Over the past two decades, India has achieved impressive gains in reducing maternal deaths. India’s maternal mortality rate (maternal deaths/100,000 live births) has decreased from 407 in 2000 to 113 in 2016-18, according to the Sample Registration System (SRS) Bulletin 2020. With this progressive decline, India was on track to achieving the United Nations Sustainable Development Goals (SDG) of 70 births/100,000 live births by 2030. These gains were achieved through increases in institutional deliveries and a focus on quality and coverage of services under National Health Mission (NHM), through various schemes such as Janani Shishu Suraksha Karyakram, Janani Suraksha Yojana, and newer initiatives like LaQshya and Pradhan Mantri Surakshit Matritva Abhiyan.
In the wake of the COVID-19 pandemic, the reduced capacity of healthcare services for women and children could reverse progress achieved over the years in reducing maternal mortality. A systematic review of the available global data on the effects of the COVID-19 pandemic published in The Lancet, on maternal and perinatal outcomes, found increased maternal mortality and stillbirth, maternal stress, and ruptured ectopic pregnancies during the pandemic compared with before the pandemic. In Low and Middle-Income Country (LMIC) settings particularly, stillbirths may have seen significant increases.
A study in Uttar Pradesh observed an overall decrease of 2.26 per cent in the number of institutional deliveries. Antenatal care services were the worst affected with 22.91 per cent decline. Birth registration data in Delhi for the months of January and February 2021, show an increase in home births, reversing the trend observed in previous years. In the three municipal corporations in Delhi, 35 to 42 per cent of births occurring in January-February 2021 were registered as home births as compared with less than 10 per cent of births registered as non-institutional in 2019. Evidence shows that the risk of postpartum haemorrhage, (PPH) the primary cause of maternal deaths in India, increases in cases of non-institutional births. Institutional deliveries, with skilled health care professionals, have reduced maternal deaths globally. These disruptions highlight the shortcomings of the fragile and unplanned health system and raise questions on the appropriateness of the health policies and programs.
Lockdowns, fear of becoming infected with COVID-19 and massive disruptions in the provision of maternal health services, such as antenatal and postnatal care and institutional deliveries, have resulted in adverse pregnancy outcomes. The reduction in safe institutional deliveries could be driven by concern about the risk of acquiring COVID-19 in health-care settings, governmental advice to stay at home, or reduced public transport and childcare access during lockdowns. The article in The Lancet reports that in High Income Countries (HIC) routine care was rapidly restructured and delivered remotely, via telephone or video-based appointments.
Although technology can provide a COVID-19-secure path to continuity of antenatal care, there remains inequality of access for people without regular access to high-speed internet or privacy in their living space. In LMICs, where remote consultations are less feasible, some may simply miss out on preventive antenatal care entirely. The impact is greatest on the most disadvantaged groups. Even where care is accessible, potentially harmful policies implemented with little evidence are liable to cause setbacks.
A study published in the journal Reproductive Health reports that while pregnant women and mothers were not found to be at higher risk for COVID-19 infection than people who are not pregnant, pregnant women with symptomatic COVID-19 could experience more adverse outcomes. They also seem to face disproportionate adverse socio-economic consequences. Severe increases in maternal mental health issues, such as clinically relevant anxiety and depression, were reported. Domestic violence appeared to spike. Women were more likely to lose their income due to the pandemic than men, and working mothers struggled with increased childcare demands. Food insecurity and financial distress due to loss of livelihoods are also likely to have reduced use of maternal health care services.
Urgent measures are required to continue providing 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; establish trust between communities and individuals, particularly frontline health care providers; provide safety equipment, such as personal protective equipment and financial incentives. Further, there is a need to monitor and routinely check-the existing facility service in different hospitals, at both local and community levels as well as private clinics.
Regulation and strict enforcement are essential so that health care institutions cannot deny providing essential maternal services. Training for health workers – including doctors, nurses and midwives – through online workshops could be initiated to provide antenatal care to patients over mobile phones or other online platforms. Research into the current status of maternal health and services that look into both supply and demand factors and ways to remove barriers to maternal health services amid the COVID-19 pandemic are also required. Special attention to address panic and anxieties about visiting health care facilities is an important supplementary step.
A special focus must be placed on ensuring maternal health services are not disrupted during the ongoing emergency response. Given the existing stresses on health care systems, it is critical that we learn from our experiences in the past year in order to safeguard pregnant women, mothers and their babies against the threats posed by the second wave of the COVID-19 pandemic.
(The article was authored by Poonam Muttreja, Executive Director of the Population Foundation of India)
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