Tag Archives: pregnancy

The Art and Science of Diagnosis

A professor from Ohio State e-mailed me the article with the deceivingly understated subject line of all-lower case “fyi.” The Hindu write-up’s headline, though, didn’t mask the shocking contents: “Appalling condition of primary healthcare services” it read. (1) Short and potent, it described the lurid details of a study carried out across the health sector in India, rural and urban, private and public. The details showed a fundamental lack of ability by medical professionals to diagnose even the most common conditions (asthma and dysentery, for example) or ask the most basic questions (whether there was “pain radiation” for an unstable angina). The result was a low rate of diagnosis, whether it was in rural Madhya Pradesh or Delhi.

Overall, healthcare providers provided the correct treatment only 30.4% of the time. (2) Even worse, 41.7% of the time the clinics provided unnecessary or even harmful treatments for “patients” that the research study trained (“from the local community”, the article notes). Many providers, even in public clinics, were unqualified. Medical guidelines and treatment protocols were followed at low rates; providers only asked 33.7% of the recommendations. In Madhya Pradesh, doctors spent 3.6 minutes with patients, while Delhi medical professionals spent a marginally better but still terrible 5.4 minutes. For reference, the Medical Council of India recommends doctors spend at least 10 minutes with each patient. (3)

The article highlighted tough facts that Calcutta Kids has been tackling for years. Through our experiences with the health clinic, we’ve worked to combat the norm of primary health in India: brief, non-comprehensive visits and a disregard for protocols and checklists. We’ve uploaded to the resources section of our website our child health World Health Organization’s IMCI and IMPAC-based Child Health and Pregnancy and Maternal Health protocols and checklists which our doctors are trained and demanded to use. Our two health clinic physicians, Drs. Pal and Sen, work with our management staff to ensure that the protocols we have provided them matches their process for diagnosing patients. See the above-mentioned resources below:

Child Health Protocol (0-2 months)
Child Health Checklist (0-2 months)
Child Health Protocol (2 months to 5 years)
Child Health Checklist (2 months to 5 years)

Pregnancy and Maternal Health Checklist and Protocol

It’s an important process that Calcutta Kids has to do to ensure our beneficiaries get not just quantity but truly quality care. It hasn’t been an easy process to bring in this cultural change into our clinic over the years, but it’s a necessary one. In addition, the creation of standardized protocols ensures a consistent level of care that our beneficiaries can expect, regardless of personnel changes. As Atul Gawande noted in his Harvard Medical School commencement, it’ll require an understanding of a team of healthcare providers- a “pit crew” that includes our health workers- not just the lone cowboy physician:

“The work is rooted in different values than the ones we’ve had. They include humility, an understanding that no matter who you are, how experienced or smart, you will fail. They include discipline, the belief that standardization, doing certain things the same way every time, can reduce your failures. And they include teamwork, the recognition that others can save you from failure, no matter who they are in the hierarchy.” (4)

Many rightly criticize the low rates of spending on health per GDP in India, ranking 171st out of 175 countries according to a WHO study. (5) But the situation is even grimmer: it is not enough to just increase spending, build more primary health centers or even to write diagnostic protocols at a national level. The groundwork of implementation at a doctor to patient level must be accomplished. At our health clinic, we work on this ground level to make sure that provision of the highest level of primary healthcare is a reality for the mothers and children of Fakir Bagan.–Pranav Reddy

Citations:

