Monday, 28 March 2011
Approach to genetic problems in rural setup
APPROACH TO GENETIC PROBLEMS IN A RURAL SETUP Dr. Shantanu Abhyankar M.D. (Ob & Gy) Modern Clinic, Wai (Satara) Maharashtra, INDIA PIN 412 803 Mb 98220 10349 INTRODUCTION Though India is being looked upon as a rapidly urbanizing society it is still a long way to go before the medical services available to the urbanites are as readily available to the rural masses. Rural practitioners find themselves in a very peculiar predicament. They are faced with a demand for the best out come with minimum expenditure. Financial considerations often overrule necessity. Medical insurance is non-existent and companies that do offer medical insurance, anyway exclude pregnancy and related disorders. Illiteracy, especially amongst the women, blind faith, social taboos, the low social status of women, ill conceived notions about pregnancy, birth defects and untoward out come all contribute to a rural practitioner’s woes. In rural areas, Doctors are (still) next to god. They are expected to provide clear unambiguous directions as to what to do next and ‘yes’ or ‘no’ answers to all queries. All the talk about counseling in a non-judgmental and non-directional manner comes a cropper when faced with such a clientele. This not to suggest that it is a lose-lose situation; it is quite the contrary. With a little bit of insight in the subject, a rural practitioner can offer his expertise and services to the optimum. WHAT DOCTORS CAN DO? Be net Savvy. Doctors need to net savvy. This is the least that they are expected to do. With internet, access readily available, getting on the net is as easy as breathing. Sites such as http://www.nlm.nih.gov/medlineplus/geneticbirthdefects.html http://www.cdc.gov http://www.birthdefects.co.uk http://www.marchofdimes.com/pnhec/4439_1206.asp provide a wealth of information. Promote Rubella vaccination Rubella is a mild disease in adults but causes serious disorders in their babies. Fortunately, we have a single dose, effective vaccine. Though many rural women are likely to be immune from natural infection, giving the vaccine is not going to cause any harm. Textbooks advise an IgG test to access need for vaccination. This test is costly, not readily available, and has to be interpreted with caution. It is better to vaccinate, than to test and vaccinate, if need be. Not many rural women will seek pre concept ional advice and avail of this service. They visit a doctor only several weeks after missing a period. Nevertheless, there are three groups of women who can be readily offered vaccination. Women undergoing treatment for infertility may be advised vaccination after due counseling. So also, post-partum and post-abortal patients may be offered this injection. Contraception for a period of three months post vaccination has been advised for the fear of iatrogenic vertical infection, since this is a live vaccine. Nevertheless, these fears are now considered more imaginary than real. Promote preconception folic acid Folic acid prophylaxis can be offered to prevent neural tube defects. A dose of 400 to 500 mcg daily is suggested for at least three months before conception. Though all couples are expected to seek counseling before conception, no one really turns up for this in rural areas. Practically we can offer this to post-abortal women, to women on O.C. pills and to women taking treatment for infertility. Picking up Thalassemia Thalassemics are the tip of the iceberg and thalassemia traits are much more common than we presume. Thalassemia is common in certain communities in India. Consanguinity will add to the problem. Ideally, a person needs to undergo Hb & CBC with blood indices, hemoglobin pattern analysis and HbA2 determination by HPCL method for a diagnosis as normal, trait or thalassemia major. However, certain features in the heamogram can help as indicators, and thus be used as cheap, universally available screening test. One may thus cull cases that are high risk for having the thalassemia trait. An RBC count of over 4.5million/cmm, with a MCV of <72fl and MCH of <22 pg is indicative of some type of hemoglobinopathy. This simple test should be a part of your antenatal profile. Correct interpretation of TORCH tests There are misconceptions galore as far as these tests are concerned. Certain guidelines need to borne in mind. Firstly, none of the TORCH agents is responsible for recurrent pregnancy loss. Secondly if ever we have to rationally diagnose and treat TORCH we should be running the test, on paired sera, drawn at least three weeks apart. Testing just once is useless, not informative enough and a waste of money. While a raised or rising IgM (regardless of the quantum) will suggest active infection, which beckons attention; a raised IgG suggests that the woman is presently immune to infection by that particular agent. A rising IgG, where levels rise by over 4 times in those paired tests, will indicate