A dying system

The death of 16 women admitted to a government hospital in Jodhpur for childbirth exposes the sorry state of the public health system in Rajasthan.

recently in Jodhpur

THE death of 16 women, who had sought obstetric care, within a span of a fortnight following infection caused by contaminated intravenous (IV) fluid injection and unhygienic conditions in a leading government hospital in Jodhpur district of Rajasthan has made a mockery of the National Rural Health Mission (NRHM), the flagship health programme of the Union government. The goal of the mission, launched in 2005, is to provide integrated comprehensive primary health care services, especially to the poor and vulnerable sections of society.

The deaths would have gone relatively unnoticed had they occurred over a period of time. It became public only after relatives of one of the deceased women raised a hue and cry.

That the deaths took place at Umaid Hospital, one of the oldest and largest government hospitals, predating Independence, was even more shocking. The majority of the women were poor or belonged to lower-middle-class families and had been admitted to the hospital in an advanced stage of pregnancy. They came from far-flung areas of Barmer, Jaisalmer and Jodhpur districts which lack facilities for obstetric care. Some of them had traversed more than 300 kilometres.

All the women who died were between 21 and 34 years of age. Fourteen of them died after giving birth to healthy babies. Women in Rajasthan are known to be vulnerable to maternal mortality owing to nutritional deficiency and the risk caused by complications during delivery. The State has the third highest maternal mortality rate (MMR) in the country, at 388 per 1,00,000 births. But the latest deaths are a scathing indictment of the state of maternal health care and the public health system in general in the State.

As many as five committees, including one by the Central government, were constituted to inquire into the incident. According to Divisional Commissioner R.K. Jain, the conclusions drawn by a three-member team deputed by the Union Ministry of Health and Family Welfare have not been made available to the State government or to the office of the Jodhpur Divisional Commissioner. A second viewpoint came from a three-member team, which included a microbiologist from Jaipur. The doctors commented on the lack of hygiene in the labour room and operation theatre of the hospital. Another inquiry, by the S.N. Medical College administration, confirmed contamination and unhygienic conditions as factors responsible for the spate of maternal deaths. A sample of the contaminated IV fluid batch has been sent to the Central Drug Laboratory in Kolkata for verification. Two more inquiries, one by the Divisional Commissioner himself and the other by a four-member team of medical experts from the Postgraduate Institute of Medical Education & Research, Chandigarh, were instituted. Meanwhile, the hospital administration suspended a storekeeper and the area drug inspector.

On the basis of the findings of the inquiry carried out by the Divisional Commissioner, the State government suspended three doctors for negligence and lapses in the procurement of medicines. This response came after repeated demands to fix responsibility on senior hospital authorities. The doctors against whom action has been taken are Sushila Boda, head of the gynaecology department at Jodhpur Medical College; Ajay Malviya, Chief Medical Officer (Stores), Mahatma Gandhi Hospital; and Mohan Makwana, Chief Medical Officer (Stores) and paediatrician at Umaid Hospital.

The patients' attendants had spent anywhere between Rs.20,000 and Rs.1 lakh for medication, in spite of the fact that they were undergoing treatment at a government hospital. The families of the women had to pay for medicines and for blood and plasma transfusions.

Demanding action against the doctors who treated the women, non-governmental organisations such as Vikalp, Gravis and Meera that work in the area of women and health care said complicated surgical procedures should be entrusted with trained doctors. They have also demanded the strengthening of health facilities in Jaisalmer, Jalore, Pali and Barmer districts, pointing out that in the absence of comprehensive health care services in those areas, families are forced to go to Jodhpur for something as basic as childbirth. They demanded that proper discharge papers be given to the patients (in fact, only a few families had any kind of papers with them) and that proper post-natal care be provided for the newborns of the women who had died.

Compensation

The government announced a compensation only after 13 deaths had taken place. Surprisingly, even after the government sealed the particular batch of IV fluids and blacklisted the Indore-based Parental Surgical India Limited and its local distributor, three more women, who were delivered of their babies, died owing to multi-organ failure and septicaemia. One woman, Sagar Kunwar, who was alive but was declared dead in the list issued by the hospital initially, finally succumbed to her illness on March 14. The previous day, Manu, the wife of an agricultural labourer, who had been admitted to the hospital on February 15, died. She had given birth to a baby boy on March 9.