  1. Appalling condition of primary healthcare services. The Hindu. R Prasad. December 6, 2012. Retrieved from http://www.thehindu.com/health/medicine-and-research/appalling-condition-of-primary-healthcare-services/article4167677.ece on Jan 1, 2013.
  2. In urban and rural India, a standardized patient study showed low levels of provider training and huge quality gaps. J Das, A Holla, V Das, M Mohanan, D Tabak, B Chan. Health Affairs. December 2012. 31(12):2774-84
  3. MCI wants docs to spend at least 10 mins with each patient. The Times of India. K Sinha. September 1, 2011. Retrieved from http://articles.timesofindia.indiatimes.com/2011-09-01/india/29953546_1_opd-patients-doctors on Jan 1, 2013.
  4. Cowboys and Pit Crews. The New Yorker. Atul Gawande. May 26, 2011. Retrieved from http://www.newyorker.com/online/blogs/newsdesk/2011/05/atul-gawande-harvard-medical-school-commencement-address.html#ixzz2H02jhJMO on Jan 1, 2013.
  5. World Health Statistics 2011 Report. World Health Organization (WHO). 2011; 127-139. Retrieved from http://www.who.int/whosis/whostat/2011/en/index.html on Jan 1 2013.

C-Section Blog Series (4 of 4)

The third part of our C-section blog series focused on the circumstances leading up to Calcutta Kids’ decision to stop partnering with private clinics for facility based deliveries, and instead (a) offer a Delivery Savings Scheme (DSS) which would provide financial assistance for beneficiaries to deliver wherever they prefer; and (b) up the ante on birth preparedness through a new home counseling curriculum. This week’s blog describes that curriculum, provides data on beneficiaries’ usage rates of the delivery savings scheme, and calls attention to the fact that more community involvement is necessary for the delivery savings program to succeed.

Throughout the pregnancies of our beneficiaries, our CHWs visit their homes at least once a month. During the last few months of pregnancy, the visits have become more standardized and focus on the following themes:

  • Danger signs. What to watch out for—especially pain in the lower abdomen, heavy white discharge or bloody discharge. In such cases, pregnant women are advised to go immediately to the facility with which they are registered, and to call their Area in Charge for support
  • What not to worry about: Many women become worried if the gestational age of their child crosses 37 weeks. The CHW’s counsel the women not to worry about this until around 40 weeks at which time they should visit their facility.
  • Preparation: The family is counseled to assure the availability of transportation to the facility regardless of the time of day or night, and to ensure that money is set aside for transport. They are also told what documentation to have ready to take with them to the facility.
  • To C or not to C: Pregnant women and their families are provided with knowledge about C-sections. They are informed of the recognized and accepted indications for C-sections; the potential risks for the mother after a C-section delivery; the potential risks for the mother during her next pregnancy; the immediate risks for the baby during a C-section delivery; and the potential long term risks for a C-section-delivered child.

The CK staff has gone through an intensive training focusing on these themes. (You can see these materials in the resources section of our website or you can click here for the Labor and Delivery Educational Session and here for the C-Section Education Session.)  They also have received refresher training on the labor and delivery process, fetal development, and complications that can occur during labor. And they are equipped with flip charts and other materials to facilitate their home-based counseling with pregnant women.

Delivery Savings Scheme Data:

  • Scheme began in July 2011
  • Since inception, 68 CK pregnant women out of 162 pregnant women in households registered with CK, have enrolled in DSS
  • Of those 68, 45 remain pregnant
    • Of the 45 who delivered, 2 had miscarriages; 29 had normal deliveries, and 14 had c-sections.
    • Of the 45 who delivered, 24 took place in private facilities and 19 took place in public facilities.
  • Currently (July 2012) there are 55 pregnant women involved with Calcutta Kids and 21 are participating in the DSS.

With a DSS user rate of around 40%, the scheme is not working as well as we would like. And the DSS is not working as a replacement for the services being provided earlier through private facilities.

Next week, Calcutta Kids will be holding a number of focus group discussions to try and figure out why it is that more pregnant women are not taking advantage of this scheme. The discussions will be held separately with those who have used the DSS and those who have not. We look forward to sharing what we learn from these discussions in a future blog.

