One evening in mid-March, Manju, a pregnant woman in her early thirties, stepped out of a shared tempo at the gate of a crowded and poorly maintained hospital in a district capital in Uttar Pradesh. She looked exhausted and was gasping. Like most other pregnant women in rural India, Manju was underweight and anaemic. She was only 33 weeks into her pregnancy, but she was having severe contractions. From her experience of previous pregnancies, she knew that these were labour pains. But this was too early for her to have a delivery. A normal delivery, after all, usually takes place between 37 and 40 weeks of gestation.



As she walked down the familiar path of the public health facility, she remembered her earlier visits to the hospital. She also wondered if she would survive this pregnancy. Of all her pregnancies, this had been the most trying and unpredictable.



Some months earlier, Manju had visited the hospital for a pregnancy test when she had missed her period for the second time in a row. The test was negative. It was only in the fourth month, when her stomach started to show, that Manju learned of her pregnancy. She visited the hospital again and an ultrasound confirmed that she was pregnant with twins!



She said, “I was shocked. I had heard that most women do not survive while delivering multiples.” Manju and her husband, Sateesh, didn’t want more kids. Not because Manju was carrying multiple babies but because they had three children already, two girls and a boy. Still, they decided to have the babies. Not that they had much of a choice. Terminating a pregnancy that late requires a complex and expensive procedure. A poor family like Sateesh and Manju’s could not have easily afforded such services. The incorrect test results had changed the calculus of their decision.



Even though Manju decided to have the babies, the thought that she could die during delivery did not leave her. “What would happen to these three children that I already have? I was worried and hence started eating less”, says Manju.



She decided to eat less to keep the size of the babies inside her womb small. According to her, and a lot of women in rural Uttar Pradesh, if babies are “large” the chance of complications during childbirth is higher. In her mind, giving birth to multiples would only have a synergistic effect. She thought that larger babies might require a caesarean section delivery. She had heard stories about caesarian section deliveries from other women – in many of the stories, the woman who had been operated on bled to death.



Manju’s perception about caesarian sections in public facilities in Uttar Pradesh has some truth to it. Negligence in public hospitals is common, and many hospitals do not have functioning blood banks to prevent maternal deaths from hemorrhage. Furthermore, where blood banks do function, they charge poor women Rs 600 as transfusion fee and only dispense blood when the woman’s family has brought blood to exchange, a process which often takes too long in an emergency.



But eating less when one is pregnant does not do any good either. It denies essential nutrition to the baby in the womb, harming the baby’s cognitive and physical development. Beliefs about nutrition and the size of the baby during pregnancy, along with widespread patriarchy, poverty, and lack of state support, mean that the babies born in rural India do not receive enough nutrients in their mothers’ wombs. In fact, recent research suggests that during the course of their pregnancy, Indian women gain only about half the weight which is required to have a healthy baby.



That evening, with great difficulty, Manju made it to the delivery room, after inching up a long ramp to the top floor of the hospital. An hour later, she luckily had normal vaginal delivery and gave birth to triplet boys. Not twins, as the ultrasound report had claimed, but triplets!



Each of the three boys weighed about 1.5 kg. Had these babies been born in a hospital in a developed country, or in one of Delhi’s elite private hospitals, they would have immediately been rushed to the neonatal intensive care unit, where they would likely have stayed for several weeks. But here, they were wiped off and handed over to their mother. The hospital did not even provide as much as a warm blanket to wrap them in.



Unlike fifty thousand other women who die during child-birth in India every year, Manju survived her pregnancy, labor, and delivery. But her babies, because they weighed so little, had a tough battle for survival ahead.



Babies born weighing less than 2.5 kg are considered low birth weight, but these triplets were way below the mark. Low birth weight babies are weak, less able to feed, and more prone to infections and hypothermia than babies born with a normal weight. Manju’s babies were also premature, which meant that their vital organs had not yet fully developed. A study conducted in one district in rural Maharashtra reported that 70% of babies born at or below 1.5 kg did not survive.



