Abstract
Recent maternal deaths following emergency cesarean deliveries in peripheral hospitals of Rajasthan have highlighted critical gaps in antenatal care. Most cases involved high-risk conditions such as toxemia of pregnancy, HELLP syndrome, and severe anemia. While surgical complications were immediate causes, upstream factors in antenatal management require urgent investigation.
The widespread use of Ayurvedic preparations during pregnancy—often unrecorded by ASHA workers, ANMs, and traditional birth attendants—may contribute to maternal vulnerability through herbal uterotonic effects, hormonal imbalances, and heavy-metal toxicity.
This deliberation proposes a structured investigation framework integrating clinical audits, toxicological analysis, and community-level surveys to systematically assess the role of Ayurvedic remedies in maternal morbidity and mortality.
By triangulating evidence across these domains, Rajasthan’s expert teams can identify preventable risk factors, strengthen antenatal surveillance, and ensure safer maternal outcomes.
Key Points from the Abstract
- Recent maternal deaths have exposed significant gaps in antenatal care in Rajasthan.
- Most affected women had high-risk conditions, including toxemia of pregnancy, HELLP syndrome, and severe anemia.
- Surgical complications were immediate causes, but upstream antenatal factors require investigation.
- Ayurvedic preparations used during pregnancy are often not documented by ASHA workers, ANMs, or traditional birth attendants.
- Potential concerns include herbal uterotonic effects, hormonal imbalances, and heavy-metal toxicity.
- A structured investigation framework is proposed using clinical audits, toxicological analysis, and community-level surveys.
- The goal is to identify preventable risk factors, strengthen antenatal surveillance, and improve maternal outcomes.
Proposed Investigation Framework Overview
| Investigation Component | Primary Objective |
|---|---|
| Clinical Audits | Evaluate antenatal records, obstetric management, and maternal risk factors. |
| Toxicological Analysis | Assess potential herbal and heavy-metal exposure from Ayurvedic preparations. |
| Community-Level Surveys | Document the prevalence and patterns of Ayurvedic remedy use during pregnancy. |
| Evidence Triangulation | Integrate findings to identify preventable contributors to maternal morbidity and mortality. |
What Are the Ayurvedic Preparations That Are Prescribed or Recommended to Pregnant Women in Rural Areas?
In rural India, pregnant women are often prescribed Ayurvedic preparations under Garbhini Paricharya (antenatal care), which emphasize milk, ghee, herbal powders, and medicated oils to support fetal growth, maternal strength, and lactation. Commonly recommended herbs include Shatavari, Ashwagandha, Yashtimadhu, and Sariva, usually taken with milk or ghee.
Key Ayurvedic Preparations for Pregnant Women
1. Dietary Preparations
The foundation of Ayurvedic pregnancy care focuses on nourishing and easily digestible foods.
- Milk & Ghee: Daily intake of milk (200 ml or more) and ghee is emphasized for nourishment and lactation.
- Sweet, Liquid, Semi-Solid Foods: Kheer (rice/ragi/daliya pudding), khichdi, fruit juices (grapes, pomegranate, orange).
- Digestive Aids: Cumin (Jeeraka) and dry ginger (Shunthi) powders are added to food for better digestion.
2. Herbal Powders & Pastes (Masanumasika Paricharya – Month-Wise Regimen)
Ayurveda recommends different herbal formulations according to the stage of pregnancy.
| Pregnancy Stage | Recommended Ayurvedic Preparations |
|---|---|
| Early Pregnancy (1st–3rd Month) | Yashtimadhu (Glycyrrhiza glabra), Ashwagandha (Withania somnifera), Devadaru (Cedrus deodara) with milk. |
| 4th–5th Month | Shatavari (Asparagus racemosus), Ashwagandha, Yashti, Kharjura (dates) medicated milk. |
| 4th–5th Month (Additional) | Sariva (Hemidesmus indicus), Madhuka flowers, Shatavari with milk. |
| 6th Month Onwards | Ghee medicated with Gokshura (Tribulus terrestris). |
| 6th Month Onwards | Herbal powders of Draksha (grapes), Yashti, Sariva, Rasna, taken with milk. |
| Later Months (7th–9th) | Complex formulations including Brhati, Kantakari, Gambhari, Nyagrodha, Udumbara, Ashwattha, Dalchini (cinnamon) with milk. |
3. External Applications
Ayurveda also recommends external therapies to improve maternal comfort during pregnancy.
