Impact of COVID-19 on abused pregnant and lactating women receiving reproductive and child health services at tertiary care hospital, New Delhi, India

The context and the problem

This article is a subset of a larger research study on abused pregnant women who visited Lok Nayak (LN) Hospital for routine ANC. It is one of New Delhi’s most important tertiary care public hospitals. The abused pregnant women who participated in the study were recruited before the COVID-19 emergency. In response to the growing need for isolation beds, the LN facility began operating as a specialized COVID-19 hospital on April 4, 2020, with appropriate isolation rooms and beds. Women who went to the ANC clinic were referred to different hospitals. As a result, the LN Hospital’s operations mirror those of other public health institutions. Because the current epidemic has affected all aspects of life, it is critical to look at the state of mother and child health. The paper aims to find out the impact of COVID-19 on abused pregnant and lactating women receiving routine RCH services at a tertiary care hospital in New Delhi, India.

Domain 1: Research team and reflexivity

This work is part of a larger interventional research effort that began in October 2018 and is still ongoing. In 2018, the interventional study project recruited abused pregnant women based on inclusion and exclusion criteria. Five highly competent women researchers from several fields, including psychology, population and social geography, social medicine and community health, yoga, and anthropology, were involved in interacting with the women participants who had experienced DV. Four of them have a Ph.D. and have worked in the community for 10–30 years. We realized that the age of the interviewer was an important factor in dealing with battered women. The group was made of people who were between the ages of 35 and 60. The researchers were given a 2-day training program to help them comprehend the study’s goal, develop a common perspective, and commit to a 2-year involvement in the project. They were also exposed to how to use the tools and questionnaires, as well as the detailed methodology, to ensure that the data and responses are of high quality dispassionately.

The women participants who came to the public hospitals were married women between the ages of 18 and 35 years who belonged to the Hindu and Muslim religions and had a poor level of education and socioeconomic status. The participants were treated fairly and unbiasedly because the researchers were not from the hospital and had no prior relationship with them, instead meeting them for the 1^st time. The researchers were successful in establishing rapport with the individuals and gaining their trust and confidence. One component of the intervention was to provide a space where individuals could receive empathy, care, respect, and support within the rushed, overcrowded, and impersonal hospital environment. This helped both the researcher and the participants gain trust and understanding of the phenomenon.

Domain 2: Study design

The ethnography method was used to gain an in-depth understanding of the participants’ everyday environments and the social meanings associated with being part of a particular family culture. The participants were abused pregnant women receiving maternal health services at LN Hospital, New Delhi. Women up to 20 weeks pregnant who came to LN Hospital for ANC were screened for DV. This study included women who had delivered babies (including miscarriages, fetal deaths, and stillbirths) and had completed 6 weeks of postnatal care (PNC). The first milestone was to create a designated space with adequate seclusion where women could speak freely without being overheard by their accompanied relatives. The room was divided into sections by moveable dividers to ensure that all participants had their privacy. The space was kept clean, orderly, and well ventilated to provide a friendly and cheerful environment, including refreshment, in which the participants could relax and express their feelings. The assurance of providing culturally competent and empathetic care, guidance in resolving problems, as well as regular interactions, helped in building trust and confidence. Interviewing the participants in the midst of the unprecedented COVID-19-induced national lockdown was easy because the rapport had already been built.

A total of 150 women were contacted for follow-up. Although each woman’s experience was unique, all of the women who had been recruited for the larger study were considered for this research. After receiving informed consent, the participants were recruited for the study. Nineteen abused pregnant women who were due to give birth in mid-April, 63 lactating mothers who had delivered before March 22, 2020, and 68 mothers with children older than 6 months who had access to child immunization services were among those interviewed. As a result, the participants were in various stages of pregnancy and lactation when we began the qualitative research. During the lockdown period, an open-ended schedule was developed focusing on the status of DV, stress and fear of contracting the coronavirus, barriers to receiving ANC, delivery, and PNC services, and problems encountered at home, such as access to essential goods and services, health, incidents of violence, and their coping strategies.

