ABSTRACT

Objective.

To assess changes in reproductive, maternal, newborn, child, and adolescent health (RMNCAH) in Haiti from August 2018 to September 2021, before and during the COVID-19 pandemic.

Methods.

A retrospective study using surveillance data from the Haitian Unique Health Information System, examining two periods: pre- and peri-COVID-19 pandemic. Health indicators at the national level in the two periods were compared using two-sample t-tests for proportions, and average absolute monthly changes were calculated using variance-weighted regression.

Results.

There was a statistically significant decline in the proportion of most of the indicators assessed from the pre- to the peri-COVID-19 pandemic period. However, the most affected indicators were the proportions of pregnant women with four antenatal care visits, with five antenatal care visits or more, and those who received a second dose of tetanus vaccine, which decreased by over 4 percentage points during the two periods. Likewise, the proportions of children who received diphtheria, tetanus, and pertussis (DTaP), BCG, polio, pentavalent, and rotavirus vaccines also all declined by over 8 percentage points. In contrast, pneumococcal conjugate vaccine increased by over 4 percentage points. A statistically significant decrease was also observed in the average absolute monthly changes of several reproductive and child health indicators assessed.

Conclusions.

The COVID-19 pandemic may have contributed to the decline observed in several RMNCAH indicators in Haiti. However, the role played by the sociopolitical crisis and control exercised by armed groups over the population in the last three years cannot be ruled out.

Keywords
Child health; family planning; maternal health; reproductive health; women’s health services; COVID-19; Haiti

RESUMEN

Objetivo.

Evaluar los cambios en materia de salud reproductiva, materna, neonatal, infantil y adolescente que se produjeron en Haití desde agosto del 2018 hasta septiembre del 2021, antes de la pandemia de COVID-19 y durante ella.

Metodología.

Estudio retrospectivo basado en datos de vigilancia del sistema único de información de salud de Haití para estudiar los periodos pre y peripandémico. La comparación de los indicadores de salud a nivel nacional de estos dos periodos se realizó mediante pruebas de t de dos muestras para comparar proporciones, y se calculó el promedio de la variación mensual absoluta mediante una regresión ponderada por la varianza.

Resultados.

Al comparar el periodo prepandémico con el peripandémico, se observó un descenso estadísticamente significativo de la mayoría de los indicadores porcentuales evaluados. Sin embargo, los indicadores porcentuales más afectados fueron los de mujeres embarazadas con cuatro visitas de atención prenatal, con cinco visitas de atención prenatal o más, o que recibieron una segunda dosis de la vacuna contra el tétanos; estos indicadores disminuyeron en más de cuatro puntos porcentuales en el segundo periodo en comparación con el primero. Asimismo, las proporciones de niños y niñas que recibieron las vacunas contra la difteria, el tétanos y la tosferina (DTPa), contra la poliomielitis, antirrotavírica, BCG, y pentavalente también disminuyeron en más de ocho puntos porcentuales. En cambio, la proporción de niños y niñas que recibieron la vacuna antineumocócica conjugada aumentó en más de cuatro puntos porcentuales. También se observó un descenso estadísticamente significativo en el promedio de la variación mensual absoluta de varios indicadores de salud reproductiva e infantil.

Conclusiones.

La pandemia de COVID-19 puede haber contribuido al descenso observado en varios indicadores relacionados con la salud reproductiva, materna, neonatal, infantil y adolescente en Haití. Sin embargo, no se puede descartar el papel que ha desempeñado en dicho descenso la crisis sociopolítica y el control ejercido por los grupos armados sobre la población en los últimos tres años.

Palabras clave
Salud infantil; servicios de planificación familiar; salud materna; salud reproductiva; servicios de salud para mujeres; COVID-19; Haití

RESUMO

Objetivo.

Avaliar mudanças na saúde reprodutiva, materna, neonatal, da criança e do adolescente no Haiti entre agosto de 2018 e setembro de 2021, antes e durante a pandemia de COVID-19.

Métodos.

Estudo retrospectivo usando dados de vigilância do Sistema Único de Informações de Saúde do Haiti, examinando dois períodos, antes e durante a pandemia de COVID-19. Os indicadores de saúde do país nos dois períodos foram comparados por meio de testes t de duas amostras para proporções, e as variações mensais absolutas médias foram calculadas por meio de regressão linear ponderada.

Resultados.

