Bashir offer a counter point on the maternal mortality in Kashmir, saying that data does not support the alarming picture painted by Salman, whose article was posted on the Blog on 29 October and is again reproduced at the bottom
(Mr. Bashir Ahmad Bhat, 46, was born in Malang Pora near Awantipora. He received his early education from a few local schools, graduated from Sri Pratap College, Srinagar, and obtained his Masters and M.Phil degrees in Geography from The Aligarh Muslim University (AMU). After joining Population Research Centre as a Research Officer in 1989, he completed his Masters degree in Population Sciences from the International Institute of Population Sciences, Mumbai, and registered for Ph. D there. In 2000 he joined the University of Kashmir as a Senior Research Officer of the rank of Associate Professor. In the last twenty years, he has completed over 50 Research Projects on Reproductive Health, Rural Development, Human Development, and HIV-AIDS in Jammu and Kashmir. Currently, he is conducting research into why cesarean deliveries are on the rise in Kashmir compared to other parts of the country. Mr. Bhat is one of the members who worked for the preparation of the ”J&K State Human Development Report,” and one of the task force members preparing, “Mid Term Appraisal Report of Eleventh Five Year Plan in J&K.” He has worked with the UNICEF for the conduct of Multiple Indicator Cluster Surveys (MICS) in India, and all three phases of “National Family Health Survey in J&K.” Mr. Bhat is a member of the International Union for the Scientific Study of Population (IUSSP), Population Association of America (PAA), Asian Population Association 9APA), Indian Association for the study of Population (IASP). Ministry of Health and Family Welfare, Government of India, has nominated Mr. Bhat as a member of the for the implementation of Mother and Child Tracking System in India.)
Maternal Mortality in Kashmir
I am writing this in response to an article by Mr. Nizami in Greater Kashmir on 4th November about pregnancy related casualties. There is no denying the fact that Maternal mortality remains a major challenge to health systems worldwide but the figures related to pregnancy related deaths and maternal Mortality rates in Kashmir are not correct and I was expecting any top official from Department of Health and Medical education to react to this article. As there were no reactions from the State so as a student of Demography, I thought it prudent to react to some of the figures quoted in the article.
Estimation of maternal mortality rate is a bit problematic because of non availability of reliable data and because it is a rare event and is calculated on the basis of per one lac live births. Due to these problems estimation of MMR is generally attempted at Country or State level. Though various national and international agencies attempted to calculate MMR for various states in India but they also could estimate MMR only for bigger States like UP and Bihar. SRS has estimated an MMR of 254 for India with a high of 480 for Assam and 312 for Bihar but it could not calculate it for States with a population of less than 2 crores again because of methodological issues. So one has to be very cautious while estimating MMR for smaller areas.
As the current population of J&K is about 1.2 crore and the crude birth rate in the State as per the most reliable sources is 20 per thousand, this would give us about 2.5 lacs births each year. If we accept Mr.Nizami figure that about 6,000 mothers die in childbirth and allied complications of pregnancy in Kashmir, then Jammu and Kashmir has a maternal mortality rate of 2400, which is the highest MMR in the world. The recently published article in Lancet shows that the MMR in the world as a whole in 208 was in the range of 221-289 with Afghanistan having the highest MMR of 1575. Most of the very poor countries in Africa also have MMR of less than 700.
Several factors that are associated with increased risk of maternal deaths are age at marriage/delivery, frequency of births, spacing between births, economic conditions, utilization of antenatal care, post partum care an, institutional delivery services etc. and J&K has achieved a remarkable success in areas that contribute to low MMR. The latest credible surveys conducted by Ministry of Health and Family Welfare (NFHS-3) in the State have shown that about 85 percent of the women utilize antenatal care services as compared to 73 percent in India. Not only this women n Kashmir visit an antenatal clinic more frequently than their Indian counterparts. This is quite contrary to what figure quoted by Mr. Nizami in the article. J&K also has one of the highest institutional delivery rates in India. As per the latest data available about 70 percent of the deliveries take place in health institutions compared with 50 percent at the national level. Higher percentage of women in J&K are also utilizing post partum care services than in most of the States which have a higher MMR. Studies across the globe have shown that MMR is high in societies which have a high birth rate, high infant mortality rate and high death rate. All these indicators are low in J&K as compared to India as a whole. For example J&K has a CBR of 18.8/1000, CDR of 7.4/1000 and IMR of 49 as compared to 22.8/1000 live births.
Kashmir also has witnessed an alarming increase in the median age at marriage. Child marriages are no longer in vogue. Finally when we look at our health care system, I feel though a lot needs to be done to improve the quality of maternal services of public health institutions in the state but the present scenario is not so ugly as we do observe in Bihar, UP, Jharkhand, Rajasthan, Orissa, Assam, Andhra Pradesh. Thus if all the determinants of MMR are far better in J&K than in most of the so called BIMURU States, then let the readers decide should we expect a MMR of 418 in Kupwara, 774 in Islamabad, 2182 in Baramulla, and 6507 in Bandipora.
