Pregnant during COVID-19: Expecting mothers left in the lurch by India's healthcare system as tackling pandemic takes priority

Neelam, 30, in her eighth month of pregnancy breathed her last after being turned away from hospitals in Noida on Friday, 5 June, according to news reports.

She showed COVID-19 symptoms and came from the containment zone of Khoda. Her family travelled around Noida by auto and then ambulance to eight hospitals who refused to treat Neelam. Thirteen hours later, she died in the ambulance.

Neelam isn’t the first pregnant woman whose death wasn’t a direct result of COVID-19, and she won’t be the last. Her case reveals the deep cracks in India’s healthcare facilities which are failing pregnant women.

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The pressure on the healthcare system due to the pandemic, India’s lockdown and lack of clear guidelines have caused severe disruptions in access to maternal healthcare and antenatal services. The critical procedures affected include routine check-ups, scans, institutional deliveries and follow-ups -- which may lead to the increased suffering and eventual deaths of pregnant women.

Experts are concerned that the pandemic will result in a huge setback for India’s strides towards equitable maternal health, and may cause a spike in maternal mortality and morbidity rates.

“Maternal morbidity and mortality will see an increase, however, it’s hard to estimate by how much at this point due to the lack of data,” said Dr Samiksha Singh, assistant professor, Indian Institute of Public Health. “However, there is a definite barrier in accessing healthcare as we see the reduction in antenatal check-ups and deliveries at hospitals.”

Challenges for pregnant women in India during the COVID-19 pandemic. Image courtesy Wikimedia Commons

Even as early as March, during the early stages of the pandemic, institutional births declined as unattended home births increased, according to reports. Data collection, reporting and monitoring have all been severely hampered by the lockdown, and so there is an incomplete picture of the exact extent of the problem which pregnant women have faced.

Job Zachariah, chief of field operations in Chhattisgarh, UNICEF noted that home deliveries may have risen to 10 times the normal. Field assessments in the state revealed that even in the initial stages of lockdown institutional delivery dropped significantly with just 2,813 births in March 2020, as against 37,630 in February 2020.

Over 79 percent of all deliveries are institutional deliveries in India, according to the National Family Health Survey (NFHS) 2015-16.

“This number may reduce in the coming months as people are afraid of contracting COVID-19 in hospitals on the one hand, and women aren’t able to access antenatal services on the other,” he said. Zachariah noted that home deliveries aren’t a problem per se, but in case of complications lack of medical intervention can be fatal for both mother and child.

India reduced its maternal mortality ratio (MMR) by 77 percent, from 556 per 1,00,000 live births in 1990 to 130 per 1,00,000 live births in 2016. India’s success in providing maternity care is thanks to several schemes and programmes, including the Pradhan Mantri Surakshit Matritva Abhiyan (PMSMA) launched in 2016. Several states have their own schemes to address various aspects of maternal care.

“All women are at equal risk when pregnant and hence need to go to the hospital regularly,” Singh said.“Many high-risk cases deliver normally and many normal cases end up becoming high-risk at the delivery table.”

The writer reached out to the Ministry of Health and Family Welfare office for a comment. The story will be updated when we have a reply.

The WHO recommends at least four antenatal care check-ups (ANC) for pregnant women in the age group of 14-49. In India, only 51 percent of that category had four or more ANC visits according to NFHS. ANC visits help doctors and midwives identify high-risk cases, monitor nutrition, and administer preventive care like tetanus shots and prescribing iron and folic acid tablets.

Every 20 minutes an Indian woman dies of pregnancy or childbirth-related complications, according to UNICEF. While India has made significant progress in curtailing maternal mortality, it still saw around 30,000 such deaths in 2017. Nearly 20-30 percent of all the country’s pregnancies are high-risk, leading to 70-80 percent of perinatal mortality and morbidity, according to India’s National Health Portal.