Entre o período anterior e o período durante a pandemia de COVID-19, houve uma queda estatisticamente significante na proporção da maioria dos indicadores avaliados. Os indicadores mais afetados, porém, foram as proporções de gestantes com quatro consultas de pré-natal, gestantes com cinco ou mais consultas de pré-natal e gestantes que receberam uma segunda dose de vacina antitetânica, que sofreram uma diminuição de mais de 4 pontos percentuais na comparação entre os dois períodos. Similarmente, as proporções de crianças que receberam vacinas contra difteria, tétano e pertússis (DTPa), BCG, poliomielite, pentavalente e rotavírus também diminuíram em mais de 8 pontos percentuais. Por outro lado, no caso da vacina pneumocócica conjugada houve um aumento de mais de 4 pontos percentuais. Além disso, foi observada uma redução estatisticamente significante nas variações mensais absolutas médias de vários indicadores de saúde reprodutiva e infantil avaliados.

Conclusões.

A pandemia de COVID-19 pode ter contribuído para a piora observada em vários indicadores de saúde reprodutiva, materna, neonatal, da criança e do adolescente no Haiti. No entanto, não se pode descartar o papel desempenhado pela crise sociopolítica e pelo controle exercido por grupos armados sobre a população nos últimos três anos.

Palavras-chave
Saúde da criança; serviços de planejamento familiar; saúde materna; saúde reprodutiva; serviços de saúde da mulher; COVID-19; Haiti

The COVID-19 pandemic has substantially affected healthcare systems worldwide. As of 3 August 2021, nearly 200 million cases had been reported globally along with 4.2 million deaths (¹1. World Health Organization. COVID-19 Weekly Epidemiological Update. Edition 51. 3 August 2021. Geneva: WHO; 2021 [cited 20 August 2021]. Available from: https://www.who.int/publications/m/item/weekly-epidemiological-update-on-covid-19---3-august-2021
https://www.who.int/publications/m/item/... ). When the World Health Organization alerted countries and then, in accordance with the International Health Regulations, in January 2020 declared a public health emergency of international concern, the initial response of many countries was characterized by extensive lockdowns to slow transmission and thereby gain time to prepare response actions and protect health services as much as possible from becoming overwhelmed (²2. Cash R, Patel V. Has COVID-19 subverted global health? Lancet. 2020;395(10238):1687–1688. https://doi.org/10.1016/s0140-6736(20)31089-8
https://doi.org/10.1016/s0140-6736(20)31... ). In many countries, a collateral effect of the lockdowns and the subsequent community transmission of COVID-19, coupled with fear and stigma surrounding COVID-19, was a reduction in demand and access to healthcare services including antenatal and postnatal care, particularly in lower income countries with fragile health systems (²2. Cash R, Patel V. Has COVID-19 subverted global health? Lancet. 2020;395(10238):1687–1688. https://doi.org/10.1016/s0140-6736(20)31089-8
https://doi.org/10.1016/s0140-6736(20)31... ). Analyses conducted by Stein et al. (³3. Stein D, Ward K, Cantelmo C. Estimating the potential impact of COVID-19 on mothers and newborns in low- and middle-income countries. Health Policy Plus. 15 April 2020. [place unknown]: PROPEL Health; 2020 [cited 3 August 2021]. Available from: https://medium.com/@HealthPolicyPlus/estimating-the-potential-impact-of-covid-19-on-mothers-and-newborns-in-low-and-middle-income-3a7887e4a0ff
https://medium.com/@HealthPolicyPlus/est... ) on four low- and middle-income countries with poor maternal, newborn, and child health outcomes predicted that the overwhelming effects of the COVID-19 pandemic could lead to 31% additional maternal and newborn deaths due to reduced access to essential services such as family planning, antenatal care, facility-based deliveries, and postnatal care (³3. Stein D, Ward K, Cantelmo C. Estimating the potential impact of COVID-19 on mothers and newborns in low- and middle-income countries. Health Policy Plus. 15 April 2020. [place unknown]: PROPEL Health; 2020 [cited 3 August 2021]. Available from: https://medium.com/@HealthPolicyPlus/estimating-the-potential-impact-of-covid-19-on-mothers-and-newborns-in-low-and-middle-income-3a7887e4a0ff
https://medium.com/@HealthPolicyPlus/est... ). In contrast, a retrospective review conducted in Ireland in 2020 by McDonnell et al. (⁴4. McDonnell S, McNamee E, Lindow SW, O’Connell MP. The impact of the Covid-19 pandemic on maternity services: A review of maternal and neonatal outcomes before, during and after the pandemic. Eur J Obstet Gynecol Reprod Biol. 2020;255:172–176. https://doi.org/10.1016/j.ejogrb.2020.10.023
https://doi.org/10.1016/j.ejogrb.2020.10... ) using data from a large tertiary hospital in Dublin found no correlation between the monthly number of COVID-19 deaths and the monthly number of perinatal deaths, preterm births, and hypertensive pregnancies. However, it should be noted that the study focused on severity of the pandemic using the number of COVID-19 deaths as a marker instead of the COVID-19 infection rate (⁴4. McDonnell S, McNamee E, Lindow SW, O’Connell MP. The impact of the Covid-19 pandemic on maternity services: A review of maternal and neonatal outcomes before, during and after the pandemic. Eur J Obstet Gynecol Reprod Biol. 2020;255:172–176. https://doi.org/10.1016/j.ejogrb.2020.10.023
https://doi.org/10.1016/j.ejogrb.2020.10... ).

