Utilization of Maternal, Nutritional and Child Health Care Services Amidst COVID-19 Pandemic in Uttar Pradesh, India


 Parihar Anand Kumar Singh1, Singh Moksha2

1PhD Scholar, Humanities of Social Sciencce, National Institute of Technology, Raipur, India.

2Assistant Professor, Humanities of Social Sciencce, National Institute of Technology, Raipur, India.

*Corresponding Author E-mail: msingh.eng@nitrr.ac.in



Background: All maternal health services are essential to be continued for pregnant mothers during lockdown and avoid COVID infection with awareness of people by following all precautions from COVID-19. We aimed to examine changes in service provision and utilization of MNCH services during the pandemic in Uttar Pradesh, India and identify the factors affecting the utilization and service delivery. Objective: To assess the effects of the COVID-19 pandemic on utilization and delivery of maternal health services at health facilities in Uttar Pradesh, India. Method: COVID -19 pandemic data has been collected form website https://prsindia.org/covid-19/cases which provides the day wise data for four major components such as confirmed cases, active cases, cured/discharged and death and pandemic effects on the maternal services including ANC registration, pregnant women registered for ANC within 1st trimester and home and institutional deliveries during April 2019, April 2020 and April 2021. At the same time, through informal discussion with key healthcare professionals and focused desk reviews of published scientific, grey and media-based information and country-specific healthcare policies. Results and summary: Huge difference in the percent change of the beneficiaries received maternal health services among April 2019, April 2020 and April 2021. It is found that there is 88 percent change in the ANC registration for pregnant women in April 2020 against April 2019. It simple means that 371065 pregnant women registered for ANC in April 2019 whereas only 44987 pregnant women registered in April 2019 which is very less number of pregnant women went for ANC visit in public health facilities in Uttar Pradesh. While, during the 2nd wave of COVID-19 pandemic regarding the ANC service, it reflects only 3 percent change based on government HMIS data set, as 361201 pregnant women registered for ANC in April 2021 and its close to April 2019 i.e. 371065. Similarly, 12 percent change for institutional deliveries was found in April 2020 and no change for the institutional deliveries during April 2021. Moreover, more institutional deliveries are occurred during April 2021 against April 2020 and April 2019. The main reason for delayed health seeking was lockdown in April 2020 due to COVID-19 pandemic. The health situation was very worst in all the public health facilities during April 2021 due to COVID-19. Conclusions: COVID-19 severely affected the provision and use of MNCH services in Uttar Pradesh, India, despite efforts at service restoration and adaptations. Strengthening logistics support, capacity enhancement, performance management, and demand creation are needed to improve service provision and utilization during and post-COVID-19.


KEYWORDS: Covid-19, MNCH, Women, ANC, Maternal, Pregnancy.




In any pandemic or disaster, women and children are most “Vulnerable” or widely exposed to the risk of outbreak and its associated social, economic and health consequences. Since December 2019, Corona Virus Disease-19 (COVID-19) caused by severe acute respiratory syndrome coronavirus 2 (SARS_CoV-2) has infected more than 320 million people globally till December 2021 and has caused more than 5.0 million death globally [1]. Covid-19 has exposed the global health sector. Irrespective of the disparity in impact, the global response to the COVID-19 pandemic has largely been a ‘one size fits all,’ centred around extensive lockdowns to ensure physical distancing whilst trying to maintain essential healthcare as much as possible [2]. Such approach has resulted in a shift of focus from essential healthcare services to providing mainly emergency services alongside COVID-19 care [3].


Measures deployed to curtail the pandemic such as lockdown and suspension of public transportation have affected access to healthcare in the public and private sectors in India. Fear of contracting the infection also suspected to lead to reduction in access of MNCH services. For a country like India who is confronting the huge burden of diseases in the form of Communicable, Maternal, Nutritional and Non-communicable diseases and composed with significantly larger proportion of Maternal and child populations, the Maternal and Child Health Services (MNCHS) requires more attention than other health services. The most affected services of MNCHS during any pandemic are prenatal services, contraception, abortion services, postnatal services and immunization as service providers are being engaged in other health services.


