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Thursday, June 5, 2014

Improving Brain Circulation
Peggy P. Ye, MD
Peggy P. Ye, MD
Family Planning Fellow
MedStar Washington Hospital Center
Washington, DC
I recently spent some time in Malawi, a country in southeastern Africa, training clinicians in placing intrauterine devices postpartum. I also had a chance to observe them providing other aspects of health care. One morning I was astounded to watch a clinical officer perform eight tubal ligations in 2 hours. In the United States, I am lucky to perform four sterilizations in that time! How could this clinician, in a room without basic infrastructure such as electricity, be able to provide more efficient care than I could in the United States? I was eager to learn his techniques.
This experience came to mind as I read the meta-analysis by Harrison et al published in the July issue of Obstetrics & Gynecology. The authors review data from 20 randomized, double-blinded, placebo-controlled trials of local anesthesia for women undergoing laparoscopic tubal ligation. Their analysis shows that applying local anesthetic to the adnexal structures or peritoneum is effective in decreasing postoperative pain within the first 8 hours, even in patients who undergo general anesthesia.
While the results of this study will have important clinical impact on the experience of women in the United States undergoing laparoscopic sterilization, it could have profound implications for patients undergoing tubal ligation internationally. Female sterilization is the most common method of family planning worldwide, with over 180 million women relying on sterilization for contraception.1 In resource-poor settings, many patients receive only local anesthesia applied to the skin incision. Options are limited if postoperative pain control is inadequate as hospital admissions are reserved for the severely ill. An intervention reducing postoperative pain could have a significant effect on women’s experiences in a setting that does not have access to resources commonly available in higher-income countries.
Disseminating the information from this study to the international community may be difficult,2,3 but we as providers can help by circulating scientific knowledge ourselves. Although few U.S.-trained obstetrician-gynecologists focus solely on international work, interest in global health is increasing among trainees.4 However, only 17% of obstetrics-gynecology residency programs offer global health experiences5 and further training in the form of post-graduate fellowships is available at only a handful of institutions.6
So what does this have to do with brain circulation? Much has been made of “brain drain,” the unilateral migration of talent from low-income to high-income countries. However, I implore for us to start promoting instead the idea of “brain circulation.” As those of us lucky enough to work internationally understand – we learn as much, if not more, than we teach. Adequate brain circulation is vital to our (global) health.
  1. EngenderHealth. Sterilization Incidence and Prevalence. In: Contraceptive Sterilization: Global Issues and Trends. New York, NY: EngenderHealth; 2002:32.
  2. Peterson HB, Haidar J, Merialdi M, et al. Preventing maternal and newborn deaths globally: using innovation and science to address challenges in implementing life-saving interventions. Obstet Gynecol 2012;120(3):636-42.
  3. Gilliam ML. Global initiatives. Obstet Gynecol 2009;114(4):716-7. 
  4. Kerry VB, Ndung’u T, Walensky RP, Lee PT, Kayanja VFIB, Bangsberg DR. Managing the demand for global health education. PLoS Med. 2011;8(11):e1001118.
  5. Hung KJ, Tsai AC, Johnson TRB, Walensky RP, Bangsberg DR, Kerry VB. Scope of global health training in U.S. obstetrics and gynecology residency programs. Obstet Gynecol 2013;122(5):1101-9.
  6. Nelson B, Izadnegahdar R, Hall L, Lee PT. Global Health Fellowships: A National, Cross-Disciplinary Survey of US Training Opportunities. J Grad Med Educ 2012;4(2):184-9.