Updated: May 15, 2020 11:32:08 am
Written by Vrishali Shekhar
Preparing and responding to COVID-19, a public health emergency, has strained the already over-stretched health system in India causing severe risk disruptions in the provision of health services, particularly for mothers and children. This could, potentially lead to increase in preventable maternal, newborn and child mortality and morbidity. Experience suggests that Ebola outbreak in 2014-15 created serious interruptions to the availability, uptake, outcomes and demand of maternal and newborn health services in Sierra Leone that consequently resulted in a 34 per cent increase in maternal mortality (MMR) and 24 per cent increase infant mortality (IMR), illustrating a massive health system failure there. Hence, to maintain the trust in the health system, it is imperative that equal thrust be given to continuing the provision of essential health services covering sexual, reproductive, maternal, new-born and child health (SRMNCAH) while countering the COVID pandemic.
India continues to contribute a massive 15 per cent of the global maternal deaths, though they are largely a preventable and treatable. In the event of a nationwide lockdown due to COVID, the restriction of physical movement and social distancing compounded with precious financial and human resources being directed towards tackling the outbreak, as also the fear of contracting the virus, negatively impacts the health-seeking behavior of pregnant women. A recent study on the impact of COVID-19 on the SRMNCAH provision in 132 low and middle income countries indicates that a modest decline of 10 per cent coverage of pregnancy and newborn health care would have serious implications for the lives of women and their newborns that could result in additional 28,000 maternal deaths and 168,000 newborn deaths. Hence assuring pregnant women have access to safe birth and continuum of antenatal and postnatal care during COVID assumes great importance, though it indeed is challenging.
The following could be suggested.
Firstly, pregnant women being more susceptible to viral infection due to immune and anatomic alteration, emphasis, therefore, must be laid on combining the optimization of home visits by ASHA and ANM workers and dedicated teleconsultation and counselling to ensure complication detection early for referral and follow up. Electronic record keeping could help in modifying schedules and giving pre-ANC appointments for reducing crowding and maintaining physical distancing. The UK and US, in response to COVID crisis are expanding their midwifery units and strengthening their telemedicine network. India has also changed the regulatory framework for providing free telemedicine services, and Odisha has already started the same. Primary health centres also need to follow strict COVID protocol in admission control, patient triage based on risk level with particular attention to women with respiratory ailments, isolation wards for pregnant COVID patients, measures counteracting emergencies, and dedicated ambulances to ensure safe institutional deliveries at district/block level apart from PPE for health staff. It is possible to achieve zero infection amongst hospitalized pregnant women as demonstrated by Shenzhen in China, by effective utilization of modified healthcare management strategies during COVID.
Secondly, India already faces a serious health staff shortage, and has much below the WHO benchmark of 22.8 health workers per 10,000 population with high urban-rural and interstate differentials. Increased workload, re-assignment of staff to treat COVID-19 patients and loss of staff due to infection or quarantine, pose serious strain on the capacity to maintain SRMNACH services. Any diversion of skilled providers of maternal and newborn care to COVID-19 response work should be discouraged.
Simultaneously, task sharing with community health workers under regulatory and legal provisions must be explored. E-training mechanisms and capacity building exercises must be undertaken for the additionally requisitioned health workforce to reduce the workload of time-sensitive commitments and non-health work. Importantly, the health workers must also be trained to reduce the risk, stigma and sensitization of pregnant women on COVID-19 symptoms, prevention and hygiene. In order to motivate the health staff, Indonesia, Malaysia and China are incentivizing them with health insurance cover and non-financial incentives such as preferential school admission to their children. This is, of course, apart from ensuring their safety and security for performance of their duties.
Thirdly, the government should look at expanding partnerships with private sector distribution points, such as pharmacies, drug shops and non-traditional outlets (e.g, district kiosks and service centres) that offer modern contraceptives, maternal and newborn life-saving drugs and supplies, maternal health equipment etc in maintaining adequate stocks and ensuring uninterrupted supply of SRMNCAH services . All installments related to schemes like Janani Suraksha Yojana and Pradhan Mantri Mantru Vandana Yojana, and IFA tablets can be given in advance to maintain continuity in maternal nutrition.
Fourthly, in times of psychological and emotional upheavals, it is equally important to remodel the traditional patterns of communication. Substituting personal contact with easily accessible, simplified, virtual communication (for example integrating SRMNCAH information in the widely downloaded Arogya Setu app) and leveraging the community networks and panchayats by conducting multiple workshops for health promotion activities, IEC campaigns, meetings of the Village Health Sanitation and Nutrition Committees/Mahila Arogya Samitis etc should be encouraged. The aim is to deal with behavioral changes for creating demand health-seeking behavior of pregnant, lactating women and caregivers.
Finally, to maintain the provision of SRMNCAH activities, health information systems must be strengthened at the national and local level to promote evidence-based decision making on health indicators, coverage, utilization, disease surveillance, quality service delivery monitoring, reporting, ensuring adequate funds etc. Recognition and reward mechanisms for the best performing teams and health facilities could also be considered.
In conclusion, throughout this crisis, women will continue to become pregnant and give birth, deserving the right to safe maternity services. This includes physical and emotional safety for the mother and baby. Hence, a well-managed system that allows pregnant women to access maternal health care with minimum exposure risk is essential during the outbreak.
Vrishali Shekhar consults with the World Bank on Social Protection, Health and Nutrition issues. The opinion expressed is personal.
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