The COVID-19 pandemic has magnified the multiple vulnerabilities of people living in urban informal settlements globally. To bring community voices from such settlements to the center of COVID-19 response strategies, we undertook a study in the urban informal settlements of Dharavi, Mumbai, from September 2020-April 2021. In this study, we have examined the awareness, attitudes, reported practices, and some broader experiences of the community in Dharavi with respect to COVID-19. We have used a mixed-methods approach, that included a cross-sectional survey of 468 people, and in-depth interviews and focus group discussions with 49 people living in this area. Data was collected via a mix of phone and face-to-face interviews. We have presented here the descriptive statistics from the survey and the key themes that emerged from our qualitative data. People reported high levels of knowledge about COVID-19, with television (90%), family and friends (56%), and social media (47%) being the main sources of information. The knowledge people had, however, was not free of misconceptions and fear; people were scared of being forcefully quarantined and dying alone during the early days of COVID-19. These fears had negative repercussions in the form of patient-related stigma and hesitancy in seeking healthcare. A year into the pandemic, however, people reported a shift in attitudes from ‘extreme fear to low fear’ (67% reported perceiving low/no COVID risk in October 2020), contributing to a general laxity in following COVID-appropriate behaviors. Currently, the community is immensely concerned about the revival of livelihoods, that have been adversely impacted due to the lockdown in 2020 as well as the continued ‘othering’ of Dharavi for being a COVID hotspot. These findings suggest that urban informal settlements like Dharavi need community-level messaging that counters misinformation and denial of the outbreak; local reinforcement of COVID-appropriate behaviours; and long-term social protection measures.

India's resurgence of COVID-19: urgent actions neededFor the Lancet Citizens' Commission on Reimagining India's Health System see www. citizenshealth.in

BackgroundAn effective referral system is key to access timely emergency obstetric care. The criticality of referrals makes it necessary to understand its pattern at the health system level. This study aims to document the patterns and primary reasons of obstetric case referral and the maternal and perinatal outcome of the cases in public health institutions in select areas of urban Maharashtra, India.MethodsThe study is based on the health records of public health facilities in Mumbai and its adjoining three municipal corporations. The information on pregnant women referred for obstetric emergencies was collected from patient referral forms of municipal maternity homes and peripheral health facilities between 2016 and 2019. Maternal and child outcome data was obtained from “Received-In” peripheral and tertiary health facilities to track whether the referred woman reached the referral facility for delivery. Descriptive statistics were used to analyze demographic details, referral patterns, reasons of referrals, referral communication and documentation, time and mode of transfer and delivery outcomes.Results14% (28,020) women were referred to higher health facilities. The most common reasons for referral were pregnancy-induced hypertension or eclampsia (17%), previous caesarean section (12%), fetal distress (11%) and Oligohydramnios (11%). 19% of all referrals were entirely due to unavailability of human resources or health infrastructure. Non-availability of emergency Operation Theatre (47%) and Neonatal Intensive Care Unit (45%) were the major non-medical reasons for referrals. Absence of health personnel such as anaesthetist (24%), paediatrician (22%), physician (20%) or obstetrician (12%) was another non-medical reason for referrals. Referring facility had a phone-based communication about the referral with the receiving facility in less than half of the cases (47%). 60% of the referred women could be tracked in higher health facilities. Of the tracked cases, 45% women delivered via caesarean section. Most of the deliveries (96%) resulted in live birth outcomes. 34% of the newborns weighed less than 2,500 grams.ConclusionImproving referral processes are critical to enhance the overall performance of emergency obstetric care. Our findings emphasize the need for a formal communication and feedback system between referring and receiving facilities. Simultaneously, ensuring EmOC at different levels of health facilities by upgradation of health infrastructure is recommended.

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