Though India reduced its maternal mortality ratio (MMR) by 77%, from 556 per 100 000 live births in 1990 to 130 per 100,000 live births in 2016, its maternal health system remains tenuous. Many districts still do not have high-quality delivery services, referral services, or emergency obstetric care services essential for preventing maternal deaths. The COVID-19 pandemic has made this precarity worse. Here, I discuss the catastrophic impact of the COVID-19 lockdown on India’s already-stressed maternal health system. My research revealed that due to the government and health system’s sole focus on COVID 19, non-COVID 19 services were severely hampered, and women were denied access to critical maternal health services, leading to avoidable maternal and neonatal deaths.
On March 24, 2020, when India had about five hundred COVID-19 cases, India announced the world’s harshest lockdown, which completely halted all economic activities and movement of citizens in the country, barring some limited activities. The Ministry of Health & Family Welfare (MoHFW) released a list of “essential” healthcare activities, which included antenatal, labor and delivery, and abortion services. Despite the essential nature of these services, my conversations with healthcare professionals revealed that women faced massive challenges accessing them due to a lack of adequate transport, restrictions placed on their mobility, and the denial of non-COVID healthcare services by many institutions. Many states even curtailed outreach services for immunisation for infants, children, and women, citing the importance of taking precautionary measures to prevent the possible spread of the virus through these interactions.
“While the MoHFW’s guidelines were detailed and comprehensive, its implementation was quite poor probably due to lack of government will,” said Dr. Kiran*, an obstetrician and a maternal health researcher, during a phone interview. She argued there were two major issues that severely affected maternal care:
The first issue is inhibiting access to care. Due to the lockdown, almost every government hospital is exclusively catering to COVID-19 patients. Many private hospitals are ‘gatekeeping’ [and] refusing women without COVID-19 negative certificates, which is having a significant impact on deliveries, antenatal care and emergencies.
Kiran’s claims are corroborated by official health data for March 2020, which reveal a significant reduction in institutional deliveries, the number of eclampsia cases treated at the facility level, and emergency treatment for obstetric complications since the start of the pandemic, especially compared to previous years. These increases are correlated with increases in unmet need. Equally problematic is a lack of blood. “Due to the lockdown, there have hardly been any blood donation drives, which has drastically reduced the availability of blood in blood banks,” said Dr. Kiran. The lack of blood is particularly significant in the case of maternal health. With anaemia a direct cause in 20% and indirect cause in 50% of maternal deaths in India, women face the distinct likelihood of needing blood transfusions due to birth complications and obstetric emergencies. Pre-COVID, India already had the world’s largest shortage of blood, which was worsened by the lockdown as blood banks were running low on reserves, forcing hospitals to contact individual donors to address the shortage of blood.
Dr. Kaavya Prakash*, a resident in the Obstetrics and Gynaecology Department of a government hospital in a North Indian town, described her experience as being similar to Dr. Kiran’s:
Formulating guidelines is one thing, implementation is another. It is absolutely ridiculous that some district level hospitals have stopped all non-COVID-19 treatment. Due to the stringent lockdown and restrictions on mobility, many women are having to travel as far as 100-120 kilometres to access maternity care. For instance, we are receiving many patients from Noida and Ghaziabad[1], who would otherwise visit nearby local private hospitals in Delhi. Due to this long time spent in travelling, many high-risk women are coming at a stage which is very precarious and leading to maternal mortality. I am seeing an average of two to three documented maternal deaths in my hospital every week, which is a significant increase. The figure usually used to be one death per month before the lockdown.
A May 2020 report by Pratigya Campaign, an abortion rights group, estimated that the lockdown and its harshest restrictions on mobility and hospital service provision may have caused between 1425 and 2165 excess maternal deaths in India. Many excess deaths have been attributed to unpreparedness on the part of the public health system to tackle the deluge of COVID 19 cases and existing health issues simultaneously.
