ABSTRACT
The Coronavirus disease 2019 (COVID-19) has been a major disruptor of health systems globally. Its emergence has warranted the need to reorganize maternity services for childbirth. However, it is not known if this comes at an additional cost to women. We conducted a hospital-based cost analysis to estimate the out-of-pocket cost of spontaneous vaginal delivery (SVD) and caesarean delivery (CD). Specifically, we collected facility-based and household costs of all nine pregnant women with COVID-19 who were managed between 1st April and 30th August 2020 at the largest teaching hospital in Lagos, the epicentre of COVID-19 in Nigeria. We compared the mean facility-based costs for the cohort with costs paid by pregnant women pre-COVID-19, identifying major cost drivers. We also estimated what would have been paid without subsidies, testing assumptions with a sensitivity analysis. Findings showed that total utilization cost ranged from US$494 (N190,150) for SVD with mild COVID-19 to US$4,553 (N1,751,165) for emergency CD with severe COVID-19. Though 32-66% of facility-based cost has been subsidized, cost of SVD and CD have doubled and tripled respectively during the pandemic compared to those paid pre-COVID. Out of the facility-based costs paid, cost of personal protective equipment (PPE) was the major cost driver (50%) for SVD and CD. Supplemental oxygen was a major cost driver when women had severe COVID-19 symptoms and required long admission (48%). Excluding treatment costs specifically for COVID-19, mean facility-based costs for SVD and CD are US$228 (N87,750) and US$948 (N364,551) respectively. Our study demonstrates that despite cost exemptions and donations, utilization costs remain prohibitive. Regulation of the PPE and medical oxygen supply chain can help drive down utilization cost and reduce mark-ups being passed to users. The pandemic offers an opportunity to expand advocacy for subscription to health insurance schemes in order to avoid any catastrophic health expenditure. KEY MESSAGESO_LITotal utilization cost ranged from US$494 (N190,150) for spontaneous vaginal delivery with mild COVID-19 to US$4,553 (N1,751,165) for emergency caesarean delivery with severe COVID-19. C_LIO_LICost of personal protective equipment was the major cost driver (50%) for vaginal and elective caesarean deliveries. Medical oxygen was a major cost driver when women had severe COVID-19 symptoms (48%) and required long admission. C_LIO_LIThough 32-66% of total cost have been subsidized, facility-based cost of vaginal and caesarean deliveries has doubled and tripled respectively during the pandemic compared to those paid pre-COVID. C_LIO_LIThe study findings highlight the urgent need to implement strategies that can help to minimize the rising costs that pregnant women with COVID-19 face in accessing and utilizing critical intra-partum care. C_LI
ABSTRACT
ObjectiveTo prospectively document experiences of frontline maternal and newborn healthcare providers during the COVID-19 pandemic. DesignCross-sectional study via an online survey disseminated through professional networks and social media in 12 languages. We analysed responses using descriptive statistics and qualitative thematic analysis disaggregating by low- and middle-income countries (LMICs) and high-income countries (HICs). Setting81 countries, between March 24 and April 10, 2020. Participants714 maternal and newborn healthcare providers. Main outcome measuresPreparedness for and response to COVID-19, experiences of health workers providing care to women and newborns, and adaptations to 17 outpatient and inpatient care processes during the pandemic. ResultsOnly one third of respondents received training on COVID-19 from their health facility and nearly all searched for information themselves. Half of respondents in LMICs received updated guidelines for care provision compared with 82% in HICs. Overall, only 47% of participants in LMICs, and 69% in HICs felt mostly or completely knowledgeable in how to care for COVID-19 maternity patients. Facility-level responses to COVID-19 (signage, screening, testing, and isolation rooms) were more common in HICs than LMICs. Globally, 90% of respondents reported somewhat or substantially higher levels of stress. There was a widespread perception of reduced use of routine maternity care services, and of modification in care processes, some of which were not evidence-based. ConclusionsSubstantial knowledge gaps exist in guidance on management of maternity cases with or without COVID-19. Formal information sharing channels for providers must be established and mental health support provided. Surveys of maternity care providers can help track the situation, capture innovations, and support rapid development of effective responses. Key MessagesO_LSTWhat is already knownC_LSTO_LIIn addition to lack of healthcare worker protection, staffing shortages, heightened risk of nosocomial transmission and decreased healthcare use described in previous infectious disease outbreaks, maternal and newborn care during the COVID-19 pandemic has also been affected by large-scale lockdowns/curfews. C_LIO_LIThe two studies assessing the indirect effects of COVID-19 on maternal and child health have used models to estimate mortality impacts. C_LIO_LIExperiences of frontline health professionals providing maternal and newborn care during the COVID-19 pandemic have not been empirically documented to date. C_LI O_LSTWhat this study addsC_LSTO_LIRespondents in high-income countries more commonly reported available/updated guidelines, access to COVID-19 testing, and dedicated isolation rooms for confirmed/suspected COVID-19 maternity patients. C_LIO_LILevels of stress increased among health professionals globally, including due to changed working hours, difficulties in reaching health facilities, and staff shortages. C_LIO_LIHealthcare providers were worried about the impact of rapidly changing care practices on health outcomes: reduced access to antenatal care, fewer outpatient visits, shorter length-of-stay in facilities after birth, banning birth companions, separating newborns from COVID-19 positive mothers, and postponing routine immunisations. C_LIO_LICOVID-19 illustrates the susceptibility of maternity care services to emergencies, including by reversing hard-won gains in healthcare utilisation and use of evidence-based practices. These rapid findings can inform countries of the main issues emerging and help develop effective responses. C_LI
