Though people have children all the time, when I went through it it was still astonishing. Even in the merely supporting/cheerleading role of the father, I can’t remember ever experiencing anything quite as frightening and, in the end, exhilarating. The everyday can still be mindblowing, when it happens to you: giving birth to a child is still difficult, painful (even with local anesthesia), and dangerous. So many things could go wrong, and yet somehow they don’t, most of the time. And at the end of the day you have in your hands the most uncanny result of all: new life.
In a way I was lucky that S. went into labor last Friday, before I came across the latest issue of the New Yorker, with a typically excellent Atul Gawande piece on the evolution of obstetric medicine. In effect, the story Gawande tells isn’t really an alarming one, though it still might have filled my mind with thoughts better avoided. Childbirth in the U.S. has become fairly safe over the years (though the threat of infant mortality and maternal mortality is still real). But what is a bit disturbing is that until fairly recently so many women (1 in 100) and newborns (1 in 30) died going through this. Interestingly, it was a woman doctor named Virginia Apgar who formulated a rating system (the Apgar scale) which gave doctors a set of criteria by which to evaluate newborns who seemed a bit iffey immediately after delivery. According to Gawande, the Apgar scale has dramatically reduced the infant mortality rate and revolutionized neo-natal care. The procedure that has made the difference with maternal mortality is the modern Caesarian section:
In the United States today, a full-term baby dies in just one out of five hundred childbirths, and a mother dies in one in ten thousand. If the statistics of 1940 had persisted, fifteen thousand mothers would have died last year (instead of fewer than five hundred) —- and a hundred and twenty thousand newborns (instead of one-sixth that number). (link)
It’s worth noting that there are disparities along racial and ethnic lines; infant mortality rates for African Americans and Native Americans are appreciably higher than for other groups. The statistics in India aren’t quite as good, though they have also improved dramatically in recent years. Here are some statistics on infant and maternal mortality in India, according to UNICEF:
- Maternal mortality: 540 in 100,000 (compare to 10 in 100,000 U.S.)
- Infant mortality: 63 in 1000 (compare to 7.5 in 1000 U.S.)
- The Under-5 mortality rate is 87 in 1000 (nearly 10%!)
- Only 43% of births had a skilled attendant at delivery
And here, you can see a map of infant mortality in India, broken down by state. Two of the states that are most behind are Madhya Pradesh and Uttar Pradesh, which is somewhat surprising to me.
Obviously, India has a long way to go here, but this isn’t necessarily another ‘bad news’ story. Even as recently as 45 years ago, the numbers were much, much worse. Since 1960, infant mortality has been more than halved, and under-5 mortality has been cut down by two-thirds. Those are impressive improvements for a country as large and famously sluggish as India is on matters of public health. I wonder if people have ideas about how India could do even better going forward.
Related posts: Taz, on low desi infant birth weights; Me, on Atul Gawande’s Complications
first of all amardeep, i’m proud of you for being there for ‘s’ during the birth of gorgeous puran.. i know it was scary for you, as it is for almost 1000% of first time dads… but i know it was an incredible experience for you..
so, onto how to improve the birth rates in india?
neonatal care needs to improve… impoverished mothers who can’t afford getting exams, via ultrasound, etc… since a lot of problems arise in the first 12 weeks when organogensis takes place and where most mutagenesis (malformations) arises.. the discrepency on using ultrasound machines and finding out the sex of your baby has hindered this in some parts…and in other parts the cost has been the biggest hurdle…
womens health care needs to improve… HIV education… prenatal vitamins (a simple folate pill can decrease the risks of having neurla tube defects such as spina bifida…
on another semi-related ‘ob/gyn’ front.. i recently saw a story about orphans in s.africa who are newborns and yearn for breast milk (breast milk ‘colustrum‘ especially the first few days is very important in building antibodies in the newborn)…and there is a group of new mothers here in america who pump milk and express it to them since they are in need…
anyways..those are my few lentils on the subject.. hope you, new mommy, and the baby are doing well! 🙂 -CP
oohhh ohhh pick me! pick me!!!
