Abstract
To examine the effect of COVID-19 on health facility delivery in Ethiopia. We used longitudinal data with a pre-post exposure to the pandemic to assess change in facility delivery patterns nationally and by urban and rural strata. We conducted design-based multivariable multinomial logistic regression comparing home, lower-level facility, and hospital delivery with date of birth as a spline term, with a knot indicating births before and on/after April 8, 2020. Six regions in Ethiopia, covering 91% of the population. Women were eligible to participate if they were currently pregnant or less than six weeks postpartum and were recontacted at six weeks, six months, and one year postpartum. 2,889 women were eligible and 2,855 enrolled. Data used in this paper come from the six-week interview, with a follow-up rate of 88.9% (2,537 women). In urban areas, women who delivered during the COVID-19 pandemic had a 77% reduced relative risk of delivering in a hospital relative to women who delivered prior to the pandemic (aRRR: 0.23, 95% CI: 0.07-0.71). There were no significant differences between the pre- and COVID-19 periods within rural strata where the majority of women deliver at home (55.6%). Overall, the effect was non-significant at a national level. Among women who delivered during the COVID-19 pandemic, 20.0% of urban women said COVID-19 affected where they delivered relative to 8.7% of rural women (p-value = 0.01). We found that delivery patterns in urban areas changed during the early months of the COVID-19 pandemic, but there was no evidence of large-scale declines of hospital delivery at the national level. Concerns about COVID-19 transmission in health facilities and ensuring lower-level facilities are equipped to address obstetric emergencies are critical to address. COVID-19 will likely slow progress towards increasing rates of institutional delivery in urban areas in Ethiopia.
Highlights
Improving the proportion of births attended by skilled health personnel, predominately through increasing the proportion of births delivered in a health facility that offers obstetric care, is a key intervention strategy to reduce high maternal mortality in low- and middleincome countries [1, 2] and is recognized as an indicator for achieving the Sustainable Development Goal-3 (SDG indicator 3.1.2)
Women who delivered during the COVID-19 pandemic had a 77% reduced relative risk of delivering in a hospital relative to women who delivered prior to the pandemic
There were no significant differences between the preand COVID-19 periods within rural strata where the majority of women deliver at home (55.6%)
Summary
Improving the proportion of births attended by skilled health personnel, predominately through increasing the proportion of births delivered in a health facility that offers obstetric care, is a key intervention strategy to reduce high maternal mortality in low- and middleincome countries [1, 2] and is recognized as an indicator for achieving the Sustainable Development Goal-3 (SDG indicator 3.1.2). While early studies based on prediction models provided valuable insight into the potential impact of the pandemic, the models are mostly based on a set of assumptions in the absence of empirical data. This is especially challenging in low- and middle-income countries where population-level data on the effects of COVID-19 on MNH care-seeking and health behaviors are extremely limited, but where evidence from previous pandemics has found serious consequences for maternal and newborn health, including increased maternal and newborn morbidity and mortality and reductions in health seeking behaviors [6,7,8]. The Ethiopian study, the only we could find in sub-Saharan Africa that assessed changes in careseeking, only included women who successfully accessed antenatal care services—a substantial limitation in understanding the effect of COVID-19 on overall maternal health care seeking
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