Assessing the impact of COVID-19 pandemic on maternal healthcare usage: evidence from routine health data in Kenya and Ethiopia

Abstract

Objectives: Lockdowns and fear of COVID-19 may have reduced access to antenatal care (ANC) and skilled birth attendance (SBA) in sub-Saharan Africa, which could undermine progress towards maternal and child survival and the sustainable development goals (SDGs). We analysed COVID-19's impact on maternal healthcare usage, focusing on subnational levels, to identify healthcare disruption hotspots that require targeted interventions and help policymakers prioritise resources to accelerate progress.

Methods and analysis: Using monthly health management information system (HMIS) data, we tracked changes in healthcare access at subnational levels in Ethiopia and Kenya during the pandemic. We compared service usage before and during the pandemic, using interrupted time series and counterfactual analyses to evaluate the pandemic's impact on healthcare usage trends. We also performed geospatial mapping of the affected regions to identify hotspots.

Results: Our results show significant changes at subnational levels. ANC declined in several Kenyan counties during the pandemic, with improvements observed in others. SBA disruptions were observed in two counties. In Ethiopia, ANC declined in the north but remained unchanged in the south, with some improvements observed in the two regions. Southern regions showed resilience in SBA, experiencing gains, while northern regions showed no change.

Conclusion: Future disease outbreaks may continue to cause further disruptions to health service delivery, affecting maternal and child health outcomes. Our analysis highlights the low resilience of subnational health systems to shocks, underscoring the need to strengthen healthcare systems and HMIS data capture for better data quality. Evidence-based research is essential in identifying hotspots and supporting targeted interventions to achieve the SDGs and improve maternal and child health outcomes.

Keywords: COVID-19; Community Health; Epidemiology; Public Health.

Figure 1. Top panel: map showing 47 counties in Kenya. Bottom panel: map showing 12 regions in Ethiopia.

Figure 2. Top panel: ANC coverage (%) for Kenya in the pre-COVID-19 period 2018–2019 (left) and during the COVID-19 period 2020–2021 (right) (green=high ANC coverage rates or increase in coverage and red=low ANC coverage rates or decrease in coverage). Bottom panel: difference in ANC coverage between pre-COVID-19 and during COVID-19 period (left) (green=increase in ANC coverage rate, red=reduction in ANC coverage rates and white=no change) and its statistical significance (right). Data source: Kenya health management information system. ANC, antenatal care.

Figure 3. Top panel: ANC coverage (%) for Ethiopia in the pre-COVID-19 period 2018–2019 (left) and during the COVID-19 period 2020–2021 (right) (green=high ANC coverage rates or increase in coverage and red=low ANC coverage rates or decrease in coverage). Bottom panel: difference in ANC coverage between pre-COVID-19 and during COVID-19 period (left) (green=increase in ANC coverage rate, red=reduction in ANC coverage rates and white=no change) and its statistical significance (right). Data source: Ethiopia health management information system. ANC, antenatal care.

Figure 4. Subnational trends in Kenya’s SBA service usage in Kericho, Tharaka-Nithi, Makueni and Siaya counties. Trends from 2016 to 2021. The dark blue trend line denotes the monthly service usage. The blue trend line represents a smoothed estimation of service usage over the same period. The red vertical line indicates a time point (month) when the first cases of COVID-19 were identified and subsequent lockdown restrictions were enforced. The green vertical line denotes a time point (month) when COVID-19 vaccines were rolled out. SBA, skilled birth attendance.

Figure 5. Top panel: SBA coverage (%) for Ethiopia in the pre-COVID-19 period 2018–2019 (left) and during the COVID-19 period 2020–2021 (right) (green=high SBA coverage rates or increase in coverage and red=low SBA coverage rates or decrease in coverage). Bottom panel: difference in SBA coverage between pre-COVID-19 and during COVID-19 period (left) (green=increase in SBA coverage rate, red=reduction in SBA coverage rates and white=no change) and its statistical significance (right). Data source: Ethiopia HMIS.

Figure 6. Counterfactual ANC usage in Embu County, Kenya (left) and Dire-Dawa region, Ethiopia (right). The blue trend denotes the observed ANC usage from 2016 to 2021. The green line indicates projected usage given the data in the pre-pandemic period. The red vertical line represents the time point (month) when the first cases of COVID-19 were observed in Kenya and Ethiopia. ANC, antenatal care.