by
K. SRINIVASAN, C. P. PRAKASAM, T. RAJARETNAM, PURUJIT PRAHARAJ
K. SRINIVASAN, C. P. PRAKASAM, T. RAJARETNAM, PURUJIT PRAHARAJ
(The following is excerpted from a paper published by The National Medical Journal of India, 2006)
Background: As a part of a project to improve the maternal and child health services in 4 primary health centres (PHCs) in Bellary and Raichur districts of Karnataka, we assessed the consistency in recording symptoms, signs and some clinical observations of pregnant women by three examiners the junior health assistant, medical officer of the PHC and a private medical practitioner.
Methods: One hundred seventy-four pregnant women were examined independently by the three examiners on the same day for 4 symptoms reported by the women themselves, 4 signs assessed by the examining person and 9 simple clinical observations. Agreement rates in each examiner pair for each parameter were assessed.
Discussion: The diagnosis of and treatment for pregnant women visiting PHCs or subcentres is based largely on symptoms and signs, either reported by the women themselves or elicited by paramedical or medical personnel. In a few cases, appropriate biochemical and pathological tests are carried out. Hence, clinical examination has an important role in the care of pregnant women visiting antenatal clinics at PHCs. Regular clinical examination of pregnant women in rural areas could help to reduce maternal morbidity and mortality.
We assessed the reliability of signs, symptoms and clinical observations among pregnant women by three types of examiners in a rural field setting in Karnataka. The findings of these examiners lacked consistency, with a high frequency of disagreement even on simple parameters, not only between the JHA (Junior Health Assistant) and doctors but also between the two doctors. For example, the agreement rates for ‘pulse rate’, presence of a ‘pale tongue’ and duration of pregnancy between the two doctors were as low as 48%, 59% and 61%, respectively. These large disagreement rates are disconcerting. Our data indicate that paramedical and medical personnel in rural areas do not take adequate care while examining pregnant women. Apathy, lack of concern for the health of mothers and sloppiness seem to underlie the poor consistency between the results obtained by two independent examiners. It may be argued that the parameters recorded have inherent problems that preclude accurate assessment. For instance, recall of the LMP (last menstrual period) date by pregnant women is known to be poor. However, the medical and paramedical personnel participating in the study had received prior training about ways to encourage correct recall of this information. Further, we ignored differences in estimated gestational age of up to 2 weeks. Thus, better agreement rates would be expected on these parameters. Surprisingly, there was significant disagreement between the doctors in the ascertainment of common signs such as ‘pale tongue’, ‘pale nails’, and ‘pale conjunctiva’. Also, there was significant disagreement in several quantitative measurements frequently used in antenatal clinics though these were measured on the same day and at the same place. In general, disagreements observed between the JHA and the doctors were similar to those between the doctors. The quality of medical care given to pregnant women on the basis of such unreliable measurements is open to question. Thus, the findings recorded by a doctor at a PHC may not be considered sacrosanct. We believe that these disagreements may be related, at least in part, to lack of attention to detail while taking measurements.
This study was carried out in the rural areas of the two most backward districts of Karnataka state, Bellary and Raichur, where medical and paramedical personnel function under difficult and deprived conditions. Hence, these findings cannot be generalized across the country. However, the study indicates the need for a regulatory and monitoring mechanism to ensure the quality of healthcare provided by healthcare personnel in rural areas under governmental programmes. Our data point to an urgent need for mandatory periodic refresher courses on maternal care for JHAs and MOs. Training manuals for medical and paramedical personnel, prepared by the Ministry of Health and Family Welfare, can be used for this. These manuals can also be used to assess the quality of services provided by the workers. In addition, efforts should be made to change the attitude of all those providing maternal healthcare. Periodic clinical examination of all pregnant women at home or at a health centre should be made a mandatory function of the staff of the PHC. It may also be necessary to modify the training curricula for JHAs and medical doctors to include ‘essential skills’ needed for maternal care. Better training, retraining and periodic assessment of the knowledge and skills of paramedical and medical workers may help improve the reliability of physical examination of pregnant women, and hence the quality of maternal care provided. There is also an urgent need to set up independent professional monitoring of the work of JHAs and doctors, by professional bodies such as the Medical and Nursing Councils.
{The italics in the excerpts are K. Srinivasan's own, and for the purpose of highlighting the key findings.}