- Email: [email protected]
Anaemia in pregnancy still a major cause of morbidity and mortality: insights from Koppal district, Karnataka, India
ISSUES IN CURRENT SERVICE DELIVERY
Anaemia in pregnancy still a major cause of morbidity and mortality: insights from Koppal district, Karnataka, India Mridula Shankar,a Bhavya Reddyb a Deputy Research Coordinator, Gender and Health Equity Project, Centre for Public Policy, Indian Institute of Management Bangalore (IIMB), India. Correspondence: [email protected] b Research Associate, Gender and Health Equity Project, Centre for Public Policy, IIMB, India
The prevalence of anaemia is unconscionably high and even rising in several states of India, including Karnataka in south India. The distribution of anaemia in the population is gender-biased towards women, with the risk of moderate to severe anaemia being even greater among pregnant women.1 Verbal autopsies by the Gender and Health Equity Project in Koppal, a deprived district of Karnataka, revealed that among 30 maternal deaths analysed, anaemia was an indirect cause of death in approximately 50% of cases and poses a serious threat to maternal survival. Specifically, anaemia either led to congestive heart failure or exacerbated the effects of blood loss in labouring women. Yet, even when anaemia was detected in pregnancy, its contribution to risk went largely unrecognised, except in very severe cases. The complex interplay of factors that increase women’s vulnerability to anaemia became evident in Koppal through the project’s work on maternal safety and rights. Cultivation in this drought-prone agrarian region does not translate into income or food security, with poor families often forced to undertake migratory or daily wage labour.2 Additionally, gender norms play out at the household level through differential access to limited food.3 Impoverishment within a structure of highly stratified gender hierarchies results in women’s lives being marked by early marriage, repeated childbearing, inadequate nutritional intake and undue physical labour. Consequently, pregnancy does not spare a woman from having to perform strenuous work for subsistence. A common symptom of anaemia such as fatigue is often normalised by families and viewed as a natural consequence of the rigours of daily life. Thus, women’s susceptibility to anaemia is as gendered as the response it evokes. The following case studies, involving fail-
ures by both families and health workers, highlight these issues:
© 2012 Reproductive Health Matters
Doi: 10.1016/S0968-8080(12)40669-3
Renukavva Renukavva was married at the age of 15 and got pregnant within a year. Her marital family supported her in accessing antenatal care by accompanying her to the local Primary Health Centre several times during her first and second trimester. Despite appearing weak during these antenatal visits, the Medical Officer did not identify her to be at risk but gave her nutritional advice and iron folic acid tablets, as he routinely did for all pregnant women. At home, Renukavva’s family advised her not to take the tablets due to the common belief that nutritional supplements increase fetal growth, making delivery more difficult. By the beginning of her third trimester, Renukavva developed swelling in her hands and feet. Her family assumed this was normal during pregnancy. Her haemoglobin was tested for the first time in her eighth month at an antenatal camp in her village, which revealed moderate anaemia (8.5g/dL); her physical symptoms were suggestive of greater severity, however. Despite this, the Medical Officer did not acknowledge her as anaemic. Within days, Renukavva developed breathlessness with a cough and worsening swelling. This time the Medical Officer recognised that she was anaemic but attributed her breathlessness to asthma. The injections and tablets (deriphyllin) he administered provided temporary relief, but could not stop her entire body from swelling over the next two days and her breathing from becoming more laboured. Her family decided to take her to a secondary health care facility, but before any action could be initiated, Renukavva succumbed to congestive heart failure. 67
M Shankar, B Reddy. Reproductive Health Matters 2012;20(40):67–68
Gowramma Gowramma was aged 22 and in her fourth pregnancy when she was detected with anaemia. At regular monthly antenatal checkups, she received iron folic acid tablets multiple times, but failed to take them as they caused nausea. From her sixth month of pregnancy Gowramma developed classic symptoms of severe anaemia: swelling in her face, blurred vision, headache, pain in her arms, legs and back, pallor and breathlessness. Her haemoglobin was tested several times during the pregnancy and in the third trimester was recorded as 7.8g/dL. The attending doctor routinely gave her nutritional advice, but failed to recommend a more aggressive treatment regimen. In her ninth month, a frontline health worker recognised the severity of her anaemia and advised her to take iron injections, but did not refer her to an appropriate facility. Gowramma gave birth to a baby girl, but while the doctor was trying to deliver the placenta she began to bleed excessively. Unable to stop the bleeding, he referred her to a higher facility. Here her placenta was removed manually, which controlled the bleeding. However, by this time, her haemoglobin had plummeted to 5.2g/dL. The doctor realised that she needed a blood transfusion immediately, but could do no more than refer her to another hospital, as there was no blood storage unit in his facility. Breathless and in shock, Gowramma did not survive the journey to the referral hospital. These narratives and the other cases we studied indicate that responses to anaemia in a region of high prevalence are undermined by a lack of recognition and acknowledgement of signs and symptoms by primary-level public health care providers and by families. Health care providers draw confidence from successes in managing deliveries of anaemic women. They also tend to overlook the link between anaemia and complications that
