An elderly female member of the family came out of the thatched hut to the courtyard and informed a middle aged man that the 'dai' needs to be called. Immediately on hearing this, the man stepped out of the house, picked up a firewood from the pile, wrapped a piece of cloth on its end, smeared it with kerosene and set it on fire. A fire torch was made. He walked towards the next village aiming to meet the 'dai' living there.The elderly woman watched him till the man vanished in the dark. The fire torch could still be seen as a bright yellow dot in the dark.
On that full-moon night, the stars were shining brightly. It was while admiring the moon that pregnant Karthika felt pain on her lower abdomen. She held her breath and clenched her teeth, waiting for the pain to ease. She walked into the house with difficulty, and lay down on the bed. But the pain occurred to her intermittently, increasing in intensity each time. She called out to her mother for help. Her mother, an elderly lady, pressed on her abdomen and realized that Karthika is having labour pains. If a 'dai' (a birth attendant) was to be called, she should be payed heavily, besides providing her a meal. If the child was a boy, she had to be gifted a saree in addition to the payment and food. Calling a doctor to attend the delivery was out of question. Karthika's family would have to pay three months' earnings to be able to pay for the doctor in the village. Karthika's mother had attended a few deliveries, so she thought she would attend the birth of her daughter, and not make it expensive by availing a 'dai's service.
Ten hours passed. Karthika was writhing with pain. She screamed loudly. Her cries echoed in the shackle. Then, after it seemed like an eon, Karthika let out another loud wail while her mother, the elderly woman, pulled the baby out of the birth canal. The baby, after being slapped on the back by the lady, let out a cry. The woman smiled with joy.
It was time to look for fresh bleeding. Once bleeding starts, the placenta will begin to separate. The placenta should be pulled out with extreme care. The intact placenta should be separated from the uterus, and the blood should be wiped off.
Karthika's mother waited, but the placenta showed no signs of separation. She applied gentle force at the end of the cord to pull the placenta out. A part of the placenta, along with the cord, separated out, followed by profuse bleeding. It was then that she decided to inform the menfolk about the bleeding, and to send them to urgently call the 'dhai'.
Women from the neighborhood, who heard about the mishap had flocked into Karthika's house and were eagerly waiting for the dhai to arrive from the next village.
After what it seemed like two hours, the dhai arrived. Karthika was lying in a pool of blood. Her face was papery-white, and her pulse was hardly palpable.She looked at Karthika's face and found that she is about to bleed to death. All she could try was to apply pressure to her abdomen to stop the arteries from bleeding, but it did not work out. After losing a large volume of blood, Karthika slowly succumbed to death.
Karthika fell victim to postpartum haemorrhage. In India, where medical care is still not affordable or not accessible for the rural folk, postpartum haemorrage is the leading cause of maternal mortality. Most of these deaths are actually preventable with good obstetric care during delivery and routine health checkups during pregnancy.
A leading cause for postpartum hemorrhage among women in India is iron deficiency. More than three-fourth of Indian women are anaemic. Anaemia is augmented during pregnancy in most women because the nutritional demand is high during pregnancy, but the foo intake continues to be poor. A 2011 study by me and my classmates (5th semester M.B.B.S students at Govt. Medical College, Kozhikode) has revealed that anemia among pre-school children in a village in Kerala is as high as 15 percent.
Myshkin Ingawale and his team have created a machine which they named ToucHb, that can be used to measure the hemoglobin level in the blood. The machine gives quick results, and can be operated by laymen. It is handy and cheap. It is so small that it can be fit into the handbag of the health worker (called ASHA worker in India). No lancets or syringes are required, eliminating the need for pricking the skin as done in conventional hemoglobin estimation. There is no fear of transmission of blood-borne infections, no Universal precautions needed, because no pricking is involved. Watch Myshkin's TED talk powered by Franklin Templeton Investments partnered the TEDxGateway Mumbai in 2012 :
ToucHb is a real innovation which uses the principles of spectroscopy to determine the hemoglobin level in the blood. The device could be connected to an Android phone to deliver the test results into an application, and store the data for future use. The machine runs on a battery, which can easily be changed by the ASHA worker using it.
Though having a prick-free hemoglobinometer is an exciting idea, I wonder if it would really be of use in large scale at the public health level. The ASHA needs to be first trained on how to use the device, the training of which will require experts, which I think is going to be difficult. The simplest test for anemia is to look for pallor. I think it would be more cost effective to train the ASHAs to look for pallor in pregnant women, than to supply them with an instrument that runs on a battery. However, pallor is sometimes inconclusive and anemia at the initial stages do not produce pallor. Besides, a lot of subjectivity would creep in while looking for pallor - that which seems like pallor for one would look perfectly normal for another. But under the existing situations where it would be expensive for the government to provide every rural health worker with a ToucHb, examining for pallor seems to be an easier option. Find out how to look for anemia here :
Studies prove that nearly 80% of all women in India become anemic during their pregnancy. The government is providing 100 iron and folic tablets to every pregnant woman in the country, free of cost. There would be no point in using a device to diagnose anemia, when every woman, regardless of her anemia status, is being provided oral iron tablets. A screening device would be useful if only if those tested positive are subjected to an intervention for curing the disease. But in practice, the Government of India is providing free iron tablets to whoever is pregnant, eliminating the need of the screening test.
Now, what if a non-anemic woman takes iron tablets? It would be beneficial for her and her baby because the extra iron will be stored in her body, and at these levels, it does not cause any toxicity. So, I think it would be cost effective to get the iron-folic acid tablets to the ASHAs and train them to look for pallor for determining compliance than to provide them with a machine.
I think the real use of ToucHb is in the peripheral health centres (PHCs) in India. It is not affordable to have an automated hemoglobinometer in the peripheral health centres. It is also not possible to run emergency blood tests and get the results quickly while at a health centre in remote villages. If a machine like ToucHb could be provided to the doctor working in the PHCs, it would be of help to her/him to find out the hemoglobin level with higher accuracy than the clinical tests, and determine the mode of management of the patient. Knowing the degree of anemia is of importance to a doctor because the mode of management of the patient depends on the level of hemoglobin in blood. For those who have mild to moderate anemia, oral iron tablets might suffice. Some might require iron infusions. Those having severe anemia might require a blood transfusion and prompt referral to a higher centre or a tertiary level hospital. The machine will also show the oxygen saturation, which is of no relevance to the ASHA worker, but certainly of use for the doctor to know the health status of the patient. The machine will quickly get the heart rate of the patient, which would help the doctor to diagnose tachy/brady-cardia, and find out the cause for it.
Yes, ToucHb is a marvelous equipment that will democratize healthcare. I wish Myshkin and BioSense all the very best in their future endeavors and hope that they invent more such instruments in future.
Thanks to IndiBlogger and Franklin Templeton Investments partnered the TEDxGateway Mumbai in December 2012 for inspiring me to write this article.
1. Did you know that Myshkin has done his research on Wikipedia just like I did?
2. At 3:00 minutes on Myshkin's TEDx video, a syringe pricking the arm is shown. It is not a syringe for collecting blood, but one that is used to test for allergy to substances such as tuberculin. Also read Mantoux test.