A mother’s trials: System falls short

Limited medical resources, long transit times and poor quality of care are leading to preventable maternal mortalities in the state.

Hubballi: Everything seemed to be going according to plan when Nandini, a 27-year-old college lecturer entered the labour ward of Ballari District Hospital on November 11 at 9 pm.

By 10 pm, she had delivered a baby boy, and the doctors informed her family that the C-section was successful. Both the mother and baby seemed fine.

Nandini was shifted to the ward at around 10:30 pm. She breastfed the baby and complained of weakness. The doctors administered a saline bottle close to midnight. This was when her health began deteriorating. “Six doctors and nurses tried to revive her at the ICU. At 2 am, they declared her dead,” says her brother Veeresh. 

A few days before Nandini’s demise, Lalithamma of Ballari’s Basarakoda suffered a similar fate. At 5 am on November 9, she delivered a healthy baby boy after a caesarian surgery. 

“Just 10 minutes after administering intravenous (IV) fluids at the district hospital, she suffered a seizure. Then, she was shifted to the ICU of Ballari Medical College and Research Centre, which has better facilities. She battled for life for two days. Doctors informed us that she died of multiple organ failure,” says her husband Manjunath.

In 45 days, two major public health institutes in Ballari have witnessed the death of six mothers under similar circumstances.

The government and doctors at the institutes blamed the supply of substandard Ringer’s lactate solution IV fluid by a West Bengal-based pharmaceutical company for the deaths. However, activists and experts believe that substandard medicine is part of a systemic issue that is leading to maternal mortalities.

Severe anaemia in expectant mothers, post-partum haemorrhage, pregnancy-induced hypertension, sepsis, stunted growth and unscientific abortions are some common issues that cause maternal death.

Other factors like poor nutritional intake, limited access to medical facilities and poor adherence to medical recommendations also contribute to the issue. 

The state’s maternal mortality ratio (MMR) has declined over the years. Karnataka Health Department documents say that the strict implementation of antenatal care (ANC), improvement in institutional deliveries, distribution of iron and folic acid tablets, follow-up of high-risk pregnancies and provision of postnatal and newborn care have substantially decreased the MMR from 178 per lakh live births in 2007-09 to 64 in 2024, as against the national average of 93.

Karnataka has also achieved the Sustainable Development Goal (SDG) set by the United Nations to restrict MMR below 70. 

However, activists point out that Karnataka is the worst performing among the five southern states — Kerala has achieved 19 MMR, Tamil Nadu (54), Andhra Pradesh (45) and Telangana (43). In the last five years, Karnataka has lost as many as 3,364 new mothers.

“A majority of maternal deaths were preventable in Karnataka, had we learnt lessons from the previous incidents,” says activist Teena Xavier of Karnataka Jan Arogya Chaluvali.

Working in the backward districts of north Karnataka over the last 35 years, she says there has been a substantial increase in public health institutes in Karnataka, but the state is still missing trained human resources and adequate medical equipment, particularly in primary and community health centres.

Non-availability of doctors, poor connectivity to referral hospitals through ambulances, inadequate availability of blood, and poor allocation of funds to improve medical facilities have also worsened the situation. 

Tina cites the instance of Mariyamma (23), from Raichur’s Sangapur. “This was in 2018. Mariyamma developed labour pain and was rushed to the nearest PHC. As the doctor was not available, she was taken to Manvi Taluk Hospital. By then, she began bleeding. But the taluk hospital neither had blood nor a doctor. She was then taken to two private hospitals in Sindhanur but was refused admission due to complications. After nearly 10 hours in transit, she reached Raichur Institute of Medical Sciences, where she lost her life after delivering a baby,” says Teena.

In terms of connectivity and referral, it seems little has improved over the years. Families continue to run from one hospital to another, hoping for safe institutional deliveries. Just last October, Sindhanur taluk recorded four maternal deaths.

Bengaluru-based activist Akhila Vasan says that since 2005, the Union government has made it mandatory to audit every maternal mortality. A committee headed by the deputy commissioner should thoroughly investigate the reasons for the deaths and fix the fault lines. But instead of taking these review meetings seriously, the stakeholders usually end up finding faults with Asha workers, medicines and patients who did not take prescribed medicines on time.

“There have been hardly any steps taken to fix the broken system,” she feels.

Doctors, Asha workers and activists from across the state, who have attended several such review meetings, say that monthly maternal mortality meetings have lost purpose and focus on finding scapegoats.

Akhila adds that the government needs to ensure full-time specialists are appointed at taluk hospitals, which are the first referral units. “What is the point in asking women to deliver in hospitals if there are no qualified specialists?” she asks.

As per the Health Management Information System (HMIS), 99.9 per cent of deliveries took place in institutions in 2019-20, out of which 61.2 per cent of deliveries took place in public health facilities.

There has also been an increase in the number of sub-centres, PHCs and Community Health Centres since 2005. As per the Rural Health Statistics report released in 2022, rural areas in Karnataka have 9,188 sub-centres, 2,176 PHCs, and 189 CHCs. This is over the required 8,024 sub-centres, 1,318 PHCs and 329 CHCs. 

In urban Karnataka, there is a 38 per cent shortage of PHCs against the requirement of 575 centres. In addition, there are 26 district hospitals, 150 sub-district hospitals and 24 government medical colleges.

However, many institutions grapple with a shortage of gynaecologists or obstetricians, anaesthetists, nurses, midwives and other specialists, making these options non-starters for patients in the state.