where do I start…
Approximately 68% of postpartum deaths occur during the first week postpartum, most of those in the first 24 hours. Hemorrhage (essentially excessive bleeding) is the single largest cause of postpartum deaths, accounting for about half of all postpartum deaths. So basically women, even if they give birth at home need to be able to be rushed to a facility where they can be treated for any complications they might have.
more births need to be attended by a skilled attendant (these need not be OB/GYNs nor need the necessarily be in hospitals) and there should be an increased use of the partograph
more midwives, nurses, general drs need to be taught Active Management of the Third Stage of Labour (AMSTL)*
Misoprostol needs to be made available and women trained how to use it because lets face it, the ONLY person garaunteed to be at any childbirth is really the pregnant woman herself (this is appropriate in some area, not all)
communities need to be mobilized so that people can both recognize danger signs and then act in a timely manner, with resources like transport and blood donors figured out ahead of time (complication readiness plans should be in place at both the family and community levels)
women need access to, and need to know the importance of antenatal care.
decision makers especially in the desi case, mother-in-laws, need to be brought into the discussion, and need to be convinced of the need for both antenatal and postpartum care for the mother as well as the child.
Illegal abortions esp in the case of foetocide need to be stopped
malaria and tetenus prevention, and nutritional support needs to be provided for mothers/newborns
ok, i’ll stop for now, but I assure you I got’s more…and there’s some REALLY interesting work going on in India that I’ll try dig up, because right now in India, the element that’s missing is not really money (like other developing countries), but the mismanagement of these funds due to bad ideas being brought to scale rather than evidence based, sustainable ones…
*The components of active management of the third stage are: 1) Administration of a drug, after the baby is born, that causes the uterus to contract (uterotonic); 2) Delivering the placenta by controlled cord traction with counter-traction on the fundus of the uterus; 3) Uterine massage after delivery of the placenta to maintain contraction.
kenyandesi has covered some really good points… i think that the greatest barrier is access to trained midwives/health professionals. most women in the villages still have local midwives/ “dai” that handle the birthing process. these midwives adhere to old practices and do not always have resources to learn new techniques or to handle adverse situations appropriately. if lucky, there may local clinics which are not always be well-equipped… hospitals are rarity in rural areas.
it may be that in hospitals and clinics in cities the mortality rate is actually similar to that in the US because there is no lack of skill in india among those who are properly trained. amardeep, i don’t know if you came across any data on cities vs rural areas.
i know a doctor who did some work in rural communities in india for a bit… he was part of a team that was trying to determine the decrease in infant mortality rate in a few villages after training the local midwives… it was a matter of simple know-how and modern techniques and there were babies and moms that had made it as a result, who may not have otherwise. this has not been published yet as it is part of a bigger study that is still going on.
like with many public health issues, the major overall barriers are the same in rural areas: lack of infrastructure, lack of access to trained professionals, lack of education. slowly but surely these are being addressed… it gets frustrating though when progress is impeded by things like improper allocation of funds. it’s considered un-PC to mention/discuss this at meetings or conferences, but corruption is a major barrier as well, in this case as with many others.
I think once most of us leave 9th grade bio and that live birth video that scares u away from sex (well, for a lil while), you really do forget what an amazing process it really is.
Good post and congrats on the beautiful baby boy.
Ah, I have nothing to add. It’s 1:30am, various SM type people just vacated chez Salil, and I’m in a happy mood.
I just can’t wait for all the little macacas to start hanging out and doing their own post-post-generational hybrid revolutionary thing. I’ll look for something significant to add tomorrow. Tonight, it just feels good to be a part of a community. 🙂
Gosh, I must be drunk. I’m getting sappy.
Amardeep, If you compare the map of IMR against a map showing the (Il)Literacy rates in India, you will see that the BiMaRUP states ( bihar ,MP, Rajasthan and UP) are right at the top of both lists. It is more a matter of awareness amongst the population. For once I can say that the Indian Government has some excellent programmes in place and it has been their relentless efforts that have succeeded in bringing down the IMR and other indicators of general health. All the “generic” solutions suggested by the Pea and kenyandesi are already in place and have shown excellent results in states with higher literacy rates. I think it s only a matter of time that we can expect the standards to improve.
