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International Journal of Environmental Research and Public Health
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  • Systematic Review
  • Open Access

6 September 2024

Impact of COVID-19 on Maternal Health Service Uptake and Perinatal Outcomes in Sub-Saharan Africa: A Systematic Review

,
,
and
1
Collective for Midwifery, Child and Family Health, Faculty of Health, University of Technology Sydney, P.O. Box 123, Broadway, NSW 2007, Australia
2
College of Medicine and Health Sciences, Hawassa University, Hawassa P.O. Box 1560, Ethiopia
*
Author to whom correspondence should be addressed.
Int. J. Environ. Res. Public Health2024, 21(9), 1188;https://doi.org/10.3390/ijerph21091188
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Abstract

Coronavirus 2019 (COVID-19) is a major global public health threat that has impeded health infrastructures in low- and middle-income countries. This systematic review examines the impact of COVID-19 on maternal health service uptake and perinatal outcomes in Sub-Saharan Africa. We searched four databases in August 2020 and updated the search on 22 December 2023: PubMed/MEDLINE, CINAHL, Maternity and Infant Care, and EMBASE. Data extraction was performed using a standardised Joana Briggs Institute data extraction format for the eligibility of articles, and any discrepancies were solved through discussion and consensus. This systematic review includes 36 studies that met the inclusion criteria. Antenatal care attendance and institutional childbirth significantly decreased during the COVID-19 pandemic, and home births increased. Fear of contracting the virus, a lack of transport, a shortage of logistic supplies, a lack of personal protective equipment, lockdown policies, economic and food security, stigmatisation of sick persons, long waiting times in the hospital, and health system weakness were barriers to accessing maternity care. The findings of this review showed a significant decrease in antenatal care attendance and institutional birth during the COVID-19 pandemic. Based on our findings, we recommend that stakeholders ensure the availability of essential medical supplies in the hospital.

1. Introduction

COVID-19 is a highly contagious viral pneumonia caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) [1]. This is a rapidly spreading virus with cases found worldwide since its first identification in Wuhan, China, in December 2019 [2,3]. The pandemic has caused a significant global public health problem that has interrupted health system service delivery and infrastructure, most notably in low- and middle-income countries (LMICs) [4].
A single disease, COVID-19, has shown how the daily lives of infected and non-infected people can be affected in many ways [5,6]. One of its effects was the restriction of non-essential movement between local areas and abroad for more than a year. Additionally, the world focused on preventing the spread of COVID-19, and the subsequent loss of key workers through illness, death, or self-isolation following contact with infected people [7] has impacted healthcare systems across LMICs.
Pregnant women have experienced the direct and indirect impacts of COVID-19 on their health, and the pandemic has continued to negatively impact many pregnant women and their offspring [8]. The physiological, immunological, anatomical, and hormonal changes that occur during pregnancy [9] leave women more vulnerable than the general population to emerging infectious diseases. Past infectious diseases such as severe acute respiratory syndrome (SARS), Middle East respiratory syndrome (MERS), Ebola virus disease (EVD), H1N1 pandemic influenza, and Zika virus [10] have caused adverse pregnancy outcomes including renal failure, sepsis, disseminated intravascular coagulation (DIC), death [11], spontaneous abortion [12], preterm birth, stillbirth [13], intrauterine growth restriction [14], preeclampsia [15], haemorrhage, and microcephaly [16,17].
A pandemic affects the efficiency of the healthcare system in several ways when it comes to providing maternal and perinatal care [18]. Limitations of infrastructure, human resources, supply chains, and financial resources compromise health system functions, making them less able to offer services and implement rapid adaptations in antenatal care (ANC) and intrapartum care access, uptake, and provision [19]. Already limited resources were shifted in resource-scarce countries to accommodate COVID-19 prevention and treatment [20], and non-emergency services may have been discontinued, affecting access and uptake of routine activities [21]. Barriers to accessing care and services include movement restrictions, a lack of public transport, and fear of contracting COVID-19 in health facilities in LMICs, including Sub-Saharan Africa [20,22].
According to initial findings, ANC and intrapartum care uptake in LMICs was disrupted [23], and maternal and newborn mortality rates increased [24,25]. This pandemic has the potential to reverse the remarkable achievements made in reducing maternal and neonatal morbidity and mortality in resource-limited countries over the past two decades [26]. With these great strides, ANC and intrapartum care uptake and rates of maternal and neonatal mortality had steadily improved in low-income countries. It is challenging for these countries to attain the Sustainable Development Goals (SDGs) [27], and extraordinary strategies have been employed to reach the desired level; for maternal mortality, a ratio of <70 maternal deaths per 100,000 live births and, for neonatal mortality, <12 neonatal deaths per 1000 live births are the Sustainable Development Goals (SDG 3.1) in every country by 2030.
Several studies have nuanced the impact of COVID-19 on maternal healthcare information in Sub-Saharan Africa. However, there is a paucity of comprehensive reviews addressing the impact of COVID-19 on maternal health service uptake and perinatal outcomes. Conducting a critical review and appraising empirical studies to synthesise their findings is crucial for providing stakeholders and policymakers with the necessary information to develop strategies aimed at achieving SDG 3.1 and preparing for future maternal health challenges, offering a valuable lesson learned. This understanding is pivotal for preserving the progress made over the past two decades and ensuring effective measures are in place to mitigate the impact of similar disruptions in the future. Therefore, this systematic review synthesises the impact of the COVID-19 pandemic on maternal health service uptake and barriers to access and perinatal outcomes in Sub-Saharan Africa.

