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

Abstract

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.

Keywords: COVID-19; child health; maternal health; public health; vaccines.

Figure 1

Antenatal indicators for Kawempe National Referral Hospital (KNRH), July 2019 to December 2020. Interrupted time-series analyses with generalised least square regression for antenatal clinic services. (A) Antenatal clinic (ANC) attendance total attendances and rates of interventions as a proportion of total ANC attendance for: (B) ANC iron administration, (C) ANC folic acid administration, (D) ANC intermittent antimalarial prophylaxis (IPTP) administration, (E) ANC blood pressure measurement, (F) ANC tetanus toxoid administration, (G) ANC HIV testing. (H) Number of women attending prevention of mother to child transmission of HIV (PMTCT) services as part of ANC, before, during and after the COVID-19 lockdown in KNRH. Red dots represent numbers/rates per month. Blue lines connect the red dots to display the observed monthly trend. Red solid lines represent the fitted regression models. Red dashed lines represent the counterfactual scenario.

Figure 2

Labour and delivery indicators for Kawempe National Referral Hospital (KNRH), July 2019 to December 2020. Interrupted time-series analyses with generalised least square regression for (A) total deliveries, (B) caesarean sections, (C) haemorrhage related to labour and delivery, (D) maternal mortality, expressed as rate per 100 000 maternities, (E) stillbirth rate as a percentage of deliveries, (F) preterm birth rate as a percentage of total livebirths, (G) low birth weight as a percentage of total livebirths, before, during and after the COVID-19 lockdown in KNRH. Red dots represent numbers/rates per month. Blue lines connect the red dots to display the observed monthly trend. Red solid lines represent the fitted regression models. Red dashed lines represent the counterfactual scenario.

Figure 3

Neonatal and child health indicators for Kawempe National Referral Hospital (KNRH), July 2019 to December 2020. Interrupted time-series analyses with generalised least squaresregression for (A) neonatal intensive care unit admissions, (B) neonatal mortality rate expressed a rate per 1000 livebirths, (C) immunisation clinic attendance, (D) inpatient pneumonia treatment, (E) inpatient diarrhoea treatment and (F) inpatient malaria treatment, before, during and after the COVID-19 lockdown in KNRH. Red dots represent numbers/rates per month. Blue lines connect the red dots to display the observed monthly trend. Red solid lines represent the fitted regression models. Red dashed lines represent the counterfactual scenario. NICU, neonatal intensive care unit; SCBU, special care baby unit.

Figure 4

Sexual and reproductive health service indicators for Kawempe National Referral Hospital (KNRH), July 2019 to December 2020. Interrupted time-series analyses with generalised least square regression for (A) oral contraceptive recipients, (B) Intrauterine Devices (IUD) insertions, (C) abortions and (D) incomplete abortions, before, during and after the COVID-19 lockdown in KNRH. Red dots represent numbers/rates per month. Blue lines connect the red dots to display the observed monthly trend. Red solid lines represent the fitted regression models. Red dashed lines represent the counterfactual scenario.

Figure 5

Medicine and vaccine unavailability in the prelockdown and postlockdown periods. Overview of medicine stockouts by month. Coloured blocks indicate no stocks available, black lines indicate start and end of lockdown. ORS, oral rehydration salts