Parveen, 28, a resident of Lucknow in Uttar Pradesh, was two-and-a-half months pregnant. She was required to undergo an abortion due to her medical condition. When she reached the nearest community health centre after a nine-km bicycle ride, the doctors refused to attend to her because they were on ‘corona-duty’. She was, therefore, had to visit a private nursing home and pay Rs 4,500 for the procedure.
When asked to describe her ordeal, Parveen said she reached the Itaunja community health centre in Lucknow at 1 PM in the scorching heat accompanied by the ASHA (Accredited Social Health Activist) worker from her village.
“There had been minor bleeding for the past two-three days, so I went for abortion with the ASHA worker. They, however, declined to do it saying that all these things are not happening here now,” said Parveen.
When contacted, the ASHA worker, said: “This was Parveen’s third child. When the ANM (Auxiliary Nurse Midwife) had examined her last in March, it came to be known that she was anaemic. Then the lockdown happened, so she couldn’t be examined further or given any medication. Because of this, the foetus got infected.”
Like Parveen, three-month-pregnant Shivani Singh, also from Lucknow, had to walk 2 kms for her pre-natal check-up and vaccination only to be returned from the community health centre saying that all these check-ups have been suspended during the lockdown. They didn’t even examine her, nor was the most important vaccine for tetanus administered to her.
Due to the prevailing lockdown, millions of women like Parveen and Shivani are not getting vaccinated and are unable to go for the pre-natal check-ups. The institutional deliveries in the government hospitals have also decreased during the lockdown. Also, the infants who are being delivered in private hospitals, are not getting vaccinated.
As per the orders of the health ministry, the pre-natal check-ups and vaccination of pregnant women are taking place at primary and community health centres, but when Gaon Connection got in touch with women in Uttar Pradesh, Bihar, Jharkhand, Chhattisgarh, Madhya Pradesh and Rajasthan, it was found that these services were largely ignored during the lockdown.
In a letter to the government after a survey in Rajasthan, Jan Swasthya Abhiyan, an organization advocating public health, wrote that since March alone, more than 2.5 lakh pregnant women have not been provided pre-natal examinations in Rajasthan alone, while four lakh children are deprived of vaccination. The letter seeks to resume vaccination and pre-natal checks at the village level at the soonest.
In Bihar, the state health committee has written to the government about the deteriorating state of severe malnutrition and death among children, and urged the government to streamline and strengthen maternal health services during the coronavirus lockdown in the state.
Dr Yogesh, the superintendent of the community health centre at Itaunja, Lucknow where Shivani Singh and Parveen had come for treatment, informed: “Vaccination and pre-natal checks remain suspended. Only those 10 per cent of the patients who are gravely ill, are coming to the hospital. Earlier, 700-800 patients visited us daily whereas only 40-50 are coming now. Delivery cases are going on continuously. From April 1 to April 17, 105 deliveries have taken place in the hospital.”
Pregnant women, children and parents as well as health workers are justifiably worried because the rising casualties in India support the widespread anxiety. According to the Website of Pradhan Mantri Safal Matritva Abhiyan, about 44,000 women die every year due to pregnancy-related complications whereas 6.6 lakh children die within 28 days of birth.
To prevent these deaths, Prime Minister Narendra Modi had launched the Pradhan Mantri Surakshit Matritva Abhiyan on July 31, 2016. Under this campaign, on the ninth of every month, all the matters related to the safe deliveries of pregnant women in each state are taken up to curtail the maternal mortality rate. But the campaign is on standstill which is preventing pre-natal check-ups, and vaccination among pregnant women and children.
The Universal Immunization Programme (UIP) being run for vaccination of children and women in India is considered to be the largest public health initiative in the world. The programme seeks to provide health services to three crore pregnant women and 2.67 crore newborns annually. Each year, over 90 lakh sessions are undertaken and the Indian government provides 12 essential vaccinations against diptheria, pertussis, tetanus, polio and measeles, free of cost, across the country.
Neelmani, who works at the Piramal Foundation, a grassroots health institution in Bihar and Jharkhand, said: “All the pre-natal check-ups are suspended due to the lockdown. The children who are currently being delivered at home or in a private hospital are not able to be vaccinated for BCG (TB vaccine at birth), which is to be taken immediately after birth. The impact will not be immediate, but there may be difficulties for these children and mothers in the coming time.”