Since hospitals often don’t weigh newborns, and it is even less common for someone to follow up with them after delivery, we do not know how many low birth weight babies in India die in the first month of their life. But surveys suggest that the number of low birth weight babies is quite high. For example, the Annual Health Survey (AHS) 2012-13, which is based on data collected in 2010, found that among 30.3% of babies who were weighed at birth in rural Uttar Pradesh (presumably the best-off babies) close to a quarter were low birth weight.



When the triplets were born, Sateesh and Manju were not worried about their weight. They did not understand how and why weight mattered for newborns. Instead, they were preoccupied by the thought that they had triplets, not twins, to take care of now. All newborn babies, when they leave the protective environment in their mothers’ wombs, require special care. Atul Gawande, a professor at Harvard Medical School, in his bestselling book ‘Better’, reports research that shows that simple measurements like birth weight are vital for understanding newborn health and help doctors produce better outcomes.



Unfortunately, no measurements are taken in many of India’s public hospitals. Many state-run maternity hospitals believe that their job begins at labor and ends with a delivery. Furthermore, news articles point to regular abuse and beating of pregnant mothers. Reports of maternal deaths reveal that many hospitals fail mothers even while “helping” them deliver a baby.



After the delivery, Manju shifted to a ward – a large room which was occupied by some 35 women and their newborn babies. Biscuit wrappers and banana peels could be seen under the beds. Uncovered trashcans, containing bio-hazardous and infectious waste, layered with red paan stains, sat in a corner of the room. The smell of a rarely-cleaned toilet wafted into the poorly lit room. Despite being born premature and low birth weight, no nurse or doctor ever came to check on Manju’s triplets. Nor did they explain to her how to take care of them. For the next 36 hours, while she was at the hospital, the only thing Manju received from the hospital staff were a few pills from a nurse in training.



When these fragile babies needed special care and a warm environment, they spent two cold nights in a thin shawl at the district hospital. When each one of them required exclusive breast feeding every 2-3 hours, no one cared to counsel Manju about how to do so. Hospital staff did not follow any of the protocols mentioned in the Facility Based Newborn Care guidelines issued by the government.



I came to know Manju accidently. I was visiting the public hospital in which she delivered the triplets to see a friend. I was interested in learning more about early life health in India. From what I had read about best practices in infant care, I was appalled at the way Manju and her triplets were treated at the hospital. Just two days earlier, I had finished reading Atul Gawande’s long essay “Slow Ideas” in the New Yorker magazine, in which he discusses the importance of easy and costless ways of saving infant lives – hand washing, protecting babies from germs, breast-feeding, and Kangaroo Mother Care (KMC). But could Manju and Sateesh increase the weight of their babies, save them from infections, and ensure their survival by adopting these strategies?



Early initiation of breastfeeding, within one hour after birth, and exclusive breastfeeding for the first six months of life are important for an infant’s health. Breast milk is a complete food, containing all essential nutrients that an infant needs. It also increases the immunity of infants to fight diseases. But early initiation and exclusive breastfeeding for the first six months is not common in India. The Annual Health Survey found that in rural Uttar Pradesh only 39% of babies were breastfed within one hour after their birth and 68% of babies were given food other than breast milk during the first six months.



Like many other mothers, Manju thought that her body was not capable of making enough breast milk and that her babies would require supplementation with cow or goat milk. But cow or goat milk exposes infants to dangerous germs and often leads to infection, as do baby formulas which must be dissolved in potentially unclean water. If a mother eats a high calorie diet with a variety of foods, keeps her body hydrated, and helps the baby latch on properly to her breasts, her body is very likely to respond well and make enough breast milk for her babies. This is true for women who have one baby, and it is even true for women who have twins and triplets.