- Abhyanga (Oil Massage): Warm sesame or coconut oil, or medicated oils like Bala taila and Dhanwantharam taila, used from the second trimester to reduce Vata imbalance, improve circulation, and prepare skin for stretching.
- Skin Care for Abdominal Itching/Stretch Marks: Pastes of Neem, Tulsi, Manjistha, and Badar applied locally.
Summary of Common Ayurvedic Preparations
| Category | Common Preparations | Purpose |
|---|---|---|
| Diet | Milk, Ghee, Kheer, Khichdi, Fruit Juices | Nourishment and lactation support |
| Herbal Preparations | Shatavari, Ashwagandha, Yashtimadhu, Sariva, Gokshura, Draksha | Support fetal growth and maternal strength |
| Digestive Aids | Jeeraka (Cumin), Shunthi (Dry Ginger) | Improve digestion |
| External Therapies | Bala Taila, Dhanwantharam Taila, Sesame Oil, Coconut Oil | Reduce Vata imbalance and improve skin elasticity |
Risks & Considerations
- Medical Supervision Is Essential: While these preparations are widely used in rural areas, dosage and suitability vary by individual.
- Potential Risks: Some herbs (e.g., Ashwagandha) may cause uterine stimulation if taken in excess.
- Integration with Modern Care: Ayurveda is often practiced alongside antenatal check-ups; rural women may rely more on traditional remedies due to accessibility and cultural continuity.
Takeaway
Ayurvedic antenatal care in rural India blends milk, ghee, herbal powders, and oil massages to strengthen the mother and nourish the fetus. Preparations are month-specific and emphasize gentle, digestible, and nourishing foods. However, professional guidance is critical to avoid misuse and ensure safe pregnancy outcomes.
Q. What Are the Known or Possible Adverse Effects of These Preparations in Terms of Their Ingredients of Powerful Herbs and Heavy Metal Ingredients?
Ayurvedic preparations given to pregnant women can pose serious risks when they contain powerful herbs or heavy metals. Documented adverse effects include miscarriage, stillbirth, congenital malformations, impaired fetal growth, and maternal toxicity due to lead, mercury, and arsenic contamination.
Risks From Herbal Ingredients
Many herbs used in Garbhini Paricharya are considered nourishing, but some have uterotonic or hormonal effects that can be dangerous in pregnancy if misused:
- Ashwagandha (Withania somnifera)
- Can stimulate uterine contractions; high doses may increase miscarriage risk.
- Shatavari (Asparagus racemosus)
- Generally considered safe, but excessive use may cause hormonal imbalance.
- Yashtimadhu (Liquorice Root)
- Contains glycyrrhizin, which can raise blood pressure and cause edema.
- Guggulu (Commiphora mukul)
- Known for anti-inflammatory effects, but may stimulate uterine activity.
- Neem, Tulsi, Manjistha (Used Externally or Internally)
- Neem in particular has abortifacient properties in high doses.
