Juniper Publishers: Three Delays and LAMA (Left Against Medical Advise): Verbal Autopsy of Still Birth from North India
JUNIPER PUBLISHERS- JOURNAL OF GYNECOLOGY AND WOMEN’S
HEALTH
Journal of Gynecology and Women’s Health-Juniper
Publishers
Authored by Arun K Aggarwal*
Abstract
Stillbirths are huge public health burden in the
developing countries. There is gross lack of understanding about the
factors contributing to the Stillbirths. Three delay models are well
documented to describe delays at family level, transport level and
facility level based on Verbal Autopsies. There is a general tendency to
put all blames on the family for any adverse outcome. High number of
“LAMA” (Left against Medical Advise) cases are often attributed to poor
treatment seeking behavior of the families. However, this may also be
due to poor quality of care being delivered to the families.
We did community based verbal autopsy for stillbirth
review and extended the case to get more information from hospital based
enquiries. The mother felt in late evening that foetus has stopped
moving in her womb, but delayed seeking consultation till next morning..
At the primary health centre time was wasted due to non availability of
health staff, and in getting the investigations done. Non-availability
of appropriate transport contributed further to the risk. Lastly, the
hospital staff did not attend to the case for 30 hours. After long wait
at the hospital, the poor family decided to shift to the private
hospital. This could have led to maternal death that was averted due to
alertness of family. However, Govt. hospital labeled this case as “LAMA”
(Left against Medical Advise). We recommend toput in place strong
accountability frameworks in the hospitals to avert such situations.
Keywords: Still birth; Verbal autopsy; LAMA; Community; IndiaAbbreviations: LAMA: Left Against Medical Advise
Introduction
Patients get admitted to the hospitals/ health
facilities to seek treatment/ resolution of their problems. However, it
has been reported in literature that many patients leave the hospitals
before their treatment gets completed. Such patients are generally
considered to be “Discharged against medical advice” or “Left against
Medical Advise” (LAMA) in the medical terms. This problem of patient
discharges against medical advise, has emerged as a pervasive problem in
general hospitals. Terminology puts the blame on the patients. It
denotes that there is problem in the health seeking behavior of the
patients. However, literature review shows that a patient leaves the
hospital when his/her expectations are not fulfilled or they get
threatened due to any social or economical reasons. Patients may
withdraw consent from continuing treatment, against medical advice, for a
number of individualized reasons that may range from personal, family,
or financial issues; conflicts with staff; dissatisfaction with hospital
care, environment, or treatment interventions; and misunderstandings
based on underlying medical, cognitive, and psychiatric issues) [1-3].
There are some cases where refusal for treatment is on account of the organic confusions on the part of the patients [4-6].
However, adults with sound mind if are withdrawing consent or are
leaving against medical advice, then it may denote serious problems with
the health systems.
LAMA cases put an important challenge to any
responsive health care organization.. There are experiences that with
better understanding of patients’ issues and better communication skills
such patients can be managed with greater success. However, many health
organizations hide their irresponsible behavior under the mask of
“LAMA”, so that blame is put on the patients itself. In fact, it is well
documented in literature that majority of the LAMA patients and their
care givers are either generally uninformed or less informed of the
entailing side effects and outcomes of their decision to leave against
medical advice [7].
We are reporting here one case
study to highlight this problem and discuss the case to draw lessons and
viewpoint for health systems improvements.
The Context
This north Indian state is one of the progressive
states in India in terms of economic and infrastructural development;
however, it still lags behind tremendously in the area of medical and
social development. The current Infant Mortality Rate (IMR) of state is
42/1000 live births and it is still yet to catch up a long way to reach
its Millenium Development Goal (MDG) target of 30 per 1000 live births.
With the deadline of achieving the MDG target nearing in time; the state
health department under the leadership of National Health Mission
officers; has been implementing various programs to check and bring down
overall IMR in the state. The Infant Death Review (IDR) program was
formally implemented in 10 high priority districts of state since 2013
with the intention of tackling infant deaths, stillbirths and maternal
deaths. In regard to this program, as an external research body; this
team had come across one case of stillbirth that was reviewed
qualitatively.
The following history is based on the verbal autopsy
recorded from the family members (parents) of the deceased intrauterine
death: Mrs “X” was pregnant for the second time, with a healthy first
born baby. She was fully compliant woman with respect to early antenatal
registration and adequate antenatal checkups with the routine health
system. She had also consumed tablets of iron and folic acid as advised;
considering anemia to be a highly prevalent health problem in the areas
of her dwelling with poor compliance to its management in general.
At 8th month of gestation, this antenatal mother
(Mrs. X) underwent ultrasound examination and was detected to be having
Breech presentation of the foetus. Health service providers assured her
that there was no need to worry, as this position could autocorrect
itself. At 9th month of gestation, one evening, mother felt that the
foetus had stopped moving in the womb. She waited overnight anticipating
the baby’s movement, and next morning visited the nearest block level
health facility with her spouse on their personal two-wheeler. However,
they had to wait for health staff for more than two hours, as no one was
available at the primary health centre (PHC) to attend to her concern.
