Yes! I have good news!!
Dr. Shantanu Abhyankar, Wai
Wah Taj! The huge, majestic edifice in white marble stands shimmering. I'm in a trance. What line and proportion, how simple yet elegant, what enchanting, heavenly beauty! One sees it again and yet again but always pines to visit again.
All of a sudden the spell is broken. Something stirs deep inside me and surfaces. The calm cracks. I think of Mumtaz Mahal and also of the several other mothers who died in labor. All of a sudden, I see the Taj, not as a timeless ode to love but as a memorial, a 'vrindavan', to all those who died in labor including my grandmother's grandmother's aunt ('kaku').
A hardcore obstetrician like me can't be but become restless in the shadows of the Taj.
Mumtaz Mahal died (1631), just 38, at Burhanpur, in her 14th pregnancy. Married at nineteen she bore 14 children in 20 years. The labor lasted for over a day. She delivered a girl child, later named Gauhar Aara Begum. Mumtaz died of severe postpartum bleeding. The Taj Mahal was built 22 years later.
Postpartum bleeding happens to be the commonest reason for maternal death to this date. Pregnancy induced hypertension, unsafe abortions and infections contribute as well.
A tale of one such fatal sepsis had left an ugly scar on my grandmother's psyche. Gladdened to know of my choice to become an obstetrician, my demented, grandmother narrated it to me. It was her grandmother's aunt's, (Kaku's), tale. My great great grandmother's aunt, she was.
She delivered at home. It was arduous. She was shouting and struggling. She was crying and grunting. Trying to bear down all the while yet to no avail. The baby's head was stuck at the perineum. Midwives were summoned from the villages around. They couldn't manage it. The men gathered and failed. The closest hospital was 50 miles away and the fastest mode of transport was a 'chakada', (an ox cart drawn by one ox). But the ox was ailing and weak for any pulling. People tried massaging and rubbing up stronger contractions, they boxed, they pushed, they kicked the rotund tummy but the head remained stuck. Finally a midwife broke her bangles, and with a particularly sharp shard, gave a cut on the perineum. This worked. kaku delivered. But the baby was still born. The dead child was hurriedly buried in the backyard, placenta and all. Not a tear was shed. The relief of delivery overshadowed any grief about the stillbirth. Folks disappeared, men back to the farms and women to the kitchen.
However, kaku was absolutely drained from the prolonged parturition. She started running fever the next day and chills and fever worsened over the week. Herbal fumes, homemade poultices, sitz baths and ointments for the wound were all tried. Holy ashes, black threads, amulets and incessant chanting of the 'shantipatha' were next. None was to enter the room without purifying one's feet by sprinkling gomutra (cow's urine), from a coconut shell placed on the 'umbara' (threshold), with a Neem twig. But she quickly developed febrile delirium and became incoherent in her speech. A 'chunabhatti', kiln to generate fumes from slaked lime, was set up. The wound was fumigated with these fumes. The swinging temperature just worsened. The wound was now tense and angry red. From the septic tissue oozed a frothy, putrid discharge with an obnoxious odor. The stink engulfed the house and it became impossible to even approach kaku, forget nursing her wound. She was left alone. Puking and peeing and defecating, all in that corner. Soon one night, her abdomen bloated up and she started bleeding. The bleed stopped only with her breath. Kaku was no more.
Her mortal remains were consigned to flames in the mango orchard. Uncle built a platform, placed a 'Tulsi vrindavan', (decorated garden pot specifically for the Tulasi plant; often nurtured in memory of a dear, revered person). The womenfolk bestowed on the place some pure and holy qualities.
Today 'Kaku's vrindavan', is a busy bus stop on a highway. Across the street is a government hospital. A well equipped, well manned ambulance is always there, awaiting the next emergency.
Inexplicably, my grandma seems to have struck a good equation with her grandma's aunt. They must have gelled well, been really close. This death was etched on my grandma's pubescent mind.
She initially believed kaku was lucky, for she died a 'saubhagyawati' (with her husband alive). But as the world around changed, she saw that scarcity of every resource, extreme helplessness and absolute absence of medical know-how, were the causes of this misfortune. Causes more potent than the stars.
She carried this burden all her life and now she was passing it on to her, soon to be obstetrician, grandson. Hoping for him to help and heal women, so as to lighten it.