might arise during childbirth. Hence, deaths are attributed to post-partum haemorrhage or congestive heart failure without identification of any underlying causes and a failure to triangulate symptoms of fatigue, breathlessness, swelling, and cough. They advise women to eat nutritious food and/or rest, which apart from being grossly inadequate as a treatment measure does not consider the scarcity of food and the strenuous lives that women lead. They also do not seem to find out about and address the fact that women do not always take the tablets they are given. Finally, the absence of treatment protocols and guidelines leads to irrational and ineffective treatment regimens. Anaemia in pregnancy must be tackled through a multi-pronged approach. Government health workers must be trained to identify anaemia from early in pregnancy and to initiate appropriate treatment. Their capacity needs to be further strengthened through institutional support in the form of a regular and sufficient supply of accurate diagnostic tools and comprehensive treatment guidelines. Harmful traditional beliefs that are detrimental to treatment compliance should be addressed through counselling for patients and their families. More broadly, considering the underlying social determinants of health, interventions to establish food security are needed and must be coupled with strategies that strengthen women’s agency within the home. Until women are empowered to claim a fair share of food and household resources, efforts to prevent nutritional anaemia will be inadequate, and anaemia will remain a gendered phenomenon and threat to women’s health and lives. Acknowledgement The Karnataka State Health Systems Resource Centre published an earlier version of this article in the second edition of the Arogyavani Newsletter.
References 1. Fostering Knowledge-Implementation Links Project. Programmatic strategies for tackling maternal anaemia: lessons from research and experience, Policy Brief No.3. Indian Institute of Management, Bangalore; 2012. 2. George A. Persistence of high maternal mortality in Koppal District, Karnataka, India: observed service
68
delivery constraints. Reproductive Health Matters 2007;15(30):91–102. 3. Iyer A, Sen G, George A. The dynamics of gender and class in access to health care: evidence from rural Karnataka, India. International Journal of Health Services 2007;37(3):537–54.
Anaemia in pregnancy still a major cause of morbidity and mortality: insights from Koppal district, Karnataka, India Mridula Shankar,a Bhavya Reddyb a Deputy Research Coordinator, Gender and Health Equity Project, Centre for Public Policy, Indian Institute of Management Bangalore (IIMB), India. Correspondence: [email protected] b Research Associate, Gender and Health Equity Project, Centre for Public Policy, IIMB, India
The prevalence of anaemia is unconscionably high and even rising in several states of India, including Karnataka in south India. The distribution of anaemia in the population is gender-biased towards women, with the risk of moderate to severe anaemia being even greater among pregnant women.1 Verbal autopsies by the Gender and Health Equity Project in Koppal, a deprived district of Karnataka, revealed that among 30 maternal deaths analysed, anaemia was an indirect cause of death in approximately 50% of cases and poses a serious threat to maternal survival. Specifically, anaemia either led to congestive heart failure or exacerbated the effects of blood loss in labouring women. Yet, even when anaemia was detected in pregnancy, its contribution to risk went largely unrecognised, except in very severe cases. The complex interplay of factors that increase women’s vulnerability to anaemia became evident in Koppal through the project’s work on maternal safety and rights. Cultivation in this drought-prone agrarian region does not translate into income or food security, with poor families often forced to undertake migratory or daily wage labour.2 Additionally, gender norms play out at the household level through differential access to limited food.3 Impoverishment within a structure of highly stratified gender hierarchies results in women’s lives being marked by early marriage, repeated childbearing, inadequate nutritional intake and undue physical labour. Consequently, pregnancy does not spare a woman from having to perform strenuous work for subsistence. A common symptom of anaemia such as fatigue is often normalised by families and viewed as a natural consequence of the rigours of daily life. Thus, women’s susceptibility to anaemia is as gendered as the response it evokes. The following case studies, involving fail-
ures by both families and health workers, highlight these issues:
© 2012 Reproductive Health Matters
Doi: 10.1016/S0968-8080(12)40669-3
