Labor Room Deaths Still Occur

At least 1,600 women die in India everyday due to the complications of pregnancy and childbirth, primary among them being totally preventable conditions like anaemia, toxemia, sudden abortions and bleeding. In addition, another 50 million expectant mothers suffer from maternal morbidity and acute complications of pregnancy. This, despite the ambitious government programmes on maternal and infant health care that have been running for several decades. Making this observation here today, Delhi Medical Association (DMA) president Dr Rajesh Chawla said while the developed countries had managed to bring down the incidence of maternal death to a minimum through early interventions, it continued to be a shocking 18 times in the developing world. Infant mortality rate was also seven times higher. ``The need of the hour is to invest in the health care services for the mothers and children and making them available in slums and rural areas, besides urban slums,' he said, adding that men tooneeded to be sensitised to their role in safe sexual and family life. According to the World Health Organisation (WHO), maternal death or maternal mortality is defined as the ``death of a woman while pregnant or within 42 days of the termination of a pregnancy, irrespective of the duration' but excluding the accidental cases. The national goal of the Safe Motherhood Programme is to bring down the incidence by half by the year 2,000.The important thing to remember is that every pregnancy faces risk. While supporting the programmes to reduce adolescent marriages, early or late pregnancies and too many pregnancies too soon and unwanted pregnancies cam also pose risk to the mother and child. In the developed world maternal deaths are now, fortunately, extremely rare events. However, the messages that can be gained from this Enquiry, almost 50 years old, are as valid today as when it first started in England and Wales in 1952. Although, sadly, some deaths remain inevitable events, many were associated with a degree of sub-standard care from which valuable lessons may be drawn. Furthermore, these deaths represent the tip of the iceberg of maternal morbidity and by ensuring all women receive optimal care, the recommendations in this Report should help to lessen physical and psychological pain for women and their wider families at a time usually associated with great happiness. This century has seen momentous changes in the safety of pregnancy for women and their babies. It is right to look back with gratitude to those who began this Enquiry and to recognise the part it has played in reducing the risks in childbirth. Complacency, however, would be a mistake. We look forward to the implementation of this Report's recommendations and to further improvements, especially in the health of underprivileged women. The annual maternal mortality ratio remained approximately 7.5 maternal deaths per 100,000 live births during 1982–1996. Since 1982 in the United States, no progress has been made toward achieving the Healthy People 2000 goal of 3.3 maternal deaths per 100,000 live births set in 1987 (objective 14.3). Maternal deaths were defined as those deaths that occurred during a pregnancy or within 42 days of the end of a pregnancy and for which the cause of death was listed as a complication of pregnancy, childbirth, or the puerperium. The first case of death associated with heparin and aspirin use among in-vitro fertilization patients has been reported. CDC investigated the death of a pregnant woman who had undergone in-vitro fertilization and aspirin and heparin therapy. Although researchers could not conclude that the woman’s death was caused by the therapy, the potential for bleeding associated with aspirin and heparin warrants vigorous scientific investigation and debate before it is recommended for routine use among in-vitro fertilization patients. The "Maternal Mortality Reports" have been appearing throughout the working lifetime of all NHS staff. Indeed, the current system of Confidential Enquiries was started in 1952, only four years after the NHS was founded, and maternal deaths had been reported to the "Ministry" on an ad hoc basis for many years before that. The Enquiries have earned the respect of clinicians over the years and the findings and recommendations of successive Reports have underpinned a large part of obstetric practice. This places a considerable responsibility on those who are now responsible for the Enquiries. It also brings disadvantages. Familiarity may dull the impact of these triennial publications and messages may be repeated from Report to Report without action being taken. Hence the new look. Some aspects of the Enquiries, however, have not changed. They are still a self-audit conducted by professionals - the longest-running example of such audit in the world. At a time of increasing pressures about imposing external audit on medicine, these Enquiries are a leading example of how doctors can review their own work and bring about dramatic improvements in health care. The involvement of midwives in this process is particularly welcome. Looking back at the first Report, which covered 1952-54, it is easy to assume that the remarkable changes have resulted from a general improvement in the health of the population over the last four decades. This is far from true. Deaths from abortion, for example, have fallen from 153 in 1952-54 to one in 1994-96 because abortion has become legal. Deaths from haemorrhage have fallen from 188 to nine because of several measures, including routine oxytocic injections, ultrasound diagnosis of placenta praevia, and improved intensive care. Even deaths from thromboembolism, now the leading cause of Direct deaths, have fallen from 138 in 1952-54 to 46 in 1994-96, partly because women no longer take prolonged bed rest after a normal delivery. The task now is to improve results that are already very good. This is not easy but it can be done. An example is provided by the anaesthetists, who have year by year reduced mortality. In 1952-54 anaesthesia caused 49 deaths; in 1982-84 it caused 18 deaths; and in 1994-96 only one death was due to anaesthesia. This reduction has been achieved by painstaking attention to detail and a refusal to compromise standards. The recommendations in this Report show how lives can still be saved in other areas. We have to make these improvements while continuing to ensure that for the majority of women pregnancy and childbirth remain as natural and enjoyable as possible. Maximum safety does not mean unnecessary medicalisation. The increasing role of evidence-based practice should help to ensure that only effective interventions are used but when it comes to rare catastrophes, scientific data may be lacking. This Report therefore represents a blend of clinical experience and evidence-based recommendations. We hope it will help professionals and the