BackgroundThe COVID-19 pandemic and response have the potential to disrupt access and use of reproductive, maternal, and newborn health (RMNH) services. Numerous initiatives aim to gauge the indirect impact of COVID-19 on RMNH.MethodsWe assessed the impact of COVID-19 on RMNH coverage in the early stages of the pandemic using panel survey data from PMA-Ethiopia. Enrolled pregnant women were surveyed 6-weeks post-birth. We compared the odds of service receipt, coverage of RMNCH service indicators, and health outcomes within the cohort of women who gave birth prior to the pandemic and the COVID-19 affected cohort. We calculated impacts nationally and by urbanicity.ResultsThis dataset shows little disruption of RMNH services in Ethiopia in the initial months of the pandemic. There were no significant reductions in women seeking health services or the content of services they received for either preventative or curative interventions. In rural areas, a greater proportion of women in the COVID-19 affected cohort sought care for peripartum complications, ANC, PNC, and care for sick newborns. Significant reductions in coverage of BCG vaccination and chlorohexidine use in urban areas were observed in the COVID-19 affected cohort. An increased proportion of women in Addis Ababa reported postpartum family planning in the COVID-19 affected cohort. Despite the lack of evidence of reduced health services, the data suggest increased stillbirths in the COVID-19 affected cohort.DiscussionThe government of Ethiopia's response to control the COVID-19 pandemic and ensure continuity of essential health services appears to have successfully averted most negative impacts on maternal and neonatal care. This analysis cannot address the later effects of the pandemic and may not capture more acute or geographically isolated reductions in coverage. Continued efforts are needed to ensure that essential health services are maintained and even strengthened to prevent indirect loss of life.

ObjectivesThis multimethods study aimed to: (1) compare the prevalence of intimate partner violence (IPV) during pregnancy pre-COVID-19 and during the COVID-19 pandemic using quantitative data and (2) contextualise pregnant women’s IPV experiences during the COVID-19 pandemic through supplemental interviews.DesignQuantitative analyses use data from Performance Monitoring for Action-Ethiopia, a cohort of 2868 pregnant women that collects data at pregnancy, 6 weeks, 6 months and 1-year postpartum. Following 6-week postpartum survey, in-depth semistructured interviews contextualised experiences of IPV during pregnancy with a subset of participants (n=24).ParticipantsAll pregnant women residing within six regions of Ethiopia, covering 91% of the population, were eligible for the cohort study (n=2868 completed baseline survey). Quantitative analyses were restricted to the 2388 women with complete 6-week survey data (retention=82.7%). A purposive sampling frame was used to select qualitative participants on baseline survey data, with inclusion criteria specifying completion of quantitative 6-week interview after the onset of the COVID-19 pandemic, and indication of IPV experience.InterventionsA State of Emergency in Ethiopia was declared in response to the COVID-19 pandemic approximately halfway through 6-week postpartum interview, enabling a natural experiment (n=1405 pre-COVID-19; n=983 during-COVID-19).Primary outcome measuresIPV during pregnancy was assessed via the 10-item Revised Conflict and Tactics Scale.Results1-in-10 women experienced any IPV during pregnancy prior to COVID-19 (10.5%), and prevalence of IPV during pregnancy increased to 15.1% during the COVID-19 pandemic (aOR=1.51; p=0.02). Stratified by residence, odds of IPV during the pandemic increased for urban women only (aOR=2.09; p=0.03), however, IPV prevalence was higher in rural regions at both time points. Qualitative data reveal COVID-19-related stressors, namely loss of household income and increased time spent within the household, exacerbated IPV.ConclusionsThese multimethods results highlight the prevalent, severe violence that pregnant Ethiopian women experience, with pandemic-related increases concentrated in urban areas. Integration of IPV response and safety planning across the continuum of care can mitigate impact.

ImportanceIn the US, more than 50 000 women experience severe maternal morbidity (SMM) each year, and the SMM rate more than doubled during the past 25 years. In response, professional organizations called for birthing facilities to routinely identify and review SMM events and identify prevention opportunities.ObjectiveTo examine SMM levels, primary causes, and factors associated with the preventability of SMM using Maryland’s SMM surveillance and review program.Design, Setting, and ParticipantsThis cross-sectional study included pregnant and postpartum patients at 42 days or less after delivery who were hospitalized at 1 of 6 birthing hospitals in Maryland between August 1, 2020, and November 30, 2021. Hospital-based SMM surveillance was conducted through a detailed review of medical records.ExposuresHospitalization during pregnancy or within 42 days post partum.Main Outcomes and MeasuresThe main outcomes were admission to an intensive care unit, having at least 4 U of red blood cells transfused, and/or having COVID-19 infection requiring inpatient hospital care.ResultsA total of 192 SMM events were identified and reviewed. Patients with SMM had a mean [SD] age of 31 [6.49] years; 9 [4.7%] were Asian, 27 [14.1%] were Hispanic, 83 [43.2%] were non-Hispanic Black, and 68 [35.4%] were non-Hispanic White. Obstetric hemorrhage was the leading primary cause of SMM (83 [43.2%]), followed by COVID-19 infection (57 [29.7%]) and hypertensive disorders of pregnancy (17 [8.9%]). The SMM rate was highest among Hispanic patients (154.9 per 10 000 deliveries), primarily driven by COVID-19 infection. The rate of SMM among non-Hispanic Black patients was nearly 50% higher than for non-Hispanic White patients (119.9 vs 65.7 per 10 000 deliveries). The SMM outcome assessed could have been prevented in 61 events (31.8%). Clinician-level factors and interventions in the antepartum period were most frequently cited as potentially altering the SMM outcome. Practices that were performed well most often pertained to hospitals’ readiness and adequate response to managing pregnancy complications. Recommendations for care improvement focused mainly on timely recognition and rapid response to such.Conclusions and RelevanceThe findings of this cross-sectional study, which used hospital-based SMM surveillance and review beyond the mere exploration of administrative data, offers opportunities for identifying valuable quality improvement strategies to reduce SMM. Immediate strategies to reduce SMM in Maryland should target its most common causes and address factors associated with preventability identified at individual hospitals.

