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.

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.

How many infants may have died in low-income and middle-income countries in 2020 due to the economic contraction accompanying the COVID-19 pandemic? Mortality projections based on forecasted declines in economic growth

ObjectivesWhile COVID-19 has a relatively small direct impact on infant mortality, the pandemic is expected to indirectly increase mortality of this vulnerable group in low-income and middle-income countries through its effects on the economy and health system performance. Previous studies projected indirect mortality by modelling how hypothesised disruptions in health services will affect health outcomes. We provide alternative projections, relying on modelling the relationship between aggregate income shocks and mortality.DesignWe construct a sample of 5.2 million births by pooling retrospective birth histories reported by women in Demographic and Health Surveys conducted in 83 low-income and middle-income countries between 1985 and 2018. We employ regression models with country-specific fixed-effects and flexible time trends to estimate the impact of gross domestic product per capita on infant mortality rate. We then use growth projections by the International Monetary Fund to predict the effect of the economic downturn in 2020 on infant mortality.ResultsWe estimate 267 208 (95% CI 112 000 to 422 415) excess infant deaths in 128 countries, corresponding to a 6.8% (95% CI 2.8% to 10.7%) increase in the total number of infant deaths expected in 2020.ConclusionsThe findings underscore the vulnerability of infants to the negative income shocks such as those imposed by the COVID-19 pandemic. While efforts towards prevention and treatment of COVID-19 remain paramount, the global community should also strengthen social safety nets and assure continuity of essential health services.

THE INTERGENERATIONAL MORTALITY TRADE-OFF OF COVID-19 LOCKDOWN POLICIES.

In lower-income countries, the economic contractions that accompany lockdowns to contain COVID-19 transmission can increase child mortality, counteracting the mortality reductions achieved by the lockdown. To formalize and quantify this effect, we build a macrosusceptible-infected-recovered model that features heterogeneous agents and a country-group-specific relationship between economic downturns and child mortality and calibrate it to data for 85 countries across all income levels. We find that in some low-income countries, a lockdown can produce net increases in mortality. The optimal lockdown that maximizes the present value of aggregate social welfare is shorter and milder in poorer countries than in rich ones.

The Intergenerational Mortality Tradeoff of COVID-19 Lockdown Policies

In lower-income countries, the economic contractions that accompany lockdowns to contain the spread of COVID-19 can increase child mortality, counteracting the mortality reductions achieved by the lockdown. To formalize and quantify this effect, we build a macro-susceptible-infected-recovered model that features heterogeneous agents and a country-group-specific relationship between economic downturns and child mortality, and calibrate it to data for 85 countries across all income levels. We find that in low-income countries, a lockdown can potentially lead to 1.76 children’s lives lost due to the economic contraction per COVID-19 fatality averted. The ratio stands at 0.59 and 0.06 in lower-middle and upper-middle income countries, respectively. As a result, in some countries lockdowns actually can produce net increases in mortality. The optimal lockdowns are shorter and milder in poorer countries than in rich ones, and never produce a net mortality increase.

Disruptions in maternal and child health service utilization during COVID-19: analysis from eight sub-Saharan African countries.

The coronavirus-19 pandemic and its secondary effects threaten the continuity of essential health services delivery, which may lead to worsened population health and a protracted public health crisis. We quantify such disruptions, focusing on maternal and child health, in eight sub-Saharan countries. Service volumes are extracted from administrative systems for 63 954 facilities in eight countries: Cameroon, Democratic Republic of Congo, Liberia, Malawi, Mali, Nigeria, Sierra Leone and Somalia. Using an interrupted time series design and an ordinary least squares regression model with facility-level fixed effects, we analyze data from January 2018 to February 2020 to predict what service utilization levels would have been in March-July 2020 in the absence of the pandemic, accounting for both secular trends and seasonality. Estimates of disruption are derived by comparing the predicted and observed service utilization levels during the pandemic period. All countries experienced service disruptions for at least 1 month, but the magnitude and duration of the disruptions vary. Outpatient consultations and child vaccinations were the most commonly affected services and fell by the largest margins. We estimate a cumulative shortfall of 5 149 491 outpatient consultations and 328 961 third-dose pentavalent vaccinations during the 5 months in these eight countries. Decreases in maternal health service utilization are less generalized, although significant declines in institutional deliveries, antenatal care and postnatal care were detected in some countries. There is a need to better understand the factors determining the magnitude and duration of such disruptions in order to design interventions that would respond to the shortfall in care. Service delivery modifications need to be both highly contextualized and integrated as a core component of future epidemic response and planning.