Immediately after the report of the first COVID-19 case in March 2020 in Haiti, the Government put several preventive measures in place to limit the spread of the virus in the country (⁵5. United Nations Office for the Coordination of Humanitarian Affairs. Haïti – COVID-19. Rapport Flash No 4. [Geneva]: UNOCHA; 2020. Available from https://www.unocha.org/publications/report/haiti/ha-ti-covid-19-rapport-flash-no-4-au-14-avril-2020-1200-ha-ti
https://www.unocha.org/publications/repo... , ⁶6. Organisation panaméricaine de la Santé. Rapport annuel 2020. Santé universelle et Pandémie–Systèmes de Santé résilients. Haiti: OPS; 2021.). Among these was the creation of the Multisectoral Commission for the Management of the COVID-19 Pandemic, to lead the strategic planning and response against COVID-19 (⁵5. United Nations Office for the Coordination of Humanitarian Affairs. Haïti – COVID-19. Rapport Flash No 4. [Geneva]: UNOCHA; 2020. Available from https://www.unocha.org/publications/report/haiti/ha-ti-covid-19-rapport-flash-no-4-au-14-avril-2020-1200-ha-ti
https://www.unocha.org/publications/repo... , ⁶6. Organisation panaméricaine de la Santé. Rapport annuel 2020. Santé universelle et Pandémie–Systèmes de Santé résilients. Haiti: OPS; 2021.). Despite the measures adopted by the Government to limit the spread of the virus, low compliance to the measures by the population was reported (⁷7. Benjamin F, Jean K, Antoine R, Prou M, Millien M, Balthazard-Accou K, et al. COVID-19: Perception of the Pandemic and the Importance of Barrier Measures by the Fruit and Vegetable Sellers of Port-Au-Prince. Eur Sci J. 2021;15(5):165. https://doi.org/10.19044/esj.2021.v17n5p165
https://doi.org/10.19044/esj.2021.v17n5p... ). Given the fragile health system and poor health indicators in Haiti, it was predicted that disruptions to health services in Haiti could leave 212 600 children without diphtheria, tetanus, and pertussis (DTaP) vaccination, and lead to 26 500 fewer deliveries in health facilities and 228 200 fewer women receiving family planning services (⁸8. Global Financing Facility. Préserver les services de santé essentiels pendant la pandémie de COVID-19. Washington, DC: GFF; 2020 [cited 3 August 2021]. Available from: https://www.globalfinancingfacility.org/sites/gff_new/files/documents/Haiti-Covid-Brief_GFF-FR.pdf
https://www.globalfinancingfacility.org/... ). To our knowledge, no previous study has been conducted to assess the impact of the pandemic on healthcare services in Haiti. This study aimed to assess the changes in reproductive, maternal, newborn, child, and adolescent health (RMNCAH) in Haiti before and during the COVID-19 pandemic and to derive lessons that would help in decision-making.

MATERIALS AND METHODS

A retrospective study was conducted using data from the Haitian Unique Health Information System (Système d’Information Sanitaire Unique – SISNU in French). SISNU is a national health information platform launched in 2013 by the Ministry of Health of Haiti to track all health-related data on RMNCAH in the country on a monthly basis. SISNU captures health-related data from more than 800 facilities from the nation’s 10 departments. The monthly reporting rate for the departments on patient attendance and outpatient clinics is estimated to be over 70%. SISNU collects data on several RMNCAH indicators that can be disaggregated by age and sex. Data collected by SISNU are periodically uploaded to the District Health Information Software 2 (DHIS2), a web-based platform that is being used by 73 low- and middle-income countries. More details on SISNU can be found elsewhere (https://dhis2.org/haiti-hmis/).

This study included all women of reproductive age (15–49 years) who had their information on reproductive and maternal health/death recorded on the above-mentioned databases from August 2018 to September 2021. The study also included newborns, under-5 children, and adolescents for which information was available for the same periods. All the data used in this study were anonymized to ensure the confidentiality of the participants. Ethical approval was obtained from the National Ethics Committee of the Ministry of Health of Haiti prior conducting the study. Participants provided verbal informed consent prior to data collection.

