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Re: [reprohealth_india] Re: [pha-ncc] serial maternal deaths - this time in Jodhpur

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  • Sama Sama
    Dear Narendra, Yes, what about others who had been on the IV fluids? Can you send the updates? SAarojini ... -- Sama- Resource Group for Women & Health B-45,
    Message 1 of 4 , Mar 1, 2011
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      Dear Narendra,

      Yes, what about others who had been on the IV fluids? Can  you send the updates?


      On Mon, Feb 28, 2011 at 10:50 AM, Narendra <narendra531@...> wrote:

      Der All:

      Besides the deaths, we are trying to find why only women in maternity ward have died because of the contaminated IV fluid injection. What happened to others if they were also injected the fluid from the same batch. Owing to flurry of activities of police and others, it is taking some time.

      Best regard.


      On Mon, 28 Feb 2011 00:00:35 +0530 wrote


      deaths in Jaipur: Police make first arrest, 2
      Published: Sunday, Feb 27, 2011,
      22:20 IST 

      Place: Jaipur | Agency: PTI

      Making the first arrest in the maternal deaths case,
      the police today took into custody an official of an
      Indore-based pharma company while Rajasthan government
      suspended a drug inspector and a store keeper of one of
      the two affected hospitals in Jodhpur.
      mounting anger over the deaths of 13 women due to
      excessive bleeding during childbirth allegedly after being
      administered contaminated intravenous fluids, chief
      minister Ashok Gehlot visited Umaid and MG hospitals and
      made a bid to calm the situation. Gehlot hails from
      The state
      government increased the Rs one lakh compensation
      originally announced to Rs five lakh each to the families
      of the victims, an official said today while announcing
      the suspension of the area drug inspector Dinesh Taneja
      and MG Hospital storekeeper Kusum Acharya.
      police commissioner Bhupendra Kumar Dak said Sanjay Shah,
      who is in the Production and Quality Control department of
      Indore-based Parental Surgical India Limited, was arrested
      with the help of the Madhya Pradesh police. "We have
      arrested Shah and the team is taking him to Jodhpur for
      the interrogation," he said.
      An official
      said the government has also blacklisted the Indore firm
      and Anshul Pharma, distributor for glucose supply.
      decisions to make the suspensions and increase the
      compensation were taken at a high-level meeting in Jaipur
      last night presided by Gehlot who also directed the
      Jodhpur Divisional Commissioner to probe thedeaths and
      submit a report within 15 days.
      At least 13
      women have died in a span of 14 days between February 13
      and 26 and three others are battling for their lives after
      they were allegedly administered IV fluids in Umaid and MG

      maternal death in Jodhpur hospital

      Trust Of India 

      Posted on Feb 26, 2011
      at 08:23pm IST


      Jodhpur: One more
      woman died on Saturday and four others were
      battling for their lives after they were
      allegedly administered contaminated intravenous
      fluids in two government hospitals in Jodhpur,
      where 13 maternal deaths have taken place in
      last 11 days.
      Rajasthan government
      announced a compensation of Rs 1 lakh for the
      families of the victims while the tragedy
      prompted the National Advisory Council (NAC)
      headed by Sonia Gandhi to seek an explanation
      from the Health Ministry.
      Bhavana, 27, died in
      Mahatama Gandhi Hospital, where she had been
      shifted from Umaid hospital on Sunday in a
      critical condition following her delivery,
      hospital sources said.
      Angry relatives of Bhavana staged
      protest at the hospital and refused to take the body.
      They demanded that the compensation be raised to Rs 5
      Minister and in charge of Jodhpur division, Rajendra
      Pareek on Saturday visited the two hospitals and held
      discussions with doctors and officials.
      He announced
      a compensation of Rs 1 lakh for the families of the
      women, who had died of haemorrhage post-delivery after
      they were allegedly administered contaminated
      intravenous fluids supplied by an Indore based which
      has been booked.
      Four other
      women, one in MGH and three in Umaid, are in serious
      condition, the sources said.
      committees which were probing the incident have
      submitted their reports. While the six-member panel of
      SM Medical College had blamed contaminated IV fluid
      for the deaths, the two-member government committee
      has suggested a slew of measures for the hospitals
      amid fears that an infection could also have led to
      the deaths.
      Meanwhile, a
      four-member police team led by a sub-inspector was in
      Indore to quiz officials of Parental Surgical India
      Private Limited and carry out futher investigations.
      A case was
      registered under section 328 IPC (causing hurt by
      means of poison with intent to commit an offence)
      against Parental Surgical India Private Limited, and a
      local distributor, for allegedly supplying the
      contaminated I V
      fluid, Madhya
      Pradesh health officials had on Friday raided the drug
      hospital Superintendent Narendra Changani had said
      that the administration has registered a complaint
      against the manufacturing company and the local
      distributor Anshul Pharam, who supplied the
      contaminated stock of the I V fluid.
      officer Dhagla Ram had said close to 10,000 bottles of
      the IV fluid have so far been seized and a report of
      FSL (Forensic Scientific Laboratory) is awaited.
      "As a
      precaution, we have kept the main operation theater
      and labour room closed for fumigation," said principal
      of the S N Medical College R K Aseri.

