The coronavirus (SARS CoV-2) outbreak started in November 2019 in Hubei province, China.1 The viral disease spread gradually affecting almost all countries and later all continents (except Antarctica) by February 2020. The coronavirus outbreak was declared as a public health emergency of international concern by the world health organization (WHO) on 30th January, 2020 and as a “pandemic” on 11th March, 2020.2 The novel coronavirus causes a viral illness which spreads through fomites and the mode of infection is mainly through droplet infection, when a person comes in close contact to a coronavirus infected person or their bodily fluids.3 The novel coronavirus being a communicable illness, has caused 30,049,278 cases and 945,320 deaths due to the virus as of 17th, September 2020.4
To prevent the spread of SARS-CoV-2 and minimise case numbers as much as possible, various measures were taken by the international organisations and national authorities such as regulations on national and international travel, national lockdowns, curfews, closure of non-essential services and centres, bans on local travel (within a city), restrictions in leaving homes unless absolutely necessary or in an emergency.5
Healthcare has also been affected with most of the outpatient departments (OPD) closed, private hospitals were temporarily shut down, elective surgery suspended and radiology departments in hospitals closed to outpatients.6 The coronavirus outbreak has caused an explosion of cases of coronavirus infected patients that have saturated hospitals and health resources. Healthcare resources across the entire world are exhausted due to the pandemic and the healthcare facilities are overloaded and burdened with the pandemic load. This has caused an inadequate supply of healthcare and health facilities to non-coronavirus infected patients. This drastic change in the world’s situation and the national/ local closure of healthcare facilities and diversion of health resources to coronavirus pandemic has caused a great impact on the health of many people, including women. The coronavirus outbreak and lockdowns has caused women to face difficulty in seeking satisfactory healthcare for themselves.
Global Burden of Women’s Health Conditions
The total population of the world as of May 2020 is 7,794,799,000, out of which 3,864,825,000 (almost half) are women.7
Women of various age groups have their characteristic health problems e.g. adolescent girls having health concerns relating to menstruation problems, sexual growth, nutrition, body issues. Reproductive age group females have concerns related to pregnancy, antepartum, intrapartum and postpartum issues, lactation, breastfeeding, contraception, abortion, infertility, miscarriage etc. Middle age and elderly females need help with menstrual problems, abnormal uterine bleeding, post-menopausal bleeding, neoplasia of reproductive organs, uterine pathologies and prolapse, urinary complaints, etc.
Thus, there are millions of health concerns of women with needs to be attended.
Impact of Coronavirus outbreak on Womem’s Health
In 2019, around 140 million pregnant females delivered babies in the world with the average fertility rate of 2.48. 8 That is, on an average, a female would deliver 2.48 babies in her lifetime. Together with a feeling of womanhood and completeness, it is also very demanding of the mother both physically and mentally. The “SAFE MOTHERHOOD INITIATIVE” was started by three UN agencies- UNFPA, the World Bank and WHO in 1987. The aim of safe motherhood was to reduce maternal mortality and provide pregnant females good maternal health service before and after delivery. It also emphasises the availability of transport services in case of emergency for females, trained birth attendants, respectful maternity care, contraception guidance, post-partum care, etc.9
The coronavirus outbreak has impacted pregnancy as many females have difficulty reaching hospitals for their scheduled antenatal visits. As many hospitals closed their OPDs pregnant females were forced to either change doctors or miss their antenatal visits.10 Many hospitals also closed their radiology departments, elective ultrasonography facilities, blood testing facilities. This also forces cancellation of ultrasonography (especially level 2 scans) because many hospitals only allowed delivery of emergency health services.
In India many females who live in remote villages and tribal areas, cannot reach hospitals for delivery due to lockdowns and ban on travel without a pass.11 This has led to raised number of home deliveries and deliveries by non-trained birth attendants negating the “safe motherhood” initiative by the WHO.
