Hospital Confronts Childbirth Deaths in Mumbai Slum

Divyakant Solanki/European Pressphoto Agency A view of the Dharavi slum in Mumbai, Maharashtra, on July 31, 2012.

DHARAVI, Maharashtraâ€" Elizabeth Nadumani, 40, pulled up the bottom of her sari as she stepped over a hole filled with milky fluid and floating debris toward the entrance of a shack in Mumbai’s Dharavi slum. Inside the tiny home, a 23-year-old mother named Chaya, who goes by one name, breastfed her one-month-old son. When Ms. Nadumani parted the thin curtain that served as a door, Chaya covered her breasts and straightened her matted hair. In hushed tones, Ms. Nadumani reminded the young mother of her son’s pending appointment for a polio vaccination, and then slipped her a package of government condoms.

“Just a reminder,” Ms. Nadumani said quietly in Marathi, “because Vishnu is your third,” she said of Ms. Chaya’s son.

Ms. Nadumani is a paid volunteer at The Urban Health Centre for Sion Hospital, in central Mumbai, and one of the unsung heroes in India’s battle against maternal and infant mortality. The center where she works is a small building commonly known by residents of Dharavi slum as Chhota Sion. Just a dusty five-minute walk from Sion’s larger government hospital, Lokmanya Tilak General Hospital. The space is easy to miss, scattered among the chai stalls, dumpsters, and repair shops that currently shield Dharavi’s complex web of poverty from the bumper-to-bumper traffic of Mumbai’s Eastern Expressway. But to the new mothers and soon-to-be mothers living in Dharavi who rely on Chhota Sion for free prenatal and early infancy check ups, the building and its staff represent, especially during that fragile period from conception to a baby’s first steps, the very center of their lives.

It is no secret that high maternal and infant mortality rates continue to haunt the vast legions of India’s poor. According to World Bank statistics, 220 mothers died for every 100,000 live births from 2008-12 in India. As a point of comparison, China’s maternal death rate was 37 out of 100,000 live births during the same period, or one-fifth India’s rate. Babies were not much luckier during those years, as India lost 47 out of every 1000 infants, or close to four times worse than China’s rate during that time.

The fight to give birth safely, is among many obstacles facing women in India, where reports of rape and acts of female infanticide continue to dominate headlines. Doctors insist that the problem requires more public attention and there is a dire need to replenish outdated equipment, expand existing work spaces, and hire more qualified staff in poorer communities for making childbirth a safer experience. For evidence, they say, look no further than the slums of Mumbai.

“Mumbai should be seen as a beacon of hope for India in terms of improving the safety of childbirth,” explained Dr. Arun Nayak, 50, an obstetrician and professor at Sion Hospital. “But because of the density of population here, many total lives are still lost, and that means that we still have work to do.”

Dr. Nayak, who heads up a commission on maternal deaths for Sion Hospital, estimates that roughly 15,000 births have occurred in his ward this year, and somewhere between 50 and 60 mothers have died. These estimates would be much closer to the slightly better maternal mortality rates of China than to those of the rest of India. According to the most recent statistics from the Indian government’s Planning Commission, the state of Maharashtra ranked third best among Indian states in maternal and infant mortality rates between 2007 and 2009, behind Tamil Nadu and Kerala, but Dr. Nayak’s estimates would eclipse even those state figures, and by a considerable margin. He attributes this success to the wide range of resources available to patients at Mumbai’s larger government hospitals, where the equipment is modern, resources are plentiful, and medical teams are fairly large.

“We have resources here in Sion, like a large blood bank,” Dr. Nayak said. “But many peripheral government hospitals and rural hospitals quite simply do not.”

According to Dr. Nayak, poorly financed government hospitals located outside the city limits are to blame for the majority of deaths he sees in the obstetrics wing of Sion. Peripheral hospitals, as doctors commonly refer to them, often lack space or sufficient manpower, making it extremely difficult for workers to deal with the potential complications that can arise during childbirth. When a peripheral hospital cannot sufficiently care for a patient, Dr. Nayak explained, the expectant mother is then transported to a larger government hospital like Sion, where her ambulance can sometimes spend hours stuck in traffic along the way. The length of this trip often amounts to a dangerous waiting game.

“Sometimes at a peripheral hospital there is only one person caring for a hundred patients at once,” Dr. Nayak said. “There is only so much these doctors can do to help.”

Divyakant Solanki/European Pressphoto Agency A group of children playing in Dharavi slum of Mumbai, on July 31, 2012.