2. Methods

2.1. Information Sources and Search Strategy

Four databases were searched in August 2020, and the search was updated on 22 December 2023: PubMed/MEDLINE (Ovid), CINAHL (EBSCO hosted platform), Maternity and Infant Care (Ovid), and EMBASE (Ovid). Specifically, the focus was on articles that assessed the impact of COVID-19 on maternal health service uptake. For a search strategy, the combination of the following medical heading subject (MeSH) terms and keywords were used: “Maternal health service” OR “Reproductive health service” OR “Antenatal care” OR “Obstetrics health service” OR “Maternal and newborn health service” OR “Maternal primary care” OR “Postnatal care” OR “Maternal Health” OR “Maternal-child health services” AND “COVID-19” OR “SARS-CoV-2” AND “Utilisation/utilization” AND “Angola” OR “Benin” OR “Botswana” OR “Burkina Faso” OR “Burundi” OR “Cameroon” OR “Cape Verde” OR “Central African Republic” OR “Chad” OR “Comoros” OR “Republic of the Congo” OR “The Democratic Republic of the Congo” OR “Cote d’Ivoire” OR “Djibouti” OR “Equatorial Guinea” OR “Eritrea” OR “Ethiopia” OR “Gabon” OR “Gambia” OR “Ghana” OR “Guinea” OR “Guinea-Bissau” OR “Kenya” OR “Liberia” OR “Madagascar” OR “Malawi” OR “Mali” OR “Mauritania” OR “Mauritius” OR “Mozambique” OR “Namibia” OR “Niger” OR “Nigeria” OR “Rwanda” OR “Sao Tome and Principe” OR “Senegal” OR “Seychelles” OR “Sierra Leone” OR “Somalia” OR “South Africa” OR “South Sudan” OR “Sudan” OR “Swaziland” OR “Tanzania” OR “Togo” OR “Uganda” OR “Zambia” OR “Zimbabwe” OR Sub Saharan Africa”. Hand searches of the reference lists were carried out to identify other potential articles of interest. The included studies were limited to the English language and human studies only. The protocol was registered with the PROSPERO International Register of Systematic Reviews (https://www.crd.york.ac.uk/PROSPERO) on 15 October 2020 and updated on 19 July 2024 (CRD42020208198). This section follows the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) checklist (Supplementary Materials) [28] to present findings on the effect of COVID-19 on maternal health service utilisation (Figure 1).
Figure 1. PRISMA (flow chart of study selection for a systematic review of the effect of COVID-19 on maternal and perinatal care in Sub-Saharan Africa).

2.2. Selection of Studies and Data Extraction

One reviewer (ZYK) ran the search strategy across the relevant databases and exported it to Endnote 20 to remove duplicate articles in the review. Data were extracted by four authors (ZYK, VS, ST, and DF) based on the article title and abstracts for eligibility. These authors (ZYK, VS, ST, and DF) also extracted all the relevant data using a standardised Joanna Briggs Institute (JBI) data extraction format for the eligibility of articles, and any discrepancies were solved through discussion and consensus. The author’s name, publication year, purpose of the study, country, study design, response rate, utilisation of maternal health services, and outcome measures were extracted.

