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Barriers to maternal and reproductive health care in India due to COVID-19

Barriers to maternal and reproductive health care in India due to COVID-19 Diamond-Smith N, et al. 2022. Barriers to maternal and reproductive health care in India due to COVID-19. Adv Glob Health. 1: 1. DOI: https://doi.org/10.1525/agh.2022.1713935 RESEARCH ARTICLE Barriers to maternal and reproductive health care in India due to COVID-19 1, 2 1 Nadia Diamond-Smith * , Lakshmi Gopalakrishnan , Sirena Gutierrez , 3 4 5 Sarah Francis , Nandita Saikia , and Sumeet Patil COVID-19 and its associated lockdowns and restrictions on movement may be impacting women and men’s access to and use of health care services including contraceptive, prenatal, and postnatal care. Yet we know little of its impact to date, especially in low- and middle-income countries, including India. Understanding how COVID-19 impacts the use of these services now, and as it persists, is essential for improving access and use today. Additionally, these data are necessary to understand fertility and other health-related outcomes we may see in the future. The objectives of this study are to understand a Facebook sample of respondent’s perceived barriers to contraceptive, prenatal, and postnatal care in India and how these changed over 4 months of the COVID-19 pandemic. To meet this need, we conducted four rounds of monthly online surveys with men and women (N ¼ 9,140) recruited using Facebook ads in India between April and July 2020, a period when the national lockdown was tapered from the strictest to restricted. While about 75% of respondents reported no barriers to contraception due to COVID-19, about half of those pregnant or postpartum reported barriers to pre- and postnatal care. Barriers to care for contraception, prenatal, and postnatal care increased significantly over time. Most respondents reported some change on fertility preferences, with more respondents reporting desire to delay, rather than to have a child sooner, due to COVID-19. Overall, as the early COVID-19 pandemic persisted, barriers to reproductive and maternal health care increased in India, suggesting that as the pandemic continued there have likely been additional challenges for people seeking these services. It is essential that health care providers begin to address these barriers to ensure access to care throughout these important time periods. Keywords: South Asia, COVID-19, Family planning care, Pregnancy care, Postpartum care, Social media Introduction highlighted the potential risk of reduced access to and There have been reports and commentaries highlighting care-seeking of prenatal, delivery, and postnatal services the possible impact of COVID-19 pandemic and associated in health facilities [2]. The aforementioned study esti- lockdowns on contraceptive services, with estimates of the mated that a 10% decrease in coverage in prenatal and pandemic resulting in mistimed or unintended pregnan- newborn care would result in an additional 28,000 mater- cies [1, 2]. UNICEF estimated a potential 7 million unin- nal and 168,000 newborn deaths. tended pregnancies globally, caused by disruptions in In India specifically, data from public health care cen- ters suggested a drop in women receiving contraception as contraception supply and use due to COVID-19 [3]. early as March when the COVID-19 pandemic started Another analysis of women in low- and middle-income receiving serious attention but before the lockdown was countries (LMICs) estimated that a 10% decline in the use of contraception could result in roughly 49 million imposed [1]. Another study among maternal and child womenwithanunmet need forcontraception andan health care providers in many countries, including India, found reports of a drop in patients coming for services, extra 15 million unintended pregnancies in the year fol- noncompliance with vaccination schedules in the postpar- lowing the COVID-19 pandemic. Other reports have tum period, and other disruptions to standards of care and procedures leading to outcomes such as increased caesar- University of California, San Francisco, CA, USA ean rates and shorter stays in the facility [4]. There are University of California, Berkeley, CA, USA myriad explanations for this, including staff shortages, the Upswell LLC, Seattle, WA, USA system being overwhelmed with COVID-19 response, and Jawaharlal Nehru University, New Delhi, India patients’ fear of visiting facilities [2]. Additionally, private Neerman, Mumbai, Maharashtra, India clinics providing contraception and abortion in India, such as Marie Stopes International, were forced to close due to * Corresponding author: Email: nadia.diamond-smith@ucsf.edu COVID-19, again reducing options for women [5]. In India, Art. 1(1) page 2 of 11 Diamond-Smith et al: Barriers to maternal and reproductive health care in India due to COVID-19 many women receive contraceptive services outside of (including place of delivery, prenatal and postnatal care) health facilities, from pharmacies and social marketing [17]. Therefore, gathering men’s perspective on maternal agencies. Lockdowns and resulting restrictions on move- and reproductive health service access and use during ment outside of the home and limits on transportation COVID-19 is important to study [17]. options are likely to make accessing contraception challeng- ing for many, in addition to supply chain disruptions [2]. India’s COVID-19 response timeline India has one of the world’s oldest family planning (or India reported its first COVID-19 case on January 30, 2020, contraceptive) programs. Post the International Confer- and as number of positive cases increased to 563, India ence on Population and Development, the government closed its international borders and enforced the world’s has integrated the contraception programs with reproduc- strictest nationwide lockdown on March 24, 2020, until tive and maternal and child health to include immuniza- April 14, 2020. During this period, all government offices tion, provision of reproductive health knowledge, and were shut for 21 days, except essential services such as services to improve maternal and child health [6]. The fire, police, and hospitals. All private and public sector government has introduced multiple programs to advance operations were shut, except essential manufacturing, maternal and child health outcomes including National banking, vegetables and groceries, and pharmacies. Logis- Rural Health Mission and Janani Suraksha Yojana in tics and supply chains were severely restricted. This con- 2005, National Urban Health Mission in 2008, Janani tainment measure was meant to give the government Shishu Suraksha Karyakram (JSSK) in 2011, Rashtriya time to prepare for a possible surge in cases [18, 19]. Kishor Swasthya Karyakram in 2014, Pradhan Mantri Sur- Further, this nationwide lockdown was extended until akshit Matritva Abhiyan (PMSMA) in 2016, and Pradhan May 17, 2020, by which time nearly 50,000 confirmed Mantri Matrutva Vandan Yojana (PMMVY) in 2017 [6, 7]. In cases were reported. Around the same time, the Indian 2013, India expanded the Reproductive and Child Health government also established a three-zone system that program to make it comprehensive under an integrated divided the districts based on the number of reported platform of RMNCHþA to include Reproductive, Mater- COVID-19 cases into red, orange, and green with certain nal, Newborn, Child, and Adolescent health along with relaxations applied based on the severity of caseload [20]. contraception services [8]. Beginning June 8, 2020, the Indian government estab- Despite overall gains and many pro-poor government lished phased reopening guidelines after 75 days of programs, many demand-side barriers exist such as social nationwide lockdown. During this phased reopening, the norms related to contraception, poor engagement from states were given autonomy to impose lockdown restric- male partners, early marriage, early childbearing, and tions only in the containment zones, while certain activi- stigma in buying contraceptives. Further, decisions made ties were allowed in other zones in a phased manner. This by mothers-in-law and husbands and low agency of first phase of reopening (June 1–30) was called Unlock 1.0 women, limited educational attainment of women, fear that permitted limited opening of private offices, start of of side effects, and patriarchal norms continue to be manufacturing with resident laborers, and shops allowed India’s challenges to achieving the Sustainable Develop- to open during certain times and days. However, night ment Goals [9–12]. curfews were observed, and gatherings or interstate travel According to the National Family Health Survey of was still not permitted [21].The next phase of reopening India (NFHS-4, 2015–2016) estimates, approximately (July 1–31), Unlock 2.0 included continued lockdown in 12.9% women have an unmet need for contraception. Just containment zones based on COVID-19 caseload but over half (54%) of married women of reproductive age allowed reopening of state borders and limited interna- (15–49 years) use modern contraception methods includ- tional travel [22]. At the time of writing this article, India ing female sterilization (36%), male condoms (5.6%), pills has instituted Unlock 4.0 phase that involves continued (4%), intrauterine devices (1.5%), and injectables (0.2%). lockdown in containment zones until September 30, The remaining just under half (46%) of women do not use 2020. Physical distancing and face coverings/masks con- any form of modern contraception. About 70% women tinue to be mandatory in public places, workplaces, and receive their contraceptive method from public sector public transport [23]. It is also important to note that the facility such as a community health center, primary health un-lockdown norms were often more stringent than cen- care center, or a rural hospital. About a quarter (24%) of ter guidelines in states and districts with high burden of women receive their contraceptive method from private COVID-19 cases. sector or a nongovernmental organization [13]. Most womeninIndia seek prenatal services, with 51% of Research objectives women having the recommended four prenatal visits To date, there are limited data on how COVID-19 has [14]. Postnatal care is much lower, with 30% of women impacted men and women’s contraceptive access and use, not having any postnatal visits. and use of prenatal and postnatal services, and what spe- Contraceptive use in India is highly women-centric due cific barriers people are facing due to COVID-19. We also to existing patriarchal norms, gender inequality, and do not know how these have