rekindling of disease and will need to be tackled. For all the agents maternal infection does not mean fetal affection. TORCH is not a routine screening test and in absence of any stigmata in the fetus, the results will throw up more questions than answers. Get recognized as a genetic center. Any place undertaking prenatal diagnostic studies needs to be recognized under the PNDT act. Such recognition is necessary even to undertake the simplest of tests such as amniocentesis. The conditions to be fulfilled are very simple and all gynecologists will find it very easy to conform to these conditions. It is thus advisable to get your place recognized as a genetic center and not just as an ultrasound clinic. By so doing, you will be able to undertake any of the prenatal diagnostic procedures yourself. Most of these procedures are simple and easy (many certainly easier than a vaginal hysterectomy). Follow up problems to the hilt Advise patients to follow up and investigate any anomaly to the hilt. Mental retardation, blindness, hearing loss, abnormal facies, physical deformities, chronic anemia or jaundice all need to be thoroughly investigated and diagnosed to the last syllable. Usually when a condition is incurable or fetal loss has occurred, the relatives are not very enthusiastic about correct diagnosis. Getting a consent for autopsy is always tricky. They should be told that a correct and complete diagnosis may lead to better management of the next pregnancy. Consanguinity This has its disadvantages as well as advantages! It maintains family ties and retains property within the family. The practice has evolved and is prevalent in many communities around the globe. In India, marriages between first cousins (children of a brother and sister marrying each other) and uncle-niece marriages are frequent. Counseling for a prospective nuptial relationship is very tricky. It should made clear at the very outset that by accepting or refusing a prospective relationship one is only reducing (or increasing) the risk of undesirable consequences of consanguinity. One can never nullify the risk of having a child with birth defect. The risks for multifactorial (NTD, cleft lip/palate, etc:) and autosomal dominant disorders are increased for the progeny of a consanguineous couple. However, these always appear to be exaggerated. The population risk is 2 to 3% while for the couple it is around 5 to 6%! CONCLUSION Though faced with many hurdles the rural practitioner can contribute to reducing the burden of birth defects in the society. With the advent of internet, the gap between a village and a city is narrowing. The rural practitioner thus should keep up with the times.
Thursday, 24 March 2011
Innovative measures to curb maternal mortality in India
Innovative measures to curb Maternal Mortality in India.
Dr. Shantanu Abhyankar
Introduction
It is no secret that the Indian society is ridden with class, caste and gender biases. All of these have worked against women for centuries. Our society has often been likened to a four-storied pyramid with the lower castes forming the base, the most oppressed section. However, it is obvious that there is one more layer to this pyramid. That below all the four layers lies the one representing women from all castes and classes of society. They form the most neglected group of the population.
Mother India is cursed with high maternal mortality. It is the result of social apathy for women, wrong priorities and poor political will. For a nation aspiring to be a superpower in near future, it is a real shame that mothers die avoidable deaths.
SHAME also is the acronym to summarize the causes.
S Sepsis
H Hemorrhage
A Abortion
M Malnourishment
E Eclampsia
I will delve on the topic touching ONLY INNOVATIVE MEASURES as the usual answers to this problem are all too well known.
SEPSIS
The best way to avoid sepsis is to have all deliveries under supervised conditions ideally in the safety of well managed maternity units. Where this is not possible home deliveries using FIVE CLEANS are good too.
The health infrastructure comes under scrutiny if a mother dies in the hospital, and rightly so, but who is responsible for allowing women to deliver at an unsafe place? The law does not hold anyone responsible for this. It is entirely up to the family to decide whether to take the mother to be, in the hospital or to call a birth attendant, or even worse, leave everything to nature and not do anything at all. There is good scope for a law to be enacted and widely publicized making it mandatory for the guardians of a pregnant woman to provide good care. If it is illegal for a mother to abandon her child, of a husband to abandon his wife and for grownups to disregard their parents; why should it not be illegal for family to ignore the basic needs of a pregnant lady? Having a law in place does not automatically change attitudes but it provides a good footing for those trying to usher in the change.
