Healthcare utilization and maternal and baby mortality in the course of the COVID-19 pandemic in 18 low- and middle-income nations: An interrupted time-series evaluation with mathematical modeling of administrative information

Month-to-month administrative information on the amount of key important well being companies between January 2018 and June 2021 have been collated from 18 nations collaborating in a monitoring exercise supported by the International Financing Facility for Girls, Youngsters, and Adolescents (GFF). Eleven nations are labeled as low-income by the World Financial institution: Afghanistan, the Democratic Republic of Congo (DRC), Ethiopia, Guinea, Liberia, Madagascar, Malawi, Mali, Sierra Leone, Somalia, and Uganda. The opposite 7 nations, Bangladesh, Cameroon, Ghana, Haiti, Kenya, Nigeria, and Senegal, are labeled as lower-middle-income. Seven companies have been chosen to symbolize the continuum of reproductive, maternal, and baby well being: household planning, antenatal care initiation (ANC1), antenatal care completion (ANC4), supply, postnatal care initiation (PNC1), bacillus Calmette–Guérin (BCG) vaccine administration, and completion of pentavalent schedule (Penta3). These companies have been chosen as a result of they’re excessive completeness throughout nations and function proxies for different companies and interventions delivered on the similar level. As well as, outpatient consultations (OPDs) have been used as a proxy for the overall use of well being companies. Consequence measures weren’t included since uncommon outcomes (e.g., maternal dying, stillbirths) are troublesome to precisely seize in facility information, or the information completeness was too poor for this evaluation. Seven nations’ administrative information programs have been lacking 1 indicator, and Uganda was lacking 2 indicators. Household planning quantity was essentially the most steadily lacking indicator and was not reported in 5 nations (see Desk A in S1 Textual content). The evaluation used available-case evaluation, the place amenities with partial facility-month observations have been included within the evaluation. Variations in indicator definitions have been noticed throughout nations, significantly in OPD (whole attendance versus whole outpatient consultations), supply (institutional deliveries versus institutional deliveries with a talented beginning attendant), and PNC1 (first postnatal go to versus time-bound PNC visits). In nations with each variations of indicators, a sensitivity test was performed to exhibit that each reporting strategies yielded comparable outcomes (see Tables B, C, and D in S1 Textual content).

HMIS information validity is commonly assessed within the context of measuring service protection ranges and may mirror challenges resulting from components similar to poor representativeness and the accuracy of inhabitants denominators [28]. Regardless of discovering shortcomings in measuring service protection, earlier authors have known as for the higher use of HMIS information, particularly absolutely the variety of companies supplied every month, in analysis and coverage selections. On this research, we don’t try to estimate inhabitants service protection however slightly assume that the change in service-specific utilization reported by amenities within the HMIS represents the proportion change in inhabitants service protection. We consider this use of HMIS, not as an estimate of protection however as an estimate of protection change, is much less topic to numerous potential biases. The power to carefully estimate modifications in service quantity regardless of limitations of facility information has been beforehand demonstrated [29]. Apart from Bangladesh and Nigeria, there needs to be excessive representativeness of amenities that report back to HMIS for the reason that public sector delivers the vast majority of care. The first concern is the attainable differential change in utilization between reporting and nonreporting amenities. Findings from family surveys and interviews with key well being system stakeholders in the course of the pandemic affirm that personal amenities and group packages didn’t compensate for the disruptions within the public sector, and there have been substantial ranges of foregone care within the inhabitants [17,20].

HMIS information have been downloaded on 22 August 2021, and have been ready for evaluation by eradicating outlier values and proscribing information for indicators with low completeness. These preparation steps are detailed within the Supporting data (see Textual content A in S1 Textual content), and the benefits and downsides of HMIS information are mentioned in earlier work [14]. To additional assess the standard and reliability of the information, we current a variety of sensitivity exams; we describe information reporting completeness (see Fig A in S1 Textual content) and embrace a sensitivity test displaying that modifications in reporting patterns didn’t drive the outcomes. We additionally specify for every nation and indicator the dates dropped resulting from poor completeness, or information availability that will scale back the prepandemic follow-up (see Desk L in S1 Textual content). The ultimate dataset included 137,192 well being amenities starting from 478 amenities in Guinea to 34,701 in Nigeria. The studies cowl 42 months and eight companies, for 21,421,125 nonmissing facility-month-service observations within the 18 nations.

