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correspondence

Indian Pediatr 2013;50: 527

Concerns Regarding Pediatrician’s Certificate of ‘Neonatal Wellbeing’ for Puerperal Sterilization


Sriram Krishnamurthy and Rangan Srinivasaraghavan

Department of Pediatrics, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Pondicherry, India. Email: [email protected] 


In a recent article [1], the authors describe the process of issuing ‘well baby certificates’ to 1668 babies whose mothers opted for puerperal sterilization within a week of delivery. It is mentioned that 210 of these babies weighed less than 2.5 kg, out of which 17 weighed less than 2 kg (16 small for gestational age and one preterm). We have some concerns regarding the observations of the authors.

Babies weighing less than 2.5 kg, small for gestational age and premature babies are known to be high risk infants [2]. Low birth weight is associated with high neonatal and infant mortality [2]. It is therefore, surprising to note that these high risk infants, known to be at increased risk for neonatal and post-neonatal deaths have been classified as ‘well babies’ and issued pediatrician’s certificate for ‘neonatal well being’. The birth weight and gestational age criteria chosen by the authors to define a well baby need to be clarified.

Secondly, it is imperative that a follow up be done to see how many of these 1668 babies were alive and thriving well at least till one year of age. This is especially important in a developing country like India where infant mortality rate is very high (57 deaths per 1,000 live births according to NFHS-3) [3]. In addition, data regarding morbidities such as congenital malformations, metabolic disorders, growth and developmental abnormalities that may not have manifested in the neonatal period also need to be assessed.

Thirdly, the National family planning programme does not contain a provision for a formal pediatrician’s signed ‘certificate’ in order to mandate puerperal sterilization [4]. It is unclear whether the ‘well baby certificates’ issued by the authors are a part of the authors’ hospital policy or departmental protocol. The legal standing for such a certificate is also unclear. Taking into account the relative uncertainty regarding the health of the newborn, pediatricians may potentially face litigations for issuing such ‘certificates’, especially in the absence of screening for disorders such as inborn errors of metabolism, hypothyroidism, cardiac or other structural abnormalities. Couples should be therefore counseled regarding these issues and written informed consent should be taken explaining these facts in case they opt for puerperal sterilization. In fact, some authorities have suggested doing away with puerperal sterilization [5], encouraging couples to delay sterilization till the child is 12 months or older (when the baby would have survived the precarious time after delivery to guarantee its survival, proper growth and development) along with increasing the availability of effective reversible contraceptives, as options that India may consider to avert post-sterilization regret. This seems to be a prudent and rational approach, given the high prevailing infant and neonatal mortality rates in India.

References

1. Karthikeyan G, Ratnakumari TL. Well baby certificate for puerperal sterilization-A critical appraisal. Indian Pediatr. 2013;50:151-2.

2. Carlo WA. The high risk infant. In: Kliegman RM, Stanton BF, St.Geme JW, Schor NF, Behrman RE. ed. Nelson Textbook of Pediatrics.19th ed. Philadephia: Elsevier; 2011. p. 625-31.

3. International Institute for Population Sciences (IIPS) and Macro International. National Family Health Survey (NFHS-3), 2005-06: India. Mumbai: IIPS; 2008.

4. Reference Manual for Minilap Tubectomy. Family Planning Division. Ministry of Health and Family Welfare. New Delhi: Government of India; 2009.

5. Singh A, Ogollah R, Ram F, Pallikadavath S. Sterilization regret among married women in India: implications for the Indian national family planning program. Int Perspect Sex Reprod Health. 2012;38:187-95.

 

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