Abstract
Background
The incidence and fear of COVID-19 continue to devastate the globe compromising the lives of over a million. As of 17th November 2020, India stands as the second-worst affected country with approximately 8.10 million recorded confirmed cases, and deaths totaling up to 131,435 (Government of India). India’s unprecedented lockdown measures and direct diversion of the country’s limited financial and workforce resources to manage COVID-19 have further aggravated India’s pre-existing fragile health system causing immense disruption of essential healthcare services. Evidence suggests that the country had witnessed significant difficulties and a sharp decline in accessibility and uptake of essential maternal healthcare services when it was under strictest lockdown (The Times of India, 2020). Although the Ministry of Health and Family Welfare, Government of India identified pregnant women as the ‘high risk group’ and ensured uninterrupted access to essential maternal health services by issuing guidelines in mid-April 2020, health facilities are currently facing immense challenges to maintain the demand (Ministry of Health and Family Welfare, 2020). More than 50% of institutional deliveries in India including urban and rural take place in public health facilities with rest occurring in private facilities and trustees (International Institute for Population Sciences Mumbai, 2016). With decades of efforts in place, India has indeed achieved progress in averting preventable maternal deaths by approximately 56% decrease in maternal mortality ratio (MMR) (254 in 2004 to 113 in 2018) with a significant rise in safe institutional and home deliveries in the presence of skilled birth attendants (Government of India, 2018; International Institute for Population Sciences Mumbai, 2016).
Impact of COVID-19 on maternal health
Public health experts are nonetheless agonized by the dire situation speculating occurrence of additional maternal and newborn deaths in coming months through unsafe and untimely deliveries and abortions. A recent report published in Lancet estimated an additional 56,700 and 115,700 maternal and child deaths respectively in low and middle-income countries (LMICs including India) under the scenario of 45% reduction in the supply of maternal health services stretched for six months (Roberton et al., 2020). Alongside, the United Nations Population Fund and partners forecasted around seven million unintended pregnancies in India under interrupted access to essential family planning services (UNFPA, 2020).
With pre-existing dearth and uneven distribution of trained healthcare providers and facilities, and recently overwhelming COVID-19 patients, the state, district, and in few cases block public facilities are immensely struggling to cater the current demand. Concerning reports from India suggest that due to facility closures, unanticipated denials from facilities, misbehavior and mistreatment (obstetric violence) by the healthcare providers, poor transport communication, and fear of infection (avoidance of visiting healthcare facilities), pregnant women are experiencing immense physical and mental hardships in accessing safe maternity care (MahatabAlam, 2020; Shrivastava & Sivakami, 2020). Evidence from previously published studies indicate that these severe forms of negative and frightening experiences during pregnancy specifically during the periods of labor and delivery could directly affect the mental health of women leading to symptoms of depression, posttraumatic stress disorders, fear of childbirth and sometimes severe forms of birth-related phobia known as ‘tokophobia’ (Jha et al., 2018).
Growing burden of fear of childbirth and associated factors
Globally, the prevalence of fear of childbirth lies between 3.7% and 43% (O’Connell et al., 2017). The data on the prevalence of fear of childbirth in India with few available studies indicate it is 13% (facility level, Chhattisgarh, India) and 45% (facility level, Rural Karnataka, India) (Jha et al., 2018; Johnson et al., 2019). While the subject has been extensively studied in high-income countries such as Scandinavian countries, it is evident that the issue is majorly overlooked and under-researched in India. Evidence shows that several women opt for C-section deliveries due to fear of childbirth (Miller et al., 2016; Thompson, 2010). Previous studies indicate that majority of the women (especially from marginalized communities) in LMICs like India receive ‘too little, too late’ (Miller et al., 2016) or disrespectful and abusive maternal care which involves lack of implementation of evidence-based clinical practices, lack of information, and consent seeking among/from women about the interventions they are receiving or likely to receive (Jha et al., 2018; Miller et al., 2016). This kind of clinical practices escalate fear or negative birth experiences among women and hence they are less likely to return to health facilities for institutional deliveries in future (Jha et al., 2018; Miller et al., 2016). With the advent of COVID-19 and disruption of safe maternity care, the situation could exacerbate the fear of childbirth among currently pregnant women particularly among unwanted pregnancies. Pregnant women may encounter a significant increase in fear of childbirth related to labor pain and grimful birth experiences. Inadequate or missed antenatal care visits, restricted access to necessary ultrasound tests, absence of birth companion during labor, instant separation from newborns and prohibition of breastfeeding post-delivery, poor communication with healthcare providers, insufficient required support from community healthcare workers (particularly auxiliary nurse midwives: ANMs and accredited social activists: ASHAs), escalation of domestic violence cases and isolation could lead to increased fear of childbirth (Jha et al., 2018; Sadler et al., 2020; Shrivastava & Sivakami, 2020). This increased fear of childbirth eventually leads to adverse intrapartum or postpartum implications and affects the overall health of both mother and new-born child.
Despite the country’s progress in improving indicators related to maternal and child mortality, the issue has not received its due attention from the policymakers and relevant stakeholders in the country. Since the subject has always been overlooked and underreported, several women and their unborn (also newborns) may have been unknowingly victims to it. Lack of investigation and insufficient knowledge around this issue has shrouded the subject with misconceptions, negativity, and secrecy. Previous studies have indicated that factors like domestic violence, abuse, unsuccessful marital relationship, level of poverty, negative and/or traumatic birth experiences, disrespectful and abusive care, and impaired communication with healthcare providers could play vital roles in fear acquisition during childbirth (Jha et al., 2018; O’Connell et al., 2017). As factors vary across different countries; it is crucial to know the root cause and associated risk factors of fear of childbirth among pregnant women in India to reduce maternal and neonatal deaths. It is imperative that the issue gets its due recognition from the governing bodies to ensure that this does not impede the decades efforts and significant advances the country has made in averting preventable maternal and child mortality.
Evidence-based non-pharmacological interventions to address fear of childbirth
There are several home-based non-pharmacological interventions that can be undertaken to mitigate the fear of childbirth and associated adverse consequences. For example, increased family support to pregnant women, proper communication between pregnant women and family members (especially mothers), and engaging partners with pregnant women. As such, it is paramount that the governing body integrates the issue of fear of childbirth as an aspect of maternal mental health into mainstream maternal and child health programs. The Government of India must promulgate mandatory awareness programs through culturally adaptive risk communication and develop guidelines through establishment of national level indicators to track progress on effective mitigation of fear of childbirth. Though Indian Council of Medical Research had issued guidelines on management of pregnant women in response to COVID-19, the maternal mental health aspect has been entirely neglected (ICMR-National Institute for Research in Reproductive Health, 2020). It is vital to unleash the issue from shrouded negativity, misconceptions, secrecy to enable vulnerable and high-risk (pregnant) women to access safe emotional and social support which is integral to their sexual and reproductive health rights. There is an urgent need for high quality large scale primary studies examining the prevalence, associated risk factors, knowledge among women, and association with fear of childbirth to inform agenda setting in local level policy making. The commentary advocates for the immediate attention of policymakers, relevant stakeholders, and public health experts to collectively respond by recognizing and preventing adverse maternal outcomes due to fear related childbirth (which is assumed to have escalated during COVID-19). This is needed at this hour, and in the future when the virus subsides.
