key: cord-0751006-ppoigyut authors: Chimhuya, S.; Neal, S. R.; Chimhini, G.; Gannon, H.; Cortina Borja, M.; Crehan, C.; Nkhoma, D.; Chiume, T.; Wilson, E.; Hull-Bailey, T.; Fitzgerald, F.; Chiume, M.; Heys, M. title: Indirect impacts of the COVID-19 pandemic at two tertiary neonatal units in Zimbabwe and Malawi: an interrupted time series analysis date: 2021-01-06 journal: nan DOI: 10.1101/2021.01.06.21249322 sha: d812cba39257796b650599c688b6df1b1325a19e doc_id: 751006 cord_uid: ppoigyut Background: Deaths from COVID-19 have exceeded 1.8 million globally (January 2021). We examined trends in markers of neonatal care before and during the pandemic at two tertiary neonatal units in Zimbabwe and Malawi. Methods: We analysed data collected prospectively via the NeoTree app at Sally Mugabe Central Hospital (SMCH), Zimbabwe, and Kamuzu Central Hospital (KCH), Malawi. Neonates admitted from 1 June 2019 to 25 September 2020 were included. We modelled the impact of the first cases of COVID-19 (Zimbabwe: 20 March 2020; Malawi: 3 April 2020) on number of admissions, gestational age and birth weight, source of admission referrals, prevalence of neonatal encephalopathy, and overall mortality. Findings: The study included 3,450 neonates at SMCH and 3,350 neonates at KCH. Admission numbers at SMCH did not initially change after the first case of COVID-19 but fell by 48% during a nurses' strike (Relative risk (RR) 0.52, 95%CI 0.40-0.68, p < 0.002). At KCH, admissions dropped by 42% (RR 0.58; 95%CI 0.48-0.70; p < 0.001) soon after the first case of COVID-19. At KCH, gestational age and birth weight decreased slightly (1 week, 300 grams), outside referrals dropped by 28%, and there was a slight weekly increase in mortality. No changes in these outcomes were found at SMCH. Interpretation: The indirect impacts of COVID-19 are context-specific. While this study provides vital evidence to inform health providers and policy makers, national data are required to ascertain the true impacts of the pandemic on newborn health. Funding: International Child Health Group, Wellcome Trust We searched PubMed for evidence of the indirect impact of the COVID-19 pandemic on neonatal care in low-income settings using the search terms neonat* or newborn, and COVID-19 or SARS-CoV 2 or coronavirus, and the Cochrane low and middle income country (LMIC) filters, with no language limits between 01.10.2019 and 21 .11.20. While there has been a decrease in global neonatal mortality rates, the smaller improvements seen in low-income settings are threatened by the direct and indirect impact of the COVID-19 pandemic. A modelling study of this threat predicted between 250000-1.1 million extra neonatal deaths as a result of decreased service provision and access in LMICs. A webinar and survey of frontline maternal/newborn healthcare workers in >60 countries reported a decline in both service attendance and in quality of service across the ante-, peri-and post-natal journey. Reporting fear of attending services, and difficulty in access, and a decrease in service quality due to exacerbation of existing service weaknesses, confusion over guidelines and understaffing. Similar findings were reported in a survey of healthcare workers providing childhood and maternal vaccines in LMICs. One study to date has reported data from Nepal describing an increase in stillbirths and neonatal deaths, with institutional deliveries nearly halved during lockdown. To our knowledge, this is the first and only study in Sub-Saharan Africa describing the impact of COVID-19 pandemic on health service access and outcomes for newborns in two countries. We analysed data from the digital quality improvement and data collection tool, the NeoTree, to carry out an interrupted time series analysis of newborn admission rates, gestational age, birth weight, diagnosis of hypoxic ischaemic encephalopathy and mortality from two large hospitals in Malawi and Zimbabwe (n~7000 babies). We found that the indirect impacts of COVID-19 were context-specific. In Sally Mugabe Central Hospital, Zimbabwe, initial resilience was demonstrated in that there was no evidence of change in mortality, birth weight or gestational age. In comparison, at Kamuzu Central Hospital, Malawi, soon after the first case of COVID-19, the data revealed a fall in admissions (by 42%), gestational 4 age (1 week), birth weight (300 grams), and outside referrals (by 28%), and there was a slight weekly increase in mortality (2%). In the Zimbabwean hospital, admission numbers did not initially change after the first case of COVID-19 but fell by 48% during a nurses' strike, which in itself was in response to challenges exacerbated by the pandemic. Our data confirms the reports from frontline healthcare workers of a perceived decline in neonatal service access and provision in LMICs. Digital routine healthcare data capture enabled rapid profiling of indirect impacts of COVID-19 on newborn care and outcomes in two tertiary referral hospitals, Malawi and Zimbabwe. While a decrease in service access was seen in both countries, the impacts on care provided and outcome differed by national context. Health systems strengthening, for example digital data capture, may assist in planning context-specific mitigation efforts. . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted January 6, 2021. . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) The copyright holder for this preprint this version posted January 6, 2021. ; 3 Yet there were disparities in the rates of decline with the sub-Saharan Africa region facing highest neonatal mortality rates 3 . Now, there is a danger that health outcomes in low-income and middle-income countries (LMICs) will fall further behind high-income countries. While countries worldwide face challenges related to the COVID-19 pandemic, LMICs are particularly struggling with financial constraints, limited testing capacity, lack of personal protective equipment, and staff shortages. 4, 5 As children are at low-risk of infection or severe disease from COVID-19, 6-10 any impacts on their health outcomes will likely be attributable to the indirect effects of the pandemic on health systems, as in previous disease outbreaks. 11, 12 These include increased rates of parental unemployment, food and housing insecurity, and reduced access to routine care. 13, 14 The NeoTree application (app) is an Android tablet-based quality improvement platform that aims to reduce neonatal mortality in LMICs. 15 Developed in collaboration with local stakeholders, it is embedded in routine practice at two . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) The copyright holder for this preprint this version posted January 6, 2021. ; 7 neonatal units (NNUs) in Zimbabwe and Malawi, providing real-time clinical decision support, neonatal care education, and digital data capture. 16, 17 We aimed to examine trends in markers of neonatal care before and during the . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) The copyright holder for this preprint this version posted January 6, 2021. ; This study is reported in accordance with the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement (Appendix 1). SMCH is a public referral hospital in Harare, Zimbabwe. It has the largest of three tertiary NNUs nationwide with 100 cots and predominantly doctor-led care. KCH, Lilongwe, is one of four regional referral hospitals in Malawi and the NNU has 75 cots. In contrast to SMCH, care in the NNU is mostly nurse-led. Both units accept local and national referrals for specialist surgical care. All neonates admitted to each NNU over a 16-month period from 1 June 2019 to 25 September 2020 (69 complete weeks) were eligible for inclusion. We applied no specific exclusion criteria. Data were collected prospectively using the NeoTree app. Health workers complete a digital form when a neonate is admitted to the unit (admission form) and when they are discharged or die (outcome form). The app guides assessment of the neonate and collects data on patient demographics, examination findings, diagnoses, and interventions. Pseudonymised forms are uploaded monthly to University College London servers (Zimbabwe data) and Amazon Web Services (Malawi data). Admission and outcome forms are linked by a unique identifier generated by the app at admission. . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) The copyright holder for this preprint this version posted January 6, 2021. 4. Diagnosis of NE: defined as "hypoxic ischaemic encephalopathy" or "birth asphyxia" recorded as a diagnosis, cause of death or contributory cause of death on the outcome form. 5. Mortality: defined as an outcome of "neonatal death" on the outcome form. All other neonates, including those discharged, transferred to another facility or who left on parental request, were considered alive. Research ethics approval was granted by the UCL Research Ethics Committee . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) The copyright holder for this preprint this version posted January 6, 2021. This study used an interrupted time series design with weekly data windows. We considered the first confirmed case of COVID-19 in each country as the intervention (Zimbabwe: 20 March 2020; Malawi: 3 April 2020). 2 For all outcomes, we hypothesised a level change impact model without a lag (for a description of these models, see Bernal et al. 20 ) . Gestational age and birth weight were modelled with linear regression. All other outcomes were modelled using quasi-Poisson regression to account for overdispersion, 21 with the logarithm of the number of admissions in each weekly window included as an offset. All SMCH models were adjusted for a period of doctors' strikes from 3 September 2019 to 22 January 2020. 22 KCH models were unadjusted. Additional models were constructed to explore the effects of a . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted January 6, 2021. nurses' strike in Zimbabwe (17 June to 9 September 2020) 23 and alternative impact models. Nested models were compared with the F-test. See Appendix 5 for model details. The funders had no role in study design, data collection, data analysis, data interpretation, or preparation of this manuscript. . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted January 6, 2021. ; https://doi.org/10.1101/2021.01.06.21249322 doi: medRxiv preprint We included 3,450 neonates at SMCH and 3,350 neonates at KCH. Figure 1 shows the seven-day moving average of admissions to the NNU. • Solid vertical line: first confirmed case of COVID-19 in each country. • Period between dashed vertical lines: industrial action by doctors in Zimbabwe. • Counts based on all admission forms completed, irrespective of match status. The level change regression model, adjusted for the doctors' strike, showed no evidence of a change in admissions after the first case of COVID-19 (relative risk [RR] 0·83; 95% confidence interval [CI] 0·60-1·14; p = 0·25) but the scatterplot indicated this model fit the data poorly (model 1, Figure 2A ). An alternative model, . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted January 6, 2021. ; additionally adjusted for the nurses' strike, again showed no change in the overall post-COVID-19 period (RR 0·90; 95%CI 0·69-1·17; p = 0·43) (model 2, Figure 2B ). However, this model suggested that admissions fell by 48% during the nurses' strike period (RR 0·52, 95%CI 0·40-0·68, p < 0·001) and fit the data better (F[1, 64] = 24·66, p < 0·001). At KCH, the mean (SD) number of weekly admissions was 54·5 (10·8) in the pre-COVID-19 period and 38·0 (10·9) in the post-COVID-19 period. The level change model suggested a 42% reduction in admissions after the first case of COVID-19 (RR 0·58; 95%CI 0·48-0·70; p < 0·001) ( Figure 2C ). . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted January 6, 2021. ; • Counts based on all admission forms completed, irrespective of match status. • SMCH: Sally Mugabe Central Hospital; KCH: Kamuzu Central Hospital . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted January 6, 2021. ; https://doi.org/10.1101/2021.01.06.21249322 doi: medRxiv preprint At SMCH, the mean (SD) gestational age at birth was 36·1 (4·4) weeks in the pre- . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted January 6, 2021. ; • Data points represent weekly mean gestational age or birth weight to avoid overplotting. • White background: pre-COVID-19 period; grey background: post-COVID-19 period. • Solid line: predicted trend from regression model; dashed line: counterfactual scenario. • SMCH models (panels A & C) adjusted for doctors' strike period, KCH models (panels B & D) unadjusted. • Data from all admission forms completed, irrespective of match status. • SMCH: Sally Mugabe Central Hospital; KCH: Kamuzu Central Hospital . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted January 6, 2021. • Data from all admission forms completed, irrespective of match status. • SMCH: Sally Mugabe Central Hospital; KCH: Kamuzu Central Hospital . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted January 6, 2021. Figure 6A ). An alternative model, additionally adjusted for the nurses' strike, again showed no change in overall mortality (RR 0·72; 95%CI 0·51-1·03; p = 0·07) but fit the data better (F[1, 64] = 11·61, p = 0·001) (model 2, Figure 6B ). is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted January 6, 2021. ; is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted January 6, 2021. ; https://doi.org/10.1101/2021.01.06.21249322 doi: medRxiv preprint We performed an interrupted time series analysis to examine changes in neonatal care provision at two tertiary NNUs in Zimbabwe and Malawi after the first cases of COVID-19. We found that admissions at SMCH did not change significantly after the first case of COVID-19 when considering this period as a whole, but there was a considerable decrease (~50%) in the number admissions in June to August 2020, coinciding with a nurses' strike. We did not find significant changes in gestational age or birth weight, source of admission referrals, prevalence of NE or mortality at SMCH. Conversely, we found several changes in markers of neonatal care at KCH after the first case of COVID-19 in Malawi. The number of admissions fell by 42% and we noted a decrease in the gestational age and birth weight of admitted neonates (by ~1 week and ~300 grams, respectively), a 28% relative decrease in outside referrals, and a small but statistically significant weekly increase in mortality by 2% after the first case of COVID-19. Although this study is descriptive, we can speculate about explanations for our results based on existing literature and discussions with local health workers. The number of admissions at SMCH fell by around 50% between June to August 2020, but we noted no change outside this strike period, suggesting some resilience to the impact of the pandemic. However, nurses went on strike over pay and availability of personal protective equipment, 23 so the strike is itself an indirect consequence of COVID-19. A similar reduction in admissions was seen at KCH, but, unlike at SMCH, this 42% decrease was noted within a week of the first case of . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted January 6, 2021. ; COVID-19. In Figure 7 , we propose several interlinked factors that might explain reduced admissions to the NNU. Several of these factors, such as fear of using health services, disrupted transport networks and staff shortages have been directly reported by local sources in LMICs and were highlighted in a recent report by Graham et al. 24 We found a slight decrease in gestational age and birth weight of neonates at KCH, but not SMCH. Studies have reported increased rates of preterm birth in pregnant women with COVID-19 compared to those without the disease, mostly from medically-induced preterm birth; although none of these studies were conducted in LMICs. 26 Preliminary analysis suggests rates of emergency caesarean section increased at SMCH and KCH, with a more marked increase at KCH (Appendix 6). . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted January 6, 2021. ; This is one potential explanation for our findings. However, we noted that the number of outside referrals decreased by 28% at KCH, and neonates referred from outside KCH are more likely to be from lower-risk pregnancies that delivered in a health centre with higher gestational ages and birth weights. Further analysis should stratify by source of admission referral to clarify this finding, but is supported by the fact that referrals were rigorously triaged by the on-call paediatrician during the pandemic, and that referrals from some areas were diverted away from KCH. We hypothesised that rates of NE would increase during the pandemic. NE is the clinical manifestation of disordered brain function and can have multiple aetiologies. 27 The term 'hypoxic-ischaemic encephalopathy' is reserved for cases where there is evidence of intrapartum asphyxia. 27 In LMICs, obstructed labour is a major cause of maternal mortality and can lead to intrapartum asphyxia with subsequent neonatal morbidity and mortality, including NE. 28 Therefore, the prevalence of NE might be expected to increase as a marker of delayed presentation to a health facility. It is reassuring that we did not find increased rates of NE at SMCH or KCH. However, these findings should be interpreted cautiously as some neonates with NE may not have presented to a health facility at all. Finally, we observed a slight increase in overall mortality at KCH (a relative increase of 2% per week after the first case of COVID- 19) , although not at SMCH. In KCH, the increase in mortality may be due to decreased gestational age and birthweight, but also due to a reduced rota of nursing staff implemented to protect healthcare workers. In fact, there was a suggestion that mortality decreased after the first case of COVID-19 in Zimbabwe, but this was not statistically significant. The reasons for . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted January 6, 2021. ; this are unclear but could include factors such as increased stillbirth rates or improved care for the smaller number of neonates on the NNU. More complete analysis of facility-based and community-based neonatal mortality is greatly needed. Some limitations should be noted. A limitation intrinsic to interrupted time series analysis is the possibility that another event occurred close to the first case of COVID-19 in either country causing spurious observations. Another potential threat to validity is changing data collection practices. For example, overstretched clinicians might not input data into the NeoTree app for all admitted neonates. However, this is unlikely as the NeoTree app is embedded into routine practice at SMCH and KCH and discussions with local collaborators suggest use of the app has continued without issue. The NeoTree app only collects data on neonates admitted to the NNU. Therefore, our analysis does not capture stillbirths or neonatal deaths that occur in the community. It is troubling to see a dramatic fall in admissions in both sites, raising the possibility that many unwell neonates did not attend a health facility and died at home. A recent study found that facility births decreased by over 50% during the lockdown in Nepal, and facility stillbirth and neonatal mortality rates increased significantly. 29 The NeoTree research team is currently collecting data on stillbirths at SMCH and KCH, but these data will still only represent stillbirths that occurred in a health facility. Given the COVID-19 pandemic is not over, it will be important to repeat our analysis over the coming months to further examine longer-term trends in neonatal care provision. . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted January 6, 2021. ; The indirect impacts of COVID-19 are context-specific, with more significant and evident effects on neonatal care provision seen at KCH (Malawi) than SMCH (Zimbabwe). While this study provides vital evidence to inform health providers and policy makers, national data are required to ascertain the true impacts of the pandemic on newborn health. . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted January 6, 2021. Sochas L, Channon AA, Nam S. Counting indirect crisis-related deaths in the context of a low-resilience health system: the case of maternal and neonatal health during the Ebola epidemic in Sierra Leone. Health Policy Plan 2017; 32(suppl_3): iii32-iii9. Yerger P, Jalloh M, Coltart CEM, King C. Barriers to maternal health services during the Ebola outbreak in three West African countries: a literature review. BMJ Glob Health 2020; 5(9). Ahmed S, Mvalo T, Akech S, et al. Protecting children in low-income and middle-income countries from COVID-19. BMJ Glob Health 2020; 5(5). . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted January 6, 2021. ; 28. Say L, Chou D, Gemmill A, et al. Global causes of maternal death: a WHO systematic analysis. Lancet Glob Health 2014; 2(6): e323-e33. Kc A, Gurung R, Kinney MV, et al. Effect of the COVID-19 pandemic response on intrapartum care, stillbirth, and neonatal mortality outcomes in Nepal: a prospective observational study. Lancet Glob Health 2020; 8(10): e1273-e81. . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted January 6, 2021. ; https://doi.org/10.1101/2021.01.06.21249322 doi: medRxiv preprint The authors have no conflicts of interest to declare. are further supported by the National Institute for Health Research Great Ormond Street Hospital Biomedical Research Centre. The funders had no role in study design, data collection and analysis, or preparation of this report. We are very grateful to the families at SMCH and KCH, and the staff members at both hospitals for their enthusiasm and commitment to the NeoTree project, without which this work would not be possible. Data collected for the study cannot yet be made publicly available yet because primary analysis for the pilot implementation evaluation of the NeoTree, as well as secondary analysis are ongoing. A goal of our pilot implementation is the establishment of an open-source anonymised research database of data collected using the NeoTree in order to maximise the reach and utility for researchers aiming to improve outcomes for neonates in low income settings. This database is under development and subject to negotiation with relevant Ministries of Health. . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted January 6, 2021. ; Background/rationale 2 Explain the scientific background and rationale for the investigation being reported 6-7 Objectives 3 State specific objectives, including any prespecified hypotheses 7 Methods Study design 4 Present key elements of study design early in the paper 7-8 Setting 5 Describe the setting, locations, and relevant dates, including periods of recruitment, exposure, follow-up, and data collection 8 Participants 6 (a) Cohort study-Give the eligibility criteria, and the sources and methods of selection of participants. Describe methods of follow-up Case-control study-Give the eligibility criteria, and the sources and methods of case ascertainment and control selection. Give the rationale for the choice of cases and controls Cross-sectional study-Give the eligibility criteria, and the sources and methods of selection of participants 8 (b) Cohort study-For matched studies, give matching criteria and number of exposed and unexposed Case-control study-For matched studies, give matching criteria and the number of controls per case Variables 7 Clearly define all outcomes, exposures, predictors, potential confounders, and effect modifiers. Give diagnostic criteria, if applicable 9 Data sources/ measurement 8* For each variable of interest, give sources of data and details of methods of assessment (measurement). Describe comparability of assessment methods if there is more than one group 9 Bias 9 Describe any efforts to address potential sources of bias 9-10 Study size 10 Explain how the study size was arrived at 10 Quantitative variables 11 Explain how quantitative variables were handled in the analyses. If applicable, describe which groupings were chosen and why 9-10 Statistical methods 12 (a) Describe all statistical methods, including those used to control for confounding 10-11 (b) Describe any methods used to examine subgroups and interactions 10-11 (c) Explain how missing data were addressed 10-11, 34 (d) Cohort study-If applicable, explain how loss to follow-up was addressed Case-control study-If applicable, explain how matching of cases and controls was addressed Cross-sectional study-If applicable, describe analytical methods taking account of sampling 10-11 . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted January 6, 2021. is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted January 6, 2021. . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted January 6, 2021. ; . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted January 6, 2021. ; . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted January 6, 2021. ; . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted January 6, 2021. . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) The copyright holder for this preprint this version posted January 6, 2021. . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) The copyright holder for this preprint this version posted January 6, 2021. . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) The copyright holder for this preprint this version posted January 6, 2021 . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) The copyright holder for this preprint this version posted January 6, 2021. • Solid vertical line: first confirmed case of COVID-19 in each country. • Period between dashed vertical lines: industrial action by doctors in Zimbabwe. • Counts based on all admission forms completed, irrespective of match status. is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) The copyright holder for this preprint this version posted January 6, 2021. ; World Health Organization. Statement on the second meeting of the International Health Regulations (2005) Emergency Committee regarding the outbreak of novel coronavirus (2019-nCoV) World Health Organization. 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Vienna, Austria: R Foundation for Statistical Computing RStudio: Integrated Development Environment for R. 1.2.5033 ed Interrupted time series regression for the evaluation of public health interventions: a tutorial Quasi-likelihood functions, generalized linear models, and the Gauss-Newton method Zimbabwe doctors end strike after billionaire's offer Zimbabwe nurses end three-month strike over pay Protecting hard-won gains for mothers and newborns in low-income and middle-income countries in the face of COVID-19: call for a service safety net Too far to walk: maternal mortality in context SARS-CoV-2 infection in pregnancy: A systematic review and meta-analysis of clinical features and pregnancy outcomes Hypoxic-ischaemic brain injury We would like to thank the funders of this study.