Kota Child Deaths: A Story Of Flailing Primary & Secondary Care, Overstretched Tertiary Care

Kota Child Deaths: A Story Of Flailing Primary & Secondary Care, Overstretched Tertiary Care

Doctors and medical staff attend to an infant in the neonatal intensive care unit of Kota’s J K Lon Hospital, which saw the death of 101 infants in December 2019.

Kota, Rajasthan: Rukhsaar Bano, 22, gave birth to her first child on December 16, 2019. Beauty, born a healthy 2.7 kg, spiked a fever on December 29, and the new mother took her to J K Lon hospital in Kota, 240 km south of state capital Jaipur. Beauty was two weeks old when she died a few hours later, in the hospital where she was born.

“She was a healthy baby, she lived with me, she was alright when we got her home,” said Rukhsaar Bano, a housewife. Her husband Asim Hussain, 27, works as a diver in the Chambal river and earns Rs 270 per day. Rukhsaar Bano is sure that if she had more money, Beauty would have lived. But the family could not afford private care.

Beauty was among the 101 infants who died in J K Lon Hospital in December 2019. While these deaths in Kota dominated the headlines, infant deaths have been reported routinely in other parts of the country as well, as IndiaSpend reported on January 9, 2020. The poor quality of health infrastructure, antenatal care, maternal health and postnatal care jeopardise the lives of children, our analysis shows.

At Kota, we found staff shortages and lack of infrastructure in primary and secondary health centres. As a result, patients arriving at tertiary centres are often critical and these centres are stretched beyond capacity. Often, children are born to malnourished mothers and have low birth-weight. Further, the winter has increased the risk of hypothermia, contributing to the deaths.

Bano holds J K Lon Hospital responsible for her daughter’s death.

Owing to the fever, Beauty was not taking feed or passing stool for about 12 hours. Her family took her to the hospital on the morning of December 29, 2019. A few hours after admission to the neonatal intensive care unit (NICU), Beauty died.

“The doctors did not even tell us the reason for her death,” Rukhsaar Bano said. “They said nothing. They just gave her to us and asked us to take her and leave.”

Rukhsaar Bano, 22, gave birth to a health baby, Beauty, on December 16, 2019. Two weeks later, a few hours after Beauty was admitted to J K Lon Hospital to be treated for a fever, Beauty died in the hospital where she was born. She was among 101 children who died in the hospital the same month.

Being a tertiary care centre, J K Lon Hospital receives referrals from Kota, Bundi (40 km away), Chittor (180 km away) in Rajasthan and in Shivpuri, Mandsaur and other districts in Madhya Pradesh, Bhupendra Singh Tanwar, Chief Medical Officer, Kota, told IndiaSpend when we met him at New Delhi. “Tertiary hospitals are overcrowded and incidence of death [in J K Lon hospital] is not as high as other states of India,” he said, adding that most deaths were of low birth-weight [babies] and children already in a “critical” condition.

J K Lon Hospital in Kota where 101 infants died in December 2019. A fact-finding team found poor infrastructure, “pathetic” sanitation and overcrowding in the hospital.

When IndiaSpend visited JK Lon Hospital on January 6, 2020, we tried reaching out to Amritlal Bairwa, the hospital’s paediatrics chief (who has been suspended); Vijay Sardana, the principal of Kota Medical College; and Suresh Dulara, the medical superintendent of the hospital. All of them refused to speak to us.

Before our visit, central and state government officials had visited the hospital to investigate the deaths.

A fact-finding team from the National Commission for Protection of Child Rights (NCPCR) had visited the hospital on December 29, 2019, after 77 infant deaths were reported from the hospital. They found sanitation to be in a “pathetic state” with “pigs roaming in the campus”, as per their preliminary report. They also found poor infrastructure: “[T]here was no glass in windows panes, gates were broken and as a result, the admitted children were suffering with the extreme weather condition (sic)”.

Of the hospital’s 15 ventilators, only nine were functional. There were no records of annual maintenance.

Administrative lacunae in J K Lon Hospital--and not doctors--were responsible for the deaths, Tanwar, the CMO of Kota, said, clarifying that the hospital does not come under his or the health department’s jurisdiction but under the state’s department of medical education. “We [state health department] can only support them if they demand--we can give them funds, nurses if they demand. According to my records, they have unused funds of Rs. 1.8 crore,” he told us.

Infant deaths a “chronic, slow-moving tragedy”

Between 2014 and 2019, infant/child deaths in J K Lon Hospital have remained consistent at 5-8% of the total admissions, hospital records show.

Source: J K Lon Hospital records accessed by IndiaSpend through sources

"A death rate [deaths per 100 admissions] of 7-10% in a district hospital is normal," said Sunil Mehra, a paediatrician and executive director of MAMTA, a non-profit that works on maternal and child health.

