How has the COVID-19 pandemic exacerbated the preexisting challenges and inequalities in reproductive, maternal, newborn, and child health (RMNCH) in Colombia?
For the past two decades, Colombia has been struggling with internal displacement due to violence, conflict, and natural disasters, and recently, the impacts from the influx of Venezuelan migrants and refugees. However, the rise of the COVID-19 pandemic has highlighted further social, economic, and structural inequalities and has had major implications — including a 69% rise in maternal deaths between 2020 and 2021.
The iMMAP COVID-19 situational analysis project team identified this significant increase during routine data gathering and analysis. The team then conducted extensive research, consolidating data from various sources and stakeholders, analyzed the causes, and then summarized and shared with the humanitarian community through the monthly COVID-19 situation analysis reports. Furthermore, the team conducted a nation-wide survey, in partnership with RIWI, studying the impacts of COVID-19 on different aspects of life in Colombia, and launched a field investigation in the Amazonas region, focusing on the communities in Leticia and Puerto Nariño, to gather relevant first-hand information from the indigenous population and NGOs serving those communities.
Reproductive, maternal, newborn and child health in Colombia
Since the adoption of Millennium Development Goal (MDG)-5 in 2000, the maternal mortality ratio across Latin America and the Caribbean has reduced by half. Colombia, specifically, boasts positive maternal healthcare compared to many middle-income countries and is above the regional average for Latin America. During the 15-year period between 2000–2015, the country saw a 34% decrease in maternal mortality, and 97% of women between the ages of 15–49 delivered in a healthcare facility, indicative of a strong and improving healthcare system.
While maternal mortality rates have decreased, Colombia still fell short of meeting the MDG-goal to reduce the maternal mortality ratio by three quarters based on 1990 figures. Colombia reported 64 maternal deaths per 100,000 live births in 2015, missing its target ratio of 45 maternal deaths per 100,000 live births.
Among women in Colombia who want to avoid pregnancy, 13% have an unmet need for modern contraception. The Guttmacher Institute has modeled that, if all demands for modern contraception in Colombia were met, maternal deaths would drop by 65%, newborn deaths would decrease by 69%, and unintended pregnancies would decline by 63%. Furthermore, the Pan-American Health Organization (PAHO) stated that the most common direct causes of maternal injury and death are excessive blood loss, infection, high blood pressure, unsafe abortion, and obstructed labor as well as indirect causes such as anemia, malaria, and heart disease; factors that highlight the need for improved maternal healthcare services.
Underlying issues with maternal healthcare in Colombia
Colombia, as many other countries, faced underlying institutional problems before the COVID-19 pandemic that affected the provision of equitable, high-quality, and timely RMNCH care. One such factor is the variation in availability and quality of RMNCH between regions, due to common problems in implementing maternal healthcare policies and the achievement of maternal health goals across provinces.
Other findings indicate that there is inadequate RMNCH medical and nursing training and education programs, which translates into lower quality maternal healthcare services. This is compounded with high rotation, a lack of opportunities, and low remuneration of medical staff — especially affecting maternal healthcare delivery in rural, insular, and remote areas of the country.
Another theme that emerged is the slow and complicated health insurance financing mechanism, which often impedes access to quality and timely healthcare. This is highlighted by the World Health Organization (WHO), stating that universal healthcare is a critical component of sustainable development and poverty reduction and a key element to reducing social inequities.
A final point that affects the provision of quality and timely services in Colombia is that unmet needs for maternal healthcare in rural, insular, and remote areas are higher compared to urban areas. The impact of geography and environment is a detrimental factor in delivering affordable maternal healthcare, while emphasizing the need to increase and adapt healthcare delivery to address ethnic and cultural traditions and taboos — specifically of the indigenous and Afro-Colombian population.
COVID-19 and the Colombia healthcare system
The underlying factors that limit access to quality and timely RMNCH have been aggravated by the influx of COVID-19 patients in Colombian hospitals. As of September 1, 2021, Colombia registered over 4.9 million COVID-19 cases across the country, and over 124 thousand deaths. This has put an enormous burden on the healthcare system to attend to COVID-19 patients while continuing to provide other quality and timely healthcare services, specifically RMNCH care.
The pandemic has severely strained the healthcare system in Colombia and led to a 69% increase in maternal deaths in 2021 alone. Preliminary data (see footnote 1) from the Ministry of Health (MoH) in Colombia shows that in the first half of 2021 (weeks 1–26) there were 265 maternal deaths in Colombia compared to a four-year average of 156.5 between 2016–2019 (during the same period), and significantly above the 2018 figure of 128. The trends in maternal mortality show a clear increase from February 2021 and then a spike between March and June across all provinces, which correlates with COVID-19 cases across the country.
What caused the 69% increase in maternal mortality between 2020 and 2021?
According to iMMAP analysis, approximately 30% of the increase in maternal deaths in Colombia can be directly attributable to COVID-19 itself — which is in line with the estimated 36% excess mortality in the general population attributable to COVID-19. Indeed, there is some evidence that COVID-19 may disproportionately affect pregnant and lactating women (PLWs) and may cause more severe outcomes as well. However, COVID-19 infections alone do not explain the full increases in maternal mortality in Colombia. The major question is ´What accounts for the remaining 70% increase in maternal deaths between 2020 and 2021? ´
One major theme identified was a lower demand for healthcare services due to fear of contracting the virus, coupled with lower levels of access to healthcare services. 44% of households on a national level reported not having access to healthcare services during the first half of 2021, based on a survey conducted by iMMAP’s partner RIWI, which collected data from 27,000 respondents across Colombia — of which 10,000 were women and 1,140 of those were PLW. Among PLW, of those who visited a hospital recently, 72% noticed an increase in waiting times, as echoed by Luis, an advisor from the Tiwa community in the Amazonas region interviewed during our field visit:
“We didn’t want to go to the hospital. You are not attended quickly there, so we met up with our grandparents and created help groups in the community.”