Ria (name changed), 31, from Chennai had a high-risk pregnancy due to a complicated medical history. She was still in her first trimester when the COVID-19 lockdown began on 24 March. She knew it was imperative she sees an OB-GYN who can monitor her precarious health and that of her baby. But through the two months of her pregnancy, coinciding with the lockdown, getting a doctor’s appointment became impossible.

Ria’s attempts at organising in-person check-ups with half-a-dozen doctors including obstetrics-gynaecologists (OB-GYN), her neurologists, and a general physician were unsuccessful. Since this was her first pregnancy, her excitement was tempered by anxiety.

“I have a high risk of clotting, and this could be harmful for me and the baby. I wanted to know how to manage this,” Ria said in April.

Just before the lockdown began to be lifted in June, Ria, who was now 11 weeks into her pregnancy, learnt that the fetus had had no heartbeat for at least three weeks. But she hadn’t been able to visit a doctor in that period. The doctor then advised a routine abortion pill, but her situation quickly turned critical when she lost a lot of blood, passed out in her room, and was rushed to the hospital.

“They knew my health problems. I saw five doctors but it felt like nobody really cared, they weren’t seeing my reports properly. Nobody was studying my case well,” she recalled.

Doctors explained that the lockdown made it difficult for them to take on new cases while following physical distancing norms. Since consultations were on only for a few days every week there was often overcrowding.

Struggles of pregnant women in this pandemic are varied and cut across class, caste and geography, as Neelam and Ria’s case show. In rural areas, and particularly for migrant workers returning home, the lack of access to maternal healthcare can be nightmarish.

Hemant, 42, witnessed a “highway delivery” in Betul district, Madhya Pradesh on the night of 6 May. The taxi driver came across a large group of migrant workers walking towards Bihar and saw that some of them were flagging the few vehicles passing by for help.

“One of the women walking from Maharashtra to Bihar was nearly eight months pregnant. She went into labour in the middle of the night,” he recalled. He made calls for an ambulance but was told they were on COVID-19 duty. He then dropped her to the nearest hospital, he said. A month on, Hemant still considers it the worst incident he has witnessed in his life.

Several more cases of migrant pregnant women going into labour were reported from central India in April and May.

“Ambulance services aren’t available in many rural areas where hospitals are generally far from villages. Moreover, villagers are using logs of wood to block access as they are afraid of COVID-19,” Zachariah said.

The Indian government’s pandemic advice in March had asked pregnant women, children and elderly to remain indoors. Singh said this led to fear and misunderstanding among people as they perceived precautions against COVID-19 to be more important than their pregnancies.

The Ministry of Health and Family Welfare guidelines declaring maternal health services as essential came only on 13 April, in the third week of the lockdown. But by then the damage had been done for many expecting mothers.

Dr Keerthana Ashwin, an OB-GYN from Chennai had to deliver disturbing news to patients just as access to maternal healthcare and scanning facilities re-opened in late April.

“Due to the lockdown, a lot of my patients missed their scans done in the 16-18th week of pregnancy to determine any anomaly in the fetus,” she said. “One of my patients will have to carry her pregnancy to term, even though the fetus has a heart defect. We found it too late, she was past the legal abortion limit of 20 weeks.”

Even a woman being unable to access family planning services can result in a spike in pregnancies and maternal deaths. Foundation for Reproductive Health Services India (FRHS), a Delhi-based non-governmental organisation, noted in their May 2020 policy brief that the lack of access to contraceptives will result in 2.38 million unintended pregnancies, 679,864 live births, 1.45 million abortions (including 834,042 unsafe abortions) and 1,743 maternal deaths.

Singh is concerned that this isn’t a temporary setback, but one whose consequences will last for years to come. “All our schemes for reducing maternal mortality and providing healthcare for pregnant women everywhere have already suffered. From antenatal care to nutrition, weight monitoring to immunisation -- every aspect of maternal and child health care has taken a hit,” she explained.

The author is an independent journalist based in Bengaluru. She tweets at @theplainjain.