HEAMORRHAGE
PPH happens to be an important cause of maternal mortality in our country. Woefully inadequate assess to blood transfusion services is a problem too. Obstetric hemorrhage is notoriously unpredictable in timing as well as volume. Quick transport by ambulance is not readily available. It is therefore imperative that our blood transfusion service should spread and be available far and wide. If delivery is to be in the ‘safe mode’, it should be within an hour’s travel time from the blood transfusion service and other expert help. Otherwise even a supervised delivery is in fact unsafe! The supervisor may hasten the decision for need of expert help but what use is the decision if no expert, no infrastructure, and no blood banks are available?
There has recently been a marked shift in the policy. The concept of satellite centers for far-flung areas has been mooted. A three-tier system has been envisaged where the regional blood transfusion center (RBTC) will be the apex body responsible for training, quality control, as well as research apart from routine blood banking activities. The blood banks under the RBTC will collect test and store blood & blood components and send it to satellite centers in remote areas. The satellite centers are responsible only for cross matching the needed product (whole blood, FFP etc) and issue the bag.
Unfortunately the system exists only on paper. Very few satellite centers are actually in place. Public interest litigation (PIL) following the AIDS epidemic was what forced the government to formulate the three tier system. May be another PIL will actually get us the satellite centers, at least one in every taluka place and at every FRU. I feel that the onus to collect and collate data regarding this lies squarely on organizations like FOGSI. (I must remind you that it was a PIL by an NGO that brought in the PCPNDT act.) Public health is the responsibility of the government, high MMR is a public health issue and it is only the government which has the reach to set up satellite centers all over the country, create a network of blood banks, maintain cold chain and keep the show running 24*7. A PIL will force the government to promise a time bound implementation and FOGSI will have done itself proud. Since ubiquitous availability of blood and blood products is the key to fighting MMR, anything done without this is tantamount to shear fraud.
If implemented in letter and spirit this will save many a life. This is certainly a practical idea. If ‘Vadilal’ can manufacture ice cream in Gujarat and sell it in Guwahatti, if the whole nation can get together and implement the pulse polio program, we should not be bothering about maintaining cold chain in such a blood banking system. This goes closest to the ideal Marxist idea ‘from all according to their deeds, to all according to their needs’. ‘Mother India’ is cursed with high MMR, satellite blood transfusion services will undo the curse, and many a ‘mother India’ will live long enough to be ‘grandmother India’.
Number of deliveries in the ‘safe mode’.
At this juncture, I feel it fit to introduce the concept safe mode deliveries. Normal delivery is a retrospective diagnosis and all will be labeled well if and when all goes well. However, safe mode is an antenatal diagnosis! Absence of high risk factors is not enough for the women to be labeled ‘in safe mode’! A woman will be expected to in labor in the safe mode when…
· She does not belong to any of the high risk groups enlisted by the government and…
· She has access to ambulance or other suitable transport within fifteen minutes of intimation.
· She has access to expert help (say FRU) within an hour’s travel time.
· She has access to blood transfusion service within an hour’s travel time.
· She has at least one women and one able man from her family to attend to her when in labor. This is essential because in rural areas labor is considered the responsibility of the elderly women in the household. Nevertheless, when it comes to crucial decision making things get difficult. If surgery is required, blood or transport is to be arranged urgently, these grand old women do not even recollect the phone number of the contact person. Hence this precondition.
· Her family circumstances are such that she is not left alone at home at any time of the day or night (say because everybody is busy in the fields).
If the above conditions cannot be fulfilled, she should be advised to move into ‘high risk homes’ set up on taluka or district hospital premises. The women from far-flung areas can be advised to lodge here with their families until they deliver. If roads and transport facilities cannot reach the women, let us get her closer to these services to avoid a delay.
Designing a NON PNEUMATIC ANTISHOCK GARMENT (NASG), will provide good first aid therapy till proper medical care is available. The idea is to have a strap on suit made of special rubber. This is wrapped around both lower limbs and pelvis, from toes upwards. Good and proper application amounts to transfusing as much as 1500cc blood from the venous pool.
Experiments at my clinic with the help of Garware Elastomers have helped us zero upon a special kind of rubber as the material of choice.
Massive blood loss requires instant access to a major vein. The technique of canulating the Internal Jugular Vein, just anterior to the sternocleidomastoide is easy, safe and readily mastered. This should be mastered by all Obstetricians and anesthetists.