The indicators of interest used in this study were grouped according to each domain of RMNCAH. The reproductive health indicators included the number of women accepting modern contraceptive methods including condoms, intrauterine device, depot medroxyprogesterone acetate (DPMA), implant, progestogen-only pills, combined oral contraceptive pill, and tubal ligation. In this study, the term “accepting” refers to any woman aged 15–49 who agreed to use a modern method of contraception for the first time in her life as part of a structured public or private family planning program. Therefore, a woman who changed method – that is to say, who previously used another method in a structured family planning program – was excluded from the category of “accepting” (⁹9. Haiti, Ministère de la Santé Publique et de la Population. Guide et Glossaire pour le remplissage du Rapport Statistique Mensuel des Services de Santé. Port-au-Prince: MSPP; 2015.).

Maternal health indicators included number of antenatal care visits during pregnancy, number of pregnant women with confirmed malaria and treated with chloroquine, and with anemia and treated for iron deficiency anemia. Also included were the number of pregnant women who received at least the second dose of tetanus toxoid vaccine (dT2+), number of institutional deliveries and deliveries by C-section, and number of women receiving post-abortion care.

Newborn and postnatal health indicators included: number of home visits/postnatal follow-up (0–3 days) after delivery, low birthweight (<2.5 kg), number of institutional live births beneficiaries of the kangaroo mother care method, and number of institutional live births with early initiation of breastfeeding.

Child health indicators analyzed were: total BCG doses (0–11 months), DTaP doses (12–23 months), measles 2 doses (12–23 months), pneumococcal conjugate vaccine 3 doses (0–11 months), polio 3 doses (0–11 months), pentavalent vaccine 3 doses (0–11 months), rotavirus 2 doses (0–11 months), and total fully vaccinated (0–11 months). Child health indicators were disaggregated by sex. It should be noted that most of the vaccine indicators were only available for 0–11 months.

Mortality indicators such as the number of maternal deaths per childbirth and number of stillbirths were also analyzed. More details about the indicators and their definition can be found in other resources (⁹9. Haiti, Ministère de la Santé Publique et de la Population. Guide et Glossaire pour le remplissage du Rapport Statistique Mensuel des Services de Santé. Port-au-Prince: MSPP; 2015., ¹⁰10. Haiti, Ministère de la Santé Publique et de la Population. SISNU, Système d’Information Sanitaire National Unique [login required]. [Port-au-Prince]: MSPP; [date unknown]. Available from: https://sisnu.net/dhis-web-pivot/index.html
https://sisnu.net/dhis-web-pivot/index.h... ). This study is reported according to STROBE guidelines for observational studies (¹¹11. Von Elm E, Altman DG, Egger M, Pocock SJ, Gøtzsche PC, Vandenbroucke JP, et al. The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement: guidelines for reporting observational studies. Ann Intern Med. 2007;147(8):573–577. https://doi.org/10.7326/0003-4819-147-8-200710160-00010
https://doi.org/10.7326/0003-4819-147-8-... ).

Data analysis

To achieve the objective of the study, the analysis was divided into two periods: pre- and peri-COVID-19 pandemic. Pre-COVID-19 pandemic included the first 19 months before the report of the first COVID-19 case in Haiti (August 2018–February 2020); and peri-COVID-19, the 19 months starting from the detection of the first case (March 2020–September 2021). Two sample t-tests for proportions were used to compare the frequency of indicators before and during the COVID-19 pandemic. Analyses for reproductive and maternal indicators were disaggregated by age, and neonatal and child health indicators were disaggregated by sex wherever possible. For indicators with unknown denominator (unavailable in SISNU to calculate proportion), we relied on data from the Haitian Institute of Statistics and Informatics for denominators such as the number of expected pregnant women during the period and population of children under 5 years. We calculated the average absolute monthly changes (AAMC) of indicators at the national level using variance-weighted regression to compare the monthly changes in RMNCAH indicators for the two periods. Statistical significance level was defined at less than 0.05. All the analyses were carried out using Microsoft Excel and Stata (Stata Statistical Software, Release 14, 2015; StataCorp, College Station, TX).

RESULTS

The proportion of women accepting a modern contraceptive method decreased significantly from the pre- to the peri-COVID-19 pandemic period (from 8.0% to 7.2%, p < 0.001) Similar results were obtained for the proportion of women who accepted condoms (from 2.3% to 1.9%, p < 0.001), DPMA (from 4.1% to 3.5%, p < 0.001), and tubal ligation (from 0.1% to 0.0%, p < 0.001). In contrast, a significant increase was observed in the proportion of women accepting intrauterine device (from 0.01% to 0.04%, p < 0.001), implant (from 0.3% to 0.4%, p < 0.001), combined oral contraceptive pill (from 0.9% to 1.0%, p < 0.001), and progestogen-only pill (from 0.3% to 0.4%, p < 0.001) (Table 1).

