What is the Impact of Covid-19 Pandemic on the RCH (Reproductive and Child Health) Programme in Rajasthan, because of nationwide lockdown (April 2020 to June 2020)?

Background: The proper, timely, adequate delivery of effective and high quality child health and reproductive (RCH) services is of greatest signicance and utmost priority mainly because of situations erupting from current ongoing pandemic of covid-19 as well as other cofactors in state of Rajasthan, India. This signicance and priority is particularly due to many factors such as huge as well as increasing population with limited qualied, skilled human resources Objective of study: The key objective effects of 3 Settings & Design: Different indicators of RCH programme i.e. immunisation, maternal and child health, family planning) for Rajasthan were observed, studied, collected and compared with previous year 2019for the period of April/May/June -2019 and 2020. The percent increase and downfall is observed, calculated, presented, from the available data to nd out the status of delivery of essential RCH health services. The need assessed and percent of achievement of assessed need is also compared and future achievement projected as per achievement. the attention have been given to very essential services of RCH in Rajasthan as evident from the results of this study. The problems in the delivery of healthcare services should be dealt properly added with a proper update latest dynamic plan to carry on essential health delivery services even in pandemics and other situations of emergencies. The Rajasthan should develop an exclusive updated latest dynamic plan to deal with situations to guarantee delivery of very essential services such as RCH during the period from pandemics or any other natural calamities-emergencies. The ongoing Covid-19 pandemic has disclosed the vulnerability of women and children’s and at the same time teaches us about importance of equity in healthcare. The children and women’s who are considered most vulnerable in emergencies and distress must have special supportive healthcare all the times especially during the period from pandemics-emergencies and other natural disasters. sympathetic and psychological care at this vital time in their lives. ANC services deliveries are signicant assess the condition of home deliveries declined this of but at are great