From this data, however, some questions arise: Does this experience coupled with the micro insurance experience indicate that families (a) don’t have surplus cash on hand or (b) aren’t willing to use surplus cash for such a purpose or (c) that the men in the family are not willing to set such money aside for this or (d) there a is basic fear (based on the reality that there is a lot of huckstering that goes on in the slum) that they might never see their money again?

Clearly we have more work to do in facilitating a good option for safe facility-based delivery among our beneficiaries. We are confident that we will be able to find a solution which benefits our beneficiaries while at the same time protecting them—and also Calcutta Kids. -Sumana Ghosh, Danya Sarkar and Noah Levinson

C-Section Blog Series (3 of 4)

In 2007, a young man visited Calcutta Kids from abroad. He was interested in exploring why Calcutta Kids at that time was working with the private health sector rather than the government sector. Instead of explaining the deplorable state of government hospitals and going into the gory details of government bureaucracy, I asked the young man if he might like to join me in visiting a nearby government hospital. He agreed and we hopped into a cycle rickshaw and headed for the hospital.

Fifteen minutes later, we stepped out of the rickshaw, walked into the hospital, and were greeted by a line of stretchers carrying corpses waiting to be picked up by the morgue. We stood there for a few moments trying to get our bearings. When we moved forward, our guest tripped over a large rat that was scurrying across the floor. The young man told me that he now understood why we worked with private hospitals and clinics.

For the most part, our experiences with private clinics and hospitals over the years have been positive ones. Our beneficiaries prefer the private sector as does most of the population of India. And, given the fact that Calcutta Kids was covering the cost of this private hospitalization partially or fully, the beneficiaries were overwhelmingly pleased with this arrangement.

Over the years, however, our understanding of both the private and public health sector in India has evolved, and as we recruited more medical staff on our team, we began to seriously question our exclusive partnership with the private sector.

Part of the evolution in our thinking resulted from a better understanding of C-sections in our area. The rising cost of C-sections our beneficiaries are paying combined with our understanding of the dangers of unnecessary C-sections frightened the Calcutta Kids team and we began to examine our options carefully.

We realized that we were facing two major issues: the first a potential major operational threat to Calcutta Kids; the second an ethical dilemma: Because we have had relationships with particular clinics and were paying the fees for deliveries at these clinics, we were in essence accrediting them; beneficiaries who trusted us throughout their pregnancies were trusting the facilities with which we partnered. This meant, in turn, that if something at these clinics were to go wrong, we would be blamed. Such a situation could create major problems for Calcutta Kids. The ethical dilemma was that since we were paying for the deliveries at these clinics which practiced excessive use of C-sections, we were partially responsible for any deleterious effects of an unnecessary C-section on a mother or child. Was it possible that while we believed we were providing the best possible care for pregnant women and children, we might be exposing them to unnecessary risk?

Below is a brief synopsis of our discussions.

  • We could speak with the private sector clinics, encourage them to follow WHO protocols on the appropriate conditions for C-sections, and then request medical reports for each C-section financed by Calcutta Kids. This option was tried without success. After all, C-sections are increasingly the norm, and the clinics did not want to follow a protocol inflicted upon them by an NGO.
  • We could open our own maternity clinic, although at an exorbitant cost. This was never really an option. Our focus is on nutrition, BCC, and preventive care and that is where it should remain.
  • We could encourage our patients to advocate themselves for normal deliveries unless a C-section is clearly warranted. This we also do but with limited success. Rarely will a poor uneducated family go against the advice of a doctor.
  • We could stop paying for C-sections altogether. But what about those rare cases where C-sections are indeed necessary and families cannot afford them?
  • We could partner exclusively with the government hospitals. But this goes against the preference of our beneficiaries.

Finding none of these options satisfactory, and recognizing the danger to our beneficiaries and to Calcutta Kids, we ended up terminating our formal partnerships with the private sector. What we put in its place is a delivery savings scheme—a financial incentive to ensure a facility-based delivery. The delivery savings scheme enables women to save money in a safe place and to receive a matched amount from Calcutta Kids of up to 2,000 rupees. The beneficiaries then can choose to spend this money at a private clinic (Rs.4000 will likely cover a normal delivery, but not the full cost of a C-section) or they can go to a government hospital where the delivery will be free and use this savings for postnatal care.

