The tragic sterilisation camp at Bilaspur, Chattisgarh
exposes the lacunae in our health care system.
In India
sterilization camps are held at health centres at regular intervals. The local health workers and the Primary
health care centre are given target and not achieving the target may be
punitive to the health personnel in-charge of the place. To achieve the target local ANMs or Health
Workers motivate eligible couples, particularly women to undergo sterilization
/ family planning / Tubectomy operation.
Special incentives are also announced for the candidates undergoing
surgery in that particular camp.
Generally the PHC doctors are trained to do these
operations. Laparoscopic sterilizations
are done by specialists specially trained in Laparoscopic sterilization. The camps are arranged in rural or semi-urban
areas. The candidates are motivated by
the Health Workers. PHC doctors arrange
for all the material and medicines. Few
well trained specialist doctors are deputed to conduct surgeries on that day. Deputed doctors will leave after the camp
(surgery) is over and local PHC medical personnel will have to provide care for
the patients for another 24 to 48 hours.
When everything is planned and executed well, and the facilities for the
number of patients underwent surgery are adequate, serious complications and
complaints are rare. Only when the
number exceeds the facilities available and medical personnel are inadequate or negligent complaints become innumerable and occasional complications
arise. Generally any inadvertent serious
complication that has occurred is immediately recognised by the doctor and the
patient will be immediately shifted to nearest higher centre where due care is
taken.
Every procedure has inherent risk. All surgical procedures have risk of
anaesthesia and inadvertent injury to the other organs and sensitivity to the
drugs used in the post-operative period.
Female sterilization/Tubectomy, the procedure is intra-abdominal, wherein
the abdomen is opened (laparotomy) or pierced with laparoscope, the possibility
of injury to other abdominal organs will be present. This is rare in
experienced hands. Rarely when it
happens in the inexperienced it can be recognised either during surgery or in
the immediate postoperative period.
Causing injury is not negligence but failing to recognise it is
considered as criminal negligence.
The surgeries done at Bilaspur are by a very experienced
surgeon who was awarded for his skills and service. Laparoscopic tubal ligation is done by the
experienced laparoscopist within five minutes.
Here the patient is kept ready and laparoscopist simply has to pass the
laparoscope and pick loop of the fallopian tube and slip the rings to occlude
the tubes. For an experienced person who
had done more than a lakh sterilizations to injure the organs even in one woman
is remote possibility. The death of 14
women is tragic and what exactly has caused the death should be investigated.
It is reported in Hindustan times
that deaths associated with female sterilization during the period 2003 – 2012
is 1434, an average of 12 per month.
Only appropriate medical statistics can bring out the exact number of
deaths due to tubectomy per se or just associated cause. In one study in United
States (1982 to 1988) has revealed that
4/100,000 women died due to sterilization and no man died for undergoing
sterilization procedure and suffered any major complication. The cost of the procedures is also 3-4 times
more for women. Though the incidence of
serious complications is negligible and
mortality is almost nil in males due to sterilization procedure, in India, men are
afraid of undergoing sterilization operation even though the incentives offered
are double than that offered for women. In one year, April 2012 to March 2013,
the total number of female sterilizations are 4.5 millions (45,00,000) and male
sterilizations were 1,20,000. This is about 2% of sterilisation operations are
vasectomies (male sterilisation operation) and rest 98% are tubectomies (female
sterilisation operation). It is generally women who are motivated to
undergo sterilization. The procedure of
sterilization in male – vasectomy is a very simple procedure, less painful and
without any serious complications and no mortality. The surgery is done by one
small nick which may not require any suturing.
It can be safely done under local anaesthesia. They can carry on normal activity within few
hours of surgery. Their virility is not compromised. They have to take precaution for three months
against causing pregnancy. Men should be
encouraged more to undergo vasectomy which is a few minutes procedure requiring
minimal anaethesia and minimal post operative care.
To reduce deaths due to sterilizations
- Improve facilities
at Primary Health Centres
- Selections of cases
should be done by specialist
- Appoint adequate
staff at the PHCs. Expert care and
transport facilities at higher centres should be available until all the
patients are discharged in good condition.
- When surgical
procedures, particularly female sterilizations are taken up, the facility
should have operation theatre to handle any emergency that needs immediate
laparotomy and extended surgical procedure.
Even in case of male sterilization facility should be available to deal
with any excessive bleeding or hematoma.
- Targets should be feasible, not fulfilling
should not be punitive
- Sterilisations
should be done regularly on fixed days, at least, twice a week
-.If ever camps are
held the maximum number of cases should be fixed depending upon the
availability of beds and medical staff capable of handling the cases during and
after the operation, until recovery.
Post operative care involves not only nursing care but appropriate
antibiotics, analgesics and IV fluids.
- Reproductive health care and education should
be part of health education in high school.
- Spread awareness of
simplicity of Vasectomy
- Spread awareness of
non surgical methods of contraception in males and females.
In this tragedy the government instead of arresting the
doctor should do some introspection and try to improve infrastructure and
formulate rules in conducting such massive sterilization camps in remote areas.
