2009 January - Note 2
Acceptable in medicine, indispensable to India – Female sterilization in a caesarean section - Dr. C. N. Purandare, M.D., MAO.(IRL), DGO, DFP, DOBST (IRL), FICOG, FICMCH, PGDMLS; President Elect - 2009, FOGSI
An element of public welfare is present in all laws, whether they are made by customs, courts, or legislatures. Ultimately, laws are meant to protect the greatest number of people from evils which are considered detrimental to the society. Sterilization in India is a potential weapon to contain population explosion, one of our greatest concerns. Laws ought to be shaped in such a manner so that they promote and facilitate sterilization rather than act as an impediment. I am trying to point out to one such legal obstacle in female sterilization here.
Can female sterilization be performed while conducting a caesarean section? A recent judgment pronounced by Uttar Pradesh State Consumer Disputes Redressal Commission has held that the decision of the gynecologist to go in for caesarean and tubal ligation “clearly reflects her lack of knowledge and also medical negligence.”
This is clearly erroneous for I can say authoritatively that medicine permits the aforesaid procedure. Any Obstetrician will agree with me, that with the abdomen opened in a ceasarean section, tubal ligation hardly requires half-a-minute and this procedure is totally risk-free. Let us not forget the legal position laid down in Bolam’s case – “A doctor cannot be held negligent if the doctor has acted with normal care, in accordance with recognized practices, accepted as proper by a responsible body of medical men skilled in that particular field, even though there may be a body of opinion that takes a contrary view.”
The second objection to this law would be on the grounds of public policy. We are a developing nation with limited resources. A majority of our citizens today are forced to live below the poverty line. Forcing this vast majority to two interventions with proportional increase in risk and expenses cannot be justified by any means.
“In a developing country like ours where teeming millions of poor, downtrodden, and illiterate cry out for healthcare, there is a desperate need for making healthcare easily accessible and affordable.” This observation of the Hon’ble Supreme Court in the landmark case of Samira Kohli v/s Dr. Prabha Manchanda & Anr. clearly points out that even the highest court of the land has recommended the need to make medicines cheaper.
But with the courts’ ruling, that conducting both the procedures together is negligence even though in my respectful submission it is permissible in medical science, obstetricans are left with no other choice but to perform two interventions where one could have given the same result with decreased risk and expenses.
Another rather shocking aspect of this whole issue is protocols followed by some Government/Municipal hospitals not to conduct both these procedures together. I am not aware whether such directions are formal or informal. The real reason behind such an exercise is to avoid liability to the Government in terms of monetary compensation in case of patient’s death who undergoes sterilization with caesarean section and if sterilization is considered the cause of death. But if both the procedures are done separately or rather after the patient has fully recovered from caesarean, then the chances of death from sterilization are miniscule and the government is able to save the compensation.
On the other hand, if a death occurs after caesarean section where a sterilization has been done, it is only to be notified to the competent authority. All the forms filled, along with the cause of death, should be given if the death occurs after 48 hours due to obstetrics causes. It is advisable to do a post-mortem as a safe option. Enquiry for deaths due to sterilization which is normally conducted in all other cases of sterilization deaths is not done here since this is not a sterilization procedural death.
The court has referred to Whitefield’s book in which he has stated quite rightly that the incidence of failure of sterilization when done along with a caesarian section would be minimally higher due to tubal edema and hypertrophy. In spite of this it is still accepted worldwide as the method of choice since the abdomen is already open. Puerperal sterilization is also a mainstay in our country due to inability of patients to come back to hospital for surgery separately at a later date.
Can saving of a few thousands of the State finances be a justification for unnecessarily subjecting a woman to two interventions and an added anaesthesia risk? The answer and consequent changes in law and practice on this very important aspect of medicine must come from all those who care for the nation and human life.