Quantitative results
Comparing the three months of Covid-19 pandemic in Natikiri, Mozambique in 2020, with the same period in 2019, concerning maternal health services access indicators, data shows increases of domiciliary deliveries (74%), of the number of pregnant women in the first ante-natal visit and women with four ante-natal visits (19%), of the number of new-born visits (14%), and decreases of 26% in the number of women in first ante-natal visit in the first trimester, and 28% of elective c-sections, all without statistical significance; a decrease of 4% on intra-hospital deliveries was statistically significant (p = 0,046, see Table 1).
Table 1
maternal health services in intervention area, Natikiri, 2019–2020.
MARRERE GENERAL HOSPITAL
|
2019
|
TOTAL
|
M+/-SD
|
2020
|
TOTAL
|
M+/-SD
|
Change
|
P
|
MARRERE HEALTH CENTRE
|
March
|
April
|
May
|
March
|
April
|
May
|
Total 1st ante-natal visits
|
158
|
NDA
|
200
|
358
|
165.33+/-31.64
|
142
|
159
|
126
|
427
|
142.33+/-16.50
|
19%
|
0.327**
|
No. women with ante-natal visit in 1st trimester
|
6
|
5
|
20
|
31
|
10.33+/-8.38
|
7
|
6
|
10
|
23
|
7.67+/-2.08
|
-26%
|
0.658*
|
No. women with 4 ante-natal visits
|
48
|
45
|
85
|
178
|
59.33+/-22.28
|
36
|
123
|
52
|
211
|
70.33+/-46.30
|
19%
|
0.730**
|
No. post-partum visits
|
153
|
155
|
185
|
493
|
199.33+/-67.86
|
371
|
5
|
187
|
563
|
108+/-40.45
|
14%
|
0.116**
|
No. intra-hospital deliveries
|
135
|
111
|
142
|
388
|
156.00+/-25.12
|
119
|
130
|
125
|
374
|
126.67+/-5.51
|
-4%
|
0.046*
|
No. extra-hospital deliveries
|
4
|
7
|
8
|
19
|
6.33+/-2.08
|
9
|
10
|
14
|
33
|
11.00+/-2.66
|
74%
|
0.074**
|
No. elective C-sections
|
8
|
3
|
7
|
18
|
6.67+/-1.53
|
6
|
4
|
3
|
13
|
4.33+/-1.53
|
-28%
|
0.135**
|
Maternity – Emergency room
|
152
|
137
|
169
|
458
|
152.67+/- 16.01
|
162
|
160
|
153
|
475
|
158.33+/-4.72p
|
4%
|
0.588**
|
Legend: M+/-SD – Mean +/- Standard deviation; NDA – No data available; % - percentage; * - Kruskal Wallis Test; ** - One-way ANOVA. |
When Krus kal Wallis and One-Way ANOVA tests are run, show that there is only statistically significant difference in the means of intra-hospital deliveries between both years when p-value is 0.046 and “α<”0.05. |
In non-intervention area, we had an increase of 125% in the number of women with four ante-natal visits, and a decrease of 12% of the number of women with first ante-natal visit in the first trimester, all without statistical significance (see Table 2).
Table 2
maternal health services in non-intervention area, Nampula, 2019–2020.
NAMPULA CENTRAL HOSPITAL
|
2019
|
TOTAL
|
M+/-SD
(25 HC)
|
2020
|
TOTAL
|
M+/-SD
(25 HC)
|
Change
|
|
25 SEPTEMBER HEALTH CENTER
|
NCH
|
25 HC
|
NCH
|
25 HC
|
HCN
|
25 HC
|
NCH
|
25 HC
|
NCH
|
25 HC
|
NCH
|
25 HC
|
P
(25 HC)
|
|
Mars
|
April
|
May
|
Mars
|
April
|
May
|
Total 1st ante-natal visits
|
NDA
|
1910
|
21
|
1640
|
NDA
|
1420
|
4991
|
1656.67+/-245.43
|
86
|
1858
|
21
|
1597
|
35
|
1186
|
4783
|
1547.00+/-338.78
|
-4%
|
0.673**
|
No. women with ante-natal visits in 1st trimester
|
NDA
|
2804
|
NDA
|
2640
|
NDA
|
2070
|
7514
|
2504.67+/-385.26
|
NDA
|
2710
|
NDA
|
2025
|
NDA
|
1858
|
6593
|
2197.67+/-451.48
|
-12%
|
0.421**
|
No. women with 4 ante-natal visits
|
NDA
|
203
|
NDA
|
180
|
NDA
|
247
|
630
|
210.00+/-34.04
|
NDA
|
197
|
NDA
|
236
|
NDA
|
982
|
1415
|
471.67+/-442.32
|
125%
|
0.513*
|
No. post-partum visits
|
NDA
|
947
|
NDA
|
815
|
NDA
|
1033
|
2795
|
931.67+/-109.81
|
NDA
|
836
|
NDA
|
1015
|
NDA
|
910
|
2761
|
920.33+/-89.95
|
-1%
|
0.897**
|
No. intra-hospital deliveries
|
NDA
|
735
|
NDA
|
852
|
NDA
|
855
|
2442
|
|
726
|
735
|
649
|
852
|
624
|
855
|
4441
|
|
NC
|
|
No. extra-hospital deliveries
|
NDA
|
NDA
|
NDA
|
NDA
|
NDA
|
NDA
|
0
|
|
NDA
|
NDA
|
NDA
|
NDA
|
NDA
|
NDA
|
0
|
|
NDA
|
|
No. elective C-section
|
NDA
|
NA
|
NDA
|
NA
|
NDA
|
NA
|
