This study is reported as per the Consolidated Criteria for Reporting Qualitative Research (COREQ) [22].

Aim, design and setting of the study

This qualitative research study was carried out by the Center for Social and Behavior Change (CSBC), Ashoka University, and funded by the Bill and Melinda Gates Foundation (BMGF). Jharkhand, Madhya Pradesh and Uttar Pradesh, India were selected as study locations, due to CSBC’s focus on these states as part of its ongoing partnership with the National Institute for Transforming India (NITI) Aayog to improve health outcomes in these states. Two districts in each of these states were selected for this study, based on the presence of development partner organisations in the districts. While preference was given to Aspirational Districts, the final selection of districts was not limited to these.

This paper draws on data collected as part of a large-scale exploratory research study led by CSBC to understand the landscape of health and nutrition services in the times of COVID-19 in March 2020, and a phased re-opening of the same in the selected states thereafter. The data was collected over a period of three months to grasp the status of services and the challenges faced by end users and service providers during the lockdown and Unlock 1.0. Ethical review and clearance were provided by the Institutional Review Board of Ashoka University. A qualitative research design was adopted to study diverse aspects of ANC services and institutional deliveries in these times.

In this paper, we share findings from 12 in-depth telephonic interviews conducted with pregnant women and 17 in-depth interviews with frontline health workers. Pregnant women’s interviews explored themes of knowledge, awareness and practices in the times of COVID-19 pandemic; fears and anxieties around pregnancy; the planning of childbirth and their needs for support (including from frontline health workers); and the challenges anticipated during childbirth. In-depth telephonic interviews with frontline health workers focussed on the change in their work schedule and responsibilities owing to the pandmeic, the institutional emphasis on preventing and managing COVID-19, and its effect on the community, especially pregnant women.

The interviews were conducted by the qualitative research team at CSBC (including the authors of this paper) and trained field enumerators, and lasted approximately 45–60 min. Each of the interview sessions was followed by a detailed debriefing. Interview guides were adapted to the categories of respondents and comprised questions that were open-ended in nature, followed by probes. While some questions could be answered just in the affirmative or negative, interviewers actively utilised probes to encourage further discussion around responses.

Sample characteristics

Convenience sampling was undertaken of pregnant women, while ensuring representation from three distinct sections of the community—general population, scheduled caste/tribes and returning migrants. Similarly, FLHWs were conveniently sampled, representing one Auxiliary Nurse Midwife (ANM), Accredited Social Health Activist (ASHA) worker, and Anganwadi worker (AWW) for each district. With the help of a matrix, each of the FLHWs were represented by one respondent from within the district central place and two from villages located far from the district centre. Table 1 outlines the inclusion criteria and distribution of the sample across the states.

Interviews were conducted in Hindi, Kho, and Bhojpuri, at a time convenient for respondents and enumerators. Oral consent was obtained from each respondent before the interviews commenced. Care was taken to ensure that the telephonic engagement took place in a safe environment and maintained participants’ confidentiality. All interviews were audiotaped, transcribed and translated verbatim into English by an external agency, and these translations were verified by interviewers to ensure accuracy.

Data analysis

The methods of thematic and narrative analyses [23] were adopted for analysing the data collected. The team followed a step-wise process of familiarising themselves with the data, identifying a thematic framework and developing a coding frame. In the preliminary stages, the data from notes taken by enumerators and CSBC researchers was thematically analysed, in order to draw high-level insights through a deductive approach. Further, the data was subjected to a thorough qualitative analysis with inductive coding, using the software Atlas.ti 9.0.

Findings

The findings highlight the different behavioural, financial, social and infrastructural factors that influenced pregnant women’s and their families decision on the uptake of the ANC services and planning of safe deliveries.

Pregnant women’s knowledge and risk perception

Pregnant women were aware about the COVID-19 situation in the country, its symptoms and the precautionary measures they had to engage in. When asked if they knew of any other diseases that compared to COVID-19 in severity, the majority of respondents expressed that COVID-19 was the most formidable disease they had ever heard of, due to its rapid spread, high rate of fatality, and the fact that no cure had been found for the disease.