changed over time as restric- female stereotyping in unions and reproduction [15]. Men tions on movement shifted throughout the course of the are important decision makers in contraceptive uptake pandemic and its corresponding response. Understanding and method choice [16]. Men are also important decision the impact of the COVID-19 pandemic and associated makers about using maternal health care services lockdowns can help us understand how to continue to Diamond-Smith et al: Barriers to maternal and reproductive health care in India due to COVID-19 Art. 1(1) page 3 of 11 provide services to women and men, which is vital since were asked “Did COVID affect your access to pre- or post- COVID-19 has continued, along with lockdowns of various natal care?” For each of these items, respondents could types. Additionally, we may see other pandemics or crises select one or more from a list of barriers, including an in the future, which could also impact reproductive and “Other” response category. While data were collected sep- maternal health care use. The primary objective of this arately from pregnant and postpartum women, data are article is to describe the impact of COVID-19 on fertility presented together here due to the similar stage in their preferences and barriers to contraception, prenatal and life course, similar services being availed and small sample postnatal care use in India, and explore trends over time. sizes. Finally, multivariable logistic regression models are run Materials and methods to look at the association between round of the survey Online survey data were collected at four time points: (time), sociodemographics, and barriers to (1) contracep- mid-April, mid-May, mid-June and mid-July, 2020. Men tion and (2) pre- or postnatal care. A binary outcome and women living in any part of India were recruited for variable for barriers was created with no barrier being the survey using Facebook advertisements (ads). Respon- coded as 0 and 1 or more barrier being coded as 1. Socio- dents could take the survey in either Hindi or English. demographic variables included in the models are age, Eligibility criteria included being over 18 years old and sex, education, region of India, rural/urban, and wealth. living in India. We used a repeated cross-sectional design, sending out the Facebook ads every month for three more Results rounds (total of four rounds) to recruit a new set of From the total 12,898 respondents who completed the respondents at each time point. This study received sample, 3,758 were dropped due to suspected fraudulent human subjects’ approval from the University of Califor- data, leaving a final sample of 9,140 (Table 1). Sample nia, San Francisco. characteristics varied across all rounds, which is expected In addition to basic demographics, the survey covered given that the investigators have no control over who domains related to barriers to pregnancy, postpartum, chooses to complete the survey unlike in face-to-face contraceptive and abortion care due to COVID-19, as well surveys. as barriers to health care in general (questionnaire will be Fertility preferences: An increasing proportion of available with open data). Given the cultural norms respondents over time stated that their or their wife’s around pregnancy and contraception use outside of mar- fertility preferences had not changed due to COVID-19, riage, our study team felt it was appropriate that unmar- ranging from 31% to 49% (Table 2). The most commonly ried respondents skipped the questions related to cited response to the impact was that respondents felt pregnancy and contraception. Additionally, all respon- that they could not afford a/another child, and this dents who reported that they were currently sterilized appeared to increase from around 12% to around 20%. skipped these questions. Midway through the second Few respondents reported that it increased their desire, round we switched the ordering of the questions to put hovering around 2-3% over time. the reproductive and maternal health questions last, after Contraceptive access: A fairly stable percentage of the demographic questions because we thought that hav- respondents reported that their contraceptive access was ing fewer sensitive questions at the end might help not affected by COVID-19 (62–74%) (Table 3). Only a small increase response rates. percentage (about 2%) said that their access to contracep- First, we cleaned the data to remove suspected fraud- tion was made easier. Generally over time, respondents ulent responses or those who did not meet eligibility became more fearful to go to the clinic, felt the economic requirements. Fraudulent results were classified as impact posed by the pandemic, and perceived less time responses that came from the same IP address as another and increased household burden. Also, 2% of respondents response, were answered very quickly (<60 s), wrote non- said that it had become easier for them to obtain their appropriate responses (e.g. words where there should have method. been letters), and noneligible were those not over age 18. In the first round of the survey, we allowed respondents Next, we describe the demographics of the sample, by the option to write in “other” responses. A common theme round. We then describe the change over time (by round) was that men and women brought up was that they were in the impact of COVID-19 on fertility preferences, barriers no longer having sex because they are now living in a dif- to contraception, and pre- and postnatal services. To mea- ferent place or separated in some way from their partner sure fertility preferences, respondents were asked “How due to COVID-19. Relatedly, respondents also wrote about have your/your wife’s pregnancy preferences been there not being a “chance” to meet now due to COVID-19, affected by COVID-19?” Given cultural norms related to which we interpreted as being related to rules about the joint decision-making and the fact that both men and women responded to the survey, the study team felt that nationwide lockdown, social distancing, and restrictions this was the appropriate phrasing for this question. To on movement. This response came up so frequently that measure barriers to contraception, nonpregnant and non- we added another response category to the subsequent sterilized respondents were asked “Did COVID-19 affect surveys; however, only 1% reported this (although this was your access to family planning/contraception?” To mea- only an option after Round 1). A number (about 20) of sure barriers to pre- and postnatal care due to COVID-19, respondents wrote that they received their method via pregnant and postpartum women (and their partners) some sort of a mobile application. Art. 1(1) page 4 of 11 Diamond-Smith et al: Barriers to maternal and reproductive health care in India due to COVID-19 Table 1. Characteristics of study participants, by round, April–July 2020 Variables Round 1 Round 2 Round 3 Round 4 Total (N) 5,980 618 1,881 659 Age ranges <20 335 (5.7%) 22 (3.6%) 52 (3.0%) 14 (3.0%) 20–29 2,985 (50.8%) 316 (51.1%) 423 (24.7%) 100 (21.4%) 30–39 1,683 (28.6%) 138 (22.3%) 495 (28.9%) 93 (19.9%) 40–49 548 (9.3%) 86 (13.9%) 348 (20.3%) 136 (29.1%) 50–59 209 (3.6%) 52 (8.4%) 398 (23.2%) 125 (26.71%) Over 60 121 (2.1%) 4 (0.7%) 0 (0.0%) 0 (0.0%) Sex of the participant Female 2,455 (41.8%) 484 (78.3%) 624 (50.5%) 124 (46.8%) Male 3,525 (58.9%) 134 (21.7%) 1,257 (66.8%) 535 (81.2%) Married 3,410 (58.0%) 412 (66.7%) 965 (78.5%) 214 (81.4%) Region of India North 2,908 (52.2%) 343 (55.5%) 628 (53.9%) 127 (51.8%) South 610 (10.9%) 39 (6.3%) 70 (6.0%) 19 (7.8%) East 1,053 (18.9%) 107 (17.3%) 234 (20.1%) 53 (21.6%) West 1,005 (18.0%) 110 (17.8%) 211 (18.1%) 41 (16.7%) Pregnancy status Pregnant 198 (6.0%) 25 (7.9%) 38 (6.7%) 7 (6.3%) Postpartum 1 month 97 (3.0%) 22 (7.0%) 15 (2.7%) 7 (6.3%) Not pregnant, not 1,346 (41.0%) 146 (46.2%) 201 (35.6%) 35 (31.5%) sterilized Sterilized/wife sterilized 613 (18.7%) 100 (31.7%) 188 (33.3%) 36 (32.4%) Education Less than high school 329 (5.8%) 11 (1.9%) 34 (3.0%) 11 (4.5%) Class tenth 794 (13.9%) 30 (5.1%) 60 (5.2%) 21 (8.6%) Vocational/some 828 (14.5%) 46 (7.9%) 97 (8.4%) 33 (13.5%) college College degree or more 3,774 (65.9%) 499 (85.2%) 961 (83.4%) 179 (73.4%) Income Less than $662 1,732 (30.2%) 169 (28.1%) 307 (26.0%) 73 (29.6%) $662–1,324 1,784 (31.2%) 177 (29.5%) 314 (26.6%) 56 (22.7%) $1324–6,620 1,676 (29.3%) 172 (28.6%) 382 (32.4%) 81 (32.8%) Over $6,620 535 (9.3%) 83 (13.8%) 178 (15.1%) 37 (15.0%) Urbanicity Urban 3,661 (64.2%) 440 (71.2%) 780 (67.5%) 145 (59.4%) Rural 2,319 (38.8%) 178 (28.8%) 1,101 (58.5%) 514 (78.0%) Prenatal and postnatal care: Between about 50% and barriers increased over time, although the N’s got quite 60% of respondents reported barriers to pre- or postnatal small by Round 4. Being unable to go to an appointment care (Table 4). Over time, fewer respondents reported no because of lockdown/restrictions on movement was the barriers to pre- or postnatal care; in other words, reports of most common barrier, with some evidence of increase Diamond-Smith et al: Barriers to maternal and reproductive health care in India due to COVID-19 Art. 1(1) page 5 of 11 Table 2. Fertility preferences, by round, April–July 2020 Round 1 Round 2 Round 3 Round 4 (N ¼ 2,691) (N ¼ 140) (N ¼ 192) (N ¼ 35) How have your/your wife’s pregnancy preferences been affected by COVID-19? N % N % N % N % It has not changed my preferences 837 31 52 37 74 39 17 49 Increased my desire to have a child/another child 61 2 4 3 7 4 1 3 Decreased my desire to have a child/another child 95 4 5 4 22 11 1 3 Feel that I can’t afford a child/another child 339 13 31 22 41 21 7 20 Scared to be pregnant/have a/another child 112 4 11 8 22 11 3 9 Want to delay having a child for the next year 246 9 19 14 24 13 3 9 Other 1001 37 35 25 42 22 10 29 Table 3. Barriers to contraceptive use, by round, April–July 2020 Round 1 Round 2 Round 3 Round 4 (N ¼ 2,584) (N ¼ 182) (N ¼ 187) (N ¼ 34) Did COVID-19 affect your access to family planning/ contraception? N % N % N % N % Not affected 1934 75 114 63 139 74 24 71 Made easier 41 2 4 2 3 2 1 3 Switched method due to COVID-19 4 2 6 3 0 0 Stopped method 58 2 1 1 5 3 0 0 Made harder because you are not allowed to go outside your home 118 5 7 4 2 1 1 3 currently due to government restrictions Made harder because the place you get your method is closed 35 1 3 2 7 4 0 0 Harder because you are afraid to go to the hospital/clinic 42 2 4 2 10 5 3 9 Harder because you are afraid to go to outside 80 3 2 1 0 0 0 0 Harder because you do not have enough money 72 3 2 1 7 4 2 6 Harder because you don’t have time due to additional household work or 93 4 4 2 12 6 3 9 childcare No longer needed