Along with the delivery savings scheme, we’ve begun a program of intensive counseling for pregnant women to help assure that they understand all that they need to know about deliveries and can make an educated decision about whether to have a C-section if the doctor recommends one.

The last blog post in this four part series will speak about Calcutta Kids’ experience with the delivery savings scheme as well as the curriculum mentioned above. –Noah Levinson

C-Section Blog Series (2 of 4)

The rise of C-section rates in many parts of the world has triggered a global debate on the use of C-sections, the ideal rate of C-section, and appropriateness of high rates in certain countries. In 1985 the World Health Organization (WHO) recommended a C-section rate of not more than 10-15%. In 2010, they withdrew that guideline and replaced it with a more general statement that, “There is no empirical evidence for an optimum percentage. What matters most is that all women who need caesarean sections receive them.” The WHO’s decision to not focus on a universal, evidence-based optimum rate makes sense in light of the difficulties of doing so but, without a specified rate, there is no easy benchmark by which to monitor and interpret the use and potential overuse of c-section deliveries.

When clinically indicated for complications during pregnancy or labor, C-sections greatly improve obstetric outcomes, which in turn improve maternal and child health outcomes. In many developing countries, women have inadequate access to emergency obstetric care leading to preventable maternal and perinatal morbidity and mortality. In such settings, it is essential to strengthen health systems and infrastructure to ensure that C-section services are provided when they are medically indicated and could save lives.

In populations with excessively high C-section rates, on the other hand, there is growing concern about the health and economic consequences when C-sections are performed for reasons other than medical necessity. A C-section is a major surgical intervention that should be carefully considered in light of associated risks that can increase maternal and perinatal morbidities, which include bleeding, infection, blood clots, and increased need for ICU care. C-sections can also have long-term consequences on child health, including increased risk of developing allergies and asthma. (1) Maternal mortality for women undergoing C-sections is four to ten times higher than for vaginal birth. A multi-country study carried out in Latin America indicated that an increase in rates of caesarean delivery is associated with increased use of antibiotics postpartum, greater severe maternal morbidity and mortality, and higher fetal and neonatal morbidity. (2) Another multi-country study carried out in Asia in 2007-8 showed that there was an increased risk of maternal mortality and severe morbidity in women who undergo C-section with no medical indication. (3) Furthermore, in low-income countries with an unmet need for C-section (where women who need C-sections are not receiving them due to inadequate access to obstetric care), the issue of resource drain is important: If C-sections are restricted to only clinical indications and not performed unnecessarily, resources would not be sapped from other sections of the health system.

http://cartoonistsatish.blogspot.in/2009/07/muhurat-c-section.html

Currently, the global C-section rate is about 15%, but there are huge variations in C-section rates across countries and regions in the world. A consistent increase has been seen in the rate of C-section deliveries in most developed countries and in many developing countries including India. Globally, China has the highest rate at an alarming 46% of births being C-section (3); Brazil follows behind at 37% (4). In the United States the rate has been steadily increasing in the past decade and is now at 30%, while in Scandinavian countries it hovers around 20%. In Asia, after China, Vietnam and Thailand have the highest rates with 36% and 34%, respectively. The lowest rate in Asia is Cambodia, with 15%. (3) Although India’s rate is not disturbingly high in the global context, its rate has spiked from 2.2% in 1992-3 to 18% today. Within India, the states of Kerala, Goa, and Andhra Pradesh have the highest rates. In West Bengal the rate rose from 3.3% in 1992-3 to 19% in 2009-10. (5)

There is also a large divide between urban and rural areas, and between public and private facilities. West Bengal as a whole has a C-section rate of 19%; the city of Kolkata’s rate is 33.5% while rural Malda District’s is 2.2%. In Kolkata as in most large Indian cities, the C-section rates in private hospitals are much higher (50% and up) than in public hospitals, which average about 12%. (6) This emerging trend is a classic example of inequalities in access to C-sections in developing countries: It means that in poor, rural areas where there is less access to emergency obstetric care, women who medically need C-sections may not be getting them, while women living in urban areas and going to private hospitals are getting C-sections that may be performed unnecessarily, causing unwarranted risk to the mother and baby.

