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. 2021 Mar 21;11(1):12–21. doi: 10.5588/pha.20.0057

Rapid assessment on the utilization of maternal and child health services during COVID-19 in Rwanda

D Wanyana 1,✉, R Wong 1,2, D Hakizimana 1
PMCID: PMC7987248  PMID: 33777716

Abstract

SETTING:

All public health facilities in Rwanda, East Africa.

OBJECTIVE:

To assess the change in the utilization of maternal and child health (MCH) services during the COVID-19 outbreak.

DESIGN:

This was a cross-sectional quantitative study.

RESULTS:

During the COVID-19 outbreak in Rwanda, the utilization of 15 MCH services in all four categories—antenatal care (ANC), deliveries, postnatal care (PNC) and vaccinations—significantly declined. The Northern and Western Provinces were affected the most, with significant decrease in respectively nine and 12 services. The Eastern Province showed no statistically significant utilization changes. Kigali was the only province with significant increase in the fourth PNC visits for babies and mothers, while the Southern Province showed significant increase in utilization of measles + rubella (MR) 1 vaccination.

CONCLUSION:

Access and utilization of basic MCH services were considerably affected during the COVID-19 outbreak in Rwanda. This study highlighted the need for pre-emptive measures to avoid disruptions in MCH service delivery and routine health services during outbreaks. In order for the reductions in MCH service utilization to be reversed, targeted resources and active promotion of ANC, institutional deliveries and vaccinations need to be prioritized. Further studies on long-term impact and geographical variations are needed.

Keywords: MCH, disease outbreak, sub-Saharan Africa, Health Management Information System, HMIS, secondary analysis

Since the first case of COVID-19 was discovered in Wuhan, China, in December 2019, the novel strain of coronavirus has quickly spread worldwide and become a pandemic.1 As of today, over 41 million people have been infected, and over one million deaths have been recorded globally.2 Several countries have instituted COVID-19 prevention measures, including testing, contact tracing, quarantine and countrywide lockdown.

COVID-19 is highly contagious, with an average of 2.2 additional cases generated by each sick person.3,4 The transmission of COVID-19 from humans to humans is mainly through droplets via sneezing or coughing and contact with surfaces touched by an infected person.5

Studies have shown that in times of epidemic crisis, the health system is compromised. The health of women and children is usually the most affected and they face the highest rate of death.6–8 The 2014–2015 Ebola outbreak in West Africa severely compromised the health systems in the affected countries. The fear of healthcare providers, as well as patients substantially reduced the utilization of antenatal care (ANC), skilled and facility-based deliveries, cesarean sections, vaccination, and other maternal health care services by about 35% to 80%.6 Evidence has shown that the decline in the utilization of MCH services after the disease outbreak did not recover to pre-outbreak levels until targeted strategies were put in place.7

Rwanda is not free from the disruption caused by the COVID-19 pandemic. Since the first case was confirmed on March 14, 2020, Rwanda has reported over 4,000 total cases of COVID-19 as of September 2, 2020.9 The country has implemented several measures to minimize the spread of the disease10,11 while essential services, such as health facilities, remain open. To the best of our knowledge, the impact of COVID-19 on the utilization of health care services related to MCH has not been assessed. This study, therefore, aimed to assess the utilization of MCH services during COVID-19 in Rwanda. The findings from this study contributed to the existing knowledge on the impact of coronavirus disease in Rwanda and will support the Ministry of Health (Kigali, Rwanda) and Rwanda Biomedical Center (Kigali, Rwanda) in implementing targeted interventions to reverse the decline in MCH services utilization.

METHODS

Study design

We analyzed data from the Rwanda Health Management Information System (HMIS).

Setting

Rwanda (estimated 2020 population: 12,663,117; 51.8% female, of whom 23.4% are of reproductive age) is made up of 30 districts in five provinces—Eastern, Northern, Western, Southern and Kigali City. In 2015, 99% of pregnant women attended at least one ANC session, 91% of deliveries took place at a health facility, a 93% immunization coverage was recorded among children aged 12–23 months, and 87% of children received all their basic vaccinations before their first birthday.13

Study period

MCH data from March and April 2019 (before the COVID-19 outbreak) were compared with those from March and April 2020 in order to account for any seasonal differences.

Sample and data collection method

MCH indicators from each of the 30 districts were extracted from the HMIS by the HMIS data manager at the Ministry of Health. The data received were aggregated at the district level from all public health facilities in Rwanda.

Data variables

The 30 MCH indicators were categorized into four groups: ANC (7 indicators), facility delivery (3 indicators), postnatal care (PNC) (4 indicators), and immunization (16 indicators). The individual indicators were listed in Tables 1–6.

TABLE 1.