This issue is underlined by data in the NFHS-5 report, which states that Karnataka has a 53.26 per cent gap in the human resources in public health institutes. Of the required 6,497 MBBS doctors, the state has only 3,281.  

The state has only 2,971 out of 5,091 specialists including gynaecologists. There is a gap of 18,342 staff nurses and 13,405 multi-purpose health workers, all required for the smooth functioning of health facilities.

Santosh Sogal, a researcher at the Institute of Public Health has been studying access to maternal health in Karnataka. He observes discrepancies in the number of PHCs in south, central and north Karnataka.

In the 18 districts of south and central Karnataka, there is one PHC for every 13,641 people. On the other hand, there is one PHC per 23,734 people in 12 districts of north Karnataka.  

“The fact that eight high-priority districts selected by the Union government to address maternal mortality are located in North Karnataka highlights the need for targeted interventions and equity-focused attention,” he says.

Lost in transit

Another major challenge has been identifying the exact area with high maternal mortality rates. Currently, a maternal death is registered in the referral hospital and not at the domicile of the victim. As a result, the numbers are high in districts with major hospitals while patients’ districts of origin might have lower numbers.

“Pregnant women are bypassing PHCs due to the over-medicalisation of maternal healthcare and the unavailability of basic laboratory services. This is placing an additional burden on taluk and district hospitals, as well as medical colleges, which are intended to provide specialised care,” Santosh says.

Santosh, who has worked for the National Health Mission in Dharwad, says that the district has ranked among the districts with high MMR over the last 10 years. Data shows that the district registered 93 MMR annually in the last decade. “The district has not shown consistent or significant reduction in MMR,” he says. 

About 60 per cent of maternal deaths that took place in Dharwad hospitals are referral cases, with patients coming in from neighbouring districts. As the tertiary referral hospital, the most complicated cases from Belagavi, Uttara Kannada, Haveri, Gadag, Koppal and Bagalkot are referred to the Karnataka Medical College and Research Institute, Hubballi. 

Shashi Patil, the Dharwad district health officer, says that they conduct regular auditing to identify PHCs and regions from where the district gets a high number of patients. During division-level meetings, they share the data with other districts so that preventive measures can be undertaken.

Under-reporting is also a common problem as mothers who succumb to health complications post-delivery are classified under ‘general death’ at the referral hospital and not as maternal death.

“This is resulting in the administration being unable to link the chain of treatment and fix the responsibility,” says Teena.

The director of Raichur Institute of Medical Sciences, Ramesh B H, provides a glimpse into the ground reality: RIMS handles nearly 30 complicated maternal cases every day of which 12 to 15 need C-sections. Almost 90 per cent of these cases are referrals from Yadgir, which lacks a multi-speciality hospital. “We also get cases from Telangana and Andhra Pradesh. For an institute which is already under stress due to the lack of human resources and limited medical facilities, the additional cases are taking a toll on the staff,” he says. 

RIMS medical superintendent Bhaskar K adds that the issue can be addressed only if the taluk-level hospitals and PHCs are strengthened.

“Most lives are lost in transit. The minimum travel time to RIMS from the taluk headquarters is around 90 minutes to two hours. We can save lives if at least the taluk hospitals are well-equipped and have enough doctors and blood availability,” he says.

Ignorance among expectant and new mothers about nutritional intake and medicines also contributes to the crisis. 

Anaemia 

Anaemia is the single largest reason for birth-related complications among women, especially those in rural areas.

Data from the NFHS-5 shows an increase in the incidence of anaemia among pregnant women in rural Karnataka. About 32 per cent of the pregnant women between the ages of 19 and 49 are anaemic in urban areas. In rural areas, 50.6 per cent of women in this age group are anaemic.

Nagalakshmi Ballari, the secretary of the Asha Workers’ Association, observes that a majority of women who become pregnant for the first time are anaemic in rural Karnataka. “There is ignorance among the new mothers regarding the importance of taking iron tablets and other medicines provided along with the ‘Madilu Kits’. There have been instances where pregnant women refuse to consult with doctors during their antenatal check-ups,” she says. 

Her claims are backed by data from the NFHS-5 report, which shows that over 29 per cent of patients did not complete four antenatal care visits. Less than 44.7 per cent of pregnant women took folic acid tablets for 100 days and just 26.7 per cent took the 180-day course.

Tanya Seshadri, a Chamarajanagar-based community health practitioner and researcher, says the time has come for the state to move beyond merely recording MMR numbers.

“We must locate cases of mothers in critical conditions or high-risk pregnancies. The government is patting its back looking at the MMR statistics but we need to address the pregnant women’s health issues at the grassroots,” she says. 

She provides the example of Chamarajnagar, which is counted among the districts with the lowest MMR. Of the four maternal deaths last year, two were women from tribal communities, whose population stands at 30,000 in the district.

“Many times, medical help does not reach women in remote areas and when they come to bigger cities like Mysuru, they are not properly guided at overcrowded hospitals. Due to poor connectivity, a majority of women do not visit hospitals for regular antenatal care visits,” she says.

Currently, government data shows that the average out-of-pocket expenditure for delivery at public hospitals is Rs 5,000 in urban and Rs 4,900 in rural areas. 

She feels there is a need to reconsider our maternal programmes while centring the geographical and socio-economic realities of the patients.

“There should be zero out-of-pocket spending from the economically weaker section of society to avail basic facilities,” she says.