{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,2,27]],"date-time":"2026-02-27T03:39:24Z","timestamp":1772163564580,"version":"3.50.1"},"reference-count":36,"publisher":"BMJ","issue":"6","license":[{"start":{"date-parts":[[2022,6,21]],"date-time":"2022-06-21T00:00:00Z","timestamp":1655769600000},"content-version":"unspecified","delay-in-days":20,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"funder":[{"DOI":"10.13039\/501100000632","name":"Healthcare Infection Society","doi-asserted-by":"publisher","award":["SRG 201802004"],"award-info":[{"award-number":["SRG 201802004"]}],"id":[{"id":"10.13039\/501100000632","id-type":"DOI","asserted-by":"publisher"}]},{"name":"International Child Health Group","award":["David Morley Bursary"],"award-info":[{"award-number":["David Morley Bursary"]}]},{"DOI":"10.13039\/501100000691","name":"Academy of Medical Sciences","doi-asserted-by":"publisher","award":["SGL018\\1064"],"award-info":[{"award-number":["SGL018\\1064"]}],"id":[{"id":"10.13039\/501100000691","id-type":"DOI","asserted-by":"publisher"}]},{"name":"National Institute of Health Research Biomedical Research Centre Great Ormond Street Hospital","award":["N\/A"],"award-info":[{"award-number":["N\/A"]}]},{"DOI":"10.13039\/100010269","name":"Wellcome","doi-asserted-by":"publisher","award":["215742\/Z\/19\/Z"],"award-info":[{"award-number":["215742\/Z\/19\/Z"]}],"id":[{"id":"10.13039\/100010269","id-type":"DOI","asserted-by":"publisher"}]},{"DOI":"10.13039\/501100000659","name":"Research Trainees Coordinating Centre","doi-asserted-by":"publisher","award":["N\/A"],"award-info":[{"award-number":["N\/A"]}],"id":[{"id":"10.13039\/501100000659","id-type":"DOI","asserted-by":"publisher"}]}],"content-domain":{"domain":["bmj.com"],"crossmark-restriction":true},"short-container-title":["BMJ Open"],"published-print":{"date-parts":[[2022,6]]},"abstract":"<jats:sec>\n                    <jats:title>Objectives<\/jats:title>\n                    <jats:p>To examine indirect impacts of the COVID-19 pandemic on neonatal care in low-income and middle-income countries.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Design<\/jats:title>\n                    <jats:p>Interrupted time series analysis.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Setting<\/jats:title>\n                    <jats:p>Two tertiary neonatal units in Harare, Zimbabwe and Lilongwe, Malawi.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Participants<\/jats:title>\n                    <jats:p>We included a total of 6800 neonates who were admitted to either neonatal unit from 1 June 2019 to 25 September 2020 (Zimbabwe: 3450; Malawi: 3350). We applied no specific exclusion criteria.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Interventions<\/jats:title>\n                    <jats:p>The first cases of COVID-19 in each country (Zimbabwe: 20 March 2020; Malawi: 3 April 2020).<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Primary outcome measures<\/jats:title>\n                    <jats:p>Changes in the number of admissions, gestational age and birth weight, source of admission referrals, prevalence of neonatal encephalopathy, and overall mortality before and after the first cases of COVID-19.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Results<\/jats:title>\n                    <jats:p>Admission numbers in Zimbabwe did not initially change after the first case of COVID-19 but fell by 48% during a nurses\u2019 strike (relative risk (RR) 0.52, 95%\u2009CI 0.41 to 0.66, p&lt;0.001). In Malawi, admissions dropped by 42% soon after the first case of COVID-19 (RR 0.58, 95%\u2009CI 0.48 to 0.70, p&lt;0.001). In Malawi, gestational age and birth weight decreased slightly by around 1\u2009week (beta \u22121.4, 95%\u2009CI \u22121.62 to \u22120.65, p&lt;0.001) and 300 g (beta \u2212299.9, 95%\u2009CI \u2212412.3 to \u2212187.5, p&lt;0.001) and outside referrals dropped by 28% (RR 0.72, 95%\u2009CI 0.61 to 0.85, p&lt;0.001). No changes in these outcomes were found in Zimbabwe and no significant changes in the prevalence of neonatal encephalopathy or mortality were found at either site (p&gt;0.05).