Summary of Herbal Risks
| Herb | Possible Adverse Effect During Pregnancy |
|---|---|
| Ashwagandha (Withania somnifera) | May stimulate uterine contractions; increased miscarriage risk at high doses. |
| Shatavari (Asparagus racemosus) | Excessive use may cause hormonal imbalance. |
| Yashtimadhu (Liquorice Root) | May increase blood pressure and cause edema due to glycyrrhizin. |
| Guggulu (Commiphora mukul) | May stimulate uterine activity. |
| Neem, Tulsi, Manjistha | Neem has abortifacient properties in high doses. |
Risks From Heavy Metals
Several Ayurvedic formulations, especially Rasa Shastra preparations, intentionally include metals processed with herbal purification. However, contamination or improper preparation can lead to toxicity:
- Lead
- Causes maternal anemia, kidney damage, hypertension.
- Fetal effects: neurodevelopmental delay, low birth weight, miscarriage.
- Mercury
- Neurotoxic; can impair fetal brain development.
- Cadmium
- Associated with placental damage and impaired fetal growth.
- Arsenic
- Linked to congenital malformations and increased risk of stillbirth.
Heavy Metal Effects During Pregnancy
| Heavy Metal | Maternal Effects | Foetal Effects |
|---|---|---|
| Lead | Maternal anemia, kidney damage, hypertension | Neurodevelopmental delay, low birth weight, miscarriage |
| Mercury | Neurotoxicity | Impaired fetal brain development |
| Cadmium | Placental damage | Impaired fetal growth |
| Arsenic | Toxicity | Congenital malformations, stillbirth |
Studies in India have found lead levels up to 18.56 mg/kg and mercury contamination in indigenous pregnancy preparations, far exceeding safe limits.
Documented Adverse Outcomes
- Stillbirths and congenital malformations reported in women consuming contaminated indigenous preparations.
- Lead poisoning cases in pregnant women in New York traced to Ayurvedic medicines imported from India, with blood lead levels as high as 64 µg/dL.
- Maternal toxicity: kidney and liver damage, hypertension, neurological symptoms.
- Fetal toxicity: impaired growth, neurodevelopmental delay, miscarriage.
Summary of Documented Outcomes
| Category | Reported Outcome |
|---|---|
| Pregnancy Loss | Miscarriage, stillbirth |
| Congenital Effects | Congenital malformations |
| Maternal Health | Kidney damage, liver damage, hypertension, neurological symptoms |
| FoetalFoetal Development | Impaired growth, neurodevelopmental delay, low birth weight |
| Heavy Metal Exposure | Lead poisoning and mercury contamination documented in indigenous preparations |
Takeaway
While Ayurvedic antenatal care emphasizes natural nourishment, powerful herbs and heavy-metal-based formulations can be unsafe in pregnancy. Risks include miscarriage, congenital anomalies, and maternal organ damage.
- Pregnant women should avoid unregulated Ayurvedic preparations.
- Extra caution is required with formulations containing Rasa Shastra metals.
- Potent herbal preparations should only be used under professional supervision.
- Qualified Ayurvedic physicians should prescribe such medicines only after proper safety checks.
Best practice: Pregnant women should avoid unregulated Ayurvedic preparations, especially those containing Rasa Shastra metals or potent herbs, unless prescribed by a qualified Ayurvedic physician with proper safety checks.
Q. Asha Workers, ANMs and Traditional Birth Attendants Who Recommend or Suggest Use of Such Preparations – Do They Keep Any Record of It? Is It Communicated to the Doctor When These Women Go for or Sent to the Hospital for Delivery?
In practice, ASHA workers, ANMs (Auxiliary Nurse Midwives), and traditional birth attendants (TBAs) in rural India rarely keep formal records of Ayurvedic or indigenous preparations recommended during pregnancy. Here’s how it typically works:
Record-Keeping Practices
ASHA & ANM Workers
- Their official registers (Mother and Child Protection Card, antenatal care registers) focus on iron–folic acid tablets, tetanus immunization, weight, BP, hemoglobin, and institutional referrals.
- Indigenous remedies or Ayurvedic preparations are not systematically documented in government records.
- Some ASHAs may note “home remedies” informally in personal diaries, but this is not standardized.