That particular day was a Sunday (holiday). (A Primary Health Centre or
PHC, is supposed to be running all 24 hours for 7 days a week and even
during holidays, under the supervision of a doctor and nurse). Later, a
Staff nurse arrived and checked the mother; and she realized that the
Foetal Heart Sounds (FHS) of the unborn baby was either scanty or not
audible. The PHC nurse asked them to get an ultrasound done from a
private service provider, instead of referring to general hospital of
the district where out of pocket expense would have been saved. This
decision made by the staff nurse was autonomous and without any
consultation with the on call duty Medical Officer in charge of the PHC.
Thereafter, the couple went to the suggested private clinic on their
own two wheeler, traversing a road terrain that was pebbly and
difficult. Ultrasound report done at the private clinic indicated that
the foetus was dead. The family came back to the PHC nurse for
consultation and now the mother was referred to general hospital for
delivery. This time, the Staff Nurse in question had called for free
government ambulatory service to transport the patient to the higher
level hospital; however, the ambulance never came and the couple had to
continue their journey via the same two wheeler. At the general hospital
(District level higher center) the staff nurse on duty admitted the
mother after 4 hours of struggle. She was not willing to admit. Lot of
pressure had to be built on her from district and state for the
admission to happen. However, even after admission she was not attended
to adequately. The duty doctors on call also refused to attend the
patient in the hospital. She remained admitted without proper treatment
for more than 30 hours. She was having pain but there was no hearing of
her problem. The couple insisted on getting delivered at the government
facility because the baby was already dead and since they were from a
socio-economically weak background who couldn’t afford treatment at
private hospital for a lost cause. At last, the dissatisfied family took
the mother to private hospital where she got delivered in half an hour.
General hospital records file mentions “LAMA”
Discussion
Three-Delays-Model is often used for health system
improvement in the field of maternal and child health care. According to
this model, the three levels of delays leading to infant/maternal death
are as follows: Delay 1: Delay in decision making to seek care (Family
Level or lack of awareness), Delay 2: Delay in reaching health care
facility (or transportation delay), Delay 3: Delay in receiving adequate
care at tertiary level centers (also includes delay in referral from
one facility to another) All three delays occurred in this case. The
history denotes that despite being aware about the routine antenatal
care, Mrs. “X” lost her baby in the womb, because she delayed her first
decision for seeking consultation after she could not feel the foetal
movements overnight. Moreover, her spouse or family members did not
necessarily feel the need to seek immediate treatment the moment this
problem started and instead waited an entire night before seeking care.
This may be due to poor quality of counseling given during antenatal
period to mothers on delivery preparedness during their 3rd or 4th
antenatal visits and thus required awareness was not created regarding
possible complications. Had the mother and family members known of the
dangers signs of pregnancy and the importance of prompt treatment, it is
anticipated that they would have visited the health facility
immediately.
Secondly, it was evident from the
history that the Mrs. “X” and her spouse never received the entitled
free government ambulatory services throughout their attempts to seek
care at various levels of the health care system. They had to instead
travel on a two-wheeler riding over a terrain that was reportedly not an
easy to ride area. This possible disturbing ride could have further
aggravated the conditions of her foetus; considering it was already
having a faint Foeatal Heart Sound (FHS). Moreover, this case indicates a
lack of proper communication between health facilities and the
ambulance control room staff which resulted in unavailability of
ambulance for this concerned case.
Thirdly, from the perspective of delay in prompt and
appropriate referral; it can be easily pointed out that initial
management at the PHC level had several underlying loopholes which could
have directly/indirectly contributed to the resultant intrauterine
death. According to the recorded history, there was no staff available
to attend Mrs. “X” at the PHC for 2 hours for a health facility that is
expected to function round the clock and throughout the week. Later when
the staff nurse arrived, even after knowing that FHS of the foetus was
scanty; she instead chose to send the patient in some private clinic for
an ultrasound instead of directly referring the case to a higher
government facility via free government ambulance. Moreover, the staff
nurse did not bother to consult the supervising medical officer in
charge of the PHC before making decision about this particular case. Had
she been punctual and made decisions based on consultation with
superiors, delay 3 could have been partially avoided.
However, apathy of the health system unfolds further
when she reaches district level general hospital on a holiday, with a
dead foetus in womb, and was not taken care of. The couple insisted on
getting delivered at the government facility because the baby was
already dead and since they were from a socio-economically weak
background who couldn’t afford treatment at private hospital for a lost
cause. However, no one at the district level hospital attended to their
concerns for more than 30 hours. Everyone including staff nurses, duty
doctors and higher officials chose to shirk away from their
responsibility. This undelivered intrauterine death could have also led
to a possible maternal death. With the history quoted in the verbal
autopsy, this is a clear case of dereliction of duties and the patient
was indirectly contemplated into seeking care elsewhere. However,
labeling such cases as “LAMA” has serious program implications.
Conclusion
Health facilities should ensure that clients are able
to recognize the seriousness of the complications and take timely
decisions to seek consultation. Accountability frameworks should be put
in place to avoid delays in providing health care/ treatment. All “LAMA”
cases should be put under active surveillance to identify potential
gaps in the provision of hospital care.
Acknowledgement
This case study was generated from the project funded
by National Health Mission of a State. Dr. Himani Anand,, project data
analyst helped in improving the manuscript, Dr Rakesh Gupta, MD (NHM)
funded the project, Dr Suresh Dalpath (State deputy director child
health) liased with the districts for supporting the project.
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