This post is being cross-posted with the express permission of Global Post (Emily Judem/GlobalPost)
Editor's Note: This is the fourth in a series of posts about child health in India, where, in 2011, 1.7 million children under the age of 5 died. Health reporting fellow Harman Boparai travels to India, where he once practiced as a physician, to take a deeper look at child health in his home country. "A Doctor's Notes" is part of a GlobalPost Special Report titled "The Seven Million," about the many challenges faced worldwide in an effort to reduce child mortality.
PANNA, India — Chunnu Bai looked out the window of her house, an opening in a wall of unbaked earth, and saw no one in sight. She had thought it would be just another morning. But then she felt a “lightening” in her belly; the baby had descended. Her mother-in-law had left to collect wood for selling in the nearest town, so she was in the room with only her three-year-old son.
The contractions came faster and stronger. She knew she would have no time to call anyone. Panic gripped her, but she took a few deep breaths and tried to calm herself down. With sweat trickling down her face, she lay down on the uncovered earth in her room. A few minutes later she delivered. It was a boy.
The village of Makri Kothad, where Chunnu Bai lives, is about 50 kilometers from the only hospital in India’s Panna District. One in four women in Panna deliver at home. Many of these births are without the presence of skilled health personnel, exposing both the mother and the newborn to a great risk if complications occur, like bleeding or an obstruction in labor, which can be fatal.
Globally, 287,000 women died in 2010 from causes related to pregnancy or childbirth, according to WHO’s Trends in Maternal Mortality report. India accounted for nearly one-fifth of those deaths.
“I still get patients who have never seen a hospital,” said Dr. Neela Namdev, the only obstetrician at Panna’s district hospital, as she walked out of the labor room. The coverage of care during pregnancy is dismally low, with less than one in eight women receiving a full ante-natal checkup and even fewer getting an ultrasound. Even with the government’s free emergency ambulance service now extending to all of Madhya Pradesh, usage and awareness are still a challenge in remote and disadvantaged villages like Makri Kothad, according to Namdev.
But Chunnu Bai was lucky; it was a normal delivery. She picked up the baby and cleaned him with her sari, placing him on the rice tray in her house.
About half an hour later the village dai, a traditional (untrained) birth attendant, came to her aid. She cut the umbilical cord with a clean blade, and tied it with a thread from the house. Then she applied some oil to the stump of the cord.
The first couple of days, the child was fine and feeding well. On the third day, Chunnu Bai noticed that he stopped sucking, and his body went into a spasm. Horrified, she called for help and took him to the hospital. But the baby had developed tetanus, which in most cases ends up being fatal. The second day at the hospital, despite intensive treatment, they could not save the child.
Neonatal tetanus causes 14 percent of all deaths in the first month, but it is easily preventable by immunizing the mother. Even in Panna, four of every five women receive at least one injection of the tetanus toxoid, but still, 21 percent remain unprotected.
Globally, of the three million newborns that die every year within a month of birth, more than a million babies die on the first day. The majority of these deaths result from complications related to preterm birth or arising during delivery — especially from unsafe home births. India has a persistently high level of newborn deaths, accounting for nearly one third of all deaths on the first day. With 309,000 neonatal deaths per year, the state of Madhya Pradesh has the highest burden in the country.
To tackle the problem of care during pregnancy, delivery and other basic health interventions, the Indian Ministry of Health and Family Welfare has started training local women to act as health educators, calling them Accredited Social Health Activists (ASHAs).
Two days after Chunnu Bai lost her baby, I went to Makri-Kothad, accompanied by the village ASHA and the doctor taking care of this and the surrounding 100 villages. The road to the village ended halfway, and we drove through dirt paths in the open land, with small huts dotting the horizon.
When we reached the village, we found Chunnu Bai in the courtyard of the two-room dwelling. She sat squatting, staring at the ground, her sari covering her face. Her mother-in-law stood by her side talking to the doctor about the hardships the family had to face. When we went inside the house I saw the place where she had delivered, a small dimly lit room at the back. A stack of firewood lay in the corner and bare earth stretched to the walls. Chunnu Bai showed me the piece of thread that the dai had used, the same unsterile thread they used to stitch torn clothes. That small pink coil may have caused the baby to get the infection.
Sterile thread is multiple times more expensive than household thread and also requires sterile gloves a sterile, sheet, and antiseptic ointments, none of which a dai usually uses.
As I stepped outside and looked at the crowd gathered to catch a glimpse of the visitors, I thought about how absurd it seemed that a spool of thread costing a few cents could take the life of a newborn. The doctor and the ASHA worker took the opportunity to announce the government programs available to the villagers.
One of the women spoke up, “We don’t have anything to eat, how are we to take care of our children?”
But the heath worker said that in Panna, nothing was too expensive, especially with schemes for families below the poverty lines.
In Panna, a kilo of rice (5 cents in US dollars), the thread (8 cents), a clean blade (1 cent) and a human life, all came cheap.
The BiliDx is a novel system for diagnosing jaundice. The device uniquely meets the Target Product Profile (TPP) developed as part of the NEST 360 initiative in that it allows blood-based testing at the bedside. This initiative is part of an emerging global consensus in the Every Newborn Action Plan that countries need functional WHO level-2 inpatient units to care for "small and sick newborns."
Now as a next step, we ask what could be done to lower the costs of the implementation of the E-MOTIVE bundle? The most obvious answer is to consider displacing the tens of thousands of disposable plastic drapes with a purpose-built reusable device.
Fortunately one of the obstetricians involved in the E-MOTIVE study, Dr. Justus Hofmeyr, had been innovating around this very issue, designing a tray with wells that could fit under a woman’s buttocks, collect and accurately measure the. blood. This tray, theMaternaWellTraywas conceived as a device that could be sterilized and reused, and is manufactured in South Africa by Umoya.