Covid-19 Pandemic Impact on Maternal and Child Health Services Access in Nampula, Mozambique: A Mixed Methods Research.


 BackgroundThe Covid-19 pandemic limited access to health services in most countries, impacting negatively global health. Last March 2020 in Mozambique, a public state of emergency restrained people’s movements, reduced public services, and launched a national information campaign. The Alert Community for a Prepared Hospital implementation research, has been promoting access to maternal and child health care, at Marrere General Hospital and Marrere Health Centre, in Natikiri, Nampula, the city with the third highest incidence of Covid-19 in Mozambique. Our research aimed to assess the impact of Covid-19 on access to maternal and children health services in Nampula and estimate Alert Community for a Prepared Hospital project sustainability.MethodsMixed-methods research, descriptive, cross-sectional, and retrospective, using review of patient visits documentation, comparing March to May 2019 to same months in 2020, and interviews with health professionals, traditional birth attendants and patients. We involved two health centres and two hospitals. The two Marrere centres were Alert Community for a Prepared Hospital intervention centres, and the other two were control centres, compared using KrushKall Wallis, One-way Anova, mean and standard deviation tests.ResultsComparing 2019 maternal health services indicators with those from 2020, the intervention area had decreases of 28% in family planning visits, 26% in women in first ante-natal visits in the first trimester, and a 74% increase in home deliveries, all without statistical significance. The decrease in hospital maternity deliveries (4%) was statistically significant (p=0.046). The non-intervention area showed a decrease in women in first ante-natal visits in the first trimester (12%). Concerning child health, the intervention area had a 20% reduction in children presenting for vaccination and an 18% in children completely vaccinated, comparable to a reduction of 16% in the non-intervention area. Interviews revealed that most health professionals, traditional birth attendants and patients, have adequate knowledge about Covid-19. ConclusionOur results demonstrate negative collateral effects of Covid-19 on maternal and child health access and a deficient health information system in Mozambique. The Government’s media campaign promoting access to preventive health services, is not achieving its aim. The Alert Community project will need further research, to assess lasting effect on reducing the negative effects of Covid-19 on sexual and reproductive health.Trial registrationThis study was not registered in any data base.

human immunode ciency virus (HIV) infections or road accidents deaths. This made us to evaluate the health units (HU) resilience to the pandemic, to support Ministry of Health (MISAU) decisions on priorities, and to access the sustainability of ACPH interventions to better MCH in Natikiri.

Methods
The aim of this study was to evaluate the impact of Covid-19 pandemic, on MCH care services access in Nampula city and estimate ACPH implementation research results sustainability. This is a mixed-methods explanatory design research, descriptive, cross-sectional, and retrospective, applying documental review (maternal and child health care statistical indicators at HU), comparing March, April, and May 2019 with the same period in 2020. This was then followed by interviews to HP, TBAs and users, respecting COREQ checklist (see additional le).
Quantitative data was obtained from HUs monthly o cial statistics, at MCH departments. We checked two health centres (Marrere, 25 de Setembro) and two hospitals (Marrere General and Nampula Central) users' tendencies, respectively with and without ACPH project intervention, collecting data during July 2020.
Quantitative data was recorded on Microsoft O ce Excel, double checked by research assistant and statistics lecture, and analysed by number and percentage. It was then run through SPSS21 to test signi cant changes in access to MCH services between 2019 and 2020, using Krushkall Wallis, One-way Anova and mean and standard deviation tests, statistically con rmed when p-value "<α<" 0.05.
ACPH had a data base with phone numbers of TBAs in the Natikiri area. They were interviewed privately by two authors (female Macaringue C. and male Abdirazak A., general practicians, FHC's lecturers, with training and experience in interviewing), with scienti c interest in the research topic, unknown and with no relationship with participants prior to study commencement. In collaboration with TBAs, we were able to further contact mothers and pregnant women to interview. HPs were interviewed in their workplace. Subjects were a proposed sample of HPs (nine), TBAs (six in Natikiri) and patients or users (six in Natikiri) of MCH services. Due to the Presidential declaration of a State of Emergency, in response to the COVID-19 pandemic, community members were interviewed by cell phone and HPs in person respecting preventive measures, during August 2020, each for 30 minutes. The interview model was developed for this study, pretested and provided by the authors, conducted in Portuguese or Emakhuwa (local language), following participant preference, taking notes in the written model. There were no refusals, drop out or repeated interviews.
Conversations were record after participants verbal consent and transcribed to Microsoft O ce Word by the same research assistants. Qualitative data was then transferred to NVIVO program for analysis. We used inductive content analysis, targeting four speech categories and ten themes: 1) Knowledge about the disease Covid-19 (cause, symptoms, prevention, social impact); 2) Impact of CoVid-19 in access to HU (population' behaviour, user's behaviour); 3) Health system response (HP, MCH); 4) Impact on motorcycle-ambulance usage (demand, service).

