“I went into labour immediately after dinner,” says the mother of three who lives in Nawada, Bihar. “Due to the lockdown, my husband could not find a vehicle to take me to the Rajauli Government Hospital, some 2 km away. After two hours of excruciating labour pain, I gave birth to my child at home.”
Her husband, who works at the local post office, says they were lucky they could get a dai (a traditional midwife with no formal training) who lives nearby on time to handle the delivery. But the newborn baby was a little less fortunate. “My two elder children were born in a hospital. We got a trained professional’s care and also medicines for free,” Kumari says, adding she was covered under the Janani Shishu Suraksha Karyakaram ( JSSK).
Launched in 2011 under the Ministry of Health and Family Welfare, the scheme gives pregnant women going to public health institutions free medicines, diagnostics and delivery. It encourages poor women to opt for institutional delivery over home delivery so that the mother and child can get better and timely care.
However, there has been a big drop in institutional deliveries during the initial phase of the lockdown. According to data released last week by the National Health Mission’s Health Management Information System (NHM-HMIS), there was a more than 50% drop in institutional deliveries from 15.48 lakh in June 2019 to 9.36 lakh in June 2020. The institutional deliveries dipped in April and May, too. Such a development would put more mothers and newborns at risk.
The NHM-HMIS, which tracks indicators from 2.2 lakh healthcare facilities across the country, had stopped publishing the data during the lockdown. The April, May and June numbers were announced in late August. The number of pregnant women who availed of free medicines under JSSK dipped almost 70% from June 2019 and 2020, according to data as on August 27. In the period, some 5.24 lakh children missed their birth dose of polio vaccine. Kumari’s newborn had to wait for 20 days for the first inoculations — usually administered within 24 hours of birth — because of lack of medical staff at the nearest anganwadi centre. The healthcare workers were on Covid duty elsewhere.
“Any delay in giving vaccines reduces its efficacy and increases the risk of infection in newborns. In some cases, they might even pass on contagious diseases to others,” says Dr Kumar Ankur, senior consultant in neonatology at the Centre for Child Health, BL Kapur Super Specialty Hospital, New Delhi.
Kumari’s child and probably hundreds of thousands of other newborns missed all this care because of the lockdown. This is a matter of concern for a country that has come a long way in promoting institutional deliveries and improving its maternal mortality ratio. “Home deliveries have harmful aftereffects on the mother and child, including long-term chronic diseases,” says Dr Narendra Saini, former secretary general of the Indian Medical Association, adding that institutional deliveries are necessary for better overall healthcare.
A key performance indicator to determining pregnancy-related safety is maternal mortality ratio or MMR — the number of women who die from pregnancy-related causes while pregnant or within 42 days of pregnancy termination per 100,000 live births. India’s MMR was 398 in 1997-98; it was 122 in 2015-2017, according to the latest data available with the Registrar General of India. This compares with 154 of Pakistan and 200 of Bangladesh in 2015.
Covid-19 has dealt a severe blow to delivery of perinatal care also, especially in rural areas, where families rely solely on public health institutions. Apart from restrictions of movement and disruption of supply chain during the lockdown, the pandemic also put most medical and paramedical staff on Covid duty.
Binita Kumari, who works as an auxiliary nurse midwife — a frontline health functionary — in Nawada district, knows the damage that has been caused. “We were posted at the Rajauli check post in Bihar-Jharkhand border for the whole of April to screen migrants for coronavirus. Vaccination and prenatal-antenatal care took a back seat,” says Binita, who otherwise would see at least a dozen pregnant women a day.
Sunita Kumari, an accredited social health activist (ASHA) in the Andharwari block of Nawada district, says her Covid duty would start at 2 pm. She would make house visits to collect samples for antigen tests. “I tried to do my perinatal visits before 2 pm. But many expecting and new mothers would not allow us inside their homes because they were afraid of getting infected,” adds Sunita.
The Ministry of Home Affairs had on April 15 said all health services deemed essential should function as usual. But many states seem to have prioritised Covid response.
Dr Ankur of BL Kapur Super Specialty Hospital says vaccination visits had dropped 80% in the initial weeks of the lockdown but the situation has started normalising since July. “We tried to accelerate the vaccination process by giving them maximum vaccines permissible at one time.”
The battle against Covid-19 seems to have disrupted almost the whole healthcare front line workers in rural areas. Even the anganwadi workers — who play a crucial role in educating and encouraging these women to visit local health centres for checkups and institutional delivery — were posted elsewhere and had to reduce their home visits. These community health workers are women selected from the local community and given training in child development, immunisation, personal hygiene, environmental sanitation, breastfeeding, ante-natal care, treatment of minor ailments and recognition of “at risk” children. So they are able to easily communicate with local women. Each anganwadi centre looks after a population of approximately 1,000 in rural and urban areas and 700 in tribal areas.
But the number of pregnant women who received four or more ante-natal check-ups has fallen from 17 lakh in April 2019 to 9.65 lakh in April 2020. Also, the number of home deliveries attended by skilled birth attendants has halved from 16,395 in April 2019 to 7,992 in April 2020.
There has been a 66% drop in children who got shots against the dreaded Japanese encephalitis — which has a mortality rate of more than 30% — in April 2020 against April 2019. In 2019, more than 100 children had died of this disease in Bihar.
In Telangana, says G Bhagyalaxmi, a child development project officer in Mahabubnagar district, “Most anganwadi centres saw a dip in visits of lactating and expecting mothers. Even the number of vaccinations have fallen. All ASHA and ANM workers were either on Covid duties or distributing dry ration during the lockdown. We have been seeing a small improvement in numbers now.”
Meanwhile, experts point to another developing situation: rising cases of unwanted pregnancies due to lack of availability of contraceptive measures. “The pandemic may have led to non-availability of contraceptive measures during the early lockdown days. That would lead to a spurt in unplanned pregnancies, which has a debilitating effect on the health of a woman. Anganwadi centres were a major source of contraceptives. But the supply chains were disrupted for months and workers were also not available in several areas,” says former health secretary Keshav Desiraju. NHM data show the number of emergency contraceptive pills that were distributed dropped from 1.43 lakh in April 2019 to 86,462 in April 2020. The number of interval intrauterine device insertions have also dropped from 2.22 lakh in April 2019 to 88,810 in April 2020.
One good news is that the unlock process has seen the resumption of many of the public health facilities that were curtailed during the early days of the lockdown. “Institutional deliveries and immunisation numbers have improved in the last one and a half months. But a lot needs to be done to make provisions to ensure these services do not stop during an emergency,” says Bijit Roy, associate director, Population Foundation of India.
The virus is still lurking in the shadows and can cause more disruptions.