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Letters to the Editor Indian Pediatrics 2002; 39:214-216 |
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What is standard practice? For any given clinical problem, there must be a standard intervention, deviation from which may be construed as negligent practice. In juris-prudence, standard practice is what the authorized agency stipulates, or what the leaders of the profession teach and practice and peers approve, and what is often stated in reputed textbooks. If prevention of vertical transmission becomes policy, then standard practice must be defined. The essence of my paper was to point out the need for policy, systematic approach to prevention and standard practice. Standard practice must be relevant to the context in a country, and based on available evidence. My approach was to base my suggestions for standard practice on Indian research, supplemented by relevant research in Thailand(2,3). Take, for example Caesa-rean section. Dr. Oswal includes elective Caesarean at 38 weeks of pregnancy for "the complete regimen" for prevention of vertical transmission. There is clear evidence for reduction of risk of vertical transmission by Caesarean, before start of labor, at 38 weeks, in studies in Europe and North America. In the Indian study, elective Caesarean did not add to the cumulative benefit from other interven-tions. The Thailand study did not even include Caesarean, probably because of problems of feasibility in a routine standard approach for prevention. A distinction must be made between "standard practice" and "complete regimen". Standard practice must be applicable at most, if not all, settings. Caesarean delivery cannot be applied in all settings in which HIV positive mothers may deliver. Its additive value to the defined interventions in the Indian and Thai studies must be investigated before it can be considered in a policy of standard practice. Caesarean must be done prior to the start of labor, which cannot be condifently predicted as at 38 weeks in our country. Subjective duration of pregnancy must be supplemented by objective criteria for better accuracy. In summary, for these reasons, Caesarean cannot be included in standard practice in India: its benefit must be investigated in India if anyone desires to include it: and the exact criteria of the timing of surgery must be established, since 38 weeks may be an inexact criterion in our setting. I had stated that "elective Caesarean before rupture of membrane or start of labor may be considered as a possible additional inter-vention to further reduce transmission", which seems to have escaped Dr. Oswal’s notice. Caesarean may be so added for those who deliver in institutions with facilities for surgery and who may choose it, after well-informed decision. I had summarized the evidence to show that the added benefit from enhanced intra-partum zidovudine to the listed interventions was not clear-cut(1). In the Thai study, prevention was already maximal with the suggested regimen, but without additional intrapartum zidovudine(3). Dr. Oswal cited an earlier Thai study in which short course zidovudine, followed by intrapartum enhanced doses, and avoidance of breast-feeding, resulted in 51% efficacy(4). Since we can obtain much better efficacy with the recommended standard practice regimen, intrapartum zidouvine does not find a place in it. If we want further clarification on this issue, a specific study must be conducted, using the listed interventions with and without the additional intrapartum doses. Dr. Oswal rightly pointed out the need to respect the autonomy of decision making by the parents. That is one of the important reasons why I included counseling of the antenatal women and their husbands as the first step in the interventions. Counseling is to ensure the informed option-choice of the family. When women first present in labor, as is often the case as mentioned by Dr. Oswal, there is usually no opportunity to counsel and test the mother. If the mother was already known to be HIV infected, then zidovudine must be given, as pointed out by Dr. Oswal. The infant must also be given zidovudine starting immediately after birth and the issue of avoidance of breastfeeding should have been considered in the interim, if at all possible.
T. Jacob John, |
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