RESUMO
Objective: Maintaining provision and utilization of maternal healthcare services is susceptible to external influences. This study describes how maternity care was provided during the COVID-19 pandemic and assesses patterns of service utilization and perinatal health outcomes in 16 referral hospitals (four each) in Benin, Malawi, Tanzania and Uganda. Methods: We used an embedded case-study design and two data sources. Responses to open-ended questions in a health-facility assessment survey were analyzed with content analysis. We described categories of adaptations and care provision modalities during the pandemic at the hospital and maternity ward levels. Aggregate monthly service statistics on antenatal care, delivery, caesarean section, maternal deaths, and stillbirths covering 24 months (2019 and 2020; pre-COVID-19 and COVID-19) were examined. Results: Declines in the number of antenatal care consultations were documented in Tanzania, Malawi, and Uganda in 2020 compared to 2019. Deliveries declined in 2020 compared to 2019 in Tanzania and Uganda. Caesarean section rates decreased in Benin and increased in Tanzania in 2020 compared to 2019. Increases in maternal mortality ratio and stillbirth rate were noted in some months of 2020 in Benin and Uganda, with variability noted between hospitals. At the hospital level, teams were assigned to respond to the COVID-19 pandemic, routine meetings were cancelled, and maternal death reviews and quality improvement initiatives were interrupted. In maternity wards, staff shortages were reported during lockdowns in Uganda. Clinical guidelines and protocols were not updated formally; the number of allowed companions and visitors was reduced. Conclusion: Varying approaches within and between countries demonstrate the importance of a contextualized response to the COVID-19 pandemic. Maternal care utilization and the ability to provide quality care fluctuated with lockdowns and travel bans. Women's and maternal health workers' needs should be prioritized to avoid interruptions in the continuum of care and prevent the deterioration of perinatal health outcomes.
RESUMO
Health facility assessments (HFAs) assessing facilities' readiness to provide services are well-established. However, HFA questionnaires are typically quantitative and lack depth to understand systems in which health facilities operate-crucial to designing context-oriented interventions. We report lessons from a multiple embedded case study exploring the experiences of HFA data collectors in implementing a novel HFA tool developed using systems thinking approach. We assessed 16 hospitals in four countries (Benin, Malawi, Tanzania and Uganda) as part of a quality improvement implementation research. Our tool was organized in 17 sections and included dimensions of hospital governance, leadership and financing; maternity care standards and procedures; ongoing quality improvement practices; interactions with communities and mapping of the areas related to maternal care. Data for this study were collected using in-depth interviews with senior experts who conducted the HFA in the countries 1-3 months after completion of the HFAs. Data were analysed using the inductive thematic analysis approach. Our HFA faced challenges in logistics (accessing key hospital-based respondents, high turnover of managerial staff and difficulty accessing information considered sensitive in the context) and methodology (response bias, lack of data quality and data entry into an electronic platform). Data elements of governance, leadership and financing were the most affected. Opportunities and strategies adopted aimed at enhancing data collection (building on prior partnerships and understanding local and institutional bureaucracies) and enhancing data richness (identifying respondents with institutional memory, learning from experience and conducting observations at various times). Moreover, HFA data collectors conducted abstraction of records and interviews in a flexible and adaptive way to enhance data quality. Lessons and new skills learned from our HFA could be used as inputs to respond to the growing need of integrating the systems thinking approach in HFA to improve the contextual understanding of operations and structure.