women for whom they care. No one in Chattarpur, a Delhi suburb, could believe that their affluent neighbour, Malti's infant sons were malnutritioned. As the wife of a prosperous confectioner it could not have been for lack of food. But then even nutritionists are unsure as to why child nutrition is far worse a problem in South Asia than elsewhere in the world. In fact, half of the world's malnourished children are to be found in just three countries - Bangladesh, India and Pakistan. Estimations made by the National Nutrition Monitoring Bureau indicate that more than two thirds of India's pre-school children are moderately or severely malnourished. Actions aimed at the problem occur too late since malnutrition peaks around 24 months of age pointing to poor infant care. Top nutritionists like Dr. V. Ramalingaswami and Dr. Jon Rohde, UNICEF chief in India say that even for poor families on the sub-continent food availability is not as much of a problem as the lack of money, time and energy to get it on the table. Contributing factors are poor hygeine and extreme patriarchy which deprives females. The fact that Malti herself suffered severe anaemia offers a clue to what experts call the 'Integrational Cycle of Transmission of Malnutrition,' which begins with a malnourished girl child who grows up to become an unhealthy mother. Malti would have continued anaemic except that she was discovered by workers of the Parivar Seva Sanstha, a Marie Stopes-affiliated NGO which launched, this week, a pilot project on the social marketing of iron tablets in the area. She said her husband was too busy to worry about her state of health. Supported by UNICEF and the Delhi state government, the project aims to raise the nutritional status of women and adolescent girls and develop an appropriate model for replication in other parts of the country, says project manager Manisha Suneja. 'Nutritional anaemia is a major micro-nutrient deficiency in India and is estimated to affect over fifty per cent of pregnant and lactating mothers across India and could be responsible for 20 per cent of maternal deaths,' she said. The last National Family Health survey conducted five years ago estimated India's materanl mortality rate (MMR) to be 4.48 per thousand although it is well known that a very large number of maternal deaths especially in the rural areas go unreported or unrecorded. At Chattarpur's local dispensary, run by the Municipal Corporation of Delhi (MCD), Dr. S. Rai Chief Medical Officer confirms that upto ninety per cent of her patients are anaemic. ' Pregnant women are no exception and we give them iron and folic acid,' she says. Dr. Rai is excited by the project. Although her dispensary functions from a large two-storey it does not even have a functional laboratory. Most Chattarpur residents seek treatment at expensive private clinics. If they cannot afford it they take a bus ride to the nearest Primary Health Centre (PHC). But Payal, a housewife with a five-month-old son says the doctor at the PHC could not even diagnose her pregnancy. 'He treated me for worms. The fact that I was carrying Akash was discovered only six months into the prgnancy,' she said. Payal never received iron tablets and the effects are apparent in Akash's lack of vitality and frequent illnesses contributed by Chattarpur's crowded and unhygeinic conditions. Malti and Payal come from different income strata in Chattarpur but both have children born to them with low birth weight in a pattern familiar to nutritionists in which poor growth extends through childood accompanied by lowered intelliegence levels. That is if the child survives at all given that 90 per cent of neonatal deaths occur among underweight babies. A four-year study covering 7,109 live births to women registered for antenatal care and confinement at the prestigious All-India Insitute of Medical Sciences (AIIMS) reported 26 per cent low birth weight babies. Another study among slum dwellers in Delhi showed that 38 per cent of children born to them were less than 2,500 gms at birth or severely underweight. 'Low birth weight indicates that the infant was malnourished in the womb and that the mother was malnourished during her own infancy, childhood, adolescence and pregnancy,' says Dr. V. Ramalingaswami, who currently holds the title of National Research Professor. According to Dr. Ramalingaswami, proper nutrition is not only about availability of food but also good sanitation and most importantly a caring environment which is grossly missing especially in the case of the girl child with disastrous consequences for the future of the community. In South Asian countries girl children are commonly discriminated against in all matters including the best portions at meal times. They are married off early and often spent the rest of their lives in subordination to men or older women in situations where care is lacking. Poor nutrition lowers resistance of all children and makes them prone to disease. In turn, disease depresses the appetite and inhibits absorption of nutrients and unless managed properly leads to a typical downward spiral of frequent infection and poor growth. In India, government recognition of the spiral is evident from a recent pamphlet which says that 'inadequate prevention and management of diarrhoeal and acute respiratory and other infections which interact with dietary intake among under-twos result in a vicious cycle of manutrition.' For the last twenty years the government has been running the Integrated Child Development Services (ICDS) which now covers 400,000 of India's 600,000 odd villages and is meant for children under six years of age. Taking advantage of food surpluses the government in recentl years introduced a mid-day meal scheme for all school-going children. But then according to Dr. Kamal Islam, Head of Nutrition at UNICEF's Country office here the problem lies not in policies but in their actual implementation with close supervision on the ground. 'There is obviously a serious gap somewhere,' he said. At Chattarpur the gaps were visible in women failing to receive iron tablets provided by the National Anaemia Prophylaxis Programme launched in 1970 and supposed to be covering 20 million women at the beginning of the eighties. The few women in Chattarpur who did receive them were swallowing them along with tea, the caffeine content in which inhibits absorption, Suneja said. Suneja's organisation emphasies an educational approach to the problem of anaemia instilling in women and their communities the perils of not taking the programme seriously enough and following prescribed regimens for groups such as pregnant and lactating mothers and adolescent girls. In his experience, Dr. Islam said, doctors spent too little time with their patients so that meaningful care and counselling were missing. Payal's misdiagnosis would appear to be an extreme example of such cursory examinations.