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

Abstract

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.

Fig 1. Percent change in volume from expected levels based on prepandemic trends by selected health services across 18 countries, March 2020–February 2021.

Note: The horizontal line at 0% represents the expected volume of services based on prepandemic trends. The gray lines plot country-specific changes in service utilization. The monthly country-specific results are presented in Table A in S1 Text. The red line is a multicountry unweighted moving average of the change in utilization plotted by a locally estimated scatterplot smoothing (LOESS) regression. Details on indicator reporting for each country can be found in Table L in S1 Text. ANC1 refers to First Antenatal Care Visit. ANC4 refers to the Fourth Antenatal Care Visit. BCG refers to bacillus Calmette–Guérin vaccination. OPD refers to Outpatient visits. Penta3 refers to the Third dose of Pentavalent vaccine. PNC1 refers to First Postnatal Care Visit.

Fig 2. Estimated and observed volume of outpatient consultations with officially reported COVID-19 deaths per 100,000 and mobility restrictions by country, January 2018–June 2021.

Note: Outpatient consultations are used as a proxy for the utilization of general health services. Data on officially reported COVID-19 deaths are compiled from Johns Hopkins University Coronavirus dashboard [1]. Population denominators for all countries are based on 2019 estimates from the World Bank Development Indicators database. Utilization volume and mortality data are normalized across countries by dividing by the highest observed monthly value within each country. Data on mobility restrictions is summarized by an index of public transport closures, stay-at-home requirements, movement limitations, school closures, and workplace closures stringency scores provided by the Oxford COVID-19 Government Response Tracker. The scores from this index are normalized, and the categorized into quintiles. Gaps in the service volume data are due to months removed because of low completeness. Details on indicator reporting can be found in Table L in S1 Text and data completeness can be found in Fig A in S1 Text. DRC is Democratic Republic of the Congo. Results for ANC1, delivery, BCG, and Penta3 are visualized in Fig B in S1 Text.