0
|
|
302
|
NA
|
268
|
NA
|
301
|
NA
|
871
|
|
NDA
|
|
Maternity – Emergency room
|
NDA
|
410
|
NDA
|
390
|
NDA
|
413
|
1213
|
|
875
|
397
|
809
|
245
|
741
|
178
|
3245
|
|
NC
|
|
Legend: NCH – Nampula Central Hospital; 25 HC – 25 September Health Centre; NDA – No data available; % - percentage; * - Kruskal Wallis Test; ** - One-way ANOVA; NC- non comparable; NA – Not applicable. |
When Kruskal Wallis and One-Way ANOVA test are run, they show no statistical significance between both years because the p-value”>α>”0.05 |
Concerning children and adolescent health services access indicators, quantitative data in the intervention area shows a decrease of 28% on family planning visits, 20% of vaccinated children and 18% of children completely vaccinated, all without statistical significance (see Table 3).
Table 3
child and adolescent health services in intervention area, Natikiri, 2019–2020.
MARRERE HEALTH CENTRE
|
2019
|
TOTAL
|
M+/-SD
|
2020
|
TOTAL
|
M+/-SD
|
|
|
March
|
April
|
May
|
March
|
April
|
May
|
Change
|
p
|
Family planning consultations
|
175
|
NDA
|
276
|
451
|
164.67+/-20.21
|
62
|
124
|
138
|
324
|
187.67+/-18.3
|
-28%
|
0.839**
|
No. children vaccinated
|
156
|
236
|
202
|
594
|
199.33+/-40.42
|
180
|
157
|
140
|
477
|
159.00+/-20.08
|
-20%
|
0.197**
|
No. children with complete vaccination
|
105
|
124
|
150
|
379
|
126.33+/-22.59
|
172
|
68
|
69
|
309
|
101.33+/-61.27
|
-18%
|
0.544**
|
Adolescents and Youth Friendly Service visits
|
NDA
|
NDA
|
NDA
|
0
|
|
NDA
|
NDA
|
NDA
|
0
|
|
NDA
|
|
Legend: M+/-SD – Mean +/- Standard deviation; NDA – No data available; % - percentage; ** - One-way ANOVA. |
When One-Way ANOVA test is run, show that there are no statistically significant differences between both years when p-value is “>” 0.5. |
In non-intervention area we had a decrease of 16% in the number of children completely vaccinated and the number of adolescents and youth visits, all without statistical significance (see Table 4).
Table 4
child and adolescent health services in non-intervention area, Nampula, 2019–2020.
NAMPULA CENTRAL HOSPITAL
|
2019
|
TOTAL
|
M+/-SD
(25 HC)
|
2029
|
TOTAL
|
M+/-SD
(25 HC)
|
|
|
25 SEPTEMBER HEALTH CENTER
|
NCH
|
25 HC
|
NCH
|
25 HC
|
NCH
|
25 HC
|
NCH
|
25 HC
|
NCH
|
25 HC
|
NCH
|
25 HC
|
|
P
(25 HC)
|
|
March
|
April
|
May
|
March
|
April
|
May
|
Change
|
Family planning Consultations
|
NDA
|
347
|
314
|
328
|
NDA
|
297
|
1286
|
324.00+/-25.24
|
401
|
315
|
314
|
293
|
234
|
389
|
1946
|
332.33+/-50.29
|
NC
|
0.81**
|
No. children vaccinated
|
NDA
|
1593
|
NDA
|
1475
|
NDA
|
1497
|
4565
|
1521.67+/-62.75
|
528
|
1567
|
494
|
1376
|
475
|
1538
|
5978
|
1493.67+/-102.93
|
NC
|
0.708**
|
No. children with complete vaccination
|
NA
|
293
|
NA
|
190
|
NA
|
193
|
676
|
225.33+/-58.62
|
NA
|
219
|
NA
|
141
|
NA
|
209
|
569
|
189.67+/-42.44
|
-16%
|
0.441**
|
Adolescents and Youth Friendly Service visits
|
NA
|
228
|
NA
|
251
|
NA
|
221
|
700
|
|
NA
|
189
|
NA
|
180
|
NA
|
218
|
587
|
|
-16%
|
|
Legend: NCH – Nampula Central Hospital; 25 HC – 25 September Health Centre; M+/-SD – Mean +/- Standard deviation; NDA – No data available; NC- non comparable; ** - One-way ANOVA; NA – Not applicable; % - percentage. |
When One-Way ANOVA test is run, it shows no statistically significant difference between both years because the p-value”>α>”0.05. |
Qualitative results
Data saturation was attained at 19th interviews and discussed among authors. Six users (mothers and pregnant women), four TBAs from Natikiri district, three MCH nurses from HC 25 Setembro, two from MHC, one from MGH and three from NCH, were interviewed, all female with a mean age of 34 years. Transcripts were returned to HPs for their comments and there were no corrections. Records were presented to TBAs and users, as they were all illiterate, and there were no corrections.