“There are other dangerous diseases, but there are solutions… there are medicines (for those diseases). But there is no treatment for this corona (sic), and that is why we are afraid.” (Pregnant Woman, District Khunti, Jharkhand)

A minority across the study areas said that this was just like the dozens of other dangerous diseases that were common, such as those borne by contaminated water. Their thinking was influenced by the high incidence of water-borne diseases in their community. They feared that the concentration of efforts on the COVID-19 situation would delay timely and appropriate treatment of other illnesses and conditions, which may, in the absence of appropriate medical attention, prove fatal just like COVID-19.

There was heightened awareness of COVID-19 being especially dangerous for pregnant women, as respondents had been told so by ASHAs. Some pregnant women across study areas reported receiving official text messages advising them to take special protective measures as they were especially vulnerable at this time. Respondents were emphatic that COVID-19 would adversely impact their health and the fetus’ development, but did not have any specific information on how this would happen. FLHWs confirmed this messaging and reported spreading these messages over phone or home visits.

“The ASHA told us “If you stay at home, you will stay safe. Don’t go to the hospital, (as) many different kinds of people are going there. It is unsafe for you, and for your child as well… that’s why you should stay in your houses.” (Pregnant Woman, District Lalitpur, Uttar Pradesh)

Pregnant women were aware of protective measures such as avoiding going out of their homes or consuming outside food, covering their faces with masks, washing hands with soap and water, and maintaining social distance. They were made aware of these, along with routine pregnancy care guidance (such as what food items to consume, and how much rest to get each day) by the FLHWs in their community. During lockdown, FLHWs typically communicated with them over phone calls, and sometimes by visiting them at home. During home visits, FLHWs made sure of no-contact and followed all the other COVID-19 protocols. At the time of the interviews, in the early months of the COVID-19 lockdown in India, the effects of COVID-19 on pregnant women were unknown, and hence there was no official guidance on the same as reported by an ASHA and reciprocated by other FLHWs across the study geographies.

“We have been told to inform pregnant women about the COVID-19 situation and that they are highly vulnerable to the infection but we don’t know how. Pregnant women ask us about this and we have no answers.” (ASHA, District Chattarpur, Madhya Pradesh)

The respondents’ other key sources of information about the virus and pandemic included their mobile phones (via SMS, Government of India mandated COVID-19 advisory caller tune, and internet for those who owned smartphones), television and word of mouth.

Anxieties around the pandemic

Almost all pregnant women reported being acutely worried about making ends meet during the pandemic and this negatively impacted the nutrition of the family and their special nutrition needs given their pregnancy. Owing to the lockdown, there was widespread loss of livelihoods, and this led to abject insecurity around access to food. All respondents reported that their husbands were at home all day, without any work that would enable them to earn wages. With their children bound to the home, respondents felt that their education was suffering in the process. Concerns around their health during pregnancy, such as consuming a nutritious, well-balanced diet, were secondary to the daily anxieties of putting food on the table for their families. This was especially true for respondents who did not have ration cards in the family and hence could not take advantage of the government’s relief schemes. Even those who received rice under the government scheme (Pradhan Mantri Garib Kalyan Anna Yojana) said that it was grossly inadequate to meet the needs of the family.

While some pregnant women received supplementary nutrition for their children, others whose children were over 5 years of age and no longer eligible for supplementary nutrition remarked that this further built up pressure on them to feed their children. Since respondents were pregnant, they were not in the physical condition to work and earn money for the household, which only compounded their stress. Some pregnant women were inconsolable as they narrated their hardships, having resorted to picking shrubs and plants from around their homes and cooking them for the children in their family, or eating roti with salt for their meals.

