Cradle of death

The Kurnool tragedy exposes the link between maternal malnourishment and neo-natal death

veenarao

Veena S Rao | September 8, 2011



Every year since 1982, the ministry of women and child development has been promoting September 1-7 as the national nutrition week. But, what the nation witnessed on September 3, 2011, in an expose by the Times Now, were the tragic deaths of 11 new born infants, less than five days old, at the Kurnool government hospital in a space of 48 hours. Some of us may recall a similar tragedy that occurred in Kolkata in June 2010, where 18 infants died in 48 hours in the state-run Dr BC Roy Child Hospital.  An enquiry was ordered, but its outcome does not seem to have been followed up in the public domain.

The causes for the infant deaths were described by the news channel as neglect by the hospital doctors, malfunctioning ventilators, callousness etc. The hospital authorities defended themselves by saying that the deceased infants were of low birth weight, premature, malnourished, with serious heart and respiratory disorders and hypothermia, and had little chance of survival. On this, the Times Now anchor started to mock the doctors’ explanations, giving another twist that just because the victims were poor, they were not given proper care and therefore died. 

While I cannot comment upon the quality of treatment given by the Kurnool hospital doctors, as I have no authentic information, what I can say is that if the deceased newborns were indeed of low birth weight (below 2.5 kg), and malnourished, then their chances of survival were rather bleak as compared with a normal weight baby. This is what the NFHS 3, 2005-2006 has to say about low birth weight babies: “Infant Mortality Rate is 49 (out of 1000 live births)for an average or large size baby, but it is 62 for a smaller than average baby and 129 for a very small baby….Neonatal mortality rate is 30% higher for a smaller than average baby and 183% higher for a very small baby.”

It is also medically established that low birth weight babies would most likely suffer from intrauterine growth restriction, that can lead to birth asphyxia, low immunity and infections, (sepsis, pneumonia and diarrhea) that contribute to 60% of neonatal deaths.(Lancet Series, Maternal and Child Undernutrition, January 2008)

The phenomenon of low birth weight babies is particularly acute in India, constituting 28% of all births between 2003-2008. Here are some of the firsts for India. We rank World Rank Number 1 for total births, (2.6 crore) and for neo-natal deaths, (9.4 lakhs), and the largest number of low birth weight babies born per year (70.4 lakhs). India has the largest share, (39%) of low birth babies born in the world. These low birth weight babies have the greatest risk of dying as neo-natals, and neonatal mortality constitutes around 36% of infant mortality in India. (All statistics from UNICEF 2009- Tracking Progress on Child and Maternal Nutrition)

One might ask why these infants are born with low birth weight. A generic response might be because they are poor. While that may well be the case, there is something more to it. They are born with low birth weight because it is most likely that their mothers were malnourished, anemic, with low body mass index and chronic energy deficiency when they gave birth. Further, these mothers did not get additional nutrition during pregnancy, mostly because of poverty and hard physical labour that consumes a substantial part of their calorie intake, but also on account of negative social custom that does not advocate additional nutrition to a pregnant woman during pregnancy, particularly in rural communities across India. The average weight gain of an Indian pregnant woman is around 5 Kg as against the desired weight gain of at least 8-10 Kgs.

If we go one step backward and ask why the mothers were malnourished, the answer is because they were malnourished, anemic and underweight as adolescent girls. Statistics confirm that at least 40% of adolescent girls in India are underweight and about 70% anemic. They probably married early in their teens and had repeated pregnancies, further deteriorating their already weak nutritional status.

These factors within their inter-generational grip remain largely invisible. They are not defined as clinical disease, are not infectious or contagious, and even those afflicted are not aware of their seriousness. Because of lack of information and awareness, they are not considered serious health concerns by the family or community, but merely accepted as natural physical traits or the results of poverty. This perhaps accounts for an absence of popular demand to address it by the sufferers, no activists for the cause, and low priority to address it by government which is already submerged by visible high priority demands, such as providing schools, health centres, drinking water, electricity, roads, etc.

Given the above scenario, the problem of India’s low birth babies is perhaps the most multi-causal in the world.  While poverty, with its attendant accompaniments of food and nutrition insecurity, illiteracy and lack of awareness, gender inequity, is a prominent cause, it is not the only cause. Over the passage of time the low status of women in family and society has translated into negative social/familial practices regarding care of the girl child, early marriage, and mother and child care practices, and gender inequity throughout the life-cycle of the girl child, that perpetuate maternal malnutrition and consequent low birth weight babies. 

The low birth weight babies that died in the Calcutta and Kurnool Hospitals are an expected outcome of the inter-generational cycle and attendant factors described above.

And yes, the weather does play an important part. The rush birth time is during the monsoon, (as auspicious months for marriage are generally between October to January), when poor household without access to safe drinking water and proper sanitation are most prone to infection and diarrhea. 

Times Now was appalled to see bed sharing by pregnant women, crib sharing by sick infants in the Kurnool Hospital. Take a look at the Safdar Jung Hospital or AIMS - the position is no different. The doctors in these hospitals have just two options – either turn away the patients who have travelled long distances, saying they have no additional beds, or treat them in corridors or shared beds. Hospitals built with 500 beds have to cater to three times the number, because primary and tertiary health care is so inadequate, that emergency cases that should be attended to those levels have to be rushed to Speciality and Referral Hospitals.

So who do we blame? The doctors – the parents – society- or the Government?

The nation appears to have forgotten Article 47 in the Directive Principles of State Policy of the Constitution that mandates the “Duty of the State to raise the level of nutrition and the standard of living and to improve public health The State shall regard the raising of the level of nutrition and the standard of living of its people and the improvement of public health as among its primary duties ……..”

Unless the Central and State Governments under their constitutional obligation formulate a comprehensive strategy to address the causes for the low birth weight and the malnourished new born in the entire life cycle, the Calcutta and Kurnool tragedies will keep repeating. .

The problem is complex, and so is the solution, but it is doable. It is the responsibility of the Government to show commitment and start the process of structuring a strategy to address it, in accordance with its responsibilities under Article 47 of the Constitution. We know the causes, we know the solutions, but must demonstrate political and administrative will towards action. The Karnataka Government is attempting to do just that through the Karnataka Comprehensive Nutrition Mission. The Maradonian explanation given by the Health Minister of Andhra Pradesh regarding the hand of God cannot hold.

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