Barriers faced by urban homeless women in accessing Maternal and Child Health Services in the wake of COVID-19 in Delhi

1) Project Background, context and needs addressed The provision of maternal healthcare in India is grossly inadequate, characterized by high levels of maternal mortality and morbidity and underutilisation of services, especially among the poor. While the maternal mortality ratio has reduced in India (Office of the Registrar General, India, 2018), the country is far behind the goal of achieving SDG target of 70 deaths per 1,00,000 live births (Suri, 2019). Studies indicate low levels of utilization of maternal health care among the urban poor (Agarwal et al., 2007; Siddaiah et al., 2018) as well as poor health outcomes such as prevalence of anaemia (Diamond-Smith et al., 2016; Dwarkanath et al., 2018). An ongoing ethnography carried out by researchers at the George Institute for Global Health (January 2019-June 2020) in Delhi, India, identified barriers to utilization of Maternal and Child Healthcare (MCH) services among homeless women. This is shaped by the unique vulnerabilities faced by the homeless as well as the lack of outreach of the health system. With the outbreak of coronavirus disease (COVID-19) in India, we have begun to observe that the homeless are unable to practise ideas of physical distancing, handwashing and other aspects of infection control, which places them at disproportionate risk of infection. Worse, with an already overburdened public health system having the pressure to manage and treat COVID-19 patients (Kumar & Jeelani, 2020), other health services, including long established ones related to MCH, are being affected. Public Interest Litigation (PIL) filed by activists earlier this month suggest that denial of services is taking place (Pal, 2020). Whether and in what ways MCH service delivery for homeless women is affected, remains unknown. The study will examine the barriers faced by urban homeless women in Delhi in accessing MCH services as a consequence of the outbreak of Coronavirus disease (COVID-19). This study will supplement the ethnography by demonstrating how the pandemic has affected health-seeking of urban homeless women vis-à-vis MCH services. The findings will be useful in informing policy about how MCH services can be streamlined and be made more accessible in the current context, providing critical insights for the PIL as well as for health system actors involved with planning and delivering services to the urban homeless and poor. 2) Aims or research questions being addressed What are the barriers faced by urban homeless women in Delhi in accessing and utilizing MCH services in the wake of public hospitals being overwhelmed with COVID-19 cases? 3) Study Design Qualitative research methods will be used to get an understanding of the present situation of urban homeless women and the challenges that confront them in the wake of the lockdown enforced because of the COVID-19 pandemic. In depth interviews (IDI) will be supplemented by field observations to see the changes that have taken place in the lives of urban homeless women in two field sites in Delhi where the recent ethnography was done. At one field site, women stay with their families under a flyover in temporary enclosures. At another field site, single women stay in pavements or nearby shelters. Key Informant Interviews will be done with activists involved in filing the PIL as well as practitioners involved in advocacy pertaining to arranging food for migrants stranded in cities after the lockdown. We expect to be able to conduct IDIs with 15 women and three key informants. We will be guided by the consolidated criteria for reporting qualitative research (COREQ) guidelines for qualitative research (Tong et al., 2007). Data collection Convenience sampling will be used to speak with women at the field site. Given the contagious nature of the current pandemic, verbal consent procedures will be used. Neither signatures will be taken on paper, nor will verbal consent be recorded. The purpose of the study will be explained to participants in detail, including the risks and benefits of participation. Precautions will be taken to maintain distance from participants to ensure distancing norms so as to safeguard the health of both the interviewer as well as interviewees. After obtaining permission from participants, interviews will be audio-recorded. Data will be stored in password-protected laptops belonging to research team members. A consultant will be hired for transcription of interviews, and asked to sign confidentiality agreement. Data analysis As in the case of the earlier ethnographic research, thematic analysis will be used to interpret findings from fieldnotes and interview transcripts. Atlas.TI software will be used for analysis, with the researcher and her supervisor carrying out coding and iteratively developing and applying a codebook. Analysis will adhere to COREQ and existing standards of quality in qualitative research, including member checking/respondent validation, reflexivity, and fair dealing (Mays & Pope 2000). 