Actually WesternGhat, (in many places, esp those where the numbers are still bad) up to now the Indian government had spent A LOT of money building big hospitals and trying to woo people to go there. But little to no attention has been paid to the local healthcare centers and terciary clinics, the places that would provide linkages to the bigger hospital. There is no good houseold to hospital continuum.
In addition, hospitals are often poorly run, filthy and overcrowded in area where women do use them, so outcomes are not much better because the chance of sepsis increases. My dad is working on a project with the Indian government to try and address these issues, but right now it’s still a bit of a mess. FOGSI (federation of ob/gyn societies of India) just got ion on the action too, (they first had to be convinced) but then lobbied the Indian gvt to run programs to teach emergency Obstertic and Neonatal Care BETTER to ANMs and general doctors (Because they’re the ones who usually are the ones on the front lines)…the pilot program was incredibly successful and the government gave them a whole ton of money to step it up.
This still does not mean enough is being done. I think hand in hand with the infrastructure and provision of services goes a social mobilization piece to create demand for those services…
I agree that things are getting better in India, but we’re NOWHERE near a solution. The problem is that the government has previously gone for high level, high tech solutions for what many people still consider a vey natural normal process, they never tried to create the demand, they ran their hospitals poorly and didn’t create linkages. These are now being done by the government but largely because NGO’s have stepped in and tried to fix things…which is all well and good…afterall a synergy of interventions is really needed to fix a problem this big in a country that size.
KD, I see the glass as half full, not half empty. And you miss the point of my post : its the literacy levels which are a better indicator. While one cannot expect to change the situation overnight , and all alone( as you rightly and eloquently point out)I am for once not entirely unhappy with the progress.
🙂
WG, I see the progress as great, but more needs to be done (and is getting done). I don’t think health care need to be linked with literacy improvements because it has been shown that even illiterates and area where literacy rates are low, vast health improvements can be made.
I definitely agree that the numbers are not surprising because anywhere you have low literacy rates, yu’re going to have all sorts of indicators that look bad.
I think a solution can come from applying sound medical knowledge consistently and with the neccessary infrastructure in an accountable, consistent manner. The Info Kenyandesi gave out; apply this to the Child Care Boards or some kind of set-up with local branches. I think it would take minimal funding to train and supply local health care workers and then some kind of institutional commitment to make sure the program can reach people effectively and that there is some periodic over-sight of activity.
At one time I believe India had ways to get things started at local levels with connections to national organizations, this would I think need to be cranked up.
This seems to be the key now, seeing as the knowledge is there, and the know-how is probably there as well. And I think, if Sepiamutiny as a community can intervene at any juncture, this would be the one. Although difficult, in part because a social movement often has to speak to the local realities if people are to be moved to action. Can we do it? Probably no one person has enough time, but 1,000 visitors to SM pulling in the same direction for a year probably could make some kind of impact. A lot would have to be done to set this up. For one thing, using SM meet-ups as a way to organize people might be possible.
I believe this is an issue that is actionable; its simple, compelling, and effective solutions exist and the project matches the skill-set of the SM audience.
Anyway. Just a thought.
The one thing in favor is there is not likely to be any entrenched opposition; social movements that fill a need and are without opposition can flourish with a small catylst, which would be a us, as a drop in an ocean of people. However, it’s worth a shot and if we’re all going to jabber on SM 24/7 anyway, how awesome to have an Update on the SM Mother, Child, and Society Project Tab.
It’s an ambitious under-taking, but a journey of a thousand miles starts with one step. Another key would be to avoid internice bickering in a group and a commitment that our own over-head would be low. I would propose if a project were to start, but some off chance, there be project managers but no leadership.
Has any one noticed that J&K is one of the best states for a mother and her new born child? One would think with all the violence across the state and breakdown of govt, the numbers would be higher. But who knows, all the violence creates problem for gathering good numbers also. Also, Arunachal, Manipur, Mizorum, Sikkim & Tripura have better numbers than most others. What could be the reason?
Now it is clear why Utteranchal wanted to be a seperate state from UP.