“We get 5 kg of rice in a month for each person, which is not sufficient for my child, husband and me. So I search the bushes around my home for anything that can be eaten. I face a lot of problems, and feel very disheartened.” (Pregnant Woman, West Singhbhum, Jharkhand)

Additionally, there was a recognition that the pandemic-induced lockdown had made their experience of pregnancy very difficult, in terms of procuring appropriate foods, medicines, etc. A small set of first-time expecting mothers reported feeling especially demoralised, as they did not have relatives nearby to guide them and could not access ANC services (as well as guidance from health workers) during the lockdown. This contributed to a feeling of helplessness as these women were facing dire material circumstances, including food insecurity, and were unable to do anything to remedy the situation.

Access to healthcare services

Access to healthcare facilities was suspended during the lockdown and when the process of unlocking began, pregnant women faced structural and behavioural challenges. Pregnant women are recommended to visit ANMs four times over the course of their pregnancy at a Primary Health Centre (PHC), Anganwadi Centre (AWC) or monthly Village Health, Sanitation and Nutrition Day (VHSND), where they receive a host of services including physical examination, injections/immunization and supplements, investigations like blood tests and ultrasounds, as well as counselling on appropriate care. Respondents expressed their fears about availing these services at health centres even after taking due precautions, since they could contract coronavirus from meeting others.

“I am afraid that it is possible for a pregnant woman to get corona easily, that's why we are… scared when we go to the hospital.” (Pregnant Woman, District Khunti, Jharkhand)

They were also especially apprehensive of seeking healthcare services when it entailed travelling, since public transport was shut down and ambulances may increase their exposure to the virus (as it was suspected that they were being used to transport COVID-positive persons). This was further confirmed by FLHWs as in the following quote,

“We do not encourage pregnant women to use the ambulances which were actually for their use but are now used to transport the COVID-19 patients due to shortage of vehicles. The ASHAs are instructed to bring them in private transport and the fare gets reimbursed…. But I don't know what they (ASHAs) are doing.” (ANM, District Faizabad, Uttar Pradesh)

In several cases, the pregnant women were discouraged from visiting health centres by FLHWs themselves due to the spread of COVID, instead being recommended to seek phone consultation. In case ANC services were not being delivered at AWCs, pregnant women had no option but to turn to higher level public health centres. Their fears around COVID-19 were compounded by their belief that hospital staff would treat them poorly, due to negative past experiences with institutional healthcare, and rumours of the discrimination and ill-treatment in the community.

Despite these apprehensions, there was angst at not being able to access ANC services during lockdown, as there was no way to know if the pregnancy was progressing normally and if the fetus was developing as it should.

“Doctors were saying that ultrasound is to be done twice… then only they come to know about the status of the baby and health of the mother. How can this be known if we don’t consult the doctor?” (Pregnant Woman, District Khunti, Jharkhand)

Pregnant women returned to AWCs and hospitals for check-ups once the lockdown was eased, since they felt it was essential for the health of their child. However, there was no mention of wanting to attend ANC contacts for the benefits to their own health- likely because during pregnancy, the health of the baby is of utmost importance, while the health of the mother is important to the extent that it impacts the baby's health, which leads to a devaluation of the latter.

Service delivery by healthcare functionaries

In some districts of Uttar Pradesh, pregnant women reported not being able to attend any ANC check-ups due to the lockdown.

“Due to the lockdown... when we went (to the hospital), there were no doctors... and no one was doing checkups, so we came back…” (Pregnant Woman, District Lalitpur, Uttar Pradesh)

However, some pregnant women reported that ANC check-ups continued as normal, except that they received vaccination, Mother and Child Protection (MCP) card and medicines (IFA, calcium, etc.) from a distance, and were guided by the ANM to wear a mask or face covering. Additionally, they were called into the AWC in small numbers for vaccination to prevent crowing. In rare occasions, pregnant women reported being given sanitiser to disinfect their hands as well prior to the meeting.

“There isn’t permission for a lot of people, so two women enter (the health centre) and get the vaccinations.” (Pregnant Woman, District Chitrakoot, Madhya Pradesh)

Of these women, some felt slighted by this new manner of service delivery, saying that they had to ask permission before entering the health centre, were told to sit at a distance from the ANM (which they felt was unnecessary), and were dealt with hurriedly. Some even said that while they were treated as usual, the FLHWs’ treatment of lower caste beneficiaries was different.