      deaths: cases filed against pharmaceutical firm, distributor

      Sunny Sebastian
      Jaipur, February 26, 2011


      Madhya Pradesh health
      officials conduct searches on the drug company in

      Cases have been registered against the manufacturer and
      supplier of the suspected killer intravenous (IV) fluid
      bottles in two major hospitals in Jodhpur — Umaid Hospital
      and Mahatma Gandhi Hospital — after the deaths of 12
      pregnant women in 10 days from February 13. The authorities
      have seized 10,000 bottles of IV fluid from the stocks of
      the Indore-based manufacturer Parental Surgical India Pvt.

      Reports on Friday said the Madhya Pradesh authorities, on
      the basis of information from the Rajasthan police, carried
      out a search on the godown of the pharmaceutical company to
      confiscate the remaining stock. The preliminary enquiries by
      a six-member medical team, headed by Narendra Changani,
      Medical Superintendent at the Umaid Hospital, indicated the
      presence of fungus in the IV fluid.

      Seven pregnant or newly delivered women, admitted to the
      Umaid Hospital, and another five in the Mahatma Gandhi
      Hospital, had bled to death reportedly after administration
      of the IV fluid on them. Five more women are in a serious
      condition in the two hospitals. The incident first surfaced
      in the Umaid Hospital and some of the women admitted there
      were shifted to the Mahatma Gandhi Hospital. However, the
      deaths continued.

      Though the suspicion is on the IV fluid being infected, the
      authorities are said to be critically examining the
      condition of the labour rooms and the operation theatres in
      these hospitals. The medical authorities are at a loss to
      explain why the same IV fluid did not cause any death in
      other patients.

      While the divisional headquarter city witnessed protests and
      road blocks daily in the past few days, action against the
      pharma firm and the local distributor sparked an agitation
      by medical store owners and pharmacy suppliers.

      8, Vijay Colony, Near Railway Station,
      Chittorgarh 312 001
      Tel : +91.1472.243788
      Fax : +91.1472.250044

      Sama- Resource Group for Women & Health
      B-45, 2nd Floor, Main Road Shivalik,
      Malviya Nagar,
      New Delhi-110017
      Ph: 011-65637632/26692730
      website: www.samawomenshealth.org
    • Geeta Sodhi
      Dears Mira, Gita, Jasho and all others, This is indeed a very sad state of affairs. Please let me know if there is any way I can contribute/ lend myself to
      Message 2 of 4 , Mar 10, 2011
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        Dears Mira, Gita, Jasho and all others,
        This is indeed a very sad state of affairs.
        Please let me know if there is any way I can contribute/ lend myself to your efforts.
        With deep regards for all of you who are taking this fight forward.
        Dr Geeta Sodhi
        ----- Original Message -----
        Sent: Wednesday, March 09, 2011 10:50 PM
        Subject: Re: [reprohealth_india] serial maternal deaths - this time in Jodhpur