Changes in use of MCH services, national level

Variables March and April 2019 March and April 2020 Change P value
Observed*/expected† (Expected number = 59,810) Utilization rate‡ ± SD Observed/expected (Expected number = 61,205) Utilization rate ± SD
ANC-related indicators
 ANC new registrations 64,711 1.06 ± 0.23 62,453 1.01 ± 0.19 −0.057 0.138
 ANC first standard visit 29,213 00.49 ± 0.12 27,361 00.45 ± 0.09 −0.041 0.042§
 ANC fourth standard visit 24,034 00.40 ± 0.14 22,042 00.36 ± 0.10 −0.039 0.083
 ANC TT 1 given 21,721 00.36 ± 0.25 20,600 00.33 ± 0.07 −0.026 0.439
 ANC TT 2 to 5 given 45,571 00.76 ± 0.21 44,264 00.72 ± 0.15 −0.035 0.284
 ANC new registrations full course of iron and folic acid supplements 59,269 00.99 ± 0.19 58,365 00.95 ± 0.15 −0.040 0.204
 ANC new registrations tested for anemia 43,273 00.73 ± 0.20 42,940 00.71 ± 0.20 −0.017 0.639
Indicators related to deliveries at health facility
 Deliveries at health facility 59,734 00.99 ± 0.19 54,658 00.89 ± 0.19 −0.103 0.004§
 Mothers in labor referred to higher level for delivery 11,996 00.20 ± 0.06 12,094 00.20 ± 0.06 −0.003 0.793
 Live births 59,461 00.98 ± 0.19 54,332 00.88 ± 0.19 −0.103 0.004§
PNC-related indicators
 PNC 1 visit: baby 50,627 00.84 ± 0.16 50,402 00.81 ± 0.13 −0.027 0.302
 PNC 1 visit: mother 51,577 00.86 ± 0.15 50,543 00.82 ± 0.11 −0.038 0.122
 PNC 4 visit: baby 25,393 00.43 ± 0.14 30,597 00.50 ± 0.13 0.071 0.005§
 PNC 4 visit: mother 26,279 00.44 ± 0.14 31,090 00.51 ± 0.13 0.064 0.011§
Indicators related to childhood vaccinations
 BCG 64,079 1.06 ± 0.19 59,057 00.95 ± 0.17 −0.104 0.002§
 Polio Zero_P0 58,412 00.97 ± 0.18 53,161 00.86 ± 0.15 −0.106 0.001§
 Polio 1 58,913 00.97 ± 0.17 55,303 00.89 ± 0.16 −0.080 0.008§
 Polio 2 57,615 00.95 ± 0.16 54,242 00.88 ± 0.14 −0.075 0.008§
 Polio 3 57,372 00.95 ± 0.16 55,587 00.90 ± 0.15 −0.050 0.081
 IPV 57,195 00.95 ± 0.16 55,578 00.90 ± 0.15 −0.047 0.101
 DTP_HepB_Hib1 58,901 00.97 ± 0.17 55,236 00.89 ± 0.15 −0.080 0.007§
 DTP_HepB_Hib2 57,624 00.95 ± 0.16 54,188 00.88 ± 0.14 −0.076 0.007§
 DTP_HepB_Hib3 57,335 00.95 ± 0.16 55,527 00.90 ± 0.15 −0.050 0.078
 Pneumococcus 1 58,925 00.97 ± 0.17 55,236 00.89 ± 0.15 −0.081 0.007§
 Pneumococcus 2 57,638 00.95 ± 0.16 54,188 00.88 ± 0.14 −0.076 0.007§
 Pneumococcus 3 57,341 00.95 ± 0.16 55,527 00.90 ± 0.15 −0.050 0.079
 Rotavirus 1 59,025 00.98 ± 0.17 55,242 00.89 ± 0.15 −0.083 0.006§
 Rotavirus 2 57,551 00.95 ± 0.17 54,180 00.88 ± 0.14 −0.075 −0.009§
 Measles + rubella 1 59,240 00.98 ± 0.17 61,235 00.99 ± 0.15 0.014 0.642
 Measles + rubella 2 53,840 00.89 ± 0.12 54,396 00.88 ± 0.13 −0.011 −0.625
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* The number of women or children who actually attended the service.

† The number of women or children who were expected to attend the service in March and April 2019–2020, calculated by multiplying the projected population of 2019/2020 by 2.9%, which is the proportion of the total population aged 0–11 months representing the proportion of women who were expected to give birth divided by 12, then multiplied by 2 for both March and April.

‡ The reported utilization rate is the average utilization of each service across all 30 districts in Rwanda.

§ Significant at P = 0.05.

MCH services that experienced an increase in average utilization rate.