Some government initiatives made provision for the supply of free iron and folic acid tablets to poor pregnant females and are distributed by government hospitals.12 Due to the coronavirus outbreak and closure of elective/ non-essential services, many poor females are unable to get their free supplies of iron and folic acid supplementation.
Due to the changed policies and guidelines in hospitals and to prevent the spread of the coronavirus, many hospitals do not allow attendants along with patients in labour rooms. This causes many females to deliver without birth companions (contrary to the advised WHO guidelines for recommended birth companion) and now have less moral support during childbirth.
Overall, the medical care and attention which pregnant females used to get in the pre-coronavirus era has diminished markedly and this creates a negative psychological and physical impact. Non-fulfilment of the hopes and expectations which females usually have for their pregnancy has caused a feeling of remorse, anxiety and dissatisfaction.
The postpartum period, also referred to as postnatal period and puerperium, is the period that begins immediately after delivery and continues for the next 6 weeks. During this period, the mother needs extensive support from healthcare workers as well as the family. Due to the coronavirus outbreak, most of the doctors are overburdened and exhausted due to the care of Coronavirus patients. In addition, if a mother suffers some symptoms resembling the symptoms of coronavirus, she suffers a dilemma whether to feed her child or not13 and also experiences anxiety pertaining to the health of the child. The national lockdowns, increasing number of deaths, house restrictions create a feeling of captivity, suffocation and anxiety among mothers and they are unable to fully enjoy their immediate motherhood and child-care fully.
Abortion and family planning services
According to the world health organisation (WHO), every year in the world there are an estimated 40-50 million legal abortions. This corresponds to about 125,000 abortions per day.14 The reasons why some females undergo induced abortion are postponement of childbearing, inability to afford a baby, relationship problems with the partner, being too young, unwanted pregnancy, does not want more children, and many more.15
The essential services of abortion care were difficult to access during the lockdown due to the COVID-19 outbreak. Dr. Jaydeep Tank, General Secretary of federation of obstetrics and gynecological societies of India (FOGSI) said “not all private clinics are open for abortions, but some are opening as knowledge about the disease improves”.16 Many health facilities banned most abortions/ stopped giving abortion care services during the coronavirus outbreak unless the abortion was urgent or medically necessary. This was done to preserve hospital beds, medical resources and facilities that are necessary during the pandemic.17
Along with abortion care services, family planning services are also hit. In 2019, as per the Health Information system (HMIS), 35,00,000 sterilizations, 57,00,000 IUCDs, 18,00,000 injectable contraceptive services were provided by the public sector. Public health facilities also distributed 4,10,00,000 cycles of oral contraceptive pills (OCPs), 25,00,000 emergency contraceptive pills (ECPs) and 32,20,00,000 condoms. The lockdown had led to the use of and access to contraception to a large extent. By the government of India’s advisory, ministry of health and family welfare, public facilities have suspended provision of sterilisation and IUCDs till further notice. The curb on domestic and local movements (lockdowns) have made access to over the counter contraceptives, condoms, OCPs, and ECPs difficult.18
It is estimated that 25.6 million couples would not have been able to access contraception services during the period of lockdown and by the time contraception services normalise. This could potentially lead to millions of unwanted pregnancies worldwide. Many women who ended up with an un-intended pregnancy may be forced to carry their pregnancy to term, since they may not have been able to access abortion care” said VS Chandrashekar, Chief Executive Officer, Foundation for Reproductive Health Services India. The overall adverse impact on FP programme in 2020 is estimated to be between -15% to -23% in terms of Couple Years of Protection compared to 2019” he added. This means that the estimated protection provided by the contraceptive methods during one year has fallen by 15-23%. The disruption in family planning services during the lockdown will result in increased demand for sterilization and abortion services once the lockdown is eased/ lifted. The United Nations study finds that the coronavirus pandemic could cause around 7 million unintended pregnancies and leave 47 million women unable to access modern contraceptive.19
As the coronavirus outbreak occurred and measures were taken to minimise its spread, one measure taken was to close down schools and colleges temporarily to minimise the social gathering of children.20
According to UNESCO, over 1.57 billion students have been affected by school closures in more than 190 countries during the pandemic. With much of the world forced to remain home instead of work or school since March 2020, it might have a mental health impact on school aged children. It also means lack of access to the resources they usually have through school. School routines are important coping mechanisms for young people with mental health issues. When schools are closed, they lose an anchor in life and their symptoms could relapse. Going to school had been a struggle for [some children with depression] prior to the pandemic, but at least they had school routines to rely on.21, 22
Also, due to the lockdown, adolescent health clinics, reproductive clinics are closed causing the adolescents unable to access help regarding their health problems related to menstruation, menstrual hygiene, diet, sex education, etc.
