Chattisgarh Tragedy

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.

Fertility

Sometimes the biology of woman makes her vulnerable to mean criticism.  This is particularly problematic if she conceives within the first month of her marital life.  If the husband and in-laws understand she will have a peaceful life.  Otherwise she will be subjected to mental trauma. 

Once, a newly married couple had come to me.  Parents-in-law also accompanied.  Young bride was shy and sat silently.  Mother-in-law told me that the girl was supposed to get her periods that week but did not get it.  I asked for pregnancy test and pregnancy was confirmed.  Except the girl there was disbelief in all others’ face.  The boy said he is married just three weeks ago and doesn’t want to have children so soon.  He expressed his doubt that how can a pregnancy occur so early and what could be the duration of pregnancy.  I understood that he is suspecting the girl’s fidelity.  He opted for a scan.  The scan was showing early gestational sac, with a fetal node – suggestive of early pregnancy of 5-6 weeks.  Now all he wanted to know if that marriage had taken place only three weeks ago how can she be more than 5 weeks pregnant.  That is a genuine doubt.

In obstetrics we count pregnancy duration – gestational age, in weeks.  This is counted from the first day of bleeding of menstrual cycle (MC).  The onset of bleeding in a MC is clearing of  the old endometrium (inner most layer of uterus which lodges embryo, nourishes in early stages and develop attachment to placenta to sustain fetus until delivery).  New endometrium starts developing along with ovum in the ovaries.  The changes in ovum that is to be released and fertilized, and endometrium so as to provide nutrition in case of successful fertilization and implantation of embryo that happens in the 3^rd week of MC.  The normal MC is 28 days cycle.  It could vary a few days – 26 to 30 days.  In a 28 day MC ovum is released on 14^th day.  If the cycle duration is more it may be delayed, in a shorter cycle it may be early.  In general, in normal MC the fertile period – chance of conception is from 12^th to 16^th day.  The first two weeks of preparatory period is also added when pregnancy dating is done.  So getting married in the 3^rd week of MC and being diagnosed to have 5weeks pregnancy a week after missing periods is perfectly normal.  There is nothing to suspect any mischief by the girl.  Though obstetrician explains the newly weds and their family the biology of conception and dating, few still doubt.   Illogical doubting spoils future togetherness.  It is good to have scientific understanding of ovulation, fertility and dating of pregnancy which will help in future family planning.

The fertility period in a woman with regular MC of 28 to 30 days is 12^th to 18^th day of MC.  First day of bleeding is considered as first day of MC.  Contraceptive methods are used to prevent either release of ovulation (OC pills) or prevent contact of sperm with ovum (barrier methods, abstinence), or prevent implantation (Intra uterine devices, emergency pill).  This awareness of fertility period in the woman helps to prevent unwanted pregnancy and improve health of woman.