Quantitative results
Comparing the three months of Covid-19 pandemic in Natikiri, Mozambique in 2020, with the same period in 2019, concerning maternal health services access indicators, data shows increases of domiciliary deliveries (74%), of the number of pregnant women in the rst ante-natal visit and women with four ante-natal visits (19%), of the number of new-born visits (14%), and decreases of 26% in the number of women in rst ante-natal visit in the rst trimester, and 28% of elective c-sections, all without statistical signi cance; a decrease of 4% on intra-hospital deliveries was statistically signi cant (p = 0,046, see Table 1). When Krus kal Wallis and One-Way ANOVA tests are run, show that there is only statistically signi cant difference in the means of intra-hospital deliveries between both years when p-value is 0.046 and "α<"0.05.
In non-intervention area, we had an increase of 125% in the number of women with four ante-natal visits, and a decrease of 12% of the number of women with rst ante-natal visit in the rst trimester, all without statistical signi cance (see Table 2). When Kruskal Wallis and One-Way ANOVA test are run, they show no statistical signi cance between both years because the p-value">α>"0.05 Concerning children and adolescent health services access indicators, quantitative data in the intervention area shows a decrease of 28% on family planning visits, 20% of vaccinated children and 18% of children completely vaccinated, all without statistical signi cance (see Table 3). Legend: M+/-SD -Mean +/-Standard deviation; NDA -No data available; % -percentage; ** -One-way ANOVA.
When One-Way ANOVA test is run, show that there are no statistically signi cant differences between both years when p-value is ">" 0.5.
In non-intervention area we had a decrease of 16% in the number of children completely vaccinated and the number of adolescents and youth visits, all without statistical signi cance (see Table 4). When One-Way ANOVA test is run, it shows no statistically signi cant difference between both years because the p-value">α>"0.05.

Qualitative results
Data saturation was attained at 19th interviews and discussed among authors. Six users (mothers and pregnant women), four TBAs from Natikiri district, three MCH nurses from HC 25 Setembro, two from MHC, one from MGH and three from NCH, were interviewed, all female with a mean age of 34 years.
Transcripts were returned to HPs for their comments and there were no corrections. Records were presented to TBAs and users, as they were all illiterate, and there were no corrections.

Knowledge of the Covid-19 disease
When evaluating knowledge of the disease, we found that the basics were known by all groups. Users and TBAs were able to mention at least three major symptoms such as cough, fever and di culty breathing.
"…it's a u, in which the person has a cough, headache, neck pain, feels cold and has fever." (TBA, Natikiri, 37 years).
They were also able to mention simple preventive methods, such as washing hands, social distancing, and wearing masks whenever in public.
"…we have to wash our hands with water and soap or ashes" (Post-partum women, Natikiri, 32 years).
As expected, HP had more knowledge on the origin of the disease, "CoVid-19 is a contagious disease originated in China and is caused by a new coronavirus SARS-cov-2" (MCH Nurse, MHC, 24 years).
Also, on symptoms, and prevention methods: "…if the person travels to a country contaminated by CoVid-19 they have to be quarantined for 14 day" (MCH Nurse, 25 September HC, 28 years).