A woman dying in labor has been a source of the holy as well as the horrible. But sainthood and vrindavan are rare. Commonly, she is said to turn into a 'hadal' (pretty ghost). The banyan tree and the village well is her common abode. She's rarely seen before some ominous signs. One will hear the bangles jingling, then a newborn's cry, followed by the smell of burning hair and then 'she' will appear; enchanting and ravishing in her looks. She will enamour the man she chooses. She's especially fond of tall, well built, handsome, young men. Unless she wooes and enchants a man, her powers wane. Once she's had a firm grip on her paramour, she will come out with her true colors only to leave the man shattered. She's now just skin and bone. A mad look in her eyes, long loose hair, red 'lugade' (traditional 9 yard sari), forearms full of green bangles and a huge red bindi on the forehead is now her 'display picture'.
Such are the folk tales created by the patriarchal society. Note the thinly veiled catharsis of the manly longings, even when making a 'hadal' out of a woman.
Respect towards women ever was and still is, sparse. Respecting her wishes, considering her views about what ails her, wasn't ever factored in. True that the work pressure is demanding and doesn't allow for too much courtesy. However isn't this a, part of routine work ethic? Health workers now received lessons about 'Respectful maternal care'. This helps. The women feel more secure and safe.
Unsafe abortion is another contributor to maternal mortality. India has the most patient-friendly and women-centric abortion laws. Maternal deaths from unsafe abortions have thus declined though not eliminated.
Pregnancy induced hypertension is a killer too. Described as, 'a secret, wrapped up in a mystery, engulfed by an enigma'; we know very little about its cause, prediction or prevention. Neither Ayurved nor any of the Indian languages have a specific word for it. Our ancestors failed to identify it as a specific disorder.
Herein blood pressure rises, proteins leak through urine and there is bloating all over. The placenta, liver, kidney, brain, coagulation and fetal growth are affected. The fetus fails to thrive and at times dies in utero. Sometimes the mother falls victim. Delivering the baby regardless of the gestational age and the chances of survival, is the final solution. Doctors still feel helpless against this marauder.
India contributes a fifth of the global maternal deaths. But such numbers are redundant. We are the most populous nation, with 'India' and 'Bharat', rolled together and thus bound to score high on numbers. The maternal mortality ratio (MMR) matters. That's the number of maternal deaths per one lakh live births.
And I have good news here!
Maternal deaths are rapidly becoming rarer and rarer. In 1990, 556 women died for every one lakh live births. Those many infants were left with just one parent. In 2014-16 the figure dropped to 130. Today, (2020), the figure is 97. The target is to bring it down to 70, by 2030.
Italy, Norway and Poland have contained MMR to single digits. Affable USA and the not so affable China hover around 19. Of course we are much ahead of Nepal (186), Bangladesh (173) or Pakistan (140). Congratulations!
The states with the highest MMR blame it on their usual woes. Poverty, illiteracy, blind faith, taboos, casteism, poor availability of doctors, drugs and equipment. Such conditions lead to a work ethic where referring a case to a higher center, rather than offering all possible aid, emerges as the best norm. A mishap elsewhere, is easier to explain and shrug off responsibility too.
Yet the target will surely be met. Uttar Pradesh, Bihar and Rajasthan started with a handicap but the MMR has been falling here too. Kerala reached 30, in 2020, much ahead of others and much beyond the target. Kerala now concentrates on the psychological problems in pregnancy.
Mothers don't die due to medical negligence alone. Negligence happens at several levels and at each level negligence has decreased.
Poverty has decreased and women are more respected. Child marriages are waning. The health services have reached far and wide. More and more women deliver under medical supervision, than at home. Blood banking services have expanded. Gone is the time when husbands scurried away at the mention of blood donation, for their bleeding beloved. Now several volunteers approach with their arms outstretched. Treatment of anemia has changed and its incidence is dropping. Small family size is now a given. Doctors have designed newer drugs, devised newer stitches, newer balloons and developed newer surgical techniques, to arrest blood loss. There are newer antibiotics for germs old and new. Ambulances in far more numbers, far well equipped and well manned now stand ready in every nook and corner. The road length and quality has seen great improvement. Mobiles and the internet have made telemedicine a reality. Advice is now a video call away. Drones deliver drugs and blood too. Schemes like the Pradhanmantri Janani Suraksha Yojana have made a huge dent. Treatment, travel and food during confinement is now free…no wonder the picture is changing. The old order changeth yielding place to new.
When I visit Agra next, I will see the Taj Mahal as a tribute to love rather than as 'Kaku's vrindavan'
