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What is the Impact of COVID-19 on the Antenatal Care Services Utilization in Public-Private-Rural-Urban Hospitals of India During the COVID-19 Pandemic Period of 2020-2021 Compared to Pre-Pandemic Era 2018-2019?

Authors: Dr Piyush Kumar;

What is the Impact of COVID-19 on the Antenatal Care Services Utilization in Public-Private-Rural-Urban Hospitals of India During the COVID-19 Pandemic Period of 2020-2021 Compared to Pre-Pandemic Era 2018-2019?

Abstract

What is the impact of Covid-19 on the Antenatal Care Services Utilization in Public-Private-Rural-Urban Hospitals of India during the COVID-19 Pandemic Period of 2020-2021 compared to pre-pandemic era 2018-2019? Dr Piyush Kumar1 1 M.B.B.S. E.M.O.C., P.G.D.P.H.M., Senior General Medical Officer, Health Department, Government of Bihar, India, drpiyush003@gmail.com Original Research Impact of Covid-19 on the Antenatal Care Services Utilization in Public-Private-Rural-Urban Hospitals Abstract Background The ongoing coronavirus (COVID-19) pandemic is well documented to have a disastrous effect on the health-care services, particularly pregnancy-related health services. In order to provide the information to the scientific community and policy makers with accredited evidence and data in the country, this retrospective cross sectional mixed research study aims to find out the impact of the COVID-19 pandemic on antenatal services utilization among pregnant women of India attending public / private / rural / urban health facilities in 36 states and union territories. Hence, the researcher hopes that result and analysis will be beneficial to important stakeholders as well as policy makers in designing strategies for prioritizing pregnancy healthcare even within the ongoing COVID-19 pandemic period. Methods A facility-based retrospective mixed cross-sectional study was conducted from 1st January 2018 to 31st May 2021 for pregnant women attending public / private / rural / urban ANC services in 36 states and union territories of India. A total of 96990524 women registered for ANC during this period across all health facilities were included in the study with a purposive sampling technique. The data required for this study is collected from HMIS of Ministry of Health and Family Welfare (MoHFW) which is the most accredited data source in India. The total number of indicators included for the study was 20.The data collected is analysed with the help of Microsoft office. Results Overall, 96990524 women registered for ANC during the study period. The analysis shows that the covid-19 pandemic era has a negative impact on several indicators. The study revealed that there is significant increase in ANC service utilization at urban and private health facility of all the services as compared to pre-pandemic era on cumulative all India basis. The study revealed that there is decrease in almost all ANC service utilization at rural health facility. Conclusion Enhancing women knowledge of protective health services, prioritizing maternal care related health services during ongoing COVID-19, and improving the accessibility of ANC service should be emphasized for getting maximum benefit to the neediest. Keywords: antenatal care, health facility, utilization, coronavirus disease, pregnant women, India Introduction Antenatal care services are well documented by several researchers to be affected by the COVID-19 pandemic despite the truth that pregnant women are considered vulnerable group [1]. However, the SARS-CoV-2 pandemic has led to maternity services disruptions in providing antenatal care due to the government enforced covid-19 restrictions regarding social distancing etc., which has negatively impacted on access to routine antenatal care. The SARS-CoV-2, which causes disease (COVID-19), has spread globally since emerging in December 2019, and the World Health Organization (WHO) declared this a global pandemic on March 11, 2020[2]. Total number of 343,516,850 confirmed cases and 5,594,994 deaths 275,116,452 recovered were reported globally as of January 21, 2022, 10:43 GMT [3]. The WHO defines Antenatal care as the care given to a pregnant mother before birth, and it involves education, screening, counselling added with treatment of problems, and immunization [4].Antenatal care is the first contact opportunity for a pregnant woman to get connected with available-accessible-affordable health services and linking herself with pregnancy related complications to an established health-referral system. Maternal mortality is significantly high. Almost 295 000 women died during and following due to pregnancy and childbirth related causes in 2017. The great majority of these deaths (94%) reported in low-resource settings, and majority could have been prevented [5]. Antenatal healthcare is targeted to reduce maternal morbidity and mortality by providing and educating about health promotion, danger signs, birth preparedness, and proper timely care for pregnancy complications. The WHO recommends a minimum of 04 ANC visit per pregnancy for pregnant women. NFHS Studies conducted in different states