Article on Respectful Obstetric Care

My article on respectful obstetric care is now online on Perspectivo Mag!!

Comments and suggestions are welcome!

Memorable Encounters- I

I used to read James Herriot many years ago. He had expressed a thought frequently in his many books, the truth of which I am realizing in my own life now. He said that he would have seen many, many patients, but a few always stay in the mind, who stand out clearly in the nebulous seas of memory.

Among the people I recall are two ladies: a daughter and her mother.
The daughter had just given birth and was suffering from engorgement of breasts, which was why she had been referred to me. This patient was in her mid-twenties; the baby who was born was a "precious baby". Of course all babies are precious, but this phrase is used to describe any baby who is born after many trials, miscarriages and so on. This lady had had a stillborn some years previously, multiple miscarriages, abortions etc and who was thrilled to finally have a live, healthy baby in her hands. Her mother had been making her drink garlic milk for a few weeks before the childbirth to increase her milk production. She felt that that was the reason why her breasts were so hard and painful.

So we chatted, I told her all the usual steps to decrease the engorgement, such as warm compresses on the breasts, frequent hand expression of milk, frozen cabbage leaves (!) and paracetemol for the pain. Just as I was about to leave, her mom said, "Doctor, can we try jasmine?"

I blinked and said, "Okay, why?"

She said, "Why, to decrease the milk flow, of course"

I frankly admitted that I had never heard of jasmine having an effect on breast milk and then she said,

"It's a very common thing in our tradition. Every time the mother needs to decrease her milk, especially in case she no longer has to feed the baby, we tie a garland of jasmine flowers around her breasts and by next day, her breasts will be empty"

"Really?" I ask. "What if she wants to get the milk again?"

"Then she just has to start breastfeeding and drink a lot of garlic milk", said the mother.

Later that evening, I googled this up and sure enough, there were a couple of papers that talked about jasmine flowers affecting prolactin, the hormone that stimulates milk flow. I also spoke to a very experienced pediatrician who agreed that this really worked. What is unclear to me, however, is how long-lasting the effects are and if they can truly be reversed with substances like garlic, which are known to stimulate milk, and how long the reversal process takes. 

Weeks later, someone else told me that jasmine flowers are never given to a new mother, for this same fear. Jasmines are not even kept in the same room, apparently.

Interesting, right?

A Muslim family told me that they feed the mother the udder of a mother-goat. Apparently it looks a bit like paneer inside and one chops it up, roasts it and makes it into soup. And a couple of days later, milk starts leaking out of the breasts like water from a tap!

The things you don't learn from a text book.... :)

A Picture Worth Your Time

What a stunningly powerful picture.

I saw it on the Washington Post. Copyright belongs to Johnathan Bachman/Reuters

The caption is pretty brief: A demonstrator protesting the shooting death of Alton Sterling is detained by law enforcement near the headquarters of the Baton Rouge Police Department in Baton Rouge, La.

Flavours and Personalities

Ahem. Kindly note the added 'u' after the 'o' in the heading above- an added sign that I'm becoming truly re-Indianized. This, of course, means that I can no longer take comfort in 'diarrhea', but will have to switch the unwieldy 'diarrhoea'... Not that I suffer from either, at least not currently anyway. But in case I did and for some reason, needed to write about it to someone, I can no longer zip off the shorter version (of the word, not the deed) without feeling like I was somehow cheating.

Anyway, I was impelled to write this blog (that too on my phone) after visiting a patient. Have I mentioned how much I love meeting patients? There's of course the obvious attraction of sounding oh so important when you can throw around the phrase 'need to see my patient'- do doctors still retain that kick out of saying it after years and years of doing so?- but to me, a basic bench scientist for donkey's years, there's the sense of astonishment and boot licking gratitude that I actually am seeing and talking to so many different people every SINGLE day!! To think that I spent more than a decade huddled under sterile hoods and hunching over lab counters, desperate to escape and resigned to never actually escaping, this freedom to wear something other than jeans and shirts and shoes that cover every inch of foot skin, to touch something without wearing gloves at work(!!), it's indescribable. If I had to try to describe it, I'd say it's like that feeling of well-being, you know, long-lasting relief that you get when you empty out your bowels after waiting a long time to do so.

Anyway, the main point of this entry was to reflect on the various personalities one comes across. Postpartum periods are funny- women are simultaneously stressed out and happy; they have a sense of completion (or sometimes, accomplishment) that the labour part of it is over and they are now anxious about how to get this kid to feed. So it's always interesting to see how women handle this period in so many different ways.m

More about this in the next post... My phone is dying.

School in India

To be sung to the tune of "We Didn't Start the Fire"

Brown paper wrapping

Sello-tape, label-sticking

Uniform buying

Tie, belt and badge hunting.

Early morning prayers

We worship all Gods,

(Some Gods more than others)

Religious tolerance in action.

Waiting outside school gate

Fine for coming late

Shoes not sparkling white

Go hide out of sight.

(We didn’t start the fire)

This is school in India

There is no complaining, only early waking.

School bag packed with books

Weighing at least 10 kgs

Who says it breaks kids’ backs?

We believe in weight lifting.

Lunch in steel box

“No plastics” bandbox

Where is my steel thermos?

Is plastic basket allowed?

PT, langdi, running race, kabbadi

Annual Day, Sports Day (JFK blown away, what else do I have to say?)

This is how we celebrate!

(We didn’t start the fire)

This is school in India

There is no complaining, only early waking.

NfAS: 5. The need for advertising: even in a government hospital where you’re offering free services.

