How Floods Are Contributing to Pregnancy Loss in India

Ashwini Khandekar was in her first few months of pregnancy when the flood came. This was July 2021, the peak of the annual monsoon season, when a downpour destroyed more than 300 houses in Ganeshwadi, a village 400 kilometers south of Mumbai in India’s Maharashtra state. Authorities instructed Khandekar and her husband to evacuate, she told me, “but I couldn’t leave my house because all the evacuation centers were full. I had nowhere to go.” Though in the end her home was spared, for the next 15 days, Khandekar lived in constant fear, praying until the waters finally abated.

Four months later, Khandekar went to the doctor for a prenatal checkup. Her child, she learned, showed signs of anencephaly, a condition in which the fetal brain and skull fail to develop normally. Usually, babies born with anencephaly die within a few hours, and most pregnancies end in miscarriage. To cross-check the doctor’s claims, Khandekar visited eight more hospitals. Everyone confirmed the same. “I was heartbroken,” she said.

When a community health-care worker, Kavita Magdum, examined Khandekar’s medical records, she found that Khandekar had suffered from a severe deficiency of iron and folic acid, a known risk factor for anencephaly. This, in turn, pointed back to the storm. “She was traumatized by the flood and wasn’t getting a nutrient-rich diet for several weeks,” Magdum told me. The roads in and out of the village were closed for 20 days, cutting off food supplies. During this time, she ate only cooked rice and wheat flatbread. Sometimes she didn’t eat at all.

By the end of December, a month after she learned of her child’s condition, Khandekar had lost the pregnancy. She was 20 years old at the time.

Though tragic, stories like Khandekar’s are not rare. A research paper published in Nature this year found that from 2010 to 2020, maternal exposure to floods led to an average of 107,888 lost pregnancies per year in low- and middle-income countries, with South Asia reporting the most cases. Lack of access to nutrient-rich foods was one of the causes the researchers identified, along with physical and mental stress, disease, and lack of housing and safe childbirth services.

This year’s monsoon season will begin in June and stretch through September. The Indian Government has forecast above-average rainfall this year, at 106% of the long-term average. In the first two decades of this century, floods impacted 1.5 billion people in Asia, accounting for 93% of the globally affected population. Last year, over 80% of hydrometeorological disasters in Asia were floods and storms.

About 89% of the world’s flood-exposed population resides in low- and middle-income countries that lack adequate health-care facilities. India alone has more than 378 million women of childbearing age, and has experienced an average of 17 yearly flood events in the past two decades. Floods affected more than 218 million people in India from 2015 to 2020, and destroyed crops on nearly 35 million hectares of farmland, leading to rampant food insecurity. During this time, stillbirths in India increased 28.6%.

For women and their children, the risk begins even before a pregnancy occurs. Simran Jamadar was also 20 years old and living in Maharashtra’s tiny Kanwad village when the floods arrived in 2021. “The water was at least four feet in our house at 5 p.m.,” said Jamadar, forcing her to evacuate. Walking through muddy water with her family to the evacuation center 10 kilometers away, she had to tread carefully lest she disturb an unseen snake. After she reached her destination, she spent 12 days crammed in with 6,000 people from 15 villages. Overstressed and underslept, Jamadar found it difficult to eat. On top of everything else, the experience brought up painful memories from just over a year before, when another flood had wiped out her home, along with all its furniture, crucial papers, and six months of food supplies.

Five months later, still grappling with the trauma of the flood, Jamadar became pregnant. At about the seven-month mark, she experienced a sudden and unbearable stomachache and vomited. Sonography reports showed that she had developed an incompetent cervix — a weakened womb unable to hold a baby. Six hours later, Jamadar gave birth. The child was born and “passed away within a day,” Anita Kamble, a community health-care worker from Jamadar’s village, told me.

