What is the impact of Covid-19 on the Antenatal Care Services Utilization in Public-Private-Rural-Urban Hospitals of India during the COVID-19 Pandemic Period of 2020-2021 compared to pre-pandemic era 2018-2019?

Abstract


Introduction
Antenatal care services are well documented by several researchers to be affected by the COVID-19 pandemic despite the truth that pregnant women are considered vulnerable group [1].However, the SARS-CoV-2 pandemic has led to maternity services disruptions in providing antenatal care due to the government enforced covid-19 restrictions regarding social distancing etc., which has negatively impacted on access to routine antenatal care.
The WHO de nes Antenatal care as the care given to a pregnant mother before birth, and it involves education, screening, counselling added with treatment of problems, and immunization [4].Antenatal care is the rst contact opportunity for a pregnant woman to get connected with available-accessible-affordable health services and linking herself with pregnancy related complications to an established health-referral system.
Maternal mortality is signi cantly high.Almost 295 000 women died during and following due to pregnancy and childbirth related causes in 2017.The great majority of these deaths (94%) reported in low-resource settings, and majority could have been prevented [5].Antenatal healthcare is targeted to reduce maternal morbidity and mortality by providing and educating about health promotion, danger signs, birth preparedness, and proper timely care for pregnancy complications.The WHO recommends a minimum of 04 ANC visit per pregnancy for pregnant women.NFHS Studies conducted in different states of India reported that educational status, maternal age, number of living children, occupation, place of residence, religion, socioeconomic status, and previous obstetric history were signi cant factors associated with the use of antenatal care service [6].
The COVID-19 pandemic challenged not only India but global countries to provide good quality, essential maternal and newborn health services [7].Pregnant women and newborns have experienced di culties accessing health services due to lockdown measures or found to be reluctant to visit health facilities due to fear of possible infection [8].The disruption of maternity services and moving resources away from most essential pregnancy care, due to COVID-19 response, increased risks of maternal morbidity and mortality [9].Anxiety, domestic violence and mental health problems in pregnant women were reported to be increased during the ongoing covid-19 pandemic [10,11].The indirect effects of COVID-19 on various other diseases at the population level, as a result of lockdown, social restrictions, and reorganization of health systems, is evident in several research studies [12] The negative impact of containment and covid-19 policies on mortality at emergency department is also evident from several research studies [13].To the best of the researcher/author knowledge, there is no published research till today 22-01-2022 exploring the effect of the COVID-19 pandemic on antenatal care services utilization by analysing 20 accredited times bound indicators for pregnant women in the country.This kind of research study is not done only in India, but also on global basis the author has not found such study which can clearly mark the impact of covid-19 on ANC through several process or output indicators.
In order to provide the information to the scienti c community and policy makers with accredited evidence and data in the country, this retrospective cross sectional mixed research study aims to nd out the impact of the COVID-19 pandemic on antenatal services utilization among pregnant women of India attending public / private / rural / urban health facilities in 36 states and union territories.Hence, the researcher hopes that result and analysis will be bene cial to important stakeholders as well as policy makers in designing strategies for prioritizing pregnancy healthcare even within the ongoing COVID-19 pandemic period.

Study Setting
The study was conducted by continuous observation of health facilities data found in HMIS of MoHFW, which is also available online.The population covered is 36 states and union territories of India.According to the data obtained from HMIS, the total ANC registered during this period is 96990524 numbers of females.In the country there are private, public, rural and urban hospitals, delivering ANC services.The nancial burden of ANC services in public hospital of India is cost free, covered by state and central governments.For getting treatment at private health facilities the pregnant women or family have to pay as oope (out of pocket expense) until unless covered by some government sponsored scheme.

Study Design and Period
A health facility-based retrospective mixed cross-sectional study was conducted for pregnant women who attended ANC and takes the available services in the selected health facilities from 1st January 2018 to 31st May 2021.The rst documented covid-19 case in India was found in January 2020 [14].Hence the year before 2020 i.e. 2018 and 2019 is pre-pandemic period utilized for comparison with the ongoing covid-19 pandemic period i.e.2020 and 2021 (up to May as data from accredited source is available till this month).The average per month is calculated and pandemic era is compared with pre-pandemic era to nd out the impact of covid-19 on ANC services utilization.