I was very surprised to see that as well. Kerala makes sense because of the high rates of female education, despite the relative poverty. But some of these other states … I don’t expect them to have either wealth or female education, so I am surprised.
Anybody know?
I was very surprised to see that as well. Kerala makes sense because of the high rates of female education, despite the relative poverty. But some of these other states … I don’t expect them to have either wealth or female education, so I am surprised.
arunachal, manipur, mizoram sikkim, tripura, kerala.
1) these states are disproportionately christian 2) those that aren’t, such as tripura and arunachal, have many ‘tribal’ people whose attitude toward gender is not the same as ‘civilized’ indians.
the fact is that many ‘barbaric’ people have more gender equitous relations than ‘civilized’ people, and that is what you are seeing i think in the tribal areas that aren’t christian. in the areas that are christian there is probably a more pro-western outlook, and emulation might be going on, in addition to the capital inputs injected by christian missionaries (this capital input would like have a salubrious impact on non-christians, and the nature of christinan culture can often also influence neighbors). i doubt there is a ‘magic bullet’ which can explain all the patterns of course, and one could posit that in the northest population density might be a parameter of importance (look at assam vs. the rest). though that can’t explain kerala.
This reminds me of a young American woman I knew who married a young orthodox UP brahmin man.
The reason why I relay the fact that he was an orthodox UP brahmin is because it might, just might, have something to do with the fact that one of her twins died within a month of birth.
His family followed the purdah tradition to some extent. Newly married bahus did NOT go out in public, and if they did, they went with the pallou of their sari completely covering their face and in the company of an elder female family member. No salwar-kameez were allowed to be worn.
They were brahmins who did not allow anyone but other brahmins in the kitchen, so the American bahu could not enter. She complained about this but I told her to count it as a blessing.
Anyway, the family was NOT AT ALL happy that their son married an American non-brahmin woman, even though she was of the same religion.
They did not want her in the house and she of course felt uncomfy their with all the bad vibes so she stayed in a guest house that was owned by the family down the street.
During the pregnancy she was totally dependent on what her husband would bring her from the market because she was not “allowed” to go out in public to shop for herself. He hardly ever brought fruits and veggies, he mostly just brought what he brought for the rest of the family – potatoes and other high carb content stuff. She complained also that she did not get enough pure, undiluted milk.
Anyway, I remember her during pregnancy relaying all the stress she was under due to his family and her living conditions (though I don’t know why she tolerated their rules like not going out), and she painted a very bleak picture when telling her tales of woe.
She says to this day that her second twin died to due her mal-nourishment and stress during pregnancy.
16 & 17: If you include most of the second tier states (Karnataka, Tamil Nadu, Punjab, West Bengal, Goa) along with first-tier states, they are more industrialized (more per capita), have higher literacy rates, and lesser density of population (though not the total population as such.
There seems to be more details in this paper.
I would say religion has an effect on this only in direct relation to the large Christian NGO presense in those states. If only there were more Hindu or Islamic NGOs, things would get better?
Actually if you look at the per capita map, the only states that have low per-capita and low Infant mortality are the states with large NGO presence. So may be the money distributed by the NGOs are making up for the low per-capita? If that is the case only one thing matters for keeping the mortality rate low, “MONEY”.
17: According to Religion map of India, Sikkim is predominantly Buddist with Hindus being largest minority.
Strangely this doc from National Family Health Survey (funded by UNICEF and USAID) seems to higher different numbers for J&K.
Need to chime in here that while C-sections save some infants and mothers, they also put women at risk. C-section indications have been a subject of heated debate in the world of women’s health for over 20 years now. When you need a C-section, you really need one, but they aren’t actually the key to improving outcomes.