Reliable estimates based on the information collected from various sources reveal that MMR in J&K has drastically declined during the last 10 years thanks to better availability and utilization of antenatal, natal and post natal care services by Kashmiri women. The MMR in J&K as per the data available from the death records of Directorate and Economics and Statistics after necessary adjustments works out to be 100. The internal Health Management Information System of the National Rural Health Mission also collects and maintains information related to Maternal Deaths has not been in a position to record many such deaths because of low prevalence. Even though the Directorate of Family Welfare offered a cash incentive to Female Health workers at Sub Centres/PHCs for reporting any maternal deaths but there was not much increase in maternal deaths. This all indicates that the situation pertaining to maternal health is not so alarming and disturbing as portrayed by Mr. Nizami.
http://kashmirforumorg.blogspot.com/search?q=nizami
Alarming Maternal Mortality Statistics in Kashmir
Salman goes where few Kashmiris have in describing alarming statistics related to deaths among women while giving birth to young ones in Kashmir
(Mr. Salman Nizami, 25, was born in Banihal tehsil of District Ramban. He completed his graduate degree in mass communication and journalism, and joined journalism in 2004. He began his professional life at The OUTLOOK magazine as a columnist, and then started writing for Greater Kashmir, Kashmir Times, Times of India, The Hindu, Asian Age, Statesman, Rising Kashmir , JK Reporter. Mr. Nizami later joined SAHARA television in New Delhi as Desk Editor, and rose to the position of Group Editor of The Rastriya Sahara. He is currently working as a Editor-in-Chief of The Revolution newspaper published from Jammu and Kashmir, Sahara television as Desk Editor and Resident Editor of MID-DAY covering Upper North India including J&K. He is also active with UNICEF India and the Hungary World (NGO) as Media advisor. In that role, he has travelled widely investigating on new developments in the media industry, taking a special interest in child problems including labour, marriage, poverty, education, etc. He is one of the first journalists to research and write extensively about the child growth in Jammu and Kashmir.)
Maternal Mortality in Kashmir
Kashmir has seen thousands of civilian deaths since 1989 due to the conflict. Men, women and children lost lives, still life continued to roll with the pace of time. But deaths of women caused during childbirth have become more alarming in Valley. As every year about 6,000 mothers die during childbirth and allied complications of pregnancy.
According to UNICEF, figures illustrated indicate that poor women have been left behind by state’s economic boom, entrusted to lift thousands of people out of poverty. India’s maternal mortality rate stands at 450 per 100,000 live births, against 540 in 1998-1999. As per a study conducted in September by the team of Dr. Meenakshi Jha from Centre for Disease Control and Prevention, of 5,476,970 population, in four districts, 357 women of reproductive age (15-49) died, and 154 died of complications during pregnancy, childbirth or the puerperal period. Maternal Morality Rate (MMR) in those four districts was 418 in Kupwara, 774 in Islamabad, 2182 in Baramulla, and 6507 in Bandipora.
Baramulla district showed the highest mortality risk ever recorded in human history, with 54% more than half of the women of reproductive age – died during 1998 and 2003.The causes of deaths were analyzed mainly in two parts: direct and indirect. Direct causes include haemorrhage, obstructed labour, cardiomyopathy, sepsis, obstetric embolism, and pregnancy-induced hypertension, whereas indirect causes were tuberculosis, malaria, and obstetric tetanus. According to the survey women who died port-partum were 64% within 42 days. 56% of these women died in the first 24 hours, other socio-economical, geographical and cultural factors contributed to the high mortality ratio. 60% Kashmiris do not have access to basic health services. Even 40% Basic Package of Health Services (BPHS) offers basic emergency obstetric care in Valley, only 7% have the capacities to provide comprehensive emergency obstetric cases according to the Ministry of Health. Most of the professional ante-and postnatal cares are used by only 20% of all pregnant women. Lack of awareness and transportation problems especially in mountainous districts have limited access to Basic Health Care Centres. Sogam basic health centre had two mini-vans that functioned as ambulances, and it took about three to four hours depending on the roads or weather conditions to haul the patient(s) to the provincial hospital in Kupwara. In accessibility to the advanced health care is one of the main barriers for pregnant women. When I was travelling to districts such as Tangdar, Teetwal, Ramhal, in mid-May, the effort was thwarted by natural disasters such as floods and avalanches, thus failed to reach the areas. There was no doubt that any emergency patients who needed the advanced care beyond the basic health care level from those effected areas could not travel to Kupwara.