         Dear Gita  , Josho , Sarojini & friends ,
        Just returned from Jodhpur . was part of the protest against Maternal Deaths , with this  International women's day being  treated as  " Shok  ( pronounced as in Poke)  Diwas  "  Day of sorrow "for the 18 maternal deaths & their babies &many more .
        From  Geeta Bhawan the Rally  led by Asha Vohra  of Meera Sansthan  Sashi Behan of Gravis , Usha of Vikalp left around 11 am . The organizers asked me to flag it off . The women many of whom were holding little babies  marched up to Ummed Hospital  , presented the demands , after heated discussion & questioning  with the acting incharge .
         From there  rally went to Mahatama Gandhi Hospital ,  after long time  gentleman incharge came to meet  the women , over 400 in number . Demands were given after extensive heated  discussions  . kavita Srivastava joined   the protest  &  from there led along with other organizers to Collectorate .
        Since Collector was  busy , later it was found that he had to go for  lottery for Liquor   contract  or  something related to it , women  protested  more vehemently . This being International women's Day .
        The women blocked the road & after substantial time , 10-12 representatives were invited  to discuss the issue . apparently rules  for not lowing all  rally members in  & also not having collector come out to meet the rally was quoted . it was hot & there was ot even  shade & water made available . Complaint which was made to the collector .
         several demands  were made
        1Making case reports   details available to the patient's families .

        2Action against absent seniors  , who left  caesarians & hysterectomies to juniors .

         3 Transference of staff  as per Guidelines   as some have been in same post  for over 20 years , establishig private  practice .

         4 Action against overcharging of even women  under JSY  to the tune of Rs60,000 to R 1.50 Lakhs .

          5Action against  Attempt at cover up by announcing IV fluids as killers when none of the male & other patients given the IV  fluids died .

        6 Improving cleanliness of the  hospital vicinity , wards , toilets etc

         7Increasing  number of  skilled trained  human power  according to the   patient workload , which  has increased tremendously because of the Janani Suraksha Yojna  related Institutional Deliveries .  .

         8 Need to provide care for the New born  babies  & other children left motherless  eg Bhawna who died has left Behind 3 baby girls  4yrold little girl , 2 year old & a 13 day old baby girl , with the father of children who was still in the mourning period  needing to work outside home from morning till night for a meagre   earning .

         9  Strengthening Public Health services at the  , one of the pregnant women who died in the village visited by sashi Tyagiji had died of Malaria , Malaria deaths in Pregnancy are not counted as Maternal Mortality , even though they are  a cause of death of many pregnant women in endemic areas .
         many of us who were involved in the 1995 Falciparum Malaria  deaths in  rajasthan  affecting 4 districts   Jodhpur , Bikaner , Barmer  , Jaisalmer recall the large number of deaths  estimated to be 4000
        compensation for women who died  from outside Jodhpur  because of the same hospital induced infection & complications  as women had come from far off villages .
         A death of a pregnant woman  with Malaria is a Maternal death & a maternal Mortality , even if it is  defined   differently & needs to be challenged .

