Factors affecting delayed and non-receipt of healthcare during the COVID-19 pandemic for women in rural Maharashtra, India: Evidence from a cross-sectional study

Abstract

Background: Pathways to low healthcare utilisation under the COVID-19 pandemic are not well understood. This study aims to understand women's concerns about the health system's priorities and their increased burden of domestic responsibilities during COVID-19 as predictors of delayed or non-receipt of needed care for themselves or their children.

Methods: We surveyed married women in rural Maharashtra, India (N = 1021) on their health and economic concerns between Feb 1 and March 26, 2021. This study period was when India emerged from the first wave of the pandemic, which had severely impacted the health systems, and before the second-even more devastating wave had started. We captured if women were concerned about access to non-COVID health services due to healthcare being directed solely to COVID-19) (exposure 1) and whether their domestic responsibilities increased during the pandemic (exposure 2). Our outcomes included women's reports on whether they delayed healthcare seeking (secondary outcome and mediator) and whether they received healthcare for themselves or their children when needed (primary outcome). We conducted adjusted regression models on our predictor variables with each outcome and assessed the mediation effects of delayed healthcare seeking for each of the exposure variables.

Findings: We found that women who were concerned that healthcare was directed solely towards COVID-19 were more likely not to receive healthcare when needed (Adjusted Risk Ratio [ARR] = 1.49, 95% CI = 1.14, 1.95). We also found that women whose domestic care burden increased under the pandemic were more likely to delay healthcare seeking (ARR = 1.84, 95% CI = 1.05, 3.21). Delayed healthcare seeking mediated the associations between each of our exposure variables with our outcome variable, non-receipt of needed healthcare.

Interpretation: Our findings suggested that women's perceptions of healthcare systems and their domestic labour burdens affected healthcare seeking during the pandemic in India, even before the second wave of COVID-19 incapacitated the health system. Support for women and health systems is needed to ensure healthcare uptake during crises.

Funding: Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, USA (grant numbers: R01HD084453- 01A1 and RO1HD61115); Department of Biotechnology, Government of India (grant #BT/IN/US/01/BD/2010); the EMERGE project (Bill and Melinda Gates Foundation Grants: OPP1163682 and INV018007; PI Anita Raj), and Bill and Melinda Gates Foundation Grant number INV-002967.

Keywords: COVID-19; Delay in seeking healthcare; Health system perception; Healthcare utilisation; India; Maternal and Child Health; Mediation.

Fig. 1

Flowchart depicting the inclusion of participants inthe study.

Fig. 2

Illustration of a model with one mediator and a vector of confounders. a: path c captures the total effect of the exposure (X) on the outcome (Y). Z is a vector of confounders between X and Y. b: path c' captures the direct effect of the exposure (X) on the outcome (Y), and paths a and b quantify the indirect effect of the exposure on the outcome via the mediator (M). Z is a vector of confounders between X and Y.

Fig. 3

Results from mediation-model-A with women's concern that healthcare is being directed only to COVID-19 as the exposure. a₁ is the coefficient for the exposure (X₁) in the regression model with the Mediator (M) as the outcome. i_M1 is the coefficient for the intercept in the regression model with the Mediator (M) as the outcome and the exposure (X₁) as the predictor. b₁ is the coefficient for the mediator (M) in the regression model with Y as the outcome, M as the exposure, while adjusting for (X₁). c₁^’ is the coefficient for the exposure (X₁) in the regression model with Y as the outcome and (X₁) as the exposure, while adjusting for the mediator M.

Fig. 4

Results from mediation-model-B with increased burden of household responsibilities as the exposure. a₂ is the coefficient for the exposure (X₂) in the regression model with the Mediator (M) as the outcome. i_M2 is the coefficient for the intercept in the regression model with the Mediator (M) as the outcome and the exposure (X₂) as the predictor. B₂ is the coefficient for the mediator (M) in the regression model with Y as the outcome, M as the exposure, while adjusting for (X₂). c₂^’ is the coefficient for the exposure (X₂) in the regression model with Y as the outcome and (X₂) as the exposure, while adjusting for the mediator M.