We obtained information from 2 further sources to evaluate whether or not service disruptions correlate with formally reported COVID-related dying charges or with mobility restrictions. Knowledge on reported COVID-19 deaths have been obtained from the Heart for Programs Science and Engineering (CSSE) at Johns Hopkins College, which compiles information from official authorities COVID-19 surveillance studies. Official accounts are prone to underreport precise mortality in settings with restricted testing capability, significantly originally of the pandemic [30]. Nonetheless, even when the official studies are inaccurate, there are lots of mechanisms by which these studies might have an effect on service utilization, similar to altering perceptions by well being suppliers and the inhabitants on the state of the outbreak. Subsequently, one option to interpret these information is as a proxy for the perceived danger of an infection. Info on the coverage measures affecting inhabitants mobility was obtained from the Oxford COVID-19 Authorities Coverage Tracker, which systematically tracks implementation dates and scores the stringency of coverage interventions. We chosen a subset of insurance policies that will have an effect on inhabitants entry to well being amenities: public transport closures, stay-at-home necessities, motion limitations, college closures, and office closures. The dataset consists of ordinal severity scores for every coverage to seize the stringency of restriction, starting from no restrictions to suggestions to necessities with minimal exceptions. We constructed an index representing the each day severity of mobility restrictions utilizing the primary part of a principal part evaluation of those chosen indicators. There’s a correlation of 0.92 between the index we assemble and the Oxford response stringency index, composed of a wider set of interventions. The Oxford COVID-19 Coverage Tracker captures as-written strictness of insurance policies however not ranges of enforcement. As we’re unaware of a dependable supply on ranges of enforcement of restrictions, variations in ranges of enforcement between nations weren’t taken under consideration.

We used an interrupted time-series strategy to foretell the amount of companies that will have been delivered had the pandemic not occurred. The interruption interval begins with the WHO pandemic declaration in March 2020, coinciding with the beginning of group transmission and mobility restrictions in most nations. Service and nations have been modeled individually utilizing a linear regression equation with the next type:

the place Y_tf is the service quantity reported by facility f in month t. T represents the time in months since January 2018 to account for a linear secular pattern (β₁), Month represents calendar months to account for seasonality (β_2..12), and α_f represents the facility-level fastened impact accounting for time-invariant facility traits. Mounted results have been changed with facility attribute covariates (province and facility kind) in Uganda, the place an replace to the executive system didn’t permit for constant identification of amenities over time. PandemicMonth denotes a collection of dummy variables for every of the months between March 2020 and June 2021. That’s, β_13..29 comprise estimated disruption for every month for the reason that pandemic.

We additional examined whether or not the estimated month-to-month modifications in service volumes confirmed statistical affiliation with the time elapsed for the reason that begin of the pandemic, the month-to-month variety of official reported COVID deaths, and the stringency of mobility restrictions. These relationships have been assessed by working the next linear regression individually for every service:

the place D_tc is the estimated month-to-month change in service quantity for month t in nation c. CovidMortality_tc represents the formally reported month-to-month variety of COVID-19-related deaths per 100,000 folks, and RestrictionStringency_tc represents the typical month-to-month stringency of the mobility restrictions. α_c represents a rustic fastened impact, and ε_tc is a usually distributed error time period.

We estimated the influence of the service utilization disruptions on absolutely the variety of baby, neonatal, and maternal deaths utilizing the Lives Saved Instrument (LiST). LiST is a mathematical mannequin that forecasts mortality estimates from the protection of 70+ RMNCH+N well being interventions, contemplating the precise demographic and epidemiological context of a rustic [31]. We assumed that the relative change within the protection of the interventions included within the LiST mannequin was the identical because the estimated relative modifications in service utilization. Every intervention was linked to the service throughout which the intervention is usually delivered or proxied by the service assumed to have an analogous utilization sample. For interventions with out a cheap proxy, similar to baby diet companies, the conservative default assumed no change within the intervention protection. This linking of service indicators to LiST interventions is described in Desk E of S1 Textual content. As a number of RMNCH interventions have been linked to a small set of indicators, small variations within the few service indicators considerably have an effect on the general mortality outcomes. To handle this, we ran a sensitivity evaluation utilizing completely different linking combos to grasp how these linking selections alter the outcomes and restrict their potential impact.

