Avoidable deaths

The next time you read about shocking numbers of child deaths, don’t just blame the hospital staff

The bigger challenge is the failure of the health system before the child gets there.

One fallout of the rash of child deaths at a government hospital in Gorakhpur in August is that the children’s wards in government hospitals across the country have come under greater media scrutiny. There has been a spate of stories in the news over the past month reporting large number of child deaths.

For instance, 90 infants dying in the district hospital in Banswara over the last two months made headlines in Rajasthan. In Maharashtra, there was focus on 55 children dying in Nashik civil hospital in August. The death of about 170 children in four months in a hospital in Jharkhand became news, as did the death of 90 infants over the year in Kolar, Karnataka.

These numbers are alarming. But tragically they are not new. Most of these hospitals have reported equally high number of deaths in previous years as well. Solely focusing on the recent numbers could distort our understanding of India’s challenge of tackling child mortality.

The case of Gorakhpur

Child deaths at government hospitals have been reported as isolated incidents for many years now. So why did the Gorakhpur tragedy attract national attention?

The deaths at the paediatric, neonatal and encephalitis wards of the Baba Raghav Das Medical College and hospital in Gorakhpur on August 10 got national attention because 23 deaths occurred on a single day, coinciding with the disruption of oxygen supply to the hospital. The hospital had failed to pay its dues to the oxygen supply company.

Regardless of whether the oxygen supply disruption was instrumental in causing the deaths, the fact that the hospital allowed supply of oxygen, which is critical to the care of severely ill patients, to run low constitutes extreme negligence. Officials and doctors at the hospital have been charged and arrested in the case.

Medical negligence should be investigated and punished and the spotlight on government hospitals is aiding that. The National Human Rights Commission has issued a notice to the Rajasthan government over the deaths at the Banswara hospital.

But not all cases of high child mortality can be traced to negligence by hospital staff. More often than not, the deaths reflect the failure of the public health system – a failure that cannot be rectified only by holding individual doctors or hospital authorities accountable.

The scale of the challenge

India accounts for 26% of all neonatal deaths – death within the first 28 days – in the world, according to the United Nations Children’s Fund. About two million infants and newborns die every year. With institutional deliveries at almost 80% now in the country, many of these deaths occur at hospitals and health facilities.

In many recent cases where child deaths have been reported, doctors have blamed the cause of death on birth asphyxia, a condition in which oxygen supply is cut off to the infant due to obstructions in its airways. Often news reports have attributed the causes of death to lack of oxygen, drawing parallels to Gorakhpur. Birth asphyxia is very different from disruption of oxygen administered externally from an oxygen pipe or cylinder. External oxygen supply is what is being investigated in the Gorakhpur case.

Doctor have also attributed the deaths to low birth weight and encephalitis. This again, while unfortunate, is not surprising. Unicef has previously estimated that 20% of newborn deaths are due to birth asphyxia, 35% of of newborn deaths are due to prematurity or pre-term birth, 33% are due to neonatal infections and 9% are due to congenital malformations.

Low birth weight and prematurity are outcomes of poor health of the mother. A 2015 study from Princeton University found that 40% of women in India are underweight when they first start their pregnancies. Moreover, they gain only about half their required weight through their pregnancies. Much of this is due to economic and cultural factors like early marriage and income poverty.

The way forward

Many deaths due to birth asphyxia and infection are preventable by improving quality of care during delivery and birth and this requires skilled healthcare workers.

There is a severe shortage of healthcare workers in many parts of India. Take Rajasthan for example. According to the Brooking India Health Monitor, there is a 35% shortage of doctors and 20% shortage of paramedics in the 36 district hospitals in the state. Uttar Pradesh’s 87 district hospitals have a 17% shortage of doctors and 16% shortage of paramedics. These shortages are more severe at the smaller sub-divisional hospitals, community health centres and primary health centres.

Access to public health services also pose a major problem. The Brookings India Health monitor shows that less than half of India’s 6,50,000 villages are within five km of basic health facilities at a sub-centre. Even when people get to sub-centres, primary health centres or community health centres, they are faced with the severe lack of infrastrastructure.

For example, community health centres in Rajasthan have a 6% shortage of functioning labour rooms, 40% shortage of newborn care corners, 25% shortage of facilities with at least 30 beds and 25% shortage of functional operation theatres. Similar shortages are seen in Uttar Pradesh and Jharkhand. Even Karnataka, which is one of the better performing states in healthcare, has shortages of at least 6% when it comes to labour rooms, newborn care corners and functional operating theatres.

The scrutiny of child deaths in India, therefore, has to go beyond remedial measures at tertiary care hospitals where children are taken once they are already severely ill. The public health system needs to be fixed from bottom up.

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