For rural mothers, take-home rations or hot-cooked meals should be available through Anganwadis under India’s Integrated Child Development Services (ICDS) program to help them get the nutrition they need to produce high-quality breastmilk. This support is especially important for a poor Dalit women like Manju. Despite struggling hard for her share of Take Home Rations, Manju got them just once in the entire course of her pregnancy.



Manju did get Rs 1400, an entitlement for opting for an institutional delivery. But this amount was barely enough to cover the costs of delivery in the hospital; there was little left over to buy food. That’s mostly because the hospital staff charges for delivery, and sends people outside the hospital to buy medicines and supplies, even though deliveries are supposed to be free. The National Food Security Act’s promise of Rs. 6000 for every mother as a maternity entitlement is yet to be implemented.



Despite the absence of state support in providing adequate nutrition for her babies, resource-constrained Manju was willing to do exclusive breastfeeding and opted for inexpensive food that could increase her milk supply. The triplets were barely 4 days old when the headlines about unseasonal rain and hailstorms hit the national media. The previous night’s rain, in north India, had flattened standing crops across the fields. In the Dalit Pasi hamlet in which Sateesh and Manju live, the hailstorm blew off several thatched roofs. “The night was terrible. This roof leaked from several places and I had to sit with an umbrella all night. Sateesh was busy bailing water from the house. We barely managed to keep the babies dry”, said Manju.



Unseasonal rain during the retreating winter caused the temperature to plummet; the relatively warmer days got colder. The triplets were battling with this sudden drop in temperatures; low birth weight babies often develop and often die from neonatal hypothermia. Yet, Manju and Sateesh didn’t initially know that the babies would have trouble maintaining their body temperatures on their own. After some explanation, they came to understand the relationship between energy and body heat. They knew that their fragile babies, along with enough breast milk, also needed warmth to grow. Sateesh, who has some education, even started keeping track of the babies’ body temperatures with a donated digital thermometer.



When the babies’ temperatures dropped below 98.4 degrees, Manju and Sateesh started using Kangaroo Mother Care, which involves keeping the baby on a parent’s chest or belly with direct skin to skin contact, to provide them warmth. Doing KMC with three babies was not an easy feat. Still, when they could manage to do it, KMC worked well. Because of KMC, the babies maintained their body temperatures despite the harsh weather. But Sateesh and Manju’s continuous efforts did not let hypothermia develop in any of the babies.



When the babies were two weeks old, Manju was spending almost all of her time in taking care of them and was getting to know them well. Of the middle-born, or manjala-wala as Manju called him, she said, “He is the Kumbhkaran. He does not cry for milk, waking him up always proves to be an uphill battle. If I succeed in doing so, the ‘little monster’ would barely feed for a few minutes and then would fall asleep again,” said Manju. Often, low birth weight babies are too weak to cry and communicate their hunger. In some cases when a baby is able to cry, she may still be too weak to suck enough breast milk to fill her hungry stomach. She may get tired and fall asleep without eating enough.



These weaknesses often go unnoticed due to lack of knowledge among parents. As a result, the manjala-wala was consistently drinking less milk than the other two babies and he, like many other low birth weight babies, developed neonatal jaundice, which turned his skin yellow. The bilirubin concentration in his blood had increased to thrice the amount considered normal.



His stomach got distended, he went on a nursing strike, and he was getting more lethargic with every minute that passed. “Over twelve hours have passed since he had a good feed,” said Manju. She tried all means that were available – from latching the manjala-wala on her breast to expressing her milk and using a spoon – to feed her dying son. But the baby would not respond.

By Nikhil Srivastav with inputs from Aashish Gupta



(Some names and identifying details have been changed to protect the privacy of individuals. Nikhil Srivastav is Research and Policy Manager at r.i.c.e., a research institute for compassionate economics. Aashish Gupta is a non-resident fellow at r.i.c.e. and a Ph.D. candidate in Demography at University of Pennsylvania.)



(This is the first part of a two-part piece. The second part will be published on March 2)

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