<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Conclusions<\/jats:title>\n                    <jats:p>The indirect impacts of COVID-19 are context-specific. While our 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.<\/jats:p>\n                  <\/jats:sec>","DOI":"10.1136\/bmjopen-2021-048955","type":"journal-article","created":{"date-parts":[[2022,6,21]],"date-time":"2022-06-21T11:26:31Z","timestamp":1655810791000},"page":"e048955","update-policy":"https:\/\/doi.org\/10.1136\/crossmarkpolicy","source":"Crossref","is-referenced-by-count":12,"title":["Indirect impacts of the COVID-19 pandemic at two tertiary neonatal units in Zimbabwe and Malawi: an interrupted time series analysis"],"prefix":"10.1136","volume":"12","author":[{"given":"Simbarashe","family":"Chimhuya","sequence":"first","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-6832-9839","authenticated-orcid":false,"given":"Samuel R","family":"Neal","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Gwen","family":"Chimhini","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Hannah","family":"Gannon","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Mario","family":"Cortina Borja","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Caroline","family":"Crehan","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Deliwe","family":"Nkhoma","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Tarisai","family":"Chiyaka","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-7091-2417","authenticated-orcid":false,"given":"Emma","family":"Wilson","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Tim","family":"Hull-Bailey","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-9594-3228","authenticated-orcid":false,"given":"Felicity","family":"Fitzgerald","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Msandeni","family":"Chiume","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Michelle","family":"Heys","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]}],"member":"239","published-online":{"date-parts":[[2022,6,21]]},"reference":[{"key":"2022062108251688000_12.6.e048955.1","unstructured":"World Health Organization . Statement on the second meeting of the International health regulations (2005) emergency Committee regarding the outbreak of novel coronavirus (2019-nCoV), 2020. Available: https:\/\/bit.ly\/3jihlAU [Accessed 04 Sep 2020]."},{"key":"2022062108251688000_12.6.e048955.2","unstructured":"World Health Organization . WHO coronavirus disease (COVID-19) Dashboard, 2021. Available: https:\/\/covid19.who.int [Accessed 31 Dec 2021]."},{"key":"2022062108251688000_12.6.e048955.3","unstructured":"United Nations Inter-agency Group for Child Mortality Estimation . Levels & Trends in Child Mortality: Report 2019. New York United Nations Children\u2019s Fund; 2019."},{"key":"2022062108251688000_12.6.e048955.4","doi-asserted-by":"crossref","DOI":"10.1016\/S0140-6736(20)31751-7","article-title":"COVID-19 worsens Zimbabwe's health crisis","volume":"396","author":"Makoni","year":"2020","journal-title":"Lancet"},{"key":"2022062108251688000_12.6.e048955.5","doi-asserted-by":"publisher","DOI":"10.1136\/bmj.m3267"},{"key":"2022062108251688000_12.6.e048955.6","unstructured":"World Health Organization . Less than 10% of African countries to hit key COVID-19 vaccination goal, 2021. Available: https:\/\/bit.ly\/3EDj6mN [Accessed 31 Dec 2021]."},{"key":"2022062108251688000_12.6.e048955.7","doi-asserted-by":"crossref","unstructured":"Castagnoli R , Votto M , Licari A , et al . Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection in children and adolescents. JAMA Pediatr 2020;174:882.doi:10.1001\/jamapediatrics.2020.1467","DOI":"10.1001\/jamapediatrics.2020.1467"},{"key":"2022062108251688000_12.6.e048955.8","doi-asserted-by":"crossref","first-page":"653","DOI":"10.1016\/S2352-4642(20)30177-2","article-title":"COVID-19 in children and adolescents in Europe: a multinational, multicentre cohort study","volume":"4","author":"G\u00f6tzinger","year":"2020","journal-title":"Lancet Child Adolesc Health"},{"key":"2022062108251688000_12.6.e048955.9","doi-asserted-by":"publisher","DOI":"10.1111\/apa.15270"},{"key":"2022062108251688000_12.6.e048955.10","doi-asserted-by":"crossref","first-page":"733","DOI":"10.1038\/s41390-020-1015-2","article-title":"Coronavirus disease 2019 (COVID-19) in children and\/or adolescents: a meta-analysis","volume":"89","author":"Mantovani","year":"2021","journal-title":"Pediatr Res"},{"key":"2022062108251688000_12.6.e048955.11","unstructured":"Viner RM , Mytton OT , Bonell C . Susceptibility to and transmission of COVID-19 amongst children and adolescents compared with adults: a systematic review and meta-analysis. medRxiv 2020."},{"key":"2022062108251688000_12.6.e048955.12","doi-asserted-by":"publisher","DOI":"10.1093\/heapol\/czx108"},{"key":"2022062108251688000_12.6.e048955.13","doi-asserted-by":"publisher","DOI":"10.1136\/bmjgh-2020-002974"},{"key":"2022062108251688000_12.6.e048955.14","doi-asserted-by":"publisher","DOI":"10.1136\/bmjgh-2020-002844"},{"key":"2022062108251688000_12.6.e048955.15","doi-asserted-by":"crossref","first-page":"e901","DOI":"10.1016\/S2214-109X(20)30229-1","article-title":"Early estimates of the indirect effects of the COVID-19 pandemic on maternal and child mortality in low-income and middle-income countries: a modelling study","volume":"8","author":"Roberton","year":"2020","journal-title":"Lancet Glob Health"},{"key":"2022062108251688000_12.6.e048955.16","unstructured":"Government of Zimbabwe . Public health (COVID-19 prevention, containment and treatment) (national Lockdown) order, 2020. Zimbabwe Veritas Zimbabwe; 2020. https:\/\/www.veritaszim.net\/node\/4046"},{"key":"2022062108251688000_12.6.e048955.17","doi-asserted-by":"publisher","DOI":"10.1136\/bmjgh-2021-006035"},{"key":"2022062108251688000_12.6.e048955.18","unstructured":"Kaponda C . No COVID-19 lockdown still threatens livelihoods and trade in Malawi. London School of Economics 2020 https:\/\/blogs.lse.ac.uk\/africaatlse\/2020\/09\/25\/no-covid19-lockdown-threatens-livelihoods-trade-trust-malawi\/"},{"key":"2022062108251688000_12.6.e048955.19","unstructured":"BBC News . Zimbabwe doctors end strike after billionaire\u2019s offer, 2020. Available: https:\/\/www.bbc.co.uk\/news\/world-africa-51205619 [Accessed 04 Aug 2020]."},{"key":"2022062108251688000_12.6.e048955.20","unstructured":"Reuters . Zimbabwe nurses end three-month strike over pay, 2020. Available: https:\/\/www.reuters.com\/article\/us-health-corononavirus-zimbabwe-strike-idUSKBN26011R [Accessed 20 Oct 2020]."},{"key":"2022062108251688000_12.6.e048955.21","unstructured":"NeoTree . NeoTree [GitHub repository], 2020. Available: https:\/\/github.com\/neotree\/neotree [Accessed 03 Oct 2020]."},{"key":"2022062108251688000_12.6.e048955.22","doi-asserted-by":"publisher","DOI":"10.1136\/bmjgh-2018-000860"},{"key":"2022062108251688000_12.6.e048955.23","doi-asserted-by":"publisher","DOI":"10.1136\/bmjoq-2020-001043"},{"key":"2022062108251688000_12.6.e048955.24","unstructured":"R Foundation for Statistical Computing . R: A language and environment for statistical computing [program]. 3.6.3 version. Vienna, Austria R Foundation for Statistical Computing; 2020."},{"key":"2022062108251688000_12.6.e048955.25","doi-asserted-by":"crossref","unstructured":"RStudio . RStudio: Integrated Development Environment for R [program]. 