal health:

1. Strengthen community awareness and education: Implement community-based awareness campaigns to educate individuals about the importance of maternal health services, address misconceptions, and promote the utilization of available services.

2. Improve transportation services: Address transport service disruptions and restrictions by collaborating with local transportation providers to ensure reliable and affordable transportation options for pregnant women seeking maternal health services.

3. Enhance economic support: Provide financial assistance or subsidies to pregnant women and their families to alleviate economic hardships associated with accessing maternal health services, such as transportation costs or medical fees.

4. Expand telemedicine and mobile health initiatives: Develop and promote telemedicine and mobile health solutions to provide remote access to prenatal and postnatal care, consultations, and health information for pregnant women in remote or underserved areas.

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

1. Define indicators: Identify specific indicators that reflect access to maternal health services, such as the number of antenatal care visits, facility delivery rates, or postnatal care visits.

2. Baseline data collection: Gather historical data on the selected indicators for a specific period before the implementation of the recommendations (e.g., pre-COVID-19 period).

3. Implement recommendations: Introduce the recommended interventions or innovations to improve access to maternal health services.

4. Data collection during implementation: Continuously collect data on the selected indicators during the implementation period to monitor changes in access to maternal health services.

5. Comparative analysis: Compare the data collected during the implementation period with the baseline data to assess the impact of the recommendations on improving access to maternal health services.

6. Statistical analysis: Use statistical methods, such as t-tests or regression analysis, to analyze the data and determine the significance of the observed changes.

7. Qualitative analysis: Conduct qualitative analysis of interviews or surveys to gather insights on the experiences and perceptions of healthcare providers and clients regarding the impact of the recommendations.

8. Interpretation and reporting: Interpret the findings of the analysis and prepare a comprehensive report summarizing the impact of the recommendations on improving access to maternal health services.

Authors & Co-Authors

Statistics:

Citations: 3

Authors: 9

Identifiers:

DOI: 10.1136/bmjopen-2021-059408

Research Areas:

Community Interventions, COVID, Health System and Policy, Maternal Access, Maternal and Child Health, Quality of Care, Sexual and Reproductive Health, Social Determinants, Workforce

Study Countries:

Ethiopia

Study Design:

Cohort Study, Cross Sectional Study, Exploratory Study, Grounded Theory, Phenomenological Study

Study Approach:

Mixed-methods, Qualitative, Quantitative

Participants Gender:

Female