“These days (lockdown period), the pregnant women in the village are neither receiving food from Anganwadi nor any vaccination. Even Anganwadi workers (AWWs) and Sahiyas (ASHA) are scared to do home visits as they haven’t received masks and sanitizers. Forget about government ambulances, because of the lockdown, it is difficult to get private vehicles for pregnant women or any other important work,” said Ramiya1Name changed for purposes of confidentiality, who works as a Sahiya herself in Ranchi district of Jharkhand, in an interaction over the phone.
She further shares about the challenges she faces regarding her role in the community, “I became a Sahiya recently. Initially in my training, I was asked to give more attention to pregnant women, their regular check-ups, vaccinations, etc. Now, a few days ago, we were suddenly called for a block level meeting with senior medical officers. We were asked to visit the homes of people, mainly labourers who came back from Uttar Pradesh, Bihar and, Kerala before and after the lockdown was announced. Many of them came with the help of truck drivers. Now we need to visit their houses and inform the ANMs (Auxiliary Nurse Midwives) about them. We were asked to take the workers to the referral hospital for identification and screening. In the midst of all this, follow-up on pregnant women for their regular check-ups has clearly been sidelined.”
In the context of COVID-19, the health system response with regard to the essential services for women’s health care have been weakened. The situation of lockdown has raised serious concerns about ensuring safe, timely and quality maternal health care at the community level. Discontinuation of ANC care, barriers in accessing institutional facility for delivery care, among many more, are immediate issues that are being reported at the community level. The suspension of transport facilities and non-availability of ambulances is posing risks to the health and lives of pregnant women, along with various other barriers induced by lockdown.
A community level activist highlighted this aspect based on the experience of a pregnant woman from Ranchi. Rajani2Name changed for purposes of confidentiality, who is an activist in the community engaged with issues of women’s health and rights, shared over the phone:
“I came to know about a pregnant woman in a village some 12 km from the block headquarter. She along with her family struggled a lot to get delivery care in time, and in the end they lost their child. The woman had reported labour pains early in the morning. But she and her family were not able to arrange a vehicle to reach the Referral Hospital located in the block headquarter. She reached the block referral hospital at 9 am bleeding heavily. She was then asked to go to Sadar hospital in Ranchi. Somehow she was sent to the Sadar hospital of Ranchi. The doctor at Sadar hospital felt her case was of high risk and that she needed to be treated at the Rajendra Institute of Medical Sciences (RIMS) hospital. She had to then travel from Sadar to RIMS in that condition. In the course of this journey, she lost a lot of blood. I came to know that she finally reached the RIMS hospital at 3:30 pm, but she lost her child during the child birth.” Rajani, reflecting on what had transpired, concluded this experience with a very pertinent question – “Now who will take responsibility of this (loss of a child)?”
The impact of the lockdown on the health and lives of women in need of maternal health care needs to be considered seriously to address the significant additional barriers in the health system. Marginalising maternal health and other reproductive and sexual health concerns in the wake of another public health issue, i.e. COVID 19, is counter-intuitive as it inevitably leads to adverse health outcomes for girls and women, particularly those from marginalized communities. Even in a crisis situation such as the present, the government is expected to be particularly meticulous in planning and ensuring preparedness of all essential health services. While the health system response to COVID is imperative, access to these services that are urgent must not be ignored or suspended so as to prevent a parallel health disaster.
Such experiences are also being reported from other states and locations where Sama works.
“Everything is in the hands of God (Sab Bhagwaan bharose hai)!” is what Meethi3Name changed for purposes of confidentiality from Pratapgarh district in Uttar Pradesh (UP) who gave birth to a girl ten days ago, lamented to a local health activist when asked how things were. She had approached the nearby public hospital for the delivery. She was turned away as the hospital was being prepared for COVID-19. She had no option but to go to a private nursing home.
“I had gone to the hospital for delivery but they asked me to go back; they said it was risky to deliver there as it was meant for COVID patients. For the delivery in the private clinic, they charged me Rs. 10,000. I had to take a loan with a high interest rate”.
Meethi belongs to a Dalit (schedule caste) community in UP; her husband used to work as a daily wage labourer in Varanasi, which is not far from her village. He had to return home two weeks ago due to the COVID-19 lockdown and has been without any work or income since then. She is distressed and uncertain about how she is going to manage her household in the absence of income and depleting food reserves at home on the one hand, and the addition of a new member to the family on the other.
The deep-seated inequalities and impoverishments based on caste, class, religion, gender, etc., become more evident in times of crisis. As a migrant woman worker emphasized while narrating her experience:
“Due to Coronavirus and the sudden lockdown announcement on 24th March (Tuesday), the factory owner immediately shut down the factories. He asked us to leave without paying us our wages. Because of no alternative available for us to stay, we started to walk along the railway tracks with our two-year-old child in our arms. Except God, nobody helped us on our way.”4Translated from Hindi to English from the news article here.
She was in the seventh month of her pregnancy and covered over 1,000 km on foot to reach her hometown to cope with the distress caused by the pandemic and the lockdown.
Such incidents reflect how existing vulnerabilities increase the distress especially marginalised women when additional restrictions are imposed on their lives without forethought, preparedness and accountability of the state. Maternal health care is particularly critical for women from these communities and must include antenatal care (ANC), delivery, postnatal care (PNC), access to contraception, comprehensive abortion care, services for those experiencing domestic and other forms of violence, etc. Maternal health care also necessitates access to food/ nutrition, maternal entitlements through schemes such as JSY/JSSK, etc. While several gaps in universal fulfillment of these entitlements have been reported time and again, in the context of the social and economic impact of public health crisis such as the current pandemic, health care and allied services must be ensured without exception.
Rendering maternal health and other SRH concerns as a ‘lesser priority area’ in the haste to manage the pandemic, are likely to have far-reaching negative health consequences. Maternal health services as well as other SRH care must be recognized as essential services and uncompromised access to them should be a part of the response to the pandemic. The States must guarantee access to timely, quality and free health care for a range of SRH issues even in the context of COVID-19 and lockdown.
This blog reflects the ground realities with regard to maternal health that have been documented through interactions with the community activists/women, community health care workers / ASHAs during the lockdown period.