conditions like covid-19 pandemic, hence this topic needs essential and special attention especially in current pandemic scenario 2020-21. India is second most populous nation after China and women's with children's constitutes a large section of current population. 2 The current ongoing covid-19/ SARS-CoV-2 pandemic situation had presented a big challenge even for highly developed healthcare systems around the world.
A sense of fear and insecurity gripped the whole world populations since 2019 due to pandemic and state of Rajasthan in India is not an exception. The limited underdeveloped healthcare system and poor health and other resources including transportation (ambulance services) manpower, infrastructure, etc.
have been largely utilized to deal with the situation erupting from pandemic of SARS-CoV2. This one sided shifting of resources added with several other factors has incredible-sensational consequences on progress various health programmes such as RCH (reproductive and child health) running previously before this covid-19 pandemic era. Historically also the children's and women usually suffer more in such vulnerable situations like disasters and pandemics.
One such nding is given by study done by Alice Reid on effects of 1918-1919 in uenza pandemic he found thatyoung children and Infants are a more vulnerable group to different forms of communicable disease, and their relative mortality was also increased abnormally in pandemic, but talk about the young is mostly limited to mentions of school closures, or in the background of illness or mortality to whole families 3 .
Children's and pregnant mother are vulnerable groups due to their special health requirements and need more attention in disasters and pandemics due to special health and safety requirements such as ANC (antenatal care) and immunisation. After birth newborns are naturally immune to several diseases because they have antibodies acquired from their mothers in natural way. However, this acquired immunity declines slowly and gradually with time as baby grows up. Hence immunisation/vaccination is required to protect them from various vaccine preventable diseases(VPD) which are provided through universal immunization programmes (UIP-1985) to all children's in India (UNIVERSALIMMUNIZATIONPROGRAMME(UIP) 4 -(See-Annexure-2).
The encouragement for child and maternal health, women up liftment have been done and addressed by many organisations of India and international repute for several years mentioning them as special vulnerable groups in times of disaster such as pandemic. The SARS-CoV-2 pandemic seems to disclose the limitations of health system to save above mentioned special groups as reported by WHO and other agencies expressing concerns over several issues related to women and children's 5 . As per current pandemic situation it is of special focus and requirement to have a separate health cadre of trained personals in the eld of RCH to protect child and mother health hazards in special situations of disasters like covid-19 pandemics. It seems many protective and advantageous essential health services is not being provided in covid-19 era which may produce undesirable and detrimental effects at mass level in coming future. The World Health Organisation (WHO) have addressed these and many other concerns such as COVID-19 causes disruptions to child protection services in more than 100 countries, UNICEF(United Nations International Children's Emergency Fund) survey, millions more cases of female genital mutilation, unintended pregnancy, violence, child marriage, expected due to the COVID-19 pandemic 6 .
To recognize the real effect of covid-19 on child health, maternal, and family planning services provided under RCH programme the service utilisation data and other outcome indicators were analysed during month of April to June 2020 (lockdown phase) with non-lockdown phase of during the period from the same months in the previous year 2019. India was also under a lockdown period from 25 th march 2020 to 31 st may 2020 for a total period of 68 days during the period from which public transportation and many other services were stopped. The Ministry of Home Affairs, Government of India had issued order number 40-3/2020-D dated 24/03/20 regarding guidelines on suppression of covid-19 epidemic in the country stating in point number 6 That all transport services i.e. air, rail, roadways will remain suspended with few exceptions 7 . The HCWs (health care workers) not having their own vehicles to do routine duties added with high rate of covid-19 infection and deaths of HCWs also seems to affect healthcare delivery services.
1.2-LITERATURE REVIEW RCH (Reproductive and child health) programme is a matter of concern for India even before independence due to several factors like socio-economic status, inequities, and lack of resources, infrastructure and many more. The practical problems in delivering these services are also faced at all levels. The RCH services are a matter of greatest concern in the ongoing pandemic era since December 2019 at global levels and particularly for countries like India. These concerns have been taken seriously by international organisations like WHO/UNICEF and alert regarding immunisation , ANC is being delivered at various levels as well as many scienti c research is being carried out in this regard. In one such study as informed by WHO thatPregnancy with SARS-COV-2 are not as much likely than non-pregnant women with SARS-COV-2 to have symptoms, but more likely to need special-intensive care if severely ill, as per most recent research ndings of the BMJ(British Medical Journal) on the risks of SARS-COV-2 for babies and pregnant women. The text literature suggests that pregnant women seen at the hospital with supposed or con rmed SARS-COV-2 are less likely to encounter a fever or muscle pain, but if they develop severe illness they are more likely to need ICU treatment than non-pregnant women with SARS-COV-2 9 . The family planning programme is equally important as the population of India is increasing at a very fast pace which is increasing more demand on available resources. The key purpose of this review is to nd out if there is convincing evidence that Rajasthan RCH programme is getting affected by SARS-CoV-2 pandemic. In the same statement mentioned before WHO, also stated that It is important to recognise the increased anxiety and stress caused by SARS-COV-2 which may be predominantly felt by children, pregnant women, their partners, in recent times-pregnant women, and families. Therefore healthcare workers have a big role in providing care to pregnant women in an appropriate and benevolent way.
The scope of this review is limited as more data and materials are required to complete it and there is also word limit for this report. As per NFHS-4(National Family Health Survey) survey data 10 the total fertility rate (TFR) in Rajasthan is 2.4 children per woman, which is more than replacement level fertility (2.1).
Fertility declined by only 0.4 children in the last 13 years period between NFHS-1 and NFHS-3, and has decreased further by 0.8 children in further 10 years period between NFHS-3 and NFHS-4.
Regarding pregnancy outcomes the NFHS-4 nding were that 91percent of previous pregnancies in the last ve years preceding the survey resulted in a live birth, and the rest 9 percent ended in fetal wastage (miscarriage, or stillbirth, abortion,).and among these miscarriage was the most commonly found responsible for fetal wastage, about 7 percent of all pregnancies, and abortions lead to 2 percent fetal wastage. NFHS-4 survey also found that most of the abortions were done in the private health sector (59percent) and only 21 percent were done in the public health sector. Added to this report of NFHS-4 is that one-fourth of women having an abortion, reported to experience complications from the abortion. NFHS-4 survey found that awareness of contraception is almost universal in Rajasthan, except some methods are still less popular. 81 percent of recently married women know about injectables methods of contraception while 11 percent know about female condoms. Among all women, only 45 percent have knowledge of emergency contraception.
Regarding antenatal-care the NFHS-4 survey reported that among pregnant women's who gave birth in the last ve years before the survey, more than 4/5th(83percent) received ANC for their last birth from a health professional (28percent from an auxiliary nurse midwife , and, lady health visitor (LHV), nurse, ormidwife55percent from a doctor). 14 percent did not get any ANC. Among mothers who gave birth in the last5years before the survey, more than 4/5th (85percent) registered the pregnancy for the most recent live birth. Among the registered pregnancies, 92 percent received MCP Card (Mother and Child Protection Card).Only 39 percent of mothers in Rajasthan acknowledged at least 4ANC visits for their last birth. Furthermore regarding delivery care the survey found that more than 4/5th of births (84percent) take place in a health facility (mostly a government facility) and 16 percent at home. The survey found that the percent of births in a health facility tripled in the 10 years period between NFHS-3 and NFHS-4, from 30 percent in NFHS-3 to 84 percent in NFHS-4. Institutional births are more common among women who have received an ANC check, women who are having their rst birth, women with 12 or more years of schooling, urban women, and Sikh women. Survey also found that 84 percent of children in Rajasthan who were born in the last ve years were born in a health facility.
Regarding immunization/vaccination the survey reports that more than half (55percent) of children between 12-23 months get all availablevaccinations against 6 (tuberculosis, diphtheria, Pertussis, tetanus, polio, and measles,) important childhood diseases before the survey. Most of the children are at least partially vaccinated; only 7 percent have not got any vaccinations at all. The survey also found that 89 percent of children have got a BCG vaccination. Added to this, very less children have received other basic vaccinations (65percent have got at least the recommended three doses of polio vaccine, 72percent have got the three recommended doses of DPT vaccine, and 78percent have been vaccinated against measles). There is remarkable dropout between the 1st and 3rd doses of DPT vaccine (from 86percent to 72percent) and polio vaccine (from 88percent to 65percent). One remarkable nding is that Coverage with all basic vaccinations is high for children whose mothers have completed 12 or more years of schooling.