because we are separated due to COVID-19 17 9 12 6 7 21 Other 173 7 38 21 53 28 13 38 Notes: Multiple responses per respondents possible, all responses combined. over time. More respondents noted that COVID-19 made When both genders are included in the model, the them more likely to deliver in a facility, rather than less odds of reporting barriers to prenatal or postnatal care likely to delivery in a facility. increased in a consistent manner over time, with respon- dents in June having increased odds times of reporting barriers compared to respondents in the first month of Multivariable models of factors associated with data collection (OR ¼ 2.73, 95% CI 1.29–5.75) (Table 6). reproductive and maternal health care barriers Theconfidenceintervals are quite large for thefourth The odds of reporting barriers to contraception increased round of data collection because the sample size became over time in a steady manner, with respondents reporting small. Since women had significantly higher odds of 4.41 times the odds (95% CI ¼ 2.14–9.08) by July com- reporting barriers, we also ran the model for women alone pared to April (Table 5). Respondents living in urban and found a similar trend, with women having an areas, who had a higher income and who were more edu- cated, reported lower odds of facing barriers compared to increased odds (OR ¼ 2.23, 95% CI ¼ 0.94–5.29 in May; rural, poorer, and less well-educated respondents. There OR ¼ 3.85, 95% CI 1.46–10.14 in June) of reporting bar- was no difference by gender or age. riers, compared to April, and the trend increasing in Art. 1(1) page 6 of 11 Diamond-Smith et al: Barriers to maternal and reproductive health care in India due to COVID-19 Table 4. Impact of COVID-19 on access to prenatal and postnatal care, by round, April–July 2020 Round 1 Round 2 Round 3 Round 4 (N ¼ 287) (N ¼ 46) (N ¼ 48) (N ¼ 11) Did COVID affect your access to pre or postnatal care? N % N % N % N % Not affected 154 54 16 35 22 46 3 27 Unable to go to your appointments because of lockdown/restrictions on 32 11 14 30 7 15 4 36 movement Unable to go to your appointments because you are afraid to go to 53 18 5 11 12 25 2 18 a facility/clinic Unable to go to your appointments because facility/clinic closed 6 13 5 10 2 18 Unable to go to your appointment because of transportation issues 3 7 — — — Less likely to/made us not deliver at a health facility because of 49 — — — — transportation issues Less likely to/made us not deliver at a health facility because of lockdown/ 15 5 3 7 2 4 0 0 restrictions on movement Less likely to/made us not deliver at a health facility because you are afraid to 24 8 1 2 4 8 1 9 go to a facility/clinic More likely to/made us deliver in a health care facility — — 1 2 12 25 2 18 Other changes of prenatal and postnatal services change 15 5 3 7 22 46 6 55 Notes: Multiple responses per respondents possible, all responses combined. a steady manner over time. No other sociodemographic respondents faced fewer barriers, raising the concern factors were significantly associated with barriers. about exacerbated reproductive health inequalities due to COVID-19. We excluded respondents who were steril- ized or whose partner was sterilized. Long-acting methods Discussion (LARCs) are not as common in India, and therefore we do COVID-19 is associated with barriers to care for contracep- not believe that the reason there as little impact on con- tion, prenatal and postnatal women in India, and these are traceptives was that most respondents or their partners increasing over time. Given that we are 2 years into the were using LARCs. The open-ended responses from the COVID-19 pandemic, this highlights the potential large- first round suggest that perhaps respondents were able scale impacts that the pandemic could be having on access to switch to getting their methods from online sources. to reproductive and maternal health services. The study from the United States, mentioned above, found Overall, COVID-19 led to changes in fertility prefer- very similar proportions of women reporting barriers to ences for about one third of respondents. Among those contraceptive care, at about 30% reporting a barrier [24]. whose preferences had changed, it was mostly in terms of Another interesting finding is that a subset, that is not wanting children at the time of the survey or due to potentially not negligible, of respondents noted that financial concerns. A study in the United States which changes in contraceptive use were due to not being with collected data using established online panels from early their partner at this time due to COVID-19 restrictions. in the pandemic (late April/early May) suggested that This has interesting implications for both interpretations 40% of women changed their fertility preferences with of method discontinuation during this time and, poten- an overwhelming majority wanting children later or fewer tially more importantly, for what might happen after children, because of COVID-19 [24]. Findings are similar in restrictions are eased and respondents are able to recon- magnitude and suggest that the impact was similar for nect with their partners. If respondents have stopped both men and women in the Indian setting. The item used using their method because of COVID-19 and then sud- in our survey was limited in that it did not differentiate denly are able to be sexually active again, perhaps without well between a woman’s preferences, a man’s preferences, much warning, this might lead to mistimed or unintended and a man’s perception of his wife’s preference. At the pregnancies. Ensuring that people have a choice of con- time of deploying the survey, this seemed like the appro- priate wording given the cultural context; however, it traceptive methods on hand for the future thus may have leads to limitations in our interpretation. added importance. The majority of respondents in our sample did not have In contrast to few impacts on contraception, prenatal their access to contraception affected by COVID-19 (75%); and postnatal care appear to have been more affected by however, barriers increased over time with the pandemic. COVID-19, with about half of respondent reporting bar- As we would expect, urban, educated, and richer riers. We also find that barriers to these services increased Diamond-Smith et al: Barriers to maternal and reproductive health care in India due to COVID-19 Art. 1(1) page 7 of 11 Table 5. Adjusted logistic regression models assessing the association between time, socioeconomic factors and antenatal and postnatal care barriers, India Both Genders (n ¼ 374) Women Only (n ¼ 180) Variables OR 95% CI p OR 95% CI p Month April 1.0 Referent 0.07 1.0 Referent 0.07 May 1.98 0.95–4.13 0.01 2.23 0.94–5.29 0.01 June 2.73 1.29–5.75 0.03 3.85 1.46–10.14 0.08 July 9.68 1.20–78.2 7.25 0.81–64.86 Sex Male 1.0 Referent 0.06 — — — Female 1.60 0.97–2.64 Age Under 30 1.0 Referent 0.99 1.0 Referent 0.92 At least 30 0.99 0.62–1.62 1.04 0.49–2.21 Rural Yes 1.0 Referent 0.94 1.0 Referent 0.64 No, urban 0.98 0.62–1.56 0.84 0.40–1.75 Region in India North 1.0 Referent 0.47 1.0 Referent 0.64 South 0.77 0.34–1.58 0.40 0.77 0.27–2.25 0.88 East 0.78 0.43–1.40 0.49 1.08 0.41–2.82 0.99 West 0.83 0.48–1.42 0.99 0.45–2.21 Income Less than $662 1.0 Referent 0.71 1.0 Referent 0.27 $662–1,324 0.90 0.51–1.58 0.82 1.65 0.67–4.03 0.18 $1,324–6,620 0.94 0.52–1.67 0.14 1.90 0.75–4.85 0.73 Over $6,620 0.51 0.21–1.25 0.81 0.26–2.59 Education Less than high school 1.0 Referent 0.57 1.0 Referent 0.15 Class tenth 0.73 0.25–2.14 0.91 0.12 0.01–2.13 0.16 Vocational/some college 0.94 0.33–2.64 0.52 0.16 0.01–2.06 0.20 College degree or more 0.73 0.28–1.89 0.22 0.02–2.30 OR ¼ odds ratio; CI ¼ confidence interval. with the course of the pandemic, and that sociodemo- antenatal care [26]. In Rwanda, there was significant graphic characteristics were not associated with bar- decline in access to and utilization of maternal care ser- riers—instead they seem to be more universal. A vices including antenatal care, deliveries, postnatal care, modeling study predicts that the coverage of maternal and and vaccinations [27]. In Bangladesh, lockdown instituted reproductive health interventions including antenatal due to COVID-19 resulted in significant drops in number care, contraception, and postnatal care have significantly of antenatal and postnatal care visits to public health declined (9.8–18.5%) in LMICs [25]. facilities [28]. Similar results were seen in Ethiopia where Other studies have documented the adverse impact of there were significant declines in utilization of antenatal COVID-19-related measures on contraception and mater- care, health facility births, contraception, and newborn nal health services in LMICs. Antenatal care coverage was immunizations, while at the same time, there was signif- also impacted in LMICs with the closure of health facilities icant increases in teenage pregnancy, stillbirths and neo- because of COVID-19 measures and lack of funds to access natal deaths, and teenage abortions [29]. Art. 1(1) page 8 of 11 Diamond-Smith et al: Barriers to maternal and reproductive health care in India due to COVID-19 Table 6. Adjusted logistic regression model assessing had moved online via telemedicine [30]. The main chal- the association between time, socioeconomic factors lenges reported by health care providers in the study and contraceptive barriers, India included lack of infrastructure and technological literacy, limited monitoring, financial and language barriers, lack Both Genders (n ¼ 2,878) of nonverbal feedback and bonding, and distrust from patients [30]. In our study, fear of going to the clinic/ Variables OR 95% CI p facilitywas amainbarrier forall typesofhealthcare Month utilization. Delays due to fear of going to the facility have been found in a few other small studies on COVID-19 from April 1.0 Referent 0.001 other countries (mostly European) and for other types of May 2.05 1.48–2.84 0.001 health care seeking [31, 32]. It is interesting that actual June 2.22 1.61–3.06 0.001 barriers due to facility closure or restrictions on move- ment were not the primary barrier, but rather respondents July 4.41 2.14–9.08 were making choices not to go, due to fear. Helping Sex women, especially those at high risk, feel safe and under- Male 1.0 Referent 0.78 stand precautions taken at facilities to protect them, is essential. Female 0.97 0.81–1.17 Some pregnant women/partners of pregnant women Age expressed fears about delivering in a facility due to COVID- Under 30 1.0 Referent 0.91 19; however, more respondents reported that it made them more likely to deliver in a facility (or want to). This At least 30 0.99 0.83–1.18 could have important implications for