This was a retrospective cross-sectional study conducted among the patients attending ANC OPD or Gynaecology OPD in a tertiary care hospital in Nadia district of West Bengal. Permission was sought to access the previous OPD records from Institute (5/6/2020). The data was collected from the records of 12^th January to 31^st May 2020. The study duration was from the beginning of lockdown for 70 days starting from 23^rd March to 31^st May during which public transport was not available. This institution has a schedule of six days routine OPD from Monday to Saturday at 9 am to 2 pm. There are separate Antenatal clinics and Gynaecology OPD on all six days. This was compared to the OPD attendance of immediate pre-lockdown period of 70 days starting from 12^th January to 22^nd March 2020.

Inclusion criteria

All patients attending the antenatal and gynaecology OPD during the study period except those mentioned in exclusion criteria.

Exclusion criteria

A questionnaire was prepared based on flu-related symptoms like fever, cough, fatigue, shortness of breath and other associated symptoms: body aches, sore throat, diarrhoea and runny nose. History of travel was also included in the questionnaire [10]. The answers were noted down as yes or no. Patients having any history suggestive of the above were sent to fever clinic for COVID-19 evaluation.

Authors had further categorised patients in Gynaecology OPD in different sub-categories depending on the complaint of the patients. Those were: a) infertility clinic; b) endocrinology clinic; c) uro-gynaecology clinic; d) Sexually Transmitted Disease (STD), Pelvic Inflammatory Disease (PID) or chronic pelvic pain clinic; e) cancer detection clinic; f) postpartum clinic; g) medical Termination of Pregnancy, abortion and family planning clinic; and h) others.

(a) Infertility clinic: In Infertility clinic workup of infertility, ovulation induction with medication was done. Assisted Reproductive Technology (ART) facility is not available in this institution till date.

(b) Endocrinology clinic: Patients with menstrual problems like menorragia, metrorrhagia, menometrorrhagia, oligomenorrhoea, polymenorrhoea, hypomenorrhoea and amenorrheoa were commonly placed under endocrine clinic at their initial visit. After history taking and examination, pregnancy was excluded and patients in reproductive age group with complaint of any of menstrual irregularities were taken into account. The patients were then investigated and managed by medical or surgical means. Commonest endocrinological cases were of polycystic ovarian syndrome, thyroid problems and menstrual irregularities due to hormonal imbalance which were subsequently managed by medications. Puberty or perimenopausal age related menstrual irregularities were also included in this category. If after a battery of investigations, the cause of menstrual irregularities were detected to be tumours, which require operative management were then excluded from endocrine clinic.

(c) Uro-gynaecology clinic: Patient attending uro-gynaecology clinic mostly came with symptoms of urinary tract infection. Those with urinary incontinence and genitourinary descent were placed under uro-gynaecology clinic. Conservative or operative management was done as per requirement.

(d) Pelvic Inflammatory Disease (PID) or chronic pelvic pain clinic: In STD/PID clinics, patients mostly presented with features of genital tract infection. The commonest complain being that of white discharge and itching in perineum. Chronic nonspecific pelvic pain was also investigated under this category.

(e) Cancer detection clinic: Cancer detection clinic mostly had patient with history or examination suggestive of genital tract neoplasm such as cervical, endometrial, ovarian carcinoma etc. Cervical cancer was most commonly seen. Surgical management considered in patients in operable stages and inoperable ones referred to Radiotherapy department with biopsy report.

(f) Postpartum clinic: Postpartum patients include patient delivered vaginally or by operative methods attending OPD in postpartum period for routine checkups or with any other complications.

(g) Medical termination of pregnancy, abortion and family planning clinic: MTP, abortion and family planning clinics included patient coming for abortion in day care basis or requiring admission. Early trimester bleeding per vagina due to threatened abortion or incomplete abortion were also included in this clinic and managed accordingly. Patients seeking contraceptive advices and ligation operation were also included in this group.

(h) Others: Patient with complaints which were not classified in any of these groups were designated as others category of patients. This group includes breast problems, gastrointestinal tract problems, local injuries to perineum, other nongynaecological problems etc.

Patient awaiting surgery and undergoing pre anaesthetic workup were excluded from the study. Separate antenatal clinics are held six days a week in this institution. Antenatal patient is recorded as new, if it is the first visit to the ANC clinic. Already booked patients are recorded as old patient.

The data was collected after proper designing of the study were represented by basic statistical analysis. Microsoft excel 2007 version 12, programming through Visual Basic for Application (VBA) was used for this purpose. The categorical variables (nominal) in the study were represented by contingency tables and bar graph. Significant differences in percentage of OPD attendance of different clinics were observed. Chi-square test was used to calculate the p-value (p<0.001).