1.3-Rationale:
One study published in the Lancet Global Health 11 by Timothy Robertson et al. about the indirect effects of SARS-COV-2 on maternal and child mortality in LMICs with use of the Lives Saved Tool (LiST), found that reduced provision and use of reproductive, maternal, newborn, and child health-care services might substantially increase maternal and child deaths but this dissertation project is a totally different study incorporating three aspects viz. Maternal health, child health and family planning based on real-time data of an accredited source to nd out impact of SARS-CoV-2 on RCH through output health indicators. This study furthermore, addresses the situations of Rajasthan, the constraints and limited access to information means that some major gures, such as for India and several other states and union territories as well as for longer periods data is not available-not been included. Finally, although several articles on this subject are available as seen in Google search, to evaluative the impact of SARS-CoV-2 on mother, child etc through studies using either qualitative or quantitative methods, to measure the effectiveness of RCH programs during the period fromSARS-CoV-2 is comparatively scarce. I have included relevant examples of these studies being done by myself for some other states and India 17,18,19,20,21 , yet it can be said at the outset that the dearth of such studies needs to be redressed by the research community. Previous studies mentioned above have found a negative impact on health indicators of RCH programmes for few states and India which aroused my interest to know the impact of SARS-CoV-2 on other states. Rajasthan is the biggest state in India so I decided to do study on Rajasthan to know how RCH programme performance in such a big state during the period from the above mentioned period.
Chapter-2 2.1-Study aim: RCH (Reproductive and child health) programme is a matter of concern for India even before independence due to several factors like socio-economic status, inequities, and lack of resources, infrastructure and many more. The key aim of this study is to understand the effect of covid19 pandemic era on RCH programme of Rajasthan for 3 months after lock down declared in the month of March 2020 i.e. April/May/June 2020 in Rajasthan.

