The fate of 30-year old Neelam, who died in the eight month of pregnancy because of lack of proper medical facilities sums up the fate of a large number of women during the COVID-19 pandemic. Despite being in her final trimester and unwell, she failed to get admitted in even one of eight hospitals whose doors her family knocked at in NOIDA, Uttar Pradesh.
Her husband and brother took the unwell woman to eight hospitals in one day but were refused admission, allegedly on grounds that each of them was already overburdened with patients.
Failure to get admitted resulted in her death, her family has alleged. Neelam is no exception. This is the situation across the country. In Jammu and Kashmir as well, several pregnant women have died due to lack of medical facilities. Two pregnant women, one of them COVID-19 positive, died in Anantnag district in the past two months after the hospitals there refused to admit them.
It is obvious that women’s lack of access to health services and other forms of discrimination have become more severe due to the frequent lockdowns and restrictions imposed on the health services.
Poonam Muttreja, executive director, Population Foundation of India (PFI), points out that post COVID-19, population services have practically disappeared. “Indian women have been let down by doctors working in both the public and the private sector,” says Muttreja.
“We expect to see 20 million babies born from January 2021 which is nine months after the announcement of the lockdown from this March, because 25 million couples in India did not have access to contraception. Another 1.85 million women have been denied access to abortion post the lockdown. Even worse, there has been a 40% decline in institutional deliveries,” Muttreja says.
She believes it was a grave mistake on the part of the government to have closed essential family planning services. Of course, the government defends itself with claims that health services and health workers have been so overwhelmed with controlling the pandemic that this was a necessary step, but they have failed to consider the repercussions in this crucial sector.
PFI has compared available data for right now with last year’s figures of the Ministry of Health and Family Planning to arrive at its conclusions. However, when the government realised that their data was showing a lack of access to sterilisation, contraception, and abortion facilities, they immediately took the data off from the ministry website, Muttreja points out.
The government may have taken data off their website but the Health Management Information System (HMIS), a portal that provides crucial information on health indicators has still provided a breakdown on the extent to how badly reproductive health has been hit in the past six months.
The HMIS points out that the number of first doses for injectable contraception fell by 36% from 66,112 in December 2019 to 42,639 in March soon after the COVID-19 outbreak.
The IUD form of contraception also showed a 21% fall from 2,60,615 last December to 2,05,395 in March. Similarly, the distribution of combined oral pill cycles and condoms came down by 15% and 23%, respectively, while in the same period, abortions came down by about 28%, the data shows.
In May, the Ministry of Health recommended that routine reproductive health services should be continued. But the key problem was that most women had little access to transport facilities which would allow them to reach government run clinics and other facilities.
Lack of access to medical facilities is evident in all aspects of reproductive health. This has been seen in several countries, but the breakdown of services is among the most evident in India.
Recently-released projections by the UNFPA and UNICEF confirm this trend. UNFPA suggests that 47 million women in 114 low and middle-income countries may not be able to access modern contraceptives and seven million unintended pregnancies are expected to occur if the lockdown carries on for six months resulting in disruptions to health services.
UNICEF highlights that for every three months the lockdown continues, there will be an additional two million women who will not have access to modern contraceptives. UNICEF estimates that in the nine months span from when Covid-19 was declared a pandemic, the countries with the highest numbers of forecast births are expected to be India (20.1 million), China (13.5 million), Nigeria (6.4 million), Pakistan (5 million) and Indonesia (4 million).
NGOs working in this field reinforce this alarming prognosis. Ipas Development Foundation, which focuses on the prevention of unwanted pregnancies, has done a series of modelling studies, to also arrive at the 1.85 million figure, emphasising that 1.85 million Indian women who would have wanted to terminate an unwanted pregnancy were not able to do so due to the lockdown.
In the first three months of the COVID-19 lockdown—that is between March 25 and June 24 —47% of the estimated 3.9 million abortions that would have likely taken place in India during normal circumstances have possibly not taken place. Ipas arrived at this conclusion following telephonic surveys of 509 public-sector facilities across eight states. They have also received feedback from members of the Federation of Obstetric and Gynaecological Societies of India, sales data on medical abortion drugs, and trend estimations from the pharmaceutical industry their website reveals.
Dr. Kanta Nayyar, a Delhi-based practising gynaecologist, is not in complete agreement with these surveys, though. “In my interactions with patients, many women who are in their early stages of pregnancy, when they found they were not able to access doctors, bought medicines to terminate their pregnancies from chemists. Even in villages, women are aware of the availability of oral medicines,” says Nayyar. “Though I agree that these drugs should be used only in the early stages of a pregnancy. For a woman to use them after nine weeks could endanger her life,” she warns.
A Lancet study published in 2015 has also highlighted that from the estimated 15.6 million abortions that happen in India annually, 73% are through drugs accessed outside facilities, 16% in private health facilities, 6% in public health facilities and 5% through traditional unsafe methods.
Millions of women would have, therefore, either continued an unwanted pregnancy or possibly undertook a late or unsafe abortion that can result in maternal death. Experts believe that the time has come to ensure that sexual and reproductive health is embedded into the country’s disaster management plan.
Dr. K Srinath Reddy, director, Public Health Foundation of India, is in agreement with how COVID-19 has channelled out limited healthcare workforce into epidemic control, diverting resources from other essential health programmes which adversely impacted maternal and child health services and reproductive health services.
Reddy says, “In the short term we need to bring in citizen volunteers and NGOs to support primary care services for Covid-19 returning many of the ASHAs and ANMs to their usual duties.” And he says that in the longer term India needs to expand the primary health workforce by doubling the number of ASHAs and ANMs and adding male multi-purpose health workers and mid-level health providers. “The epidemic teaches us that unless the health system is functioning fully with efficiency and equity in usual times, we cannot quickly build surge capacity during public health emergencies. Focusing only on the emergency with the limited resources available will extract of cost in terms of other services being neglected,” Reddy says.
India’s 3.3 million health service providers including ASHA and ANM workers have been in the forefront of fighting the pandemic. Most public health facilities were converted to COVID care centres thereby limiting the care available to women. Many health workers complained that they were not provided PPEs, which risked both the healthcare worker and patient. Similarly, private health facilities shut down due to unavailability of doctors, inadequate protective gear, or lack of COVID-19 testing arrangements.
Experts also warn that it is highly unlikely that people would invest in contraceptives during a period of economic recession. An unmet need in contraception will also see the rise of adolescent pregnancies. The fallout will be a rise in unsafe abortions. Social marketing organisations must support the government in ensuring uninterrupted supply of reversible methods of contraception.
The availability of self-care methods like condoms, oral contraceptive pills, emergency contraceptive pills, pregnancy test kits and sanitary pads at the pharmacies are a must. Furthermore, continuity of contraceptive supply chain is imperative to ensure proper stocks are maintained in both district hospitals and primary health centres.
ASHA workers and other community level health workers should be supported to ensure continued access to family planning services. Both the government and private sector must ensure counselling on family planning issues through helplines, telemedicine services, community radios, chatbots and mobile services.
The author is a freelance journalist. The views are personal.