MCH = maternal and child health; SD = standard deviation; ANC = antenatal care; TT = tetanus toxoid; PNC = postnatal care; BCG = bacille Calmette-Guérin; IPV = inactivated polio vaccine; DTP = diphtheria; HepB = hepatitis B; Hib = hemophilus influenza.

TABLE 6.

Changes in utilization of MCH services, Southern Province

Variables March and April 2019 March and April 2020 Change P value
Utilization rate* SD Utilization rate SD
ANC-related indicators
 ANC new registrations 0.91 0.06 0.90 0.09 −0.004 0.879
 ANC first standard visit 0.47 0.08 0.46 0.10 −0.012 0.718
 ANC fourth standard visit 0.40 0.09 0.36 0.08 −0.040 0.199
 ANC TT 1 given 0.28 0.05 0.31 0.04 0.022 0.192
 ANC TT 2 to 5 given 0.69 0.11 0.69 0.10 0.003 0.932
 ANC new registrations full course of iron and folic acid supplements 0.86 0.07 0.88 0.09 0.015 0.614
 ANC new registrations tested for anemia 0.62 0.15 0.62 0.15 0.004 0.935
Indicators related to deliveries at health facility
 Deliveries at health facility 0.89 0.15 0.80 0.13 −0.092 0.074
 Mothers in labor referred to higher level for delivery 0.22 0.07 0.21 0.07 −0.015 0.565
 Live births 0.89 0.15 0.80 0.13 −0.090 0.081
PNC-related indicators
 PNC 1 visit: baby 0.77 0.15 0.75 0.12 −0.020 0.673
 PNC 1 visit: mother 0.78 0.15 0.76 0.12 −0.018 0.702
 PNC 4 visit: baby 0.37 0.11 0.43 0.16 0.058 0.243
 PNC 4 visit: mother 0.38 0.11 0.44 0.15 0.061 0.211
Indicators related to childhood vaccinations
 BCG 0.97 0.12 0.88 0.10 −0.097 0.021†
 Polio Zero_P0 0.91 0.12 0.81 0.09 −0.094 0.016†
 Polio 1 0.86 0.13 0.81 0.11 −0.046 0.275
 Polio 2 0.83 0.10 0.79 0.08 −0.035 0.279
 Polio 3 0.83 0.08 0.82 0.09 −0.017 0.577
 IPV 0.83 0.09 0.82 0.09 −0.013 0.674
 DTP_HepB_Hib1 0.86 0.12 0.81 0.11 −0.050 0.227
 DTP_HepB_Hib2 0.83 0.10 0.79 0.08 −0.036 0.259
 DTP_HepB_Hib3 0.84 0.08 0.82 0.09 −0.019 0.535
 Pneumococcus 1 0.86 0.12 0.81 0.11 −0.050 0.227
 Pneumococcus 2 0.83 0.09 0.79 0.08 −0.036 0.258
 Pneumococcus 3 0.83 0.09 0.82 0.09 −0.015 0.643
 Rotavirus 1 0.87 0.12 0.81 0.11 −0.054 0.197
 Rotavirus 2 0.82 0.09 0.79 0.08 −0.027 0.364
 Measles + rubella 1 0.85 0.08 0.92 0.06 0.066‡ 0.019†
 Measles + rubella 2 0.77 0.07 0.82 0.08 0.050 0.076
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* The reported utilization rate is the average utilization of each service across the eight districts in the Southern Province.

† Significant at P = 0.05.

‡ MCH services that experienced an increase in average utilization rate.

MCH = maternal and child health; SD = standard deviation; ANC = antenatal care; TT = tetanus toxoid; PNC = postnatal care; BCG = bacille Calmette-Guérin; IPV = inactivated polio vaccine; DTP = diphtheria; HepB = hepatitis B; Hib = hemophilus influenza.

TABLE 3.