The mortality rate in Kashmir would not improve unless the availability, accessibility and awareness of Kashmir people improve. Much mortality on both mothers and children occur during home births. Home births are widespread especially in rural areas where roads are tough and people are more conservative. Some of the women I have interviewed in the hospitals have told me that male members of the family such as husbands and fathers refuse to send their wives or daughters (in-laws as well) to health facilities because of cultural and religious reasons create difficulties in serving people. In Trehgam and Kalaroo, most of the women are not allowed to travel on their own, and if they have to, they need to be accompanied by Maharam, a legal guardian, a male member of the family. Even if women do want to go to the local health facilities, if husbands or fathers – patriarch of the family – does not allow, they would not be able to see doctors or skilled midwives. As Dr Meenakshi’s report points out, inability to leave the home without the permission or escort of a male relative is a big barrier for women to access proper health care in bigger towns. Chronic poverty and limits on education are also important factors in high maternal mortality rate in Kashmir.
My visit and experience on Kashmir maternal mortality tells a story of a woman who died of port-partum complications due to tuberculosis, the disease widely known as the product of poverty. Her death could have been prevented if proper family planning and prenatal healthcare were provided. The story follows her from the hospital when she was recovering from her delivery to the funeral in her village. Through the journey of following this woman, I documented the process of how a woman could lose her life from such unbelievable causes. When I first met Khalida , a very thin, fragile looking 26-year-old Kashmiri woman from a remote village at the recovery room at Uri Hospital in Baramulla district, she was lying on her bed next to her 75 year-old mother-in-law, Jabeena, and her unnamed son. It was five days after the caesarean section and she did not seem to have the energy to move, she rose slowly as I walked in. The nurse explained to me that she had tuberculosis. Her thinness was from the disease. She looked sick, but not too much ill. The baby was the second child as her first child died in childbirth a few years ago. Two days later, she began to suffer from fever. Doctors and nurses injected medicine and provided oxygen even though the oxygen machine went occasionally out of power due to lack of electricity. One of the doctors said, “I am very worried about this patient. I need some more blood for her, but there’s no more blood in the blood bank. The family cannot afford to buy the blood.”
After one week, she was transferred to the general patients ward from the maternity ward in the same hospital. It turns out she has been suffering from deadly complications after the delivery, meningitis, hypothermia, and toxoplasmosis. She was barely conscious in a room filled with other female patients and visitors. The family could not get the blood, but one pack of blood did not seem to have been the remedy. Her conditions have deteriorated, and she constantly moaned in pain. Nurses were injecting painkillers so much; she had a string of injection marks on her left arm. She kept groaning, and the baby was crying. Jabeena, the mother-in-law, was rocking the baby. She said, “We don’t even have money to buy milk. My son is jobless. What can we do?” Later in the afternoon, the doctor decided to move her to another room and put the oxygen mask on her. However, by that point, doctors were sceptical about her conditions. “The condition is very poor. I think she will die,” one of them said. The mother-in-law did not say too much. It seemed that she had to accept the destiny or too tired to tend the bed. The husband, Qamar Din, dropped in the room and called her name. “Khalida, hey Khalida.” He swayed Khalida’s face left and right a bit, then covered his face with hands. He walked outside.
The oxygen and the pulse level were dwindling over time. By 8:30 pm, Khalida stopped breathing. Qamar Din and hospital staff were absent. Jabeena, who was sitting on the bed next to Mustafa with her grandson, slowly rose and approached to her. She was already dead. “Khalida, Khalida.” Jabeena called her name a couple of times, tapped her both cheeks a bit, and then confirmed her death. She closed her eyes and called the caretaker. The hospital staff came. One doctor said, “This is the problem of Afghanistan. There was no way we could cure her.” The caretaker tied Khalida’s face and toes with white linen straps, and moved her on the stretcher. There was no morgue or freezer for dead bodies in the hospital. Her corpse was kept in an empty patients’ room. On next day, Jabeena, Qamar Din, and a couple of relatives decided to carry the body back to their village. They knew that the roads were closed from the area called Kreeri, about few hours from Uri, due to rains. They went to the point in which cars could no drive any longer, then decided to walk to the village for two hours: which was common for Kashmiris in rural areas. A couple of workers from a nearby bridge construction came to assist them. After crossing landslides and tough roads, they reached the house. They slowly laid the stretcher down in the living room. Qamar Din began crying as relatives and workers laid down. The next morning, family members including Jabeena began their normal day. Khalida’s baby was in the hands of Jabeena as she put a pacifier on his mouth. Women baked bread and prepared tea. They seemed to accept death and life and moved on pretty quickly. Khalida is not the only mother who died in childbirth but is an example of thousands of women who lost their lives in child birth.