The Covid-19 pandemic has posed serious threat and unprecedented situation to the MNCH related services delivery coupled with the Covid-10 associated health consequences. During the pregnancy, women passes through several hormonal and immune changes, in result women body become very sensitive to any changes hence a small stress can sever the situation [4]. Several studies suggest that pregnant women and non-pregnant women in the same age group have developed mild to moderate symptoms if infected with covid-19. However, pregnant women are at higher risk of mortality and morbidity if they get respiratory infections. Other studies also suggest that respiratory viral infection can cause the problem of low birth weight and preterm birth [5]. The Disease Control and Prevention (CDC) analysed data on pregnant and non-pregnant women who were infected with covid-19. The analysis suggests that pregnant women were more prone to be hospitalised than non-pregnant women and to be admitted in ICU though the risk of death is almost same. Relative to Asymptomatic pregnant women, symptomatic pregnant women have higher rate of miscarriage also higher rate of infant death [6]. Studies also suggest that most of the pregnancy outcomes were successful and not affected by Covid-19 but majority of Covid-19 women underwent C-Section along with higher proportion of premature delivery [7-8].


At the same time, the Covid-19 pandemic has been affected the delivery of MNCH care services in several indirect ways. In the lack of proper guidelines and evidence, countries imposed tough lockdown to curb the transmission of covid-19 outbreak and restrictions on MNCH services as well, as these services were not mentioned as essential service in the guidelines. It had thus created a hindrance to the availability and accessibility of the maternal and child health services and it was difficult to avail the MNCH Services [9]. A study of selected Low- and middle-Income countries (LMICs) suggest that between March and May 2020, there was a reduction in availing the MNCH services such as antenatal care, family planning and immunisation due to tough lockdown and fear of infection of Covid-19. The shortage of health care workers in MNCH services was reported as health workers were shifted towards dealing the pandemic cases [10].


Few rapid assessments on the impact of Covid-19 pandemic have reported the similar interruptions in the utilization of MNCH services in India too. There was an overall decrease of 2.3% in number of institutional deliveries; antenatal care services were the worst affected with 22.9% decline and immunization services also dramatically decreased by more than 20% in Uttar Pradesh, India [11]. In Rajasthan, India, 37% of Family Planning (FP) service provider stated that supply of 80% FP services were interrupted for a month or longer. At the peak of lockdown in 2020, only 18% of facilities in Bihar were accessed on a fixed day. Services could have resumed back to normal situation in about six months [12]. A UNFPA technical note reported that about 47 million women in 114 low- and middle-income countries (LMICs), including India, will not be able to use contraception, in result there would be 7 million unwanted pregnancies. In India, the shortage and lack of access of contraception will results in 2.4 million unwanted pregnancies and 1.45 million abortions [13].


From the equity perspective, the conceptual frameworks like social determinants of health (SDH) or the work of the Social Exclusion Knowledge Network (SEKN) shows that social exclusion is a process which starts by under-mining related political, economic and cultural factors [14]. These factors are key in shaping the health of the vulnerable and socially excluded groups and are often neglected in blanketed or top-down approaches. As a result, vulnerable groups suffer the most and may become excluded further [3]. Additionally, current pandemic focused approach is likely to cause additional public health crisis for mothers and children especially for the demographically backward States such as Uttar Pradesh and Bihar where almost 1/3rd India’s population lives, by disrupting access to usual healthcare and adding additional MNCH-related mortality and morbidity.

Past Ebola experience suggests that it is of paramount importance for the LMICs to embark on a resilient health system which is adaptive enough to adopt approach to meet pandemic related challenges as well as continue to maintain focus on the pre-COVID healthcare needs/priorities. To do so, the first step is to explore, understand and contextualise how the pandemic has tested health system resilience [3, 15]. Here, we have considered the disruption in utilisation of MNCH care as a result of the COVID-19 pandemic in the most populous State of the Country i.e. Uttar Pradesh and highlight the need for a responsive health system approach to mitigate ongoing and future crises in MNCH care in Uttar Pradesh and similar approach in other States.


In this article, we are trying to figure out the impact of covid-19 on MNCH services in India using the National Health Management Information System (HMIS) of India; and through informal discussion with key healthcare professionals and focused desk reviews of published scientific, grey and media-based information and country-specific healthcare policies. We have examined both the direct and indirect impacts of Covid-19 on maternal and child health services in rural Uttar Pradesh, India. Many research papers show that indirect impact is more deepen than direct impact. In direct impact, we will discuss how covid-19 infection affects the health of pregnant women during the course of pregnancy. And in indirect impact, we will discuss how medical facilities affect the health of mother and child.