Population
The actual population was all the pregnant women who attended ANC or utilized ANC related health services in the selected health facilities of choice, during the data collection period of this research study was considered as study population.
Accordingly, a total of 96990524 numbers of female's pregnant women who ful lled the inclusion criteria were included in the study.

Sample Size and Sampling Technique
A total of 96990524 women registered for ANC were included in the study with a purposive sampling technique.The data required for this study is collected from HMIS of Ministry of Health and Family Welfare (MoHFW) which is the most accredited data source in India.The total number of indicators included for the study was 25.The data collected is analysed with the help of Microsoft o ce.

Study Variables and Operational De nition
The outcome variable of this research study was antenatal care utilization.Antenatal care utilization for this study was de ned as 1.Total number of pregnant women registered for ANC MoHFW.The whole data collection and analysis is solely done by the author.To assure data quality the researcher has taken help of his wife to do cross check as well.Furthermore, there was daily supervision of data collected in the data collection process.Finally, it was checked for accuracy, reliability, completeness and consistency.

Data Management and Analysis
All data was checked for inconsistencies, any missing values, and for incompleteness, then entered into Microsoft o ce software and also exported to STATA for further analysis.

Data Availability
The data for study is available on HMIS of Ministry of Health and Family Welfare, Government of India.The link to the source is given below:https://hmis.nhp.gov.in/#!/standardReports Ethical Consideration Ethical clearance was not applicable as this research study have not utilized any human or animal for trials etc. or involved them in any way which requires ethical considerations.Furthermore the data used is available for public and the researcher have not disclosed any hidden or secret data.The purpose of this study is well explained above, and consent or approval is not required for such studies based on secondary data available in public domain.The researcher is a medical doctor and this research study is a part of author usual routine.

Socio-Demographic Characteristics of Respondents
A facility-based retrospective mixed cross-sectional study was conducted from 1st January 2018 to 31st May 2021 for pregnant women attending all / public / private / rural / urban ANC services in 36 states and union territories of India.Thus, a total of 96990524 women registered for ANC were included in the study with a purposive sampling technique.See Table 1 The study revealed that there is decrease in ANC service utilization at public health facility of following services as compared to pre-pandemic era on cumulative all India basis:- The study revealed that there is signi cant increase in ANC service utilization at urban health facility of all the services as compared to pre-pandemic era on cumulative all India basis.This research study nding also revealed that urban health facility where maximum private health facilities are available was found to be associated with signi cantly increased utilization of antenatal care services in the pandemic era.This nding was supported by the accredited data source of HMIS -MoHFW-GoI.This might be related to the fact that pregnant women residing in urban areas may have better access as well as affordability-availability of different health facilities and better knowledge about the signi cance of ANC utilization.
This research study nding also revealed that rural health facility where mostly public health facilities are available was found to be associated with signi cantly decreased utilization of antenatal care services in the pandemic era.This nding was supported by the accredited data source of HMIS -MoHFW-GoI.This might be related to the fact that pregnant women residing in rural areas may have limited access as well as limited affordability-availability of different health facilities and lesser knowledge about the signi cance of ANC utilization added with lack of transport accessibility.This might be because of other reasons like fear of contracting disease stay-at-home orders leading to greater loss of income, reduced capability or (OOPE) purchasing power, resulting in inability to pay for services which in turn limit utilization of ANC services.
The situation is harsher in rural areas of developing countries like India due to the lack of proper infrastructure at public health facilities and limited resources.This might be due to public health system collapse or intentional individual choices made by public in responding to the pandemic, workforce diversion-reduction at rural-public health facilities, access reduction, and also some health facility may have restricted number of regular ANC visits due to possible fear of the pregnant women contracting coronavirus.

Strength and Limitation of the study
The cross-sectional retrospective nature of this study was one of the main limitations of this research study.Another limitation is availability of data from any other accredited and established source recognized worldwide.Furthermore, this study is not done with primary method of data collection.The main strength is that the whole study is based on real time based accredited government data sources which is also available 24x7 to the visitors.

Conclusion And Recommendation
This research study ndings showed that the covid-19 pandemic reduced the utilization of various antenatal health care services among pregnant women in India as compared to the pre-pandemic period.Hence author recommends more efforts in rural areas as well as improvement in public health facilities for enhancing ANC health services.Various types of IEC (Information, Education and Communication) materials should be distributed to raise awareness regarding the protective ANC services for pregnant women during the COVID-19 pandemic.It is also useful to start telecommunication-consultation services to help pregnant women.In addition, virtual consultation with gynaecologist-obstetricians can be provided via teleconsultation services, to women who need maternal health services.