Renukavva Renukavva was married at the age of 15 and got pregnant within a year. Her marital family supported her in accessing antenatal care by accompanying her to the local Primary Health Centre several times during her first and second trimester. Despite appearing weak during these antenatal visits, the Medical Officer did not identify her to be at risk but gave her nutritional advice and iron folic acid tablets, as he routinely did for all pregnant women. At home, Renukavva’s family advised her not to take the tablets due to the common belief that nutritional supplements increase fetal growth, making delivery more difficult. By the beginning of her third trimester, Renukavva developed swelling in her hands and feet. Her family assumed this was normal during pregnancy. Her haemoglobin was tested for the first time in her eighth month at an antenatal camp in her village, which revealed moderate anaemia (8.5g/dL); her physical symptoms were suggestive of greater severity, however. Despite this, the Medical Officer did not acknowledge her as anaemic. Within days, Renukavva developed breathlessness with a cough and worsening swelling. This time the Medical Officer recognised that she was anaemic but attributed her breathlessness to asthma. The injections and tablets (deriphyllin) he administered provided temporary relief, but could not stop her entire body from swelling over the next two days and her breathing from becoming more laboured. Her family decided to take her to a secondary health care facility, but before any action could be initiated, Renukavva succumbed to congestive heart failure. 67
M Shankar, B Reddy. Reproductive Health Matters 2012;20(40):67–68
Gowramma Gowramma was aged 22 and in her fourth pregnancy when she was detected with anaemia. At regular monthly antenatal checkups, she received iron folic acid tablets multiple times, but failed to take them as they caused nausea. From her sixth month of pregnancy Gowramma developed classic symptoms of severe anaemia: swelling in her face, blurred vision, headache, pain in her arms, legs and back, pallor and breathlessness. Her haemoglobin was tested several times during the pregnancy and in the third trimester was recorded as 7.8g/dL. The attending doctor routinely gave her nutritional advice, but failed to recommend a more aggressive treatment regimen. In her ninth month, a frontline health worker recognised the severity of her anaemia and advised her to take iron injections, but did not refer her to an appropriate facility. Gowramma gave birth to a baby girl, but while the doctor was trying to deliver the placenta she began to bleed excessively. Unable to stop the bleeding, he referred her to a higher facility. Here her placenta was removed manually, which controlled the bleeding. However, by this time, her haemoglobin had plummeted to 5.2g/dL. The doctor realised that she needed a blood transfusion immediately, but could do no more than refer her to another hospital, as there was no blood storage unit in his facility. Breathless and in shock, Gowramma did not survive the journey to the referral hospital. These narratives and the other cases we studied indicate that responses to anaemia in a region of high prevalence are undermined by a lack of recognition and acknowledgement of signs and symptoms by primary-level public health care providers and by families. Health care providers draw confidence from successes in managing deliveries of anaemic women. They also tend to overlook the link between anaemia and complications that
might arise during childbirth. Hence, deaths are attributed to post-partum haemorrhage or congestive heart failure without identification of any underlying causes and a failure to triangulate symptoms of fatigue, breathlessness, swelling, and cough. They advise women to eat nutritious food and/or rest, which apart from being grossly inadequate as a treatment measure does not consider the scarcity of food and the strenuous lives that women lead. They also do not seem to find out about and address the fact that women do not always take the tablets they are given. Finally, the absence of treatment protocols and guidelines leads to irrational and ineffective treatment regimens. Anaemia in pregnancy must be tackled through a multi-pronged approach. Government health workers must be trained to identify anaemia from early in pregnancy and to initiate appropriate treatment. Their capacity needs to be further strengthened through institutional support in the form of a regular and sufficient supply of accurate diagnostic tools and comprehensive treatment guidelines. Harmful traditional beliefs that are detrimental to treatment compliance should be addressed through counselling for patients and their families. More broadly, considering the underlying social determinants of health, interventions to establish food security are needed and must be coupled with strategies that strengthen women’s agency within the home. Until women are empowered to claim a fair share of food and household resources, efforts to prevent nutritional anaemia will be inadequate, and anaemia will remain a gendered phenomenon and threat to women’s health and lives. Acknowledgement The Karnataka State Health Systems Resource Centre published an earlier version of this article in the second edition of the Arogyavani Newsletter.
References 1. Fostering Knowledge-Implementation Links Project. Programmatic strategies for tackling maternal anaemia: lessons from research and experience, Policy Brief No.3. Indian Institute of Management, Bangalore; 2012. 2. George A. Persistence of high maternal mortality in Koppal District, Karnataka, India: observed service
68
delivery constraints. Reproductive Health Matters 2007;15(30):91–102. 3. Iyer A, Sen G, George A. The dynamics of gender and class in access to health care: evidence from rural Karnataka, India. International Journal of Health Services 2007;37(3):537–54.