A major strength of this study is that it relies on routinely collected and contemporaneously reported data from the maternity department. This means that data is readily and quickly available to monitor outcomes and trends, and any systematic errors in data collection are likely to remain constant from month to month. However, it is possible that if wards are short-staffed and staff working under additional pressure, this may affect the way they report outcomes, for example, being less likely to recognise and report cases of post-partum haemorrhage (PPH).
Another limitation is that the measures chosen may not perfectly represent the outcomes of interest. For example, antenatal care booking status represents coverage, but not quality of antenatal care provided. Additionally, none of the indicators selected represent important structural measures of quality, such as staff shortages and drug stock-outs, both of which have occurred before and during the Covid-19 lock-down period. Finally, our findings must be interpreted in the context of the limited epidemic and time period (three months) of Covid-19 and control measures in Zimbabwe thus far. Outcomes may continue to change and it will be important to monitor this.
Workload: The overall reduction in number of deliveries being conducted at Mpilo raises the question of where women are delivering instead. It would be interesting to examine statistics from other clinics within the city to see if their deliveries have increased. More women may choose to deliver locally, perceiving increased risk of Covid-19 at the central hospital or difficulties with transport. Some families moved back from urban to rural areas when lock-down was announced and may be delivering at rural clinics and district general hospitals. The critical question is whether these women are still delivering in safe environments and complications recognised.
Fewer Caesarean sections are being done, this may be in part due to cancellation of elective Caesarean sections, but also reduced capacity in maternity theatres associated with resource and staffing shortages (due to illness or quarantine). Emergency Caesarean sections are known to be associated with more complications for mother and baby than elective procedures, however these outcomes are not captured by our data.
Antenatal care: The number of women presenting in labour with an unbooked pregnancy has almost doubled since Covid-19 lockdown measures were instituted. The antenatal clinic at Mpilo has been closed since April 2020, and no women have been able to book their pregnancies there. This trend is therefore likely to continue until antenatal services are restored. Women may be booking elsewhere, for example at local clinics, which in time may be reflected in an increase in referrals from other health centres. We would expect an increase in adverse outcomes to occur as fewer women access antenatal care. It may still be too soon, however, to observe the impact on women who would have booked their pregnancies during lockdown and will present for delivery later in the year.
Maternal and perinatal outcomes: Overall there has been no considerable change in maternal outcomes. The small increase in cases of uterine rupture may reflect barriers in accessing and delivering obstetric care on labour ward, however the numbers for all the outcomes are so small that it is difficult to draw any significant conclusions. The increase in early neonatal deaths could be due to problems within the obstetric or neonatal departments at Mpilo, at referring health centres, or delayed presentation associated issues within the community such as transport. Further investigation would be needed to clarify these issues.
Finally, the data on maternal deaths recorded here does not capture deaths occurring outside hospital or at other health centres and hospitals within the region. It would be important to explore this data for the whole region when it is available, to see whether women are experiencing excess morbidity and mortality outside Mpilo, unable to access the central hospital itself.
Similarly to many southern African countries, the healthcare system in Zimbabwe is fragile and vulnerable to the effects of internal and external crises such as Covid-19(19). In Zimbabwe, the Covid-19 pandemic has occurred on the background of a weakened healthcare system that has experienced persistent shortages of resources and underfunding. A prolonged junior doctors strike in 2019 lasted four months from October, ending at the beginning of January 2020.
We were surprised by our findings, that did not fit our hypothesis that maternal and perinatal morbidity and mortality would increase during the lockdown period. Our experience of working during this time has been of increased challenges and adversity associated with logistical, resource, and staffing difficulties. Interestingly, a study of the effects of Covid-19 lockdown measures on access to primary care in rural South Africa had similar unexpected results(20).
Explanations for our results include statistics being recorded differently during the lock-down period due to other pressures on staff time, adverse outcomes not being captured as they occur outside of the hospital environment, or that it is still too soon to see the result of impacts such as lack of antenatal care. Women delivering now are likely to still have had some, if limited, antenatal care.
Even so, the results presented here could also be seen to represent the significant efforts of healthcare workers and maternity services showing remarkable resilience in difficult circumstances, with great commitment to keeping women and their babies safe. Several elements of organisational design, commonly used to analyse strategic success(21), may describe the way that resilience is manifested at Mpilo hospital to prevent adverse outcomes. The structure and systems of the Mpilo maternity department are oriented to identifying women at risk of complications and intervening early. The focus is on reducing morbidity and preventing mortality by early recognition and timely involvement of senior midwifery and medical staff. Regular rounds by maternity matrons identify issues and escalate promptly to consultants if necessary. Both medical and midwifery staff are resilient and adaptable, with experience of working in difficult conditions. They are skilled at responding to complex emergencies and scenarios on labour ward such as eclampsia, uterine rupture and major PPH, with competencies such as Caesarean hysterectomy as routine. They are conditioned to working with suboptimal availability of resources and improvising. There is a shared value of commitment to keeping women and babies safe despite a lack of resources. Finally, leadership style in the department tends to be formal and directive, with an emphasis on accountability. This may not suit all environments but can provide clear and consistent guidance when trying to achieve specific goals and maintain standards in challenging circumstances such as those presented by Covid-19.
While the results presented here are positive, it will be essential to continue monitoring outcomes as the epidemic in Zimbabwe escalates and further lockdown measures and changes to services are being made. There is still potential for poor maternal and perinatal outcomes if access to healthcare remains restricted and healthcare workers are increasingly burnt out by chronic under-staffing and difficult working conditions.