Devina Buckshee is a first-year M.P.H. student at the Yale School of Public Health. She is also a health journalist who has been monitoring the COVID-19 crisis in India over the past year. What follows is the third and final instalment of Buckshee’s reports on the human toll of the coronavirus pandemic in India. She hopes that sharing firsthand accounts of the situation in India will encourage others to support relief efforts there.

As the latest COVID-19 surge subsides in India, public health experts fear the pandemic’s toll on other public health concerns heading into 2022.

During the pandemic, women’s health worsened across several areas, from nutrition to stress to reproductive services, according to public health officials and published reports. Often called a “hidden pandemic,” violence against women, worryingly, also increased.

Women’s health, especially their sexual and reproductive health, is often complicated by societal taboos and women’s second-tier status in some communities. With widespread restrictions imposed in India during the pandemic, women’s access to health services was severely limited.

In addition, while India has one of the world’s most progressive abortion laws, stigma and misinformation surrounding abortion continue to contribute to high maternal mortality rates.

To more clearly understand how the COVID-19 pandemic has impacted women’s health in India, where women were already struggling to access adequate health care and support, one must step back and review what has transpired since the pandemic began 19 months ago.

The Lockdown

India imposed a nationwide lockdown on March 25, 2020, in response to the COVID-19 pandemic. On April 14, 2020, the government declared abortion an essential service. But travel restrictions and stigma around contraception and abortion led to many women not receiving the critical health care they needed.

During the pandemic, many women and couples had difficulty seeing doctors and other health care providers for their sexual and reproductive health. As a result, women failed to get timely birth control, emergency health services and abortions. Despite abortion being deemed an essential health care service, many people perceived it to be unavailable due to poor communication within communities.

“With limited access, private services became one of the few options, but this was often unaffordable for many, especially the young,” said Sangeeta Rege, coordinator of CEHAT (Centre for Enquiry Into Health and Allied Themes), a Mumbai research center engaged in human rights advocacy.

A damning report by Marie Stopes International (now known as MSI Reproductive Choices) revealed that between January and June 2020, 1.3 million women in India lost access to abortion and contraceptives. The international non-government organization also reported that 920,000 fewer safe abortion and post-abortion care services were delivered.

“Antenatal services, delivery services, and medications for tuberculosis and other illnesses were impacted by the lockdown,” Rege said. While the public sector continued to provide these services in limited capacities during India’s first (2020) and second (2021) waves, the private health care sector stopped providing services in most states.

In an added layer of complexity, many women were forced to move back home with their parents during the pandemic and were unable to move freely during lockdown – especially to access reproductive services. These problems were particularly difficult for adolescents, unmarried couples and those marginalized because of their gender or sexual identity.

Existing barriers of misinformation, stigma and provider bias were amplified during the lockdown. While the figures provided in the MSI report expose the numerical magnitude of the situation, the real toll goes far beyond numbers. The loss of agency and bodily autonomy impacted the mental health of some individuals already dealing with other personal losses from the pandemic.

Reproductive Rights Gain Ground

Despite the steep loss of many sexual health services during the pandemic, there has been massive behind-the-scenes work over the past year to improve India’s sexual and reproductive rights.

“This is evident in the changes to the MTP law,” said Rege. She is referring to India’s Medical Termination of Pregnancy (MTP) Act of 1971, which was amended in 2020 and passed in Parliament on October 13, 2021. It is now called the MPT (Amendment) Act 2021. The amended act allows abortion up to 24 weeks into pregnancy for a more human rights-based approach to comprehensive, universal reproductive health care. It also extends the upper limit for abortion for special categories of women – including rape survivors, victims of incest, disabled women and minors – to 24 weeks from the previous 20 weeks.

“This is long overdue, but we are glad to have it,” said Dr. Nozer Sheriar, former Secretary-General of the Federation of Obstetric and Gynaecological Societies of India. Having worked on the original 1971 MTP Act, Dr. Sheriar added that these continual improvements to the law are essential in advancing women’s health rights and care. While abortion has been legal in India for 47 years, it is still not solidified as a woman’s right. This directly translates to unsafe practices, resulting in abortion being the third-leading cause of maternal mortality in India, behind postpartum hemorrhages and infections.

Despite recent gains, Dr. Sheriar said there are still miles to go to create laws and policies in India that firmly center a woman’s voice and autonomy. The focus on public health as a result of the pandemic, however, has created an opportunity to reimagine a new normal with equitable health care solutions for everyone.

“We need to increase the provider base (to help vulnerable and remotely-located women) and push for more women’s autonomy,” he said.