Background: Deaths from COVID-19 have exceeded 1.8 million globally (January 2021). We examined trends in markers of neonatal care before and during the pandemic at two tertiary neonatal units in Zimbabwe and Malawi .
Methods: We analysed data collected prospectively via the NeoTree app at Sally Mugabe Central Hospital (SMCH), Zimbabwe, and Kamuzu Central Hospital (KCH), Malawi . Neonates admitted from 1 June 2019 to 25 September 2020 were included . We modelled the impact of the first cases of COVID-19 (Zimbabwe : 20 March 2020; Malawi : 3 April 2020) on number of admissions, gestational age and birth weight, source of admission referrals, prevalence of neonatal encephalopathy, and overall mortality . Findings: The study included 3,450 neonates at SMCH and 3,350 neonates at KCH . Admission numbers at SMCH did not initially change after the first case of COVID-19 but fell by 48% during a nurses' strike (Relative risk (RR) 0.52 , 95% CI 0.40-0.68, p <0.002). At KCH, admissions dropped by 42% (RR 0.58; 95% CI 0.48-0.70; p <0.001) soon after the first case of COVID-19 . At KCH, gestational age and birth weight decreased slightly (1 week , 300 grams), outside referrals dropped by 28%, and there was a slight weekly increase in mortality . No changes in these outcomes were found at SMCH . Interpretation: The indirect impacts of COVID-19 are context-specific . While this 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 . Funding: International Child Health Group, Wellcome Trust