We ran 2 LiST analyses for every nation and quarter: first, a “with out pandemic” state of affairs, utilizing solely the counterfactual protection values, to acquire the anticipated deaths within the absence of the pandemic; and second, a “with pandemic” state of affairs, to acquire the anticipated deaths in the course of the pandemic. LiST solely takes yearly enter values, so we entered quarterly values as yearly values (for 2020 or 2021, as acceptable), and divided the ensuing anticipated deaths by 4, to acquire the anticipated deaths for the quarter. We took the distinction in anticipated deaths between the “with pandemic” and “with out pandemic” eventualities to symbolize the extra deaths because of the pandemic. For every nation and age group, we report the variety of deaths that we might have anticipated within the absence of the pandemic for the interval March 2020 to June 2021, the estimated variety of further maternal and baby (together with neonatal) deaths because of the change in service utilization throughout this similar interval, and the relative enhance in mortality due to service utilization declines in the course of the pandemic. The RECORD guidelines is included within the Supporting data (S1 RECORD Guidelines). Examine limitations embrace the belief that the modifications in service-specific utilization reported within the HMIS represents the proportion of service protection change within the inhabitants, and the shortcoming to account for differential modifications in health-seeking behaviors throughout severity of want.

We focus first on the variety of outpatient consultations as a proxy for normal service utilization. As proven in Desk 2, the cumulative variety of reported outpatient consultations between March 2020 and June 2021 is considerably decrease than anticipated, given the prepandemic tendencies in all nations aside from Cameroon, Liberia, and Somalia. These 3 nations additionally skilled substantial month-to-month declines in outpatient consultations in comparison with anticipated values, however the reductions over the 16-month period are usually not statistically vital (see Desk A in S1 Textual content). On common, the nations on this evaluation skilled a cumulative discount of 13% in outpatient consultations in comparison with historic utilization tendencies. The biggest decline of 40% is estimated for Bangladesh, adopted by 25% in Haiti and Kenya. Massive declines between 10% and 20% are estimated for Ethiopia, Ghana, Guinea, Madagascar, Nigeria, Senegal, Sierra Leone, and Uganda. As seen in Fig 1, unweighted shifting common month-to-month outpatient service volumes are under anticipated for all months between March 2020 and June 2021.

Fig 1. P.c change in quantity from anticipated ranges primarily based on prepandemic tendencies by chosen well being companies throughout 18 nations, March 2020–February 2021.

Be aware: The horizontal line at 0% represents the anticipated quantity of companies primarily based on prepandemic tendencies. The grey traces plot country-specific modifications in service utilization. The month-to-month country-specific outcomes are offered in Desk A in S1 Textual content. The purple line is a multicountry unweighted shifting common of the change in utilization plotted by a domestically estimated scatterplot smoothing (LOESS) regression. Particulars on indicator reporting for every nation may be present in Desk L in S1 Textual content. ANC1 refers to First Antenatal Care Go to. ANC4 refers back to the Fourth Antenatal Care Go to. BCG refers to bacillus Calmette–Guérin vaccination. OPD refers to Outpatient visits. Penta3 refers back to the Third dose of Pentavalent vaccine. PNC1 refers to First Postnatal Care Go to.

https://doi.org/10.1371/journal.pmed.1004070.g001

The disruptions to RMNCH companies are smaller on common than these noticed in outpatient consultations. For baby vaccination, 10 out of 18 nations skilled vital cumulative reductions within the variety of youngsters receiving the third dose of the pentavalent vaccine. Out of the 14 nations with HMIS information on administered BCG vaccine doses, 8 skilled vital cumulative reductions. In most nations, the month-to-month reductions in vaccination have been largest at first of the pandemic and returned to the prepandemic expectation by July 2020 (see Fig 1). Whereas the return to the anticipated ranges is encouraging, we don’t see a rise representing facility-based catch-up for the vaccinations missed early in the course of the pandemic. A unique sample is noticed for antenatal care initiation (ANC1). An preliminary lower is adopted by a rise above the anticipated quantity, indicating that some girls might have delayed their go to with out fully forgoing antenatal care. Reproductive and maternal well being companies disruptions have been extra context-specific than disruptions in outpatient care and baby vaccination. Important declines within the supply indicators, for instance, are estimated in 10 out of the 18 nations. On the similar time, Cameroon, Ethiopia, Madagascar, and Senegal reported volumes considerably exceeding these anticipated primarily based on prepandemic tendencies. Important cumulative reductions in household planning companies are estimated for six out of 12 nations with obtainable information. Massive reductions in household planning quantity of a minimum of 10% have been skilled in Guinea, Mali, and Sierra Leone.