Kamble spoke to more than 30 community health-care workers from the flood-affected villages and found a similar pattern of stillbirths associated with stress — even when that stress began before the women became pregnant. This squares with other findings from the Nature study, which showed a significant association between pregnancy loss and exposure to floods even six months before conception. A controlled study of 340 women from Sweden who’d been pregnant in the same year found that 54% of those who experienced stress during pregnancy such as depression or anxiety gave birth prematurely.

With flooding, disruptions and their attending stressors can last for months, and sometimes even years. “The trauma was visible on her face,” Kamble said of Jamadar.

“The most important buffer for stressed pregnant women is social support,” Gloria Giarratano, a professor of nursing at Louisiana State University Health Sciences Center, told me. That includes resources to help cope with psychiatric stressors. Giarratano was the lead author of a study of women in New Orleans post-Hurricane Katrina, which found that women without a network of trusted people to rely on were the most likely to become depressed while pregnant. The more support they have, Giarratano told me, the more that risk decreases.

India, however, for its population of 1.3 billion people, has just 9,000 psychiatrists and 1,000 psychologists. In the face of this challenge, community health-care workers like Magdum and Kamble have devised ad hoc solutions.

What India lacks in licensed medical practitioners, it somewhat makes up for in community-based health programs. India has over a million all-women community health-care workers, known as Accredited Social Health Activists, or ASHAs, who make public health care accessible. Appointed for every 1,000 people from the same village, they are responsible for at least 70 health-care tasks, including providing ante- and postnatal care and ensuring that infants and children are vaccinated on time. In the past seven years, they have gone beyond their duty to help pregnant women recover from the trauma caused by floods and other climate disasters.

After Jamadar lost her baby, for instance, Kamble began visiting her every three to four days, asking about her problems and listening patiently to the answers, sometimes for several hours. Often, Jamadar spoke of her fear of floods. Kamble started talking to more women and found that they all needed someone to share their frustration and fears with. “In several villages, even today, women aren’t allowed to talk about their stress,” Kamble told me.

She started organizing informal discussions in the community where women including Jamadar could be free to share their trauma — and where Kamble could monitor their stress levels and nutrition. “I knew I wasn’t alone in this, and listening to others gave me confidence that we could recover together,” Jamadar told me.

In April 2024, Jamadar gave birth to a child, Aiza, without complications. “From the start, we did everything right and made sure Jamadar wasn’t stressed,” Kamble told me proudly.

In addition to listening, Kamble also started making a list of where pregnant women could be evacuated safely in case of another flood. She would then check if these places had essential facilities like access to good-quality drinking water and sanitation. ASHAs also started pre-arranging private vehicle transport for pregnant women in case of emergency.

Through lengthy and careful community engagement, the ASHAs have started to compile lists of women they expect to become pregnant well before they actually are. “Three months before someone decides to conceive, we start providing them with iron and folic acid tablets,” Magdum told me. This has helped her reduce the anemia rate in her village by 50%. “Earlier, people didn’t take it seriously, but now everyone inquires beforehand about the tablets,” she said.

None of this has been easy, especially because many ASHAs themselves are victims of recurring floods and have faced tremendous personal losses. The state doesn’t consider them full-time workers, and pays them only an honorarium based on the number of tasks completed. In India’s wealthiest state, Maharashtra, the average income is just 4,000 to 7,000 Indian Rupees, or $48 to $83, per month, and often the payments are delayed. As a result, many ASHAs are forced to double up as farmworkers to make ends meet.

Despite the challenges, ASHAs keep coming up with solutions. “If we stop working in such stressful times, how will the health-care system survive?” asked Kamble, who handles around 20 pregnancy cases every year and has counseled over 100 pregnant women since 2017. Since ASHAs are unionized, they often meet to discuss best practices and share their experiences. Today, thousands of ASHAs across India are helping women recover emotionally from the trauma caused by climate change.

“ASHA means hope in several Indian languages,” Kamble said, “and I am proud to bring a smile and hope to several women.”