This is because district hospitals are overcrowded and cannot turn away patients, Mehra said. This is unlike the primary and secondary care centres which can refer patients to the district hospital if they are overcrowded or under-equipped.

There is also a perception among patients that the best care will only be available in a district hospital, which makes all the patients rush to district hospital--which may not be able to cope with them, he added.

The average occupancy of the 372-bed J K Lon hospital was 220%, according to the documents uploaded on Rajasthan’s medical education website. That is, at least two patients share each bed.

“Our framing it [infant deaths in Kota] as a sudden tragedy is suspect. It is a chronic, slow-moving tragedy,” said Oommen Kurian, senior fellow, health, Observer Research Foundation, a New Delhi-based think-tank. Reports indicate the hospital was ill-equipped but that didn't happen in December; that has always been the case and many of the deaths were avoidable, he said.

Inside the hospital: Dirty washrooms, sick babies sharing beds

When IndiaSpend visited the hospital, we found the washroom in the maternity ward dirty. “Nobody cleans them [washrooms],” said Zainab Bi, 54, who was in the hospital for her daughter-in-law’s delivery. “We have told the nurse so many times. There is no water in the washroom. We will catch infections.”

The hospital was stretched beyond its capacity, patients told us.

“They usually keep two children in the machine,” said Bhagwati (she uses one name), who worked in J K Lon Hospital for a year and a half as a cleaner, referring to a warmer. “If there is less space, they keep three children also.”

Two to three children are kept on the same bed when they are given “an IV through a bottle”, she said referring to intravenous administration of medicine, glucose, etc.

When IndiaSpend visited the hospital, there was only one child per bed in the 32-bed neonatal care ward. Of 32 children admitted, 12 had pneumonia. Many of the children we met were underweight.

“If there are well-functioning primary healthcare centres and people seek care early, children have a higher likelihood of surviving,” said Chandrakant Lahariya, physician and public health specialist based in New Delhi.

Staff shortage, poor infrastructure

Primary care is inefficient, centres are often shut, doctors are frequently absent and infrastructure in inadequate, our visits to one community health centre (CHC), two primary health centres (PHC) and two health sub-centres around Kota showed.

Of these, only the CHC at Digod had an MBBS doctor. The health sub-centre at Tathed and the PHCs at Simliya and Godalyaheri had AYUSH doctors. The health sub-centre at Jhalipura was closed.

Under the National Health Mission, each point of delivery (PHCs) should have a newborn care corner, first referral units (CHCs) should have newborn stabilisation units, and district hospitals should have special newborn care units.

Services that newborn corners should offer include resuscitation including provision of warmth, early initiation of breastfeeding, weighing the newborn, and initial care to sick newborns.

“Ideally, babies who have infections or are critical should be referred to the tertiary centres like J K Lon,” said Mehra of MAMTA. Currently, low birth-weight babies (born less than 2.5 kg) are also referred to the district hospital when they can be handled at the primary and secondary level.

“In case of premature births, weak neonates, or if the child has low birth-weight, we mostly refer the patient to JK Lon hospital in Kota,” said Sahiblal Meena, the medical officer in charge of the CHC in Digod.

This trend is not restricted to Kota. Although 95% (561) CHCs in Rajasthan have a functional labour room, less than half (288) have functioning stabilisation units for newborn babies. Also, 18% (107) of these centres do not have a newborn care corner.

Not a single sub-centre, PHC or CHC in the state fulfills the norms under the Indian Public Health Standards, according to Rural Health Statistics 2018.

Further, funds are not spent effectively. Fund utilisation has been usually low in Rajasthan, said Avani Kapur, director of Accountability Initiative, Centre for Policy Research, Delhi.

“In 2018-19, for instance, in Rajasthan, as per government-reported data, for facility-based newborn care [where clinical care is provided by skilled personnel round the clock], only 23% of the allotted budget was spent,” Kapur said. “This could be due to a number of reasons, from delayed releases to administrative bottlenecks and complicated tendering processes.”

Why tertiary care centres see high deaths

“Kota is not just a district hospital; it is a regional hospital, [and] all cases from the Hadoti region are referred to Kota,” said Vivek Gupta, president of the body of paediatricians in the Hadoti region, one of four cultural regions in Rajasthan that includes Kota, Baran, Bundi and Jhalwar districts. “About 3,500 children below the age of one are dying every year in these four districts. All these district mortalities are being transferred to Kota,” he added.

Newborns, preterm and low birth-weight babies are more prone to hypothermia--where the body loses heat faster than it can generate it.

