Indirect effect of COVID-19 pandemic on maternal and neonatal health care in resource-poor setting

Reeta Bora, Pranay Phukan, Kiran R. Konda


Background: COVID-19 pandemic has been affecting maternal and neonatal health worldwide. Our study was done to find the indirect effect of the pandemic due to associated lockdown, travel restrictions, etc. on maternal and neonatal health in a rural resource-limited area in northeast India.

Methods: In this retrospective observational study, mothers of a rural, resource-limited area were enrolled if they delivered in the institution where the study was done. Hospital data regarding maternal mortality and stillbirth rate (SBR) from November 2019 till February 2020 (no-lockdown) was compared with the lockdown period (March 2020 till June 2020). Neonatal data of the no-lockdown and lockdown period were analysed and compared. All inborn and sick neonates delivered outside and admitted in the institution's neonatal unit after delivery (outborn) were included.

Results: There was a 33% reduction of institutional delivery rate in Lockdown compared to the no-lockdown period. Outborn admission to the newborn unit was reduced by 41%. Stillbirth and death due to perinatal events increased significantly (relative risk (RR) 1.45, 95% CI: 0.85-2.48) amongst inborn in the lockdown period. During lockdown period maternal mortality increased from 551/100000 to 761/100000 live births (LB) (RR 1.38, 95% CI: 1.21-1.52) and NMR from 26/1000 to 32/1000 LB (RR: 1.23, 95% CI: 0.73-2.04).

Conclusions: Significant adverse indirect effect of COVID-19 pandemic is observed on maternal and neonatal health. Ways for avoidance of reversion of gain achieved in NMR and MMR in the last few years in lower and middle-income countries (LMIC) needs to be urgently looked at.


COVID-19 pandemic, Indirect effect, Maternal and child health

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HQSS, Lancet Global Health Commission on high-quality health systems in the SDG era. Available at: Accessed on 19 May 2019.

Dicker D, Nguyen G, Abate D, Abate KH, Abay SM, Abbafati C, et al. Global, regional, and national age-sex-specific mortality and life expectancy, 1950–2017: a systematic analysis for the Global Burden of Disease Study 2017. The Lancet. 2018;392(10159):1684-735.

Blencowe H, Cousens S, Jassir FB, Say L, Chou D, Mathers C, et al. National, regional, and worldwide estimates of stillbirth rates in 2015, with trends from 2000: a systematic analysis. The Lancet Global Health. 2016;4(2):98-108.

WHO & UNICEF. Every Newborn Action Plan: Country Progress Plans and moving forward. ENAP Country Progress Tracking report. 2015.

ACOG/Clinical. Novel Corona Virus Practice Advisory, July 2020. Available at: https://www. Accessed on 23rd August 2020.

Shahbazi Sighaldeh S, Ebrahimi Kalan M. Care of newborns born to mothers with COVID-19 infection; a review of existing evidence. The Journal of Maternal-Fetal & Neonatal Medicine. 2020;1-3.

Karimi-Zarchi M, Neamatzadeh H, Dastgheib SA, Abbasi H, Mirjalili SR, Behforouz A, et al. Vertical transmission of coronavirus disease 19 (COVID-19) from infected pregnant mothers to neonates: a review. Fetal and Pediatric Pathology. 2020;39(3):246-50.

Kirtsman M, Diambomba Y, Poutanen SM, Malinowski AK, Vlachodimitropoulou E, Parks WT, et al. Probable congenital SARS-CoV-2 infection in a neonate born to a woman with active SARS-CoV-2 infection. CMAJ. 2020;192(24):647-50.

Vivanti AJ, Vauloup-Fellous C, Prevot S, Zupan V, Suffee C, Do Cao J, et al. Transplacental transmission of SARS-CoV-2 infection. Nature Communications. 2020;11(1):1-7.

Von Kohorn I, Stein SR, Shikani BT, Ramos-Benitez MJ, Vannella KM, Hewitt SM, et al. In utero severe acute respiratory syndrome coronavirus 2 infection. Journal of the Pediatric Infectious Diseases Society. 2020;9(6):769-71.

