ANC first visit, health facility delivery, early PNC, new contraceptive accepters, repeat contraceptive accepters, safe abortion care, Pentavalent-3 recipients and number of under-five years old children treated for pneumonia decreased by 7%, 2.5%, 9.3%, 20.3%, 9.3%, 23.7%, 4.7% and 77.2%, respectively in the first eight months of the COVID-19 pandemic compared to the pre-pandemic average performance. This might be related to inadequate supply of personal protective equipment, redirecting human workforce and services towards responding to COVID-19 pandemic. In addition, fear of acquiring COVID-19 by clients/patients if attended health facilities and financial barriers to seek health services might negatively affect services utilization [26, 27].
Early PNC visit significantly declined by 9.3% in the period March to October compared to the July 2019 to February 2020 period. Similarly, a study conducted in South West Ethiopia showed that PNC decreased by 29.1% in the period March-June 2020 . PNC is a critical time for the well-being of mothers and newborns as most maternal deaths occur during the postpartum period, particularly within the first two days following delivery. Health professionals can use the opportunity to provide care while the mother is already in a health facility; however, this is the most neglected period for the provision of quality services [24, 28]. Likewise, safe abortion care significantly decreased by 23.6% in the same period. This finding is in line with a case study conducted at a tertiary facility in Addis Ababa whereby a decline of 14.5% was reported in safe abortion service during the period March-May 2020 . On the other hand, in this study, post abortion care increased by 17.8% in the first eight months during the COVID-19 pandemic. This is consistent with the results of a study conducted in another region of Ethiopia . In Kenya 45% of pregnancies ended up with severe abortion complications during the COVID-19 pandemic . The increased post abortion care in our study might be explained by women, who stayed at home during lockdown, were more prone to sexual abuse including rape even by their partners .
Institutional early neonatal death significantly increased by 13.3% in the period March-October 2020 compared to July 2019-February 2020. This is consistent with finding of a study done in Nepal . In the Ethiopian context, institutional early neonatal death mainly defines the quality of obstetric care in a health facility . The increase in institutional early neonatal death in this study may be related to compromised Intensive Care Unit (ICU) services; both space and equipment were redirected to COVID-19 care. Also, experienced ICUs staffs were more likely to be moved to COVID-19 treatment centers. Our study result underscores the importance of strengthening quality of health care services.
The percentage of Pentavalent-1and Pentavalent-3 recipients and full vaccinated children decreased in the period March-October 2020 compared to the July 2019 -February 2020 average performance. This is consistent with findings of study conducted in India . The desire to decrease COVID-19 spread in health care facilities and the repurposing of health workers may have led to hesitation to continue routine immunization services in health facilities during the early period of the COVID-19 pandemic .
The trends in most of the services began to decline during January-March 2020 when COVID-19 began in Ethiopia. This was a time when the daily COVID-19 reported cases in Ethiopia, particularly in Addis Ababa were high . In Ethiopia, as part of early response, there was intense media coverage about the COVID-19 outbreak, particularly in March 2020 after the country reported the first confirmed case. This might make the public fear of disease transmission and may have forced them to stop using health care services .
Some services including ANC four or more visits, early PNC visit, repeat contraceptive accepters and pentavalent-1 vaccination began to decline during October-December 2019 a quarter preceding the onset of COVID-19 pandemic in Ethiopia. The reductions in these services may be related to other reasons.
In this study, accelerated decline was observed in ANC first visit, ANC four or more visits, early PNC visit, new contraceptive accepters, repeat contraceptive accepters, pentavalent-3 recipients and the number of under-five children treated for pneumonia during April-June 2020 following national lockdown. The lockdown period in Ethiopia has been accompanied by measures including travel restrictions, flexible working arrangements, suspending public gathering and requirements for social distancing [10, 11]. This may have negative consequences on access to health services. Findings of studies in other regions of Ethiopia [11, 27] and other countries  also revealed decline trends of MCH services during lockdown.