health care delivery Rural if systems become overcrowded. However, fundamentally, Yes 1.0 Referent 0.001 more research, including qualitative interviews with men and women, could help uncover reasons for these fears No, urban 0.70 0.58–0.84 and the other barriers described above. Region in India These findings were collected early in the pandemic, North 1.0 Referent 0.43 and more research is needed on the impact on access to care as COVID-19 has persisted. Additionally, how barriers South 1.13 0.83–1.53 0.89 have translated into changes in health care use and out- East 0.98 0.78–1.24 0.72 comes is essential, for example, if there have been unin- West 0.96 0.77–1.20 tended pregnancies or more adverse maternal or infant health outcomes. Much more evidence is needed about Income impacts of COVID-19 on place of delivery, and what longer Less than $662 1.0 Referent 0.013 term effects this has on maternal and newborn health $662–1,324 0.75 0.60–0.94 0.001 outcomes. $1,324–6,620 0.68 0.54–0.85 0.004 Limitations Over $6,620 0.63 0.45–0.86 Despite its strengths in terms of collecting data rapidly Education (and inexpensively) on the emerging pandemic’s impact, and doing so over time, this study has limitations. From Less than high school 1.0 Referent 0.89 a methodological standpoint, due to COVID-19, there is Class tenth 1.03 0.69–1.55 0.20 increasing interest in methods of data collection that can Vocational/some college 0.76 0.50–1.16 0.04 collect data quickly from respondents without personal interactions, such as over the phone and online. Recruit- College degree or more 0.70 0.49–0.99 ment via social media platforms, such as Facebook, is one OR ¼ odds ratio; CI ¼ confidence interval. such approach for recruiting respondents and collecting data from them. A number of studies have employed this technique during the recent pandemic, and interesting contributions are being made in terms of thinking about There has been a shift to the provision of prenatal and the ethics, representativeness, weighting, and general some postnatal care via telemedicine in India, as else- approaches of such methods [33, 34]. where, and more research is needed on how much of care Limited research of this nature has been carried out in has been able to be moved to telemedicine and the longer LMICs, especially studies involving multiple rounds of term impact of this approach on maternal and child out- data collection. One recent study that did use Facebook comes and experiences. In a worldwide survey of health ads for recruitment in India noted that they found no care providers, 58% of them stated that maternal and other published studies in India using this approach newborn care services such as online birth preparedness [35]. These authors noted that while the sample recruited classes, antenatal and postnatal care by video/phone, on Facebook was not representative of the population a COVID-19 helpline, and online psychosocial counseling broadly, it did have a wide geographical spread. Studies Diamond-Smith et al: Barriers to maternal and reproductive health care in India due to COVID-19 Art. 1(1) page 9 of 11 using Facebook or other social media approaches for barriers exist to seeking reproductive and maternal health recruitment do have limitations in that we do not know care due to COVID-19, and they may worsen with time. the exact population from which we are drawing our sam- ple; however, by adjusting our models for socioeconomic Recommendations covariates, we are able to still draw inferences about fac- In light of our current study, we suggest programs or tors associated with outcomes of interest. policy makers focus on ensuring that women and men are Another limitation of note is that, especially in the later receiving the reproductive and maternal health care that rounds, the sample size of respondents to questions on they need as the pandemic persists, with a focus on vul- reproductive and maternal health was quite small. This nerable and disadvantaged populations. Addressing con- reduces our ability to draw conclusions about the impacts cerns about fears related to going to facilities through of the pandemic on access and behaviors, or how those mass media or social media might help assuage fears or changed over time. We were interested in a broad range of address misperceptions. Ensuring that widespread misin- questions and wanted to capture gendered effects; had we formation and disinformation regarding COVID-19 and more narrowly targeted our Facebook ads for women of immunizations can help reduce concerns of affected reproductive age only (and not collected data on men), we populations. likely would have recruited larger samples. Also, we did not offer an incentive for each round, which might have Data availability statement increased the sample, although this likely would have We are currently working on share our data on the CORNET drawn bots or more fraudulent or duplicated responses. platform funded by BMGF. https://covidresearchnetwork. Partly due to the small sample size, we were unable to slack.com/join/shared_invite/zt-ffgukmau-9G0wYJRzxg stratify our data by other important characteristics, such as XHeVQX0YZr7Q#/. age, geography, caste, education level, and so on. India is a heterogenous and diverse country and these different Competing interests subpopulations would likely be differentially impacted by The authors declare that they have no competing interests. COVID-19. However, we are forced to make generalized statements about India as a whole, which hide the subtle- Author contributions ties that likely exist. Finally, our survey was rather long, NDS: conceptualization, methodology, writing; LG: con- and midway through the second round we switched the ceptualization, project management, investigation, meth- ordering of the questions to put the reproductive and odology; SG: analysis, data cleaning; SF: data curation, maternal health questions last (upon advice that having resources, methodology; NS: supervision, writing; SP: fewer sensitive questions at the end might increase supervision. respondents). However, this likely ended up reducing the sample that answered these questions specifically. Ethical approval It is essential that these findings, both because of their This study received human subjects’ approval from the sample size and recruitment approach, not be generalized University of California, San Francisco. to a wider population. At best, these provide some sug- gestive insights into the impact of the pandemic on Patient consent a social media using population, mostly in the north of All respondents read and gave consent to participate India. online at the start of the survey. Conclusions References Our study, based on a sample of women and men in India 1. Vora KS, Saiyed S, Natesan S. Impact of COVID-19 on recruited using social media, suggests that respondents family planning services in India. Sex Reprod Health faced some barriers to their prenatal and postnatal care Matters. 2020;28(1): 1785378. due to COVID-19 and associated lockdowns, and these 2. Riley T, Sully E, Ahmed Z, et al. Estimates of the poten- worsened over the first few months of the pandemic, even tial impact of the COVID-19 pandemic on sexual and after official restrictions loosened. The pandemic seems to reproductive health in low- and middle-income coun- be making some respondents more likely to want to delay tries. Int Perspect Sex Reprod Health. 2020;46: 73–76. or not have children, primarily due to financial concerns. 3. UNFPA. Impact of the COVID-19 pandemic on family One of the main takeaways is that the pandemic did not planning and ending gender-based violence, female appear to increase respondents’ desire to have more chil- genital mutilation and child marriage [Internet]. dren at the time of the survey. If we do see additional 2020. Available: /resources/impact-covid-19-pan births, as has been widely touted as a possibility by the demic-family-planning-and-ending-gender-based- news media, we have some limited evidence that these violence-female-genital. Accessed 18 August 2020. were unintended [36]. 4. Semaan A. Voices from the frontline: findings from This study provides timely information about the a thematic analysis of a rapid online global survey impact of COVID-19 and related lockdowns/restrictions of maternal and newborn health professionals facing on movement on reproductive and maternal health care the COVID-19 pandemic. BMJ Global Health. 2020;5: access and use. These findings are suggestive that some e002967. Art. 1(1) page 10 of 11 Diamond-Smith et al: Barriers to maternal and reproductive health care in India due to COVID-19 5. Marie Stopes International. Stories from the frontline 1Guidelines_30052020.pdf. Accessed 13 September [Internet]. Marie Stopes International; 2020. Avail- 2020. able: https://www.mariestopes.org/covid-19/stories- 22. Unlock 2.0 Guidelines, Ministry of Home Affairs, Gov- from-the-frontline/. Accessed 18 August 2020. ernment of India [Internet]. 2020. Available: https:// www.mha.gov.in/sites/default/files/MHAUnlock2_ 6. Srinivasan K. Population Concerns in India: Shifting 29062020.pdf. Accessed 13 September 2020. Trends, Policies, and Programs. New Delhi, India: 23. Unlock 4.0 Guidelines, Ministry of Home Affairs, Gov- SAGE Publishing India; 2017, 348 p. ernment of India [Internet]. 2020. Available: https:// 7. Bhatia M, Dwivedi LK, Banerjee K, et al. Pro-poor pol- www.mha.gov.in/sites/default/files/MHAOrder_ icies and improvements in maternal health outcomes Unlock4_29082020.pdf. Accessed 13 September 2020. in India. BMC Pregnancy Childbirth. 2021;21(1): 389. 24. Lindberg L,VandeVusse A, Mueller J, et al. Early impacts 8. Taneja G, Sridhar VSR, Mohanty JS, et al. India’s of the COVID-19 pandemic: findings from the 2020 RMNCHþA strategy: approach, learnings and limita- Guttmacher survey of reproductive health experiences tions. BMJ Glob Health. 2019;4(3): e001162. [Internet]. Guttmacher Institute. 2020. Available: 9. Wulifan JK, Brenner S, Jahn A, et al. A scoping review https://www.guttmacher.org/report/early-impacts- on determinants of unmet need for family planning covid-19-pandemic-findings-2020-guttmacher-survey- among women of reproductive age in low and middle reproductive-health. Accessed 3 September 2020. income countries. BMC Women’s Health. 2016;16: 2. 25. Roberton T, Carter ED, Chou VB, et al. Early estimates 10. Garg S, Singh R. Need for integration of gender equity of the indirect effects of the COVID-19 pandemic on in family planning services. Indian J Med Res. 2014; maternal and child mortality in low-income and 140(Suppl): S147–S151. middle-income countries: a modelling study. Lancet 11. Pathfinder International. Barriers to effective family Glob Health. 