Traditional Birth Attendants (Dais/TBAs)
- Usually rely on oral tradition and community knowledge.
- They do not maintain written records of herbal or Ayurvedic prescriptions.
- Advice is passed verbally, often without dosage or ingredient details.
Communication to Doctors
At Hospital Admission for Delivery
- Doctors and nurses typically receive information only about visible complications (e.g., bleeding, edema, convulsions).
- Use of Ayurvedic or indigenous preparations is rarely volunteered by the patient or reported by ASHA/ANM workers, unless specifically asked.
- This creates a blind spot: physicians may not know if the woman has consumed herbs with uterotonic effects or heavy-metal-containing preparations.
Barriers to Communication
- Cultural hesitation: Women may not disclose traditional remedies, fearing disapproval.
- Lack of awareness: ASHAs/ANMs may not recognize the potential toxicity of Ayurvedic formulations.
- Systemic gap: No structured mechanism exists to integrate indigenous medicine use into antenatal or delivery records.
Summary Table
| Aspect | Current Practice | Impact |
|---|---|---|
| ASHA & ANM Records | Focus on routine antenatal care; Ayurvedic preparations are generally not recorded. | Important exposure history may be missed. |
| Traditional Birth Attendants | Depend on oral knowledge without written documentation. | No reliable treatment history is available. |
| Communication with Doctors | Usually limited to pregnancy complications rather than traditional medicine use. | Potential risks remain unknown during treatment. |
| System Gap | No structured mechanism for documenting indigenous remedies. | Public health surveillance remains incomplete. |
Implications
- Doctors may miss important clues about toxicity, drug interactions, or uterine stimulation.
- Adverse outcomes (miscarriage, preterm labor, neonatal complications) may be wrongly attributed to “unknown causes.”
- Without documentation, public health surveillance cannot capture the risks of these preparations.
Takeaway
ASHA workers, ANMs, and TBAs do not formally record or communicate the use of Ayurvedic preparations to hospital staff. This gap means obstetricians often remain unaware of potentially harmful herbal or heavy-metal exposures during pregnancy.
A practical solution would be to add a simple column in antenatal registers for “traditional/home remedies used,” so that frontline workers can note them and doctors can assess risks during hospital delivery.
Q. Recently Wide Spread Post Cesarean Delivery Deaths Have Been Reported from Peripheral Hospitals of Rajasthan
Recently wide spread post cesarean delivery deaths have been reported from peripheral hospitals of Rajasthan. Expert teams have been detailed to investigate. What has emerged is they were all in emergency cesarean operations in high risk cases. The reported high risk conditions were Hypertension as Toxemia of Pregnancy, HELLP (Hemolysis, Elevated Liver Enzymes, and Low Platelets) Syndrome, severe Anemia etc. The cause of increase in number of such cases would be in the antenatal care provided. Use of Avurvedic preparations in antenatal care has greatly increased, Should it not be investigated?
Upstream Causes in Antenatal Care Deserve Equal Scrutiny
You are absolutely right to raise this concern. When clusters of maternal deaths occur after emergency cesarean deliveries in high-risk cases like toxemia of pregnancy, HELLP syndrome, and severe anemia, the immediate clinical factors are clear. But the upstream causes in antenatal care deserve equal scrutiny.
Why Ayurvedic Preparations Should Be Investigated
- Growing use in rural antenatal care: Reports indicate that reliance on Ayurvedic and indigenous remedies has increased, often promoted by local health workers or traditional practitioners.
- Potential contribution to high-risk conditions:
- Licorice (Yashtimadhu) → can worsen hypertension and edema.
- Ashwagandha → may stimulate uterine activity, unsafe in preeclampsia.
- Heavy-metal containing Rasa Shastra medicines → can cause anemia, liver dysfunction, and thrombocytopenia, mimicking or aggravating HELLP.
- Documentation gap: As discussed earlier, ASHA/ANM workers rarely record indigenous remedy use, so hospitals may not know what exposures occurred during pregnancy.