Using the National Health Management Information System (HMIS) of India, we collected and compared information on utilization of selected MNCH services for 1 month during the pandemic (April 2020 & April 2021) and the same months in 2019. The services were selected from the list of SDG indicators and were operationalised into two groups: a) basic MNCH care that can be provided in the community or in the outpatient clinics of healthcare facilities (such as ANC, family planning (FP) and child immunisation services), and b) advanced MNCH care usually provided for patients admitted into healthcare facilities (such as normal vaginal deliveries (NVD) and caesarean sections (CS)). We then explored the underlying factors influencing the utilization of these MNCH services during the COVID-19 pandemic through informal discussion with key healthcare professionals and focused desk reviews of published scientific, grey and media-based information and country-specific healthcare policies.



A survey questionnaire to assess research needs in MNCH was developed. Specific priority research domains were identified through a review of previous survey results, and literature on global priorities in maternal newborn and child health. Some of the key stakeholders reviewed the survey and research domains included, and provided input that was incorporated; the final survey was derived by consensus. The following six broad research domains were identified, according to the principles of thematic analysis: vaccine preventable diseases, outbreak preparedness, primary healthcare integration, maternal health, neonatal health, and infectious diseases. The survey consisted of 32 questions which focused on these six broad domains. Under each domain, recorded informal discussions with key healthcare professionals were conducted. In each domain, participants had the option to nominate a different research topic not included in the prepared list; these could be ranked by importance in the same manner. Since this was a informal assessment, we employed convenience sampling, based on a snowball sampling strategy. Further, we did not target any specific sample size; we analyzed all responses that we received.


Utilisation of basic MNCH care during the COVID-19 pandemic

Table 1 presents the patterns in the utilisation of basic MNCH care by months between 2019 and 2021 using the HMIS Data of Uttar Pradesh, India. Uttar Pradesh recorded a decline in registration for formal ANC; no. of women received 4 or more ANC Check-ups; essential health care screening including the Hb measurement, hypertension and other ANC health care services during April 2020 and again increased in April 2021 in comparison to the same months in 2019. There was a significant decline in delivery preparedness counselling among pregnant women in the third trimester. Similar patterns are observed in Child Health and Immunization Services across both Public and Private Health Facilities. The institutional deliveries shown decline during the lockdown month in April 2020 and then increased during April 2021 compared to April 2019. It is likely that the overall changes in deliveries in Uttar Pradesh might have been influenced by resort to care in private facilities and tertiary facilities and home confinements during the pandemic. On the other hand, the data for Uttar Pradesh also shows an increase in CS delivery rates. There was a slight shift from public to private hospitals for MNCH service utilization.


Table 1 Utilisation (Number) of basic MNCH care by months between 2019 and 2021, HMIS Data, Uttar Pradesh, India

Key MNCH indicators (N)













ANC registration










ANC registration within 1st trimester










Number of PW received 4 or more ANC check ups










PW measured for BP during ANC examination










Pregnant women visited for ANC check up










New Cases of pregnant women with hypertension










PW tested for Hb(4 or >4 times in ANCs)










Pregnant women having Hb level<11 (tested cases)










Hb < 7 mg










Number of pregnant women whose birth plan have been prepared and reviewed during third trimester of pregnancy










Home Deliveries by SBA & non-SBA both










NB received 7 HBNC










Institutional delivery(including C-section)










Total C -Section deliveries performed










Women discharged under 48 hours of delivery










NB received 6 HBNC after institutional delivery










Women receiving post-partum checkup within 48 hours after delivery










Women getting a post-partum check-up between 48 hours and 14 days










BCG dose










Fully immunised children (9-11 months)- total










ANC: Ante Natal Care; PW: Pregnant Women; SBA: Skilled Birth Attendant; NB: New born


Huge difference in the percent change of the beneficiaries received maternal health services among April 2019, April 2020 and April 2021. It is found that there is 88 percent change in the ANC registration for pregnant women in April 2020 against April 2019. It simple means that 371065 pregnant women registered for ANC in April 2019 whereas only 44987 pregnant women registered in April 2019 which is very less number of pregnant women went for ANC visit in public health facilities in Uttar Pradesh. While, during the 2nd wave of COVID-19 pandemic regarding the ANC service, it reflects only 3 percent change based on government HMIS data set, as 361201 pregnant women registered for ANC in April 2021 and its close to the figure if April 2019 i.e. 371065. Similarly, 12 percent change for institutional deliveries was found in April 2020 and no change for the institutional deliveries during April 2021. Moreover, more institutional deliveries are occurred during April 2021 against April 2020 and April 2019. From the above, it is clear that the main reason for delayed seeking of MNCH services was the lockdown imposed in April 2020 due to COVID-19 pandemic. The health situation was very worst in all the public health facilities during April 2021 due to COVID-19. However, this worst health situation has been countered back to some extant for all the MNCH services during the 2nd wave of Covid-19 pandemic in April 2021.


