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Baby in a sari

A new large-scale study has revealed a significant increase in cases and deaths from severe maternal complications in India during the COVID-19 pandemic.

India is currently experiencing a devastating second wave of SARS-CoV-2 infections. In addition, national and regional lockdowns have restricted access to wider healthcare, including sexual and reproductive health services. Researchers from NDPH’s National Perinatal Epidemiology Unit (NPEU) together with clinicians from India have found evidence that these disruptions have caused an increase in unsafe abortions, severe complications in pregnancy, and maternal death in India. The results are published today in EClinicalMedicine.

The study data came from 15 hospitals across five states in India, and included a total of 202,986 hospital births for the period December 2018 through to May 2021 (15 months pre-pandemic and 15 months during the pandemic). For each month, the researchers counted the number of cases and deaths from nine types of maternal complications (such as eclampsia and postpartum haemorrhage). In addition, monthly Government Response Stringency Index (GRSI) scores for India were used to measure how the strictness of restrictions imposed to control the SARS-CoV-2 outbreak affected hospital births, severe maternal complications and death.

Key results:

  • During the study period, 24,978 women were admitted to the 15 hospitals with at least one of the surveyed pregnancy complications, and 1,020 of them died.
  • The number of hospital births significantly decreased during the pandemic. Compared with the corresponding month in the pre-pandemic period, hospital births decreased by nearly 5% for every 10% increase in GRSI score.
  • During the pandemic, the overall incidence of maternal complications increased by 10%. This was mainly due to a significant rise in hospital admissions from septic abortion, which were 56% higher during the pandemic.
  • The overall case fatality from the nine complications surveyed increased by 23% during the pandemic period compared with the pre-pandemic period.
  • In particular, there was a doubling in the case fatality for heart failure in pregnancy, increasing from 29 to 58%.

According to the research team, the results indicate that lockdown and other restrictions had a strong negative impact on the number of births taking place in hospitals across India. This would have affected access to care at childbirth, including emergency obstetric services. In addition, the quality of hospital care during the pandemic may have been compromised due to shortage of healthcare staff and reallocation of medical supplies.

Manisha Nair, Associate Professor in the NPEU, who led the study, said: ‘We should not forget that every number is a mother, a wife, a sister, a partner, an employee, an employer, a friend who left behind a traumatised family amidst the most devastating pandemic. These are all preventable deaths. Policy makers are in a good position to revert this crisis using the existing systems and by creating public awareness about the need for timely access to reproductive health services.’

According to Professor Saswati Sanyal Choudhury, an Obstetrician and Gynaecologist at Guahati Medical College and Hospital, Assam, India, and a co-investigator in the study, the increase in septic abortion indicates a worrying rise in unsafe abortions. ‘The unmet need for contraception increased and access to safe abortion services decreased during lockdowns. Women went to local unqualified providers or ended up self-medicating, taking abortion pills in wrong doses and late in pregnancy which led to incomplete abortion, sepsis and other complications.’

Professor (Major) Anjali Rani, Obstetrician and Gynaecologist, Banaras Hindu University, Uttar Pradesh, and a co-investigator, added: ‘As an obstetrician working in one of the hospitals, I was frustrated to see so many women with severe complications coming to our hospital very late. They could not receive timely treatment. The pandemic affected health seeking for all women irrespective of their socioeconomic status, but the poor were disproportionately affected.’

The study was conducted through the Maternal and perinatal Health Research collaboration, India (MaatHRI), a UK-India collaboration for maternal and perinatal health research. The MaatHRI platform and this study was funded by a Medical Research Council Career Development Award to Associate Professor Manisha Nair.