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Authors are the souls of any journal, and deserve much respect. To publish a journal manuscripts are needed from authors. Authors have a great responsibility for producing facts of their work in terms of number and results truthfully and an individual honesty is expected from authors in this regards. Both ways its true "No authors-No manuscripts-No journals" and "No journals–No manuscripts–No authors". Reviewing a manuscript is also a very responsible and important task of any peer-reviewed journal and to be taken seriously. It needs knowledge on the subject, sincerity, honesty and determination. Although the process of reviewing a manuscript is a time consuming task butit is expected to give one's best remarks within the time frame of the journal.
Salient features of the JCDR: It is a biomedical, multidisciplinary (including all medical and dental specialities), e-journal, with wide scope and extensive author support. At the same time, a free text of manuscript is available in HTML and PDF format. There is fast growing authorship and readership with JCDR as this can be judged by the number of articles published in it i e; in Feb 2007 of its first issue, it contained 5 articles only, and now in its recent volume published in April 2011, it contained 67 manuscripts. This e-journal is fulfilling the commitments and objectives sincerely, (as stated by Editor-in-chief in his preface to first edition) i e; to encourage physicians through the internet, especially from the developing countries who witness a spectrum of disease and acquire a wealth of knowledge to publish their experiences to benefit the medical community in patients care. I also feel that many of us have work of substance, newer ideas, adequate clinical materials but poor in medical writing and hesitation to submit the work and need help. JCDR provides authors help in this regards.
Timely publication of journal: Publication of manuscripts and bringing out the issue in time is one of the positive aspects of JCDR and is possible with strong support team in terms of peer reviewers, proof reading, language check, computer operators, etc. This is one of the great reasons for authors to submit their work with JCDR. Another best part of JCDR is "Online first Publications" facilities available for the authors. This facility not only provides the prompt publications of the manuscripts but at the same time also early availability of the manuscripts for the readers.
Indexation and online availability: Indexation transforms the journal in some sense from its local ownership to the worldwide professional community and to the public.JCDR is indexed with Embase & EMbiology, Google Scholar, Index Copernicus, Chemical Abstracts Service, Journal seek Database, Indian Science Abstracts, to name few of them. Manuscriptspublished in JCDR are available on major search engines ie; google, yahoo, msn.
In the era of fast growing newer technologies, and in computer and internet friendly environment the manuscripts preparation, submission, review, revision, etc and all can be done and checked with a click from all corer of the world, at any time. Of course there is always a scope for improvement in every field and none is perfect. To progress, one needs to identify the areas of one's weakness and to strengthen them.
It is well said that "happy beginning is half done" and it fits perfectly with JCDR. It has grown considerably and I feel it has already grown up from its infancy to adolescence, achieving the status of standard online e-journal form Indian continent since its inception in Feb 2007. This had been made possible due to the efforts and the hard work put in it. The way the JCDR is improving with every new volume, with good quality original manuscripts, makes it a quality journal for readers. I must thank and congratulate Dr Hemant Jain, Editor-in-Chief JCDR and his team for their sincere efforts, dedication, and determination for making JCDR a fast growing journal.
Every one of us: authors, reviewers, editors, and publisher are responsible for enhancing the stature of the journal. I wish for a great success for JCDR."
Thanking you
With sincere regards
Dr. Rajendra Kumar Ghritlaharey, M.S., M. Ch., FAIS
Associate Professor,
Department of Paediatric Surgery, Gandhi Medical College & Associated
Kamla Nehru & Hamidia Hospitals Bhopal, Madhya Pradesh 462 001 (India)
E-mail: drrajendrak1@rediffmail.com
On May 11,2011
Dr. Shankar P.R.
"On looking back through my Gmail archives after being requested by the journal to write a short editorial about my experiences of publishing with the Journal of Clinical and Diagnostic Research (JCDR), I came across an e-mail from Dr. Hemant Jain, Editor, in March 2007, which introduced the new electronic journal. The main features of the journal which were outlined in the e-mail were extensive author support, cash rewards, the peer review process, and other salient features of the journal.
Over a span of over four years, we (I and my colleagues) have published around 25 articles in the journal. In this editorial, I plan to briefly discuss my experiences of publishing with JCDR and the strengths of the journal and to finally address the areas for improvement.