Factors associated with the decline in utilisation of basic MNCH care during the COVID-19 pandemic

To substantiate the findings of the HMIS data and to understand the reasons and alleviating factors responsible for decline in the utilisation of basic MNCH care during the COVID-19 pandemic in Uttar Pradesh, India, we had informal discussion with key healthcare professionals and focused desk reviews of published scientific, grey and media-based information and country-specific healthcare policies. Here, we tried to outline the impact of measures for enforcing lockdowns and ensuring healthcare provision in Uttar Pradesh on the MNCH services. After reviewing media and government reports, policy papers and scientific publications, we identified following main factors that caused the decline in utilisation of MNCH services in relation to the COVID-19 response:


1.      Sudden Disruption of peoples’ lives due to lockdown and related measures

2.      Fear and lack of safety measures for healthcare workers

3.      Stigma in visiting health care facilities

4.      Affordability


On 24th March, 2020, the Government of India ordered a nationwide lockdown for 21 days, limiting movement of the entire 1.38 billion (138 crore) population of India as a preventive measure against the COVID-19 pandemic in India which was subsequently extended twice but with some relaxations in the transport and movement of people. The main mandate of imposing the lockdown was to restrict people stay at home. This not only resulted in loss of income but also reduced life-related day-to-day activities. While access to health care facilities was one of the few exceptions to stay-at-home orders during the lockdown, care-seeking behaviors and health care provision were nevertheless significantly affected. Usual health care seeking practices such as MNCH were severely reduced and mostly restricted to emergency healthcare needs.


Several factors could explain this. On the supply-side, hospitals were preoccupied with COVID-19 preparations or caseloads resulting in fewer resources for non-COVID cases. This may be particularly relevant in public hospitals, which have been the primary focus of the policy response in ensuring the treatment to the Covid-19 affected people, and thus could not extend to routine health care activities such as MNCH. Private hospitals reduced services out of fear among health workers that they will become infected or among owners that their business outlook will be jeopardized if they are perceived to be treating COVID-19 patients. On the demand-side, people opted to delay or forego treatment, vaccinations, immunizations and routine health check-ups due to fear of infection at a hospital, they may not be able reach hospitals due to public transport shutdowns and mobility constraints, or the nascent economic crisis may affect financial considerations related to seeking care. Lockdown regulations and the need for social distancing discouraged attendance in healthcare facilities including MNCH services, partly attributable to the fear of contracting the infection. The lack of preparedness in respect to the scale of the pandemic meant that other than the free rations, no proper economic relief plan was put in place for the period of the lockdown. There did not seem to be sufficient financial plans to mitigate loss of earnings and the discomfort associated with social distancing. Although India eventually announced a social relief and economic stimulus package, their impact on preventing or mitigating impending economic catastrophe across various socioeconomic groups is yet to be assessed.


At the same time, lack of logistical support for healthcare providers and inadequate screening facilities made the circumstances unsafe for service provisions. Globally, two of the most crucial components of COVID-19 guidance are the provision of screening facilities and the availability of personal protective equipment (PPE) and vaccines for healthcare staff. The informal discussion with health care workers revealed particularly of Government health facilities informed that they faced acute shortage/unavailability of PPE kits and even of the basic hygiene material and equipment. There was also situation when they were forced to repeat the same PPE kit for multiple days. Rationing of limited PPE and quarantine regulations for healthcare workers deemed to have exposed the healthcare providers to the infection and worsened healthcare provision further [16-18].


Our study here show that the use of lockdown and social distancing measures as the universal COVID-19 response has weakened inherent community socio-economic dynamics by ignoring the social, political, economic and cultural factors, especially for the socially vulnerable groups. While such approach has affected health care priorities in economically poor States such as Uttar Pradesh and Bihar, over time it is likely to cause the vulnerable groups to remain excluded from healthcare leading to the disparities in these States growing more. The informal discussion with health care workers confirm these trends implying a large increase in the number of home deliveries and related pregnancy complications and outcomes such as maternal deaths. It is certainly plausible, due to transport shutdowns and possibly the diminished role of ASHA workers due to lockdown, who otherwise play an important role in ensuring that women deliver at a health care institution. However, a more benign explanation would be that deliveries are still happening at government hospitals.