The interview was conducted with the participants between March 23 and May 22, 2020, during the first lockdown period. The interviews were conducted in Hindi, the participant’s native language. Each participant’s every word was meticulously documented. The participants’ anonymity was maintained throughout the process. The women were called over the phone in a non-obtrusive manner, keeping their privacy at home in mind. It took a long time to reach most women because they did not have their own phones and shared their husbands’. Without danger of being interrupted or eavesdropped on, the women chose a convenient date and time to respond to the interview schedule. Apart from maintaining research ethics and standards, all of these precautions were necessary to ensure their safety. A small number of women with personal smartphones were also contacted through social media messaging apps. Spouses answered the phones and denied access to talk with the women in several cases; some denied their presence at home and many women were found to be in their native places before the lockdown. The phones were frequently found to be turned off, making the procedure of interviewing them time-consuming. The confidentiality of the women was preserved at all points.

An interview was carried out with each woman on the same set of questions regarding their barriers and challenges. In virtual communication, there were a few difficulties were found. Women were reluctant to answer questions about violence, which they deemed unimportant as opposed to their immediate concerns about food and money. Some women refused to answer questions over the phone, preferring instead to meet in person at the hospital. Each participant’s file details were generated because they were followed up for roughly 5–7 months before the pandemic. As a result, no audio recording was required. Each woman came to the hospital for longer than their scheduled follow-up to interact with the research team before the pandemic. The majority of the time, they were told not to come since the study team needed to devote their time to other participants. They would frequently come to the room out of turn to exchange ideas and seek additional assistance. Interaction, observation, body language, emotional shifts, tone changes, and other factors all contributed to a better understanding of their problems. This is how the responses are triangulated.

Domain 3: Analysis and findings

Using NVivo 12 software, the researcher organized and coded the data. Themes were identified in the data, the pilot tools, and secondary resources such as news articles and information about the ongoing public health issue caused by the COVID-19 epidemic. A few open-ended responses by the participants using pseudonyms (to protect the participants’ identities) are presented in a descriptive format to supplement and complement the themes. Thematic analysis was used to examine the interview data. Two major themes were assessed, such as (i) Status of DV and (ii) barriers to access and utilization of health-care services during the lockdown. A three-point scale was used to determine whether the incidence and frequency of violent events among the women had increased, reduced, or stayed unchanged over the lockdown period. The type of violent occurrence was documented along with incidental details. Many subthemes were grouped and categorized under the second theme, including inadequate patient information, restrictions on movement from one hospital to another, communication breakdown with the healthcare team, healthcare system barriers, including increased uncertainty of health-care facilities, stress, and anxiety.

Status of DV

Amidst the lockdown, there is a rising trend of DV. The women were subjected to verbal abuse, physical violence, and psychological harm while secluded at home with the perpetrators under the same roof for extended periods of time with no social connectivity. Analysis shows that the level of DV has increased for 62.7% of women, remained the same for 28.1%, and 9.2% of women have never experienced violence. About 59.3% of women reported verbal abuse, 22.0% reported physical abuse, 3.3% reported sexual assault, and 15.4% reported no violence during the lockdown.

Women silently tolerate assaults within their homes and are exposed to dangerous consequences because they have nowhere to flee and limited mobility. Men’s anger and frustration levels have been discovered to be higher, and the prohibition of alcohol and tobacco products (gutka, bidi) has resulted in withdrawal, hostility, and irritation between couples, which they invariably vent to the housewives. Due to the financial crisis, employment uncertainty, indebtedness, and an unclear future, nearly three-quarters of women reported increased violence. One woman, who is currently 9 months pregnant, had her hand burned by her husband, and she managed to flee to her parents’ house. Further, men turn to coitus as a kind of leisurely enjoyment and bodily pleasure when they are ordered to stay indoors, have no meaningful paid labor to do, and their regular routines are disrupted. Around 46% of women expressed their concern over the phone that their parents from the last trimester till childbirth had been cancelled. Devyanshi has been dealing with financial demands from her in-laws who have threatened to evict her if she does not comply. Nagma, a 23-year-old lactating mother, has disturbed sleep habits as a result of excessive work at home; she feels physically “fatigued and drained out the entire day.”

Access to and utilization of healthcare services during the lockdown

The following sub-themes emerged from the responses reported by the women on the barriers and problems they encountered in accessing health-care services.

Ethical statement

Ethical Clearance has been obtained from IRB, National Institute of Health and Family Welfare (NIHFW), New Delhi and informed consent was obtained following ICMR, 2018 guidelines.

Author’s contributions

MM: Conceptualization, designing the study, literature review, methodology, analysis, and writing. SR: Literature review, data collection, analysis, writing, and editing the paper. PN: Data collection, analysis, and writing. SP: Data collection. AJ: Data collection.