- Public health blind spot: Without systematic inquiry, the role of these preparations in worsening maternal risk factors remains invisible.
Why This Matters for Rajasthan’s Investigation
The following observations explain why this issue deserves careful examination:
| Observation | Possible Significance |
|---|---|
| The pattern of deaths in emergency cesareans suggests women were already critically unstable before surgery. | May indicate underlying antenatal risk factors rather than surgical causes alone. |
| If antenatal care included unregulated Ayurvedic preparations. | Potential exposure requiring investigation. |
| Masked anemia until late stages. | Could delay diagnosis and treatment. |
| Exacerbated hypertension or liver dysfunction. | May increase the severity of pregnancy-related complications. |
| Introduced toxic exposures (lead, mercury, arsenic). | Potential contributor to maternal morbidity requiring toxicological assessment. |
| Investigating this link could explain why peripheral hospitals saw sudden spikes in maternal mortality despite following surgical protocols. | May help identify preventable antenatal risk factors. |
Recommended Steps
- Include indigenous medicine use in case audits: Every maternal death review should ask explicitly about Ayurvedic/home remedies.
- Toxicology screening: Blood samples for lead, mercury, arsenic, and herbal alkaloids in affected mothers.
- Training frontline workers: ASHAs/ANMs should be sensitized to record and report traditional remedy use.
- Policy integration: State maternal health programs should add a column in antenatal registers for “traditional preparations used.”
- Community awareness: Educate families about risks of unregulated herbal and metallic preparations in pregnancy.
Summary Table of Key Recommendations
| Recommendation | Objective |
|---|---|
| Include indigenous medicine use in maternal death audits. | Identify possible contributing exposures. |
| Conduct toxicology screening. | Detect heavy metals and herbal toxins. |
| Train ASHAs and ANMs. | Improve documentation of traditional medicine use. |
| Integrate reporting into antenatal records. | Strengthen surveillance and policy planning. |
| Increase community awareness. | Reduce avoidable maternal health risks. |
Conclusion
Yes, the widespread use of Ayurvedic preparations in antenatal care must be investigated as a possible contributing factor to the surge in maternal deaths after emergency cesareans in Rajasthan. Ignoring this dimension risks missing a preventable cause of maternal morbidity and mortality.
Q. Draft a Structured Investigation Framework (With Clinical, Toxicological, and Community-Level Components) That Rajasthan’s Expert Teams Could Adopt to Systematically Assess the Role of Ayurvedic Preparations in These Deaths.
Here’s a structured investigation framework that Rajasthan’s expert teams could adopt to systematically assess the role of Ayurvedic preparations in the recent maternal deaths:
Clinical Component
Case Audit of Maternal Deaths
- Collect detailed antenatal histories (including traditional remedies).
- Document high-risk conditions (hypertension, HELLP, anemia) and their progression.
- Review timing of complications relative to use of Ayurvedic preparations.
Hospital Records Review
- Examine admission notes for disclosure of indigenous remedies.
- Compare outcomes between women who reported Ayurvedic use vs. those who did not.
Risk Factor Correlation
- Assess whether Ayurvedic preparations contributed to worsening anemia, hypertension, or liver dysfunction.
- Identify patterns (e.g., clustering of HELLP cases among users of certain remedies).
Clinical Component Summary
| Focus Area | Investigation Objective |
|---|---|
| Maternal Case Audit | Review antenatal history, traditional remedies, and disease progression. |
| Hospital Records | Identify disclosure of Ayurvedic medicine use and compare outcomes. |
| Risk Correlation | Assess links between Ayurvedic preparations and maternal complications. |
Toxicological Component
Sample Collection
- Blood, urine, and hair samples from affected mothers (or stored biological material).
- Collect leftover medicines, powders, oils, or ghee preparations used antenatally.