The trend in rising C-section rates in India and other parts of the world is driven by many reasons factors including, but not limited to:

  • Increase in facility-based deliveries and improved access to emergency obstetric care; improved surgical and anesthetic techniques
  • Doctors’ preference for the procedure due to ease, timing, and financial   incentive compared to vaginal delivery
  • Women’s preference for the procedure to avoid long labor and delivery
  • Over medicalization of childbirth process
  • Lack of information on natural birth options for women
  • Perception of safety of the procedure; casual attitudes about surgery and limited awareness about realities of surgery
  • Increase in heavier women and older women giving birth
  • Increase in multiples (twins, triplets, etc) due to fertility drugs and IVF

How do rising C-section rates affect Calcutta Kids?

Our beneficiaries at Calcutta Kids are very much affected by C-section trends in West Bengal, as their deliveries are taking place in government and private hospitals in Howrah. In the past five years, we have witnessed increasing rates of C-section for women who are participating in our program. In a preliminary analysis of data, our C-section delivery rate has increased from 10% in 2007 to 30.4% in 2012. There may be many contributing factors, including an increase in facility-based deliveries from 67% in 2005 to 90% in 2012. However, we are conducting further analysis to assess these trends and explore the reasons behind them.

Calcutta Kids is not involved in the childbirth process for our beneficiaries and we cannot directly affect any decisions made once a woman has been admitted to the facility, so we do not have any control over C-section rates among our beneficiaries. However, we can take advantage of opportunities during pregnancy to raise awareness about birth preparedness and help a woman understand what she can expect at the facility, including what decisions will be made once the birth process has begun.

Next week’s blog post will cover Calcutta Kids’ experience with facility deliveries and C-sections , followed by a blog post on our work with health workers and pregnant women on birth preparedness and facility delivery. -Danya Sarkar

Citations:

  1. Mode of Delivery Is Associated With Asthma and Allergy Occurrences in Children. Muhammad T.Salam, MBBS, MS, Helene G. Margolis, PhD, Rob McConnell, MD, James A. McGregor, MD, Edward Avol, MS, Frank D. Gilliland, MD, PhD. Annals of Epidemiology, Volume 16, Issue 5, May 2006; 341–346.
  2. Caesarean delivery rates and pregnancy outcomes: the 2005 WHO global survey on maternal and perinatal health in Latin America. José Villar, Eliette Valladares, Daniel Wojdyla, Nelly Zavaleta, Guillermo Carroli, Alejandro Velazco, Archana Shah, Liana Campodónico, Vicente Bataglia, Anibal Faundes, Ana Langer, Alberto Narváez, Allan Donner, Mariana Romero, Sofi a Reynoso, Karla Simônia de Pádua, Daniel Giordano, Marius Kublickas, Arnaldo Acosta, for the WHO 2005 global survey on maternal and perinatal health research group. Lancet 2006; 367: 1819–29.
  3. Method of delivery and pregnancy outcomes in Asia: the WHO global survey on maternal and perinatal health 2007–08. Pisake Lumbiganon, Malinee Laopaiboon, A Metin Gülmezoglu, João Paulo Souza, Surasak Taneepanichskul, Pang Ruyan,Deepika Eranjanie Attygalle, Naveen Shrestha, Rintaro Mori, Nguyen Duc Hinh, Hoang Thi Bang, Tung Rathavy, Kang Chuyun, Kannitha Cheang, Mario Festin, Venus Udomprasertgul, Maria Julieta V Germar, Gao Yanqiu, Malabika Roy, Guillermo Carroli, Katherine Ba-Thike, Ekaterina Filatova, José Villar, for the World Health Organization Global Survey on Maternal and Perinatal Health Research Group. Lancet 2010; 375: 490–99.
  4. The Role of Nonclinical Factors in Cesarean Section Rates in Brazil. Kristine Hopkins and Ernesto Amaral. Population Research Center, University of Texas at Austin.
  5. Levels and Trends in Caesarean Births: Cause for Concern? Sancheeta Ghosh, K S James. Economic & Political Weekly January 30, 2010 vol xlv no 5.
  6. Telegraph article: To C or not to C?