- Luis, local community advisor
In addition, 60% of PLW felt that COVID-19 restrictions and quarantine measures limited access to services, guidance, or means regarding exclusive breastfeeding, while 42% of lactating women said that there was less access to health and nutrition services for children under five. Yenica, an indigenous midwife in Puerto Esperanza echoed these sentiments stating that “during the pandemic, pregnant women did not attend healthcare centers for assistance, as the assistance was focused on cases of COVID-19 and there was a fear of contracting the virus.”
The RIWI survey identified some interesting statistics about the sample of PLWs. Compared to the survey average, PLWs who responded to the survey were seven times more likely to report having a disability; four and a half times more likely to have no education; three times more likely to be Venezuelan or Indigenous; and twice as likely to be displaced, a victim of armed conflict, a Colombian returnee from Venezuela, or Afro-Colombian. The frequency with which vulnerable groups appear in the sample of PLWs suggests that pregnancies occur more frequently in women from marginalized groups. Indeed, many women who have access to contraceptive methods, and have been able to choose, have chosen to delay pregnancies during the COVID-19 pandemic. Inequality means that such choices may not be readily available, to more vulnerable women.
“During the pandemic, pregnant women did not attend healthcare centers for assistance, as the assistance was focused on cases of COVID-19 and there was a fear of contracting the virus.”
- Yenica, indigenous midwife
A higher proportion of pregnancies in women from marginalized sections of society could affect the maternal death rate in multiple ways. Firstly, through the well documented inequalities that predict poorer RMNCH outcomes for poor and marginalized women. Second, individuals from lower socio-economic and marginalized communities may be more exposed to COVID-19 due to living in overcrowded conditions, less access to hygiene items, and continuing to work unsafely to earn a livelihood. The findings of the iMMAP survey indicate PLW were less likely to protect themselves against COVID-19, either due to their own choices or their inability to do so. Exposure can also be increased by risk perception and health seeking-behaviors. According to the survey results, lactating women versus non-lactating women were 25% less likely to isolate if infected with COVID-19, three times less likely to isolate if infected with COVID-19 because they “don’t want to”, twice more likely to ‘probably not get a vaccine’ — mainly due to worries about safety and against religious beliefs, and three times more likely to ‘definitely not get a vaccine’ — mainly due to worries about safety and against religious beliefs.
Understanding that the majority of pregnancies appear to be occurring amongst marginalized women, who usually suffer from worse RMNCH outcomes and have an increased exposure risk and decreased risk perception of the virus, may partially explain the significant increases in maternal mortality. This is also coupled with the need to tailor maternal healthcare services to more culturally and traditionally appropriate methods within the country. Yenica explained to iMMAP that “Traditional births consist of practices which are not suitable for attending to childbirth, hygiene conditions are not the best, and due to lack of knowledge they can lead to complications.”
Another major driver could be the overall bed occupancy across healthcare facilities throughout the country — which would affect the type and quality of care a woman could expect to receive, if at all. In May and June 2021, the average bed occupancy stood at 60%, with some provinces such as Casanare showing 99% and 100% bed occupancy across all healthcare facilities. Furthermore, between April-June 2021, there was an average bed occupancy of 83% across Intensive Care Units (ICUs) in the country. There is a clear correlation in the trend of increases in COVID-19 cases, bed occupancy rates, and maternal deaths. Whilst correlation is not causation, a diversion of resources to COVID-19 at the expense of RMNCH and other life-saving services is likely, making healthcare services less accessible for those in need. Results from excess mortality studies in multiple countries have confirmed this unfortunate relationship.
In addition, since the beginning of the pandemic, 63,108 healthcare workers contracted COVID-19, and at least 316 died as a result. Due to COVID-19 infections amongst staff, 442,000 medical days were lost, all at a time of increased medical needs, and decreased availability of services. Decreased healthcare worker to patient ratio undermines the quality of care that a patient would receive even if they were admitted to a facility. The trend in COVID-19 infections amongst healthcare workers also shows that the majority of infections (61%) were reported in the first half of 2021, the period during which maternal mortality also increased significantly.
The pandemic has magnified the continued problems across the globe — especially those nations struggling with ongoing natural disasters, epidemics, and internal conflict. In Colombia, this is evident with a 69% increase in maternal mortality between 2020 and 2021. However, only around 30% of those maternal deaths are directly linked to COVID-19 cases. The rest of the mortality cases, as seen here, can be explained by lower demand for healthcare due to fears of contracting the virus, lower levels of access to quality and timely healthcare services, and an overwhelmed healthcare system due to high bed occupancy rates and decreased availability of healthcare workers. These consequences occurred as a result of the COVID-19 pandemic have contributed to the ongoing issues faced by the healthcare system in the delivery of quality and timely healthcare to the population.
iMMAP’s Data Lab Stories is a collection of stories curated from experts and data archives, an initiative to uncover and share meaningful insights while showcasing iMMAP’s support to the humanitarian and development community.
The COVID-19 Situational Analysis project is funded by USAID and implemented in partnership with Data Friendly Space. It aims to collect and analyze data provided by humanitarian stakeholders and other relevant actors such as academia, private sector, and government agencies to produce regular joint situational analysis reports to facilitate a better understanding of the humanitarian impact of COVID-19 to support response operations in target countries while supporting global efforts.
iMMAP is an international not-for-profit organization that provides information management services to humanitarian and development organizations, enabling partners to make informed decisions that ultimately provide high-quality targeted assistance to the world’s most vulnerable populations.