Changes in utilization of MCH services, Eastern Province

Variables March and April 2019 March and April 2020 Change P value
Utilization rate* SD Utilization rate SD
ANC-related indicators
 ANC new registrations 1.14 0.16 1.11 0.11 −0.039 0.454
 ANC first standard visit 0.53 0.12 0.49 0.12 −0.040 0.380
 ANC fourth standard visit 0.44 0.11 0.41 0.12 −0.031 0.482
 ANC TT 1 given 0.35 0.04 0.35 0.03 0.002 0.901
 ANC TT 2 to 5 given 0.72 0.13 0.72 0.12 0.001 0.978
 ANC new registrations full course of iron and folic acid supplements 1.07 0.20 1.04 0.13 −0.038 0.564
 ANC new registrations tested for anemia 0.80 0.10 0.82 0.18 0.024 0.671
Indicators related to deliveries at health facility
 Deliveries at health facility 1.07 0.19 0.97 0.08 −0.097 0.092
 Mothers in labor referred to higher level for delivery 0.23 0.05 0.23 0.03 −0.007 0.68
 Live births 1.06 0.19 0.97 0.08 −0.095 0.098
PNC-related indicators
 PNC 1 visit: baby 0.92 0.23 0.90 0.07 −0.022 0.731
 PNC 1 visit: mother 0.96 0.19 0.91 0.07 −0.049 0.368
 PNC 4 visit: baby 0.47 0.19 0.54 0.10 0.076 0.205
 PNC 4 visit: mother 0.50 0.20 0.56 0.10 0.059 0.324
Indicators related to childhood vaccinations
 BCG 1.14 00.22 1.06 00.11 −0.080 0.225
 Polio Zero_P0 0.99 00.22 00.90 00.14 −0.088 0.219
 Polio 1 1.05 00.18 00.99 00.12 −0.054 0.360
 Polio 2 1.00 00.12 00.96 00.12 −0.039 0.412
 Polio 3 1.00 00.14 1.00 00.15 0.001 0.988
 IPV 1.00 00.13 1.00 00.15 0.003 0.962
 DTP_HepB_Hib1 1.04 00.18 00.99 00.12 −0.050 0.392
 DTP_HepB_Hib2 1.00 00.12 00.96 00.12 −0.039 0.411
 DTP_HepB_Hib3 1.00 00.14 1.00 00.15 0.001 0.987
 Pneumococcus 1 1.04 00.18 00.99 00.12 −0.051 0.381
 Pneumococcus 2 1.00 00.12 00.96 00.12 −0.039 0.411
 Pneumococcus 3 1.00 00.14 1.00 00.15 −0.002 0.976
 Rotavirus 1 1.04 00.18 00.99 00.12 −0.051 0.384
 Rotavirus 2 1.00 00.12 00.96 00.12 −0.038 0.417
 Measles + rubella 1 1.07 00.12 1.13 00.15 0.063 0.242
 Measles + rubella 2 0.94 00.12 00.94 00.17 0.004 0.940
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* The reported utilization rate is the average utilization of each service across the seven districts in the Eastern Province.

MCH = maternal and child health; SD = standard deviation; ANC = antenatal care; TT = tetanus toxoid; PNC = postnatal care; BCG = bacille Calmette-Guérin; IPV = inactivated polio vaccine; DTP = diphtheria; HepB = hepatitis B; Hib = hemophilus influenza.

TABLE 4.

Changes in Utilization of MCH Services, Northern Province

Variables March and April 2019 March and April 2020 Change P value
Utilization rate* SD Utilization rate SD
ANC-related indicators
 ANC new registrations 1.01 0.13 0.89 0.08 −0.123 0.021†
 ANC first standard visit 0.53 0.11 0.45 0.04 −0.072 0.069
 ANC fourth standard visit 0.38 0.12 0.34 0.07 −0.038 0.387
 ANC TT 1 given 0.34 0.05 0.32 0.03 −0.017 0.317
 ANC TT 2 to 5 given 0.73 0.14 0.67 0.08 −0.060 0.247
 ANC new registrations full course of iron and folic acid supplements 0.96 0.15 0.85 0.09 −0.103 0.073
 ANC new registrations tested for anemia 0.69 0.14 0.62 0.15 −0.063 0.353
Indicators related to deliveries at health facility
 Deliveries at health facility 0.89 0.09 0.77 0.11 −0.125 0.011†
 Mothers in labor referred to higher level for delivery 0.16 0.06 0.16 0.06 0.005 0.836
 Live births 0.89 0.08 0.77 0.11 −0.123 0.011†
PNC-related indicators
 PNC 1 visit: baby 0.82 0.09 0.74 0.10 −0.081 0.074
 PNC 1 visit: mother 0.84 0.10 0.76 0.11 −0.084 0.093
 PNC 4 visit: baby 0.46 0.06 0.53 0.14 −0.076 0.14
 PNC 4 visit: mother 0.47 0.06 0.53 0.14 −0.067 0.189
Indicators related to childhood vaccinations
 BCG 0.95 0.12 0.84 0.11 −0.110 0.044†
 Polio Zero_P0 0.90 0.11 0.79 0.11 −0.108 0.041†
 Polio 1 0.92 0.11 0.81 0.11 −0.116 0.031†
 Polio 2 0.90 0.12 0.82 0.10 −0.084 0.109
 Polio 3 0.90 0.11 0.83 0.10 −0.069 0.146
 IPV 0.89 0.11 0.83 0.10 −0.067 0.159
 DTP_HepB_Hib1 0.92 0.12 0.81 0.11 −0.115 0.033†
 DTP_HepB_Hib2 0.90 0.12 0.82 0.10 −0.083 0.115
 DTP_HepB_Hib3 0.89 0.11 0.83 0.10 −0.066 0.170
 Pneumococcus 1 0.92 0.11 0.81 0.11 −0.115 0.032†
 Pneumococcus 2 0.90 0.12 0.82 0.10 −0.082 0.118
 Pneumococcus 3 0.89 0.10 0.83 0.10 −0.068 0.144
 Rotavirus 1 0.92 0.11 0.81 0.11 −0.115 0.033†
 Rotavirus 2 0.90 0.12 0.82 0.10 −0.083 0.114
 Measles + rubella 1 0.91 0.10 0.90 0.12 −0.007 0.888
 Measles + rubella 2 0.87 0.07 0.86 0.11 −0.005 0.902
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* The reported utilization rate is the average utilization of each service across the five districts in the Northern Province.