2.2-Study Objective:
To know the real effect of SARS-CoV-2 on child health, maternal health, and family planning services provided under RCH programme the service utilisation data and other outcome indicators were analysed during the month of April to June 2020 (lockdown phase) with non-lockdown phase of during the period from the same months in the previous year 2019. India was also under a lockdown period from 25 th march 2020 to 31 st may 2020 for a total period of 68 days during the period from which public transportation and many other services were stopped. The Ministry of Home Affairs, Government of India had issued order number 40-3/2020-D dated 24/03/20 regarding guidelines on containment of SARS-CoV-2 epidemic in the country stating in point number 6 That all transport services i.e. air, rail, roadways will remain suspended with few exceptions Chapter-3-study Methods

3.1-Study Design
The study design is retrospective mixed quantitative and qualitative analysis of the RCH programme of Rajasthan.

3.2-Study setting and duration
To know the impact of pandemic era on RCH programme of Rajasthan during 3 months after lock down declaration in the month of March 2020 i.e. April/May/June 2020 in Rajasthan. The data period under consideration is for the year 2019 and 2020, which was analysed to report several outcome indicators of interest.

3.3-Sampling method
The data obtained from HMIS (Health Management Information System) of Ministry of Health and Family Welfare (MoHFW), Government of India for RCH programmes (Reproductive and Child Health) .The data analysis was done by Microsoft o ce software. The data is available for free distributions as mentioned by MoHFW-see excel table 2 below 12 .Differentoutcome indicators were taken into account to know the effect of SARS-CoV-2 Pandemic on delivery of health services to mother and child as well as family planning health services under the umbrella of RCH programme

3.4-Study Participants
This study has not involved any human or animals in real or for experiments.
Inclusion criteria-Different indicators group of RCH programme (immunisation, maternal and child health, family planning) for Rajasthan during the month of April/May/June -2019 and 2020. (ANNEXURE -4) Exclusion criteria-Different indicators group of RCH programme (immunisation, maternal and child health, family planning) for Rajasthan other than the month of April/May/June -2019 and 2020.

3.5-Study tools and measurements
The data analysis was done by Microsoft o ce software. The data is available for free distributions as mentioned by MoHFW-see excel table 2 below 12 . Different outcome indicators were taken into account to know the effect of SARS-CoV-2 Pandemic on provision of health services to mother and child as well as family planning health services under the umbrella of RCH programme.
Outcome-The study outcome is presented in the form of tables, graphs and literature.
Exposure-All the relevance to the study is listed in reference as well as data source is also documented.

3.6-Data collection tool
The data obtained from HMIS (ANNEXURE -3- Table 2

3.8-Data collection process (Settings and Design):
Different indicators group (immunisation, maternal and child health, family planning) of RCH programme for Rajasthan were taken into consideration for the study and data collected and compared from previous year during the month of April/May/June -2019 and 2020.

3.9-Data analysis
The percent increase and decline is calculated from the collected and available data to know the status of provision of important and essential health services. The need assessed and percent of achievement of assessed need is also compared and future achievement projected as per achievement. The data analysis was done by Microsoft o ce software. The data is also shown in tabulated as well as graphical form for ease of understanding. All the data obtained were analysed using Microsoft o ce software.

Chapter-4
Ethical Consideration-The ethical committee have been requested to provide clearance over the ethical issue as this study has not involved any human or animals in real or for experiments. Chapter-5