4) Approach used to maximise the impact of research outputs, to improve health and the research community This study will be conducted in partnership with our long-term collaborator Centre for Equity Studies (CES), an organization we have collaborated with for the recent ethnography as well. CES runs recovery shelters in collaboration with Delhi Urban Shelter Improvement Board of the Delhi government for ailing homeless women and women. The organization additionally provides mobile van based health services to urban homeless people in several locations in Delhi and other cities in India. In the wake of the lockdown enforced in India in second half of March 2020, members of CES along with other practitioners have been involved with advocacy for the urban poor and migrants who have been displaced as well as working alongside the Delhi government to make arrangements for the distribution of food to urban poor people living in various parts of the city. The findings of our study can therefore be used by CES to improve and streamline their service delivery and support of MCH related health-seeking and service utilisation. Further, we believe their association with the Delhi government will be useful in helping us share the findings of the study with government for its immediate perusal so that action may be timely taken to safeguard the health of urban homeless women. Based on the findings of the study, we will also make a fact-sheet on the needs of the community during the pandemic and carry out dissemination with the organisations involved PIL as well other non-governmental organizations and fund-raising entities working with the homeless and/or urban poor. 5) Expected outcomes The findings will: • Be useful in helping our partner organization, CES, in realigning their current strategies towards prioritizing services for urban homeless pregnant and lactating women. • Add to the evidence base for the urban poor and contribute towards larger subsequent grants to test interventions for improvement of MCH outcomes. • Supplement the PIL by providing evidence for the state government to reorient health services for maternal and child healthcare for urban poor women in public hospitals. 6) Your role in the project The applicant will be engaged in making of interview guide, consent procedures, and in getting the approval from Institutional Ethics Committee. She will also be engaged in data collection, that is conducting interviews, as well as in the analysis of data, and writing of the report, in addition to the subsequent writing of manuscripts. All of this will be done under the supervision of her supervisor, Dr Devaki Nambiar. References Agarwal, P., Singh, M. M., & Garg, S. (2007). Maternal health-care utilization among women in an urban slum in Delhi. Indian Journal of Community Medicine, 32(3), 203. https://doi.org/10.4103/0970-0218.36829 Blas, E., & Kurup, A. S. (2010). Equity, social determinants and public health programmes. World Health Organisation. Diamond-Smith, N. G., Gupta, M., Kaur, M., & Kumar, R. (2016). Determinants of Persistent Anemia in Poor, Urban Pregnant Women of Chandigarh City, North India: A Mixed Method Approach. Food and Nutrition Bulletin, 37(2), 132-143. https://doi.org/10.1177/0379572116637721 Dwarkanath, P., Vasudevan, A., Thomas, T., Anand, S. S., Desai, D., Gupta, M., Menezes, G., Kurpad, A. V., & Srinivasan, K. (2018). Socio-economic, environmental and nutritional characteristics of urban and rural South Indian women in early pregnancy: Findings from the South Asian Birth Cohort (START). Public Health Nutrition, 21(8), 1554-1564. https://doi.org/10.1017/S1368980017004025 Kumar, A., & Jeelani, G. (2020, April 18). Agonising wait for non-Covid patients in Delhi. India Today. https://www.indiatoday.in/mail-today/story/agonising-wait-for-non-covid-patients-in-delhi-1668256-2020-04-18 Office of the Registrar General, India, M. of H. A., Government of India. (2018). Special Bulletin on Maternal Mortality in India 2014-16 (p. 3). Office of the Registrar General, India. http://censusindia.gov.in/vital_statistics/SRS_Bulletins/MMR%20Bulletin-2014-16.pdf Pal, S. (2020, April 23). COVID-19: 'Treat Women's Health as Top Priority,' Delhi HC tells State Government. NewsClick. https://www.newsclick.in/COVID-19-Delhi-High-Court-On%20Women-and-Health Siddaiah, A., Kant, S., Haldar, P., Rai, S. K., & Misra, P. (2018). Maternal health care access among migrant women labourers in the selected brick kilns of district Faridabad, Haryana: Mixed method study on equity and access. International Journal for Equity in Health, 17(1), 171. https://doi.org/10.1186/s12939-018-0886-x Suri, S. (2019, June 5). An analysis of maternal health condition across parliamentary constituencies in India. ORF. https://www.orfonline.org/expert-speak/an-analysis-of-maternal-health-condition-across-parliamentary-constituencies-in-india50535/ Tong, A., Sainsbury, P., & Craig, J. (2007). Consolidated criteria for reporting qualitative research (COREQ): A 32-item checklist for interviews and focus groups. International Journal for Quality in Health Care, 19(6), 349-357. https://doi.org/10.1093/intqhc/mzm042