There were also reductions in the proportion of women receiving first antenatal care in the first trimester of pregnancy (from 26.6% to 25.4%, p < 0.001). Additionally, reductions were observed in women receiving four antenatal care visits (from 26.3% to 22.0%, p < 0.001) and in those receiving five or more (from 22.3% to 17.4%, p < 0.001).

Regarding recommended practices, anemia during pregnancy was less registered (from 27.4% to 24.1%, p < 0.001), with a significant reduction in pregnant women treated for iron deficiency anemia (from 26.3% to 21.9%, p < 0.001) during the same period. Reductions were also observed in pregnant women who received at least a second dose of tetanus toxoid (from 53.7% to 39.2%, p < 0.001). Conversely, there were increases in the proportions of pregnant women with confirmed malaria treated with chloroquine (from 0.2% to 0.3%, p < 0.001), and who received an insecticidal mosquito net (from 5.2% to 8.4%, p < 0.001).

There were also reductions in the proportion of institutional delivery (from 69.2% to 67.7%, p < 0.001) and vaginal delivery (from 76.3% to 74.0%, p < 0.001). When institutional delivery was disaggregated by age, no significant differences were observed for adolescent women younger than 15 years and for those aged 15–19 (p > 0.05). On the contrary, the C-section rate increased from 17.5% to 20.2% (p < 0.001) during the same period (see Figure S1 in the supplementary material).

Finally, the maternal mortality ratio showed a statistically significant increase from 195 to 230 per 100 000 live births from the pre- to the peri-COVID-19 pandemic period (p = 0.0082). The stillbirth rate also increased from 24.4 to 27.1 per 1 000 births during the same period.

Table 2 presents the newborn and child health indicators during the pre- and peri-COVID-19 pandemic periods. Statistically significant decreases were observed in the proportions of early initiation of breastfeeding among institutional live births (from 60.0% to 58.6%, p < 0.001) and low birthweight (from 11.1% to 10.9%, p = 0.0078). However, there were statistically significantly increases during the same period in the proportion of institutional live births beneficiaries of the kangaroo mother care method (from 8.6% to 10.4%, p < 0.001) and home visits/postnatal follow-up during days 0–3 (from 36.8% to 40.0%, p < 0.001).

The proportion of fully vaccinated children (0–11 months) decreased from 48.9% to 46.8% (p < 0.001). However, when the data were disaggregated by sex, these proportions seemed to decrease for female but increase for male children. We believe that such difference could be random and not due to a real difference between males and females in access to vaccination services in the country. The proportion of children aged 6–23 months who received a third dose of vitamin A increased from 1.7% to 2.1% (p < 0.001) and aged 24–59 months, from 2.0% to 2.2% (p < 0.001). There was a slight reduction in the proportion of under-5 children seen for the first time, screened for acute malnutrition (from 12.6% to 12.3%, p < 0.001) as well as for chronic malnutrition (from 3.5% to 3.0%, p < 0.001) (Table 2).

In the supplementary material, Table S1 and Figure S2 summarize the AAMC in RMNCAH during the two periods. Pre-COVID-19 pandemic we observed an average absolute monthly reduction in the number of pregnant women with at least a second dose of tetanus toxoid (–241.8, p = 0.010), the number of under-5 children seen for the first time, screened for acute malnutrition (–194.3; p = 0.003) and for chronic malnutrition (–52, p = 0.017). When data were disaggregated by age, average absolute monthly reductions were also observed in the number of children aged 24–59 months seen for the first time and screened for acute malnutrition (–81.5, p = 0.010). Likewise, we observed a significant reduction per month in the number of children aged 6–23 months (–28.1, p = 0.012) and 24–59 months (–25.0, p = 0.009) seen for the first time and screened for chronic malnutrition.

There was a statistically significant reduction per month for the number of women accepting DPMA (–102.1, p = 0.034). However, the number of women accepting combined oral contraceptive (86.0; p = 0.026), progestogen-only pill (78.2, p = 0.007), and having four antenatal care visits (102.3, p = 0.004) showed significant increases per month during the peri-COVID-19 pandemic period (see Table S1 in the supplementary material).

Figure 1 presents the evolution of the maternal mortality ratio during the two periods. The maternal mortality ratio decreased slightly from 195.0 in August 2018 to 183.0 per 100 000 live births in February 2020. The highest ratio was observed in June 2020 (372.4 per 100 000 live births) and in November 2020 (356.6 per 100 000 live births). During the peri-COVID-19 pandemic, it increased from 179.6 in March 2020 to 185.9 per 100 000 live births in September 2021.

