In the past year, much has been written and said about the gendered nature of disaster situations, as COVID 19 challenged the healthcare system. Disruptions to health services coupled with inequalities in access to services, disadvantage vulnerable groups, particularly women and girls. Past global experiences from the Ebola and Zika epidemics suggest that resources were redirected from routine health services, including antenatal and post-natal health care and contraceptive services on efforts to contain the epidemics. This exacerbated already limited access to maternal, sexual and reproductive health services for women and girls.
In the wake of the second more severe wave of COVID-19 in the country, the reduced capacity of healthcare services catering to women will push back progress made over the years in reducing maternal mortality. These gains were accomplished thanks to increased institutional deliveries and improvement in quality and coverage of services under the National Health Mission (NHM), through various schemes such as Janani Shishu Suraksha Karyakram, Janani Suraksha Yojana, and more recently launched initiatives like LaQshya and Pradhan Mantri Surakshit Matritva Abhiyan. The maternal mortality rate in the country had come down to 113 in 2016-18 from 167 in 2011-13, as reported by Sample Registration System.
Lockdowns, restricted mobility, fear of infection from the virus and disruptions in the provision of maternal health services, such as antenatal and postnatal care and institutional deliveries, are likely to result in adverse pregnancy outcomes directly and indirectly. Memories from last year, when a pregnant woman was not admitted by eight hospitals in Delhi died in an ambulance still haunt our collective memories. According to a study in the International Journal of Gynaecology and Obstetrics, the institutional deliveries declined by 45 percent from April to August 2020 after the COVID-19 hit; there was a 7.2 percent increase in high‐risk pregnancies and a two-and-a-half-times increase in admission to the intensive care units.
Recent research has revealed that pregnant women may be at increased risk of pre-term births and other adverse pregnancy outcomes. An analysis of about 400,000 women in the age group of 15 to 44 years by the US Center for Disease Control and Prevention revealed that pregnant women with COVID-19 are more likely to require I.C.U. beds, invasive ventilation. The risk of death is 70 percent higher in pregnant women than in non-pregnant women infected with COVID-19. Expecting mothers are also at an increased risk for developing blood clots.
A recent UNICEF report, Direct and Indirect Effects of COVID-19 Pandemic and Response in South Asia estimates that disruptions due to the pandemic will result in significantly higher numbers of maternal and child deaths, unwanted pregnancies and disease-related mortality in women and adolescents than in previous years. Maternal deaths are estimated to rise by 18 percent and stillbirths by 10 percent. Of the 3.5 million additional unintended pregnancies estimated due to disruptions in access to reproductive healthcare and family, 3 million are likely to be in India.
UNICEF estimates that India alone is likely to record an additional 154,000 child deaths. The fear of infection, as well as limited access to health services, has led to depression and anxiety among pregnant women and mothers which is expected to impact health outcomes for both women and infants in the long run.
The second COVID-19 wave has resulted in many more pregnant women getting infected and dying compared with last year. So far, the Indian government has allowed COVID-19 vaccinations for lactating mothers but not pregnant women. Public health experts have called for the government to prioritise pregnant women in the vaccination process as the benefits of vaccination clearly outweigh possible risks. Other countries, including United States, Belgium, and the United Kingdom have safely vaccinated expectant and lactating mothers for vaccination, and there is no reason for the Government of India to not revise their advisory to include pregnant women.
After devastating India’s biggest cities, the resurgent COVID-19 wave is now ravaging rural areas across India. A lack of infrastructure, limited awareness, and non-adherence to COVID Appropriate Behaviour (CAB) are some reasons why rural India has not been well equipped to deal with this second wave of the pandemic. In rural areas, where access to medical facilities was limited even before the outbreak, the number of impacted children and new mothers is likely to increase.
Since front line workers, especially ASHAs have been engaged in the COVID response, the delivery of antenatal care has been seriously impacted, especially in remote areas. A study in Uttar Pradesh observed an overall decrease of 2.26 percent in the number of institutional deliveries. Antenatal care services were the worst affected with a 22.91 percent decline. Experts have also warned that pregnant women may be unable to access the health care, including timely emergency obstetric care that they need. Reporting from rural areas point to an increase in numbers of home deliveries as compared with pre-pandemic years.
As the health system is overstretched, new-borns and very young children could miss out on life-saving immunisation, treatment for diarrhoea, pneumonia or severe and acute malnutrition. Many ICDS centres that previously provided children with regular meals are shut, reducing their access to nutritious food. Children are also not receiving their Mid-Day Meals as schools are shut.
Urgent measures are required to ensure the uninterrupted provision of high-quality maternal health services during and after the COVID-19 pandemic. These include the need to develop special interventions for pregnant women in emergency situations; provision of safety equipment, such as personal protective equipment and financial incentives for women. The scaled-up adoption of telemedicine services could ensure that pregnant women continue to receive routine medical care.
Furthermore, there is a need to effectively use social and behaviour change communication (SBCC) strategies to increase awareness on Covid Appropriate Behaviours (CAB) and address fear and anxiety amongst pregnant women. Going forward, health system strengthening is vital to ensure that maternal, new-born and child health care, and family planning services are not compromised during emergency situations like the COVID-19 pandemic.
—Poonam Muttreja is Executive Director, Population Foundation of India. Views expressed are personal
(Edited by : Ajay Vaishnav)