Allotey J, Stallings E, Bonet M, Yap M, Chatterjee S, Kew T, et al. Clinical manifestations, risk factors, and maternal and perinatal outcomes of coronavirus disease 2019 in pregnancy: living systematic review and meta-analysis. BMJ. 2020;370.

Menendez C, Gonzalez R, Donnay F, Leke RG. Avoiding indirect effects of COVID-19 on maternal and child health. The Lancet Global Health. 2020;8(7):863-4.

Roberton T, Carter ED, Chou VB, Stegmuller AR, Jackson BD, Tam Y, et al. Early estimates of the indirect effects of the COVID-19 pandemic on maternal and child mortality in low-income and middle-income countries: a modelling study. The Lancet Global Health. 2020;8(7):901-8.

Directorate of Economics and Statistics (2016–2017) Economic survey of Assam. Available at: mic-survey-assam. Accessed on 28 May 2021.

IAMR, Planning Commission Govt of India. India Human Development Report. 2018. Available at: Accessed on 28 May 2021.

Assam: Poverty, Growth & Inequality - World Bank Document. Available at: https://documents1. Accessed on 28 May 2021.

Latest minimum wages for shops and establishments in Assam. Available at: https://www.simpliance. in/minimum-wages/assam. Accessed on 28 May 2021.

National Health Family Survey 2019-20, Fact Sheet Assam. Ministry of Health and Family Welfare, Govt of India. Available at: Accessed on 28 May 2021.

Goudar SS, Goco N, Somannavar MS, Kavi A, Vernekar SS, Tshefu A, et al. Institutional deliveries and stillbirth and neonatal mortality in the Global Network's Maternal and Newborn Health Registry. Reproductive Health. 2020;17(3):1-9.

WHO, UNICEF, United Nations Population Fund, World Bank Group, United Nations Population Division. Trends in maternal mortality: 1990 to 2015. Geneva: World Health Organization, 2015. Available at: ions/monitoring/ maternal-mortality-2015/en/. Accessed on 09 September 2020.

Blencowe H, Cousens S, Jassir FB, Say L, Chou D, Mathers C, et al. National, regional, and worldwide estimates of stillbirth rates in 2015, with trends from 2000: a systematic analysis. The Lancet Global Health. 2016;4(2):98-108.

UNICEF, WHO, World Bank, and UN. Level and trend of child mortality 2019. New York, NY: United Nations International Children's Emergency Fund, 2019. Available at: levels-and-trends-child-mortality-report-2019. Accessed on 09 September 2020.

WHO, Regional Office for Europe/Health topics/Coronavirus disease (COVID-19) pandemic. Available at: Accessed on 23 August 2020.

Semaan A, Audet C, Huysmans E, Afolabi B, Assarag B, Banke-Thomas A, et al. Voices from the frontline: findings from a thematic analysis of a rapid online global survey of maternal and newborn health professionals facing the COVID-19 pandemic. BMJ Global Health. 2020;5(6):e002967.

Riley T, Sully E, Ahmed Z, Biddlecom A. Estimates of the potential impact of the COVID-19 pandemic on sexual and reproductive health in low-and middle-income countries. International Perspectives on Sexual and Reproductive Health. 2020;46:73-6.

Ashish KC, Gurung R, Kinney MV, Sunny AK, Moinuddin M, Basnet O, et al. Effect of the COVID-19 pandemic response on intrapartum care, stillbirth, and neonatal mortality outcomes in Nepal: a prospective observational study. The Lancet Global Health. 2020;8(10):1273-81.

Delamou A, El Ayadi AM, Sidibe S, Delvaux T, Camara BS, Sandouno SD, et al. Effect of Ebola virus disease on maternal and child health services in Guinea: a retrospective observational cohort study. The Lancet Global Health. 2017;5(4):448-57.

Boerma T, Requejo J, Victora CG, Amouzou A, George A, Agyepong I, et al. Countdown to 2030: tracking progress towards universal coverage for reproductive, maternal, newborn, and child health. The Lancet. 2018;391(10129):1538-48.

Bora R, Sable C, Wolfson J, Boro K, Rao R. Prevalence of anemia in pregnant women and its effect on neonatal outcomes in Northeast India. The Journal of Maternal-Fetal & Neonatal Medicine. 2014;27(9):887-91.