When a mother ‘can’t cope’: The tragedies in death of Bengaluru twin babies

The symptoms had lasted at least two-and-a-half months, beginning six weeks after Umadevi delivered their twin daughters. Their birth, on May 5, came after a long wait for the couple and one round of failed IVF. On September 1, Umadevi allegedly drowned the four-month-olds, and was stopped on time as she was trying to kill herself.

Ramelingappa says that while Umadevi appeared to be coping after the birth of the twins, changes in her behaviour were evident after a while. She began sleeping and eating poorly, became withdrawn and repeatedly told her husband and mother-in-law that she was “frightened” of the babies and did not feel capable of caring for them.

At times, she said she wanted to send the children to an ashram or go there herself, he says.

Geetha Desai, Professor of Psychiatry at NIMHANS and professor in-charge of its Mother-Baby Unit, says these are symptoms typical of postpartum mental illness.

“Women with postpartum depression may experience persistent sadness, anxiety, exhaustion, loss of appetite and difficulty sleeping. Some may also develop a deep sense of inadequacy and feel that they are not capable of caring for their baby,” Desai adds.

Umadevi, who had come to NIMHANS earlier too for treatment, is back at the institute after the death of the twins.

While the Bengaluru Police has registered a case in connection with the deaths and Umadevi’s attempt to take her own life, she is under psychiatric care and her medical condition is being assessed before further course is decided.

Could the deaths have been averted?

Sources familiar with Umadevi’s case say the tragedy could have been prevented had she got medical help on time.

Ramelingappa says they tried, as best as they knew. He and his mother took over the bulk of the care of the twins as Umadevi battled symptoms, and consulted a psychiatrist in Bengaluru. Umadevi met the psychiatrist, but there was no improvement. So, on August 8, the family took her to NIMHANS.

Ramelingappa says the 40-year-old was assessed for postpartum depression, prescribed medication, and advised inpatient psychiatric treatment. But Umadevi refused admission.

“She had seen patients being physically restrained and was afraid the same would happen to her. Her condition also kept fluctuating. On some days she appeared normal, while on other days she was withdrawn, anxious and struggled to eat or sleep,” Ramelingappa says, describing the ups and downs which also lie at the heart of the Clancy case. The family and ex-husband of Clancy – who is paralysed from waist down after throwing herself out of a window after allegedly killing her children – have sued her doctors for “medical malpractice”, saying they missed the extent of her troubles.

The day of the incident, Ramelingappa was at home till about 12.20 pm, when he had to step out for some work and to make arrangements for a religious ceremony the family was planning in their native village in Andhra Pradesh, to mark the twins’ birth. The ceremony is usually held when a baby enters the third month, but the family had postponed it as Umadevi was not keeping well.

Ramelingappa’s mother, two sisters and Umadevi’s mother were at home with her and the twins.

In his complaint at the Talaghattapura Police Station, Ramelingappa said that when he returned around 2.50 pm, the family told him Umadevi had locked herself into a room with the twins, covering the window with a cloth.

Ramelingappa told police that he forced open the door with the help of a friend, and found Umadevi near the window grille with a dupatta around her neck. The family rushed to untie it and found her struggling to breathe.

The twins were discovered in their cradle, unresponsive. They were taken to a nearby hospital, where doctors declared them dead of suspected drowning.

Soon after, Umadevi was taken to NIMHANS.

Why time is of the essence

A systematic review and meta-analysis of postpartum depression, published in the Bulletin of the World Health Organization in 2017, estimated the prevalence of the condition to be as high as around 22% among newborn mothers, or over one in five of them.

A similar review, published this year in the journal Women and Health, covering 62 studies and more than 21,000 women, reported a prevalence rate of 23.5%.

However, not all women with postpartum depression require hospitalisation or intensive psychiatric care, points out Sundarnag, a Professor in the NIMHANS Psychiatry Department. Many women can be treated within the family environment, with medication, psychological intervention and regular follow-ups.

But, if the illness becomes severe, some women may become withdrawn and develop thoughts of harming themselves or, in some cases, their babies, says Desai.

Postpartum psychosis, a much-rarer condition, can develop rapidly and may involve a loss of touch with reality, including fixed false beliefs, hallucinations and extreme suspiciousness, adds Desai.

In a written response to questions from The Indian Express, Dr Rezaul Hamid, a consultant psychiatrist and researcher, as well as founder of the Assam-based Mindcare Neuro Psychiatry Research Centre, said: “Postpartum psychosis affects approximately one to two women per 1,000 deliveries.” He also said that while it may begin within the first two weeks after delivery, “clinically significant onset may occur during the broader six-week… period (after delivery)” – the same timeframe as when Umadevi’s symptoms reportedly appeared.

Dr Hamid identified “emergency warnings signs” as “near-total insomnia, confusion, rapidly changing behaviour, suspiciousness, hallucinations, infant rejection, suicidality”, among others.

Dr Hamid also emphasised that “the overwhelming majority of women” with postpartum depression or psychosis “do not harm their children”.

Prof Harish Thippeswamy, Professor of Psychiatry at NIMHANS and Deputy Medical Superintendent, says many families turn to faith healers or rituals in search for a cure, losing crucial time.

A 2018 study by Thippeswamy, Desai and Prof Prabha Chandra, involving 123 women with postpartum severe mental illness treated at NIMHANS, found that 52.8% had first sought help from a psychiatrist, 26% from a faith healer and 21.1% from a general medical practitioner. As many as 44% of the women were found to have seen delay in getting psychiatric care.

Sources familiar with the investigation into the Umadevi case suspect her condition developed over time, starting with the prolonged struggle to conceive, and getting compounded due to an unsuccessful IVF attempt. After she struggled to cope, her reluctance to be admitted for treatment may have worsened matters.

Dr Hema Divakar, consultant obstetrician and gynaecologist at Divakars Speciality Hospital, Bengaluru, and former president of the Federation of Obstetric and Gynaecological Societies of India, says mental health problems can sometimes start from pregnancy itself.

She points to the pressure surrounding pregnancy, particularly when conception has followed years of fertility treatment, as well as the pressure mothers bring upon themselves.

Calling for mental health screening to be made part of routine antenatal and postnatal care, rather than being considered only if a mother develops severe symptoms, Divakar says: “Even a brief set of questions can help identify women who may need further assessment.”

Ramelingappa and Umadevi’s twin daughters are buried in a grave that bears no names. The four-month-olds were yet to be given one.

More than 1 in 5 affected

* Studies put the prevalence of postpartum depression at around 22% of new mothers, or more than one in five

* Postpartum psychosis, a much-rarer condition, may afflict one to two women per 1,000 deliveries, says an expert

* A 2018 study of women with postpartum severe mental illness at NIMHANS found 44% of them saw a delay in getting psychiatric care