Lockdown locks down sexual and reproductive healthcare in India

The lockdown deprived Indian women of access to reproductive healthcare services (MIG photos/Richa Nigam)

Millions of women in India will pay a rather heavy price as they were denied access to sexual and reproductive healthcare during lockdown. Situation is far from normal even now.

The three month long nationwide lockdown brought with it problems and inconveniences for people from different socio-economic background. However, for nearly two million women in India, it turned out to be a menace as they were left to fend for themselves while dealing with unplanned or unwanted pregnancy.

According to recent research by Ipas Development Foundation (IDF), due to the lockdown, over 1.85 million abortions in India are likely to be ‘compromised’ by Covid-19. That represents nearly 12 pc of an estimated 15.6 million that are carried out in India every year. IDF is an international NGO working in providing reproductive and sexual healthcare access to women.

IDF says that the 1.85 million abortions are likely to be compromised due to several issues linked to the lockdown. These include mobility restrictions, redeployment of health facilities and staff for COVID-19 care, closure of private clinics/hospitals, suspension of public transport and disruption of supply chain of drugs.

The Foundation for Reproductive Health Services India (FRHS India), an affiliate of Marie Stopes International (MSI) that provides women and girls personalised contraception and safe abortion services in 37 countries, is the largest non-governmental provider of clinical contraception in India.

It estimates that the disruption of services, despite being medical and thus exempt from lockdown rules, was extremely serious. ‘‘The non-availability of reproductive health care services during the pandemic was quite serious, especially from late March to end of May 2020 and the clients served for the quarter April-June 2020 fell by 88 pc compared to the same period in 2019. The drop in March 2020 was 25 pc and during April and May almost 99 pc. Since the lockdown began and till May 31, we were able to provide services to only 10,978 clients against a planned 47,387, in other words 77 pc or 36,407 were not able to access our services. And this is just the data about our organisation. The situation with other NGOs, private sector and public sector was more or less similar,’’ VS Chandrashekar, CEO, FRHS India tells Media India Group.

Even though the nationwide lockdown has been eased in phases since June, the situation of access to reproductive healthcare remains alarming across the nation. Lockdowns, travel restrictions, supply chain disruptions, the huge shift of health resources to combat COVID-19 and fear of infection continue to prevent many women and girls from care. FRHS India says that since June, it has seen some improvement with NGOs, government and private providers resuming service provision. ‘‘However, the pace of resumption is slow and not uniform across districts. Our services were down 50 pc in June; 26 pc in July and estimated 25 pc in August when compared to the same period in 2019. Among the three states we work, Bihar, Rajasthan and Uttar Pradesh, resumption has been maximum in Rajasthan, followed by Bihar, while UP continues to be an issue,’’ says Chandrashekar.

Vinoj Manning, CEO at Ipas Development Foundation, New Delhi, says that even though lockdown easing has been accompanied by a sharp spike in number of Covid-19 cases, it would not necessarily have a negative impact on reproductive healthcare access. ‘‘I would suspect not. The healthcare access continues to be a challenge, but it wouldn’t increase. During the first stage of lockdown, almost all healthcare facilities were geared towards dealing with Covid-19 and a number of private hospitals and clinics were closed. However, over a period of time these hospitals have begun to open and the system has begun to stabilise and people have access to healthcare. So, I don’t think there is a direct correlation between ease of health access and rising Covid-19 numbers. It is still sub-optimal, but we have seen a lot of improvement over the past few weeks. The access does remain challenging in a more localised only place where lockdowns are still enforced and it would impact that population. But it is not nationwide and only in the pockets where strict lockdowns are still imposed,’’ he says.

In late April FRHS India analysed data and estimated the impact of Covid-19 on India’s family planning services for three scenarios and the worst case scenario estimated that 27.18 million couples would not be able to access their choice of contraception since the lock down till September, resulting in 2.95 million unintended pregnancies, 844,483 additional live births and 2,165 maternal deaths due to inability to access family planning services and products. ‘‘Women in general have been impacted by this shortage, but it was more acute for poor and rural women since they depend entirely on public health systems for their Sexual Reproductive Health (SRH) needs and the lack of public transport paralysed them and kept the healthcare out of their reach for long after the lockdown began to be eased,’’ says Chandrashekar.