The doctors said nothing clearly. They said she has tuberculosis and cancer and that they had to take out the uterus because there was a gaanth [the local word for fibroid or a cyst], said Rekha Ram, Manu's brother-in-law. He called up from Jodhpur to inform Frontline that his sister-in-law was dead and that the hospital was pressuring his family to take away her body.

She was in the ICU [intensive care unit] for seven days. We are agricultural workers from Osian block in Barmer. We get work sometimes. We do not even have a BPL [below poverty line] card. Yet, we have borrowed and spent Rs.70,000 so far. The doctors should at least tell us what is wrong with her, said Manu's husband, Dewa Ram. He gave this information to Frontline when Manu was still alive. Manu's two previous childbirths were conducted in the village itself. This time she had developed pain and fever, and that is why she was taken to Umaid Hospital.

The government announced a compensation of Rs.5 lakh to each of the 16 bereaved families. Its mandate of compensation was limited to the deaths that had taken place owing to the contaminated IV fluid. The families of Manu, Prem and Sagar Kunwar, the three women who died between March 13 and15, were not entitled to any compensation.

After the first three deaths were reported on February 13, fourteen other cases were shifted to the ICU wards of the super-speciality M.G. Hospital and Mathura Dass Mathur Hospital, both of which are attached to S.N. Medical College. Umaid Hospital was declared out of bounds for the media after the negative publicity it got following the deaths. A junior doctor, on condition of anonymity, told Frontline that the number of inpatients had dropped. There was no doubt, he said, that referral systems were totally absent in the rural areas. There is a reason why they come here. The primary health care centres [PHCs] and the community health centres [CHCs] are not at all equipped. They have neither personnel nor infrastructure. What is the point of appointing a gynaecologist at a PHC without providing for other enabling infrastructure and personnel? he asked. He said that on some days the corridors of Umaid Hospital would be filled with patients.

According to R.K. Jain, people generally preferred to go the district hospital or they went there because someone in the family had delivered there. He said there should be some regulation to restrict the inflow of patients to the district hospitals in order to prevent overcrowding. Stating he was not a medical expert, he said he would look into administrative lapses; procurement issues; tendering processes, especially those involving the procurement of IV fluids; the absence of infrastructure in the source areas from where the patients came; and negligence on the part of officials.

Twenty thousand deliveries are done annually at Umaid Hospital, 30 per cent of them by Caesarean section. There are some 70 cases of maternal mortality every a year. The hospital is overburdened. Most of the cases where the deaths took place were complicated ones, almost gone' cases. There were two cases of intrauterine death, he said.

The hospital was equipped to conduct only 40 deliveries a day but 70 deliveries took place each day, he said. I am going to propose a mechanism to regulate the inpatient traffic here. I am also going to find out the reasons why the CHCs referred the patients to Umaid Hospital in the first place. I will also take to task any auxiliary nurse midwife or Chief Medical Health Officer if any negligence has been found on their part, he said, adding that not all cases were referred ones. Even if the hospital was overburdened with patients, it was common knowledge that almost all the senior doctors had a flourishing private practice, which on many occasions was conducted when they were required to be at the hospital.

On March 13, when Prem, who was admitted to the ICU of M.G. Hospital, died, her relatives insisted that she was entitled to government compensation to which the medical superintendent, Arun Mathur, agreed in principle. She had been admitted to Umaid Hospital on January 31 and then referred to M.G. Hospital, where she died of multi-organ failure. Arun Mathur declined to comment whether contaminated IV fluid was responsible for the death. She had undergone dialysis and had low blood pressure. She had been put on ventilator as well, he told Frontline.

Most of the women died owing to post-partum haemorrhage and septicaemia followed by multi-organ failure, or multi-organ dysfunction syndrome, the medical term used to describe this condition. In some cases, it was a combination of several causes, including disseminated intravascular coagulation. What was shocking was that some of the women had given birth to healthy children earlier and had survived childbirth.

Frontline spoke to five of the affected families, including those who were not on the government's compensation list, and found that all of them were in deep debt owing to costs incurred during the period of medical treatment. They uniformly complained of the attitude of the doctors, including the head of the gynaecology department of Umaid Hospital. Arif Chhipa, a resident of Khanda Falsa in Jodhpur town whose 20-year-old wife, Rukhsana, died on February 22 from a variety of listed causes, including renal failure and multi-organ failure, said the doctors in the ICU at M.G. Hospital were laughing when her haemoglobin level showed no improvement despite blood infusions. Rukhsana had a Caesarean section and gave birth to a baby girl on February 14. Her condition began to worsen subsequently.

