The impact of COVID-19 on use of maternal and reproductive health services and maternal and perinatal mortality

South Africa experienced two waves of COVID-19 infection in the financial year 2020/21. This study examines the impact of these waves on maternal and perinatal mortality and their effect on the use of and access to maternal and reproductive health services. Data from the District Health Information System on maternal and perinatal deaths, births, antenatal visits, and use of contraceptive termination of pregnancy services were used, and the 2020/21 and 2019/20 financial years were compared in order to formulate national and provincial perspectives. Data on visits for initiating antenatal care, births, contraceptive prescriptions and termination-of-pregnancy services were used to assess utilisation of maternal and reproductive health services respectively; and the number and rates of maternal and perinatal deaths were examined to assess impact. A second descriptive analysis of pregnant women who had delivered after having contracted COVID-19 was performed using a separate database set up by the National Department of Health/South African Medical Research Council/University of Pretoria (NDoH/ SAMRC/UP), specifically to monitor the effects of COVID-19). The data suggest that there was a marked increase (of 40%) in maternal deaths (p<0.00001), 10% in stillbirths (p<0.00001), and 3% in (p=0.31) neonatal deaths when compared with the same period in 2019/20. There was a mean 28% increase in the institutional maternal mortality ratio in all provinces during the second wave compared with the first wave (p<0.0001), except in the Western Cape which had a decrease of 1%. Data from the National Institute for Communicable Diseases showed that the case fatality rate for pregnant women with COVID-19 was high (4.5%), as was the perinatal mortality rate (70.6 per 1 000 births), while the institutional maternal mortality ratio for South Africa was 16.94/100 000 live births. An increase of 3.6% in in-facility births in 2020/21 compared with 2019/20 was observed, with increased movement of pregnant women to the more rural provinces and districts for delivery. Antenatal care services were maintained overall, but use of reproductive health services declined (contraceptive prescriptions by 5%, and termination of pregnancy by 17% overall). The effect of the COVID-19 epidemic on pregnant women and its collateral damage is severe. Strengthening the health system to maintain essential services during a pandemic and vaccination of healthcare workers and pregnant women are key to reducing maternal and perinatal mortality.