While the issues highlighted by Dr. Prakash and Dr. Kiran largely hold true for the majority of pregnant women, those belonging to upper and middle economic classes and castes were able to leverage social media networks to strategize around the lockdown’s restrictions. They either reached out to officials and ministers directly, or requested prominent journalists and celebrities to share their plight so that their pleas could reach the designated officials. On May 19, 2020, I received a forwarded WhatsApp message (Figure 2) from a woman in labor, who had been denied entry to a government hospital in Delhi. In response, and by mobilizing my own social and political capital, I sought help from a government acquaintance to help the woman get admitted in a hospital.
However, those from economically disadvantaged and socially marginalized backgrounds have no such options, primarily due to their lack of access to the professional and social networks that would be able to facilitate access to hospitals. In one especially shocking case, a woman and her newborn died after seven hospitals turned her away because she hailed from a rural district with a high number of COVID-19 cases. The hospitals’ refusals to accept her went against the MoHFW’s guidelines, which require hospitals to provide care irrespective of location or patient’s residency. In another case in Madhya Pradesh, a woman who had been turned away by two hospitals died shortly after childbirth. In Karnataka, a Muslim woman was forced to give birth in an autorickshaw after five hospitals refused to admit her.
At the community level, ASHA workers are getting frantic calls from women for support. Accredited Social Health Activists are a key category of volunteer community health workers, who are responsible to provide maternal and newborn care services in India at the local level. They counsel and guide women to access primary, secondary and tertiary maternal and newborn health care services, but they do not conduct deliveries. They are often the first person that women turn to for help, for themselves as well as their children, when it is otherwise difficult to access healthcare services.
I spoke to Anita Gupta*, an ASHA worker in an informal settlement in Delhi. She told me, “Problems have increased after the lockdown, particularly in context of deliveries. While outpatient facilities are shut, I have instructed women to rush to emergency departments if there is any major problem. Last week, a woman delivered without being given the mandatory tetanus toxoid injections as the local primary health centers were closed.” In 2015, India was declared neonatal and maternal tetanus free by the WHO, though tetanus could again resurface if lockdown constraints on its availability and administration aren’t addressed quickly. Already, due to the pandemic’s curtailment of immunization programs, experts have expressed concerns about public health successes, such as polio eradication, being reversed.
These events are not only consistent with the trend of women from marginalized communities being less likely to access maternity care. They also confirm how barriers and challenges to accessing care have been exacerbated due to lockdown restrictions and concerns around COVID-19. In 1999, the WHO, UNICEF and United Nations Population Fund (UNFPA) declared that access to safe maternal health services is a human right. Thus, the denial of maternal healthcare services by institutions despite official guidelines constitute a violation of women’s human rights. As these cases show, in some instances the lockdown serves as a pretext to continue discriminating against marginalized women because the sole focus on COVID-19 has reduced the accountability of public services in other domains.
On April 22, 2020, a public interest litigation was filed in the Delhi High Court by Sama, a women’s health group, which sought judicial intervention to to ensure that no pregnant woman could be denied essential health services and to take action against hospitals that refuse women’s access and/or admission. In response, the Court directed the central and Delhi government to launch a helpline. The ruling stated that, “The helpline number shall be publicised adequately in the newspapers and the social media as also through the Delhi Police, wherever possible. Union of India and Government of National Capital Territory of Delhi shall work in tandem to make sure that no barriers are faced by pregnant ladies and their family members residing in hot spots during the lockdown.”
Overall, it is evident that the lockdown has put India’s maternal health system under severe stress and worsened women’s experience of precarity during pregnancy, labour and delivery, and the immediate postpartum period. Given that the COVID-19 vaccine and its dissemination are far into the future, the central and state governments in India should prioritize the effective functioning of the maternal health system and ensure that pregnant woman’s rights are neither neglected nor violated.
*The names offered here are pseudonyms.
Devanik Saha is a PhD candidate at the Institute of Development Studies & Centre for Cultures of Reproduction, Technology & Health, University of Sussex, UK. His doctoral research is an ethnographic study of men’s experiences of pregnancy and childbirth in India. He can be reached at D.Saha1@ids.ac.uk or on Twitter at @devanikindia.
[1] Noida and Ghaziabad are urban towns surrounding Delhi but administratively belong to the state of Uttar Pradesh