† Significant at P = 0.05.

MCH = maternal and child health; SD = standard deviation; ANC = antenatal care; TT = tetanus toxoid; PNC = postnatal care; BCG = bacille Calmette-Guérin; IPV = inactivated polio vaccine; DTP = diphtheria; HepB = hepatitis B; Hib = hemophilus influenza.

TABLE 5.

Changes in Utilization of MCH Services, Western Province

Variables March and April 2019 March and April 2020 Change P value
Utilization rate* SD Utilization rate SD
ANC-related indicators
 ANC new registrations 1.01 0.11 0.97 0.14 −0.048 0.320
 ANC first standard visit 0.40 0.13 0.41 0.07 0.014 0.733
 ANC fourth standard visit 0.30 0.11 0.32 0.07 0.013 0.699
 ANC TT 1 given 0.28 0.04 0.29 0.04 0.008 0.629
 ANC TT 2 to 5 given 0.68 0.09 0.67 0.13 −0.009 0.837
 ANC new registrations full course of iron and folic acid supplements 0.93 0.11 0.93 0.14 −0.001 0.991
 ANC new registrations tested for anemia 0.70 0.20 0.76 0.22 0.058 0.478
Indicators related to deliveries at health facility
 Deliveries at health facility 0.94 0.08 0.82 0.09 −0.119 0.002†
 Mothers in labor referred to higher level for delivery 0.20 0.06 0.20 0.04 −0.000 0.981
 Live births 0.93 0.09 0.80 0.10 −0.128 0.001†
PNC-related indicators
 PNC 1 visit: baby 0.86 0.12 0.80 0.09 −0.058 0.152
 PNC 1 visit: mother 0.86 0.12 0.81 0.09 −0.051 0.199
 PNC 4 visit: baby 0.48 0.11 0.55 0.10 0.070 0.091
 PNC 4 visit: mother 0.49 0.12 0.56 0.09 0.065 0.116
Indicators related to childhood vaccinations
 BCG 1.01 0.10 0.89 0.12 −0.118 0.009†
 Polio Zero_P0 0.92 0.11 0.80 0.12 −0.119 0.009†
 Polio 1 0.97 0.12 0.84 0.12 −0.121 0.012†
 Polio 2 0.97 0.15 0.84 0.11 −0.132 0.016†
 Polio 3 0.94 0.14 0.86 0.11 −0.088 0.078
 IPV 0.94 0.14 0.86 0.11 −0.086 0.087
 DTP_HepB_Hib1 0.97 0.12 0.84 0.12 −0.122 0.011†
 DTP_HepB_Hib2 0.97 0.15 0.84 0.11 −0.131 0.016†
 DTP_HepB_Hib3 0.94 0.14 0.86 0.11 −0.088 0.078
 Pneumococcus 1 0.97 0.12 0.84 0.12 −0.121 0.012†
 Pneumococcus 2 0.97 0.15 0.84 0.11 −0.132 0.016†
 Pneumococcus 3 0.94 0.14 0.86 0.11 −0.088 0.078
 Rotavirus 1 0.97 0.12 0.84 0.12 −0.120 0.012†
 Rotavirus 2 0.97 0.15 0.84 0.11 −0.130 0.017†
 Measles and rubella 1 0.96 0.15 0.93 0.10 −0.037 0.456
 Measles and rubella 2 0.93 0.08 0.87 0.11 −0.058 0.120
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* The reported utilization rate is the average utilization of each service across the seven districts in the Western Province.

† Significant at P = 0.05.

MCH = maternal and child health; SD = standard deviation; ANC = antenatal care; TT = tetanus toxoid; PNC = postnatal care; BCG = bacille Calmette-Guérin; IPV = inactivated polio vaccine; DTP = diphtheria; HepB = hepatitis B; Hib = hemophilus influenza.

