When Ranjani* announced her pregnancy to her family at the dinner table, her family was not happy with the news. They thought it was an inane decision on her part to have a child at a time such as this, with the coronavirus spreading fast everywhere.
“I didn’t expect such a welcome for the life in my womb, from my family that boasts of a prominent social worker and doctors,” she said.
With the surge of COVID-19 and the worldwide campaign to ensure oxygen and other essentials for saving lives, everyone seems to have ignored the future generation.
Maternal and child health service is an essential health care service, particularly in rural India. In the absence of private players unlike in urban areas, millions of rural poor are dependent on public health care service.
In rural India, millions of children are born every year in public health facilities that lack basic amenities, infrastructure and skilled personnel. And every year thousands of young women die due to pregnancy and childbirth related complications.
While target 3.1 of Sustainable Development Goals set by the United Nations (UN) aims to reduce global maternal mortality ratio (MMR) to less than 70 per 1,00,000 live births, current MMR in India is 113 according to a special bulletin on maternal deaths released by the Office of the Register General in July 2020.
It is a very hard-earned achievement, considering that the MMR was 2,000 in the year 1946. States like Assam (215), Uttar Pradesh (197), Madhya Pradesh (173), Bihar (149), Chhattisgarh (159), Odisha (150) and Rajasthan (164) have higher MMR than the national ratio. Jharkhand (71) did fairly well in reducing the MMR, compared to many of the states.
According to World Bank data, in 2016 alone 37,000 women died due to pregnancy and child birth related complications, though it had reduced from 103,000 in the year 2000. In 2016 World Health Organization (WHO) reported that five women in India die every hour during child birth. The sample registration system (SRS) bulletin of Census of India reveals that 70% of these women are below the age of 30 years.
Our experience from the ground in tribal heartland shows that many of the pregnant women die simply because of delay in deciding to seek care, delay in reaching health facility or delay in getting critical care.
In Jharkhand, a decade back when I was part of the core team that designed the Mamta Vahan call center for free medical ambulance service, we found that thousands of precious lives could be saved by simply proving free transportation facility.
During verbal autopsies – a method of gathering information and determining the cause of death in rural areas – conducted in remote regions and tribal areas, it was found that majority of the women died because transportation could not be arranged at night. It was due to lack of financial resources or a vehicle or the person who makes decision was not present, or a delay in deciding to send the women to a health facility.
Pregnancies during pandemic
If that was the situation in normal circumstances, then think of the current situation where we have nationwide or locally imposed lockdowns and travel restrictions. One can only imagine the plight of these rural women.
With weaker immune system, pregnant women have higher risk of infections. The risk of death is 70% higher in pregnant women than in non-pregnant women, indicated a report by Centers for Disease Control and Prevention.
The COVID-19 bulletins do not report COVID-19 maternal death. Social media has also failed to listen and echo the cry of dying mothers of India. In rural Punjab, 23 COVID-19 maternal deaths were recorded in a year from March last year till 31 March, 2021. There were 23 such deaths recorded in 50 days in rural parts of the state from 1 April to 20 May this year. In rural India this is likely to have been common.
In India around 67,000 babies are born every day; or 26,932,586 babies are born every year. This number indicates that these many women get pregnant every year. A UN report anticipated the highest number of maternal deaths of 7,750 – an 18% increase – in India.
Evidences show that by ensuring continuum of care at different stages of life that includes quality antenatal care (ANC) services, delivery attended by skilled personnel and postpartum care can save millions of lives. Any deviation from it can have multiplier negative effect on overall health outcome of a country.
The guidelines on Enabling Delivery of Essential Health Services during the COVID 19 Outbreak released by Ministry of Health and Family Welfare on 14 April, 2020 recognized the provision of essential services for mother, child and adolescents.
Decline in registered pregnancies
Data extracted from Health Management Information System and a comparison between data pertaining to financial year (FY) 2019-20 and FY 20-21 shows that there is a decline in total number of pregnant women registered for ANC in most states except Andhra Pradesh, Himachal Pradesh, Jammu & Kashmir, Punjab, and Tamil Nadu.