Simple balloon attached to red rubber catheter has been used as effective tamponade to stop acute PPH. This method has been tried in many resource poor settings with good effect. This simple technique should be popularized
ABORTION
Abortions, spontaneous or willful will cause deaths amongst the unwary women seeking help from quacks and unskilled doctors. Innovations such as Medical Abortion and MVA have helped a lot in making abortions a lot safer than earlier. We now need to bridge the gap between felt need and unmet need.
Avoiding unwanted pregnancies will minimize deaths related to abortions and hence innovative ideas to promote contraception in the right perspective will help the cause. Here are a few innovations towards this end.
One innovation would be to make each individual / couple a ‘contraceptive literate’ person/couple. Let me explain. Contraceptive needs of a person defer in various phases of the reproductive life. Throughout his/her life a person may go through all or some of these phases. These are; a sexually active teenager, a newlywed, lactating women intending to postpone the next pregnancy, women following abortion/MTP, person wanting terminal methods of contraception…and so on. A person/couple will be termed ‘contraceptive literate’ only if he/she is aware of suitable methods in her current and expected reproductive phase.
Contraception in the context of real life situations
No advertisements, barring a few, face life situations. There is no material which enlists options for the newlywed, options for the post partum women, options for the couple having infrequent sex, for a couple after an MTP etc: Such health education material should be widely publicized. The onus of seeking contraceptive advice, before marriage or say post partum should squarely rest on the girl’s parents, as delivery is usually at the women’s maiden home.
Thus a newlywed should know about delaying the first pregnancy. Marriage in India is almost synonymous with conception and birth of the first baby within a year of married life. Couples aware about various family planning methods will use them not only to terminate fertility when they think it fit but also to space children. Delaying the arrival of the first baby means many things in the Indian society. It means that the couple has indeed imbibed the meaning of family welfare and has willfully chosen not to conceive. It means that as and when they actually decide to have a baby it will be by design and not by accident. It means that the man really cares for his wife and looks upon the partnership as something more meaningful than baby creating venture. It means this lady is more likely to receive optimal care during pregnancy and child birth and is an unlikely candidate to become modern day Mumtaj Mahal. It means they have decided to fight social norms, familial expectations and placed their own choice above everything else. Such a couple is more likely to space the subsequent pregnancies too.
Sensing this, the DHO for Satara has announced a scheme, aptly named Honeymoon Yojana, to offer monetary incentives to couples willfully delaying the first child. Extending the scheme for those willfully delaying the second pregnancy and implementing it throughout India will sure cut down maternal mortality.
Contraception for pleasure filled sex.
Most family planning advertisements harp on the ‘precaution against unwanted pregnancy’ theme. The focus should be ‘stress free and pleasure filled sex’. One of the pioneers of the family planning movement Mr. R.D. Karve has said ‘people will not accept family planning because it benefits the country, but only if they are satisfied that it helps their families in the long run’. Let go a step further, and let us try and convince them that it helps them well, as a couple!
Statutory warning on condom packs
Emergency contraception is perhaps gynecology’s best-kept secret! People hardly are aware of the modality. If failure of condoms is one of the prime indications for use of emergency contraception then it is understood that the condom user should be aware of the method. I suggest that all condom packets should carry a statutory warning, as all cigarette packs have! Something like ‘if you find that the condom has torn after use, you may still try and prevent pregnancy, contact your doctor within three days for further information’.
‘Contraception is safer than abortion’
This slogan will take care of the great Indian myth which lulls people into believing that it is better to abort an unwanted pregnancy than to prevent it. Contraception is looked upon as having too many side effects, too clumsy, too intrusive and worthless an idea. Especially since these services are patronized by the government and offered for free. Abortion is considered quick, effective, safe and acceptable than contraception. In fact every abortion is a telling evidence of the unmet need.
Need to study the decision making process in fertility regulation
Though extensive and intensive research goes on in devising newer and safer methods of contraception, little research has been done to study the decision making process of a couple which opts for or opts out of contraception. In the Indian society, the decision mostly is with the husband, the mother in law etc: It will be beneficial to study their mindset and the thinking process. Only then can we think of effective methods of changing it.
Similarly the process of opting for abortion also needs to be thoroughly studied. More social science research is needed to tackle this problem and help us to frame strategies.