My experiences of publishing with JCDR: Overall, my experiences of publishing withJCDR have been positive. The best point about the journal is that it responds to queries from the author. This may seem to be simple and not too much to ask for, but unfortunately, many journals in the subcontinent and from many developing countries do not respond or they respond with a long delay to the queries from the authors 1. The reasons could be many, including lack of optimal secretarial and other support. Another problem with many journals is the slowness of the review process. Editorial processing and peer review can take anywhere between a year to two years with some journals. Also, some journals do not keep the contributors informed about the progress of the review process. Due to the long review process, the articles can lose their relevance and topicality. A major benefit with JCDR is the timeliness and promptness of its response. In Dr Jain's e-mail which was sent to me in 2007, before the introduction of the Pre-publishing system, he had stated that he had received my submission and that he would get back to me within seven days and he did!
Most of the manuscripts are published within 3 to 4 months of their submission if they are found to be suitable after the review process. JCDR is published bimonthly and the accepted articles were usually published in the next issue. Recently, due to the increased volume of the submissions, the review process has become slower and it ?? Section can take from 4 to 6 months for the articles to be reviewed. The journal has an extensive author support system and it has recently introduced a paid expedited review process. The journal also mentions the average time for processing the manuscript under different submission systems - regular submission and expedited review.
Strengths of the journal: The journal has an online first facility in which the accepted manuscripts may be published on the website before being included in a regular issue of the journal. This cuts down the time between their acceptance and the publication. The journal is indexed in many databases, though not in PubMed. The editorial board should now take steps to index the journal in PubMed. The journal has a system of notifying readers through e-mail when a new issue is released. Also, the articles are available in both the HTML and the PDF formats. I especially like the new and colorful page format of the journal. Also, the access statistics of the articles are available. The prepublication and the manuscript tracking system are also helpful for the authors.
Areas for improvement: In certain cases, I felt that the peer review process of the manuscripts was not up to international standards and that it should be strengthened. Also, the number of manuscripts in an issue is high and it may be difficult for readers to go through all of them. The journal can consider tightening of the peer review process and increasing the quality standards for the acceptance of the manuscripts. I faced occasional problems with the online manuscript submission (Pre-publishing) system, which have to be addressed.
Overall, the publishing process with JCDR has been smooth, quick and relatively hassle free and I can recommend other authors to consider the journal as an outlet for their work."
Dr. P. Ravi Shankar
KIST Medical College, P.O. Box 14142, Kathmandu, Nepal.
E-mail: ravi.dr.shankar@gmail.com
On April 2011 Anuradha
Dear team JCDR, I would like to thank you for the very professional and polite service provided by everyone at JCDR. While i have been in the field of writing and editing for sometime, this has been my first attempt in publishing a scientific paper.Thank you for hand-holding me through the process.
Dr. Anuradha
E-mail: anuradha2nittur@gmail.com
On Jan 2020
Original article / research
Full Version
Prevalence of Anaemia in Women with Unsupervised Medical Abortion- An Observational Study
Correspondence Address :
Dr. Neelam Patel,
Flat No. 2, MIG C Block, Peoples Campus,
Bhopal, Madhya Pradesh, India.
E-mail: drneelamjipmer88@gmail.com
Introduction: According to American College of Obstetricians and Gynaecologists (ACOG) and other organisations such as the Society of Family Planning (SFP) and American Society for Reproductive Medicine (ASRM), abortion services are considered as an essential component of comprehensive healthcare. Such services are considered as a time-sensitive issue, as delay in getting comprehensive abortion services may be associated with significant impact on physical health, wellbeing and mental health of the individual.
Aim: To determine proportion of women presenting to Gynaecologyy Outpatient Department (OPD) with unsupervised use of abortion pills and to estimate the percentage of anaemia among these women.
Materials and Methods: The present observational study was conducted on 148 women attending the Gynaecology OPD in People’s Hospital, Bhopal, Madhya Pradesh, India and seeking treatment for complications due to unsupervised use of abortion pills during the study period of 18 months. A thorough history was obtained and a thorough physical examination was conducted. Haemoglobin estimation and Ultrasonography (USG) was done to determine complications. Data was compiled using Microsoft excel and results were expressed in terms of frequency and percentages and mean±SD.
