More than 54 million people globally have been infected with the Coronavirus Disease (COVID-19), with rates of infection continuing to rise globally. Among the many implications of the pandemic on physical, social, and mental well-being, researchers at the Johns Hopkins Bloomberg School of Public Health raised concerns about how COVID-19 could affect pregnant women’s place of delivery — a key maternal health service component that has a direct impact on pregnancy and newborn outcomes.
To assess the immediate impact of the COVID-19 pandemic on women’s delivery patterns in Ethiopia, an analysis was conducted using data from the Performance Monitoring for Action (PMA) Ethiopia survey. The project is led by Dr. Linnea Zimmerman, Principal Investigator for the PMA Ethiopia project and Assistant Professor in the Department of Population, Family, and Reproductive Health at Johns Hopkins Bloomberg School, and Drs. Solomon Shiferaw and Assefa Seme at Addis Ababa University. Results from this analysis showed that as of June 2020, at the national level, there was no difference in the proportion of women who delivered in a hospital. However, in urban areas where COVID-19 rates were highest, the proportion of women who delivered in lower-level health facilities significantly increased while deliveries in hospitals declined. Home delivery rates remained unchanged.
Launched in 2014, the PMA Ethiopia survey generates nationally and regionally-representative data on key RMNCH indicators to measure the coverage, barriers, and facilitators of RMNCH care. The survey has three main components:
- A longitudinal, or panel, survey in six regions that enrolls pregnant women and follows up with them at six-week, six-months, and one-year postpartum.
- A cross-sectional survey of women of reproductive age in all regions.
- A service delivery point (SDP) survey assessing facility readiness in providing RMNCH services in all regions.
Data collection for the longitudinal survey began in 2019 and enrolled recently postpartum women (less than 8 weeks postpartum at enrollment) and pregnant women. The longitudinal survey, in particular, provides a unique opportunity to gauge how the COVID-19 pandemic affected health seeking behavior, specifically a pregnant woman’s decision on place of delivery by comparing women who delivered during COVID-19 restrictions to those who delivered prior to the pandemic.
Looking within urban areas, women who delivered during May and June, after COVID-19 restrictions started, were significantly less likely to deliver in a hospital relative to women who delivered prior to the pandemic. “Though it is reassuring that home delivery rates did not increase, shifts to lower-level facilities are potentially problematic given their lower levels of readiness”, said Dr. Zimmerman. Findings from the PMA Ethiopia SDP surveys show that health posts and health centers generally have much lower capacity to handle birth complications, both in terms of essential medications and procedures, such as Caesarean sections.
Regardless of the time period, wealthier women, more educated women, women who had never given birth before, and women aged 30+ in urban areas were more likely to deliver in a hospital than poorer, less educated, or younger, and multiparous women during COVID-19 restrictions. The pattern of delivery location among rural women was no different before or after the pandemic. Similar to the patterns observed in urban areas, higher age, education, wealth, and having never given birth were associated with a higher likelihood of delivering in a health facility (including hospitals, health centers, and health posts) compared to home delivery.
Among women who indicated that the pandemic affected where they delivered, about three in four said they were afraid of getting or spreading COVID-19; two in five were scared of being alone in a health facility while delivering and more than one-third said there was no transportation available.
These differences align with the unfolding of the pandemic in Ethiopia. Early in the pandemic, COVID-19 diagnoses were more frequent in urban areas than rural, particularly in Addis Ababa. Information on the spread and prevention of COVID-19 was also more easily accessible in urban areas compared to rural. These two factors, combined with stricter guidelines/compliance of travel restrictions, could have contributed to the lower rates of hospital delivery in urban areas. With an increasing burden of COVID-19 cases, hospitals were likely to prioritize treatment and infection control of COVID-19, leaving health posts and health centers as the primary providers of delivery services and other basic RMNCH services.