of India reported that educational status, maternal age, number of living children, occupation, place of residence, religion, socio-economic status, and previous obstetric history were significant factors associated with the use of antenatal care service [6]. The COVID-19 pandemic challenged not only India but global countries to provide good quality, essential maternal and newborn health services [7]. Pregnant women and newborns have experienced difficulties accessing health services due to lockdown measures or found to be reluctant to visit health facilities due to fear of possible infection[8]. The disruption of maternity services and moving resources away from most essential pregnancy care, due to COVID-19 response, increased risks of maternal morbidity and mortality [9]. Anxiety, domestic violence and mental health problems in pregnant women were reported to be increased during the ongoing covid-19 pandemic [10,11].The indirect effects of COVID-19 on various other diseases at the population level, as a result of lockdown, social restrictions, and reorganization of health systems, is evident in several research studies[12] The negative impact of containment and covid-19 policies on mortality at emergency department is also evident from several research studies [13]. To the best of the researcher/author knowledge, there is no published research till today 22-01-2022 exploring the effect of the COVID-19 pandemic on antenatal care services utilization by analysing 20 accredited times bound indicators for pregnant women in the country. This kind of research study is not done only in India, but also on global basis the author has not found such study which can clearly mark the impact of covid-19 on ANC through several process or output indicators. In order to provide the information to the scientific community and policy makers with accredited evidence and data in the country, this retrospective cross sectional mixed research study aims to find out the impact of the COVID-19 pandemic on antenatal services utilization among pregnant women of India attending public / private / rural / urban health facilities in 36 states and union territories. Hence, the researcher hopes that result and analysis will be beneficial to important stakeholders as well as policy makers in designing strategies for prioritizing pregnancy healthcare even within the ongoing COVID-19 pandemic period. Materials and Methods Study Setting The study was conducted by continuous observation of health facilities data found in HMIS of MoHFW, which is also available online. The population covered is 36 states and union territories of India. According to the data obtained from HMIS, the total ANC registered during this period is 96990524 numbers of females. In the country there are private, public, rural and urban hospitals, delivering ANC services. The financial burden of ANC services in public hospital of India is cost free, covered by state and central governments. For getting treatment at private health facilities the pregnant women or family have to pay as oope (out of pocket expense) until unless covered by some government sponsored scheme. Study Design and Period A health facility-based retrospective mixed cross-sectional study was conducted for pregnant women who attended ANC and takes the available services in the selected health facilities from 1st January 2018 to 31st May 2021. The first documented covid-19 case in India was found in January 2020[14]. Hence the year before 2020 i.e. 2018 and 2019 is pre-pandemic period utilized for comparison with the ongoing covid-19 pandemic period i.e.2020 and 2021 (up to May as data from accredited source is available till this month). The average per month is calculated and pandemic era is compared with pre-pandemic era to find out the impact of covid-19 on ANC services utilization. Population The actual population was all the pregnant women who attended ANC or utilized ANC related health services in the selected health facilities of choice, during the data collection period of this research study was considered as study population. Accordingly, a total of 96990524 numbers of female’s pregnant women who fulfilled the inclusion criteria were included in the study. Sample Size and Sampling Technique A total of 96990524 women registered for ANC were included in the study with a purposive sampling technique. The data required for this study is collected from HMIS of Ministry of Health and Family Welfare (MoHFW) which is the most accredited data source in India. The total number of indicators included for the study was 25.The data collected is analysed with the help of Microsoft office. Study Variables and Operational Definition The outcome variable of this research study was antenatal care utilization. Antenatal care utilization for this study was defined as Total number of pregnant women registered for ANC Out of the total ANC registered, number registered within 1st trimester (within 12 weeks) Number of PW given TT1/ Td1 Number of PW given TT2 / Td2 Number of PW given TT Booster/ Td Booster Number of PW provided full Course 180 Iron Folic Acid (IFA) tablets