“Their (ANM’s) behaviour towards the Ahirwal family was quite indifferent. Untouchability is a big problem.” (Pregnant Woman, District Chhatarpur, Madhya Pradesh)

In the phase of unlock 1 (early May 2020), ANC services were being delivered by ANMs in their most rudimentary form at the AWC—among them, immunisation and physical examination were prioritised. IFA supplementation delivery varied from district to district—while some pregnant women reported receiving their share of IFA tablets from the AWC, others said that the AWC was shut and hence there was no supply of tablets, while still others said that they had not received any tablets from the AWC since the start of the pandemic but were yet to finish their stock from earlier. In many places, blood and urine tests and weight check could not be accessed because of non-functioning infrastructure or because FLHWs did not have time to administer them.

“I was thinking that (the strip of IFA tablets distributed) may have been touched by many people and may carry the virus when I returned from the hospital. But later I thought that it is not good to not eat the medicine, (and) I removed the negativity (sic).” (Pregnant Woman, District Khunti, Jharkhand)

According to FLHWs, their engagement in the COVID-19 related tasks allowed very little time to cater to the ANC needs of the pregnant women. They promoted the use of tele-consulting as it saved time and effort and was the safest means in the given situation. With most of the services suspended, they could not cater to their ANC needs and the disruption of supply of the IFA, calcium and zinc tablets caused shortage in supply.

Several pregnant women in West Singhbhum (Jharkhand) and Chhatarpur (Uttar Pradesh) reported only able to access ANC services and guidance at government hospitals (often travelling long distances on motorcycle in the heat and paying out of pocket for investigations like ultrasounds) because health functionaries were, in some cases, hesitant to enter the village due to the spread of COVID. For instance, the ANMs in West Singhbhum would call these pregnant women and give them a reminder to get vaccinated at the government hospital nearby but visited in person only once in a month. This reminder was only issued for immunisation, and not for any other services under the ANC umbrella after the unlocking process began towards early June in most of the districts under study.

In rare cases, during the lockdown, FLHWs guided and accompanied pregnant women to hospitals for health checks when these services were not being delivered at AWCs. Others reported not being able to access any healthcare services in pregnancy during the lockdown as they had contacted their FLHW at the beginning of the lockdown, who had told them that services were suspended and that she would intimate them when they resumed. Still others mentioned that their frantic calls to their community’s FLHWs, seeking clarity on the status of service delivery, had gone unanswered, which further contributed to a feeling of anxiety and hopelessness.

“Now they (ANMs) say, “Sit a little far away”, they don’t give information properly. They give it in a hurry, and finish off in a hurry. We’re not able to avail benefits of services like earlier.” (Pregnant Woman, District Lalitpur, Uttar Pradesh)

Some women, who normally visited private hospitals, found that services like ultrasounds were not available in these facilities during the lockdown, and hence were compelled to turn to government hospitals. These women were usually belonging to a relatively higher socio-economic group (compared to the majority of respondents), and may have felt that services delivered were of a higher quality in these private facilities. Forced to visit crowded and lower quality (in their perception) government hospitals during the pandemic, they reported feeling stressed.

Respondents felt that the sporadic frequency of service delivery by FLHWs was not adequate for them, and not being able to meet FLHWs in person limited the usefulness of their interaction. This may have been because those services that were perceived to be the most valuable (such as lab investigations like ultrasounds and blood tests) were not being administered, and in the case of those who could only contact FLHWs over the phone, even physical examination was not possible. Some pregnant women also reported not having adequate clarity on the timing of FLHWs’ availability in the village and being confused on whom to approach for guidance in their absence, which led to additional confusion and a feeling of alienation from the health system. They reported seeking information on their mobiles (via internet search) or contacting the ASHA over the phone for recommendations of medicines and care practices. Others were discouraged and lost faith in FLHWs, turning to others for assistance.