While the government failed to respond to the needs of women, fortunately some NGOs were able to step in and fill in some of the gap. The NGOs advocated for classifying abortions as essential services and this was accepted by the Ministry of Health and Family Welfare. Even during the stringent lock down, NGO-run clinics were able to provide abortion and post abortion contraception services. Family Planning Association of India and FRHS India resumed services in their clinics in the first week of April and other NGOs followed suit. ‘‘NGOs went out of their way to help women who needed an abortion by sending ambulances to bring clients and drop them back; work with district authorities to facilitate movement of clients who needed an abortion and some like FRHS India dropped prices by 50 pc. NGOs like Hidden Pockets used their helpline to support women and refer them to facilities that were open and CEHAT in Mumbai supported a number of women during the severe lockdown,’’ Chandrashekar adds.

Challenging access to pills

Another issue that has plagued reproductive healthcare is the disruption in availability of drugs for these. Of the estimated 15.6 million abortions that happen in India annually, 73 pc are through medical abortion (MA) drugs accessed outside of facilities, 16 pc in private health facilities, 6 pc in public health facilities, and 5 pc through traditional unsafe methods. Despite the near total dependence upon drugs for carrying out medical abortion, there is a severe shortage of these pills across India, says FRHS India. A study by FRHS India says there is an overwhelming shortage of medical abortion pills in Madhya Pradesh, Punjab, Tamil Nadu, Haryana and Delhi.

Short-term & long-term implications

IDF’s Manning says that there are several mid-term and long-term implications of the crisis and lessons to be learnt from there to strengthen response to a future disaster. ‘‘In the mid-term, what has happened in terms of contraception or abortions, there is a demand shift. For example, due to the delay in abortions, people who were looking for early-stage abortions at home will now look for second-trimester abortion, which means that the treatment will shift from an OPD (outpatient department) to in-clinic treatment. Also, earlier a lot of women used to opt for long-term contraception methods like IUCD or sterilisation, but now couples who wanted to go with these options are not doing it due to the fear of contracting Covid-19 in the hospitals and instead they are going with contactless contraception devices like condoms and oral contraceptive pills. So, there is a demand shift which the healthcare system will have to account for and provide,’’ Manning tells Media India Group.

Chandrashekar says that this situation places additional responsibilities on the health system to undertake a recovery plan to ensure remedial options for the affected women – both during and after the COVID-19 recovery period. He cautions of severe repercussions of the crisis on the healthcare system. ‘‘Unless proactive steps are taken to resume services to pre-Covid-19 days quickly and improve access, the gains made by the national family planning programme and in reducing maternal mortality and morbidity could be reversed. Many NGOs and small health care facilities in private sector have been hit financially, since they could not provide services, but continued to pay salaries and incur other costs. The costs of providing services have also increased since additional infection prevention measures have to be put in place. NGOs like FRHS India are also looking at consolidating teams due to lack of funding. In the long term, this is likely to reduce the supply of SRH services, which will adversely affect women in general and vulnerable women in particular,’’ warns Chandrashekar.

Manning of IDF agrees that urgent and important steps need to be taken. ‘‘One of the lessons that anyone in public healthcare system would have learnt in Covid-19 is that we need to programme and integrate sexual reproductive healthcare services into our disaster mitigation plan as these are essential services. A key lesson learnt here is that when a disaster strikes, be it a pandemic, flood or cyclone, we need to have alternate mechanism of deliveries which includes telemedicine. We need to have alternate platforms to provide facilities even if the main system is entirely disrupted. So, even in worst crisis, if people need something they would know that there are these three four places where they would get it. It would need development of alternate, community-based services and medicine deliveries that are localised so that people don’t have to travel,’’ concludes Manning.