How will maternal and child health be affected by COVID-19?

In times of COVID-19, other health issues have been put on a back-burner. The lockdown has affected many essential health services, maternal and child health (MCH) services being one of them. Neglect of MCH services can lead to the possible rise in morbidity and mortality among mothers and children. This impact will be exacerbated among underprivileged women and children, who have constrained access to health services, even under non-pandemic conditions. Health care accessibility, morbidity and mortality patterns among women and children need to be studied from previous epidemics, for the effective management of MCH.

It is necessary to understand that while COVID-19 already puts maternal and child health at risk due to their weak immune systems, its indirect impact could be even more serious. There have been reports about increase in cases of domestic violence towards women and possibly even children, since the lockdown began. It is important to have data on MCH during and after the pandemic, so that the health system can be prepared for such incidents in the future. The focus should be on capacity building of health systems and rationally using the available health resources. Maternal Mortality Ratio and Infant Mortality Rates are indicators of a country’s overall development and the strength of its health system. If MMR and IMR increase, it is going to add even more pressure to India’s public health system, post-COVID-19. Hence, it is imperative that essential health services for women and children be continued.

Accessing MCH services:

Pregnancy is a condition where timely care is required, for both mother and baby to be healthy. Pregnant women living in COVID-19 hotspots are affected the most, as movements are severely restricted. Even if there are nursing homes in the vicinity, transport may not be easily available in the lockdown conditions. There is also a high possibility of pregnant women’s mental health getting affected due to misinformation and fear mongering. This may prevent women from seeking antenatal check-ups.

Women belonging to socio-economically disadvantaged groups are mostly dependent on ASHAs for reliable information and guidance through their pregnancy phase.  Among many other duties, ASHAs are responsible for counselling women on birth preparedness, ensuring they have institutional deliveries by taking them for antenatal visits, monitoring feeding practices and immunisation schedule of children. However, the pandemic has led to the diversion of these frontline workers from their usual roles to surveillance and contact tracing for COVID-19. Thus, the reach of ASHAs to pregnant women living in rural areas and poor urban pockets is compromised.

Another concern is about nutrition. In times of lockdown, women who by themselves or whose families depend on daily wages, may not be able to obtain nutritious meals, impacting their health.  As nutrition will be affected for pregnant women, so will it be for infants and children. Many children are dependent on the meals they get at Anganwadis and schools through Mid-day Meal program, but their closure may increase the burden on poor families to feed their children. Anganwadi workers have been asked to deliver rations and meals to the houses of children. However, as is the case with ASHAs, AWWs are also entrusted with COVID-19 duties and this may come in the way of delivering meals to the beneficiaries.

The Government has suspended services under Pradhan Mantri Surakshit Matritva Abhiyan –  a scheme that guarantees a minimum package of antenatal care services to women in their 2nd/3rd trimesters of pregnancy at designated government health facilities. With the suspension of these services, the health of pregnant women and their unborn babies is bound to be affected. Even though, private hospitals can be approached through Pradhan Mantri Jan Arogya Yojana, there is a shortage of ASHAs who generally guide women towards utilisation of these services. The Government has also recommended the suspension or lessening of immunisation services. Pregnant women and infants are always considered to be high-risk groups for any kind of health threat, due to their weak immune systems. With the reach of immunisation limited, the risk of other diseases will increase, for infants and pregnant women.

How was maternal health affected during other outbreaks?

When Ebola broke out in West Africa, a rise in Maternal Mortality Ratio (MMR) was observed during and after the epidemic. This was mainly due to women not able to access health facilities and misconceptions about the spread of the virus. As a result, many of the women were forced into giving births at home, wherein the hygiene and safe practices were compromised. The vaccination schedules were also affected, which lowered the immunity of pregnant women. Lessons need to be taken on how misconceptions arising out of fake information or lack of information need to be addressed.

In the case of SARS and MERS outbreaks, pregnant women who were affected by these diseases had severe pregnancy outcomes such as miscarriage, premature delivery, intrauterine growth retardation. While there have been no such cases till now, in pregnant women affected by COVID-19, the possibilities should not be ignored as SARS and MERS viruses belong to the same genus as COVID-19. Fortunately, in all of the coronavirus diseases mentioned, there has been no evidence of vertical transmission through breastmilk, placenta or amniotic fluid. However, there are chances of transmission post the delivery. Hence, utmost post-partum care should be taken.

What could be the possible solutions?

First and foremost, it is essential that maternal and child health services be continued. It is understandable that COVID-19 has to be given priority, but health resources should be used rationally so that other essential health services are not halted. Since there is a lack of evidence on how exactly COVID-19 affects pregnancy outcomes, pregnant women should be constantly monitored. Pregnancy wards and COVID-19 wards should be located away from each other. If not needed, C-section surgery should be avoided, as surgery adds to the risk of infection. When a COVID-19 positive patient gives birth, the baby should be kept away from her for at least 14 days, to monitor for symptoms.

Some foundations have started with virtual clinics for pregnant women, wherein gynaecologists counsel on birth preparedness and give medical advice as much as possible. State governments could provide funds to NGOs, to expand such services, thereby reducing the burden on the health system. They should also hire more frontline workers, to fill up the already existing vacancies and ensure all of them have sufficient PPEs, which will help them to distribute the workload evenly and enable them to deliver the MCH services effectively. A real time dashboard could be designed to understand how many frontline workers are deployed and which areas need more workers. ASHAs should prepare a schedule for all the pregnant women in the area, to identify suitable appointment times with the registered primary health centres, which will avoid crowding at the PHCs and ensure all of them receive antenatal care.