Article Text

Disruptions in maternal health service use during the COVID-19 pandemic in 2020: experiences from 37 health facilities in low-income and middle-income countries
  1. Zeus Aranda1,
  2. Thierry Binde2,
  3. Katherine Tashman3,4,
  4. Ananya Tadikonda5,
  5. Bill Mawindo2,
  6. Daniel Maweu6,
  7. Emma Jean Boley6,
  8. Isaac Mphande7,
  9. Isata Dumbuya2,
  10. Mariana Montaño1,
  11. Mary Clisbee8,
  12. Mc Geofrey Mvula7,
  13. Melino Ndayizigiye9,
  14. Meredith Casella Jean-Baptiste8,
  15. Prince F Varney6,
  16. Sarah Anyango6,
  17. Karen Ann Grépin10,
  18. Michael R Law11,
  19. Jean Claude Mugunga3,12,
  20. Bethany Hedt-Gauthier13,14,
  21. Isabel R Fulcher3,4
  22. on behalf of the Cross-site COVID-19 Syndromic Surveillance Working Group
    1. 1Compañeros En Salud/Partners In Health–Mexico, Ángel Albino Corzo, Mexico
    2. 2Partners In Health–Sierra Leone, Koidu, Sierra Leone
    3. 3Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts, USA
    4. 4Harvard Data Science Initiative, Boston, Massachusetts, USA
    5. 5Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
    6. 6Partners In Health–Liberia, Harper, Liberia
    7. 7Abwenzi Pa Za Umoyo/Partners In Health–Malawi, Neno, Malawi
    8. 8Zanmi Lasante/Partners In Health–Haiti, Croix-des-Bouquets, Haiti
    9. 9Partners In Health–Lesotho, Maseru, Lesotho
    10. 10School of Public Health, Li Ka Shing Faculty of Medicine, University of Hong Kong, Hong Kong, Hong Kong
    11. 11Centre for Health Services and Policy Research, The University of British Columbia, Vancouver, British Columbia, Canada
    12. 12Partners In Health, Boston, Massachusetts, USA
    13. 13Harvard Medical School, Boston, Massachusetts, USA
    14. 14Biostatistics, Harvard University T.H. Chan School of Public Health, Boston, Massachusetts, USA
    1. Correspondence to Zeus Aranda; zaranda{at}


    The COVID-19 pandemic has heterogeneously affected use of basic health services worldwide, with disruptions in some countries beginning in the early stages of the emergency in March 2020. These disruptions have occurred on both the supply and demand sides of healthcare, and have often been related to resource shortages to provide care and lower patient turnout associated with mobility restrictions and fear of contracting COVID-19 at facilities. In this paper, we assess the impact of the COVID-19 pandemic on the use of maternal health services using a time series modelling approach developed to monitor health service use during the pandemic using routinely collected health information systems data. We focus on data from 37 non-governmental organisation-supported health facilities in Haiti, Lesotho, Liberia, Malawi, Mexico and Sierra Leone. Overall, our analyses indicate significant declines in first antenatal care visits in Haiti (18% drop) and Sierra Leone (32% drop) and facility-based deliveries in all countries except Malawi from March to December 2020. Different strategies were adopted to maintain continuity of maternal health services, including communication campaigns, continuity of community health worker services, human resource capacity building to ensure compliance with international and national guidelines for front-line health workers, adapting spaces for safe distancing and ensuring the availability of personal protective equipment. We employ a local lens, providing prepandemic context and reporting results and strategies by country, to highlight the importance of developing context-specific interventions to design effective mitigation strategies.

    • COVID-19
    • maternal health
    • health services research
    • health systems
    • public health

    Data availability statement

    The data underlying this article will be shared on reasonable request to the corresponding author. We have provided an example dataset with code on our GitHub repository: [].

    This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See:

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    Data availability statement

    The data underlying this article will be shared on reasonable request to the corresponding author. We have provided an example dataset with code on our GitHub repository: [].

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    • Handling editor Seye Abimbola

    • Twitter @KarenGrepin, @myclaw, @jcmugunga, @BHedtGauthier

    • Collaborators The Cross-site COVID-19 Syndromic Surveillance Working Group is composed of the following—Partners In Health (PIH)/Boston: Jean-Claude Mugunga; PIH/Haiti: Peterson Abnis I Faure, Wesler Lambert, Jeune Marc Antoine; PIH/Liberia: Emma Jean Boley, Prince F Varney; PIH/Lesotho: Meba Msuya, Melino Ndayizigiye; PIH/Malawi: Moses Aron, Emilia Connolly; PIH/Mexico: Zeus Aranda, Daniel Bernal; PIH/Rwanda: Vincent K Cubaka, Nadine Karema, Fredrick Kateera; PIH/Sierra Leone: Thierry Binde, Chiyembekezo Kachimanga; Harvard Medical School: Dale A Barnhart, Isabel R Fulcher, Bethany Hedt-Gauthier, Megan Murray; Hong Kong University: Karen A Grépin; University of British Columbia: Michael Law.

    • Contributors ZA is the first author of the manuscript and has worked on the conceptualisation of the manuscript, literature search and all stages of writing. TB is the second author and has participated in the drafting of the original version of the manuscript. KT has performed data cleaning and analysis. AT has participated in writing the original draft and editing the final version of the text. BM, DM, EJB, IM, ID, MM, MC, MGM, MN, MCJ-B, PFV, SA, KAG, MRL, JCM and BH-G have reviewed the original text and edited the final version of the manuscript. IRF actively participated in the conceptualisation of the manuscript, led statistical methods development and oversaw the development of the manuscript. All authors, including the Cross-site COVID-19 Syndromic Surveillance Working Group, discussed the results and provided comments on the manuscript.

    • Funding This work was supported by a grant from the Canadian Institutes of Health Research.

    • Competing interests None declared.

    • Provenance and peer review Not commissioned; externally peer reviewed.

    • Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.