1.2.5033 version. Boston, MA RStudio, Inc; 2019.","DOI":"10.1007\/978-3-662-62518-7_1"},{"key":"2022062108251688000_12.6.e048955.26","doi-asserted-by":"publisher","DOI":"10.1093\/ije\/dyw098"},{"key":"2022062108251688000_12.6.e048955.27","doi-asserted-by":"publisher","DOI":"10.1136\/jech.53.4.235"},{"key":"2022062108251688000_12.6.e048955.28","doi-asserted-by":"crossref","unstructured":"Bikwa Y , Murewanhema G , Kanyangarara M , et al . Impact of COVID-19 on maternal and perinatal outcomes in Harare, Zimbabwe: a comparative maternal audit. J Glob Health Rep 2021;5.doi:10.29392\/001c.28995","DOI":"10.29392\/001c.28995"},{"key":"2022062108251688000_12.6.e048955.29","doi-asserted-by":"publisher","DOI":"10.1136\/bmjgh-2020-002754"},{"key":"2022062108251688000_12.6.e048955.30","doi-asserted-by":"crossref","first-page":"100446","DOI":"10.1016\/j.eclinm.2020.100446","article-title":"SARS-CoV-2 infection in pregnancy: a systematic review and meta-analysis of clinical features and pregnancy outcomes","volume":"25","author":"Khalil","year":"2020","journal-title":"EClinicalMedicine"},{"key":"2022062108251688000_12.6.e048955.31","unstructured":"Robertson NJ , Groenendaal F . Hypoxic-ischaemic brain injury. In: Rennie JM , ed. Rennie and Roberton\u2019s Textbook of Neonatology. 5th ed. London: Churchill Livingstone, 2012: 1114\u201355."},{"key":"2022062108251688000_12.6.e048955.32","doi-asserted-by":"crossref","first-page":"e323","DOI":"10.1016\/S2214-109X(14)70227-X","article-title":"Global causes of maternal death: a who systematic analysis","volume":"2","author":"Say","year":"2014","journal-title":"Lancet Glob Health"},{"key":"2022062108251688000_12.6.e048955.33","doi-asserted-by":"crossref","DOI":"10.1186\/s12913-021-06878-3","article-title":"Covid-19 pandemic impact on maternal and child health services access in Nampula, Mozambique: a mixed methods research","volume":"21","author":"das Neves Martins Pires","year":"2021","journal-title":"BMC Health Serv Res"},{"key":"2022062108251688000_12.6.e048955.34","doi-asserted-by":"crossref","first-page":"197","DOI":"10.2147\/CLEP.S176723","article-title":"Sample size and power considerations for ordinary least squares interrupted time series analysis: a simulation study","volume":"11","author":"Hawley","year":"2019","journal-title":"Clin Epidemiol"},{"key":"2022062108251688000_12.6.e048955.35","doi-asserted-by":"crossref","first-page":"e1273","DOI":"10.1016\/S2214-109X(20)30345-4","article-title":"Effect of the COVID-19 pandemic response on intrapartum care, stillbirth, and neonatal mortality outcomes in Nepal: a prospective observational study","volume":"8","author":"Kc","year":"2020","journal-title":"Lancet Glob Health"},{"key":"2022062108251688000_12.6.e048955.36","doi-asserted-by":"publisher","DOI":"10.1016\/0277-9536(94)90226-7"}],"container-title":["BMJ Open"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/syndication.highwire.org\/content\/doi\/10.1136\/bmjopen-2021-048955","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2022,6,21]],"date-time":"2022-06-21T11:26:53Z","timestamp":1655810813000},"score":1,"resource":{"primary":{"URL":"https:\/\/bmjopen.bmj.com\/lookup\/doi\/10.1136\/bmjopen-2021-048955"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2022,6]]},"references-count":36,"journal-issue":{"issue":"6","published-online":{"date-parts":[[2022,6,21]]},"published-print":{"date-parts":[[2022,6]]}},"alternative-id":["10.1136\/bmjopen-2021-048955"],"URL":"https:\/\/doi.org\/10.1136\/bmjopen-2021-048955","relation":{"has-preprint":[{"id-type":"doi","id":"10.1101\/2021.01.06.21249322","asserted-by":"object"}]},"ISSN":["2044-6055","2044-6055"],"issn-type":[{"value":"2044-6055","type":"print"},{"value":"2044-6055","type":"electronic"}],"subject":[],"published":{"date-parts":[[2022,6]]}}}