DISCUSSION

We showed the overall changes in RMNCAH indicators during the first 19 months following the first reported COVID-19 case in Haiti compared with the previous 19 months. Most of the indicators analyzed declined from the pre- to the peri-COVID-19 pandemic period. However, the most affected indicators were for antenatal care and childhood immunization. Indicators such as the proportions of pregnant women with four antenatal care visits, pregnant women with five antenatal care visits or more, and pregnant women who received a second dose of tetanus vaccine (dT2+) declined by over 4 percentage points from the pre- to the peri-COVID-19 pandemic period. Likewise, the proportions of children who received BCG, DTaP, polio, pentavalent, and rotavirus vaccines all declined by over 8 percentage points during the same period. The only indicator that increased by more than 4 percentage points during the period was for pneumococcal conjugate vaccine.

Several studies have demonstrated the indirect impact of the pandemic on RMNCAH services (¹²12. Ahmed T, Rahman AE, Amole TG, Galadanci H, Matjila M, Soma-Pillay P, et al. The effect of COVID-19 on maternal newborn and child health (MNCH) services in Bangladesh, Nigeria and South Africa: call for a contextualised pandemic response in LMICs. Int J Equity Health. 2021;20(1):77. https://doi.org/10.1186/s12939-021-01414-5
https://doi.org/10.1186/s12939-021-01414... –¹⁵15. Kc A, 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. Lancet Glob Health. 2020;8(10):e1273–e1281. https://doi.org/10.1016/s2214-109x(20)30345-4
https://doi.org/10.1016/s2214-109x(20)30... ). Balogun et al. (¹⁴14. Balogun M, Banke-Thomas A, Sekoni A, Boateng GO, Yesufu V, Wright O, et al. Challenges in access and satisfaction with reproductive, maternal, newborn and child health services in Nigeria during the COVID-19 pandemic: A cross-sectional survey. PLoS One. 2021;16(5):e0251382. https://doi.org/10.1371/journal.pone.0251382
https://doi.org/10.1371/journal.pone.025... ), in a cross-sectional study conducted in 2021, revealed that in Nigeria one-third of the women included in the study had limited access to RMNCH services during the pandemic due to the lockdown measures imposed by the Government, unavailability of transport, and closure of some health facilities. Likewise, Baloch et al. (¹³13. Baloch AA, Baig N, Baloch F, Suhag Z. Impact on the Utilization of Reproductive, Maternal, Newborn and Child Health Care Services at Primary Health Care Level During First Wave of COVID-19 Outbreak in Pakistan. Cureus. 2021;13(8):e17430. https://doi.org/10.7759/cureus.17430
https://doi.org/10.7759/cureus.17430... ) in Pakistan, using data from DHIS, showed that the number of clients who availed of routine care or RMNCH services at the primary health care level declined considerably during the initial phase of the first wave of the COVID-19 pandemic. Such decline may be explained by the immense pressure on the healthcare system in managing COVID-19, disruption in health services due to fear of contacting the virus and restrictions on movement, and closure of certain RMNCH services, among others (¹³13. Baloch AA, Baig N, Baloch F, Suhag Z. Impact on the Utilization of Reproductive, Maternal, Newborn and Child Health Care Services at Primary Health Care Level During First Wave of COVID-19 Outbreak in Pakistan. Cureus. 2021;13(8):e17430. https://doi.org/10.7759/cureus.17430
https://doi.org/10.7759/cureus.17430... , ¹⁴14. Balogun M, Banke-Thomas A, Sekoni A, Boateng GO, Yesufu V, Wright O, et al. Challenges in access and satisfaction with reproductive, maternal, newborn and child health services in Nigeria during the COVID-19 pandemic: A cross-sectional survey. PLoS One. 2021;16(5):e0251382. https://doi.org/10.1371/journal.pone.0251382
https://doi.org/10.1371/journal.pone.025... ). Both of these are lower-middle-income countries that might share similar obstacles in delivering sufficient services in times of crisis, comparable with Haiti. In contrast, Shikuku et al. (¹⁶16. Shikuku DN, Nyaoke I, Gichuru S, Maina O, Eyinda M, Godia P, et al. Early indirect impact of COVID-19 pandemic on utilization and outcomes of reproductive, maternal, newborn, child and adolescent health services in Kenya. medRxiv. 2020.09.09.20191247. https://doi.org/10.1101/2020.09.09.20191247
https://doi.org/10.1101/2020.09.09.20191... ), investigating the initial impact of COVID-19 pandemic on RMNCAH services in Kenya, found no significant change in the mean total hospital attendance. Nonetheless, the short period examined might be a possible explanation for the absence of significant impact of the COVID-19 pandemic on RMNCAH services in that study.

