Saturday, October 07, 2006

Childbirth in the U.S. and India

Though people have children all the time, when I went through it it was still astonishing. Even in the merely supporting/cheerleading role of the father, I can't remember ever experiencing anything quite as frightening and, in the end, exhilarating. The everyday can still be mindblowing, when it happens to you: giving birth to a child is still remarkably difficult, painful (even with local anesthesia), and dangerous. So many things could go wrong, and yet somehow they don't, most of the time. And at the end of the day you have in your hands the most uncanny result of all: new life.

In a way I was lucky that S. went into labor last Friday, before I came across the latest issue of the New Yorker, with a typically excellent Atul Gawande piece on the evolution of obstetric medicine. In effect, the story Gawande tells isn't really an alarming one, though it still might have filled my mind with thoughts better avoided. Childbirth in the U.S. has become fairly safe over the years (though the threat of infant mortality and maternal mortality is still real). But what is a bit disturbing is that until fairly recently so many women (1 in 100) and newborns (1 in 30) died going through this. Interestingly, it was a woman doctor named Virginia Apgar who formulated a rating system (the Apgar scale) which gave doctors a set of criteria by which to evaluate newborns who seemed a bit iffey immediately after delivery. According to Gawande, the Apgar scale has dramatically reduced the infant mortality rate and revolutionized neo-natal care. The procedure that has made the difference with maternal mortality is the modern Caesarian section:

In the United States today, a full-term baby dies in just one out of five hundred childbirths, and a mother dies in one in ten thousand. If the statistics of 1940 had persisted, fifteen thousand mothers would have died last year (instead of fewer than five hundred) —- and a hundred and twenty thousand newborns (instead of one-sixth that number). (link)

It's worth noting that there are disparities along racial and ethnic lines; infant mortality rates for African Americans and Native Americans are appreciably higher than for other groups.

The statistics in India aren't quite as good, though they have also improved dramatically in recent years. Here are some statistics on infant and maternal mortality in India, according to UNICEF:

  • Maternal mortality: 540 in 100,000 (compare to 10 in 100,000 U.S.)
  • Infant mortality: 63 in 1000 (compare to 7.5 in 1000 U.S.)
  • The Under-5 mortality rate is 87 in 1000 (nearly 10%!)
  • Only 43% of births had a skilled attendant at delivery

And here, you can see a map of infant mortality in India, broken down by state. Two of the states that are most behind are Madhya Pradesh and Uttar Pradesh, which I found somewhat surprising.

Obviously, India has a long way to go here, but this isn't necessarily another 'bad news' story. Even as recently as 45 years ago, the numbers were much, much worse. Since 1960, infant mortality has been more than halved, and under-5 mortality has been cut down by two-thirds. Those are impressive improvements for a country as large and famously sluggish as India is on matters of public health. I wonder if people have ideas about how India could do even better going forward.


Kerim Friedman said...

This article on childbirth and global inequality, originally published in the Guardian UK, was just reprinted in the Taipei Times.

10:20 AM  
Sourav said...

Only 43% of births had a skilled attendant at delivery

I think that pretty much sums up the reason for India's low infant mortality rate. Most people prefer to have babies delivered at home as opposed to hospitals. And in some cases, they probably don't have an option.

1:34 AM  
Sharat chandra said...

sir,infant mortality is something natural and tragic.but the problem that india is facing right now is the abortion of the girl child .it is truly reaching alarming levels

1:10 PM  
Devan said...

The Under-5 mortality rate is 87 in 1000 (nearly 10%!)

That's nearly 1%.

3:49 PM  
Amardeep said...


87 is nearly 100.
100/1000 == .1 == 10%.

That's admittedly an English professor doing mathematics, but I don't see where I've made a mistake.

4:07 PM  
Mahesh said...

there is a ridiculous practice prevalent in south india which probably accounts for a significant proportion of maternal mortality. before, during and for some time after parturition, women are forbidden from drinking any fluids. this causes severe dehydration and predisposes these women to fatal conditions such as pulmonary embolus and stroke due to deep venous thrombosis and cerebral venous thrombosis, respectively.

i undertooli some training last year at nimhans in bangalore, which is india's premier neurology institute, where i saw dozens of women being brought in with strokes after delivering a baby. the neurologists explained that due to this dangerous tradition of peri-partum dehydration, there is an incredibly high incidence of stroke, one of the highest in the world, in women of childbearing age in south india (stroke in young women, and men, is a rare disease, it usually affects those over 55-60)

5:08 AM  
zp said...

This post has been removed by the author.

11:27 AM  
Dev Kumar said...

Amartya Sen had once commented that the poor in Kerala have access to better health care facilities than the blacks in the U.S.A. I also remember the writer P. Sainath (Everybody Loves A Good Draught ) mentioning in an article he had written that Kerala is the only state in India where nurses outnumber doctors. Food for thought here. But I must say that the situation in the BIMARU belt of India is abysmal. I remember seeing a baby being born at the roadside. A group of people, most of them strangers to the mother-to-be, had used an old sari and cordoned off the area. This incident had occured within a 100 metres of a Government Hospital.

12:55 PM  

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