By: Salman Nizami
Kashmir has seen thousands of civilian deaths since 1989 due to the intensified insurgency. 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 in 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 Center for Disease Control and Prevention , of the 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. MMR in those four districts was 418 in Kupwara, 774 in Anantnag, 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 pregrancy-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-economic, geographic 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 Centers. Sogam basic health center 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 traveling 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 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 cesarean 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 agony of her pains. 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 skeptical 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 p.m., 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.