Number of PW provided full Course 360 Calcium tablets Number of PW given one Albendazole tablet after 1st trimester Number of PW received 4 or more ANC check ups Number of PW given ANC Corticosteroids in Pre Term Labour Out of the new cases of PW with hypertension detected, cases managed at institution Number of Eclampsia cases managed during delivery Number of PW tested for Haemoglobin (Hb ) 4 or more than 4 times for respective ANCs Number of PW having severe anaemia (Hb < 7) treated Number of PW tested for Blood Sugar using OGTT(Oral Glucose Tolerance Test) Number of PW tested positive for GDM Number of PW given insulin out of total tested positive for GDM Number of PW tested using POC test for Syphilis Number of pregnant women tested for Syphilis Number of syphilis positive pregnant women treated for Syphilis, Data Collection and Quality Assurance Data were continuously collected, observed analysed using Microsoft office software from electronic records of HMIS from MoHFW. The whole data collection and analysis is solely done by the author. To assure data quality the researcher has taken help of his wife to do cross check as well. Furthermore, there was daily supervision of data collected in the data collection process. Finally, it was checked for accuracy, reliability, completeness and consistency. Data Management and Analysis All data was checked for inconsistencies, any missing values, and for incompleteness, then entered into Microsoft office software and also exported to STATA for further analysis. Data Availability The data for study is available on HMIS of Ministry of Health and Family Welfare, Government of India. The link to the source is given below:- https://hmis.nhp.gov.in/#!/standardReports Results Socio-Demographic Characteristics of Respondents A facility-based retrospective mixed cross-sectional study was conducted from 1st January 2018 to 31st May 2021 for pregnant women attending all / public / private / rural / urban ANC services in 36 states and union territories of India. Thus, a total of 96990524 women registered for ANC were included in the study with a purposive sampling technique. See Table 1, 2, 3, 4, 5, (some extra data table is also attached at end for researcher’s interest) This research study is ongoing and more analysis and interpretation will be available in next version of this research study with more data. Impact of COVID-19 Pandemic on ANC Service Utilization Table – 1- Comparison of ANC service utilization across India (all health facilities) before and after covid-19 pandemic Indicator/ Variable Average per month-Pandemic Era (2020-21) Average per month-Pre-Pandemic Era (2018-2019) Total number of pregnant women registered for ANC 2309294.7 2414769 Out of the total ANC registered, number registered within 1st trimester (within 12 weeks) 1725702.3 1662208 Number of PW given TT1/ Td1 1650691.2 1734836 Number of PW given TT2 / Td2 1459628.4 1555820.5 Number of PW given TT Booster/ Td Booster 514934.24 497145.75 Number of PW provided full Course 180 Iron Folic Acid (IFA) tablets 2080879.9 2072583.5 Number of PW provided full Course 360 Calcium tablets 1853213.6 1474173.5 Number of PW given one Albendazole tablet after 1st trimester 1143783 945783.85 Number of PW received 4 or more ANC check ups 1801079 1802186.5 Number of PW given ANC Corticosteroids in Pre Term Labour 38021.317 35867.25 New cases of PW with hypertension detected 46943.875 48617.71 Out of the new cases of PW with hypertension detected, cases managed at institution 33567.525 32482.96 Number of Eclampsia cases managed during delivery 5051.6167 5005.875 Number of PW tested for Haemoglobin (Hb ) 4 or more than 4 times for respective ANCs 1803885.8 1927255.5 Number of PW having Hb level<11 (out of total tested cases)(7.1 to 10.9) 1508156 1706392.5 Number of PW having Hb level<7 (out of total tested cases) 72676.35 88738.625 Number of PW having severe anaemia (Hb < 7) treated 44108.592 49309.625 Number of PW tested for Blood Sugar using OGTT(Oral Glucose Tolerance Test) 368095.89 343927.75 Number of PW tested positive for GDM 10798.183 11486 Number of PW given insulin out of total tested positive for GDM 2990.3917 2328.4165 Number of PW tested using POC test for Syphilis 215142.48 32339.21 Out of above, number of PW found sero-positive for Syphilis 1499.9917 379.2083 Number of pregnant women tested for Syphilis 694791.53 732651.45 Number of pregnant women tested found sero positive for Syphilis 3670.8917 3673.542 Number of syphilis positive pregnant women treated for Syphilis 1573.55 1261.375 The study revealed that there is decrease in ANC service utilization of following services as compared to pre-pandemic era on cumulative all India basis:- Total number of pregnant women registered for ANC-Number of PW given TT1/ Td1 Number of PW given TT2 / Td2 Number of PW received 4 or more ANC check ups Number of PW tested for Haemoglobin (Hb) 4 or more than 4 times for respective ANCs Number of pregna

Keywords

10.36099/mamr.220522, antenatal care, health facility, utilization, coronavirus disease, pregnant women, India

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