MALNOURISHMENT, MEANING ANEMIA
Malnutrition, especially anemia forms a stark backdrop to the overall gloomy picture of women’s health. According to the family health survey (98-99), 51.8% of Indian women of childbearing age are anemic. This is a huge burden, and affects the overall health of women. Anemia awareness, detection, and treatment should be taken up as a socio-political program. Lal Bahadur Shastri had asked all Indians to fast once a week to fight food scarcity. May be some day we will be able to convince our politicians to appeal to every household to get the hemoglobin of the women checked, and avail of treatment when indicated.
Girls forced to forgo schooling will soon land up in matrimony, will be usually undernourished, will very soon conceive and are potential maternal deaths. Just as health workers list eligible couples, they should list girls of marriageable age and pursue the family to get their hemoglobin checked, and corrected.
Marriage after 18 and with hemoglobin of 12 gm%
Marriage in India is synonymous with conception at the earliest. Early marriages are common. They are illegal in the eyes of the law but not ‘void’. The risks of early marriage are linked to early pregnancy. Thus, the health workers should actively promote contraception to such couples.
Contraception too carries its own burden of taboos. Postponing the first pregnancy is thought to result in sub fertility or infertility later. Termination of pregnancy is thought to be safer than contraception. The IEC material and advertisements touting these products should address these issues on a war footing.
Seeing off the girl only after a hemoglobin level of 12 gm%
A women’s maiden home is an institution in India. Seeing off a girl after marriage or after delivery is a family affair packed with emotion, commotion and lots & lots of gifts. If only we could inculcate the responsibility of checking the girl’s hemoglobin before she leaves her maiden home!
Treatment of anemia
We are yet to find a cheap yet hassle free treatment for this common problem. Newer injectable irons appear to be safe. Intra muscular administration was painful, caused skin discoloration and carries the risk of anaphylaxis. The new irons are safe and their liberal use needs to be promoted. If only we could develop a drug delivery system to safely administer iron, all of it, at one sitting, it will go a long way in solving the problem of non compliance.
ECLAMPSIA
PIH is responsible for a large burden of the problem. Alas, we do not yet have any inkling of the exact patho-physiology. Funding good research in PIH will yield high dividends. PIH is much more prevalent and accounts for much higher morbidity and mortality than many celebrated diseases such as AIDS. Advocacy directed towards generating funds for PIH research is something that FOGSI needs to take up.
Treatment for eclampsia is more or less standardized, and providing MgSO4 in prefilled syringes will go a long way in easing the administration of the drug in semi skilled hands. With such a drug delivery system more and more health workers will use this drug prophylactically, preventing much misery, morbidity and mortality.
COMMUNICATION
Well maintained road network will certainly make a dent in the MMR. Rapid transport will help in getting timely help. Extensive coverage of mobile networks is a boon too.
CONCLUSION
I hope I have penned ideas that are innovative enough. I thank the organizers for the contest it set me on the thinking path, which was enjoyable.
Dr. Shantanu Sharad Abhyankar
Modern Clinic
Wai
Dist: - Satara
Maharashtra
PIN 412 803
Age 47yr
Private Practitioner at a rural place.
M.D. (Ob & Gyn). FICOG
Member Satara Obstetrics & Gynecological Society
Fellow ICOG
Mb 98220 10349
Dr. Shantanu Abhyankar
Introduction
It is no secret that the Indian society is ridden with class, caste and gender biases. All of these have worked against women for centuries. Our society has often been likened to a four-storied pyramid with the lower castes forming the base, the most oppressed section. However, it is obvious that there is one more layer to this pyramid. That below all the four layers lies the one representing women from all castes and classes of society. They form the most neglected group of the population.
Mother India is cursed with high maternal mortality. It is the result of social apathy for women, wrong priorities and poor political will. For a nation aspiring to be a superpower in near future, it is a real shame that mothers die avoidable deaths.
SHAME also is the acronym to summarize the causes.
S Sepsis
H Hemorrhage
A Abortion
M Malnourishment
E Eclampsia
I will delve on the topic touching ONLY INNOVATIVE MEASURES as the usual answers to this problem are all too well known.
SEPSIS
The best way to avoid sepsis is to have all deliveries under supervised conditions ideally in the safety of well managed maternity units. Where this is not possible home deliveries using FIVE CLEANS are good too.