Results: During the study period, a total of 360 cases with abortions were registered, of them 150 cases were unsupervised attributing to 41.7% cases. Out of 150 females with unsupervised abortions, 2 females did not give consent to participate and thus a total of 148 females were enrolled. Consumption of unsupervised abortion pills resulted in incomplete abortion in 77 (52%) cases, while complete abortion was reported in only 22 (14.9%) cases. Other complications observed in a few cases were septic shock, in 7 (4.7%) haemorrhagic shock in 4 (2.7%), secondary infertility in 3 (2%), inevitable abortion in 3 (2%), ruptured ectopic pregnancy in 3 (2%) and chronic ovarian ectopic in 1 (0.7%). Missed abortion was documented in 20 (13.5%) cases after complete examination and in 8 (5.4%) cases viable intrauterine pregnancy was diagnosed. Mild, moderate and severe anaemia was observed in 19 (12.8%), 98 (66.2%) and 12 (8.1%) females, respectively.
Conclusion: The unsupervised use of abortion pills not only increases maternal morbidity but also has been associated with life threatening complications such as septic shock, haemorrhagic shock, ruptured ectopic pregnancy etc. Anaemia is one of the most common complication of unsupervised pill consumption and preventing the latter may obviate the need for blood transfusion.
Complications, Diagnosis, Period of gestation
According to World Health Organisation (WHO), an abortion is defined as unsafe abortion when an unwanted pregnancy is terminated by various procedures/methods either by unskilled person or in an unsafe environment (lacking the minimal medical standards), or both (1). The rate of unsafe abortions and associated mortalities are reported to be much higher in developing countries when compared to developed nations (2). However, the exact proportions of induced abortions are often underestimated due to rampant practice of self-administration of unsupervised abortion pills (3). Though, medical abortion when practiced with strict adherence to Medical Termination of Pregnancy (MTP) guidelines is a safe method for termination of pregnancy, with approximate success rate of 95-99% (4). According to MTP Act (2020- latest amendment), medical termination of pregnancy can be done upto 20 weeks of gestation by a certified registered medical practitioner at the designated facilities (5).
Misoprostol and mifepristone are approved by Drug Controller General of India as medical methods of termination of pregnancy. Central Drugs Standard Control Organisation, Directorate General Of Health Services (DGHS) approved a combi-pack of Mifepristone (1 tab 200 mg) and Misoprostol (4 tabs 200 mcg each) and this can be given for termination of pregnancy upto 63 days of gestation (6). Medical termination of pregnancy act law enforces strict confidentiality of pregnant females undergoing medical termination of pregnancy. Despite the confidentiality, majority of the beneficiaries opt for unsafe mode of abortion by using unsupervised drugs due to easy availability of over the counter drugs or seek treatment from the quacks (5).
India faces a huge unmet need of contraception. Though, the contraceptives are available even at primary centres, their use is suboptimal, however, abortion pills are being used as an alternative to contraceptive methods. These unsupervised and over the counter use of abortion pills results in life threatening complications and is associated with high morbidity as well as mortality (7). One of the disadvantage associated with medical abortion is incomplete abortion, which is reported in 0.2-3% of cases (8),(9). Incomplete abortion is associated with excessive bleeding per vaginum and cause anaemia of varying severity which may be life threatening (10). According to ACOG and other organisations such as the Society of Family Planning (SFP) and American Society for Reproductive Medicine (ASRM), abortion services are considered as an essential component of comprehensive healthcare. Such services are considered as a time-sensitive issue, as delay in getting comprehensive abortion services may be associated with significant impact on physical health, wellbeing and mental health of the individual. It has been recommended to collaborate communitybased and hospital-based clinicians so as to ensure timely access to abortion care services especially during the Coronavirus Disease (COVID) time (11). Given the higher proportion of cases taking unsupervised abortion pills and associated increase in maternal and foetal complications, this study was carried out to determine proportion of women presenting to Gynaecology OPD with unsupervised use of abortion pills and to estimate the percentage of various complications particularly anaemia among these women.
This study was conducted as an observational study on women attending the Gynaecology OPD in People’s College of Medical Science and Research Centre, Bhopal, Madhya Pradesh, India and seeking treatment for complications due to unsupervised use of abortion pills during the study period from 1st November 2019 to 30th April 2021. After obtaining ethical clearance from Institutes Ethical Committee [PCMS/OD/2019/1439(18)], all the females fulfilling inclusion criteria were enrolled and written consent was obtained from all of them.
During the study period, a total of 360 cases with abortions were registered, of them 150 cases were unsupervised attributing to 41.7% cases. Out of 150 females with unsupervised abortions, 2 females did not give consent to participate and thus a total of 148 females were enrolled.