Background Globally, 2–14% of women experience intimate partner violence (IPV) during pregnancy. Timely response to IPV is critical to mitigate related adverse health outcomes. Barriers to accessing limited IPV support services are pervasive in low- and middle-income countries (LMICs), such as Ethiopia; key barriers include mistrust, stigmatization, and self-blame, and discourage women from disclosing their experiences. Infection control measures for COVID-19 have the potential to further disrupt access to IPV services. Methods In-depth qualitative interviews were undertaken from October-November 2020 with 24 women who experienced IPV during recent pregnancy to understand the needs and unmet needs of IPV survivors in Ethiopia amid the COVID-19 pandemic. Trained qualitative interviewers used a structured note-taking tool to allow probing of experiences, while permitting rapid analysis for timely results. Inductive thematic analysis identified emergent themes, which were organized into matrices for synthesis. Results Qualitative themes center around knowledge of IPV services; experiences of women in seeking services; challenges in accessing services; the impact of COVID-19 on resource access; and persistent unmet needs of IPV survivors. Notably, few women discussed the violence they experienced as unique to pregnancy, with most referring to IPV over an extended period, both prior to and during COVID-19 restrictions. The majority of IPV survivors in our study heavily relied on their informal network of family and friends for protection and assistance in resolving the violence. Though formal IPV services remained open throughout the pandemic, restrictions resulted in the perception that services were not available, and this perception discouraged survivors from seeking help. Survivors further identified lack of integrated and tailored services as enduring unmet needs. Conclusions Results reveal a persistent low awareness and utilization of formal IPV support and urge future policy efforts to address unmet needs through expansion of services by reducing socio-cultural barriers. COVID-19 impacted access to both formal and informal support systems, highlighting needs for adaptable, remote service delivery and upstream violence prevention. Public health interventions must strengthen linkages between formal and informal resources to fill the unmet needs of IPV survivors in receiving medical, psychosocial, and legal support in their home communities.

Background The delivery of evidence-supported treatments (EST) in children’s mental health could be a valuable measure for monitoring mental healthcare quality; however, efforts to monitor the use of EST in real world systems are hindered by the lack of pragmatic methods. This mixed methods study examined the implementation and agency response rate of a pragmatic, claims-based measure of EST designed to be applied as a universal quality measure for child psychotherapy encounters in a state Medicaid system. Methods Implementation potential of the EST measure was assessed with healthcare leader rankings of the reporting method’s acceptability, appropriateness and feasibility (n = 53), and post-implementation ratings of EST rate accuracy. Ability of the healthcare system to monitor EST through claims was measured by examining the agency responsivity in using the claims-based measure across 98 Medicaid-contracted community mental health (CMH) agencies in Washington State. Results The analysis found the reporting method had high implementation potential. The method was able to measure the use of an EST for 83% of children covered by Medicaid with 58% CMH agencies reporting > 0 ESTs in one quarter. Qualitative analyses revealed that the most significant barrier to reporting ESTs was the operability of electronic health record systems and agencies’ mixed views regarding the accuracy and benefits of reporting. Conclusions Measurement of child mental health ESTs through Medicaid claims reporting has acceptable implementation potential and promising real world responsiveness from CMH agencies in one state. Variation in reporting by agency site and low to moderate perceived value by agency leaders suggests the need for additional implementation supports for wider uptake.

Objective: This study documents 2000-2017 trends in stillbirth rates and changes in associations between known maternal and fetal risk factors and stillbirths for 2000-2002 versus 2015-2017 in the US. Study design: We conducted a retrospective, population-based analysis of stillbirths and live-births using national vital statistics data. We calculated annual stillbirth rates overall and by gestational age; and examined rates by maternal age, race-ethnicity, and state for 2000-2002 versus 2015-2017. We used chi-squared tests to examine associations between maternal and fetal risk factors for early (20-27 weeks) and late (28+ weeks) stillbirths compared to live-births for 2000-2002 versus 2015-2017. Results: Stillbirth rates declined 7.5% (p<0.001) during 2000-2006 but remained flat at about 6 stillbirths per 1,000 births thereafter. Throughout 2000-2017, there were significant improvements in stillbirth rates at 39+ weeks nationally (p<0.001), but rates varied greatly between and within states. Socio-demographic factors (advanced maternal age, Black race, low education, unmarried status, rural residence), obstetric and other medical factors (3+ births, infertility treatment, obesity, diabetes, chronic hypertension, eclampsia, no prenatal care, tobacco use) were significantly more prevalent in women with late than early stillbirths or live-births. Notably, late and total stillbirth rates were about 30% higher for women 35+ than for women <35 years and twice as high for non-Hispanic Black than non-Hispanic White women; American Indian/Alaska Native women represented the only racial-ethnic group with significantly higher late stillbirth rates in 2015-2017 than in 2000-2002. Pregnancy and fetal factors (multiple pregnancy, male fetus, breech presentation) were more prevalent in women with early than late stillbirths or live-births. Conclusion: US stillbirth rates have plateaued since 2006. There are persistent differential risk profiles for early versus late stillbirths, which can inform stillbirth prevention strategies (e.g., close observation of women with risk factors for stillbirth) and new research into causes of stillbirths by gestational age.

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