Assess impact of COVID-19 pandemic in selected health services with estimation of ‘excess maternal deaths’

Overview

The Department of Health Services (DoHS) has conducted a mixed method study to understand the understand the initial impacts of COVID-19 on routine reporting systems, availability and utilisation of services on selected key indicators and excess maternal deaths. The final report of this study was published by DoHS.

Executive Summary

The Government of Nepal (GoN) adopted a complete lockdown strategy to contain and curb the spread of the Coronavirus Disease 2019 (COVID-19) pandemic from 24 March 2020 to 21 July 2020, which led to closures of Outpatient Departments(OPDs) and widespread fear of COVID-19 transmission in institutional settings. This has threatened the progress made by Nepal in health care in the last three decades, with early evidence suggesting reduced coverage of institutional births, low utilisation of Reproductive Health (RH) services and increased institutional stillbirth and neonatal mortality rates.

This study aimed to understand the initial impacts of COVID-19 on routine reporting systems, availability and utilisation of services on selected key indicators and excess maternal deaths so as to help the GoN to plan actions that can strengthen its response strategy and evaluate its response for the future.

A mixed-method approach was used with secondary analysis of routine health information system (Health Management Information System (HMIS), Maternal and Perinatal Death Surveillance and Response (MPDSR) and One-stop Crisis Management Centres (OCMCs), monitoring data of health facilities and qualitative interviews with key stakeholders. The study analysed trends of service utilisation from Falgun 2075 to Bhadra 2077, with Falgun 2076 taken as the cut-off point to distinguish the pre-COVID-19 and COVID-19 periods. Descriptive statistics were used to examine the change, i.e., difference from the same month of the previous year and monthly rate of change. A local polynomial regression with smoothing curve was used to examine the trend. The Autoregressive Integrated Moving Average (ARIMA) model was used to estimate the excess maternal deaths by forecasting the maternal deaths after Falgun 2076 in the absence of pandemic. Key results are summarised below by themes.

Availability of services

Antenatal Care (ANC) and Family Planning (FP) services were unavailable in a higher proportion of referral facilities(25–80%) and for several days compared to fewer days in peripheral facilities (14–50%). In peripheral facilities, delivery services were unavailable (36–80%), drugs were stocked out (20–100%) and ambulance services were unavailable (17–80%) for several days. Fifty percent or more of Birthing Centres (BCs) and Basic Emergency Obstetric and Neonatal Care (BEONC) facilities were closed for delivery services, while all referral hospitals remained open for institutional delivery, except for a couple of days in the early lockdown period.

Service utilisation

The monthly rate of change for all service utilisation indicators from Falgun 2076 to Chaitra 2076 was negative at national level. The magnitude of decline varied from 56 per cent to 7 percent and by province and type of health facility, with a greater decline in peripheral health facilities. However, there was strong rebound over the following couple of months (Baisakh 2077 to Asar 2077) as the average returned to pre-COVID-19 levels or higher for several indicators. Institutional delivery services declined by 18 per cent between Falgun 2076 and Chaitra 2076 but increased by 19 per cent from Jestha 2077 to Asar 2077. The gain was even higher for postnatal services, with the average returning above preCOVID-19 levels. The FP method with the biggest decline was permanent sterilisation, with a 56 per cent decline in the number of procedures. New users of long-acting reversible contraceptives declined in
Chaitra 2076, with the average returning to higher than pre-COVID-19 levels in the following few months.

There was a sharp decline (36% decline in the first month) in abortion procedures performed, with the national average well below pre-COVID-19 level in subsequent months. The number of children immunised with three doses of the combined diphtheria, tetanus toxoid and pertussis vaccine (DPT3) declined by 55 per cent in the first COVID-19 month but there was a strong rebound, with an increase in the next three months.

Excess maternal deaths

A total of 153 maternal deaths were reported in the COVID-19 months (Chaitra 2076 to Bhadra 2077). The equivalent period of last year (Chaitra 2075 to Bhadra 2076) recorded 104 deaths. The preliminary estimates from modelling suggest that there were 47 excess maternal deaths in COVID-19 months.

Functioning of routine reporting system: No noticeable impact was observed in the timeliness of HMIS reporting in COVID-19 months, with an improvement seen in the long term (Falgun 2075 to Bhadra 2077). A small increase in the percentage of non-reporting facilities was observed (4.5 percentage points from Shrawan 2077 to Asar 2077). Qualitative findings suggested that despite initial difficulties alternative approaches (virtual communication) were used for normal functioning of HMIS. Overall, improvements in timeliness of reporting as well as the percentage of facilities reporting to HMIS were attributed to regular monitoring and mentoring support from the Integrated Health Management Information System (IHIMS) to the provincial, local and hospital focal persons. There has been a gradual increase in the number of OCMC reporting sites over the years. However, disaggregated data on how many sites were listed by Fiscal Year (FY) was unavailable for all FYs, limiting the ability to gain a full picture on the reporting situation. The functionality of MPDSR systems in peripheral hospitals was more adversely affected by COVID-19 (e.g., no separate discussion of maternal deaths, inability of verbal autopsy due to feasibility issues) than in federal-level hospitals. Inadequate institutionalisation of systems, poor access to internet facilities, and inadequate human resources and monitoring systems were identified as the major factors influencing the poor functionality of the MPDSR during the pandemic period.

Health Sector Response

The Ministry of Health and Population (MoHP) has developed more than 50 plans, guidelines, standards and protocols for effective response to COVID-19 and continuity of regular services. These have been made public through the MoHP website. Some of the key documents include the Health Sector Emergency Response Plan for COVID-19 Pandemic, Rapid Action Plans and Interim Guidelines for continuity of specific health services, such as Reproductive, Maternal, Newborn and Child Health (RMNCH), leprosy, geriatric health care services, rehabilitation and physiotherapy of persons with COVID-19 in acute care settings, services for people with disabilities, dental services, ambulance services and Ayurveda and alternative medicine services. In addition to these, the MoHP has circulated several ‘circulars and directives’ for specific purposes, such as human resource management, case management and compliance to the developed guidelines. Qualitative findings suggest that the development of guidelines, setting up of COVID-19 dedicated hospitals and follow-up of maternal deaths were some of the key initiatives undertaken by the clusters and sub-clusters as support to the MoHP in continuing health service delivery during the pandemic. However, study results also showed that there was a lack of clear communication of service provision, not only to consumers but also within the health care system, contributing to service utilisation decline.

In conclusion, this mixed-method study showed that there were interruptions to public health care service availability and utilisation in Nepal immediately after the introduction of lockdown. This is not surprising as literature suggests that previous pandemics or outbreaks have resulted in service utilisation decline in resource-constrained settings like Nepal.

The health care system has shown signs of resilience, as some of the indicators have returned to pre-COVID-19 levels. However, preliminary estimates of maternal deaths suggest that the pandemic may have taken away some of the progress made in the last three decades. Further analysis to estimate the net effect of missed childhood vaccinations, unplanned pregnancies and lost primary care visits may show a clearer picture. The magnitude of impact varied by province and type of health facility. Further research is needed to fully understand the reasons and the extent of disruptions to public health care delivery and the population groups they have affected the most.