Published: 4th June 2020
The indirect impacts of Covid-19: an additional 253,500 child and maternal deaths?
A comment on: Early estimates of the indirect effects of the Covid-19 pandemic on maternal and child mortality in low- and middle income countries: a modelling study
A new paper published in the Lancet co-authored by Dr Timothy Roberton from the Johns Hopkins Bloomberg School of Public Health revealed dramatic estimates of increased maternal and under-5 child mortality due to the Covid-19 pandemic. In low- and middle-income countries, where health systems are already compromised, the outbreak might cause an increased number of deaths due to indirect effects, such as potential disruption of health systems and decreased access to food.
The authors modelled three hypothetical scenarios of reduced essential maternal and child health interventions, using the Lives Saved mathematical modelling tool to estimate the additional maternal and under-5 child deaths under different scenarios of disruption. The study focused on 118 low- and middle income countries.
Even in the best scenario, with least disruption and restrictions regarding access to healthcare, the team of researchers estimated that up to 253,500 child deaths and 12,200 maternal death could be attributed to Covid-19 related impacts on the health system across six months. In the scenario with the highest disruption, where the largest number of health workers were unable to provide care in addition to interference with the pharmaceutical supply chain and inability to travel to healthcare centres, the study estimates that there will be 1,157,000 child and 56,700 maternal excess deaths attributable to the lockdown.
In perspective, the latter implies a rise of 45% in child deaths and 38% in maternal deaths. As the authors affirm: “The increase in child and maternal deaths will be devastating”.
A closer look: how does the pandemic impact on children and maternal health?
The authors argue that the reasons for the increased mortality are twofold. Firstly, as mentioned, the direct disruptions to healthcare facilities, health workers being sick or reassigned, and a reduced income due to the lack of jobs that would limit people from seeking help.
Indeed, in a recent workshop on the SDGs, Dr Kaja Abbas, Assistant Professor in Disease Modelling at London School of Hygiene and Tropical Medicine and author of the article “Benefit-risk analysis of health benefits of routine childhood immunisation against the excess risk of SARS-CoV-2 infections during the Covid-19 pandemic in Africa” highlighted that also national immunisation programmes are at risk of suspension. The constraints in the health systems and physical distancing measures can potentially increase indirect child deaths due to immunisation coverage reductions during the outbreak.
The second reason for the high rate of mother and child mortality relates to an increase in the incidence and prevalence of child wasting. WHO defines wasting as low weight-for-height. When wasting occurs, children under-5 years of age appear too thin for their height, and there is a rapid deterioration in nutritional status over a short period of time. The disruption brought by Covid-19 may result in higher levels of child wasting as it impacts the capacity of people to provide for their families: jobs are lacking, and food prices might escalate.
Could there be an impact of Covid-19 on stunting too?
As Prof Claire Heffernan, Principal Investigator at the UKRI GCRF Action against Stunting Hub, noted: understanding the direct and indirect impacts of Covid-19 across vulnerable communities is an urgent task for the global community. Models such as the one undertaken by Dr Roberton and his co-authors demonstrate that we need to both better understand the wider implications of Covid-19 and equally respond quickly to these issues to prevent more unnecessary deaths.
Dr Naomi Bull, Interdisciplinary Research Fellow for the UKRI GCRF Action against Stunting Hub explains that stunting was not included in the modelling for this paper, as it happens over a longer time period and won’t cause deaths to rise straight away. However, as stunting is caused by the same factors that contribute to wasting, it is highly likely that the pandemic will cause levels of stunting to increase too. This underlines the importance of the work of the Action Against Stunting Hub, as stunting sadly remains a huge challenge in many countries around the world and this may only worsen as a result of Covid-19. The Hub’s holistic Whole Child Approach will be key to developing child-focused interventions to prevent, improve and even reverse some key features of this global issue.
Our role: The UKRI GCRF Action against Stunting Hub
The UKRI GCRF Action against Stunting Hub applies a Whole Child Approach to better understand the synergies and interactions between the drivers of child stunting. Covid-19 directly and indirectly impacts the communities we work with. In the following, the three Country-Leads from Indonesia, India and Senegal share their views.
Dr Umi Fahmida, Deputy Director for Program, Southeast Asian Ministers of Education Organisation Regional Center for Food and Nutrition (SEAMEO RECFON): Indonesia ranks fifth highest in the world for child stunting, with more than 7 million children under-5 who are stunted. The Covid-19 pandemic impacted on household food security and child care, and eventually on maternal and child undernutrition. With the beginning of our fieldwork involving pregnant women, we will have the opportunity to better understand better the impact of the Covid-19 pandemic and its interaction with the Whole Child components (physicality, home, food, education and cognition). The study will provide valuable information to improve our understanding of stunting in the post Covid-19 period.
Dr Bharati Kulkarni, Senior Grade Deputy Director at National Institute of Nutrition: India has the highest number of stunted and wasted children in the world. It is feared that, with the direct and indirect effects of the Covid-19 pandemic, this number would increase substantially. The analysis by Dr Roberton shows that the disruption of health and other services during the pandemic may lead to a rise of 45% in child deaths globally and almost 18-23% of these deaths would be accounted for by wasting. Likely, the medium-term impact of services disruption and broader economic implications may also be visible in the form of increased rates of stunting. The interdisciplinary work of the Stunting Hub will be essential to understand how to prevent and improve stunting in the post-Covid-19 period.
Prof Babacar Faye, Professor in Parasitology at the Faculty of Medicine, at the University of Cheikh Anta DIOP: in Senegal, although it seems that children are less affected by Covid-19 (few cases diagnosed in this population), the impact of this pandemic on their health will be undeniable. A large part of health resources has been redirected towards the fight against this pandemic; this will not be without repercussions on children, especially those with morbidities such as stunting and malnutrition. We have noted a significant decrease in hospital attendance, and programmes such as the EPI are negatively impacted by this situation. The fight against certain diseases such as malaria, in which 90% of mortality occurs among children and pregnant women, is likely to be affected, jeopardizing efforts to pre-eliminate this disease in our country.
At the economic level, the confinement, the slowdown of professional activities and job losses will most certainly affect the poorest households, especially since the appearance of this pandemic coincides with the lean season (March – September).
These factors and implications this will have to be measured by multidisciplinary studies including health economists, modellers and the health system specialists. The Stunting Hub allows us to address all these issues. The a posteriori analysis of the data, in particular the child and maternal mortality data from the health information system, will help to better measure the impact of the Covid-19 pandemic and analyse the findings of Dr Roberton.