Data management and analysis

The raw data were converted into rates by calculating the projected populations based on the growth rate of each district in 2019 and 2020 from the country’s population projection records provided in the Rwanda Population size, structure and distribution report.12 The number of women expected to use MCH services was calculated for each district by multiplying each district projected population by 2.9%, the proportion of the total population aged 0–11 months representing the proportion of women who were expected to give birth.12 Finally, the utilization rate for each MCH service was calculated by dividing the raw data (i.e., the number of women or children who actually attended the service) by the number of women or children who were expected to attend the service. The utilization rates for each of the 30 MCH indicators were calculated at each district for 2019 and 2020. t-tests were used to analyze the difference in utilization of each indicator between March and April 2019 and March and April 2020 at the national level and at the provincial level. All statistical analyses were conducted using SPSS v.23 (IBM, Armonk, NY, USA); P value was set at 0.05.

Ethical consideration

This study was approved by the University of Global Health Equity Institutional Review Board (Kigali, Rwanda) and the Rwanda Ministry of Health, Kigali, Rwanda. As this was a secondary data analysis study with aggregated data, no identifiable data were used; informed consent was thus waived for the study.

RESULTS

Nationally, there was significant decrease in the utilization of 13 indicators: ANC first standard visits from 0.49 to 0.45 (P = 0.042), deliveries at health facility from 0.99 to 0.89 (P = 0.004), live births from 0.98 to 0.88 (P = 0.004), vaccinations: bacille Calmette–Guérin (BCG) from 1.06 to 0.95 (P = 0.002), polio zero from 0.97 to 0.86 (P = 0.001), polio 1 from 0.97 to 0.89 (P = 0.008), polio 2 from 0.95 to 0.88 (P = 0.008), diphtheria, tetanus, pertussis, hepatitis B and hemophilus influenza (DTP_HepB_Hib) 1 from 0.97 to 0.89 (P = 0.007), DTP_HepB_Hib 2 from 0.95 to 0.88 (P = 0.007), pneumococcus 1 from 0.97 to 0.89 (P = 0.007), pneumococcus 2 from 0.95 to 0.88 (P = 0.007), rotavirus 1 from 0.98 to 0.89 (P = 0.006) and rotavirus 2 from 0.95 to 0.88 (P = 0.009). Two indicators showed increase in utilization: postnatal care (PNC) 4 visit for baby from 0.43 to 0.50 (P = 0.005) and PNC 4 visit for mother from 0.44 to 0.51 (P = 0.011) (Table I).

Table 2 gives the change in utilization across all five provinces in Rwanda. Of the 30 indicators, 15 significantly decreased (−) and three significantly increased (+) in utilization. The Northern and Western Provinces had the greatest number of MCH services with respectively nine and 12 services experiencing a significant decrease in utilization compared to the other provinces. The South experienced a significant decrease in two services and an increase in one, while Kigali had a significant decrease in three services and an increase in two services. The East showed no statistical differences across all 30 indicators. BCG and polio zero vaccination services showed decreases in utilization in at least three out of five provinces.

TABLE 2.

Summary of MCH service utilization changes across all five provinces

Variables Eastern Northern Western Southern Kigali
ANC new registrations −0.123
ANC first standard visit −0.195
ANC TT 2 to 5 given −0.244
Deliveries at health facility −0.125 −0.119
Live births −0.123 −0.128
PNC 4 visit: baby +0.086
PNC 4 visit: mother +0.079
BCG* −0.110 −0.118 −0.097
Polio Zero_P0* −0.108 −0.119 −0.094
Polio 1 −0.116 −0.121
Polio 2 −0.132
DTP_HepB_Hib1 −0.115 −0.122
DTP_HepB_Hib2 −0.131
Pneumococcus 1 −0.115 −0.121
Pneumococcus 2 −0.132
Rotavirus 1 −0.115 −0.120
Rotavirus 2 −0.130 −0.143
Measles + rubella 1 +0.066
Number of services with decreased utilization 9 12 2 3
Number of services with increased utilization 1 2
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* Decreased utilization in at least three provinces.

MCH = maternal and child health; ANC = antenatal care; TT = tetanus toxoid; PNC = postnatal care; BCG = bacille Calmette-Guérin; DTP = diphtheria; HepB = hepatitis B; Hib = hemophilus influenza.

DISCUSSION

The analyses showed that there was a decrease in utilization of 13 MCH services across Rwanda since the COVID-19 outbreak, particularly in utilizations related to health facility deliveries and child vaccinations services.

Countrywide, the utilization of 13 MCH services significantly decreased. However, PNC 4 visits for both the baby and mother showed a significant increase. The Northern and Western Provinces were affected most, with significant decrease in respectively nine and 12 services. Kigali had significant changes in five services, while the Southern Province had changes in three services. The Eastern Province had no statistically significant utilization changes in any of the 30 MCH indicators. Kigali was the only province with significant increase in utilization of two services, while the Southern Province showed significant increase in utilization of one service. Our study results only captured the initial impact of the COVID-19 in Rwanda. As the pandemic continues, the utilization might be further impacted.

