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Assessing the hidden burden and costs of COVID-19 pandemic in South Asia: Implications for health and well-being of women, children and adolescents

PLOS Global Public Health · 12 authors, 9 centres

AI SUMMARY

FIDELITY 100%

POPULATIONWomen, children, and adolescents in six South Asian countries (Afghanistan, Bangladesh, Nepal, India, Pakistan, Sri Lanka)

INTERVENTIONCOVID-19 pandemic response measures including lockdowns and school closures

COMPARISONPre-pandemic period (2019) service coverage and health outcomes

This summary was generated by AI from a single paper. It has not been reviewed by a clinician and is not clinical advice. Verify against the source before acting on it.

AGENT 01 · STRUCTURED SUMMARY

TRACE TO SOURCE

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TL;DR

This study analyzed health system data from six South Asian countries and found that COVID-19 pandemic disruptions reduced essential maternal and child health service coverage by up to 60%, leading to an estimated 19,000 additional maternal deaths and 317,000 additional child deaths between January 2020 and June 2021. Prolonged school closures likely resulted in 9 million permanent dropouts, with 4.5 million girls at risk of early marriage and adolescent pregnancy. The indirect mortality effects of the pandemic on women and children in South Asia likely exceeded direct COVID-19 deaths in the region.

Full summary

4,208 CHARS

**Background:** The COVID-19 pandemic has disproportionately affected vulnerable populations, with evidence from past crises showing women and children are especially vulnerable through reduced access to antenatal care, immunizations, and schooling. Early modeled estimates predicted 253,500–1,157,000 additional child deaths and 12,200–56,700 additional maternal deaths within one year globally. However, most studies in low- and middle-income countries have been limited to small settings or early pandemic data. This study aimed to assess actual disruption in essential health services across six South Asian countries using administrative data through June 2021, and model the downstream consequences on mortality, education, and adolescent health.

**Methods:** The researchers collaborated with UNICEF Regional Office for South Asia to collect data from Health Management Information Systems (HMIS) in Afghanistan, Bangladesh, Nepal, India, Pakistan, and Sri Lanka. Data covered essential sexual, reproductive, maternal, neonatal, and child health (SRMNCH) service utilization from January 2019 to June 2021. Disruption was assessed by comparing quarterly service utilization in 2020 and 2021 against the same calendar months in 2019. The Lives Saved Tool (LiST) and FamPlan modules of Spectrum were used to estimate increases in under-5 child mortality, maternal mortality, stillbirths, and unintended pregnancies. For Pakistan only, monthly district-level data from 150+ districts allowed calculation of 95% confidence intervals. Educational impact was modeled using population estimates from UNESCO, net attendance ratios from DHS, and school dropout rates adapted from the 1997 East Asian financial crisis in Indonesia. Economic costs were estimated using returns to education of 4.04% per primary year and 2.44% per secondary year, with a 3% discount rate over 45-year working lifetimes.

**Key Results:** Coverage of essential SRMNCH services decreased by up to 60%, with the largest disruptions observed between April and June 2020. Bangladesh and Pakistan experienced the most disruption; Sri Lanka the least. Recovery occurred from July 2020 to March 2021, but most gains were reversed in April/May 2021 during the delta variant surge. Estimated additional deaths between January 2020 and June 2021 included: 317,000 child deaths (13% increase overall; India 15%, Pakistan 12%), with over 150,000 in the neonatal period (14.6% increase); 150,000 additional stillbirths (10.8% increase; India 13%, Pakistan 10%); and 19,000 maternal deaths (18.7% increase; India 23%, Pakistan 18%). More than 5.4 million additional unintended pregnancies occurred, with approximately 5.0 million in India. Prolonged school closures resulted in an estimated 9.4 million children permanently dropping out (7.5 million in India), with 4.5 million being girls. This cohort faces 15–30% decreased lifetime earnings. Among girls who dropped out, an estimated 476,587–498,250 additional adolescent pregnancies could occur, leading to 769–804 maternal deaths, 13,514–14,128 neonatal deaths, 153,195–160,159 low birthweight births, and 27,937–29,207 stunted children by age two. The indirect mortality effects likely exceeded direct COVID-19 deaths in South Asia.

**Clinical Implications:** The study demonstrates that pandemic response measures caused greater harm to women and children through indirect effects than the direct effects of COVID-19 itself. Coverage of essential services remained below pre-pandemic levels even by March 2021, with further setbacks during the delta wave. The findings underscore the critical need for continued provision of essential SRMNCH services and keeping schools open during future health emergencies. Strategies must address inequities through targeted implementation reaching marginalized groups, including zero-dose children. Building back better requires increased investments in health systems, poverty alleviation, education, and gender equity. The vast inequities in global COVID-19 vaccine rollout (only 15% in low-income countries vs 72% in high-income countries by April 2022) highlight systemic vulnerabilities that must be addressed for future pandemic preparedness.