5-RESULTS
Antenatal care is very much essential for safeguarding the health of women and their unborn children. ANC provide with preventive health care as well as pregnant women know from trained healthcare personnel regarding good healthy measures during the period from pregnancy, and better knowledge of danger signs during this period from pregnancy and childbirth, and receive social, sympathetic and psychological care at this vital time in their lives. The ANC services and institutional deliveries are signi cant to assess the condition of maternal care .Although home deliveries declined during this period of observation but at the same time the institutional deliveries also decreased which are matters of great concern.
The data analysis results regarding RCH services performance in the state of Rajasthan during the period from the month of April to June 2020 (during the period from lockdown) as compared to previous year 2019(no lockdown) for same months suggest that the immunisation services had been adversely affected during the period from the lockdown period in 2020. It is evident from the ndings of the study that not only newborn children but also the older ones have not received basic immunisation services.
Due to increasing population there is a general trend of increase in need assessed as well as numbers achieved every year in all above indicators every year. The decline in achievement of such important indicators clearly signi es that SARS-CoV-2 pandemic have a negative effect on provision of RC health services such as maternal and child health. The role of family planning is very important in context of Rajasthan with increasing population and scanty natural resources. All family planning programmes reduced from previous year timeline for the same months indicating that the population control strategy of Rajasthan also suffered during this period.
5.1--Immunisation coverage for 2019 and 2020 during the month of April to June (Rajasthan) Table number 1 shows that as compared to previous year 2019 data-For BCG immunisation there is a decline of 14.5percentin 2020, Since BCG is given at birth it seems that either less number of children's is born during the period from this period or many have not received it, For Penta3+DPT3 the decline was 32.4percent in 2020 ,For DT or DPT5 the decline was 34.1percent in 2020,For Measles+MR the decline was 10.7percent in 2020,For OPV3 the decline was 32.4percent in 2020,For TT10 the decline was 40.7percent in 2020,For TT16 the decline was 43.9percent in 2020,For vitamin A which is given from 9 months of age 1 st dose declined by 9.9percent in 2020, Vitamin A 2 nd to 9 th dose starts from 16 months of age (one dose every 6 month),Vitamin A 5 th dose declined by 61.6percent in 2020, Vitamin A 9 th dose declined by 77.4percent in 2020.Here it is important to mention that vitamins A and OPV both are given orally. OPV3 is given at the age of 14 weeks whereas vitamin A is started from 9 month onwards. This observation suggests that the immunisation coverage for children of all ages declined in 2020 during April/May/June as compared to 2019 when the pandemic was not in existence.        ITEM CODE  NUMBERS OF  ACHIEVEMENTDURING  THE PERIOD FROM  APRIL TO JUNE 2020-21   NEED  ASSESSED  2020-21   PERCENT  OF NEED  ACHIEVED  DURING  THE  PERIOD  FROM  APRIL TO  JUNE  2020-21   NUMBERS OF  ACHIEVEMENTDURING  THE PERIOD FROM  APRIL TO JUNE -2019-20   NEED  ASSESSED  2019-20   PERCENT OF  NEED  ACHIEVED  DURING THE  PERIOD FROM  APRIL TO  JUNE 2019-   Note-Sterilisation includes both tubectomy and vasectomy but need to be shown separately as per international guidelines and moreover the two processes are also different, tubectomy is done for female sterilisation whereas vasectomy is done for male sterilisation. The percentage of achievement of need assessed is different from the percentage comparison of numbers of achievement during the period from April to June of two nancial years. Chapter-6