2020;8(7): e901–e908. planning: evidence from research literature [Internet]. 26. Endarwati S, Rasyidah LK, Asdary RN. The disruptions June 2021. 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Avail- COVID-19 pandemic: a snapshot survey of 4075 pae- able: https://thewire.in/covid-19-india-timeline. diatricians in the UK and Ireland. Arch Dis Child. Accessed 13 September 2020. 2020;106: archdischild-2020-319848. 21. Unlock 1.0 Guidelines, Ministry of Home Affairs, Gov- 33. Del Fava E, Cimentada J, Perrotta D, et al. The differ- ernment of India [Internet]. 2020. Available: https:// ential impact of physical distancing strategies on www.mha.gov.in/sites/default/files/PR_UNLOCK social contacts relevant for the spread of COVID-19 Diamond-Smith et al: Barriers to maternal and reproductive health care in India due to COVID-19 Art. 1(1) page 11 of 11 [Internet]. Epidemiology. May 2020. Available: http:// Facebook, Mechanical Turk, and Qualtrics. Polit Sci medrxiv.org/lookup/doi/10.1101/2020.05.15. Res Methods. 2020;8(2): 232–250. 20102657. Accessed 19 August 2020. 36. Times of India. COVID-19 baby boom? India expected 34. Perrotta D, Grow A, Rampazzo F, et al. Behaviors and to have the highest number of births this year [Inter- attitudes in response to the COVID-19 pandemic: net]. Times of India. 7 May 2020. Available: https:// insights from a cross-national Facebook survey. medR- timesofindia.indiatimes.com/life-style/parenting/ xiv. 2020; 2020.05.09.20096388. pregnancy/covid-19-baby-boom-india-expected-to- 35. Boas TC, Christenson DP, Glick DM. Recruiting large have-the-highest-number-of-births-this-year/ onlinesamples in theUnited Statesand India: articleshow/75602754.cms. Accessed 22 June 2022. How to cite this article: Diamond-Smith N, Gopalakrishnan L, Gutierrez S, et al. Barriers to maternal and reproductive health care in India due to COVID-19. Adv Glob Health. 2022;1(1). https://doi.org/10.1525/agh.2022.1713935 Editor-in-Chief: Craig R. Cohen, University of California, San Francisco, CA, USA Senior Editor: Sarah Ssali, Makerere University, Kampala, Uganda Section: Achieving Gender Equality Published: July 4, 2022 Accepted: June 4, 2022 Submitted: October 17, 2021 Copyright: © 2022 The Author(s). This is an open-access article distributed under the terms of the Creative Commons Attribution 4.0 International License (CC-BY 4.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. See http://creativecommons.org/licenses/by/4.0/. Adv Glob Health is a peer-reviewed open access journal published by University of California Press. http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Advances in Global Health University of California Press

Barriers to maternal and reproductive health care in India due to COVID-19

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Diamond-Smith N, et al. 2022. Barriers to maternal and reproductive health care in India due to COVID-19. Adv Glob Health. 1: 1. DOI: https://doi.org/10.1525/agh.2022.1713935 RESEARCH ARTICLE Barriers to maternal and reproductive health care in India due to COVID-19 1, 2 1 Nadia Diamond-Smith * , Lakshmi Gopalakrishnan , Sirena Gutierrez , 3 4 5 Sarah Francis , Nandita Saikia , and Sumeet Patil COVID-19 and its associated lockdowns and restrictions on movement may be impacting women and men’s access to and use of health care services including contraceptive, prenatal, and postnatal care. Yet we know little of its impact to date, especially in low- and middle-income countries, including India. Understanding how COVID-19 impacts the use of these services now, and as it persists, is essential for improving access and use today. Additionally, these data are necessary to understand fertility and other health-related outcomes we may see in the future. The objectives of this study are to understand a Facebook sample of respondent’s perceived barriers to contraceptive, prenatal, and postnatal care in India and how these changed over 4 months of the COVID-19 pandemic. To meet this need, we conducted four rounds of monthly online surveys with men and women (N ¼ 9,140) recruited using Facebook ads in India between April and July 2020, a period when the national lockdown was tapered from the strictest to restricted. While about 75% of respondents reported no barriers to contraception due to COVID-19, about half of those pregnant or postpartum reported barriers to pre- and postnatal care. Barriers to care for contraception, prenatal, and postnatal care increased significantly over time. Most respondents reported some change on fertility preferences, with more respondents reporting desire to delay, rather than to have a child sooner, due to COVID-19. Overall, as the early COVID-19 pandemic persisted, barriers to reproductive and maternal health care increased in India, suggesting that as the pandemic continued there have likely been additional challenges for people seeking these services. It is essential that health care providers begin to address these barriers to ensure access to care throughout these important time periods. Keywords: South Asia, COVID-19, Family planning care, Pregnancy care, Postpartum care, Social media Introduction highlighted the potential risk of reduced access to and There have been reports and commentaries highlighting care-seeking of prenatal, delivery, and postnatal services the possible impact of COVID-19 pandemic and associated in health facilities [2]. The aforementioned study esti- lockdowns on contraceptive services, with estimates of the mated that a 10% decrease in coverage in prenatal and pandemic resulting in mistimed or unintended pregnan- newborn care would result in an additional 28,000 mater- cies [1, 2]. UNICEF estimated a potential 7 million unin- nal and 168,000 newborn deaths. tended pregnancies globally, caused by disruptions in In India specifically, data from public health care cen- ters suggested a drop in women receiving contraception as contraception supply and use due to COVID-19 [3]. early as March when the COVID-19 pandemic started Another analysis of women in low- and middle-income receiving serious attention but before the lockdown was countries (LMICs) estimated that a 10% decline in the use of contraception could result in roughly 49 million imposed [1]. Another study among maternal and child womenwithanunmet need forcontraception andan health care providers in many countries, including India, found reports of a drop in patients coming for services, extra 15 million unintended pregnancies in the year fol- noncompliance with vaccination schedules in the postpar- lowing the COVID-19 pandemic. Other reports have tum period, and other disruptions to standards of care and procedures leading to outcomes such as increased caesar- University of California, San Francisco, CA, USA ean rates and shorter stays in the facility [4]. There are University of California, Berkeley, CA, USA myriad explanations for this, including staff shortages, the Upswell LLC, Seattle, WA, USA system being overwhelmed with COVID-19 response, and Jawaharlal Nehru University, New Delhi, India patients’ fear of visiting facilities [2]. Additionally, private Neerman, Mumbai, Maharashtra, India clinics providing contraception and abortion in India, such as Marie Stopes International, were forced to close due to * Corresponding author: Email: nadia.diamond-smith@ucsf.edu COVID-19, again reducing options for women [5]. In India, Art. 1(1) page 2 of 11 Diamond-Smith et al: Barriers to maternal and reproductive health care in India due to COVID-19 many women receive contraceptive services outside of (including place of delivery, prenatal and postnatal care) health facilities, from pharmacies and social marketing [17]. Therefore, gathering men’s perspective on maternal agencies. Lockdowns and resulting restrictions on move- and reproductive health service access and use during ment outside of the home and limits on transportation COVID-19 is important to study [17]. options are likely to make accessing contraception challeng- ing for many, in addition to supply chain disruptions [2]. India’s COVID-19 response timeline India has one of the world’s oldest family planning (or India reported its first COVID-19 case on January 30, 2020, contraceptive) programs. Post the International Confer- and as number of positive cases increased to 563, India ence on Population and Development, the government closed its international borders and enforced the world’s has integrated the contraception programs with reproduc- strictest nationwide lockdown on March 24, 2020, until tive and maternal and child health to include immuniza- April 14, 2020. During this period, all government offices tion, provision of reproductive health knowledge, and were shut for 21 days, except essential services such as services to improve maternal and child health [6]. The fire, police, and hospitals. All private and public sector government has introduced multiple programs to advance operations were shut, except essential manufacturing, maternal and child health outcomes including National banking, vegetables and groceries, and pharmacies. Logis- Rural Health Mission and Janani Suraksha Yojana in tics and supply chains were severely restricted. This con- 2005, National Urban Health Mission in 2008, Janani tainment measure was meant to give the government Shishu Suraksha Karyakram (JSSK) in 2011, Rashtriya time to prepare for a possible surge in cases [18, 19]. Kishor Swasthya Karyakram in 2014, Pradhan Mantri Sur- Further, this nationwide lockdown was extended until akshit Matritva Abhiyan (PMSMA) in 2016, and Pradhan May 17, 2020, by which time nearly 50,000 confirmed Mantri Matrutva Vandan Yojana (PMMVY) in 2017 [6, 7]. In cases were reported. Around the same time, the Indian 2013, India expanded the Reproductive and Child Health government also established a three-zone system that program to make it comprehensive under an integrated divided the districts based on the number of reported platform of RMNCHþA to include Reproductive, Mater- COVID-19 cases into red, orange, and green with certain nal, Newborn, Child, and Adolescent health along with relaxations applied based on the severity of caseload [20]. contraception services [8]. Beginning June 8, 2020, the Indian government estab- Despite overall gains and many pro-poor government lished phased reopening guidelines after 75 days of programs, many demand-side barriers exist such as social nationwide lockdown. During this phased reopening, the norms related to contraception, poor engagement from states were given autonomy to impose lockdown restric- male partners, early marriage, early childbearing, and tions only in the containment zones, while certain activi- stigma in buying