Making childbirth a horror

(The snaps in this post could be repulsive to many. Viewer discretion advised)

Last week, we had one of the worst rupture uteri we've ever seen. Worst in the sense that it was quite repulsive when we got the history. 

SS, a 30 year old lady with no living issue had become pregnant the third time. As with her previous two pregnancies, she had thought that she would deliver without any problem at home. Her previous two babies were born at home but died before they attained the ages of five.

However, the progress of labour in the third pregnancy was eventful. The baby just refused to come down as the previous two had come. The family sensing that something was wrong took her to the nearby government health centre. There was no doctor or nurse at the place. 

Someone suggested a 'reliable quack'. 

The quack gave her two injection and started to applied pressure with his bare hands on her bulging tummy. He was trying to somehow push the baby out of the uterus. He had not even done a per vaginal examination. After about half an hour of applying pressure on the abdomen, she felt something give way. 

But, there was no baby. The tummy still looked swollen. The labour pain had disappeared. But she started to feel quite nauseated and sick. By this time, one of her relatives who was a Sahiya had turned up. She realised that something had gone wrong. 

It was around evening when the family reached NJH with SS. As always, the diagnosis was quite easy . . . a rupture uterus . . . 

Snaps of the surgery and how it looked . . . A grim reminder of how archaic obstetric care remains for quite a lot of our fellow citizens . . .

Tried to get a snap of the abdominal contour in a rupture uterus.
There is fullness of the suprapubic and the epigastric regions. 

The surgical team led by Dr. Shishir . . . 

The baby appears like he's sleeping . . . 

The aftermath of the violent abdominal massage . . . 

The uterine rent well sutured . . .

Maternal Mortality . . . Struggling

The press has reported a United Nations Report saying that India is going to miss the Millennium Development Goal (MDG) related to maternal health. We had targeted to reach a Maternal Mortality Rate (MMR) of 109 per 100,000 live births by 2015. However, the MMR as of today is about 212 per 100,000 live births . . . a far cry from what we want to achieve. . .

If you had been following my blog, the state of poor maternal and child health has been something I had been trying to portray. Recently, I had been trying to put some statistics from where I could look at what we may need to do extra to bring down the high maternal mortality rate. 

Thanks to Mr. Luke, a visiting student who has been helping us with computerizing our data, we have been able to look at maternal deaths. So far, we have been able to data for the last 3 years. Considering the way we keep our statistics, I'm sure that the data is incomplete. 

However, below is data related to diagnosis of the 89 maternal deaths which happened over the last 3 years - 2009-12. 

Diagnosis	Nos.
Anemia	8 (10%)
Eclampsia	48 (57%)
Malaria	1 (1%)
Unknown	3 (4%)
Obstructed labour	1 (1%)
Pneumonia	1 (1%)
PPH	5 (6%)
Rupture uterus	4 (5%)
Sepsis	10 (12%)
Unknown	3 (4%)
TOTAL	84 (100%)

Table 1

We had been suspecting it for some time. Although this is institutional based data, a diagnosis of Eclampsia causing death in 57% of the Maternal Deaths over the last 3 years is a major finding.

Well, for the uninitiated, according to the 2005 World Health Report, the following are the causes of maternal deaths - - - 

Causes of MM	%
Hemorrhage	25%
Infections	13%
Unsafe abortions	13%
Eclampsia	12%
Obstructed labour	8%

Table 2

I did some calculations for the populations that we serve. I hope the following table is self-explanatory . . .

	Total pop.	Pop. catered	Birth Rate	Births	MMR	Maternal Deaths
Palamu	1936319	1452239	0.026	37758	0.0021	80
Garhwa	1322387	661194	0.026	17191	0.0021	36
Latehar	725673	362837	0.026	9434	0.0021	20
TOTAL	3984379	2476269		64383		136

Table 3

According to our rough calculations, NJH caters to about 75% of the Palamu district and 50% of Latehar and Garhwa districts - this means that in our catered population, we would have a total of 136 deaths every year . . . 

There are documents putting the institutional delivery rates as low as 18% as well as those putting it at 50%. We estimate that about 30% of deliveries happen in institutions. Therefore, we recalculated and got the following statistics . . . 

	Maternal Deaths	Institution Del Rate	Maternal Deaths
Palamu	80	0.3	24
Garhwa	36	0.3	11
Latehar	20	0.3	6
TOTAL	136		41

Table 4

So, it means that 41 maternal deaths occurs in hospitals. However, this can be an underestimation as most of them had been trying for home delivery and reach hospital quite late after realizing of possibility of a complication.

I thought about re-looking the statistics for 2011 alone . . . We, at NJH had a total of 29 maternal deaths in 2011 . . . Below is the table showing the diagnosis of the maternal deaths. . .

Diagnosis	Nos (%)
Anemia	2 (7%)
Eclampsia	10 (34%)
Malaria	1 (3%)
Unknown	2 (7%)
Obstructed labour	1 (3%)
Pneumonia	1 (3%)
PPH	3 (10%)
Rupture uterus	2 (7%)
Sepsis	4 (14%)
Unknown	3 (10%)
TOTAL	29 (100%)

Table 5


The predominance of Eclampsia being the commonest diagnosis in a maternal death remains. For the 29 maternal deaths that happened at NJH in 2011, I have put an additional column in Table 5 and looked at where the 29 maternal deaths came from . . .

	Maternal Deaths in target community	Institution Del Rate	Maternal Deaths in institutions (calculated)	Maternal Deaths at NJH (2011)
Palamu	80	0.3	24	16
Garhwa	36	0.3	11	4
Latehar	20	0.3	6	7
Others	-	-	-	2
TOTAL	136		41	29

Table 6

2 of the patients had come from Gaya district. Well, table nos. 6 speaks volumes of the influence NJH has in the Maternal and Child Health Care in the region.

Well . . . there is quite a lot that we need to learn. We had looked at the possibility of a community based survey about maternal health care. Unfortunately, the clinical load has prevented us from doing it . . .

There are quite a lot of people who has put in their input behind this post . . .and I'm indebted to them. Just a couple of names without whom this would not have been possible. First of all, for a discussion with Dr Anil Cherian, the Director at Community Health, Emmanuel Hospital Association which stimulated me to look at this and Mr. Luke Gray who computerised all the records . . .

So, at the end of it . . . questions remain. . . The major ones being . . . 

1. Is hemorrhage the commonest cause of maternal death in the country?

2. Eclampsia is a major problem in many of our rural areas . . .Does nutrition have a role in the pathophysiology of hypertensive diseases of pregnancy?

3. How serious is our public healthcare about maternal health? 

To answer the last question . . . The saddest part remains that at least our local public healthcare authorities are hardly bothered about maternal deaths . . . We had been filling up the Institutional Maternal Death Review Forms since last August. It is going to be one year. I'm yet to be called for at least one meeting about this . . .