Inclusion criteria: Women with history of consumption of abortion pills without any medical supervision, upto 20 weeks of pregnancy and presenting with complications were included.
Exclusion criteria: Females with unknown Urine Pregnancy Test (UPT) status, receiving abortion pills under supervision and unsupervised pills consumed after 20 weeks of pregnancy were excluded.
Unsupervised consumption of abortion pill refers to women taking over the counter pills without prescription from registered medical practitioner or Gynaecologist or taking prescription from traditional healers or quacks.
Study Procedure
A thorough sociodemographic variables (age, education), gravida status, mode of presentation was obtained from all the females using a proforma. Their obstetric history period of gestation, method of abortion, duration between consumption of abortion pill and seeking care etc. was obtained. These participants were then subjected to thorough physical examination. All the females were subjected to routine blood investigations and ultrasonography for Retained Product of Conception (RPOC). Based upon the findings of examination, the participants were categorised as incomplete, inevitable, missed, septic abortion, complete abortion and ectopic pregnancy. Haemoglobin estimation was done in all the cases and severity of anaemia was classified according to World Health Organisation (WHO) classification (12). Appropriate management was carried out in each case for example suction and evacuation in each case, laparotomy in case of ectopic pregnancy.
Statistical Analysis
Data was compiled using Microsoft (MS) excel and analysed using International Business Management (IBM) Statistical Package for Social Sciences (SPSS) software version 20.0. Categorical data was expressed as frequency and proportion whereas continuous data was expressed as mean and standard deviation.
Mean age of women who underwent unsupervised abortions was 27.14±4.29 years. Majority of females were third gravida 51 (34.5%). Only 61 (41.2%) women achieved atleast primary level of education whereas about 22 (14.9%) females were illiterate (Table/Fig 1).
On ultrasonography, consumption of unsupervised abortion pills resulted in incomplete abortion in 77 (52%) cases, while complete abortion was reported in only 22 (14.9%) cases (Table/Fig 2).
Mean haemoglobin levels in females following consumption of unsupervised abortion pills was 9.15±1.41 gm/dL, majority of females presented with anaemia (haemoglobin <11 gm/dL). Mild, moderate and severe anaemia could be observed in 19 (12.8%), 98 (66.2%) and 12 (8.2%) females, respectively while no anaemia was observed in 19 (12.8%) (Table/Fig 3). Blood transfusion was required in nine patients in the present study due to severe anaemia and associated excessive bleeding.
Suction and Evacuation (S&E) was the most common method used for management of complicated cases. About 4 (2.7%) cases required laparotomy in view of ectopic pregnancy and 1(0.7%) case delivered a healthy neonate at term gestation (Table/Fig 4). Overall, blood transfusion was required in 9 patients (8 with S&E and 1 with MTP).
Though pregnancy and child birth are universally celebrated event, but the decision of entering into motherhood is a life changing experience. The unwanted pregnancy and methods of dealing with the unwanted pregnancy may have deleterious effect on health of not only mother but of the child as well. The MTP act was passed in 1971 in India to reduce the maternal morbidity and mortality due to unsafe and illegal abortion by preventing such abortions. The law enforces strict confidentiality, despite which, majority of the beneficiaries opt for unsafe mode of abortion by using unsupervised methods (11). Easy and over the counter availability of abortion pills allow the female to consume the pill for not only abortion but also for other variety of reasons such as limiting family size, failure of contraception, birth spacing etc (13). Thus, even after the decades of legalisation of abortions in India, the morbidity and mortality due to unsafe abortion remains high (14). There is huge under-reporting of abortion due to associated social stigma. Literature suggest that majority of unwanted pregnancies are dealt outside the health facilities. Thus, the actual figure of unsafe and unsupervised abortions are often under-reported and only those with complications seek care at the health facility (3).
In the present study, the proportions of unsupervised abortions was 41.7%. The incidence of unsupervised abortions was 31.2% in a study of Nivedita K and Shanthini F, (3) Singh S et al., (15) and Yokoe R et al., (16) reported the proportions of unsupervised abortions as 73% and 67.1%, respectively. All these studies were conducted in India. Shamsi S et al., (17) reported much higher rate of unsupervised abortions in their study in Bangladesh. Overall, the percentage of unsupervised abortions have been documented to be higher in countries with restrictive abortion laws (approximately 75%) (18).