DISCUSSION
The observation, study, calculation and analysis of data obtained from HMIS (health management information system), Ministry of Health and Family Welfare website for RCH programme in Rajasthan shows that the lock down period and initial early phase of SARS-CoV-2 pandemic had a negative effect on the provision of RCH health services as detailed in results above. Besides the pandemic Rajasthan is also having lack of resources, skilled manpower poor infrastructure as well as positive deviance at community level 13 .These are the hindrances in the provision of RCH services beside the epidemic. RCH (reproductive and child health) service provision is always a priority and great concern for populous nations particularly India with high levels of fertility. During the period from theSARS-CoV-2 pandemic era it's more challenging to deliver such essential services due to fear factors at community as well as health personal level. Fall in rate of immunisation can lead to emergence of diseases which is being controlled by immunisation programmes. If an unvaccinated child is open to the elements to disease microorganisms, the child's body may not be physically powerful as much as necessary to ght the disease. Before the discovery and invention of vaccines, several children's died from diseases that vaccines now put off; such examples are whooping cough, measles, and polio. Though same microorganisms are present today, but since babies are cosseted by vaccines, we don't see these diseases nearly as frequently.
Immunizing particularly children's also helps to guard the health of our community, in particular those who cannot be immunized (children who are too young to be vaccinated, or those who can't receive assured vaccines for medicinal/therapeutic reasons), and the little percentage of children who don't act in response to a particular vaccine. Vaccine-preventable diseases have an expensive brunt, resulting in hospital visits, hospitalizations, and early premature morbidity and mortality. Sick children can also cause parents to lose time from work 14 .
Limited, insu cient and under quality ANC services will pose a threat to maternal as well as foetus life. Good quality antenatal care also provides pregnant women with micronutrient supplementation, management for hypertension to inhibit eclampsia, as well as immunization against tetanus. Antenatal care makes available HIV testing and provides drugs to prevent mother-to-child transmission of HIV in pregnancy, childbirth, or breastfeeding (through breast milk).
In malaria endemic zones, health personnel can make available pregnant women with drugs and insecticide-treated mosquito nets (ITNs) to help put off this devastating and sometimes deadly disease 15 .
The insu ciency in family planning coverage will add more to burden of population explosion putting more pressure on available resources depletion. Women should be encouraged for making the choice, to take decision about the number and spacing of their conception. Family planning can help women protect their health and fertility and also in improving the quality of their own and family lives. Family planning also help in getting better children's health and ensuring access to enough food, clothing, housing, and educational opportunities. Family planning achieves these improvements in health and value of life in a better way compared with fund investments in most other health and social interventions. Committing human and nancial assets for improving family planning services will get better health and well-being of women and children, and at the same time it will also prop up efforts to achieve a sustainable global population 16 .
All states and union territories of India have enforced various different strategies but it appears to be not totally effective to get good results on RCHealth programme. The Government of Rajasthan should consider taking help of local intellectual people and communities as well as increasing skilled human resources working to safeguard maternal and child health in situations of distress-emergency such as SARS-CoV-2 pandemic. For this the barriers in provision of RCH services like less number of skilled doctors, nurses, other resources should be reduced-recti ed and promoters of RCH programme like health promotion activities creating awareness of bene ts and addressing misbelieves and questions needs to be considered by policy-decision makers to achieve the maximum output from efforts and available resources.
Observations and analysis based on HMIS data from Bihar, Uttar Pradesh, Andhra Pradesh and India has also been conducted and submitted for peer reviewed publications which is available online for further reference. 17,18,19,20,21 The topic is of prime concern particularly for LMICs (low and middle income countries).Some researchers have used one modern LiST (lives saved tool) method to calculate the impact. One such study done by Timothy Roberton et al, found the indirect impacts of the SARS-COV-2 pandemic on maternal and child mortality in LMICs in which the health service coverage of essential maternal and child health interventions is reduced by 9·8-51·9% and the prevalence of wasting is up by 10-50% 22 .

Chapter-7
Limitations of the Study-The data although collected from an accredited source may have some errors of reporting and human error etc. Moreover it's stated by government that they use to refresh the data if some corrections are required. If the data is changed by the government which is usually rare the results will change accordingly.
Chapter-8 CONCLUSION: India and different states has launched several plans and strategies to deal with SARS-CoV-2 pandemic. However this study report found that insu cient attention have been given to very essential services of RCH in Rajasthan as evident from the results of this study. The problems in the provision of healthcare services should be dealt properly added with a proper update latest dynamic plan to carry on essential health delivery services even in pandemics and other situations of emergencies. The Rajasthan should develop an exclusive updated latest dynamic plan to deal with situations to guarantee provision of very essential services such as RCH during the period from pandemics or any other natural calamities-emergencies.
The ongoing SARS-CoV-2 pandemic has disclosed the vulnerability of women and children's and at the same time teaches us about importance of equity in healthcare. The children and women's who are considered most vulnerable in emergencies and distress must have special supportive healthcare all the times especially during the period from pandemics-emergencies and other natural disasters.
India is the second most populous country in the world after china. To control the ongoing population explosion including Rajasthan all states should have a robust population control strategy to working in all the conditions of emergency as well as in normal conditions. Data availability -The data is available as supplement as well as at the following web serviceshttps://www.mohfw.gov.in/index.html Declarations -This paper has not been previously published and is not currently under consideration by another journal. The document is Microsoft word with English (India) language & 8555 words Total.
-Ethics approval and consent to participate: Not applicable. This study has not involved any human or animals in real or for experiments.
-Consent for publication: Not applicable -Availability of data and materials: The data & materials for study are mentioned in article and available as reference.
-Con icts of Interest/ Competing Interest: There are no con icts / competing of interest -Funding-Self sponsored. No aid taken from individual or agency etc. -Acknowledgements-I am thankful to Advocate Anupama my wife and my daughters Aathmika-Atheeva for cooperation.
-Author information: The author is currently working as Senior medical o cer for the government of Bihar.
-Financial Support & sponsorship: Nil -Author contact information