“Anyway, those people (FLHWs) don't do anything, (and) they don't ask about our pregnancy, so we go to the hospital and ask the doctor.” (Pregnant Woman, District West Singhbhum, Jharkhand)

Some pregnant women also reported not utilising ANC services even before COVID-induced lockdown (due to a variety of reasons such as not feeling they were valuable, not being permitted by their in-laws to attend, and so on), so they were not impacted in terms to a great degree by the lockdown.

Plans for delivery

Nearly all the respondents reported a strong preference for institutional deliveries, owing to the supervision of the birth by trained medical personnel and access to vital information on caring for their newborn. They mentioned that by virtue of giving birth in the hospital, they would be able to receive important medication for themselves and their newborn if needed. Some even mentioned that delivering in a hospital brought the added advantage of helping them qualify for assistance under the government’s maternal health schemes.

“If deliveries happen at home, where will we get information from (about the schemes and benefits)? When we go to the hospital, we will get information and services, and can take advantage of government schemes as well. (If we deliver at home), we won’t get anything.” (Pregnant Woman, District Lalitpur, Uttar Pradesh)

Some respondents discussed the experiences of women who had delivered children in their community during the pandemic. All of these new mothers had reportedly opted for institutional delivery, and had not encountered any difficulties. Some differences were reported in the protocol followed at the onset of labour and during childbirth; only one family member was allowed to accompany the pregnant woman to the hospital, while there were no such restrictions before the pandemic. This resulted in anxieties for pregnant women as it was either the husband accompanying them in cases of lack of transport or ambulance to reach the hospitals without a female family companion, while in other cases, some other women family member was anticipated to accompany them whom they depicted signs of distrust in absence of the husband.

When at the hospitals, women in labour were kept further apart than was usual, and were discharged at the earliest possible time after delivery. When pregnant women responded to this, they showed some apprehensions as they were not sure if they would receive proper treatment and if the treatment they received would be sufficient. Some FLHWs even reported that pregnant women were mandated to be tested for COVID-19 prior to admission in the hospital for delivery, but this could not be corroborated by respondents.

“It (deliveries) can’t happen like before. For example, earlier there used to be two to four sisters (nurses), who are not there now. They say that only one sister can do it (supervise the delivery).” (Pregnant Woman, District West Singhbhum, Jharkhand)

When respondents (in particular, those who preferred institutional deliveries) spoke of their own plans for delivery in the thick of the COVID-19 pandemic, they expressed trepidation, since they were unsure of whether they would actually be able to give birth in the hospital and what the process would look like. This was due to their having had limited or no access to the regular course of institutional ANC services during their pregnancy and decreased FLHW interactions which meant they were not sure what to expect as they neared their delivery date.

“My delivery will take place in a hospital but if this is not possible..(trails off). It may happen, it may not happen, we don’t know.” (Pregnant Woman, District Chitrakoot, Uttar Pradesh)

Some pregnant women reported a fear of complications arising in delivery, while others were nervous about the process of childbirth because they did not know what steps to take if they started experiencing labour pains. This sentiment was echoed by even those pregnant women who had received check-ups and ultrasounds and were nearing their expected date of delivery. They claimed that since the start of the lockdown, all pregnant women in their locality had delivered in hospitals, not at home. Despite their fear of contracting the virus and confusion about the process, they still emphatically expressed a preference for delivery in health facilities over home birth.

However, the respondents were unable to articulate whom (FLHW) they planned to contact at the onset of labour, and how they planned to go to the hospital for delivery, given that they were apprehensive of using the ambulance. There was a deep sense of fear and confusion without any accompanying guidance on how to navigate the delivery. Additionally, due to the pandemic creating unprecedented conditions (such as constraints on mobility and limited access to healthcare functionaries and facilities), women could not look to their elders or community for guidance on managing their pregnancies, since they were also experiencing these conditions for the first time. For these reasons, pregnant women felt demoralised and confused, without any clear course of action.