2.3. Inclusion and Exclusion Criteria

Studies assessing the impact of COVID-19 on ANC attendance, institutional birth, and pregnancy outcomes were eligible for inclusion in this systematic review. The included studies were those that compared pre- and during COVID-19 maternal service uptake and were conducted with the following study designs: case series, observational studies (cross-sectional, pre-post, and cohort (prospective and retrospective studies)), and qualitative studies regardless of their study settings. Editorial letters, commentaries, review articles, articles that did not compare maternal health service uptake pre- and during COVID-19, case reports with incomplete information, modelling studies, magazine articles, and personal opinions were excluded. The most recent article was used when multiple publications of the same data were found.

2.4. Assessment of Quality of Included Studies

The data quality was assessed using the Joanna Briggs Institute (JBI) [29] critical appraisal checklist for simple prevalence, containing nine checklist items and ten items for qualitative studies. This tool lists the following criteria to assess the quality of studies: the sample frame must be appropriate to address the target population; the study participants must be sampled in an appropriate way; the sample size must be adequate; the study subjects and the setting must be described in detail; the data analysis must be conducted with sufficient coverage of the identified sample; valid methods must be used for the identification of the condition; the condition must be measured in a standard, reliable way for all participants; an appropriate statistical analysis must be utilised; and the response rate must be adequate; and the low response rate must be managed appropriately [29]. Studies that scored below five out of these nine points were considered to be of low quality, while those with scores above five were deemed sufficient for inclusion in this review.

2.5. Data Analysis

A narrative synthesis was used to present the findings. The findings were presented by highlighting the decrease in the number of women attending ANC, the impact of COVID-19 on institutional births and mode of birth, complications during childbirth, and barriers to the uptake of maternity care during the pandemic.

3. Results

In this study, 829 studies were retrieved from four databases, 155 articles were removed due to duplication, and 603 articles were removed based on the title and abstract screening. Full-text screening of 71 articles was conducted, and studies were excluded if they did not compare and report maternal health services uptake and perinatal outcomes pre-COVID-19 and during the pandemic. Thirty-six studies were finally included in this systematic review. Figure 1 illustrates the process of screening and reviewing the articles.

3.1. Study Characteristics

Articles included in this systematic review were from Ethiopia (n = 9) [30,31,32,33,34,35,36,37,38], Kenya (n = 9) [38,39,40,41,42,43,44,45,46], Uganda (n = 6) [21,38,47,48,49], Nigeria (n = 3) [49,50,51], Sierra Leone (n = 3) [22,38,52], the Democratic Republic of Congo (DRC) (n = 2) [53,54], South Africa (n = 2) [55,56], Mozambique (n = 2) [57,58], Liberia (n = 2) [22,59], Guinea (n = 2) [49,60], Tanzania (n = 2) [38,49], Rwanda (n = 1) [61], Zimbabwe (n = 1) [62], Ghana (n = 1) [63], and Lesotho (n = 1) [22]. Nine studies had a cross-sectional study design [32,33,35,39,44,55,56,60,61], nine studies had a qualitative study design [21,34,40,41,42,46,48,50,51], seven studies had an interrupted times series design [22,38,43,45,47,53,58], six studies had a mixed methods design [36,37,49,52,57,59], two studies were retrospective cohort studies [54,62], and three studies had a pre–post study design [30,31,63] (Table 1). This study included articles that used a minimum of two months pre-COVID-19 and two months during COVID-19. The maximum data used were 12 months pre-COVID-19 and 12 months during COVID-19 to assess the impact of COVID-19 on maternal health services uptake. The study participants in this review were pregnant women, women in labour, postnatal women, healthcare providers, and policymakers. Table 1 is a summary of the included studies.
Table 1. Summary of studies included in the systematic review in Sub-Saharan Africa and key findings.
After reviewing and summarising the included studies, four main themes were identified: a decrease in the number of women attending ANC; the impact of COVID-19 on institutional births and mode of childbirth; complications during childbirth; and barriers to the uptake of maternity care. Table 2 presents the themes and the papers associated with those particular themes.
Table 2. Main themes.