Knowledge of the Covid-19 disease
When evaluating knowledge of the disease, we found that the basics were known by all groups. Users and TBAs were able to mention at least three major symptoms such as cough, fever and difficulty breathing.
“…it’s a flu, in which the person has a cough, headache, neck pain, feels cold and has fever.” (TBA, Natikiri, 37 years).
They were also able to mention simple preventive methods, such as washing hands, social distancing, and wearing masks whenever in public.
“…we have to wash our hands with water and soap or ashes” (Post-partum women, Natikiri, 32 years).
“…we have to use masks, whenever we go out!’” (Pregnant women, Natikiri, 25 years).
As expected, HP had more knowledge on the origin of the disease,
“CoVid-19 is a contagious disease originated in China and is caused by a new coronavirus SARS-cov-2” (MCH Nurse, MHC, 24 years).
Also, on symptoms, and prevention methods:
“…if the person travels to a country contaminated by CoVid-19 they have to be quarantined for 14 day” (MCH Nurse, 25 September HC, 28 years).
“…everyone needs to use masks and maintain social distancing of 1.5m.” (MCH Nurse, NCH, 32 years).
Impact of CoVid-19 in access to health units
During interviews, all groups stated that they anecdotally saw the number of people frequenting the HUs decreased significantly, due to the fear of contamination in the HU.
The TBAs related that there was a reduction in the number of patients seen in the community. Also, both users and TBAs, mentioned that due to the CoVid-19 pandemic, important tasks such as going preaching their religion in churches and mosques was prohibited. Adolescents’ traditional initiation rites were also conditioned, as they are considered activities of populational agglomeration. Work overall was affected, as they were forced to stay home, farming was reduced to intermediate days or ceased completely. Additionally, TBAs referred a decrease in the number of community members who visited them. They mentioned that they also respected and enforced prevention measures, on the few community members who visited them.
“The number of health professionals has decreased, and they leave early, so the waiting time has increased a bit” (TBA, Natikiri, 28 years).
HPs recognise a much lower workload but also a reduction in MCH HPs number and work hours, so as a population behaviour change in terms of personal hygiene.
“The flux of patients is reduced; it may be because they fear coming to the hospital thinking that they might be contaminated here in the Nampula Central Hospital” (MHC Nurse, NCH, 36 years).
“…in the wards there is only one nurse per shift, and because of the pandemic if one gets sick, we will be forced to work every day to cover her!” (MHC Nurse, MGH, 26 years).
Interviews with patients show they recognise population’ behaviour change to prevent the infection, and in reducing access to health services.
Health system response
The lack of HPs in HUs was unanimous for the three levels (MHC and Health Centre 25 de Setembro – level 1, MGH – level 3 and NCH – level 4). This is a recurrent complaint from HPs, TBAs and patients.
HPs keep educating users about CoVid-19 prevention methods, and the necessary conditions for consultations.
“…community awareness speeches about prevention methods continue.” (MHC Nurse, MHC, 26 years).
“…we reinforce measures and make the community understand, to comply to the measures of prevention of this disease.” (MGH Nurse, NCH, 36 years).
“the health professionals refuse to treat patients with no masks and that didn’t wash their hands” (MCH Nurse, NCH, 34 years).
Users and TBAs mentioned that they continue to frequent the healthcare services, mostly to vaccinate their children, because the vaccines are no longer available in the communities, forcing parents to go to the HU to get the child vaccinated (mobile brigades have not been going to the communities to deliver the vaccines).
“…these vaccines have not come to the community, so the mothers have to go to the hospital!” (Post-partum women, Natikiri, 22 years).
Impact on motorcycle-ambulance usage
With regards to the usage of motorcycle ambulances, a delivering women and emergencies transportation system implemented by ACPH project in Natikiri, the nurses in MHC and MGH were not able to provide any satisfactory answers (they had no information of this intervention). The users and TBAs mentioned that the motorcycle ambulances continued to circulate normally in some areas and in others reduced.
“…the motorcycle ambulances have reduced their circulation because of the disease!” (TBA, Natikiri, 28 years).