        10  Credible  conduction of   Maternal Death Audits & Maternal death Audit  Reviews .

        11  Stopping Private practice of senior doctors  , there was evidence of  repeated  ordering of Sonography from Private diagnostic centres & prescription of drugs .
         13 Rationalization of Medicine Procurement , Prescription writing .
        the  string of Private medicine  shops & Diagnostic testing   Labs  outside the 2 Hospitals ,  are doing a roaring  business  & denial of quality care  is  one aspect of the problem, the exploitation of the poor,  patients is really pathological . .
        The   Sasti sarkari Dawaiyon  Ki dukans  were there in both the hospital Ummed & Mahatama Gandhi  but brands &prescribed by the doctors are not there
         There were several other demands .
        While at the 2 hospitals we saw many anxious & bewildered  poor patients, men & women  who had been given  costly prescriptions , which these patients could not afford . One old man had been prescribed an  antibiotic for cellulitis ,which he could not afford , he had been sent to  collector's office to get  a letter to say he was poor  needing help in  payment of medicines .
         another man was limping around with   wounds on his foot infected & oozing needing treatment & antibiotics which he could not afford .
        An extemely anaemic & sick young woma patient leaning on 2 older women  slowely shuffled out of the Hospital was put in an auto , with all 3 women in Ghoonghats . Tried to ask what was wrong  repeatedly , but they looked sad & anxious  & would not  say a word
        The issue is not  just of the maternal deaths & maternal care  which is affordable & of quality , but care for all those who are sick  & with great difficulty manage to reach a" big "hospital , having knocked at the doors of subcentre & PHCs .
        Maternal Death audit is not enough , there is a need for  social audit &  that too at multiple levels .
         As we were leaving we were called back as one more death had taken place post hysterectomy, from Bleeding . She was not pregnant , but the need to find whether it was an avoidable death  was important .
        6 committees have been set up Centre , State , Internal etc etc . , media has been covering the issue doggedly ,  the Collector  says he will ensure that some of the  demands  are met   . The  lady SDM has been assigned regarding follow up .
          Obviously urgent change is required at many levels , the increasing comercialization of Medical Care on one hand & collapse of systematic  downward trend of Public Health services  is  blatantly obvious . specially in the periphery where even the role of Dai has been stamped out , without ensurig of gender sensitive , easily accessible , affordable , quality maternal & health service  , specially services ensuring safe pregnancy, safe childbirth & most importantly Post natal Care to the mother & neonate
        . most of the women died of bleeding , most were  anaemic . the presence of DIC Disseminated Intravascular Coagulation in 3   ,  fever etc is indicative  of Infection , definately IATROGENIC  infection .

         What was the source of infection may come out  in the reports by the State & Central Team as they had access to case records etc .
         The Action that gets taken to prevent even a single preventable death in the future  is the most important .  not just in Ummed Hospital , Mahatama Gandhi Hospital or in in any hospital in  Jodhpur , Rajasthan , but every village , every part of our country .
         the  fact that needless maternal deaths continue   like this is reflective of  much deeper pathologies  , which need to be  confronted .
        The fact in each & every case  where these young mothers died the  husbands & families ,spent whateverthey could , took loans , paid through their nose  & still lost  their wives  & mothers of their babies , which makes it sadder still .
        It should really not be allowed to go on  like this . 

        Mira Shiva

        From: Gita sen <Gita@...>
        To: reprohealth_india@yahoogroups.com; Narendra <narendra531@...>
        Cc: sama.genderhealth@...; namhhr.india@...; Aruna Kashyap <kashyaa@...>; coordinator@...; pha-ncc@yahoogroups.com; aditiyer@...; Anuradha. Sreevathsa <anuvathsa@...>
        Sent: Mon, March 7, 2011 4:13:37 PM
        Subject: RE: [reprohealth_india] serial maternal deaths - this time in Jodhpur

        Dear Narendra and all,


        From our experience of doing many verbal autopsies, it is very important to have an independent doctor on the team, but also to have a trained person interviewing the family and other community members.


        We have been arguing for some time that after JSY has started, the institutions are the real weak links in the chain. I am not at all surprised that you did not find contaminated IV to be the cause of death. There is probably a set of different biomedical reasons for each case, most of which can be traced back to weaknesses on the services side.


        We can try to provide whatever long distance support we can in getting to the bottom of this. If you need my team’s help, let us know.