In the study, it was found that in the 70 days of pre-lockdown period total antenatal attendance was 3212. New ANC patients attending for first enrolment were 948 (29.51%) and old ANC attendance was 2264 (70.49%). During the lockdown period of 70 days total antenatal attendance was 977. Among those 374 (38.28%) were new cases of antenatal mother whereas the number of old booked cases who came for check up were 603 (61.71%) as depicted in [Table/Fig-1].

In the year 2019, total ANC attendance of the institution was 4804 (26.2%) new cases and old booked patient attending were 13490 (73.8%). An average of 400 new antenatal patients enroll every month and an average of 1124 already booked (old) cases come for check up monthly in normal times. There was a total 69.6% reduction in footfall of antenatal mothers during the lockdown period in comparison to pre-lockdown period (p<0.001). During the lockdown period, old cases attendance were decreased (57.9%) more in percentage when compared to the new cases (43.4%).

In Gynaecology OPD, a total 6977 patient attended during 70 days pre-lockdown period compared to a meagre of 889 patients in 70 days lockdown period as illustrated in [Table/Fig-2]. There was a total of 87.3% decrease in footfall of patients attending the GOPD in lockdown period.

The current study revealed that there was a significant difference in the number of patients attending the OPD in comparison to pre-lockdown days. Percentage decrease in attendance was more in GOPD (87.3%) than in ANC OPD (69.6%). The country went into lockdown in four phases. Places were divided into red, orange and green zone according to severity of affection. This institution was in green zone throughout the lockdown period. Patients were scared of acquiring COVID-19 infection from hospital environment. There was also unavailability of any public transport during those days preventing patients to avail hospital services. Telemedicine facility was not available in this institution. However, OPD services and 24 hours emergency services remained unaffected. Patient admission continued as per requirement. Although elective surgeries were withheld for the time being, emergency operations and elective caesarean sections were performed regularly. Percentage of booked old antenatal mothers coming for routine checkups was on a decline than percentage of new first time enrolment. This was done in compliance to guidelines laid down by the Indian Council for medical research (ICMR) wherein the routine care was tailored to minimum number of visits in order to reduce exposure of patients [11]. In a multicentre Italian study, significant reduction in number of admissions due to pelvic pain, vulvovaginitis, genital bleeding in both reproductive and postmenopausal women were observed in comparison to those indications related to first trimester of pregnancy [12].

In comparison to patients attending different clinics, it was seen there was a reduction in percentage of patients in infertility and postpartum clinics. Unavailability of conveyance, fear of contracting infection and nonemergency conditions were major factors keeping them at home. Restructuring of antenatal and postnatal services by reducing contacts, enabled better protection of the patients as well as health care workers [13]. Educating patients about the signs and symptoms of COVID-19, preventive measures and timely access to health care in case of suspected infection should be conveyed during their routine visits. Percentage attending cancer detection clinics remained the same. The management of cancer patients has also undergone major transformation throughout the globe starting from teleconsultation services to adaptation of new diagnostic pathways to postponement of surgeries were observed [14]. Pap smear, colposcopy and biopsy for diagnosis remained unaffected in this institution. Relative percentage of attendance increased in uro-gynaecology, endocrine and MTP clinics, though there was no significant difference. During the initial 21 days of lockdown, the OPD attendance was minimum which gradually increased during the second half of the lockdown phase indicating the acceptability of the situation and dire need of health care among the people in general. In a study published in Portuguese Journal of Public health, there was a significant drop in number of emergency service use in March 2020 [15]. When considering surgical indications, the decision is individualised by the treating gynaecologist. In the initial phase of pandemic outbreak, it was observed that self regulation resulted in patients themselves cancelling scheduled elective consultations and interventions which were similar to a study in Brazil [16]. Others nonspecific category patients were also decreased. Due to inadequate record, keeping it was not possible to find out the exact number of different types of patients in the above category.

Small sample size taken during the initial phase of pandemic.

COVID-19 pandemic has changed the way of dealing with patients to a great extent. Protecting the hospital staff and doctors, considering environmental precautions for prevention of droplet and fomite transmission also needs to be changed. Across the world, health care professionals are continuing their duties with a great risk of contracting the disease. In the days to come, there is a need to have proper clinical strategies, active screening of patients along with effective counselling sessions and build an infrastructure to cater large number of patients maintaining proper social distancing and adequate personal protective equipment to prevent transmission of this novel coronavirus. This will serve as assurance for the health care providers and in turn might alleviate the fear and bring back the patients lost in follow-up.