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IntroductionIn sub-Saharan Africa, referral hospitals are important sources of key maternal health services, especially during a crisis such as the COVID-19 pandemic. This study prospectively assessed the effect of the COVID-19 pandemic on maternal health service utilisation in six large referral hospitals in Guinea, Nigeria, Tanzania and Uganda during the first year of the pandemic.MethodsMixed-methods design combining three data sources: (1) quantitative data based on routine antenatal, childbirth and postnatal care data collected March 2019–February 2021, (2) qualitative data from recurring rounds of semi-structured interviews conducted July 2020–February 2021 with 22 maternity skilled heath personnel exploring their perceptions of service utilisation and (3) timeline data of COVID-19 epidemiology, global, national and hospital-level events. Qualitative and quantitative data were analysed separately, framed based on the timeline analysis and triangulated when reporting.ResultsThree periods including a first wave, slow period and second wave were identified. Maternal health service utilisation was lower during the pandemic compared with the prepandemic year in all but one selected referral hospital. During the pandemic, service utilisation was particularly lower during the waves and higher or stable during the slow period. Fear of being infected in hospitals, lack of transportation, and even when available, high cost of transportation and service closures were key reasons affecting utilisation during the waves. However, community perception that the pandemic was over or insinuation by Government of the same appeared to stabilise use of referral hospitals for childbirth.ConclusionUtilisation of maternal health services across the continuum of care varied through the different periods and across countries. In crisis situations such as COVID-19, restrictions and service closures need to be implemented with consideration given to alternative options for women to access and use services. Information on measures put in place for safe hospital use should be communicated to women.

IntroductionReferral hospitals in sub-Saharan Africa are located in crowded urban areas, which were often epicentres of the COVID-19 pandemic. This paper prospectively assesses how maternal healthcare was provided in six referral hospitals in Guinea, Nigeria, Tanzania and Uganda during the first year of the COVID-19 pandemic.MethodsMixed-methods design using three data sources: (1) qualitative data from repeated rounds of semi-structured interviews conducted between July 2020 and February 2021 with 22 maternity skilled heath personnel (SHP) on perceptions of care provision; (2) quantitative monthly routine data on caesarean section and labour induction from March 2019 to February 2021; and (3) timeline data of COVID-19 epidemiology, national and hospital-level events. Qualitative and quantitative data were analysed separately, framed based on timeline analysis, and triangulated during reporting.ResultsWe identified three periods: first wave, slow period and second wave. The first wave was challenging for SHP given little knowledge about COVID-19, lack of infection prevention and control training, and difficulties reaching workplace. Challenges that persisted beyond the first wave were shortage of personal protective equipment and no rapid testing for women suspected with COVID-19. We noted no change in the proportion of caesarean sections during the pandemic, and a small increase in the proportion of labour inductions. All hospitals arranged isolation areas for women suspected/confirmed with COVID-19 and three hospitals provided care to women with suspected/confirmed COVID-19. Breastfeeding was not discouraged and newborns were not separated from mothers confirmed with COVID-19. Care provision was maintained through dedication of SHP, support from hospital management and remote communication between SHP.ConclusionRoutine maternal care provision was maintained in referral hospitals, despite first wave challenges. Referral hospitals and SHP contributed to guideline development for pregnant women suspected/confirmed with COVID-19. Maternity SHP, women and pregnancy must always be included in priority setting when responding to health system shocks, including outbreaks.

ObjectivesThe COVID-19 pandemic affected provision and use of maternal health services. This study describes changes in obstetric complications, referrals, stillbirths and maternal deaths during the first year of the pandemic and elucidates pathways to these changes.DesignProspective observational mixed-methods study, combining monthly routine data (March 2019–February 2021) and qualitative data from prospective semi-structured interviews. Data were analysed separately, triangulated during synthesis and presented along three country-specific pandemic periods: first wave, slow period and second wave.SettingSix referral maternities in four sub-Saharan African countries: Guinea, Nigeria, Tanzania and Uganda.Participants22 skilled health personnel (SHP) working in the maternity wards of various cadres and seniority levels.ResultsPercentages of obstetric complications were constant in four of the six hospitals. The percentage of obstetric referrals received was stable in Guinea and increased at various times in other hospitals. SHP reported unpredictability in the number of referrals due to changing referral networks. All six hospitals registered a slight increase in stillbirths during the study period, the highest increase (by 30%–40%) was observed in Uganda. Four hospitals registered increases in facility maternal mortality ratio; the highest increase was in Guinea (by 158%), which had a relatively mild COVID-19 epidemic. These increases were not due to mortality among women with COVID-19. The main pathways leading to these trends were delayed care utilisation and disruptions in accessing care, including sub-optimal referral linkages and health service closures.ConclusionsMaternal and perinatal survival was negatively affected in referral hospitals in sub-Saharan Africa during COVID-19. Routine data systems in referral hospitals must be fully used as they hold potential in informing adaptations of maternal care services. If combined with information on women’s and care providers’ needs, this can contribute to ensuring continuation of essential care provision during emergency.

burst abdomen is a preventable complication of caesarean section that carries an increased risk of maternal death, especially in developing countries including Tanzania. The study aimed to identify the risk factors and high-risk patients for burst abdomen at Muhimbili National Hospital in Tanzania. a case-control study was performed at Muhimbili National Hospital in Dar es Salaam from 2 April to 27 December 2019. Characteristics of interest of one case of burst abdomen were compared to three randomly selected controls that consisted of caesarean deliveries either 24 hours before or after the time of delivery of cases. The chi-square test, Fischer´s exact test, and multivariate analysis were used. The level of significance was p < 0.05. a total of 524 women that met the inclusion criteria, comprising 131 cases and 393 controls, delivered by caesarean section in the most recent pregnancy at Muhimbili National Hospital. Cases were independently associated with perioperative illness, including cough (OR 3.8, 95%CI 1.9-7.6), chorioamnionitis (OR 4.5, 95% CI 1.3-14.7), and surgical site infection (OR 3.2, 95% CI 1.7-6.4), and a vertical midline incision wound (OR 1.9, 95% CI 1.2-3.1) compared to control group. Most cases (70%) had intact sutures and loose surgical knots. burst abdomen remains a cause of unnecessary severe maternal morbidity and is independently associated with perioperative illnesses such as cough, chorioamnionitis surgical site infection, and a vertical midline abdominal incision. Thus, there is a need for modifying abdominal fascia closure techniques for patients at risk.