A recent report on institutional delivery in Jharkhand recounts a pregnant woman’s experience of being asked by a government hospital’s staff to clean up her blood, and then being turned away for fear of “spreading coronavirus”. After suffering this shameful treatment, the woman wrote to the chief minister that she was abused because she was Muslim and that the experience culminated in the loss of her baby.
If previous experiences of infectious disease pandemics are anything to go by, the collateral damage of COVID-19 will be far greater than the number of people infected by it. A frightening but pertinent example of this was recently quoted in special guidelines released by the World Health Organisation (WHO) to help countries maintain essential health services during the COVID-19 pandemic. Mainly in the context of three African countries, the document stated that “during the 2014-15 Ebola outbreak, the increased number of deaths caused by measles, malaria, HIV-AIDS and tuberculosis (TB) attributable to health system failures exceeded deaths from Ebola.”
So far, COVID-19 is proving to be a proverbial lesson in ‘learn from your mistakes’ as reports of impaired access to medicines for TB and HIV patients in India have surfaced. India’s aggressive measure of a sudden and ill-prepared lockdown has exacerbated the issues of its weak and inadequate public health system. Particularly for women during this pandemic, health on a continuum has been compromised with sharp rise in cases of domestic violence, barriers to using safe abortion services, and severe challenges in access to and quality of maternal and child health services.
Prima facie, the Jharkhand incident adds to several other instances of communal hatred in India in the immediate wake of COVID-19. However, an underlying issue in this account is a specific and normalised form of violence against women during labour, variously known as ‘disrespect and abuse’, ‘mistreatment’, ‘dehumanised care’, and ‘obstetric violence’. It is a globally naturalised phenomenon accompanying institutional birth within an over-medicalised setting, drawing upon power hierarchies between the patient and providers. It has been conceptualised as seven comprehensive categories, which include brazen forms of physical and verbal abuse of women, as well as the nuanced problems of a woman’s loss of autonomy during labour and lack of informed consent for unindicated medical procedures.
According to this classification, the neglect and abandonment displayed in the report from Jharkhand would fall under ‘failure to meet professional standards of care’. Concurrently, the category of ‘stigma and discrimination’ would encompass the religion-based, prejudiced mistreatment meted out to the woman.
In another instance, a local newspaper in Madhya Pradesh has reported a case of negligence where a pregnant woman reached a government hospital in Indore but the doctor refused to come close to the patient and prescribed medicines without a check-up. The woman was then taken to a private hospital where they demanded Rs 25,000 but upon the husband’s return with the money, they referred the patient back to the government hospital. This unnecessary back and forth, including the delay due to an unclear and exorbitant fee, resulted in the woman’s death and is another form of ‘obstetric violence’, categorised as ‘health system conditions and constraints’.
India’s health policy and programmes have recognised the existence of this form of violence against women and responded with guidelines to improve quality of care around birth (LaQshya) and an initiative focused on assured delivery of maternal and newborn healthcare services (SUMAN). As we soldier on through the COVID-19 outbreak, a guidance note released by the Ministry of Health and Family Welfare has included maternal, newborn and child health within essential health services. Specifically, ‘ensuring safe institutional delivery’ has been recognised as the right of every woman.
Despite this recognition and official government advisory, the ground reality is grim. Lack of transportation to health facilities, which was already a major concern for women in rural areas, has been aggravated by the lockdown, as arranging a pass is a privilege and women are instead resorting to home deliveries. Even when women reach institutions, the lack of proper facilities and adequate human resources puts women at risk of maternal mortality, a major public health concern for India. The vulnerable period of pregnancy needs to be treated with the same urgency as we do the novel coronavirus outbreak.
As India moves well into the third stage of the spread of the disease, and is an extended period of national lockdown, the country needs to aggressively ramp up testing by actively seeking cases and isolating suspected cases in urban and rural areas alike. The frontline workers from doctors and nurses to ASHAs and ANMs need to be supplied with personal protective equipment and enabled to save lives without compromising their own. Simultaneously, contact tracing needs to be adopted without the burden of stigma and discrimination, a practice which will encourage health care professionals to respond sensitively to patients with other health issues.
One must not forget that even before the novel coronavirus crisis, women were already suffering from violence and abuse, lack of access to contraception or safe abortion services, teenage pregnancies, among many other issues. Therefore any effort to tackle COVID-19 cannot sideline public health issues which will remain even when this virus has been taken down. It is paramount that India’s governing bodies and health care professionals facilitate an environment which allows women to access quality care on a continuum because while the fight against this contagion continues, the future of women’s health hangs in the balance.
Surbhi Shrivastava is a senior research associate at the Centre for Enquiry into Health and Allied Themes (CEHAT), Mumbai. M. Sivakami is a professor and the chairperson of the Centre for Health and Social Sciences, School of Health Systems Studies, Tata Institute of Social Sciences (TISS), Mumbai.