3.2. Decrease in the Number of Women Attending ANC during COVID-19

COVID-19 has, directly and indirectly, interrupted the health system in LMICs, particularly in Sub-Saharan Africa. Outpatient services are more affected due to the closure of non-emergency services, and ANC services were also disturbed in Sub-Saharan countries during COVID-19 [22]. Evidence showed that ANC1 uptake significantly declined by 43% (IRR: 0.57, 95%CI: 0.35 to 0.91, p = 0.02) in DR Congo [53] and by 25% in Liberia during the lockdowns [59]. Similarly, ANC4 declined by 28% in Liberia (Table 1). Movement restrictions, a lack of transport, increased transport fees, and closure of non-emergency services could all have contributed to the decline in ANC uptake during the lockdowns [59].
ANC1 uptake significantly decreased in the Southwest region, Ethiopia (p < 0.0001) [32], Rwanda (p = 0.042) [61], Liberia [59], Guinea [60], and Sierra Leone [22] during COVID-19. ANC4 significantly decreased in the Tigray region, Ethiopia [31], Kenya [45], Ghana [63], Liberia [59], and Guinea (p < 0.001) [60] during COVID-19. The reasons for these findings indicate that COVID-19 affected ANC uptake indirectly, with fear of contracting a COVID-19 infection [34], staff redeployment to COVID-19 centres [59], restriction of movement due to lockdowns, a lack of PPE [41], shortages of medications and vaccine supplies for clients [59], and a partial closure of routine services [49] being common causes of the drop in ANC uptake during COVID-19 (Table 1). In DRC, immediately post-lockdowns, ANC1 contact significantly increased by 4% (1.04, 95% CI: 1.01 to 1.07, p = 0.007). Meanwhile, this review showed that the rates of uptake for ANC1 and above in South Africa [56], Ethiopia [33,35,36,37], Kenya [39,43], and Mozambique [57,58] did not significantly differ during COVID-19 compared with the pre-COVID-19 period (Table 1).

3.3. Impact of COVID-19 on Institutional Birth and Mode of Birth

Studies showed that institutional birth rates significantly increased in the early stages of COVID-19 [31,52,53,56]. For example, the institutional birth rates significantly increased by 8.57% (p = 0.0001) in the Tigray region, Ethiopia [31]. Immediately post-lockdowns, institutional births significantly increased by 8% (1.08, 95% CI: 1.05 to 1.011, <0.001) in DRC [53] and by 3.7% in South Africa in 2020 [56]. However, the incidence of institutional births was not significantly altered during the pandemic lockdowns compared to pre-COVID-19 in the Amhara region, Ethiopia [33], DRC [53], and Zimbabwe [62].
Other studies in Mozambique, Sierra Leone, Guinea, Uganda, Rwanda, and Ethiopia showed that during COVID-19, institutional births significantly decreased [30,32,47,52,57,60,61]. Hospital birth rates declined by 77% in urban areas of Ethiopia, immediately after COVID-19 infections were reported there (aRRR: 0.23, 95% CI: 0.07 to0.71) [30]. Similarly, in Mozambique, hospital births significantly decreased by 4% (p = 0.046) [57]. At the same time, the study found that home births increased by 74% [57], and in Kenya, home births also increased during COVID-19 [40,41]. Evidence showed that women preferred home births due to fear of contracting the virus [40], delayed care, a lack of money, perceived poor quality of care during COVID-19 [34], and a lack of transportation due to lockdowns [49,51,59], leading to increased numbers of stillbirths and neonatal deaths during this period [31,32,39,47,55].
During COVID-19, caesarean section births significantly increased [31,32,39]. Caesarean section births in Ethiopia [31] substantially increased by 28.05% (p = 0.0040), and in Kenya [39], caesarean births increased from 14.6% to 15.8% (p < 0.0001) during COVID-19. However, other studies did not find a significant difference in the numbers of caesarean section births before and during COVID-19 in Mozambique [57], Sierra Leone [52], and Zimbabwe [62] (Table 1).

