Vampa Ankrur is a freelance writer who specializes in writing about nothing and everything. The Journal of Fetal Radiology is pleased to share excerpts from a free-flowing conversation that Ankrur had with Dr. Rijo Mathew Choorakuttil, National Coordinator for Samrakshan, which is an Indian Radiological and Imaging Association (IRIA) program to reduce avoidable deaths of babies during pregnancy and soon after childbirth in India.
VA: Good morning, Doctor and thank you for the opportunity to have a sit down with you. We know you do wear a lot of organizational and academic hats in Indian Radiology, this time let us focus on your latest responsibility.
RM: Good morning. My pleasure.
VA: I understand you are coordinating the Samrakshan program. Can you tell us more about this program?
RM: Samrakshan is a national program of IRIA that aims to reach every district in India to reduce avoidable deaths in pregnant women or babies during pregnancy. Samrakshan is a program that aims to use the skill sets of Radiologists in India to provide optimal care for pregnant women and fetuses in India. Radiologists are uniquely placed to help. They have been trained over a period of a minimum of 3 years in various modalities to diagnose fetal well-being, including ultrasound studies, use of CT and MRI, use of Doppler, Fetal Echo and exposure to ultrasound guided interventions. The training is comprehensive and includes an understanding of medical physics, instrumentation and anatomy. Radiologists can identify problems early and work with other members of the pregnancy care team for a safe delivery. However, for some reason, radiologists are not included in conversations around pregnancy care. Samrakshan aims to fill this gap.
VA: Why is Childbirth a priority? Aren’t there other pressing issues where Radiologists can contribute more?
RMC: I guess it is a matter of perspective. We do have to realize that all issues are important, however, at times we have to choose to focus on one rather than another issue. It does not mean that something else is not important.
As all of us know, India has a large number of child births every year, running in the crores. We have focused a lot on population overgrowth, effects of population crowding, and the need to control that. One aspect, I feel, that has consistently slipped under the radar in a general conversation is the number of pregnant women and babies that die during pregnancy. This is part of health care conversations, part of development conversations, and consequently a part of the sustainable development goals, but has not attained a maximum priority status.
In India, every year approximately 3 million women develop pre-eclampsia (increased blood pressure during pregnancy) and approximately 3.5 million women have childbirth before term, what we call as preterm births. Approximately 26% babies are born with low birth weight and around 40% have growth restriction inside the uterus. India has a high perinatal mortality rate and remains a major contributor to the poor perinatal statistics worldwide, which I feel is a shame for us as a society.
VA: Those are large numbers.
RMC: Yes, they are. The importance is placed in perspective when we understand that there are short term and long-term consequences of illness and death in pregnant women and illness in babies during and immediately after pregnancy. It is not a one-time number that is there just for a year. We are looking at a number each year that cumulatively adds to long term health effects in our society.
As a starter, pregnant women are in what we may call the “productive” age group and illness and death translates to a loss of productivity for the woman, the family and consequently the society. The woman is the fulcrum for most of our family units, even if we may not be willing to acknowledge that, and anything that affects the health of the woman has a cascading effect on the family-subtle or unsubtle. The effects of ill health during pregnancy can affect the mother and the baby for a long time after childbirth. Believe me, there is nothing good that happens to a society when a woman falls ill, especially during pregnancy.
VA: Aren’t there enough efforts to tackle this already?
RMC: Yes, there are plenty of wonderful efforts going on. India has achieved much in reducing maternal deaths, child deaths and improving maternal health thanks to these efforts. They have to be appreciated and we need to promote these more.
VA: So, where do you see Radiology playing a role in this? Coming back to the question, why Samrakshan?
RMC: We are looking at this from a different perspective. We appreciate great work done in the field of child birth care and delivery, health of new born babies, infants, efforts in the development sector focused on improved living conditions, hygiene, water, education, nutrition. These are very important cogs of the wheel.
We see and place Samrakshan as supplementing these efforts. What is the specific focus in terms of time period of Samrakshan? It is the period the baby is in the womb of the mother. The time period of pregnancy.
VA: Let us get to specifics, then. How can a Radiologist help in this time frame of pregnancy?