On a recent afternoon, Dr. Nayak was forced to perform an emergency operation on a woman who had incurred life threatening vaginal injuries while giving birth in a peripheral hospital located in the city of Bhiwandi, nearly 40 kilometers, or 25 miles, from Sion. The woman, who was not named out of respect for her privacy, was treated in a ward filled with 10 other pregnant women. To anyone who has seen a maternity ward of a private hospital, the idea of giving birth in a cramped room with other women might seem extraordinarily uncomfortable. But Sion is among the most spacious government hospitals available to women in Mumbai. And Dr. Nayak believes that space helped to save his patient’s life, and the life of her child.

“We lost four women here this August that were transferred from peripheral hospitals,” Dr. Nayak said. “She became uncomfortably close to becoming the fifth.”

Space is a precious commodity in a city of 18.4 million residents, and more of it cannot be simply willed into existence Chotta Sion was built over two decades ago as Dharavi swelled to become one of the most populated slums on the planet. A more direct means of providing health care to residents was needed to clear room from its larger parent hospital, Lokmanya Tilak General.

One wall in the health station bears signs that detail the sobering statistics of Dharavi slum’s ever-surging populace, setting the stage for that herculean task of caring for all of them:

“Total Population - 87,388, Birth Rate - 13.89%, Death Rate - 5.24%, Infant Mortality - 27.14%, Maternal Mortality - 0.06%.”

Monitoring those 87,388 people is the team working out of Chotta Sion’s primary health post, a rectangular room saturated with fluorescent lights and stacked to the ceiling with boxes of tuberculosis medications. Overseeing this room is Dr. Girish Gaikwad, 29, an energetic post-graduate doctor who, along with immunizing patients and attending to emergency cases, gives direction to the many paid volunteers like Ms. Nadumani, who go door-to-door checking on people in Dharavi during pregnancy and early infancy.

“If someone is pregnant, the volunteers find out and advise the mother on where to go and what to do,” Dr. Gaikwad said.  “If the women remain reluctant to seek medical help, they will counsel them on the benefits.”

Ignorance and superstition are major obstacles to overcome in rural villages, where dangerous home deliveries are commonplace. But Dr. Gaikwad estimates that 90 percent of expectant mothers in Dharavi are booked for hospital stays well in advance, a testament to the goodwill and strong communication lines that have been established here between medical staff and the local community. The process of registering patients for delivery begins as soon as one of the door-to-door volunteers learns of a new pregnancy. A file is then prepared for the mother-to-be, charting her progress leading up to and after the moment of childbirth. Along the way, crucial medicines and vitamins are freely distributed to balance out deficiencies in the diets of women who oftentimes cannot afford adequate nutrition in their daily meals.

While another post-graduate will eventually replace Dr. Gaikwad, Ms. Nadumani and her colleagues have been serving their community for two decades now.

“I remember when I first started these shifts, 20 years ago,” Ms. Nadumani said. “I had to warn so many more women about the dangers of passing HIV/AIDS to their babies back then.”

She is satisfied that her efforts in the community are paying off not because of what shows up in statistics, but because of the reduction in HIV-positive patients she now witnesses first hand.

“People listen to me because I live here,” Ms. Nadumani explained. “I’m part of the neighborhood.”

Today, however, Ms. Nadumani’s most important duty is not educating people about a disease like HIV/AIDS, or even advising pregnant women, but helping to control the population itself. After women give birth to a second child, Ms. Nadumani and the other volunteers urge them to try using condoms in the hopes of reducing the birth rate. There are certain stigmas against using condoms, however, and these women can instead opt for temporary or permanent sterilization. The government then compensates those who apply for such measures with checks of 500-1000 rupees ($8-$15). The community here can ill afford any increases to its 13.89% birth rate.

While Chhota Sion has made impressive progress in improving the safety of childbirth in Dharavi, workers fear that they are working against the clock: the birth rate of 13.89%, for example, indicates the percentage rise of new people born into the slum each year, and the death rate, 5.24%, indicates the numbers of human beings taken away from it. In concert, those numbers paint a picture of a population that increased roughly 8.5% percent over the course of the last calendar year, not to mention migration to the area. Should that trend continue apace, Sion could eventually find itself stretched as thin as those peripheral hospitals mentioned by Dr. Nayak, erasing what has become a bright spot in the war against maternal and infant mortality. It is an outcome that everyone who works here is eager to avoid.

Michael Edison Hayden is an American writer currently living in Mumbai. You can follow him on twitter @MichaelEHayden