Effects of COVID-19 on Maternal and Neonatal Outcomes and Access to Antenatal and Postnatal Care, Malawi

Abstract

We used national facility-level data from all government hospitals in Malawi to examine the effects of the second and third COVID-19 waves on maternal and neonatal outcomes and access to care during September 6, 2020-October 31, 2021. The COVID-19 pandemic affected maternal and neonatal health not only through direct infections but also through disruption of the health system, which could have wider indirect effects on critical maternal and neonatal outcomes. In an interrupted time series analysis, we noted a cumulative 15.4% relative increase (63 more deaths) in maternal deaths than anticipated across the 2 COVID-19 waves. We observed a 41% decrease in postnatal care visits at the onset of the second COVID-19 wave and 0.2% by the third wave, cumulative to 36,809 fewer visits than anticipated. Our findings demonstrate the need for strengthening health systems, particularly in resource-constrained settings, to prepare for future pandemic threats.

Keywords: Africa; COVID-19; Malawi; SARS; SARS-CoV-2; Surveillance; coronavirus; coronavirus disease; interrupted time series; maternal health; respiratory infections; severe acute respiratory syndrome coronavirus 2; viruses; zoonoses.

Figure 1

Epidemic data used in study of effects of COVID-19 on maternal and neonatal outcomes and access to antenatal and postnatal care, Malawi. A) Daily confirmed COVID-19 cases; B) daily confirmed COVID-19 deaths. The epidemiologic curve shows the beginning of second and third waves of COVID-19 in Malawi. Grey bars indicate daily case counts; blue lines indicate centered 14-day moving averages; orange vertical lines indicate proposed time points for the interruptions in the segmented time series analysis: January 1, 2021, just before the second COVID-19 wave; and June 20, 2021, just before the third COVID-19 wave. Data are from the Johns Hopkins University Center for Systems Science and Engineering (https://coronavirus.jhu.edu/map.html).

Figure 2

Maternal death rates in study of effects of COVID-19 on maternal and neonatal outcomes and access to antenatal and postnatal care, Malawi. Circles indicate observed data; blue lines indicate model fit from actual data, including step and slope changes during second (January 1, 2021) and third (June 20, 2021) COVID-19 waves. Dashed orange line indicates the counterfactual scenario of no second or third COVID−19 waves. Blue shaded areas indicate 95% CIs; yellow shaded areas indicate 95% CIs for the counterfactual scenario. Background shaded areas indicate the second (light gray) and third (dark gray) COVID−19 waves in Malawi. Pseudo R² = 0.06.

Figure 3

Neonatal death rates in study of effects of COVID-19 on maternal and neonatal outcomes and access to antenatal and postnatal care, Malawi. Circles indicate observed data; blue lines indicate model fit from actual data, including step and slope changes during second (January 1, 2021) and third (June 20, 2021) COVID-19 waves. Dashed orange line indicates the counterfactual scenario of no second or third COVID−19 waves. Blue shaded areas indicate 95% CIs; yellow shaded areas indicate 95% CIs for the counterfactual scenario. Background shaded areas indicate the second (light gray) and third (dark gray) COVID−19 waves in Malawi. Pseudo R² = 0.02.

Figure 4

Stillbirth rates in study of effects of COVID-19 on maternal and neonatal outcomes and access to antenatal and postnatal care, Malawi. Circles indicate observed data; blue lines indicate model fit from actual data, including step and slope changes during second (January 1, 2021) and third (June 20, 2021) COVID-19 waves. Dashed orange line indicates the counterfactual scenario of no second or third COVID−19 waves. Blue shaded areas indicate 95% CIs; yellow shaded areas indicate 95% CIs for the counterfactual scenario. Background shaded areas indicate the second (light gray) and third (dark gray) COVID−19 waves in Malawi. Pseudo−R² = 0.04.

Figure 5

Antenatal clinic visits in study of effects of COVID-19 on maternal and neonatal outcomes and access to antenatal and postnatal care, Malawi. Circles indicate observed data; blue lines indicate model fit from actual data, including step and slope changes during second (January 1, 2021) and third (June 20, 2021) COVID-19 waves. Dashed orange line indicates the counterfactual scenario of no second or third COVID−19 waves. Blue shaded areas indicate 95% CIs; yellow shaded areas indicate 95% CIs for the counterfactual scenario. Background shaded areas indicate the second (light gray) and third (dark gray) COVID−19 waves in Malawi. Pseudo R² = 0.01.

Figure 6

Postnatal clinic visits in study of effects of COVID-19 on maternal and neonatal outcomes and access to antenatal and postnatal care, Malawi. Circles indicate observed data; blue lines indicate model fit from actual data, including step and slope changes during second (January 1, 2021) and third (June 20, 2021) COVID-19 waves. Dashed orange line indicates the counterfactual scenario of no second or third COVID−19 waves. Blue shaded areas indicate 95% CIs; yellow shaded areas indicate 95% CIs for the counterfactual scenario. Background shaded areas indicate the second (light gray) and third (dark gray) COVID−19 waves in Malawi. Pseudo R² = 0.12.