Laboratory Analysis
- Heavy metals: lead, mercury, arsenic, cadmium.
- Herbal alkaloids and glycosides (e.g., glycyrrhizin from licorice, uterotonic compounds).
- Adulterants or contaminants (e.g., steroids, synthetic drugs).
Correlation with Clinical Findings
- Match toxicology results with maternal complications (e.g., lead → anemia, mercury → liver dysfunction, licorice → hypertension).
Toxicological Component Summary
| Investigation Area | Purpose |
|---|---|
| Biological Samples | Identify evidence of toxic exposure. |
| Medicine Testing | Detect heavy metals, herbal toxins, adulterants, and contaminants. |
| Clinical Correlation | Link laboratory findings with maternal complications. |
Community-Level Component
Field Surveys
- Interview ASHA workers, ANMs, TBAs about common antenatal remedies recommended.
- Document sources of Ayurvedic preparations (local vaidyas, over-the-counter, homemade).
Community Practices
- Identify cultural drivers of increased Ayurvedic use (beliefs, accessibility, cost).
- Map distribution networks of these preparations in rural areas.
Awareness & Disclosure
- Assess whether women disclose use of traditional remedies to health workers.
- Identify barriers to communication (fear of disapproval, lack of awareness).
Community-Level Component Summary
| Area | Objective |
|---|---|
| Field Surveys | Understand the prevalence of antenatal Ayurvedic remedy use. |
| Community Practices | Identify cultural and accessibility factors driving usage. |
| Disclosure Assessment | Evaluate communication gaps between pregnant women and healthcare providers. |
Integration & Reporting
Multidisciplinary Review Board
Clinicians, toxicologists, public health experts, and Ayurvedic specialists jointly analyze findings.
Data Triangulation
Link clinical outcomes, toxicology results, and community practices.
Policy Recommendations
- Add “traditional remedy use” column in antenatal registers.
- Train ASHAs/ANMs to record and report indigenous medicine use.
- Regulate distribution of Ayurvedic preparations in pregnancy.
- Launch awareness campaigns on risks of unregulated remedies.
Policy Recommendations Summary
| Recommendation | Expected Benefit |
|---|---|
| Add traditional remedy documentation | Improve maternal health surveillance. |
| Train ASHAs and ANMs | Enhance early identification of potential risks. |
| Regulate Ayurvedic preparations | Reduce exposure to unsafe or contaminated products. |
| Community awareness campaigns | Promote informed decision-making during pregnancy. |
Conclusion
This framework ensures that Rajasthan’s investigation does not stop at surgical outcomes but probes the antenatal exposures that may have predisposed women to fatal complications. It combines clinical audits, toxicology testing, and community surveys to build a complete picture.
Highlights
- Maternal deaths cluster in high-risk cases: Emergency cesarean fatalities in Rajasthan were predominantly linked to toxemia of pregnancy, HELLP syndrome, and severe anemia.
- Unregulated Ayurvedic use is a hidden risk: Widespread antenatal reliance on herbal and metallic preparations may exacerbate hypertension, anemia, and liver dysfunction, yet remains undocumented in official records.
- Documentation gap undermines surveillance: ASHA workers, ANMs, and TBAs rarely record indigenous remedy use, leaving clinicians unaware of exposures during hospital admissions.
- Toxicology screening is essential: Heavy-metal contamination (lead, mercury, arsenic) and potent herbal compounds must be investigated as contributors to maternal morbidity and mortality.
- Policy integration required: Adding “traditional remedy use” to antenatal registers, training frontline workers, and regulating distribution of risky preparations can strengthen maternal health systems and prevent avoidable deaths.
Written By: Dr.Shri Gopal Kabra, MBBS, LLB, MSc, MS(Anatomy), MS(Surgery) Director Clinical Services, Bhagwan Mahaveer Cancer Hospital, Jaipur-302017
Email: [email protected], Ph no: 8003516198