3.4. Complications during Birth

Quality ANC and intrapartum care are essential for the early identification of complications, readiness for high-risk newborns, and prompt intervention [64] that can reduce stillbirth and neonatal mortality. During COVID-19, ANC uptake and institutional birth declined in LMICs [22]. Studies in Ethiopia and Kenya [31,32,39] found that stillbirths significantly increased during COVID-19, increasing by 7.6% (p = 0.0062) in the Tigray region, Ethiopia [31] (Table 1). Likewise, studies in Ethiopia, Uganda, and South Africa showed that neonatal deaths significantly increased [32,47,55,56] during COVID-19: For example, in South Africa, the neonatal death rate increased by 47% (p = 0.025) [55]. In Uganda, the neonatal mortality rate increased by ten neonatal deaths per 1000 live births/month (IQR 2–10; p < 0.001) at the end of the lockdowns [47]. Neonatal death rates did not, however, significantly differ in Ethiopia and Zimbabwe [31,62] before and during COVID-19. It is important to highlight that reporting of these deaths may be confounded by methods of reporting and systemic data collection issues.

3.5. Barriers to the Uptake of Maternity Care

Effective strategies to improve the accessibility and availability of maternal healthcare is essential to increasing its uptake. The pandemic has indirectly encumbered and overstretched the infrastructure [4] that had previously been in place to increase the uptake of maternity care. Fear of the virus and lockdown measures to prevent the spread of COVID-19 meant that transport became more expensive and often unavailable [51], making it difficult for women to access maternity care (Table 1).
Studies conducted in Nigeria [51], Uganda [48], and Ethiopia [36,37] found a lack of transport and rising transport fees to be barriers to accessing maternity care during COVID-19. Evidence illustrates how fear of contracting the virus was a barrier to the uptake of maternity care in Sierra Leone [52], Guinea [49], Nigeria [49,50,51], Tanzania [49], Uganda [21,48,49], Kenya [40,42,46], and Ethiopia [36,37] during COVID-19 (Table 1). Similarly, shortages of medical supplies [34,57], a lack of PPE [37,51], shortages of human resources [50], health staff burnout [51], a lack of skilled workers [21], the shift of healthcare providers to COVID-19 centres [59], and closure of non-emergency services [49,59] were identified as barriers to accessing to maternity care during COVID-19 (Table 1).

