The impact of the COVID-19 pandemic on maternal mortality in a South African metropole (2020 - 2021): A retrospective cohort study.

BACKGROUND

During the COVID-19 pandemic, there was a notable increase in maternal deaths across South Africa (SA). Pre pandemic, the Western Cape Province, SA, had made significant strides towards reducing maternal mortality, including HIV-related deaths. However, this progress was reversed in the pandemic period despite a relative protection of maternity services. The direct biological impact of SARS- CoV-2 may not be the sole reason for the increase in mortality.

OBJECTIVE

To evaluate the relative change in the maternal death rate (MDR) for non-SARS-CoV-2-related deaths during the pandemic v. pre pandemic in 2019.

METHODS

We conducted a retrospective cohort study including all pregnant women with a pregnancy outcome enumerated in the Provincial Health Data Centre in the Metro West region of Cape Town from 1 January 2019 to 31 January 2022. Cause of in-facility maternal death and relationship to SARS-CoV-2 infection was determined by folder review. We used interrupted time series (ITS) analysis to assess the impact of the pandemic period on non-SARS-CoV-2 causes of maternal mortality.

RESULTS

Over 98 000 women were included, with 68 deaths reviewed. The ITS model demonstrated no statistically significant change in the MDR for non-SARS-CoV-2-related deaths during the pandemic, with confidence intervals (CIs) that crossed the null for both a step change at the start of the pandemic (3.12/10 000 pregnancy outcomes; 95% CI -1.66 - 7.90) and a subsequent attenuation in the pre-pandemic downward gradient in MDR (slope change 0.47/10 000 pregnancy outcomes per month (95% CI -0.02 - 0.96). Folder review of deaths demonstrated an increase in opportunistic infections as a cause of death relative to the pre-pandemic period, mainly in women with HIV.

CONCLUSION

Maternal healthcare services were largely protected from service disruptions during the COVID-19 pandemic. However, the increase in HIV-related opportunistic infections suggests that optimising maternal health requires an all-encompassing, functional healthcare ecosystem that can robustly maintain services for all health conditions.