She added: “In Bihar, pre-natal check-ups and institutional deliveries have now gone down by about 50 per cent. Fifty per cent of women are anaemic so their state may deteriorate in the absence of regular check-ups. The Village Health Nutrition Day (VHND), which was observed every month in the village, is also completely ignored. The condition of community and primary health centres is anyway bad. According to the government, these tests are going on, but, in reality, they aren’t.”
In a letter issued by the Bihar State Health Committee on April 17, the pre-natal check-up facility has declined by 50 per cent and institutional deliveries by 48 per cent. The letter seeks these health services to be put to order again. The pre-natal care for pregnant women is essential because only 30.3 per cent of Indian women consume iron and folic acid tablets for 100 days or more. Due to this, 50.3 per cent of pregnant women and 58.4 per cent of children are anaemic. These deficiencies are the main reason behind maternal mortality rate and infant mortality rate at birth.
Talking about the decline in pre-natal check-ups and institutional deliveries in Bihar, Rahul Kumar, the district magistrate of Purniya district, said: “These facilities were temporarily withheld to prevent the infection of COVID-19 for a few days in the beginning, but have recently been resumed. Women are still avoiding coming to the hospital because of fear. We have now put up a private ambulance at every primary health centre so that women do not have any difficulty in coming to the hospital during the lockdown.”
As per the district magistrate, 2,511 deliveries have happened between March 25 to April 7 in the Purya district, which he admitted were lower than the usual.
When asked about the ill-effects of not conducting pre-natal checkups, Dr Usha Kumar, a gynaecologist, said: “No checkups are very dangerous for both, the mother, and the child. A delay of a couple of months in vaccination won’t make any significant difference, but the initial three months of check-ups and ultrasound are very important. During the nine months, all the tests and ultrasound are required to be done monthly,” Dr Usha is a senior consultant at Max Hospital in Delhi, which has undertaken the task of regularly monitoring pregnant women with the help of tele-consultants and video conferencing.
A survey of 30 tribal villages was conducted by the ‘Jan Swasthya Abhiyan’ during the lockdown in Pratapgarh district of Rajasthan in which 150 pregnant women were found to be deprived of the prenatal check-ups, and about 250 children of vaccination.
Chhaya Patchuli, a member of the campaign, who works in Pratapgarh district of Rajasthan, informed: “In Rajasthan, all the health activities at the village level were stopped even before the lockdown in Rajasthan. According to the government, all these facilities are going on at all health centres. Had the women in the rural areas been so aware, the government would not need to celebrate the maternal, child health and nutrition day at the village level with the help of ASHAs and ANMs every month.”
In Rajasthan, a Maternal Child Health and Nutrition day (MCHN) is observed at Anganwadi centres once a month in every village at the rural level to continuously review the pre-natal check-ups and vaccination of women. The activity is presently suspended due to the lockdown.
Rohit Kumar Singh, the additional chief secretary, Department of Medical and Health, Rajasthan, said: “We have not stopped any service related to pregnant women. Everything is going on as before.”
When Gaon Connection spoke to the ANM working in a remote village in the Pratapgarh district, she said on the condition of anonymity: “Vaccination and checkups are still not happening at the community health centre as well as the primary health centre. These pregnant women are at risk due to coronavirus, so no risk is being taken. There are 15 pregnant women in our area which need to be checked up.”
She added: “We are at a distance of 25 kilometres from the primary health centre and the district hospital. There is no mode of transportation now and the ambulance will not take pregnant women for check-ups.”
Naresh Kumar Thakral, the mission director at the National Health Mission, Rajasthan, said, “All the labour rooms that are there in all the district hospitals and special mother and child hospitals, there has been no effect on these services. Primary and community health centres are all undertaking necessary check-up and vaccinations. Only the OPDs have been curtailed.”
Recently, the husband of a Muslim woman alleged that the government hospital in Bharatpur district of Rajasthan did not admit his wife to the hospital under the suspicion of her being associated with the jamaatis. The woman gave birth to the child in an ambulance. The child died a little later.
“At present, the condition of health centres has further deteriorated. No patient other than those who are corona-infected are being taken care of by the health department. There is a demand from our government that this service should not be resumed at the village level at the earliest by following social distancing, otherwise, the situation will become very serious in the coming time,” said Chhaya Pachauli.