The number of women opting for the contraceptive implant and children receiving a third dose of pneumococcal conjugate vaccine increased significantly from the pre- to the peri-COVID-19 pandemic period. This result is, in part, consistent with findings from a study by Karp et al. (¹⁷17. Karp C, Wood SN, Guiella G, Gichangi P, Bell SO, Anglewicz P, et al. Contraceptive dynamics during COVID-19 in sub-Saharan Africa: longitudinal evidence from Burkina Faso and Kenya. BMJ Sex Reprod Health. 2021;47(4):252–260. https://doi.org/10.1136/bmjsrh-2020-200944
https://doi.org/10.1136/bmjsrh-2020-2009... ) who, using longitudinal data collected from women at risk of unintended pregnancy in sub-Saharan Africa during the pre- and peri-COVID-19 pandemic periods, showed that most women did not change contraceptive status in the early months of the pandemic, and those who did were more likely to adopt contraception than to discontinue. On the other hand, the increase observed in Haiti in the number of children who received a third dose of pneumococcal conjugate vaccine may be explained by the fact that this vaccine was recently introduced into the Government’s routine immunization program in 2018 (¹⁸18. GAVI The Vaccine Alliance. Hundreds of thousands of children set to be protected against the leading cause of pneumonia in Haiti. Geneva: GAVI; 2018 [cited 3 August 2021]. Available from: https://www.gavi.org/hundreds-of-thousands-of-children-set-to-be-protected-against-the-leading-cause-of-pneumonia-in-haiti
https://www.gavi.org/hundreds-of-thousan... ). Thus, the Government might be more motivated to distribute the new vaccine and vaccinate as many children as possible. However, our results show that the proportion of children aged 0–11 months that were fully vaccinated decreased significantly by 2.1 percentage points from the pre- to the peri-COVID-19 pandemic period.

The maternal mortality ratio also increased significantly during the COVID-19 pandemic. This finding is in line with the observations made by de Carvalho et al. (¹⁹19. de Carvalho-Sauer RCO, Costa MDCN, Teixeira MG, do Nascimento EMR, Silva EMF, Barbosa MLA, et al. Impact of COVID-19 pandemic on time series of maternal mortality ratio in Bahia, Brazil: analysis of period 2011–2020. BMC Pregnancy Childbirth. 2021;21(1):423. https://doi.org/10.1186/s12884-021-03899-y
https://doi.org/10.1186/s12884-021-03899... ) in Bahia, Brazil, indicating a marked rise in the maternal mortality ratio during the COVID-19 pandemic (¹⁹19. de Carvalho-Sauer RCO, Costa MDCN, Teixeira MG, do Nascimento EMR, Silva EMF, Barbosa MLA, et al. Impact of COVID-19 pandemic on time series of maternal mortality ratio in Bahia, Brazil: analysis of period 2011–2020. BMC Pregnancy Childbirth. 2021;21(1):423. https://doi.org/10.1186/s12884-021-03899-y
https://doi.org/10.1186/s12884-021-03899... ). Such increase might result from maternal illness directly linked to COVID-19 infection, or to the indirect consequence of disruptions in health services and other secondary effects induced by the pandemic.

When we assessed the time trends in RMNCAH indicators with statistically significant AAMC (p < 0.05) during the COVID-19 pandemic, several dips were observed, particularly coinciding with the peaks of COVID-19 in the country (May–July 2020, December 2020–February 2021, and May–July 2021).

Only a small number of indicators, such as the use of intrauterine devices and rate of C-section, increased during the pandemic. An increase in intrauterine device demand during the pandemic might be attributed to the likelihood of women seeking long-acting reversible contraceptives, which offer effective contraception over an extended duration without necessitating frequent visits to healthcare facilities. Alterations in labor and delivery procedures within certain healthcare environments may have led hospitals to adopt new protocols aimed at limiting access to labor-inducing methods, like walking or hydrotherapy, while increasing reliance on surgical interventions such as C-sections. Additionally, expectant mothers may have been more predisposed to choose C-section out of concern for contracting COVID-19 in a hospital environment. The complete lockdown implemented by the Government in March 2020 in response to the swift spread of COVID-19 in other countries, alongside concerns about the risk of COVID-19 infection in facilities also treating COVID-19 patients, could partially account for the decline observed in RMNCAH services in Haiti.

The COVID-19 pandemic came on top of a country already deeply affected by a sociopolitical and economic crisis, with a precarious healthcare system, and ravaged by corruption (²⁰20. United Nations Office for the Coordination of Humanitarian Affairs. Aperçu des besoins humanitaires, Haïti: Cycle de programme humanitaire, 2021. [Geneva]: UNOCHA; 2021. Available from: https://www.unocha.org/publications/report/haiti/ha-ti-aper-u-des-besoins-humanitaires-2021-mars-2021
https://www.unocha.org/publications/repo... ). Since 2017, Haiti has been severely affected by political unrest, violent protests, national lockdowns, armed gang activities, and frequent kidnappings, all of which are frequently associated with disruption in essential RMNCAH services.