Since COVID-19 is a novel strain, there have not been any similar studies. However, changes in MCH service utilization during previous outbreaks have been well documented in other countries. Similar declines in MCH services observed in our study were reported in West Africa during the 2014 Ebola outbreak.14–19

The significant decline in child health services across the country is alarming, although not surprising. Similar findings were observed in Guinea and Sierra Leone during the Ebola outbreak.17,19 The interruptions and reductions in childhood vaccinations could have detrimental vaccine-preventable disease outbreaks in the future.20,21 In Guinea, 2 years after a decrease in measles vaccination during the Ebola outbreak, the measles incidence drastically increased from 2.7 per million in 2015 to 11.5 per million in 2016.22

Some of the imminent challenges due to the COVID-19 outbreak were related to transport restrictions, reduced communication on existing routine health services due to heightened focus and resource allocation to the public health crisis response, as well as fear of contracting the virus by leaving home and going for routine medical checkups and procedures.6,15,17,18,23–25 However, the decreases could be compounded by pre-existing challenges, such as poor quality of services, poor road conditions, interrupted delivery of supplies to health facilities, and lack of infrastructure for domestic production of medical supplies.8,23,24

Regional variations were also seen across different provinces. The Western Province had the highest number of changes in MCH service utilization. Its close proximity to the Democratic Republic of Congo, where a huge number of COVID-19 cases were reported might have increased the burden on the already limited healthcare workforce and diverted resources to cater to COVID-19 patients.26,27 As reported in a recent study, health workers, facilities and equipment have been reassigned to address the influx of COVID-19 cases, which may have affected the provision and utilization of MCH services.8 Vertical efforts to mitigate COVID-19 may undermine other essential health services and leave women and children vulnerable to delays in accessing care which may lead to life-threatening complications and future public health crises.28 Furthermore, the stay-at-home order issued by the Rwandan government in different provinces29 also likely contributed to the disparities in health service utilization, as the restrictions and ability to move varied from region to region depending on the number of COVID-19 cases in each area. Furthermore, although the spread of COVID-19 was concentrated in Kigali City, the awareness of the ongoing transmission may have influenced health-seeking behavior in all the other provinces across the country.13 Despite the overall decline in service utilization, the utilization of PNC by both babies and mothers in Kigali, and the measles and rubella (MR) 1 vaccination service in the Southern Province increased (Tables 6 and 7). Such variations could be due to the continuation of community-based interventions in the South and the recent community PNC sensitization campaigns in Kigali.29–31 However, further investigation is needed to find out the root causes of the changes observed in service utilization.

TABLE 7.

Changes in utilization of MCH services, Kigali Province

Variables March and April 2019 March and April 2020 Change P value
Utilization rate* SD Utilization rate SD
ANC-related indicators
 ANC new registrations 1.50 0.37 1.35 0.24 −0.149 0.428
 ANC first standard visit 0.62 0.10 0.42 0.08 −0.195 0.003†
 ANC fourth standard visit 0.60 0.21 0.42 0.12 −0.175 0.109
 ANC TT 1 given 0.82 0.66 0.50 0.05 −0.314 0.271
 ANC TT 2 to 5 given 1.27 0.13 1.02 0.09 −0.244 0.004†
 ANC new registrations full course of iron and folic acid supplements 1.30 0.23 1.12 0.17 −0.179 0.153
 ANC new registrations tested for anemia 0.96 0.29 0.70 0.21 −0.264 0.103
Indicators related to deliveries at health facility
 Deliveries at health facility 1.34 0.17 1.27 0.18 −0.073 0.487
 Mothers in labor referred to higher level for delivery 0.14 0.03 0.15 0.02 0.018 0.182
 Live births 1.33 0.17 1.27 0.18 −0.067 0.522
PNC-related indicators
 PNC 1 visit: baby 0.83 0.10 0.93 0.16 0.106 0.204
 PNC 1 visit: mother 0.85 0.09 0.89 0.09 0.043 0.410
 PNC 4 visit: baby 0.30 0.06 0.39 0.04 0.086‡ 0.015†
 PNC 4 visit: mother 0.32 0.07 0.40 0.05 0.079‡ 0.046†
Indicators related to childhood vaccinations
 BCG 1.38 0.17 1.25 0.16 −0.134 0.189
 Polio Zero_P0 1.28 0.17 1.13 0.15 −0.146 0.141
 Polio 1 1.21 0.14 1.14 0.13 −0.072 0.368
 Polio 2 1.22 0.11 1.10 0.10 −0.123 0.079
 Polio 3 1.24 0.13 1.10 0.13 −0.138 0.091
 IPV 1.23 0.14 1.10 0.13 −0.130 0.118
 DTP_HepB_Hib1 1.21 0.14 1.13 0.12 −0.078 0.314
 DTP_HepB_Hib2 1.22 0.12 1.09 0.10 −0.129 0.061
 DTP_HepB_Hib3 1.23 0.13 1.09 0.12 −0.138 0.08
 Pneumococcus 1 1.21 0.14 1.13 0.12 −0.081 0.299
 Pneumococcus 2 1.23 0.12 1.09 0.10 −0.132 0.056
 Pneumococcus 3 1.24 0.13 1.09 0.12 −0.142 0.074
 Rotavirus 1 1.22 0.14 1.13 0.12 −0.093 0.232
 Rotavirus 2 1.24 0.11 1.09 0.10 −0.143 0.039†
 Measles + rubella 1 1.24 0.17 1.16 0.14 −0.086 0.368
 Measles + rubella 2 1.06 0.08 0.95 0.17 −0.112 0.171
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* The reported utilization rate is the average utilization of each service across the eight districts in the Southern Province.