ANC first visit declined during the first eight months of the pandemic compared to the previous eight months average performance. On the other hand, a relative increase was observed in ANC four or more visits during the same period. The possible explanation might be that the three previous ANC visits occurred before March 2020 when Ethiopia reported its first confirmed COVID-19 case. Trend assessment showed that both ANC first and four or more visits recovered and reached above the pre-pandemic baseline level average performance during the July-September 2020 (the last quarter of national lockdown) period. This may be related to an increased awareness of pregnant women about the disease transmission and its prevention method, which might have helped them to decrease their fear on COVID-19 and to visit health care facilities . Also, a continuous services performance improvement across quarters in early PNC visit was observed since July-September 2020. In particular, in the last quarter of the study period (January-March 2021), recovery almost approached to pre-pandemic baseline level, and this was found to be an encouraging trend. These increasing trends in service provision may be due to efforts of the government to disseminate information on basic infection prevention control methods and guidance on safe care-seeking behavior . Similarly, a study conducted in some districts of four regions in Ethiopia showed that most maternal health care services had already recovered by the end of July 2020 .
New contraceptive accepters significantly decreased by 20.3% and repeat contraceptive accepters decreased by 9.5% in the first eight months of the COVID-19 pandemic. A study conducted in India showed a reduction in FP services in March 2020 compared to December 2019 . Services performance recovery in contraceptive accepters was observed in the periods July-September 2020 and October-December 2020; however, new and repeat contraceptive accepters again began to decline and no recovery was observed in the period January-March 2021. Evidence indicates that a decrease in access to FP services results in increased poor outcomes related to unintended pregnancies and abortions . The magnitude of unintended pregnancy during the COVID-19 pandemic among women attending ANC was 47.2% in Northwest Ethiopia .
The trend in Measles first dose vaccination across quarters remained above the pre-pandemic baseline level, although a slight positive decrement trend was observed during the periods January-March 2020, July-September 2020 and October-December 2020. Accelerated increment was observed in the period April to June 2020 following lockdown. This may be explained by the nationwide home to home campaign that was conducted in June 2020 in Ethiopia. About 15 million children have been vaccinated against measles in Ethiopia in an effort by the Ministry of health to maintain essential services despite COVID-19 challenges . The country undertook the campaign taking into account the local COVID-19 transmission and implementing COVID-19 prevention measures . Similarly, the trend in fully vaccination across quarters remained above the pre-pandemic baseline level with accelerated increment during April-June 2020 following lockdown. Nonetheless, positive decrement trend was observed in the periods July-September 2020 and at the end of the study period (January-March 2021).
Although increasing trend was observed in pentavalent-1 vaccination in April-June 2020 and July-September 2020, it continuously declined in the periods October to December 2020 and January to March 2021. A review of routine immunization data from 15 African countries showed that the number of children vaccinated with DPT1, DPT3 and MCV1 declined in the early period of the COVID-19 pandemic . During an epidemic, even a temporary interruption of routine immunization services may lead to secondary health crises such as outbreaks during or after the recovery phase . The deaths prevented by sustaining routine childhood immunization in Africa outweigh the excess risk of COVID-19 deaths associated with vaccination clinic visits, especially for the vaccinated children .
There has been a dramatic reduction in the average number of children under-five years old treated for pneumonia in the first eight months of the COVID-19 pandemic compared to the preceding eight months. Also, we observed significant and accelerated decline trend in the periods April-June 2020 and July-September 2020 (during national lockdown). This may be due to the reduced under-five clinic services provision by health care facilities or reduced demand for health care services by clients/patients. However, in the periods October to December 2020 and January to March 2021 (after lockdown), slow reversal in a negative trend was observed, but does not appear to have recovered to the pre-pandemic baseline level. Pneumonia is the leading cause of under-five morbidity and mortality in Ethiopia, accounting 18.0% of all causes of mortality and killing over 40,000 children in under-five age group every year in the country . Therefore, further study is warranted to investigate the reasons for the declining trend of under-five years old children treated for pneumonia.
This study attempted to understand the performance status of selected RMNCH services using routine data in the context of COVID-19 pandemic. However, other studies showed high rates of inaccuracies in health records in Ethiopia [40, 41], and as we used routine HMIS data this study may share the inherent limitation of secondary data such as: inconsistency, incompleteness and inaccuracy. Nevertheless, extensive efforts have been made by the research team to ensure the data quality. The data collectors and supervisors cross checked the HMIS data at health facilities level whenever discrepancies occurred during the data review period.