Institutional Deliveries at Public and Private Health Institutions in Punjab: A Comparative Study of Pre-Lockdown, Lockdown and Post-Lockdown Periods in Selected Districts

Abbreviations

HIMS: Health Management Information System; OPD: Out- patient; DCHC: Dedicated Covid Health Centres; JSY: Janani Suraksha Yojana; JSSK: Janani Shishu Suraksha Karyakaram; CCC: Covid Care Centres.

Introduction

Lockdown was imposed in India across various States in different phases as a preventive measure to control Investigation Paper spread of COVID-19. Starting from 25 March 2020, there was a complete lockdown in Punjab till 31 May 2020 in four different phases affecting almost all types of services except delivery of essential services. Out-patient (OPD) services were closed and entry to medical institutions was restricted to emergency services. The four distinctive phases of lockdown were 25 March 2020 – 14 April 2020 (21 days, phase-1), 15 April 2020–3 May 2020 (19 days, phase-2), 4 May 2020–17 May 2020 (14 days, phase-3), and 18 May 2020–31 May 2020 (14 days, phase 4). Further, lockdown restrictions continued for night movement in the State in various phases.

Transport services were drastically cut-down and mobility was controlled. Most of the district hospitals in Punjab were made Level-2 Dedicated Covid Health Centres (DCHC) for critical COVID Care. In some of the district hospitals like one in Sri Muktsar Sahib district, labour room services were shifted to another hospital namely the mission hospital. Since institutional deliveries constitute an important ingredient of maternal and child health care facilities, it is important to study and examine the impact on institutional births in Punjab in the context of lockdown and suggest future policy implications. Ezenwa BN, et al. [1] assessed the effect of COVID-19 lockdown on deliveries and neonatal admissions in Lagos, Nigeria. During lockdown (April–June 2020) and found there was a marked fall of about 50% in in- hospital deliveries and admissions to the neonatal wards for both in and out-born infants compared with pre-lockdown (January–March 2020) and a comparison period (April–June 2019). On the other hand, Subedi A, et al. [2] on the basis of the performance of their health facility found that there was no significant change in the number of deliveries during the lockdown period on comparing to the non-lockdown period and this may be due to the diversion of patients to their center from the government hospital which was converted to COVID dedicated center, Additionally, they found that the percentage of maternal complications (17.38%) was similar to that of non-lockdown period (18.43%) with no case of maternal mortality in the study period. Sharma S, et al. [3] also analyzed the Health Management Information system (HIMS) data from and observed that there was a decreasing trend noted in institutional deliveries in 2020 and 2021 among all major states. Sehgal A, et al. [4] found that COVID-19 pandemic resulted in fall in institutional delivery and rise in still birth rate and maternal mortality ratio. Gestational hypertension remained the leading cause of maternal mortality during COVID-19 pandemic.

Objectives

The paper analyzes the patterns of actual institutional deliveries in the selected districts of Punjab and to study the variations in three-distinct phases, i.e. pre-lockdown (before March 2020), lockdown (March-July 2020) and the post- lockdown (after July 2020). In addition, an attempt has been made to study the delivery by type (normal or caesarean) and delivery by location (core or periphery).

Methods and Area

The study assesses the impact on institutional deliveries in two randomly selected districts of Punjab namely Patiala and Sri Muktsar Sahib. Month-wise data have been procured for all delivery points (facility-wise) from District Programme Management Unit (DPMU) of the respective district for the periods April 2019 to June 2021 (total 27 months). For study purpose, the data have been classified into three continuous time periods, such as (April-March 2020 as pre-lockdown, April-July 2020 as lockdown and August 2020-June 2021 (as post-lockdown) periods. Further, institutional delivery data have been classified into normal deliveries and caesarean (C-Section) deliveries, both for both the government and for private sector health institutions.

Summary and Conclusions

Skilled attendance at delivery by a competent health care provider is a fundamental requirement for safe motherhood; confinement of COVID-19 significantly affected Maternal and Child Health Services, leading to adverse outcomes in several crucial aspects. National Family Health Survey-5 (NFHS-5) , based on births in the last 5 years before the survey shows that overall institutional births have increased in the state (92% as against 90.5%) as well as selected districts (97.3% as against 96.9% in Patiala district and 96.4% as against 93.6% in Sri Muktsar Sahib district) during NFHS-5 and NFHS-4 respectively. HMIS data also shows that home deliveries as a percentage of total deliveries constituted an extremely low proportion in both the selected districts (0.1% in Patiala district and 0.8% in Sri Muktsar Sahib district).