PICO

PPOPULATION

Women, children, and adolescents in six South Asian countries (Afghanistan, Bangladesh, Nepal, India, Pakistan, Sri Lanka)

IINTERVENTION

COVID-19 pandemic response measures including lockdowns and school closures

OOUTCOME

Coverage disruption of essential SRMNCH services; maternal, neonatal, and child mortality; stillbirths; unintended pregnancies; school dropout rates; adolescent pregnancies; low birthweight births; childhood stunting

STUDY TYPE

other

SPECIALTY

public_health

SUMMARISED BY

AI pipeline

FIDELITY CHECK

100% · A

ORIGINAL PAPER

PMC10096516

Assessing the hidden burden and costs of COVID-19 pandemic in South Asia: Implications for health and well-being of women, children and adolescents

PLOS Global Public Health

READ THE FULL PAPER

ABSTRACT

The COVID-19 pandemic has disproportionately affected vulnerable populations. With its intensity expected to be cyclical over the foreseeable future, and much of the impact estimates still modeled, it is imperative that we accurately assess the impact to date, to help with the process of targeted rebuilding of services. We collected data from administrative health information systems in six South Asian countries (Afghanistan, Bangladesh, Nepal, India, Pakistan and Sri Lanka), to determine essential health services coverage disruptions between January–December 2020, and January–June 2021, compared to the same calendar months in 2019, and estimated the impact of this disruption on maternal and child mortality using the Lives Saved Tool. We also modelled impact of prolonged school closures on continued enrollment, as well as potential sequelae for the cohort of girls who have likely dropped out. Coverage of key maternal and child health interventions, including antenatal care and immunizations, decreased by up to 60%, with the largest disruptions observed between April and June 2020. This was followed by a period of recovery from July 2020 to March 2021, but a reversal of most of these gains in April/May 2021, likely due to the delta variant-fueled surge in South Asia at the same time. We estimated that disruption of essential health services between January 2020 and June 2021 potentially resulted in an additional 19,000 maternal and 317,000 child deaths, an increase of 19% and 13% respectively, compared to 2019. Extended school closures likely resulted in 9 million adolescents dropping out permanently, with 40% likely being from poorest households, resulting in decreased lifetime earnings. A projected increase in early marriages for girls who dropped out could result in an additional 500,000 adolescent pregnancies, 153,000 low birthweight births, and 27,000 additional children becoming stunted by age two years. To date, the increase in maternal and child mortality due to health services disruption has likely exceeded the overall number of COVID-19 deaths in South Asia. The indirect effects of the pandemic were disproportionately borne by the most vulnerable populations, and effects are likely to be long-lasting, permanent and in some cases inter-generational, unless policies aimed at alleviating these impacts are instituted at scale and targeted to reach the poorest of the poor. There are also implications for future pandemic preparedness.

CITATION EXPORT

Aatekah Owais, Arjumand Rizvi, Muhammad Jawwad et al.. Assessing the hidden burden and costs of COVID-19 pandemic in South Asia: Implications for health and well-being of women, children and adolescents. PLOS Global Public Health. (2023). https://doi.org/10.1371/journal.pgph.0001567

AUTHORS

12 · 9 CENTRES

Aatekah Owais, Arjumand Rizvi, Muhammad Jawwad, Susan Horton, Jai K. Das, Catherine Merritt, Ralfh Moreno, Atnafu G. Asfaw, Paul Rutter, Phuong H. Nguyen, Purnima Menon, Zulfiqar A. Bhutta

1 Centre for Global Child Health, Hospital for Sick Children, Toronto, Canada
2 Division of Women and Child Health, Aga Khan University, Karachi, Pakistan
3 School of Public Health and Health Systems, University of Waterloo, Waterloo, Canada
4 Institute of Global Health and Development, The Aga Khan University, South-Central Asia, East Africa & United Kingdom
5 UNICEF Headquarters, New York, New York, United States of America
6 UNICEF ROSA, Kathmandu, Nepal
7 International Food Policy Research Institute, Delhi, India
8 Center of Excellence in Women and Child Health, The Aga Khan University, South-Central Asia, East Africa & United Kingdom
McGill University, CANADA

EDITOR / REVIEWER

Madhukar Pai