4. Discussion

Over the past two decades in Sub-Saharan African countries, improvements in the quality and availability of ANC and institutional birth have been made, leading to a substantial decline in maternal and neonatal mortality rates. In the 2000–2020 period, remarkable progress was made in these countries in lowering maternal and newborn mortality [65]. Nonetheless, Sub-Saharan countries still experience a significant number of maternal and newborn deaths.
Findings show that in Sub-Saharan countries, ANC utilisation declined during the pandemic [22,31,32,45,49,53,56,59,60,61,63]. This finding coincides with studies conducted in India [66], a systematic review of the impact of the Ebola virus on maternal and perinatal care in West Africa [67], and a worldwide systematic review and meta-analysis which revealed significantly decreased ANC uptake during the pandemic [68]. The decline in ANC utilisation was a consequence of a range of factors such as the lockdowns [66], fear of contracting the virus [69], a lack of transport [70], the shortage of medical supplies [44], and the long waiting times [50].
ANC contact can play a significant role in promoting and increasing institutional birth, which leads to a reduction in the number of neonatal and maternal deaths [71]. ANC achieves this by preventing pregnancy-related complications through early identification and treatment of existing diseases [72]. Conversely, low engagement with ANC can decrease institutional birth rates, leading to increased neonatal and maternal mortality [72].
In this review, some studies demonstrate that the number of institutional births was not significantly altered during the pandemic compared to pre-COVID-19 in Ethiopia [33], DRC [53], and Zimbabwe [62]. This could be because less health facilities may have referred labouring women to hospital due to fear of contracting COVID-19 [22].
This review demonstrates that institutional births [30,32,52,57,60,61,63] substantially decreased during the pandemic. This finding aligns with studies conducted in India [73] and Nepal [25,74], which indicated that institutional birth decreased by half during the COVID-19 lockdowns. This dramatic reduction in institutional births might be due to women’s fears of contracting the virus [21,36,37,40,41,44,46,48,50,51,59], a lack of transport availability during the lockdowns [36,37,44,48,50,60], financial hardship [40,46], and health facilities becoming inaccessible [44,51,59]. Consequently, women might prefer traditional birth attendants’ home support [40,41,57].
Similarly, the findings from this review showed an increase in caesarean section births during the pandemic [31,32,39]. The rise in births by caesarean section could have been due to less maternal and foetal monitoring during labour [25], the restriction on companions attending births [75], and women choosing a caesarean section instead of waiting for spontaneous labour due to fear of contracting the virus [76]. The decline in accessing ANC follow-up can prevent women from receiving early detection of pregnancy complications and health promotion counselling and can lead to an increase in home births [40,41,57] and obstetric complications [48,62]. These findings are consistent with a study conducted in LMICs [77] which explored the decrease in ANC and the rise in home births during the pandemic.
Findings demonstrate that during the pandemic, obstetric complications were more common, potentially leading to an increase in stillbirths [31,32,39] and neonatal deaths [32,47,55,56]. These complications and consequences may have been due to the lower ANC uptake and suboptimal care during the antenatal period that led to unidentified and untreated existing diseases such as preeclampsia, increasing the risk of stillbirth [78] and neonatal deaths [79]. In addition, suboptimal intrapartum care and home birth may have led to increased rates of stillbirth [80] and neonatal deaths [81].
The synthesised evidence emerging from this systematic review of the impact of COVID-19 on maternal health service utilisation in Sub-Saharan Africa has implications for future responses to similar emergencies. From this evidence, policymakers and obstetric care providers can gain insight into how the pandemic in Sub-Saharan Africa has affected the provision and uptake of maternal health services. In health facilities, the existing guidelines need to be adopted and implemented and the modification of maternal and neonatal safety guidelines should be a priority during any pandemic. Furthermore, this review provides an input and lessons learned that can serve as a touchstone for a better understanding of and response to the direct and indirect impacts of future epidemics and pandemics.
Some potential limitations of this review are noted, including the small sample size of some studies, methodological differences, no population-level denominators, missing data, and a lack of population-level data collection methods in place. Moreover, all included studies did not specifically address the consequences of COVID-19 on access, uptake, and provision of ANC and institutional birth. The results of this systematic review should be taken cautiously, given that the included studies represent only a few countries, and full-text language was restricted to English. Nevertheless, the results from this systematic review are a valuable input to designing policies for scaling up the coverage and quality of ANC and institutional birth through interventions that promote adopting and adapting safe maternity care guidelines in present and future pandemics [82,83].

5. Conclusions

The findings from this review showed a decrease in the number of women accessing ANC and institutional birth during the COVID-19 pandemic and an increase in births by caesarean section and neonatal deaths. Based on these findings, it is recommended that stakeholders and healthcare providers act to reverse the decline in ANC and institutional uptake by collaborating via community mobilisation/involvement and building trust with the community regarding access to maternal healthcare services. The government needs to ensure the availability of essential medical supplies in hospitals during pandemics, while healthcare providers need to strictly monitor maternal and foetal health during labour to reduce the risk of institutional neonatal deaths. Rigorous studies are needed to examine both the short- and long-term impacts of COVID-19 on maternal and perinatal outcomes.

Supplementary Materials

The following supporting information can be downloaded at: https://www.mdpi.com/article/10.3390/ijerph21091188/s1, Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) checklist [84].

Author Contributions

Z.Y.K. developed the draft proposal under the supervision of D.F. and V.S. All authors (Z.Y.K., V.S., S.T. and D.F.) made significant contributions to the conception and conceptualisation of the study protocol. All authors have read and agreed to the published version of the manuscript.

Funding

There was no funding or sponsoring organisation for this paper.

Institutional Review Board Statement

Not applicable.

Data Availability Statement

All analysed data are included in this manuscript. PROSPERO registered number = CRD42020208198.

Acknowledgments

The authors acknowledge all information resources included in this review.

Conflicts of Interest

The authors declare that there are no competing interests.

Abbreviations

ANC = antenatal care, EVD = Ebola virus disease, MERS = Middle East respiratory syndrome, NC = postnatal care, SARS = severe acute respiratory syndrome, SDG = Sustainable Development Goal, SARS-CoV-2 = severe acute respiratory syndrome coronavirus 2, and WHO = World Health Organization.

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