When taking children to hospital, the relatives cannot manage the supportive temperature for the baby, which leads to hypothermia, Tanwar, the CMO of Kota, told IndiaSpend.

A newborn baby transported from the delivery room to the NICU within the same hospital can become hypothermic with a NICU admission temperature lower than 36 degrees Celsius, increasing its chances of mortality, said Somashekhar Nimbalkar, associate dean and professor of paediatrics at Pramukhswami Medical College, Gujarat. “In our hospitals, we have mothers and babies travelling more than 30 km in auto-rickshaws, often resulting in severe hypothermia, with temperature lower than 32 degrees Celsius, which reduces chances of survival drastically.”

“If there are enough centres at the community level that can stabilise the patient before moving it to a higher centre, the mortality improves significantly,” said Sinha of MAMTA, referring to the Encephalitis Treatment Centres created in CHCs and private hospitals in Uttar Pradesh to prevent encephalitis-related deaths.

Also, while some state of the art private hospitals can treat premature babies and infants born weighing as low as 500 grams, even babies born weighing 1.5 kg can struggle to survive in government hospitals, Nimbalkar said.

While the National Health Mission funds special newborn care units at district hospitals, medical colleges such as J K Lon need to depend on state government funds. “Medical colleges do not have the flexibility to increase the number of staff or beds as per the demand as the staff strength is linked to MCI [Medical Council of India] guidelines,” he said.

Rajasthan had second-most infant deaths in 2018-19

In 2018-19, Rajasthan saw 24,451 infant deaths, the second highest after Madhya Pradesh (25,786), according to the Health Management Information System (HMIS). Rajasthan accounted for 12.8% of all infant deaths (190,646) reported in the country that year.

Between April and December 2019, too, Rajasthan had the second-highest number of infant deaths (17,613), lower only than Madhya Pradesh (22,770).

In 2017, Rajasthan had the seventh highest infant mortality rate at 38 deaths per 1,000 live births, after Madhya Pradesh (47), Assam (44), Arunachal Pradesh (42), Odisha (41), Uttar Pradesh (41) and Meghalaya (39), as per the latest Sample Registration System bulletin. The national average was 33.

Rajasthan also ranks 16th among 21 large states on NITI Aayog’s Healthy States, Progressive India report for 2018. The state also had over 40% decline in the proportion of low birth-weight newborns, attributed to measures such as “early registration of pregnancies, early detection and management of high risk pregnancies, regular monitoring of HMIS data”, said the NITI Aayog’s report.

One in every five (21.4%) babies who are weighed after birth in health institutes in Rajasthan are low birth-weight--associated with foetal and neonatal mortality and morbidity, poor cognitive development and an increased risk of chronic diseases later in life, according to the World Health Organization.

Malnourished, anaemic mothers give birth to children with low birth-weight

Pooja (she uses one name), 20, was diagnosed with severe anaemia in the sixth month of her pregnancy in December 2019.

“I went for a check-up at J K Lon, the doctor asked me to get sonography done after which they said I did not have enough blood,” Pooja told IndiaSpend. “I was admitted to the hospital for two to three days so they could inject blood. They asked me to leave on December 14 after which I came home and had a sudden delivery.”

Pooja delivered a premature baby weighing around 400 gm. She was placed in an incubator for 5-6 hours, after which the family was informed that the baby had died.

Pooja, 20, was severely anaemic and delivered a premature baby in the sixth month of pregnancy. The baby weighed 400 gm at birth, and died a few hours later.

In 2015-16, 46.6% of pregnant women were anaemic in Rajasthan and only 38.5% of pregnant women got at least four antenatal check-ups as they should, as per the National Family Health Survey 2015-16 (NFHS-4).

When mothers get married early and give birth without adequate spacing between deliveries, the result is babies born too early and born underweight, as IndiaSpend reported on March 29, 2018.

Children of mothers who are severely anaemic are seven times as likely to be severely anaemic as children of mothers who are not anaemic. Severe anaemia can prove fatal for both mother and child, and preventing anaemia is critical to reducing maternal and infant mortality.

A child born to a mother who can read is 50% more likely to survive past five years of age; each year of mother’s schooling decreases the probability of infant mortality by 5-10%, according to the United Nations Educational, Scientific and Cultural Organization’s 2011 report, Education Counts, as IndiaSpend reported on January 16, 2018.

Only one in four (25.3%) women had more than 12 years of education and one in three (35.4%) women aged 24 were married before the age of 18; 6.3% of women had become pregnant in teenage, according to NFHS-4.

(Tiwari is a principal correspondent with IndiaSpend and HealthCheck. With inputs from Swagata Yadavar, special correspondent at IndiaSpend and HealthCheck, and Shreya Raman, data analyst at IndiaSpend and HealthCheck.)

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