The effect of the first wave of Covid-19 on use of maternal and reproductive health services and maternal deaths in South Africa

Abstract

AIM : To monitor the impact of the first wave of the Covid-19 pandemic on use of maternal and reproductive health services, and maternal mortality. METHOD : Data from the District Health Information System (DHIS) was used and 2020 data compared with 2019 as a control. Visits for initiating antenatal care, termination of pregnancy services, contraceptive use and births in facilities were used to assess usage of maternal and reproductive health services; and number of maternal deaths to assess impact. A descriptive analysis of pregnant women who had delivered after having confirmed Covid-19, was performed from the NDoH/SAMRC/UP national monitoring database of Covid-19 in pregnancy, which deals only with public hospitals. RESULTS : There were more births each month in facilities in 2020 than 2019 although there was a decline in lockdown stage 5. There was a marked movement of pregnant women to the more rural provinces and districts for delivery. Use of antenatal care as measured by the number starting antenatal care remained relatively steady, but with pregnant women attending clinics later than usual. Use of reproductive health services (contraceptive and termination of pregnancy) declined markedly. ere has been a marked increase in maternal deaths of 30% (an excess of 132 maternal deaths) since lockdown started when compared with the same period in 2019. ere have been 667 women reported who have delivered having had Covid-19 in the NDoH/SAMRC/UP database. Twenty-nine maternal deaths (case fatality rate 4,3%) were recorded, and 22 stillbirths and 16 neonatal deaths (perinatal mortality rate 57 per 1000 births). The caesarean delivery rate was 55%, prevalence of hypertensive disorders in pregnancy 14%, but spontaneous preterm labour only 3%. There has been a 20% increase in stillbirths in Mpumalanga after lockdown (second quarter 2020 when compared with the second quarter of 2019), but in many provinces there were discrepancies between DHIS and PPIP data so national still birth data is not presented in this report CONCLUSION : There has been an increase of 30% in maternal deaths since lockdown started and the epidemic peaked in 2020, compared with the same period in 2019. Use of maternal services (in facility birth and antenatal care) has remained relatively steady, but use of reproductive health services (contraception and termination of pregnancy) have declined sharply since lockdown. There has been two markedly different regional effects of Covid-19 on maternal care; the rural provinces experiencing increased pressure on their services due to pregnant women migrating from metropolitan areas back to their homes, increasing the burden on already under-resourced facilities; and metropolitan areas were inundated with severe Covid-19 specific conditions leading to an increased burden in these areas resulting in an inability to manage routine emergencies. INTERPRETATION : It is very unlikely that the majority of excess maternal deaths are due to undiagnosed SARS-Cov-2 infection and much more likely that the deaths are due to the indirect effects of Covid-19 on maternal care services.