contraceptives. Further, decisions made ties were allowed in other zones in a phased manner. This by mothers-in-law and husbands and low agency of first phase of reopening (June 1–30) was called Unlock 1.0 women, limited educational attainment of women, fear that permitted limited opening of private offices, start of of side effects, and patriarchal norms continue to be manufacturing with resident laborers, and shops allowed India’s challenges to achieving the Sustainable Develop- to open during certain times and days. However, night ment Goals [9–12]. curfews were observed, and gatherings or interstate travel According to the National Family Health Survey of was still not permitted [21].The next phase of reopening India (NFHS-4, 2015–2016) estimates, approximately (July 1–31), Unlock 2.0 included continued lockdown in 12.9% women have an unmet need for contraception. Just containment zones based on COVID-19 caseload but over half (54%) of married women of reproductive age allowed reopening of state borders and limited interna- (15–49 years) use modern contraception methods includ- tional travel [22]. At the time of writing this article, India ing female sterilization (36%), male condoms (5.6%), pills has instituted Unlock 4.0 phase that involves continued (4%), intrauterine devices (1.5%), and injectables (0.2%). lockdown in containment zones until September 30, The remaining just under half (46%) of women do not use 2020. Physical distancing and face coverings/masks con- any form of modern contraception. About 70% women tinue to be mandatory in public places, workplaces, and receive their contraceptive method from public sector public transport [23]. It is also important to note that the facility such as a community health center, primary health un-lockdown norms were often more stringent than cen- care center, or a rural hospital. About a quarter (24%) of ter guidelines in states and districts with high burden of women receive their contraceptive method from private COVID-19 cases. sector or a nongovernmental organization [13]. Most womeninIndia seek prenatal services, with 51% of Research objectives women having the recommended four prenatal visits To date, there are limited data on how COVID-19 has [14]. Postnatal care is much lower, with 30% of women impacted men and women’s contraceptive access and use, not having any postnatal visits. and use of prenatal and postnatal services, and what spe- Contraceptive use in India is highly women-centric due cific barriers people are facing due to COVID-19. We also to existing patriarchal norms, gender inequality, and do not know how these have changed over time as restric- female stereotyping in unions and reproduction [15]. Men tions on movement shifted throughout the course of the are important decision makers in contraceptive uptake pandemic and its corresponding response. Understanding and method choice [16]. Men are also important decision the impact of the COVID-19 pandemic and associated makers about using maternal health care services lockdowns can help us understand how to continue to Diamond-Smith et al: Barriers to maternal and reproductive health care in India due to COVID-19 Art. 1(1) page 3 of 11 provide services to women and men, which is vital since were asked “Did COVID affect your access to pre- or post- COVID-19 has continued, along with lockdowns of various natal care?” For each of these items, respondents could types. Additionally, we may see other pandemics or crises select one or more from a list of barriers, including an in the future, which could also impact reproductive and “Other” response category. While data were collected sep- maternal health care use. The primary objective of this arately from pregnant and postpartum women, data are article is to describe the impact of COVID-19 on fertility presented together here due to the similar stage in their preferences and barriers to contraception, prenatal and life course, similar services being availed and small sample postnatal care use in India, and explore trends over time. sizes. Finally, multivariable logistic regression models are run Materials and methods to look at the association between round of the survey Online survey data were collected at four time points: (time), sociodemographics, and barriers to (1) contracep- mid-April, mid-May, mid-June and mid-July, 2020. Men tion and (2) pre- or postnatal care. A binary outcome and women living in any part of India were recruited for variable for barriers was created with no barrier being the survey using Facebook advertisements (ads). Respon- coded as 0 and 1 or more barrier being coded as 1. Socio- dents could take the survey in either Hindi or English. demographic variables included in the models are age, Eligibility criteria included being over 18 years old and sex, education, region of India, rural/urban, and wealth. living in India. We used a repeated cross-sectional design, sending out the Facebook ads every month for three more Results rounds (total of four rounds) to recruit a new set of From the total 12,898 respondents who completed the respondents at each time point. This study received sample, 3,758 were dropped due to suspected fraudulent human subjects’ approval from the University of Califor- data, leaving a final sample of 9,140 (Table 1). Sample nia, San Francisco. characteristics varied across all rounds, which is expected In addition to basic demographics, the survey covered given that the investigators have no control over who domains related to barriers to pregnancy, postpartum, chooses to complete the survey unlike in face-to-face contraceptive and abortion care due to COVID-19, as well surveys. as barriers to health care in general (questionnaire will be Fertility preferences: An increasing proportion of available with open data). Given the cultural norms respondents over time stated that their or their wife’s around pregnancy and contraception use outside of mar- fertility preferences had not changed due to COVID-19, riage, our study team felt it was appropriate that unmar- ranging from 31% to 49% (Table 2). The most commonly ried respondents skipped the questions related to cited response to the impact was that respondents felt pregnancy and contraception. Additionally, all respon- that they could not afford a/another child, and this dents who reported that they were currently sterilized appeared to increase from around 12% to around 20%. skipped these questions. Midway through the second Few respondents reported that it increased their desire, round we switched the ordering of the questions to put hovering around 2-3% over time. the reproductive and maternal health questions last, after Contraceptive access: A fairly stable percentage of the demographic questions because we thought that hav- respondents reported that their contraceptive access was ing fewer sensitive questions at the end might help not affected by COVID-19 (62–74%) (Table 3). Only a small increase response rates. percentage (about 2%) said that their access to contracep- First, we cleaned the data to remove suspected fraud- tion was made easier. Generally over time, respondents ulent responses or those who did not meet eligibility became more fearful to go to the clinic, felt the economic requirements. Fraudulent results were classified as impact posed by the pandemic, and perceived less time responses that came from the same IP address as another and increased household burden. Also, 2% of respondents response, were answered very quickly (<60 s), wrote non- said that it had become easier for them to obtain their appropriate responses (e.g. words where there should have method. been letters), and noneligible were those not over age 18. In the first round of the survey, we allowed respondents Next, we describe the demographics of the sample, by the option to write in “other” responses. A common theme round. We then describe the change over time (by round) was that men and women brought up was that they were in the impact of COVID-19 on fertility preferences, barriers no longer having sex because they are now living in a dif- to contraception, and pre- and postnatal services. To mea- ferent place or separated in some way from their partner sure fertility preferences, respondents were asked “How due to COVID-19. Relatedly, respondents also wrote about have your/your wife’s pregnancy preferences been there not being a “chance” to meet now due to COVID-19, affected by COVID-19?” Given cultural norms related to which we interpreted as being related to rules about the joint decision-making and the fact that both men and women responded to the survey, the study team felt that nationwide lockdown, social distancing, and restrictions this was the appropriate phrasing for this question. To on movement. This response came up so frequently that measure barriers to contraception, nonpregnant and non- we added another response category to the subsequent sterilized respondents were asked “Did COVID-19 affect surveys; however, only 1% reported this (although this was your access to family planning/contraception?” To mea- only an option after Round 1). A number (about 20) of sure barriers to pre- and postnatal care due to COVID-19, respondents wrote that they received their method via pregnant and postpartum women (and their partners) some sort of a mobile application. Art. 1(1) page 4 of 11 Diamond-Smith et al: Barriers to maternal and reproductive health care in India due to COVID-19 Table 1. Characteristics of study participants, by round, April–July 2020 Variables Round 1 Round 2 Round 3 Round 4 Total (N) 5,980 618 1,881 659 Age ranges <20 335 (5.7%) 22 (3.6%) 52 (3.0%) 14 (3.0%) 20–29 2,985 (50.8%) 316 (51.1%) 423 (24.7%) 100 (21.4%) 30–39 1,683 (28.6%) 138 (22.3%) 495 (28.9%) 93 (19.9%) 40–49 548 (9.3%) 86 (13.9%) 348 (20.3%) 136 (29.1%) 50–59 209 (3.6%) 52 (8.4%) 398 (23.2%) 125 (26.71%) Over 60 121 (2.1%) 4 (0.7%) 0 (0.0%) 0 (0.0%) Sex of the participant Female 2,455 (41.8%) 484 (78.3%) 624 (50.5%) 124 (46.8%) Male 3,525 (58.9%) 134 (21.7%) 1,257 (66.8%) 535 (81.2%) Married 3,410 (58.0%) 412 (66.7%) 965 (78.5%) 214 (81.4%) Region of India North 2,908 (52.2%) 343 (55.5%) 628 (53.9%) 127 (51.8%) South 610 (10.9%) 39 (6.3%) 70 (6.0%) 19 (7.8%) East 1,053 (18.9%) 107 (17.3%) 234 (20.1%) 53 (21.6%) West 1,005 (18.0%) 110 (17.8%) 211 (18.1%) 41 (16.7%) Pregnancy status Pregnant 198 (6.0%) 25 (7.9%) 38 (6.7%) 7 (6.3%) Postpartum 1 month 97 (3.0%) 22 (7.0%) 15 (2.7%) 7 (6.3%) Not pregnant, not 1,346 (41.0%) 146 (46.2%) 201 (35.6%) 35 (31.5%) sterilized Sterilized/wife sterilized 613 (18.7%) 100 (31.7%) 188 (33.3%) 36 (32.4%) Education Less than high school 329 (5.8%) 11 (1.9%) 34 (3.0%) 11 (4.5%) Class tenth 794 (13.9%) 30 (5.1%) 60 (5.2%) 21 (8.6%) Vocational/some 828 (14.5%) 46 (7.9%) 97 (8.4%) 33 (13.5%) college College degree or more 3,774 (65.9%) 499 (85.2%) 961 (83.4%) 179 (73.4%) Income Less than $662 1,732 (30.2%) 169 (28.1%) 307 (26.0%) 73 (29.6%) $662–1,324 1,784 (31.2%) 177 (29.5%) 314 (26.6%) 56 (22.7%) $1324–6,620 1,676 (29.3%) 172 (28.6%) 382 (32.4%) 81 (32.8%) Over $6,620 535 (9.3%) 83 (13.8%) 178 (15.1%) 37 (15.0%) Urbanicity Urban 3,661 (64.2%) 440 (71.2%) 780 (67.5%) 145 (59.4%) Rural 2,319 (38.8%) 178 (28.8%) 1,101 (58.5%) 514 (78.0%) Prenatal and postnatal care: Between about 50% and barriers increased over time, although the N’s got quite 60% of respondents reported barriers to pre- or postnatal small by Round 4. Being unable to go to an appointment care (Table 4). Over time, fewer respondents reported no because of lockdown/restrictions on movement was the barriers to pre- or postnatal care; in other words, reports of most common barrier, with some evidence of increase Diamond-Smith et al: Barriers to maternal and reproductive health care in India due to COVID-19 Art. 1(1) page 5 of 11 Table 2. Fertility preferences, by round, April–July 2020 Round 1 Round 2 Round 3 Round 4 (N ¼ 2,691) (N ¼ 140) (N ¼ 192) (N ¼ 35) How have your/your wife’s pregnancy preferences been affected by COVID-19? N % N % N % N % It has not changed my preferences 837 31 52 37 74 39 17 49 Increased my desire to have a child/another child 61 2 4 3 7 4 1 3 Decreased my desire to have a child/another child 95 4 5 4 22 11 1 3 Feel that I can’t afford a child/another child 339 13 31 22 41 21 7 20 Scared to be pregnant/have a/another child 112 4 11 8 22 11 3 9 Want to delay having a child for the next year 246 9 19 14 24 13 3 9 Other 1001 37 35 25 42 22 10 29 Table 3. Barriers to contraceptive use, by round, April–July 2020 Round 1 Round 2 Round 3 Round 4 (N ¼ 2,584) (N ¼ 182) (N ¼ 187) (N ¼ 34) Did COVID-19 affect your access to family planning/ contraception? N % N % N % N % Not affected 1934 75 114 63 139 74 24 71 Made easier 41 2 4 2 3 2 1 3 Switched method due to COVID-19 4 2 6 3 0 0 Stopped method 58 2 1 1 5 3 0 0 Made harder because you are not allowed to go outside your home 118 5 7 4 2 1 1 3 currently due to government restrictions Made harder because the place you get your method is closed 35 1 3 2 7 4 0 0 Harder because you are afraid to go to the hospital/clinic 42 2 4 2 10 5 3 9 Harder because you are afraid to go to outside 80 3 2 1 0 0 0 0 Harder because you do not have enough money 72 3 2 1 7 4 2 6 Harder because you don’t have time due to additional household work or 93 4 4 2 12 6 3 9 childcare No longer needed because we are separated due to COVID-19 17 9 12 6 7 21 Other 173 7 38 21 53 28 13 38 Notes: Multiple responses per respondents possible, all responses combined. over time. More respondents noted that COVID-19 made When both genders are included in the model, the them more likely to deliver in a facility, rather than less odds of reporting barriers to prenatal or postnatal care likely to delivery in a facility. increased in a consistent manner over time, with respon- dents in June having increased odds times of reporting barriers compared to respondents in the first month of Multivariable models of factors associated with data collection (OR ¼ 2.73, 95% CI 1.29–5.75) (Table 6). reproductive and maternal health care barriers Theconfidenceintervals are quite large for thefourth The odds of reporting barriers to contraception increased round of data collection because the sample size became over time in a steady manner, with respondents reporting small. Since women had significantly higher odds of 4.41 times the odds (95% CI ¼ 2.14–9.08) by July com- reporting barriers, we also ran the model for women alone pared to April (Table 5). Respondents living in urban and found a similar trend, with women having an areas, who had a higher income and who were more edu- cated, reported lower odds of facing barriers compared to increased odds (OR ¼ 2.23, 95% CI ¼ 0.94–5.29 in May; rural, poorer, and less well-educated respondents. There OR ¼ 3.85, 95% CI 1.46–10.14 in June) of reporting bar- was no difference by gender or age. riers, compared to April, and the trend increasing in Art. 1(1) page 6 of 11 Diamond-Smith et al: Barriers to maternal and reproductive health care in India due to COVID-19 Table 4. Impact of COVID-19 on access to prenatal and postnatal care, by round, April–July 2020 Round 1 Round 2 Round 3 Round 4 (N ¼ 287) (N ¼ 46) (N ¼ 48) (N ¼ 11) Did COVID affect your access to pre or postnatal care? N % N % N % N % Not affected 154 54 16 35 22 46 3 27 Unable to go to your appointments because of lockdown/restrictions on 32 11 14 30 7 15 4 36 movement Unable to go to your appointments because you are afraid to go to 53 18 5 11 12 25 2 18 a facility/clinic Unable to go to your appointments because facility/clinic closed 6 13 5 10 2 18 Unable to go to your appointment because of transportation issues 3 7 — — — Less likely to/made us not deliver at a health facility because of 49 — — — — transportation issues Less likely to/made us not deliver at a health facility because of lockdown/ 15 5 3 7 2 4 0 0 restrictions on movement Less likely to/made us not deliver at a health facility because you are afraid to 24 8 1 2 4 8 1 9 go to a facility/clinic More likely to/made us deliver in a health care facility — — 1 2 12 25 2 18 Other changes of prenatal and postnatal services change 15 5 3 7 22 46 6 55 Notes: Multiple responses per respondents possible, all responses combined. a steady manner over time. No other sociodemographic respondents faced fewer barriers, raising the concern factors were significantly associated with barriers. about exacerbated reproductive health inequalities due to COVID-19. We excluded respondents who were steril- ized or whose partner was sterilized. Long-acting methods Discussion (LARCs) are not as common in India, and therefore we do COVID-19 is associated with barriers to care for contracep- not believe that the reason there as little impact on con- tion, prenatal and postnatal women in India, and these are traceptives was that most respondents or their partners increasing over time. Given that we are 2 years into the were using LARCs. The open-ended responses from the COVID-19 pandemic, this highlights the potential large- first round suggest that perhaps respondents were able scale impacts that the pandemic could be having on access to switch to getting their methods from online sources. to reproductive and maternal health services. The study from the United States, mentioned above, found Overall, COVID-19 led to changes in fertility prefer- very similar proportions of women reporting barriers to ences for about one third of respondents. Among those contraceptive care, at about 30% reporting a barrier [24]. whose preferences had changed, it was mostly in terms of Another interesting finding is that a subset, that is not wanting children at the time of the survey or due to potentially not negligible, of respondents noted that financial concerns. A study in the United States which changes in contraceptive use were due to not being with collected data using established online panels from early their partner at this time due to COVID-19 restrictions. in the pandemic (late April/early May) suggested that This has interesting implications for both interpretations 40% of women changed their fertility preferences with of method discontinuation during this time and, poten- an overwhelming majority wanting children later or fewer tially more importantly, for what might happen after children, because of COVID-19 [24]. Findings are similar in restrictions are eased and respondents are able to recon- magnitude and suggest that the impact was similar for nect with their partners. If respondents have stopped both men and women in the Indian setting. The item used using their method because of COVID-19 and then sud- in our survey was limited in that it did not differentiate denly are able to be sexually active again, perhaps without well between a woman’s preferences, a man’s preferences, much warning, this might lead to mistimed or unintended and a man’s perception of his wife’s preference. At the pregnancies. Ensuring that people have a choice of con- time of deploying the survey, this seemed like the appro- priate wording given the cultural context; however, it traceptive methods on hand for the future thus may have leads to limitations in our interpretation. added importance. The majority of respondents in our sample did not have In contrast to few impacts on contraception, prenatal their access to contraception affected by COVID-19 (75%); and postnatal care appear to have been more affected by however, barriers increased over time with the pandemic. COVID-19, with about half of respondent reporting bar- As we would expect, urban, educated, and richer riers. We also find that barriers to these services increased Diamond-Smith et al: Barriers to maternal and reproductive health care in India due to COVID-19 Art. 1(1) page 7 of 11 Table 5. Adjusted logistic regression models assessing the association between time, socioeconomic factors and antenatal and postnatal care barriers, India Both Genders (n ¼ 374) Women Only (n ¼ 180) Variables OR 95% CI p OR 95% CI p Month April 1.0 Referent 0.07 1.0 Referent 0.07 May 1.98 0.95–4.13 0.01 2.23 0.94–5.29 0.01 June 2.73 1.29–5.75 0.03 3.85 1.46–10.14 0.08 July 9.68 1.20–78.2 7.25 0.81–64.86 Sex Male 1.0 Referent 0.06 — — — Female 1.60 0.97–2.64 Age Under 30 1.0 Referent 0.99 1.0 Referent 0.92 At least 30 0.99 0.62–1.62 1.04 0.49–2.21 Rural Yes 1.0 Referent 0.94 1.0 Referent 0.64 No, urban 0.98 0.62–1.56 0.84 0.40–1.75 Region in India North 1.0 Referent 0.47 1.0 Referent 0.64 South 0.77 0.34–1.58 0.40 0.77 0.27–2.25 0.88 East 0.78 0.43–1.40 0.49 1.08 0.41–2.82 0.99 West 0.83 0.48–1.42 0.99 0.45–2.21 Income Less than $662 1.0 Referent 0.71 1.0 Referent 0.27 $662–1,324 0.90 0.51–1.58 0.82 1.65 0.67–4.03 0.18 $1,324–6,620 0.94 0.52–1.67 0.14 1.90 0.75–4.85 0.73 Over $6,620 0.51 0.21–1.25 0.81 0.26–2.59 Education Less than high school 1.0 Referent 0.57 1.0 Referent 0.15 Class tenth 0.73 0.25–2.14 0.91 0.12 0.01–2.13 0.16 Vocational/some college 0.94 0.33–2.64 0.52 0.16 0.01–2.06 0.20 College degree or more 0.73 0.28–1.89 0.22 0.02–2.30 OR ¼ odds ratio; CI ¼ confidence interval. with the course of the pandemic, and that sociodemo- antenatal care [26]. In Rwanda, there was significant graphic characteristics were not associated with bar- decline in access to and utilization of maternal care ser- riers—instead they seem to be more universal. A vices including antenatal care, deliveries, postnatal care, modeling study predicts that the coverage of maternal and