RMC: A Radiologist can help in many ways. To begin with, the radiologist can confirm the pregnancy. The radiologist can also do what we call as dating of the pregnancy where we estimate the accurate (within a range) age of the fetus or weeks of pregnancy. It is important to date pregnancy early and to not change this estimate later as it is the basis to find out if the baby is growing normally and to determine when childbirth can be expected. The radiologist can give a customized or personalized risk estimate if the woman may develop pre-eclampsia or have a growth restricted fetus. The radiologist can recommend preventative methods based on this personalized estimate. The radiologist can detect abnormalities in the fetus and do additional exams to confirm the abnormality and recommend a plan for child birth in liaison with the treating physician. The radiologist can monitor growth, look for blood flow and supply to the fetus, identify problems that may affect the brain and development of the baby early. The radiologist can provide information to the obstetrician and the neonatologists to help them plan for child birth and immediate post child birth care.
As a Radiologist, we do not have the expertise or all the bandwidth to change what happens before pregnancy or after child birth. The reality is that we have limitations in what we can do during those periods before and after pregnancy. What we can do, however, with utmost skill and confidence during pregnancy, is to assess the health of the baby and share that information with the child care team and give the best possible chance for the child and mother to survive through and after pregnancy.
VA: That is a lot you can do. What are the components of Samrakshan? How is Samrakshan aligning all of this?
RMC: Samrakshan has several aspects to the program. We have a training or continuous medical education component that is organized state wise where we focus on bringing radiologists up to speed with latest evidence and protocols. We supplement these with an online learning portal that is free, available and accessible 24×7. We have an outreach component, at the district level, where we have a dialogue with the obstetricians and neonatologists crystallizing ways on how we can work together, as a team, complementing skills. We have a social outreach component where we talk with different community stake holders improving awareness of what is possible during pregnancy. Radiologists voluntarily submit data that is analyzed monthly and shared back to the larger community as reports. These form part of our continuous evaluation of the program.
VA: There is a lot of activity and a lot of scale up to reach every district. That is going to cost a lot. How will the program fund itself?
RMC: We are taking a different approach to the whole issue. We are saying, let us start by improving our efficiency in what we do daily as a routine. We are not looking at huge infrastructure changes, more equipment, costly equipment, more staff etc. Instead, we are saying, let us improve ourselves first. In the way we do things, with what we have. Let us make it systematic and cut inefficiency.
So, our primary focus is convincing ourselves to continuously improve even within the resources we currently use. To do this, we do not need additional funds. We need to share our expertise with each other without adding the limitation of non-affordable pay walls.
Why do we feel this is important? We feel if we work on improving ourselves, automatically everything around will improve- services improve, health improves, mortality has no choice but to reduce. So, rather than tackle the larger problem, we are tackling the immediately doable part in our control-changing ourselves- and using that to address the larger problem. One small bite at a time.
So, we start improving our work in our clinics, our interactions with our patients and our interactions with our peers in the childcare team. These don’t need financial investments, just a mind-set investment. We encourage our patients also to take responsibility, talking with the family as well as the woman emphasizing how pregnancy care is a team work and the woman and her family are partners in care.
VA: Is it working? Can you share any details?
RMC: It is early days still. We are into the 9th month of the program. We have started in 25 districts of 10 states in phases. The program has identified women at risk-nearly 10% of pregnant women are at risk for pre eclampsia and nearly 35% women are at risk for growth restriction. We have recommended preventative methods and liaised continuously with child birth teams to improve outcomes. These are early days, but the neonatal mortality rate was about 15 per 1000 live births as per our latest data, a significant fall compared to national statistics. We have published our baseline data that we aim to use to benchmark progress. We have a free online resource library, a You Tube channel, dedicated WhatsApp groups state wise to discuss cases and to connect instantly with mentors and experts, a telegram channel. We are also starting a dedicated health education and health literacy initiative focused on pregnant women in the Vernacular languages as well as English.
A long way to go still. As the poem goes- Miles and miles to go..but we are focused on small yet sure and doable steps.
VA: Thank you so much for sharing these details. I do hope to sit down again to review progress.
RMC: Of course. And thank you for listening!!