In time of crisis like the COVID-19 pandemic, when governments and other decision-makers must prioritize which health services to maintain, women’s sexual and reproductive health services are among the first to be affected (²¹21. Bukuluki P, Kisaakye P, Mulekya F, Mushomi J, Mayora C, Palattiyil G, et al. Disruption in accessing sexual and reproductive health services among border populations during COVID-19 lockdown in Uganda. J Glob Health. 2022;12:04065. https://doi.org/10.7189/jogh.12.04065
https://doi.org/10.7189/jogh.12.04065... , ²²22. Damavandi S. The Critical Importance of Sexual and Reproductive Healthcare During Emergency Settings: Recommendations for the U.S. Government and Global Humanitarian Organizations. Washington, DC: International Center for Research on Women; 2022. Available from: https://www.icrw.org/wp-content/uploads/2022/12/SRHR-Emergency_v3.pdf
https://www.icrw.org/wp-content/uploads/... ). It is important to highlight that such services become even more crucial, given that pandemic response measures could potentially result in a rise in unintended and unwanted pregnancies due to shortages in contraceptive supplies and the closure of certain healthcare services, which represents a violation of reproductive and sexual rights by impeding access to essential reproductive and sexual health services (²²22. Damavandi S. The Critical Importance of Sexual and Reproductive Healthcare During Emergency Settings: Recommendations for the U.S. Government and Global Humanitarian Organizations. Washington, DC: International Center for Research on Women; 2022. Available from: https://www.icrw.org/wp-content/uploads/2022/12/SRHR-Emergency_v3.pdf
https://www.icrw.org/wp-content/uploads/... –²⁴24. Ott MA, Bernard C. Preserving the reproductive rights of girls and women in the era of COVID-19: the need for a least restrictive solution. Am J Bioeth. 2020;20(7):120–122. https://doi.org/10.1080/15265161.2020.1779865
https://doi.org/10.1080/15265161.2020.17... ).

Our study has strengths and limitations. As strengths, we were able to use a long period to compare the indirect impact of COVID-19 on several RMNCAH indicators nationally. We considered that such a period was sufficient to assess time trends in the indicators and see the effect of public health measures on limiting the spread of the virus. We used data collected from more than 800 health facilities distributed in the 10 geographic departments, with a monthly reporting rate of over 70%. The analyses were disaggregated by age, and by sex when applicable. However, in terms of limitations, our analyses relied on secondary data from SISNU–DHIS2, which may include inaccurate and incomplete reporting, as frequently found in low- and middle-income countries (²⁵25. Bhattacharya AA, Umar N, Audu A, Felix H, Allen E, Schellenberg JRM, et al. Quality of routine facility data for monitoring priority maternal and newborn indicators in DHIS2: a case study from Gombe State, Nigeria. PLoS One. 2019;14(1):e0211265. https://doi.org/10.1371/journal.pone.0211265
https://doi.org/10.1371/journal.pone.021... , ²⁶26. Nielsen P. Advancing health information systems: Experiences from implementing DHIS 2 in Africa. WHO, Accountability for Women’s and Children’s Health, iERG call for evidence. 2012. Available from: https://www.researchgate.net/publication/341204244_Advancing_Health_Information_Systems_Experiences_from_Implementing_DHIS_2_in_Africa
https://www.researchgate.net/publication... ). For example, we were unable to distinguish between missing data and true zero values. Nonetheless, in this analysis, the only variable with missing data was the pneumococcal conjugate vaccine indicator, which had a 5% missing rate during the pre-COVID-19 pandemic period. We believe that this level of missing data would likely have minimal or negligible impact on the study’s results. Moreover, the SISNU–DHIS2 reporting system itself may have been negatively impacted by COVID-19, as well as the political turmoil and natural events that have affected Haiti.

Conclusion and recommendations

The COVID-19 pandemic may have contributed to the decline observed in those RMNCAH indicators. However, we cannot rule out the role played by the sociopolitical crisis, natural disasters, as well as the control exerted by armed groups over the population in the last three years. Coordinated actions at multiple levels are necessary to strengthen the quality and accessibility of RMNCAH services in the country and accelerate progress across the Sustainable Development Goals (SDGs), specifically SDGs 3.1 and 3.2, as well as toward achieving universal access to health and universal health coverage. More studies are needed to understand the factors and root causes of the declines observed in such indicators.

Disclaimer.

Authors hold sole responsibility for the views expressed in the manuscript, which may not necessarily reflect the opinion or policy of the RPSP/PAJPH and/or the Pan American Health Organization (PAHO).

REFERENCES

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