Along with the cross-country variation, the magnitude of service quantity disruption diverse in the course of the pandemic. Fig 2 presents the instance of outpatient consultations and portrays a country-specific relationship between the magnitude of the estimated disruptions, the time elapsed for the reason that starting of the pandemic, and the month-to-month variety of reported COVID-related deaths. To evaluate the correlations of the disruptions with these components, we current cross-country regression ends in Desk 3. The biggest utilization reductions have been skilled in April and Could 2020, and this decline is unrelated to pandemic severity as proxied by reported COVID-19-related mortality. Household planning is the one service with massive drops within the second quarter of 2021. Furthermore, there isn’t a vital relationship between the variety of month-to-month formally reported COVID-19-related deaths and the magnitude of change in any service. There may be, nonetheless, a major relationship between imposed restrictions and the magnitude of the estimated disruptions in outpatient consultations, baby vaccinations, and the fourth antenatal care go to. For instance, a typical deviation within the mobility restrictions stringency is related to a 3.9% discount in outpatient session quantity (Column 1 of Desk 3).

Fig 2. Estimated and noticed quantity of outpatient consultations with formally reported COVID-19 deaths per 100,000 and mobility restrictions by nation, January 2018–June 2021.

Be aware: Outpatient consultations are used as a proxy for the utilization of normal well being companies. Knowledge on formally reported COVID-19 deaths are compiled from Johns Hopkins College Coronavirus dashboard [1]. Inhabitants denominators for all nations are primarily based on 2019 estimates from the World Financial institution Growth Indicators database. Utilization quantity and mortality information are normalized throughout nations by dividing by the very best noticed month-to-month worth inside every nation. Knowledge on mobility restrictions is summarized by an index of public transport closures, stay-at-home necessities, motion limitations, college closures, and office closures stringency scores supplied by the Oxford COVID-19 Authorities Response Tracker. The scores from this index are normalized, and the categorized into quintiles. Gaps within the service quantity information are resulting from months eliminated due to low completeness. Particulars on indicator reporting may be present in Desk L in S1 Textual content and information completeness may be present in Fig A in S1 Textual content. DRC is Democratic Republic of the Congo. Outcomes for ANC1, supply, BCG, and Penta3 are visualized in Fig B in S1 Textual content.

https://doi.org/10.1371/journal.pmed.1004070.g002

Desk 4 reveals estimates of the influence of service disruptions on baby, neonatal, and maternal mortality. The nation with the best estimated enhance in mortality was Bangladesh, with a 14.9% enhance in baby mortality, 9.7% enhance in neonatal mortality, and three.9% enhance in maternal mortality. Haiti, Kenya, Nigeria, Sierra Leone, and Uganda have been additionally estimated to have baby mortality will increase of 5% or higher. Cameroon, Liberia, and Somalia have been estimated to have small reductions in baby mortality, and 6 nations have been estimated to have minor reductions in maternal mortality. We estimate that 27.6% of the extra baby deaths and 24.3% of the extra maternal deaths occurred resulting from utilization declines in Quarter 2 of 2020, reflecting the above outcomes (see Desk G in S1 Textual content). In sum, absolutely the variety of further deaths throughout the 18 nations from March 2020 to June 2021 is estimated to be 110,686 baby deaths (0 to 59 months), 32,061 neonatal deaths (<1 month), and three,276 maternal deaths. Many components, together with inhabitants dimension and baseline mortality price, drive absolutely the variety of further deaths. Normally, estimated will increase in maternal mortality throughout all nations have been smaller than will increase in baby or neonatal mortality resulting from smaller facility supply reductions than these in outpatient and vaccination companies.

We performed 2 sensitivity analyses to grasp the potential error within the mortality outcomes. First, we used the higher and decrease 95% confidence intervals of the service disruption estimates and located that the extra deaths might be 43.8% increased or 42.9% decrease than the estimates in Desk 4. Given the proper correlation within the error of the disruption estimates that this strategy assumes, these bounds are overly conservative. Second, we diverse the linkage of service indicators to LiST interventions by setting all interventions to every service in flip and randomizing the hyperlink between interventions and companies. We discovered that the mortality estimates might be as much as 31.8% increased or 55.1% decrease than Desk 4. Nonetheless, given the intense assumptions that we examined associated to the linkage between the HMIS indicators and the LiST interventions, these bounds are additionally conservative. For extra element on these sensitivity analyses, see Tables G and H in S1 Textual content.