April 24^th 2016

Today, the hospital ambulance that takes us to the PHC is not around. I volunteer to drive everybody in my (new) car. It takes some effort to get the car out of its parking spot, where two other cars have parked neatly and very closely in front of and behind it, but I somehow manage without bumping anything or anybody. We drive to the clinic. The garbage dump outside the clinic has grown to truly monumental proportions, overflowing fully on to the street, with an equally compelling smell. It is its own ecosystem, with gangs of dogs, rowdy goats and lazy cows sitting on it. One especially sleepy cow meanders to the middle of the heap and stands there, eyes gazing into some distant future, completely blocking the road/ garbage pile upon which I am to drive. I honk, more people behind me honk, but to no avail. Soon I realize that the people are honking at me- apparently, I am to go forth despite the bovine obstruction. I gingerly let go of the brake and loose my grip on the clutch. The car is inches away from the cow. Should I bump it gently? Or would that be considered sacrilege by the denizens of this place? I tell the family medicine resident to hit it. She is a small girl and her thumps on the bovine backside are met with no reaction from its owner. Finally she removes her ID badge from around her neck and hits the cow with the neck tie and the good cow condescends to move a bit. We cheer and drive inside the compound to park.

The postnatal clinic is full. It had been closed the previous week for the Tamil New Year, so a lot of people have turned up. I go to my little room and wait. While I wait, I download the WHO growth charts for boys and girls 0-5 years old on my phone. I’ve been doing a lot of reading about these charts in the recent past, ever since our new pediatrician informed us that our daughter was low weight (what is it with this country and low weight kids? How do even reasonably healthy kids in the US suddenly end up low weight over here, I had ranted to my husband). So I had checked up his charts (yes, I can be a bit overbearing as a mom. What to do? Kindly bear with me) and realized he was using the CDC scale which has age and weight on the axes, whereas, according to the WHO scale, which has weight and height on the axes, she is perfectly normal.  “Since we are not Americans or Caucasians, why should we go by the CDC charts?” I ask my long-suffering husband. So from long sleepless nights where I wondered how I could safely and consistently increase the weight of my baby, I swung to extreme relief, even jubilation. Thus am I a slave to numbers and charts. 

Anyway, all this mental overload with growth charts means that I now want to bring those here to the PHC. How wonderful if I could show a worried mother that hey, her kid isn’t doing too badly after all! Even more wonderful would be if I could chart the kid’s progress over time, but that requires far more infrastructure than I have.

I wait. And wait. No patients. What is going on? I decide enough is enough. I go over to every attender I see in the clinic and schmooze. And remind them to send the mothers and their kids to me, as soon as the kids have received their shots. A slow trickle of patients begins. Life in a PHC is not so different from that in a hospital or in a laboratory, after all. If you want something, be nice to the attenders, the nurses, the lab technicians.

A couple walks in, day laborers at a nearby construction site, with their kids. For once, the father seems more concerned about the children’s food intake. I am surprised and pleased and I tell him so.  It is highly unusual for men to visit the clinic on postnatal day and this man actually accompanied his wife! I congratulate him on his forward thinking. They are worried that the kids are low weight, but I suspect that the kids are fine. I whip out my growth charts, we estimate the heights of the kids (note to self: bring a tape measure next time), we check the weights (approximate, since the weighing machine doesn’t work too well) and I figure out the percentiles. Both kids are around the 10^th percentile. I mentally run through the conversation where I would try to explain what a percentile is, and then decide not to embark upon it. Instead I tell them that the kids can do better and we then spend a pleasant 15 minutes or so discussing various diets. Fun times.

Altogether I see about a dozen people in my time there- better than the previous session, but only about half of what I had seen in my earlier visits. I should continue the schmoozing sessions and also bring in a few more chairs into the room, so I can ask patients to be seated while they are waiting for me. I should also bring a couple of crayons and paper for the kids to use during the wait.

On our drive back, we are waylaid by the garbage dump again, this time by goats and lambs gamboling about in blithe oblivion. This time my fellow-passengers are better prepared. They roar and clap their hands and click their tongues and the goats make way. “Wonderful!” I cry. “You guys are the best!” 

Something doesn’t seem right with the car on the drive back. It isn’t till a week later that I realize that I have punctured one of the tires. That garbage dump had the final say after all.

NfAS: The Day I Learn About Worms

April 7^th 2016

Only 5 patients today. Why? What happened to my high numbers? I sit in my little office, reading a novel on my iPhone, occasionally standing forlornly by the door hoping for someone to walk in. It doesn’t help to see the pediatrics resident inundated in patients. 

A woman walks in, smiling at me. She looks awfully familiar. Hey, didn’t I see you a few weeks back, I ask her. Yes doctor, she says. I came back to talk to you again. 

I am thrilled. Someone actually likes me enough to return! Then I tell myself to get a grip and not to be so needy. She thinks her one year old has worms because his tummy looks big. She says she has been trying to get him to have a flatter tummy for months now, but always, it looks like he has a “thondi” (pot belly). Oh yeah… worms… I’d totally forgotten about them, coming from my decade-long American background. I’d been dewormed multiple times as a child and that thought triggers multiple memories. “Does his bum itch?” I ask. “Does he keep wanting to eat weird things, such as paint or erasers?” Have his bowel movements changed? Does he keep wanting to eat continuously?” 

No, no and no, she says. He’s totally normal that way.
Okay, does he play in the mud?
Yes.
Do you wash his hands afterward?
Yes.

I tell her to talk to the pediatrician for albendazole, though it doesn’t seem like the kid has worms. I reassure her on the pot-belliness of infant bellies and explain about stomach muscles and how they tighten over time. I end by asking her detailed questions about the baby’s diet and praise her for a good job done.

Soon after, we get up to leave and I catch hold of the pediatrics resident and ask her to tell me all about worms. 

All these weeks, all these kids in their dirt-stained clothes and mud-stained hands and their low weights, and I never thought about worms before. A bulb just switched on in my head.