NFHS-5 fact sheets , based on births in the last 5 years before the survey, further reveals that the share of public sector in overall institutional births fell in the State (47% in NFHS-5 from 51.7 in NFHS-4) but rose in the two selected districts (57.1% in Patiala from 55.5% and 61.3% in Sri Muktsar Sahib) during NFHS-5 and NFHS-4 respectively. However, the share of public sector health facilities in overall institutional deliveries fell continuously during 2020-21 and during the first quarter of 2021-22 in both the Patiala and Sri Muktsar Sahib districts from the pre-Covid period (2019- 20) while the share of private sector institutional deliveries is rising continuously since the onset of COVID-19. Home deliveries constituted only a very low proportion of total deliveries (< 0.1% in Patiala district and < 0.8% in Sri Muktsar Sahib district). The overall classification of deliveries by type of delivery and by type of institution shows that for normal deliveries during pre-COVID times, the clients were more inclined towards public health facilities in both the selected districts. However, after onset of COVID-19, the share of private sector started rising while the share of public sector hospitals went on declining. NFHS-5 shows that the private sector had a high share in Caesarean or C-Section deliveries in the State (53.7% for private sector as against 31.4% for public sector) and in selected districts (54.7% in private as against 45.7% in public sector in Patiala district and 24.1% in private sector as against 16.5% in public sector in Sri Muktsar Sahib district). But, HMIS data reveals a trend shift. For caesarean deliveries, the public-private share was nearly equal in Patiala during 2019-20 while the share of private sector was higher in case of Sri Muktsar Sahib district. After the onset of COVID-19 restrictions, the share of public sector in total caesarean deliveries also declined in both the districts. This decline was much sharper for Sri Muktsar Sahib district as compared to Patiala district. The share of private sector in caesarean deliveries continues to rise after March 2020. This may be due to the fear of getting COVID-19 infection among the patients as almost all of the public sector hospitals were also designated as Covid Care Centres (CCC). As the data on CCC variable was not available, a general pattern was observed as revealed by the available data. [5, 6].

The distribution of total normal deliveries by type of facility in public sector for selected districts shows that after the lockdown the share of peripheral health facilities like CHC and PHC had increased while the share of district hospitals declined. The above observation is somewhat unique as residents, irrespective of their past behaviour, relied more on peripheral health institutions near to their residences for normal deliveries. This observation is quite distinct as it was expected that the share of DH deliveries will increase because of better infrastructure and manpower available at these hospitals. However, the actual delivery data showed a contrary behaviour due to people’s concerns of COVID-19 cases being attended in district hospitals and the risk involved. On the other hand, the distribution of caesarean deliveries in public sector facilities in both the Patiala and Sri Muktsar Sahib districts shows that the percentage share of DH increased in Patiala district during the lockdown and post-lockdown period (from 56% to around 60%) while in case of Sri Muktsar Sahib district, the share of DH remained unchanged during the lockdown period but declined thereafter in favour of peripheral health facilities.

The authors had a discussion with the health functionaries in both these districts. It was found that absolute number of institutional deliveries declined in both the districts during 2020-21 in comparison to 2019-20 at government health institutions, as their clientele, primarily consisting of poor and labour class, left for their native places in their home states. The work was not available to them even in the post-lockdown period. Moreover, all District Hospitals were made Level-2 Covid Centres and labour rooms were also shifted to other institutions such as Mission Hospital in case of Sri Muktsar Sahib district. As undertaking COVID-19 test was mandatory for government health institutions, the households who could afford financially, avoided visiting government health institutions and went straight to private sector hospitals. Fear of being positive after the test made them do so. Among the other reasons, in Sri Muktsar Sahib district, the Gynecologist post was lying vacant at district hospital for almost 11 months (October 2021-July 2022) and some other key specialists also left their jobs to join private sector hospitals.

The month-wise data on institutional deliveries by type of health facilities (government or private) clearly shows that there was an edge of government sector in both the selected districts during pre-lockdown period which started intermingling during the lockdown period and completely reversed in favour of private sector during the post-lockdown period. This reversal indicates that people in general lost confidence in government health facilities and started relying more on private health facilities. This might have serious repercussions for poorer households with larger out of pocket expenditure. There is further need to assess the performance of several centrally or state sponsored Schemes such as Janani Shishu Suraksha Karyakaram (JSSK), Janani Suraksha Yojana (JSY), Mata Kaushalya Scheme, etc. from this angle. What forced so many clients to shift to private sector? Whether the shift was by choice or was it thrust upon them forcibly due to lack of available resources such as manpower, equipment and medicines, etc. in government health facilities during post-lockdown periods?