The health infrastructure comes under scrutiny if a mother dies in the hospital, and rightly so, but who is responsible for allowing women to deliver at an unsafe place? The law does not hold anyone responsible for this. It is entirely up to the family to decide whether to take the mother to be, in the hospital or to call a birth attendant, or even worse, leave everything to nature and not do anything at all. There is good scope for a law to be enacted and widely publicized making it mandatory for the guardians of a pregnant woman to provide good care. If it is illegal for a mother to abandon her child, of a husband to abandon his wife and for grownups to disregard their parents; why should it not be illegal for family to ignore the basic needs of a pregnant lady? Having a law in place does not automatically change attitudes but it provides a good footing for those trying to usher in the change.
HEAMORRHAGE
PPH happens to be an important cause of maternal mortality in our country. Woefully inadequate assess to blood transfusion services is a problem too. Obstetric hemorrhage is notoriously unpredictable in timing as well as volume. Quick transport by ambulance is not readily available. It is therefore imperative that our blood transfusion service should spread and be available far and wide. If delivery is to be in the ‘safe mode’, it should be within an hour’s travel time from the blood transfusion service and other expert help. Otherwise even a supervised delivery is in fact unsafe! The supervisor may hasten the decision for need of expert help but what use is the decision if no expert, no infrastructure, and no blood banks are available?
There has recently been a marked shift in the policy. The concept of satellite centers for far-flung areas has been mooted. A three-tier system has been envisaged where the regional blood transfusion center (RBTC) will be the apex body responsible for training, quality control, as well as research apart from routine blood banking activities. The blood banks under the RBTC will collect test and store blood & blood components and send it to satellite centers in remote areas. The satellite centers are responsible only for cross matching the needed product (whole blood, FFP etc) and issue the bag.
Unfortunately the system exists only on paper. Very few satellite centers are actually in place. Public interest litigation (PIL) following the AIDS epidemic was what forced the government to formulate the three tier system. May be another PIL will actually get us the satellite centers, at least one in every taluka place and at every FRU. I feel that the onus to collect and collate data regarding this lies squarely on organizations like FOGSI. (I must remind you that it was a PIL by an NGO that brought in the PCPNDT act.) Public health is the responsibility of the government, high MMR is a public health issue and it is only the government which has the reach to set up satellite centers all over the country, create a network of blood banks, maintain cold chain and keep the show running 24*7. A PIL will force the government to promise a time bound implementation and FOGSI will have done itself proud. Since ubiquitous availability of blood and blood products is the key to fighting MMR, anything done without this is tantamount to shear fraud.
If implemented in letter and spirit this will save many a life. This is certainly a practical idea. If ‘Vadilal’ can manufacture ice cream in Gujarat and sell it in Guwahatti, if the whole nation can get together and implement the pulse polio program, we should not be bothering about maintaining cold chain in such a blood banking system. This goes closest to the ideal Marxist idea ‘from all according to their deeds, to all according to their needs’. ‘Mother India’ is cursed with high MMR, satellite blood transfusion services will undo the curse, and many a ‘mother India’ will live long enough to be ‘grandmother India’.
Number of deliveries in the ‘safe mode’.
At this juncture, I feel it fit to introduce the concept safe mode deliveries. Normal delivery is a retrospective diagnosis and all will be labeled well if and when all goes well. However, safe mode is an antenatal diagnosis! Absence of high risk factors is not enough for the women to be labeled ‘in safe mode’! A woman will be expected to in labor in the safe mode when…
· She does not belong to any of the high risk groups enlisted by the government and…
· She has access to ambulance or other suitable transport within fifteen minutes of intimation.
· She has access to expert help (say FRU) within an hour’s travel time.
· She has access to blood transfusion service within an hour’s travel time.
· She has at least one women and one able man from her family to attend to her when in labor. This is essential because in rural areas labor is considered the responsibility of the elderly women in the household. Nevertheless, when it comes to crucial decision making things get difficult. If surgery is required, blood or transport is to be arranged urgently, these grand old women do not even recollect the phone number of the contact person. Hence this precondition.
· Her family circumstances are such that she is not left alone at home at any time of the day or night (say because everybody is busy in the fields).