Declining ANC registrations have been observed more in states like Uttar Pradesh (~70,000 decline), Bihar (~30,000), Delhi (~18,000) and Kerala (~11,000). Similarly, almost all major states expect Andhra Pradesh, Madhya Pradesh, Maharashtra, Odisha, and Telangana have reported negative trend in difference in comparing first trimester registration from 2019-20 to 2020-21.
In states like Bihar the difference is as much as about 30,000. In Uttar Pradesh it is almost 15,000 and in Delhi about 10,000. All the states across the country have reported a decline in total number of Institutional deliveries.
In Uttar Pradesh the difference in institutional delivery is around 30,000, Gujarat about 12,000 and West Bengal 11,000. At the same time as assumed, many of the states have reported an increase in number of home deliveries. States like Rajasthan (~4,500); West Bengal (~4,000) and Uttarakhand (~3500) have reported a greater number of home deliveries.
Reasons for decline
Due to closure of anganwadis, the Village Health Sanitation and Nutrition Days (VHSNDs) were suspended or conducted with minimal provisions. In villages, VHSNDs are where the basic maternal health services including registration, ANC and referral take place.
In the wake of the first and second waves of COVID-19, the accredited social health activists (ASHAs) were delegated COVID-19 response and surveillance. This reduced their number of home visits, thus disrupting the listing of pregnant women.
A large number of auxiliary nurse midwives (ANMs) and community health officers (CHOs) posted in remote areas in health subcenters (HSCs) and newly-created health and wellness centers (HWCs) were deputed in COVID care facilities.
With shortage of personnel, most of the HSCs are being run by single staff. Many of the HSCs have been closed or function irregularly. Thus, pregnant women did not have access to a health facility close by. Infections among health workers reduced the overall staff strength.
Crippled by a lack of infrastructure trained staff and life-saving essentials like oxygen, and referral transport facilities, very few HSCs function as delivery centers. The pandemic has further reduced the number of HSCs where deliveries could be handled.
With many of the government health facilities and private hospitals converted for COVID care, the number of beds for pregnant women has reduced.
Lockdown regulations, travel restrictions and the need for social distancing discouraged attendance in healthcare facilities including maternal, newborn and child health services, partly attributable to the fear of contracting the infection.
Lack of logistical support for healthcare services providers and inadequate screening facilities made services difficult. Staff have been observed to provide health care services from a distance. But for ANCs and check-up of pregnant women, physical contact is essential. In many cases, disappointed by the service, pregnant women did not come for subsequent ANCs.
The Indian diaspora, individuals and a host of donor agencies and organizations have shown their overwhelming support in India’s fight against COVID-19, by providing oxygen concentrators, etc. But many of the supplies centered around urban locations.
Similar support needs to be extended to rural India. Because they are voiceless, and the story of their agony is never captured in the media. Even volunteers from the corporate or other sectors never visited them.
Saving pregnant women has to be prioritized within the COVID-19 response strategy. On a request for maternal health support a few days back, the head of the largest donor agency said, “As of now our only focus is on COVID-19 response, people are dying.” A change in this perception is needed.
There needs to be a shift in the one-size-fits-all approach to a more humane, women-sensitive approach in COVID-19 response.
The HSCs and HWCs need to be funded and equipped so that pregnant women will have a nearby facility for delivery. After the first COVID-19 wave, Transforming Rural India Foundation (TRIF) in association with public health system equipped 10 HWCs with an investment of Rs 4.25 lakhs per facility to make it fully functional.
All these equipped HWCs are now conducting eight to 10 deliveries per month. The equipment will be functional for a minimum of three years, provided the government supplies the required essentials. It would help save the lives of about 350 pregnant women and neonates in three years. Philanthropists and organizations can support such interventions.
Our experience shows that placing professionals in a public health system coupled with community-based interventions supported by ANMs and ASHAs can bring about changes leading to saved lives.
In Atmanirbhar Bharat, it is the responsibility of each of us to save the young mothers of rural India. The words of M. Gabriela Mistral, a 20th century Chilean diplomat, “Many things can wait. Children cannot. Today their bones are being formed, their blood is being made, their senses are being developed. To them we can’t say Tomorrow. Their name is Today” holds true today.
*Name changed to protect privacy.
Shyamal Santra leads the COVID-19 response activities and Aspirational District Program at TRIF. Views are personal. Email: firstname.lastname@example.org