In the present study, majority of females presented after 15 days of consumption of abortion pills 71% whereas only 4.7% cases presented as early as during the first seven days of consumption. This study findings were supported by findings of Mishra N, in which, majority of females presented with irregular bleeding of more than two weeks following consumption of abortion pills (19). In contrast, Nivedita K and Shanthini F, documented that maximum females presented within first five days of consumption of abortion pills (3). Munshi KS et al., also observed that majority of women presented within 1-10 days after consumption of the pills (13).
Unsupervised consumption of abortion pill at any gestational age along with improper dosage may be associated with serious life threatening complications including ectopic pregnancy or haemorrhagic shock. In the present study, irregular bleeding per vagina was the most common symptoms at presentation observed in 37.8% cases. Similarly, excessive bleeding was the most common symptom following unsupervised pills in previous studies (3),(12),(13).
Based upon the presenting symptoms and examination, diagnosis of incomplete abortion was established in 52% cases. However, missed abortion and continuation of pregnancy was noted in 13.5% and 5.4% cases, respectively. The present study findings were supported by findings of Nivedita and Shanthini F, in which incomplete abortion was noted in 62.5% of the patients and failed abortion in 22.5% cases. About 7.5% females presented with incomplete abortion with sepsis (3). Giri A et al., reported incomplete abortion in 60% cases and septic abortion and ectopic pregnancy in 6.5% cases each (10). Pawde AA et al., reported incomplete abortion in 30% cases following medical method of abortion which was associated with self-administration or due to incorrect dosage and drugs (20). Incomplete abortion was the most common diagnosis observed in 80% cases in a study by Munshi KS et al., (13). This study documented anaemia in greater than 85% cases and majority had moderate anaemia 66.2%. Excessive bleeding may cause anaemia and anaemia further aggravate bleeding. Blood transfusion was required in 9 patients in the present study due to severe anaemia and associated excessive bleeding. Similar to present study, Nivedita K and Shanthini F, (3) and Giri A et al., (10) observed anaemia in 100% and 80%cases respectively, with mild to moderate anaemia in maximum cases. Gupta R et al., reported anaemia in 92.5% cases (21). Dogra A and Kumar V, observed anaemia leading to blood transfusion in 38% patients (22).
The strength of the present study was that it helped in highlighting the higher burden and unsupervised harmful practice of consuming abortion pills and its consequences in Indian population, despite legalisation and confidentiality of MTP act. Based upon this study, following recommendations have been suggested. First, women and their family must be educated regarding the family planning methods and beneficiaries must be encouraged to use family planning method to prevent the untimely conception. Second, awareness regarding the medical termination of pregnancy act, its confidentiality clause must be created in general public so that they could utilise the safe services provided to them without compromising their health status. Third, education particularly female education or literacy level must be encouraged, so that they are able to perceive their right, right to choose the time of entering the motherhood, right to health. Fourth, over the counter availability of abortion pills must be banned and abortion pills should be dispensed only in presence of prescription signed and sealed by registered medical practitioner. Fifth, a dedicated centre for distribution of abortion pills must be made in each health centre to reduce the availability of over the counter medications.
Limitation(s)
The females who underwent complete abortion could have been missed as these women might may not feel the need of supervised abortions as well as are unaware of the consequences of unsupervised abortions.
Though medical termination of pregnancy is legal in India, approximately half of women, irrespective of their marital status prefer using unsupervised abortion pills. The abortion pills not only increase maternal morbidity but also has been associated with maternal mortality. Anaemia and incomplete abortion rate remain high in cases of unsupervised abortion pill use. It is necessary to curtail this harmful practice and strict legislative laws must be enforced to limit and restrict the sales of over the counter abortion pills.
DOI: 10.7860/JCDR/2022/57245.17019
Date of Submission: Apr 26, 2022
Date of Peer Review: May 26, 2022
Date of Acceptance: Jul 21, 2022
Date of Publishing: Oct 01, 2022
AUTHOR DECLARATION:
• Financial or Other Competing Interests: None
• Was Ethics Committee Approval obtained for this study? Yes
• Was informed consent obtained from the subjects involved in the study? Yes
• For any images presented appropriate consent has been obtained from the subjects. NA
PLAGIARISM CHECKING METHODS:
• Plagiarism X-checker: May 04, 2022
• Manual Googling: Jul 19, 2022
• iThenticate Software: Jul 20, 2022 (6%)
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