If the above conditions cannot be fulfilled, she should be advised to move into ‘high risk homes’ set up on taluka or district hospital premises. The women from far-flung areas can be advised to lodge here with their families until they deliver. If roads and transport facilities cannot reach the women, let us get her closer to these services to avoid a delay.
Designing a NON PNEUMATIC ANTISHOCK GARMENT (NASG), will provide good first aid therapy till proper medical care is available. The idea is to have a strap on suit made of special rubber. This is wrapped around both lower limbs and pelvis, from toes upwards. Good and proper application amounts to transfusing as much as 1500cc blood from the venous pool.
Experiments at my clinic with the help of Garware Elastomers have helped us zero upon a special kind of rubber as the material of choice.
Massive blood loss requires instant access to a major vein. The technique of canulating the Internal Jugular Vein, just anterior to the sternocleidomastoide is easy, safe and readily mastered. This should be mastered by all Obstetricians and anesthetists.
Simple balloon attached to red rubber catheter has been used as effective tamponade to stop acute PPH. This method has been tried in many resource poor settings with good effect. This simple technique should be popularized
ABORTION
Abortions, spontaneous or willful will cause deaths amongst the unwary women seeking help from quacks and unskilled doctors. Innovations such as Medical Abortion and MVA have helped a lot in making abortions a lot safer than earlier. We now need to bridge the gap between felt need and unmet need.
Avoiding unwanted pregnancies will minimize deaths related to abortions and hence innovative ideas to promote contraception in the right perspective will help the cause. Here are a few innovations towards this end.
One innovation would be to make each individual / couple a ‘contraceptive literate’ person/couple. Let me explain. Contraceptive needs of a person defer in various phases of the reproductive life. Throughout his/her life a person may go through all or some of these phases. These are; a sexually active teenager, a newlywed, lactating women intending to postpone the next pregnancy, women following abortion/MTP, person wanting terminal methods of contraception…and so on. A person/couple will be termed ‘contraceptive literate’ only if he/she is aware of suitable methods in her current and expected reproductive phase.
Contraception in the context of real life situations
No advertisements, barring a few, face life situations. There is no material which enlists options for the newlywed, options for the post partum women, options for the couple having infrequent sex, for a couple after an MTP etc: Such health education material should be widely publicized. The onus of seeking contraceptive advice, before marriage or say post partum should squarely rest on the girl’s parents, as delivery is usually at the women’s maiden home.
Thus a newlywed should know about delaying the first pregnancy. Marriage in India is almost synonymous with conception and birth of the first baby within a year of married life. Couples aware about various family planning methods will use them not only to terminate fertility when they think it fit but also to space children. Delaying the arrival of the first baby means many things in the Indian society. It means that the couple has indeed imbibed the meaning of family welfare and has willfully chosen not to conceive. It means that as and when they actually decide to have a baby it will be by design and not by accident. It means that the man really cares for his wife and looks upon the partnership as something more meaningful than baby creating venture. It means this lady is more likely to receive optimal care during pregnancy and child birth and is an unlikely candidate to become modern day Mumtaj Mahal. It means they have decided to fight social norms, familial expectations and placed their own choice above everything else. Such a couple is more likely to space the subsequent pregnancies too.
Sensing this, the DHO for Satara has announced a scheme, aptly named Honeymoon Yojana, to offer monetary incentives to couples willfully delaying the first child. Extending the scheme for those willfully delaying the second pregnancy and implementing it throughout India will sure cut down maternal mortality.
Contraception for pleasure filled sex.
Most family planning advertisements harp on the ‘precaution against unwanted pregnancy’ theme. The focus should be ‘stress free and pleasure filled sex’. One of the pioneers of the family planning movement Mr. R.D. Karve has said ‘people will not accept family planning because it benefits the country, but only if they are satisfied that it helps their families in the long run’. Let go a step further, and let us try and convince them that it helps them well, as a couple!
Statutory warning on condom packs
Emergency contraception is perhaps gynecology’s best-kept secret! People hardly are aware of the modality. If failure of condoms is one of the prime indications for use of emergency contraception then it is understood that the condom user should be aware of the method. I suggest that all condom packets should carry a statutory warning, as all cigarette packs have! Something like ‘if you find that the condom has torn after use, you may still try and prevent pregnancy, contact your doctor within three days for further information’.