        Gita Sen


        Centre for Public Policy

        Indian Institute of Management

        Bannerghata Road

        Bangalore 560076



        Tel: +91 80 2699 3076

        Fax: +91 80 2658 4050


        From: reprohealth_india@yahoogroups.com [mailto:reprohealth_india@yahoogroups.com] On Behalf Of Jashodhara
        Sent: Thursday, March 03, 2011 11:57 PM
        To: Narendra
        Cc: sama.genderhealth@...; reprohealth_india@yahoogroups.com; namhhr.india@...; Aruna Kashyap; coordinator@...; pha-ncc@yahoogroups.com
        Subject: [reprohealth_india] serial maternal deaths - this time in Jodhpur


        Dear Narendra,
        Thanks very much for sharing the findings from your first visit.
        I am unable to see a pattern of causes in the list of deaths since I am
        not a technical person, hopefully Chinu, Mira and others will comment.
        The mystery of why IV fluids were immediately labelled /announced as the
        cause of death is another conundrum: who made this instant diagnosis and
        The costs you mention are shocking, but our earlier studies with JSY
        have indicated similar expenditures especially for complicated cases.
        The question now is, what should be our strategy: Should another civil
        society team go in and complete the verbal autopsy for the other women?
        Can we expect the government to present its maternal death enquiry findings?
        Hoping to hear more thoughts on this,
        In solidarity,

        On 03-03-2011 1:30 PM, Narendra wrote:
        > Dear Jashodhara, Sarojini & friends:
        > Kavita Shrivastava, Meeta Singh (Dr.) and I went to Jodhpur to
        > investigate on maternal deaths happened in the tertiary (Medical
        > College) hospital of Jodhpur. We did maternal death audit of four women
        > by using the format prepared by Kirti Iyengar (Dr.)by modifying the
        > usual one to be relevant for the tertiary hospital deaths. Sharad
        > Iyengar was available on phone.
        > This is the second biggest hospital of Rajasthan and is in the
        > constituency of the present Chief Minister of Rajasthan. It is the same
        > hospital where about one and half years back, six children of
        > Thalessemia were infused HIV infected blood and 15 others suffered from
        > Hepatitis.
        > The district administration provided a list of 14 deaths which took
        > place between 13th February 2011 till 27th February 2011. Three more
        > deaths have been reported since then. Please find attached the list of
        > 14 women who died. The list has information about the date and time of
        > admission, date and time of delivery (vaginal or LSCS), date and time
        > of re-operation (hysterectomy), date and time of death, diagnosis and
        > causes of death. I am also attaching the audit proforma we used to get
        > information on chronology of events from the husband/attendants of the
        > deceased women. We could do only four audits in one day. Out of them
        > three had LSCS and one was admitted after her normal delivery
        > elsewhere. Preliminary analysis shows that it is unlikely that these
        > women died owing to infusion of contaminated IV fluid. We are not
        > counting the woman (for time being)who delivered outside and had no
        > LSCS because its possible that she was brought in very fatal condition.
        > LSCS and re-operation was performed on others. Most common cause of
        > death has been DIC, Hellp Syndrome, Septicemia and so on.
        > The questions still unresolved and we are trying to analyse. We need a
        > guidance of a good physician for this:
        > 1. What is the link between DIC and contaminated IV fluid infusion?
        > 2. In how much time contaminated IV fluid could cause DIC?
        > 3. How contaminated IV fluid infusion led to PPH because in some
        > instance it seems to have happened within few hours and in others, it
        > took days.
        > Our cursory understanding (Kirti, Meeta, Sharad and I) is that deaths
        > do not have link with contaminated IV fluid infusion because then why
        > only these women died and not others who are given the same fluid. We,
        > as yet do not know that how many others were given IV fluid (trying to
        > get under RTI by invoking clause of life and liberty). It is a common
        > practice in medical college hospitals that women who deliver normally
        > are also infused IV fluid. We will share more details about it soon.
        > But please help us in understanding the link between DIC and
        > contaminated IV fluid.
        > Secondly, these deaths show that JSY is a complete failure. Relatives
        > of all these patients spent roughly in the range of INR 50,000/- to
        > 2,50,000 for treatment. Injections, some of which costed INR 6000 per
        > ampule were asked to be bought.
        > Thirdly, there are disproportionately high LSCS done in the hospital
        > under investigation.
        > Women's groups of Jodhpur have decided to organise a protest rally on
        > 8th March on this issue. Those wish to join, please contact Kavita.
        > More later.
        > Best regards.
        > Narendra
        (Ms) Jashodhara Dasgupta

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