The reports from India read more like the review of a horror movie rather than a detailing of a government funded surgical program – 83 women receiving a surgical sterilization leaving 11 dead and another 50 hospitalized, 20 of whom (as of this posting) are seriously ill. And all of this happened in six hours with one surgeon at a government sponsored sterilization camp.
As an OB/GYN I want to tell you how bad this actually is…
The most common method of tubal ligation is by laparoscopy, which is major surgery. An operating telescope is placed into the belly and a clip is placed across the Fallopian tubes to clamp them shut. Sometimes doctors remove the Fallopian tubes or burn them. The biggest risk from the surgery is inadvertently injuring the bowel (spilling stool leading to potentially catastrophic infection, bleeding, and even death), cutting a blood vessel (resulting in uncontrollable bleeding), and infection (from non bowel injury causes). There is also risk from the anesthesia. Patients are counselled about warning signs of these complications so they can get care sooner rather than later should a problem arise.
With competent surgeons, anesthesiologists, and nurses and clean hospitals the risks of laparoscopic tubal ligation are low. In one study of over 9,000 tubal ligations in the United States there was one serious complication and no deaths. Using a more liberal definition of serious complication the rate rose to 1%. A Swiss study indicates no deaths in a review of more than 27,000 procedures. Overall, the estimate is that 1-2 women will die for every 100,000 laparoscopic tubal ligation with most deaths anesthetic related. Basically, 99% of healthy women should expect to have no major issues beyond a day or two of recovery and for the women who do have major complications most involve getting a larger surgical incision and immediate repair of the damage with no long-term issues.
The other method of tubal ligation is done through the uterus and called a hysteroscopic tubal ligation. This can be done in the office (and takes about 20 minutes start to finish versus 40 minutes for a laparoscopic tubal ligation), saving the risk of the anesthesia. It is also less expensive. The risk of injuring blood vessels and bowel is still there (if the device is inserted incorrectly it can puncture the uterus and potentially cause bleeding/bowel injury/and infection), but studies tell us that the complication rate is likely lower than a laparoscopic tubal ligation.
It is likely the women in India had laparoscopic tubal ligations as the procedures are described in the press as “tubectomies” (impossible to do through the uterus).
That is why 11 deaths and 50 women hospitalized with 20 seriously ill is so appalling. A mortality rate of 13% for a procedure that should have a mortality rate of 0.001-2%.
83 tubal ligations in 6 hours and reportedly one surgeon and one or perhaps two assistants is nothing short of a horror show. It takes an average of 40 minutes to give a women an anesthetic, clean her belly, insert the instruments, clip the tubes, make sure nothing is injured, remove the scope, sew or glue the incisions, reverse the anesthetic, and get her off the operating table. It is possible, if everything is going smoothly and there are no complications, to sometimes have this done in 20-30 minutes. Even if there were 3 surgeons, 83 women in 6 hours is impossible unless of course hands were not cleaned and dirty intruments were just stabbed into bellies. The thought that the women may not have had adequate (or even any) anesthesia makes it even more horrifying. How could they given what has been described?
That the government funded this horror show is terrible. That a doctor was involved with this makes it even worse. Agreeing to such a perversion of health care is an abomination – 83 women simply can not have tubal ligations in 6 hours even with 3 competent surgeons and 3 anesthesiologists in a modern hospital never mind in a field. Understanding that doesn’t require a medical degree, just common sense and compassion. Money was offered to the women increasing an element of coercion. How many were forced by their families to go?
Government quotas for sterilization don’t empower women to make better decisions for themsleves and their families they only treat women like livestock. Or worse.
***November 13, 2014 update***
The BBC is reporting that the surgeon, Dr. RK Gupta, has been arrested. Sadly, the death toll has climbed to 15 women. 14 women died at the first camp (mentioned above) and 1 from another sterilization “camp” that was held two days later. Apparently 130 women were operated on over two day by just Dr. Gupta and an assistant.
Dr. Jen Gunter 
This is what happens (sickeningly) when women’s rights. education and access to contraception are slim or non-existent. And I agree that mistakes/problems/issues are not limited to first world countries. All of these things, no matter where they occur, need to be discussed openly in society.