Her hands and feet were swollen. Her stitches were leaking. They took Arif's consent to do a dialysis on her. She was perfectly healthy when she walked into the operation theatre, said Shamim, a relative of Rukhsana's who was with her throughout. In fact, the cleaning of the patient, post- and pre-partum, was done by the attendants and not by the hospital staff. The government-appointed nurses and other staff would not do anything. We got the sanitary pads ourselves and had to clean her up. The table on which she lay was not cleaned properly, she said. Arif suspects that contaminated glucose was responsible for the death. We have no bills but we spent around Rs.1.5 lakh on the treatment, he said.

Narender, a resident of Masuriya Colony in Jodhpur town, was the first to raise a hue and a cry after his 20-year-old wife, Bhawana, was declared dead by M.G. Hospital, where she had been admitted after being referred to by Umaid Hospital. Interestingly, the cause of death was not listed in the information given by the administration. As in the case of Rukhsana, Bhawana's body was swollen like a balloon. This was not Bhawana's first delivery. She had given birth to two children before.

According to Narender, who is a graduate and is unemployed, she was admitted on February 19 at 10 a.m. (though the hospital records say she was admitted at 4-30 p.m. and list the time of delivery as 3-56 p.m.). She delivered at around 4 p.m. and then started bleeding. She bled all night, and the doctors took Narender's consent to remove her uterus. However, the bleeding did not stop. It was then decided to move her from Umaid Hospital to M.G. Hospital. Narender said they were fumbling with the oxygen cylinder even as her heartbeat was getting faint.

On February 24, she began bleeding from her nose and mouth, and dialysis was tried. At 3-30 p.m., the doctors called me aside and said they were trying to revive her, but an hour later they said she had died. They did not even bother to explain to me what had gone wrong. When I insisted, they asked me if I knew better than they, Narender said. I don't know how I am going to bring up my girls. They are so small. The newborn wakes up in the middle of the night. My eldest one, Kirti, does not know her mother is dead, but she knows something is wrong she remains quiet all day, he said.

Ashish is another young man who lost his 21-year-old wife, Prem Sheela. The cause of her death was listed as renal failure, jaundice and multi-organ dysfunction syndrome. He said they had taken her for check-up regularly at the government hospital at Paota and that no problem had been detected at any stage. She was to deliver on February 5, but then five days later she was referred to Umaid Hospital. On February 11, a healthy baby girl, weighing three kilograms, was born. My daughter-in-law was educated and progressive. She had even taught in a nearby school and wanted to go back to work once things stabilised. She never used to cover her head like other women in Rajasthan, said a distraught Shiv Rattan, an employee with Bharat Sanchar Nigam Limited. From February 16, Prem Sheela's condition worsened.

After the C-sec, she couldn't get sleep. They did not let us inside, so we do not know what was going on with her, said Ashish. Two rounds of blood tests were done, for which the family paid, and it turned out that she had jaundice. They even said she might die and referred her to Mathura Dass Mathur Hospital. We bought plasma as well on more than three occasions, he said, showing three receipts of Rs.1,200 each issued by the Umaid Hospital Medicare Relief Society.

The family spent around Rs.50,000 on the treatment. For 12 days, Prem Sheela battled for her life. On February 21, she breathed her last. We do feel the doctors are to blame, said Shiv Rattan.

According to the Sample Registration System statistical report of 2008, the MMR in India is 254 deaths for every 1,00,000 live births. Recently, the fourth Common Review Mission (CRM), an assessment of the NRHM, reviewed 14 States, including Rajasthan. It identified gaps in infrastructure and a lack of human resource, especially shortage of specialists, second auxiliary nurse midwives and multi-purpose health workers. It also observed the need for proper procurement systems and the establishment of laboratory services at peripheral levels at affordable rates.

The fourth CRM has recommended contractual appointment under the NRHM, which, given the state of the health care system, may not be a good idea. A Planning Commission study of the NRHM has indicated uneven progress in the implementation of the programme in States such as Andhra Pradesh, Uttar Pradesh, Rajasthan and Bihar.

Responding to a question in Parliament on the condition of the PHCs, the Union Health Minister replied that many PHCs had been made functional to provide round-the-clock services and newborn baby care units had been established in them. If such a facility was really available in Rajasthan, perhaps many deaths could have been avoided. For the moment, the State government is in the dock and everyone is waiting for an explanation for the denial of proper medical care at the government hospital.