‘Contraception is safer than abortion’
This slogan will take care of the great Indian myth which lulls people into believing that it is better to abort an unwanted pregnancy than to prevent it. Contraception is looked upon as having too many side effects, too clumsy, too intrusive and worthless an idea. Especially since these services are patronized by the government and offered for free. Abortion is considered quick, effective, safe and acceptable than contraception. In fact every abortion is a telling evidence of the unmet need.
Need to study the decision making process in fertility regulation
Though extensive and intensive research goes on in devising newer and safer methods of contraception, little research has been done to study the decision making process of a couple which opts for or opts out of contraception. In the Indian society, the decision mostly is with the husband, the mother in law etc: It will be beneficial to study their mindset and the thinking process. Only then can we think of effective methods of changing it.
Similarly the process of opting for abortion also needs to be thoroughly studied. More social science research is needed to tackle this problem and help us to frame strategies.
MALNOURISHMENT, MEANING ANEMIA
Malnutrition, especially anemia forms a stark backdrop to the overall gloomy picture of women’s health. According to the family health survey (98-99), 51.8% of Indian women of childbearing age are anemic. This is a huge burden, and affects the overall health of women. Anemia awareness, detection, and treatment should be taken up as a socio-political program. Lal Bahadur Shastri had asked all Indians to fast once a week to fight food scarcity. May be some day we will be able to convince our politicians to appeal to every household to get the hemoglobin of the women checked, and avail of treatment when indicated.
Girls forced to forgo schooling will soon land up in matrimony, will be usually undernourished, will very soon conceive and are potential maternal deaths. Just as health workers list eligible couples, they should list girls of marriageable age and pursue the family to get their hemoglobin checked, and corrected.
Marriage after 18 and with hemoglobin of 12 gm%
Marriage in India is synonymous with conception at the earliest. Early marriages are common. They are illegal in the eyes of the law but not ‘void’. The risks of early marriage are linked to early pregnancy. Thus, the health workers should actively promote contraception to such couples.
Contraception too carries its own burden of taboos. Postponing the first pregnancy is thought to result in sub fertility or infertility later. Termination of pregnancy is thought to be safer than contraception. The IEC material and advertisements touting these products should address these issues on a war footing.
Seeing off the girl only after a hemoglobin level of 12 gm%
A women’s maiden home is an institution in India. Seeing off a girl after marriage or after delivery is a family affair packed with emotion, commotion and lots & lots of gifts. If only we could inculcate the responsibility of checking the girl’s hemoglobin before she leaves her maiden home!
Treatment of anemia
We are yet to find a cheap yet hassle free treatment for this common problem. Newer injectable irons appear to be safe. Intra muscular administration was painful, caused skin discoloration and carries the risk of anaphylaxis. The new irons are safe and their liberal use needs to be promoted. If only we could develop a drug delivery system to safely administer iron, all of it, at one sitting, it will go a long way in solving the problem of non compliance.
ECLAMPSIA
PIH is responsible for a large burden of the problem. Alas, we do not yet have any inkling of the exact patho-physiology. Funding good research in PIH will yield high dividends. PIH is much more prevalent and accounts for much higher morbidity and mortality than many celebrated diseases such as AIDS. Advocacy directed towards generating funds for PIH research is something that FOGSI needs to take up.
Treatment for eclampsia is more or less standardized, and providing MgSO4 in prefilled syringes will go a long way in easing the administration of the drug in semi skilled hands. With such a drug delivery system more and more health workers will use this drug prophylactically, preventing much misery, morbidity and mortality.
COMMUNICATION
Well maintained road network will certainly make a dent in the MMR. Rapid transport will help in getting timely help. Extensive coverage of mobile networks is a boon too.
CONCLUSION
I hope I have penned ideas that are innovative enough. I thank the organizers for the contest it set me on the thinking path, which was enjoyable.
Dr. Shantanu Sharad Abhyankar
Modern Clinic
Wai
Dist: - Satara
Maharashtra
PIN 412 803
Age 47yr
Private Practitioner at a rural place.
M.D. (Ob & Gyn). FICOG
Member Satara Obstetrics & Gynecological Society
Fellow ICOG
Mb 98220 10349
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