Impact of CoVid-19 in access to health units
During interviews, all groups stated that they anecdotally saw the number of people frequenting the HUs decreased signi cantly, due to the fear of contamination in the HU.
The TBAs related that there was a reduction in the number of patients seen in the community. Also, both users and TBAs, mentioned that due to the CoVid-19 pandemic, important tasks such as going preaching their religion in churches and mosques was prohibited. Adolescents' traditional initiation rites were also conditioned, as they are considered activities of populational agglomeration. Work overall was affected, as they were forced to stay home, farming was reduced to intermediate days or ceased completely. Additionally, TBAs referred a decrease in the number of community members who visited them. They mentioned that they also respected and enforced prevention measures, on the few community members who visited them.
"The number of health professionals has decreased, and they leave early, so the waiting time has increased a bit" (TBA, Natikiri, 28 years).
HPs recognise a much lower workload but also a reduction in MCH HPs number and work hours, so as a population behaviour change in terms of personal hygiene.
"The ux of patients is reduced; it may be because they fear coming to the hospital thinking that they might be contaminated here in the Nampula Central Hospital" (MHC Nurse, NCH, 36 years).
"…in the wards there is only one nurse per shift, and because of the pandemic if one gets sick, we will be forced to work every day to cover her!" (MHC Nurse, MGH, 26 years).
Interviews with patients show they recognise population' behaviour change to prevent the infection, and in reducing access to health services.

Health system response
The lack of HPs in HUs was unanimous for the three levels (MHC and Health Centre 25 de Setembro -level 1, MGH -level 3 and NCH -level 4). This is a recurrent complaint from HPs, TBAs and patients.
HPs keep educating users about CoVid-19 prevention methods, and the necessary conditions for consultations.
"…we reinforce measures and make the community understand, to comply to the measures of prevention of this disease." (MGH Nurse, NCH, 36 years).
"the health professionals refuse to treat patients with no masks and that didn't wash their hands" (MCH Nurse, NCH, 34 years).
Users and TBAs mentioned that they continue to frequent the healthcare services, mostly to vaccinate their children, because the vaccines are no longer available in the communities, forcing parents to go to the HU to get the child vaccinated (mobile brigades have not been going to the communities to deliver the vaccines).
"…these vaccines have not come to the community, so the mothers have to go to the hospital!" (Post-partum women, Natikiri, 22 years).

Impact on motorcycle-ambulance usage
With regards to the usage of motorcycle ambulances, a delivering women and emergencies transportation system implemented by ACPH project in Natikiri, the nurses in MHC and MGH were not able to provide any satisfactory answers (they had no information of this intervention). The users and TBAs mentioned that the motorcycle ambulances continued to circulate normally in some areas and in others reduced.
"…the motorcycle ambulances have reduced their circulation because of the disease!" (TBA, Natikiri, 28 years).

Discussion
Primary and secondary health care services assessment on a pandemic, is an effort to attain global health towards universal health cover. We assessed the two systems, where primary care should be a strong leader. Government's Covid-19 pandemic preventive measures might have reduced the case number in Mozambique, but they have reduced maternal, children and adolescent's health services access in Nampula. These facts are recognised globally. 10 It is also known that countries' primary care systems strength, does not in uence the pandemic mortality rate, which is more dependant of perceived stringent border control, movement restriction, and testing regimes. 11 Behaviour change promoted by the government on preventive activities, targeting community health workers, TBAs, traditional leaders and healers with trainings, 12 and general population with a media campaign through television and radio, launched in May 2020, has attained most population, concerning Covid-19, but reduced users and HP' MCH preventive attitudes and behaviours, within the public health system, in primary and secondary health care services.
This might be an opportunity to MISAU to reformulate its population information and education strategy. 13 The health information system is de cient like in other countries in Africa, 14 and restrained conclusions. A quaternary hospital has poor quality records and a tertiary hospital incorporates a primary health care centre' indicators.
The number of pregnant women with four ante-natal visits increased, but we consider this result independent of Covid-19 impact, since the three previous visits have occurred before the state of emergency.