The US has one of the highest in C-section rates in the world (29.1% of all births in 2004 versus 10.7% in Sweden in 1991) and ranks 26th (last I checked) in infant mortality among the world’s nations. For comparison:
Infant Mortality Rate (per 1,000 live births): United States 10.4 United Kingdom 9.4 Germany 8.5 Denmark 8.1 Canada 7.9 Norway 7.9 Netherlands 7.8 Switzerland 6.8 Finland 5.9 Sweden 5.9 Japan 5.0 http://www.huppi.com/kangaroo/L-healthcare.htm http://www.hsph.harvard.edu/now/dec10/apha_infant.html
So perhaps it isn’t really the best system for India to use as a model. In fact, following in the wake of the USA is likely part of why India has opted for high-tech solutions like big centralized hospitals…
Next: breastfeeding in the first three months provides remarkable protection and perfect nutrition to neonates and reduces or eliminates the risk of water-borne disease. For this reason, breastfeeding exclusively for the first two years of life is recommended by the WHO and every other source for infant-maternal health. It is actually quite rare for a woman NOT to be able to breastfeed. Rather, the social pressures, especially in developing nations, to “be modern” or do as the upper-income women do gets new mothers off-track and they end up in a cycle of buying formula they can’t afford, watering it down to make it go further and/or failing to boil water used to reconstitute the formula due to the cost of fuel.
Last point: the year before conception turns out to be very important nutritionally (especially folate intake and a normal BMI) for producing healthy babies, so improving the lives of reproductive age women is also important, not just those who know they are pregnant.
See this WHO publication for the reasons for infant and maternal mortality: article and the next chapter for recommendations to improve these conditions.
Most of this is NOT high-tech, not even intermediate-tech like ultrasound. And it has to do with the status of women in society and their access to education, health care and nutrition.
These are definitely issues that can be addressed at the community level. Respect and care for women are at the heart of any good maternal-infant health care system.
in apologia for US infant mortality rates, i have heard that one issue is due to premature births being induced for medical reasons (otherwise the pregnancy won’t complete to term). these premies have high mortality rates.
Yes, premies do worst than full-term infants. Maternal health is the number one indicator for preventing premature onset of labor.
The CDC has a section on US infant mortality that’s pretty interesting. Comparing infant mortality from country to country is a tricky business…..
maybe
Why? Other than the preemie issue, is there anything else? It seems pretty easy to count live births and subsequent deaths … can’t see that the definitions change from country to country.
The USÂ’s Poor Performance In Infant Mortality Is Not A Measurement Error is a fairly good discussion of the infant mortality rates and how they compare. And it was just posted yesterday (How verry current we are!)
They look at differences between races/cultures in the US and how that affects birth outcomes. And they refute fairly well any “accounting methodology errors” argument, I think. Then they move on to a fairly tedious argument about racism vs. race as the cause of the stats. But worth a look.
And the CDC and everyone else talks all about maternal health and neonatal in-home care practices as the keys to reducing maternal infant mortality. If they didn’t think the stats were real, they wouldn’t be prioritising these recommendations.
Oh, here an even better refutation (seems to me) of the “they count them differently in other countries” argument… Regarding the USÂ’s High Infant Mortality Rate
where’s razib?
Could another reason for US infant mortality rates be the fashion for shooting up fert drugs and IVF, not culling the resultant muliple fetuses because that would be “against God’s will,” and then intentionally producing premature litters?
Guys, this is an area of controversy in the published literature. I don’t have time, but the CDC website goes into the controversy. There are studies that look at how the data is collected, how age of mother, number of children the mother has, willingness/ability to bring more complicated pregnancies to term, fertility drugs, race/ethnicity, social class, immigration patterns, etc, etc, affect prematurity and other outcomes. gitanjali: I should have been more clear. I’m sure the rate is higher however you measure it. What that means, and why it should be that way are more difficult to discern and that is where ideologues on all sides swoop in……
That link is just further underscores the controversy and difficulty in analyzing the data, gitanjali. Thanks for the link! Interesting.
NPR had this commentary yesterday.
The way Infant Mortality is counted in different countries is different.
In India, if a baby dies before 28 weeks of gestation it is considered to be a spontaneous abortion and is not counted towards Infant Mortality. The reason is babies below 28 weeks of gestation are considered unable to survive (Unviable) in the Indian setup. (Low tech neonatal care, low birth weight.. etc)
In developed countries, the limit is 20 or 22 weeks.
Death of (some of) the babies in 22 to 28 weeks gestational age add up to IMR in developed countries and while it is excluded in the IMR calculation of India.