C-Section Blog Series (1 of 4)

For the month of July, Calcutta Kids’ weekly blog will be on the topic of C-section deliveries, and the challenges of working in maternal and child health during a time when C-sections are becoming the norm.

According to a December 2011 article  in the Telegraph, West Bengal “has more Caesarean section deliveries in private hospitals than anywhere else in the country”, and Kolkata has the highest rate at 33.5%. C-sections are convenient for doctors and lucrative for facilities, so doctors are beginning to schedule deliveries regardless of a medical need. Some of the best private hospitals in Kolkata have even removed labor rooms altogether, and only offer the C-section option.

C-section deliveries can lead to serious complications such as hemorrhage, lingering abdominal pain, hernia, blood clots, and long-term effects including a required hysterectomy and even death. C-sections can also impact the child, and can lead to increased incidence of asthma and allergies, as well as possible neurological disorders. In addition, C-sections are expensive and recovery time is often greater than for a vaginal birth. As a public health organization, Calcutta Kids encourages best practices for maternal and child health. This includes safe prenatal care; a vaginal, facility-based delivery (wherever possible); access to comprehensive emergency obstetric and newborn care; exclusive breastfeeding for the first six months after birth, and critical health messages given to the new mother and family.

Through this series, readers can learn more about C-section rates in India and West Bengal, decisions made at the facility level, and our difficulty in having an impact in the delivery room. We will also share what Calcutta Kids is trying to do to empower women through birth preparedness, and welcome your comments and suggestions on ways we can address these challenges. -Margy Elliott

Flip-Charts, Training and a Community Center – Oh MY(CHI)!

Originally posted in the Fall 2011 Newsletter

The Maternal and Young Child Health Initiative (MYCHI) staff has been working diligently over the past nine months to make our programs even more effective. Danya and Sumana have been revising the pregnancy care program to reflect changes in international maternal and neonatal health guidelines and to utilize the lessons we have learned over the past 6 years. We now have two excellent flip charts that are culturally appropriate to help counsel families about best practices and the early detection of problems.

In May, we had an in-depth training on the new pregnancy care program with all of our community health workers and other MYCHI staff. In this training, we were able to explain exactly why each type of data is collected; to provide refresher information on the complications that can occur during pregnancy, delivery and the first few months of life; and to talk through specific problems that have arisen in our area. In the course of the training, we also were able to strengthen the bonds that have enabled us to work as a team and to have fun together!

We are also working to revise the child health program to better tackle the non-food related causes of malnutrition as well as to update the program more generally. During the past six months, we worked with a small sample of severely malnourished children to find out with precision the causes of their malnutrition. We found that many of these children were suffering from anemia, a high worm load, several micronutrient deficiencies and stress in the home, all of which hinder the absorption of nutrients and, in turn, impede affect mental and physical development. We now can use this information to inform our protocols as we redesign the child health program. We are very excited about the new community center, located in Fakir Bagan itself, which will be opening in December – a safe, clean and attractive site where we can hold our regular community meetings and gatherings of small support groups – a space for women and children to come together comfortably for support and information.