CORTH Blog: 22 June 2020
Jashodhara Dasgupta
Senior policy advocate, training expert and researcher with over 30 years of experience working on women’s health and rights issues
In a shocking incident in early June, a pregnant woman died in an ambulance in NOIDA after being turned away from a number of private and government hospitals. This raises a chilling question for all of us: if this can happen somewhere close to a nation’s capital, what is happening in the corners of the country, far from the reach of the media? A second question that comes to mind immediately is, when the lockdown was suddenly announced and then extended, what exactly was the plan for the millions of women who are due for childbirth?
Over the last 15 years the state has been promising maternal well-being to pregnant women provided they turn up at public hospitals during labour, and has been providing a cash incentive to those that have institutional birth. Consequently, it has become almost routine for all pregnant women to reach health facilities during labour; the 75th NSSO (2018) estimates barely 10% women give birth at home. Elaborate tracking systems have been instituted by the Ministry of Health and Family Welfare to track every pregnant woman, infant and child until they turn five.
However, during the imposition of lockdown, the state appears to have forgotten those millions of women expected to give birth in the last twelve weeks. Even though coronavirus epidemics like SARS, MERS, Ebola Virus and Zika Virus had identified pregnant women as ‘high risk’ (Hall et al, 2020), the political leadership made no reference to emergency services for pregnant women who would attempt to reach facilities. Frontline workers like ANMs and ASHA workers were pressed into community surveillance, monitoring and awareness building for COVID 19, with less time for tracking the status of pregnant women under their care or arranging ambulances. The public health system was overburdened with handling the pandemic: most secondary and tertiary hospitals are either designated COVID facilities while others are unequipped with enough PPE kits.
The recent news has been providing many glimpses of the fallout of lockdown upon pregnant women and infants. There was the 20-year old in Telegana with anaemia and high blood pressure, who died after being turned away by six hospitals. Similarly, a 25-year old woman in labour coming from a COVID-19 containment area in Delhi, was turned away from at least six hospitals and maternity clinics in the span of 48 hours. She finally gave birth outside All India Institute of Medical Sciences. The Mumbai High Court also issued orders on a case of a pregnant woman who was turned away from four hospitals because she could not produce a COVID-negative certificate, and finally gave birth at home. The media has also reported cases of stigma and paranoia: discrimination against women from the Muslim community as being ‘carriers of the disease’. There have been multiple reports of births taking place on highways as millions of unregistered workers without health coverage or maternity benefits walked out of cities that offered them no social protection.
Innumerable other incidents have possibly gone unreported in the peripheral and rural areas and not made it into national media. These indicate that the pregnant women who needed critical care (15% of the estimated 6 million women giving birth in these twelve weeks would be around 900,000) had to face enormous hurdles to actually obtain treatment at an appropriate hospital. Added to this are the women who have miscarriages or seek abortions: that would be another approximately 45,000 women every single day. Yet the instant cessation of all movement, enforced by a belligerent police force, meant that these women could not access facility-based care. Even as the lockdown eased, pregnant women living within ‘Containment Zones’ where all movement is prohibited, continue to face a similar predicament.
The government rather belatedly issued a set of guidelines a month after lockdown started, but compounded the confusion about emergency admissions. Pregnant women have to be ‘recently’ tested COVID negative to enter a ‘general hospital’ but it is not clear how this can happen once they are in labour, as the test results need a day’s turnaround at the very least.
The health policy makers need to acknowledge the shortcoming of an overstretched under-resourced system in responding to the critical care needs of pregnant women during crises.
Pregnant women who develop complications are usually compelled to turn to private hospitals for Caesarean sections or other procedures (75th NSSO 2018). Although 80% doctors and 64% beds in India are in the private sector, clinics closed down during the pandemic and private hospitals stepped back fearing infections, while larger hospitals began charging exorbitant amounts. The role of the private sector during this pandemic therefore needs to be scrutinised.
India had reduced the Maternal Mortality Ratio comes down to 122 deaths per 100,000 live births (SRS 2017). This is a major shift in a country that expects 48 million pregnancies every year, of which around 25 million end up as live births. Much effort and investment over many years has led to this decrease; but the hard-won gains of the last fifteen years can be erased with one stroke.
The pandemic has amplified many inequalities and shows up sharply the state’s abdication of responsibility for prevention of lives lost, putting the entire responsibility of health protection on the individual citizen. The fundamental question here is: when the state compels people to modify their behaviour through an inducement like a cash incentive, does that not put the onus on the state for ensuring effective systems for maternal care?
In order to win back the trust of pregnant women, the state will have to account publicly for how the millions of deliveries took place; or how abortions, miscarriages and childbirth complications were handled. Improved maternal health was the lynchpin around which public health systems had been strengthened over the last fifteen years. As the country slowly emerges from a total lockdown into a longer-term management strategy, it is time to consider doing things differently for improving maternal well-being.