Those instruments cannot have been sterilised in any meaningful way. No operating theatre, even in the West has 83 sets/scopes on hand. Even 40. A mini autoclave cycle would be 30 mins generally in between cases. And we have stopped using mini autoclaves in main operating theatres in the UK due to increasingly stringent traceability requirements.
I find it incredibly difficult that this doctor will have been attended by other healthcare professionals, all of whom were knowingly carrying out these procedures in worse than substandard conditions. Dr. Gupta’s assertions that he was “morally obligated” to operate on these women because the administration rounded up 83 of them is another load of absolute rubbish for which I don’t have words,
It’s also about poverty, the women operated on came from the lowest and most impoverished caste.
And the place of men and women in society; a vasectomy is quicker and less invasive than a tubal ligation, but apparently not so acceptable to men. India did have a vasectomy policy some years ago, this seems to have been curtailed.
The “Little Sister” and similar types of small autoclaves were useful when someone accidentally contaminated an instrument; it didn’t take long to autoclave it. However, doubts were raised about how effective it was.
The local paper here had an article about this, contaminated drugs are suspect. On the other hand it said he had performed 50,000 such operations, from what you say that seems pretty unreasonable.
I’ve seen that about the contaminated drugs too. It sounds more like blame shifting.
It’s also reported that the scalpel was sterilised by dipping it in spirit between cases, and being discarded after 10 or so. The towel clips were similarly sterilised. Anyone with any understanding of the sterilisation of surgical instruments would see this as about as useful as dipping instruments in holy water.
I have yet to see an explanation of how it is possible to do a “tubectomy” in two to four minutes.
It looks like there’s something to the contamination claim:
And just to throw a little more insult into the horror show, part of the money the women received for this had to be given back immediately to the van driver who took them to the surgeon. Sick.
Dr Jen. Please advise about reading of HSV IgG positive (33) in first test and unequivocal in the second test after 15 days. Does it suggest virus has become dormant?
Reblogged this on Conversations I Wish I Had.
With the rapes in India and now this, women are obviously not honored. It is shameful in 2014 to read of this kind of slaughter–that’s really what it is.
Unlicensed (and even those with licenses) medical professionals can and do make horrible decisions that lead to unnecessary suffering by patients and their loved ones whether in India, Japan, or the United States. The profit motive for both doctors and patients, poor regulation, public health policy concerns, and a whole host of other issues created an environment where this happened.
Unfortunately, Americans have a habit of cherry picking news like this to support their unsophisticated opinions about other nations (look up confirmation bias). Does India have a problem with rape? Yes. The United States has problems with rape, gender pay equality, domestic violence, age discrimination disproportionately aimed at women, body image shaming of women who do not fit pop culture ideals, and racism just to name a few but none of us condemn your nation. We call this bigotry.
Perhaps your shame and scorn extends to the events occurring in the United States but I don’t know. I do know doctors like Jennifer Gunter bring valuable experience to explain the news. There needs to be a discussion on solving the problems in India but discourse such as yours does nothing to advance any useful cause.
It may be that there is a caste problem; all the women came from the poorest, most disadvantaged caste.
Even with all the problems this country this has, I am feeling blessed.
This is just sickening.
What does that mean ….!!!!
I’m not an Ob/Gyn but was a general surgeon, and I do understand the procedures.
The reports speak of “tubectomy” rather than tubal ligation. Even so, to do such a procedure in five minutes or less, which is what the figures imply is impossible. Even under local anaesthesia, it is impossible.
Dr M de Bakey used to lots of heart valve replacements; but he had five or so operating theatres, and five teams. Each team would prepare the patient, including any necessary heart by-pass; Dr De Bakey only replaced the valve, the team completed the operation.
Even if this was how so many patients were “managed”, it still allows only a few minutes for the surgeon to clip the tubes after the anaesthesia (if any) has been given and the pneumoperitoneum to be established. Even so, I cannot see how so many women were operated on by one surgeon and an assistant in such a short time; it is just not credible.
Reblogged this on Jessica A Bruno (waybeyondfedup).