It was not possible to confirm that, while the disruption pattern and factors have been similar to the better States in terms of economy and health care facilities such as Kerala and Tamilnadu to some extent, whether economically poor States such as Uttar Pradesh and Bihar face higher mitigation challenges, an context which have more robust, better financed and resilient health systems. On the other hand, such disruption in access will also affect other domains of health- care. Hence, as projected by Roberton et al. [19], observations reported in this article are likely to be applicable to the increase mortality and morbidity of women and children and by extension to other vulnerable groups- chronically ill (diabetic care, HIV/AIDS treatment), elderly, and people with disabilities including mental health challenges [3].



Considering the inevitability of multiple waves of the COVID-19 pandemic globally, consideration of political, economic and contextual factors in formulating appropriate responses is crucial for a resilient health system. The key theme that emerged from this study seeking to identify MNCH public health research priorities in India within the context of an unprecedented pandemic was the importance of systems strengthening rather than undertaking novel research. The findings of this exercise appeared to signal a shift from those of recent priority setting exercises in MNCH, both from India and globally, which were conducted prior to the COVID-19 pandemic. While our results highlight essential steps to the roadmap for sustaining and advancing maternal and child health during and after the COVID-19 pandemic in the Indian setting, these learnings are relevant to other emerging global economies as well, given the similarities in their respective health systems.


India’s national lockdown had a significant impact on utilization and delivery of MNCH services in Uttar Pradesh. There were also changes in utilization patterns across socio-demographic groups and a slight shift from the public to private sector. Around the world, health systems have been struggling to cope under conditions of social distancing and lockdowns. It is possible that intermittent tightening and loosening of pandemic suppression measures will be necessary for many months to come. Ensuring that these have the least possible impact on key health programs will be an ongoing challenge that merits continued close monitoring. However, on a global scale, the state of MNCH is a reference point for public health. Thus, the blanket coronavirus pandemic response is likely to undermine progress towards country-defined SDG targets and cause additional public health crises especially in the poor performing States in India. To avoid this, innovative strategies in specific contexts should prioritise maintaining existing health priorities (e.g., MNCH) while responding to the challenges of the COVID-19 pandemic by adopting a holistic approach.


Communities and health professionals can help inform locally designed approaches to ensure more effective non-draconian social distancing, use of masks, and adoption of effective vaccines. The key should include coordination between actors through more efficient use of various approaches, including digital platforms, to establish communication and information and reporting channels. In addition, further research is required to enable culturally relevant and context-appropriate approaches to address the health care challenges posed by this and future pandemic(s) whilst maintaining other essential health care services including MNCH. Local MNCH care providers and managers need to be consulted to understand the breadth of the socio-economic impact of COVID-19 and COVID- 19 response measures, and their relation to MNCH care provision. Further, the COVID-19 mitigation strategies should be integrated and embedded within the existing HMIS, in order to facilitate acquisition of data on trends, thereby helping to generate evidence-based policy decisions to inform resource allocation and tracking of MNCH and other non- COVID-19 services as well as COVID-19 services.


In conclusion, our study might be limited by its cross-sectional nature and restricted to study participants from a specific area. However, the existence of an accessible sample of randomly selected health care workers in public health facilities of Uttar Pradesh was a motivating factor to undertake this study in the rapidly changing Covid-19 scenarios. Data were self-reported and not primary health or outcome data and were not collected prior to the lockdown or epidemic so making firm conclusions about its affect is difficult. Nevertheless, the impact of COVID-19 pandemic and lockdown on health and healthcare was negative. The exaggeration of income inequality during lockdown can be expected to extend the negative impacts beyond the lockdown.


Future studies are recommended to evaluate the impact of economic slowdown, unemployment and financial constraints in each household with time as people’s responses focus on livelihood rather than lives. In order to build a sustainable future for maternal and child health during and post COVID-19 in India, national authorities should prioritize investments and develop frameworks to strengthen existing public health systems. Governmental investments in health research should be measured against defined benchmarks, and central and state governments should invest in building research capacity by developing a local workforce of well-trained and motivated researchers. Stronger collaborations between researchers and policymakers will ensure that research is taken outside the academic institutions and into public health programmes. Further, national research networks could be established to coordinate research efforts by fostering collaboration and information exchange between academic institutions, governmental and non-governmental organizations [20, 21].



This commentary was not possible without the healthcare providers and researchers who are at the front line of this fight against COVID-19. In spite of their struggle and responsibilities of providing healthcare and conducting research amidst COVID-19, many of them were kind enough to share their experience.



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Received on 27.10.2023        Modified on 10.11.2023

Accepted on 24.11.2023        © A&V Publication all right reserved

Int. J. Ad. Social Sciences. 2023; 11(4):211-217.

DOI: 10.52711/2454-2679.2023.00033