and vaccinations [27]. In Bangladesh, lockdown instituted reproductive health interventions including antenatal due to COVID-19 resulted in significant drops in number care, contraception, and postnatal care have significantly of antenatal and postnatal care visits to public health declined (9.8–18.5%) in LMICs [25]. facilities [28]. Similar results were seen in Ethiopia where Other studies have documented the adverse impact of there were significant declines in utilization of antenatal COVID-19-related measures on contraception and mater- care, health facility births, contraception, and newborn nal health services in LMICs. Antenatal care coverage was immunizations, while at the same time, there was signif- also impacted in LMICs with the closure of health facilities icant increases in teenage pregnancy, stillbirths and neo- because of COVID-19 measures and lack of funds to access natal deaths, and teenage abortions [29]. Art. 1(1) page 8 of 11 Diamond-Smith et al: Barriers to maternal and reproductive health care in India due to COVID-19 Table 6. Adjusted logistic regression model assessing had moved online via telemedicine [30]. The main chal- the association between time, socioeconomic factors lenges reported by health care providers in the study and contraceptive barriers, India included lack of infrastructure and technological literacy, limited monitoring, financial and language barriers, lack Both Genders (n ¼ 2,878) of nonverbal feedback and bonding, and distrust from patients [30]. In our study, fear of going to the clinic/ Variables OR 95% CI p facilitywas amainbarrier forall typesofhealthcare Month utilization. Delays due to fear of going to the facility have been found in a few other small studies on COVID-19 from April 1.0 Referent 0.001 other countries (mostly European) and for other types of May 2.05 1.48–2.84 0.001 health care seeking [31, 32]. It is interesting that actual June 2.22 1.61–3.06 0.001 barriers due to facility closure or restrictions on move- ment were not the primary barrier, but rather respondents July 4.41 2.14–9.08 were making choices not to go, due to fear. Helping Sex women, especially those at high risk, feel safe and under- Male 1.0 Referent 0.78 stand precautions taken at facilities to protect them, is essential. Female 0.97 0.81–1.17 Some pregnant women/partners of pregnant women Age expressed fears about delivering in a facility due to COVID- Under 30 1.0 Referent 0.91 19; however, more respondents reported that it made them more likely to deliver in a facility (or want to). This At least 30 0.99 0.83–1.18 could have important implications for health care delivery Rural if systems become overcrowded. However, fundamentally, Yes 1.0 Referent 0.001 more research, including qualitative interviews with men and women, could help uncover reasons for these fears No, urban 0.70 0.58–0.84 and the other barriers described above. Region in India These findings were collected early in the pandemic, North 1.0 Referent 0.43 and more research is needed on the impact on access to care as COVID-19 has persisted. Additionally, how barriers South 1.13 0.83–1.53 0.89 have translated into changes in health care use and out- East 0.98 0.78–1.24 0.72 comes is essential, for example, if there have been unin- West 0.96 0.77–1.20 tended pregnancies or more adverse maternal or infant health outcomes. Much more evidence is needed about Income impacts of COVID-19 on place of delivery, and what longer Less than $662 1.0 Referent 0.013 term effects this has on maternal and newborn health $662–1,324 0.75 0.60–0.94 0.001 outcomes. $1,324–6,620 0.68 0.54–0.85 0.004 Limitations Over $6,620 0.63 0.45–0.86 Despite its strengths in terms of collecting data rapidly Education (and inexpensively) on the emerging pandemic’s impact, and doing so over time, this study has limitations. From Less than high school 1.0 Referent 0.89 a methodological standpoint, due to COVID-19, there is Class tenth 1.03 0.69–1.55 0.20 increasing interest in methods of data collection that can Vocational/some college 0.76 0.50–1.16 0.04 collect data quickly from respondents without personal interactions, such as over the phone and online. Recruit- College degree or more 0.70 0.49–0.99 ment via social media platforms, such as Facebook, is one OR ¼ odds ratio; CI ¼ confidence interval. such approach for recruiting respondents and collecting data from them. A number of studies have employed this technique during the recent pandemic, and interesting contributions are being made in terms of thinking about There has been a shift to the provision of prenatal and the ethics, representativeness, weighting, and general some postnatal care via telemedicine in India, as else- approaches of such methods [33, 34]. where, and more research is needed on how much of care Limited research of this nature has been carried out in has been able to be moved to telemedicine and the longer LMICs, especially studies involving multiple rounds of term impact of this approach on maternal and child out- data collection. One recent study that did use Facebook comes and experiences. In a worldwide survey of health ads for recruitment in India noted that they found no care providers, 58% of them stated that maternal and other published studies in India using this approach newborn care services such as online birth preparedness [35]. These authors noted that while the sample recruited classes, antenatal and postnatal care by video/phone, on Facebook was not representative of the population a COVID-19 helpline, and online psychosocial counseling broadly, it did have a wide geographical spread. Studies Diamond-Smith et al: Barriers to maternal and reproductive health care in India due to COVID-19 Art. 1(1) page 9 of 11 using Facebook or other social media approaches for barriers exist to seeking reproductive and maternal health recruitment do have limitations in that we do not know care due to COVID-19, and they may worsen with time. the exact population from which we are drawing our sam- ple; however, by adjusting our models for socioeconomic Recommendations covariates, we are able to still draw inferences about fac- In light of our current study, we suggest programs or tors associated with outcomes of interest. policy makers focus on ensuring that women and men are Another limitation of note is that, especially in the later receiving the reproductive and maternal health care that rounds, the sample size of respondents to questions on they need as the pandemic persists, with a focus on vul- reproductive and maternal health was quite small. This nerable and disadvantaged populations. Addressing con- reduces our ability to draw conclusions about the impacts cerns about fears related to going to facilities through of the pandemic on access and behaviors, or how those mass media or social media might help assuage fears or changed over time. We were interested in a broad range of address misperceptions. Ensuring that widespread misin- questions and wanted to capture gendered effects; had we formation and disinformation regarding COVID-19 and more narrowly targeted our Facebook ads for women of immunizations can help reduce concerns of affected reproductive age only (and not collected data on men), we populations. likely would have recruited larger samples. Also, we did not offer an incentive for each round, which might have Data availability statement increased the sample, although this likely would have We are currently working on share our data on the CORNET drawn bots or more fraudulent or duplicated responses. platform funded by BMGF. https://covidresearchnetwork. Partly due to the small sample size, we were unable to slack.com/join/shared_invite/zt-ffgukmau-9G0wYJRzxg stratify our data by other important characteristics, such as XHeVQX0YZr7Q#/. age, geography, caste, education level, and so on. India is a heterogenous and diverse country and these different Competing interests subpopulations would likely be differentially impacted by The authors declare that they have no competing interests. COVID-19. However, we are forced to make generalized statements about India as a whole, which hide the subtle- Author contributions ties that likely exist. Finally, our survey was rather long, NDS: conceptualization, methodology, writing; LG: con- and midway through the second round we switched the ceptualization, project management, investigation, meth- ordering of the questions to put the reproductive and odology; SG: analysis, data cleaning; SF: data curation, maternal health questions last (upon advice that having resources, methodology; NS: supervision, writing; SP: fewer sensitive questions at the end might increase supervision. respondents). However, this likely ended up reducing the sample that answered these questions specifically. Ethical approval It is essential that these findings, both because of their This study received human subjects’ approval from the sample size and recruitment approach, not be generalized University of California, San Francisco. to a wider population. 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Behaviors and to have the highest number of births this year [Inter- attitudes in response to the COVID-19 pandemic: net]. Times of India. 7 May 2020. Available: https:// insights from a cross-national Facebook survey. medR- timesofindia.indiatimes.com/life-style/parenting/ xiv. 2020; 2020.05.09.20096388. pregnancy/covid-19-baby-boom-india-expected-to- 35. Boas TC, Christenson DP, Glick DM. Recruiting large have-the-highest-number-of-births-this-year/ onlinesamples in theUnited Statesand India: articleshow/75602754.cms. Accessed 22 June 2022. How to cite this article: Diamond-Smith N, Gopalakrishnan L, Gutierrez S, et al. Barriers to maternal and reproductive health care in India due to COVID-19. Adv Glob Health. 2022;1(1). https://doi.org/10.1525/agh.2022.1713935 Editor-in-Chief: Craig R. Cohen, University of California, San Francisco, CA, USA Senior Editor: Sarah Ssali, Makerere University, Kampala, Uganda Section: Achieving Gender Equality Published: July 4, 2022 Accepted: June 4, 2022 Submitted: October 17, 2021 Copyright: © 2022 The Author(s). This is an open-access article distributed under the terms of the Creative Commons Attribution 4.0 International License (CC-BY 4.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. See http://creativecommons.org/licenses/by/4.0/. Adv Glob Health is a peer-reviewed open access journal published by University of California Press.

Journal

Advances in Global HealthUniversity of California Press

Published: Jul 4, 2022

Keywords: South Asia; COVID-19; Family planning care; Pregnancy care; Postpartum care; Social media

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