Infant and Neonatal Mortality During the Covid-19 Pandemic: An Interrupted Time Series Analysis From Five Low- and Middle-Income Countries

BackgroundThe Covid-19 pandemic led to widespread changes to health and social institutions. The effects of the pandemic on neonatal and infant health outcomes in low- and middle-income countries (LMICs) are poorly understood, and nationally representative data characterizing changes to health care and outcomes is only now emerging. MethodsWe used nationally representative survey data with vital status and perinatal care information on 2,959,203 children born in India, Madagascar, Cambodia, Nepal, and the Philippines. Using interrupted time series models, we estimated the change in neonatal mortality (death in first 30 days of life) and infant mortality (death in first year of life) following the start of the Covid-19 pandemic, controlling for granular location fixed-effects and seasonality. FindingsWe analyzed 2,935,052 births (146,820 deaths) before March 2020 and 24,151 births (799 deaths) after March 2020. We estimated that infant mortality increased by 9.9 deaths per 1,000 live births after March 2020 (95% CI 5.0, 15.0; p<0.01; 22% increase) and neonatal mortality increased by 6.7 deaths per 1,000 live births (95% CI 2.4, 11.1; p<0.01; 27% increase). We observe increased mortality in all study countries. We also estimated a 3.8 percentage point reduction in antenatal care use (95% CI -4.9, -2.7; p<0.01) and a 5.6 percentage point reduction in facility deliveries (95% CI -7.2, -4.0; p<0.01) during the pandemic. InterpretationSince the start of the Covid-19 pandemic, neonatal and infant mortality are higher than expected in five LMICs. Helping LMICs resume pre-pandemic declines in neonatal and infant mortality should be a major global priority. FundingNational Institute of Child Health and Development (R01HD104835 PI Wagner) Research in contextO_ST_ABSEvidence before this studyC_ST_ABSThe impact of the Covid-19 pandemic on infant and neonatal mortality in low- and middle-income countries (LMICs) is not well-understood. We searched PubMed using the terms "COVID" AND (("child" OR "infant" OR "neonatal") AND "mortality")) AND ("low- and middle-income countries" OR "developing countries") on May 10, 2023, without language restrictions. The existing evidence is mixed. Increased mortality rates have been documented in Ghana, Nigeria, Uganda, and Nepal while decreased rates documented in South Africa and Guinea. Prior analyses were mainly based on clinic and hospital administrative data and were often confined to a selection of facilities or geographic areas, hampering the generalizability of the existing evidence. We found no published article that leveraged nationally representative data sources to provide a general assessment of infant or neonatal mortality in LMICs following the start of the Covid-19 pandemic. Added value of this studyTo our knowledge, this study provides the most comprehensive and generalizable investigation of the impact of the Covid-19 pandemic on infant and neonatal mortality in LMICs to date. Using nationally representative survey data from five LMICs that were recently released, we estimated an increase of 9.9 and 6.7 deaths per 1,000 live births in infant and neonatal mortality, respectively, during the Covid-19 pandemic. We also found significant reductions in antenatal care use and facility deliveries, which could partly explain the changes in mortality we document. Implications of the available evidenceOur study highlights significant increases in infant and neonatal mortality rates in five LMICs following the start of the Covid-19 pandemic, which sets back about a decades worth of progress. The decline in antenatal care services and facility births documented in our study suggests mortality increases were partly driven by disruptions in health service access induced by Covid-19 control measures. Helping to get reductions in neonatal and infant mortality back on track in LMICs should be a major global priority.