Savita Sharma, an ASHA worker posted in the village of Eintkhedi in Bhopal, said: “The ambulance is not coming even for the delivery of pregnant women. In our area, two deliveries have taken place at home within the last three days as the ambulance did not come to take them to the hospital. We are not aware of anything about their pregnancy due to the lack of pre-natal check-ups. Which woman is anaemic? Who is at high risk? No problem occurring during pregnancy is being known.”
Although the Madhya Pradesh government had ordered all regular health facilities to run as before, it had already deputed all responsible officers of these facilities on COVID-19 duty. Besides Pallavi Jain Govil, the principal Secretary, Department of Health, more than 50 people of the health department are infected with coronavirus. About 200 people of the health department have been quarantined. A nurse, a doctor and a police officer, have already died of this infection.
Amulya Nidhi, the national co-convener of the public health campaign in Madhya Pradesh, said: “The state’s condition is not hidden from anyone. In such circumstances, it is very difficult to ensure regular check-ups and vaccination of pregnant women for there is already a load of work on the ASHAs. Several officials associated with the health department are in the grip of this infection. Normal death has also increased. How the situation would improve remains a matter yet unresolved.”
Meanwhile, the nation has already witnessed one whole month of lockdown. Only a handful of essential services are operational to avoid the spread of coronavirus infection. Most of the private hospitals are also closed due to which the load on government hospitals has further increased. Talking to several states, it was established that smooth vaccination and pre-natal check-ups should be started at the earliest by following social distancing to protect pregnant women and newborns from health risks.
“Vaccination and pre-natal checks have been gravely disturbed due to lockdown in Chhattisgarh. Vaccination has started ten days ago but the check ups are still not taking off. At present, the entire system is engaged in COVID-19, pre-natal check-up of women is not being taken seriously. The number of arrivals of these women at district hospitals and community centres has gone down substantially due to lack of transport facilities,” said Sulakshna Nandi, national co-convener of Jan Swasthya Abhiyan, about the situation in Chhattisgarh.
Dr Maheshwar Prasad, civil surgeon, Jamshedpur, Jharkhand said: “Although the check-ups are going on in our district, fewer people are coming due to the fear of coronavirus infection.”
Sahiya Saathi Bhasha Sharma, who works at the village level with pregnant women, said: “A week before vaccination has started only a week ago. The centres at the village level will start checkups from April 27.”
Kusum Singh, an ASHA worker from Atesuva village in Uttar Pradeh took Gaon Connection to the homes of eight-ten pregnant women in her village whose checkups and vaccinations were not done due to lockdown. The four-month-pregnant Sarita Devi, 20, was sitting in the courtyard of the house. She said: “Initially, I had been to my mother’s house so there was no checkup and vaccination done and when I returned, the lockdown had happened.”
“With no check-up, we are not able to know anything about their blood pressure, sugar or hemoglobin level. In the absence of check-ups, we are not able to know about their probable high risk or the condition of the child inside,” said Kusum Singh.
Uttar Pradesh is second in the country in terms of maternal mortality rate — out of one lakh women, 258 die. Uttar Pradesh ranks first in the entire country in terms of infant mortality rate. Out of 1,000, 32 infants die at birth across the country, in Uttar Pradesh, the death is double, 64.
Meanwhile, in the sultry heat of the day, Shivani was sitting and waiting with her mother-in-law outside the community health centre for about 1.5 hours. Shivani’s mother-in-law said: “She is not eating anything now. If only doctor sees her once and gives some medicine, she would at least be able to have something. This being her first pregnancy, she is bit worried for there hasn’t been any check-up so far.”
Pregnant women have to be checked for the following during nine months. The first three months are very crucial for any pregnant woman as per Dr Usha. All blood tests such as HIV, blood sugar, thyroid should be done during this time. Ultrasound at this time shows whether the child is in the tube or not.
In the fifth month, there is a second ultrasound that shows the child’s body parts and its mental development. The first tetanus vaccine should be taken in three months and the other in the fifth month. There should be a blood sugar test in 26 weeks to find out the possibility of diabetes in the child and mother. In 8.5 months, there is another ultrasound that shows what position the foetus is in and complications if there are any. Routine checkups must be done after every three months.
