In India, Coronavirus Is Taking a Toll on Pregnant Women

On May 26, Mandya Institute of Medical Sciences Hospital, near Bangalore in southern India, allegedly denied admission to a 24-year-old woman, Sonu, who was 29 weeks pregnant, pending a COVID-19 test. She later delivered a premature stillborn baby.

Sonu has survived, though she will need months to heal, physically and emotionally.

With the abrupt lockdown that started in March 2020, India’s health care system started to prioritize services for COVID-19 over other pressing health issues. This sudden change in policy dramatically affected the pregnancy experience of nearly 25 million women in the country. Experts fear that lack of maternity services could aggravate India’s already high maternal mortality rate (113 per 1,00,000 live births) and under-5 child mortality rate (37 per 1,000 live births).

Several hospitals in India stand accused of turning away pregnant women at the time of delivery because of fears of exposure to coronavirus, even though the pandemic guidelines issued by the government in April 2020 clearly state that health care centers have to provide maternity services without seeking a COVID test.

The guidelines were issued after many pregnant women died in labor after being denied admission during the lockdown. Small hospitals and nursing homes remained shut for months due to an acute shortage of safety gear and N95 masks.

Although India has ramped up its medical infrastructure, the massive second wave of the pandemic, which began in March of this year, has overwhelmed hospitals. The official COVID-19 death toll is more than 363,000, but actual numbers could be much higher. Women are very worried.

Dr. Anant Bhan, a researcher of bioethics and global health policy, and adjunct professor at Yenepoya University in Mangalore, says, “There is now adequate data which shows access to maternal health care has been impacted negatively during the pandemic. With many facilities being converted to COVID-care facilities only, and requirements around COVID negativity for accessing care, especially for delivery, many pregnant women have been unable to receive timely care. This can have implications for the health of these women and their babies.”

In March 2021, UNICEF released a report that estimated that disruptions of essential health services across South Asia due to COVID-19 may have contributed to 11,000 more maternal deaths in 2020 than the 57,000 maternal deaths recorded in 2019. In India, where 80 percent of the South Asian population resides, these disruptions played out in many ways.

At least eight prenatal checkups, a tetanus vaccination, one ultrasound before 24 weeks of pregnancy, and a daily intake of iron and folic acid supplements are recommended for a healthy pregnancy outcome, according to the World Health Organization.

However, pregnant women have faced inability to access health care and reduced mobility due to discontinuation of public transportation. Community transmission of COVID in many areas resulted in infections of pregnant women as well.

Indian doctors have observed a greater need for high oxygen ventilation for COVID-positive pregnant women, a need for more surgeries to prematurely deliver babies, and a higher incidence of miscarriage.

“Many expecting mothers avoid visiting their gynecologists for routine pregnancy check-ups,” says Dr. Shailesh Mohite, medical superintendent of BYL Nair Hospital in Mumbai, which has so far assisted deliveries for more than 1,000 COVID-positive mothers. “The stress of catching the infection at home or hospital and keeping the newborn safe is quite high among already stressed pregnant women and new mothers.”

The pandemic’s impact on maternal health has been felt globally. According to a review of 95 studies globally published in January in BMC Reproductive Health by Bethany Cotlar of the Harvard T.H. Chan School of Public Health, “Prenatal care visits decreased, healthcare infrastructure was strained, and potentially harmful policies were implemented with little evidence” in high-income as well as low- and middle-income countries. Cotlar’s review also noted a high frequency of maternal mental health problems, such as anxiety and depression, during the epidemic in many countries.

A quarter of women of reproductive age in India are undernourished, says a UNICEF report, and a significant population relies on the government health care system, which provides supplements such as iron and calcium to pregnant women as a part of prenatal care. Many states offer food as well to expecting mothers in areas where malnutrition is high. “These services are crucial for undernourished mothers, as severe anemia during pregnancy increases the risk of premature births that can severely impact a child's growth,” according to Latika Rajput, an activist who advocates for the rights of people who have been affected by the Sardar Sarovar Dam project in the Nandurbar district of Maharashtra. “But lockdown restrictions disrupted these services, forcing a large number of rural and tribal women to rely on staple food only,” she says.

Women who contract COVID-19 during pregnancy are over 50% more likely to experience complications such as premature birth and pre-eclampsia, more likely to require intensive care, and at higher risk of death, said an INTERCOVID study in the journal JAMA Pediatrics published in April 2021.

Dr. Dimple Arora, a Delhi-based dentist and a mother of a 3-year-old, died due to COVID-19 in April late in her pregnancy.

Scores of pregnant women have reportedly died of the coronavirus, according to media reports and social media mentions, but no official data is available in this regard so far. The situation is likely to be worse in rural areas, where COVID mortality is high and good health care services are fewer.

Lack of sensitivity by government officials has also taken a few expecting mothers’ lives. Kalyani Agrahari, 27, a teacher in a village in the Jaunpur district of the northern state Uttar Pradesh, for instance, was forced to do duty as an election worker in mid-April at the peak of the pandemic, although she pleaded with the education department that she was eight months pregnant. Fifteen days later, she died of COVID before the baby was delivered.

The government of India began its vaccination program in mid-January, but it has been running at a slow pace due to a shortage of vaccines; less than 15 percent of the population has received one jab so far. Nevertheless, immunization wasn't an option for Dr. Arora or Agrahari, as the government did not approve the vaccine for pregnant women in India until Friday. The delay in making them available has left women high and dry.

The Indian Council of Medical Research (ICMR) has released data suggesting that the case fatality rate among pregnant and postpartum women in the second wave of the pandemic (February to mid-May2021) was 5.7% (22 of 387) compared to 0.7% (8 out of 1,143) in the first wave (April 2020 to January 2021). “The study underlines the importance of vaccination of pregnant and lactating women against COVID-19,” the ICMR stated.

Dr. Sudhir Naik, gynecologist and director of Shri Guru Maternity and Children’s Nursing Home in Mumbai, says, “The second wave is on decline, but the government must ramp up vaccination and include pregnant women as well so that we can face the third wave in a better way.”