† Significant at P = 0.05.

‡ MCH services that experienced an increase in average utilization rate.

MCH = maternal and child health; SD = standard deviation; ANC = antenatal care; TT = tetanus toxoid; PNC = postnatal care; BCG = bacille Calmette-Guérin; IPV = inactivated polio vaccine; DTP = diphtheria; HepB = hepatitis B; Hib = hemophilus influenza.

MCH care is a national priority and the Rwandan government has worked hard to reverse negative trends and improve MCH care in all parts of the country through various strategies.32 The COVID-19 outbreak threatens these improvements, and therefore the results from this study are useful to inform policies and practices to mitigate and reverse the negative impacts of the outbreak. One important implication of this study is its emphasis on the need for proactive measures to be put in place to prepare for any outbreaks that may occur in the future. These measures include planning for resources such as strict implementation of safe practices in health facilities, infection, prevention and control (IPC) trainings, routine monitoring, rapid COVID-19 screening for staff, and infrastructural changes to assure the public that they are safe once they come to health facilities.6,33

Innovative strategies to provide services during COVID-19 need to be implemented such as different and safe modes of transportation, or bringing MCH services closer to the community through home visits and mobile clinics. Supplemental immunization activities (SIAs) should also be conducted to address the observed reductions in child vaccinations during this COVID-19 era. Finally, it is crucial to integrate outbreak response and communication with existing healthcare services, such as malaria, HIV, TB and MCH services, to ensure the progress made in routine healthcare services is not weakened during emergency response.25

This study successfully quantified the change in MCH services utilization in public health facilities across all five provinces in Rwanda during the COVID-19 outbreak. However, the findings of the study should be viewed in light of its limitations. First, when this study was conducted, HMIS data was only available up to April 2020, while the COVID-19 outbreak was still in its early stages in Rwanda. We anticipate that the utilization of MCH services would be further affected as the outbreak continues. Further follow-up is therefore needed to determine the continued effects of coronavirus disease on MCH care in Rwanda. Second, the available HMIS reports at the Ministry of Health only presented aggregated data. The lowest level of data that was analyzed in this study was at the provincial level. It would be useful to further analyze the impact at the district level and at individual health facilities in order to observe a more detailed pattern and design even more specific interventions. Third, since in this “before and after” study we observed the change through the course of a 1-year timeline, we cannot fully attribute the change solely to the pandemic. Finally, the specific root causes of the change in MCH utilization were not investigated in this rapid assessment study. However, as in previous epidemics, potential causes have been disruptions in provision of routine health services as human resources, medical equipment and efforts are shifted to respond to the emergency. Campaigns to offer MCH services may have been minimized, postponed or cancelled, and global medical and pharmaceutical supply chains disrupted due to COVID-19.8 Movement restrictions and reduced public transportation methods have negative effects on the economy, which likely pushed marginalized populations further into poverty, thus increasing their barriers to healthcare access.8 Nonetheless, this study provided the basis for further investigation on the barriers and facilitators of accessing MCH services in Rwanda during the COVID-19 global health crisis.

CONCLUSION

This study quantified the current utilization of MCH services and highlighted the need for pre-emptive measures to avoid disruptions in health service delivery and to maintain routine health services during outbreaks. In order for these reductions in MCH service utilization to be reversed, proactive and targeted interventions are needed. Further studies to identify the root causes of the reduction and long-term impact of the decrease in MCH service utilization on the health outcomes of mothers and children should also be conducted.

Acknowledgments

The authors wish to thank the University of Global Health Equity (Kigali, Rwanda), and the Health Management Information System (HMIS) team, E Ntawuyirusha and A Muhire, at the Rwanda Ministry of Health (Kigali, Rwanda) for their support.

References

Articles from Public Health Action are provided here courtesy of The International Union Against Tuberculosis and Lung Disease

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