Peri and post-menopausal women
The perimenopause is the transition period from ovulatory cycles to the menopause. It is associated with erratic fluctuations in hormone levels, irregular menstruation, vasomotor symptoms, mood changes, sexual dysfunction, etc.23 The closure of OPDs and elective health services has caused decreased quality of life for these women.
Impact of cancellation of non- emergency operative procedures
Many patients requiring operative procedures for their respective health problems have faced disappointment and cancellation of surgery during the coronavirus outbreak.
Many females suffering with health conditions such as early stage cervical cancer, abnormal uterine bleeding due to leiomyoma, polyps, endometrial causes, endometrial cancers, etc. require surgery to diagnose and treat their disease.
Non- emergency surgery is on hold in the coronavirus outbreak era and even some serious operations are getting delayed. This delay may result in delayed morbidity and potential mortality.24
Psychological impact of coronavirus pandemic
Women of all age groups suffer health problems specific to their age and expect a prompt and appropriate healthcare delivery system. The unexpected coronavirus outbreak has caused an acute impact on the mental health of women of all age groups. There is an increase in anxiety, stress, distress, uncertainty towards the future in women who suffer from ailments and also healthy women. COVID-19 has exacerbated pre-existing inequalities and exposed gaps in our system, amplifying the effects of the pandemic. The social distancing and stay- at- home orders have had large impact for women in every sphere of their lives. The sharp rise in unemployment and limited access to social protection has caused many women to have a higher risk of falling into poverty as they hold less secure jobs or they work in informal economy.25
Due to the various lockdowns implemented all over the world to contain the spread of coronavirus, people cannot move freely and are home bound. This causes many women to suffer depression and loneliness as they are stuck inside four walls and do not have ways to cope with their emotions.26
Long term impact of COVID-19 on women’s health
The coronavirus outbreak (COVID-19) is an unprecedented pandemic for which the world was not ready. The rampant disease has spread like wildfire affecting millions of people worldwide. People affected with the coronavirus illness are suffering and face a threat to their lives, but other people who are not yet directly affected with the disease are also suffering because of it. Women of all age groups and categories; pregnant patients, adolescents, young girls, elderly females are facing difficulty in getting the best care for themselves. Women are not getting adequate and satisfactory OPD services, abortion and family planning services, menstrual and sexual health counselling, infertility services, operative management, etc. This has happened due to diversion of the medical resources towards the ongoing COVID-19 pandemic and also limited health resources.
The ongoing pandemic and the world’s battle against it, has impacted all people greatly, including women. The development in women’s healthcare has taken a toll as the ongoing health programs and goals have come to a still due to shift in focus from development in women healthcare to just provision of basic and essential healthcare services.
Various health schemes have been initiated by the government of India in the past few years eg reproductive, maternal, newborn, child and adolescent health (RMNCH+A) programme, Rashtriya Bal Swasthya Karyakram (RBSK), The Rashtriya Kishor Swasthya Karyakram, Shishu Suraksha Karyakram. All such programmes are aimed at improving maternal and child health, adolescent health and women’s health in general.27 Due to the ongoing coronavirus pandemic, progress of these schemes have faltered due to closure of many health services and difficulty in implementing such schemes.
Thus, the coronavirus pandemic has hampered women’s health in all aspects and the uncertain future about the course of the COVID-19 disease worldwide gives only a faint idea about the future of women healthcare.