Assessing Health Care Resilience in Mozambique: A mixed methods analysis of COVID-19 impact on maternal and child health service delivery in urban districts of Manica and Maputo provinces.

Abstract

Background:COVID-19 disrupted health care services around the world. Maternal and child health care is of particular concern in Mozambique, given that neonatal disorders are a leading cause of death and that studies from 2021 demonstrate significant reductions in maternal and child health services during the pandemic. This study aims to provide a sub-national assessment at how services were affected throughout the pandemic and characterize facilitators and barriers to service delivery. Methods: We utilized a two-phased mixed methods explanatory-convergent design. In phase one, we extracted electronic routine data for 9 selected maternal and child health care indicators across all districts within Manica and Maputo provinces from 2018 to March 2022. Quantitative data were analyzed by time-series and LOESS regression graphs using R. In phase two, two districts and four health facilities were purposively selected for analysis involving semi-structured interviews (n=4) and focus group discussions (n=8). Qualitative data were analyzed by iterative coding and thematic analysis. Results: Our quantitative results demonstrated reductions in critical maternal and child health services during the pandemic, but impact varied across location and sector. First family planning visits showed the greatest reductions, dropping 14.7% in 2020-2021 from 2018-2019. Immunizations (Polio3 [-6.9%], and DTP3 [-7.5%]) also dropped, while first and fourth antenatal visits (+3.6% and +17.0%) and institutional births (+0.9%) increased in average services delivered. Qualitative data revealed multiple perceived barriers to service delivery, including insufficient personal protective equipment, insufficient human resources, unmet heath facility infrastructure needs and isolation spaces, insufficient financial support of providers, and fear of contracting COVID-19 in health centers. Facilitators included bi-directional communication between health facility, district and province, adapted communication mechanisms, teamwork, and provider self-efficacy. Conclusion: Reductions in many MCH services, particularly family planning, and immunizations were confirmed during 2020-2021 compared to pre-pandemic years, but with trends showing recovery in early 2022. Multiple system-level barriers to service delivery were identified by providers in urban districts of Manica and Maputo Provinces which affected perceived quantity and quality of care. Strengthening health system infrastructure, material and human resource support of providers may help to improve resilience to future pandemics or emergencies.