Implications Of The Study
COVID-19 pandemic has caused interference in delivery of health services on the global scale, including ANC.Due to this global pandemic, women who are considered a vulnerable group in time of distress particularly pregnant women are facing more barriers in availing-affording-accessing healthcare services.This is due to several reasons including covid-19 guidelinesrestrictions, transport related, anxiety, and fear of being exposed to coronavirus.This study demonstrates that improving the public and rural health facilities requirements which are not doing well in pandemic era would help to improve ANC services utilization during ongoing pandemic.Effective guidelines of preventive and clinical strategies are required to be implemented to control COVID-19 infection among pregnant women.Governments should also need to make policies during ongoing pandemic to make sure that pregnant-women can access ANC health services to protect themselves and their babies.
Additionally, more arrangements should be made during pandemic to ensure transportation, accessibility, affordability and availability of ANC services during lockdown etc., to achieve SDG goal as well as health for all goals. Indicator/

2 .
Out of the total ANC registered, number registered within 1st trimester (within 12 weeks) 3. Number of PW given TT1/ Td1 4. Number of PW given TT2 / Td2 5. Number of PW given TT Booster/ Td Booster .Number of PW provided full Course 180 Iron Folic Acid (IFA) tablets 7. Number of PW provided full Course 360 Calcium tablets .Number of PW given one Albendazole tablet after 1st trimester 9. Number of PW received 4 or more ANC check ups 10.Number of PW given ANC Corticosteroids in Pre Term Labour 11.Out of the new cases of PW with hypertension detected, cases managed at institution 12. Number of Eclampsia cases managed during delivery 13.Number of PW tested for Haemoglobin (Hb ) 4 or more than 4 times for respective ANCs 14. Number of PW having severe anaemia (Hb < 7) treated 15.Number of PW tested for Blood Sugar using OGTT(Oral Glucose Tolerance Test) 1 .Number of PW tested positive for GDM 17. Number of PW given insulin out of total tested positive for GDM 1 .Number of PW tested using POC test for Syphilis 19.Number of pregnant women tested for Syphilis 20.Number of syphilis positive pregnant women treated for Syphilis, Data Collection and Quality Assurance Data were continuously collected, observed analysed using Microsoft o ce software from electronic records of HMIS from

Table - 2
-Comparison of ANC service utilization at public health facilities across India before and after covid-19 pandemic The study revealed that there is decrease in ANC service utilization of following services as compared to pre-pandemic era on cumulative all India basis:-Total number of pregnant women registered for ANC-Number of PW given TT1/ Td1 Number of PW given TT2 / Td2 Number of PW received 4 or more ANC check ups Number of PW tested for Haemoglobin (Hb) 4 or more than 4 times for respective ANCs Number of pregnant women tested for Syphilis An important nding is increase in following ANC service utilization during covid-19 pandemic Era:-Number of PW tested using POC test for Syphilis Out of above, number of PW found sero-positive for Syphilis Number of syphilis positive pregnant women treated for Syphilis

Table - 3
-Comparison of ANC service utilization at private health facilities across India before and after covid-19 pandemic The study revealed that there is decrease in ANC service utilization at private health facility of following services as compared to pre-pandemic era on cumulative all India basis:-Out of the new cases of PW with hypertension detected, cases managed at institution Number of Eclampsia cases managed during delivery Number of PW tested for Haemoglobin (Hb) 4 or more than 4 times for respective ANCs Number of PW tested for Blood Sugar using OGTT (Oral Glucose Tolerance Test) Number of pregnant women tested for Syphilis Number of syphilis positive pregnant women treated for SyphilisTable -4-Comparison of ANC service utilization at urban health facilities across India before and after covid-19 pandemic.

Table - 5
-Comparison of ANC service utilization at rural health facilities across India before and after covid-19 pandemic The study revealed that there is decrease in almost all ANC service utilization at rural health facility except following services as compared to pre-pandemic era on cumulative all India basis: An important nding is increase in following ANC service utilization during covid-19 pandemic Era:-Number of PW tested using POC test for Syphilis Out of above, number of PW found sero-positive for Syphilis Number of syphilis positive pregnant women treated for Syphilis