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23rd June 2016

Mother and baby mortality: the silent pandemics

Dawlen Tirkey, a nurse who had just delivered a baby girl, was one of 45,000 Indian mothers to die after childbirth last year. In India, and elsewhere, the infant mortality numbers are even higher – but it doesn’t have to be like this.

It was her second child. Dawlen had given birth to her son, Abhinaw at home almost 10 years previously in an uncomplicated home delivery. She and her husband, Manoj, decided to try for another child and were delighted to bring a new life into the world.

Tragically, Dawlen’s time with her daughter was short. Within 12 hours, the baby who they named Abhilash, meaning ‘wish’, would lose her mother for reasons which remain a mystery.

Manoj’s world had been turned upside down. He had gone from extreme joy to devastation. It was hard to accept. ‘I was hoping she would be okay, like in the movies, where we see people coming back to life again after dying,’ he told the FT . ‘But it didn’t work out that way.’

The grim reality for women like Dawlen living in poor regions of India is that the day they give birth is the most dangerous day of their lives. As a nurse, Dawlen would have been acutely aware of the risks. Trained and experienced staff are hard to find and medical facilities often lack basic equipment for monitoring the health of babies and mothers during this perilous process.

Risky move

10 years ago, due to concerns about the safety of home birth in rural villages, the government began incentivising pregnant women to register with, and give birth in, local health facilities. While fewer women and babies are now dying at home, more are dying while being transferred from local facilities to a centre with more specialist staff.

Like many of its kind, the clinic near Dawleen’s house is understaffed and ill-equipped to deal with complications and obstetric emergencies. Obstructed birth, an urgent caesarean section, or a blood transfusion require patients to be moved to another centre – which may itself be overcrowded.

Dawlen had a blood test that showed she was mildly anaemic, a common problem arising from poor nutrition, which increases the risk of shock following post-partum bleeding. She asked to be transferred to a private clinic where she had a Caesarean section a few hours after she arrived.

The procedure is not without risk, particularly if operating rooms are not well equipped or the chances of infection are high, but Dawlen’s surgery appeared to have gone well. Sadly, while she was recovering in intensive care, things took a dramatic turn for the worst. Her blood pressure plummeted. A junior doctor tried to bring her around and sent for two senior doctors but it was too late. Hours later she was dead.

Her family still does not know whether the cause of death was a heart attack, a blood clot, an infection or some other complication. But they know Dawlen is gone.

A global crisis

This is far from an isolated incident. 45,000 women like Dawlen die every year in India during or shortly after childbirth. Only Nigeria, where the figure is 58,000, records more maternal deaths.

It may be hard to imagine but the number of infants who die in their first 28 days of life is even higher. In India, 696,000 babies don’t make it to their second month. Pakistan (245,000), Nigeria (240,000), Democratic Republic of Congo (94,000) and Indonesia (74,000) also report tens of thousands of infant deaths.

If a disease like Zika or Ebola were causing this much misery a global state of emergency would be declared.

The real tragedy is that a large number of these deaths are preventable. Developed countries have slashed both infant and maternal mortality, but so too have many low- and middle-income nations.

Modern health facilities are kitted out with sophisticated heart monitoring equipment, ultrasound scanners and state-of-the-art operating theatres.

But some of the most valuable tools are relatively ‘low tech’. One of the most valuable is the humble stethoscope which can monitor the foetus’s heart rate during labour to check for distress.

This can help doctors decide whether labour ought to be accelerated or if an emergency Caesarean section might be in order. Crucially, it could inform the decision to seek specialist support before it is too late.

Even ultrasound equipment is becoming more accessible with some smart phones capable of being adapted to display images from a plug-in scanner.

Low-tech solutions

Blood pressure monitors – whether they are the latest high-tech models or a simple cuff – can pick up early warning signs of high blood pressure, a major cause of maternal death.

Preeclampsia, a form of chronic high blood pressure, can be diagnosed during pregnancy helping doctors and expectant mothers to plan ahead rather than endure a risky hospital transfer half-way through labour.

Good pregnancy care should also include regular blood tests which can pick up everything from hormonal changes to HIV infection. Where HIV is diagnosed early, swift treatment can reduce the risk of the virus being passed to the baby in utero.

Electronic and mobile health solutions also promise to connect understaffed clinics with experts in high-volume specialist centres, offering potentially life-saving guidance when vital decisions must be made.

Together, better equipment and better-trained staff can go a long way to reducing the enormous number of unnecessary maternal and infant deaths recorded every year.