We read an editorial titled “Constrained Evidence-Based Practice” ^[1] with interest and dolor. The dolor clearly comes from the reports of 90-100% mortality in neonates with gastroschisis and health inequality that simply comes from the geographical place of birth.

Gastroschisis is a complex and relatively uncommon congenital surgical pathology. The relative rarity of the condition and need for multi-disciplinary care as well as multi-layered care initiatives that include antenatal care, education, safe transport from peripheral to surgical facilities, and development of surgical expertise, have the potential to dissuade healthcare administrators from prioritizing resource allocation in this area. However, with gastroschisis, the outcomes are dire when appropriate management is lacking although excellent survival rates with good developmental outcomes are reported with well-instituted treatment protocols.

Geographical variation in incidence with local clustering has been reported in gastroschisis. With limited resources in public health, quantifying the burden of problems in low-income countries may be difficult. Where possible, measurement of incidence and outcomes of neonates with gastroschisis by establishing mechanisms of local data collection on agreed variables could be undertaken. This has the potential to identify the reasons for poor outcomes, establish benchmarking and start with the deployment of scarce resources in a strategic way.

Education in the management of gastroschisis, when an infant is born in a non-tertiary setting, is important. This could begin with education in the use of cheap clear plastic cling-film, intravenous hydration, temperature management, antibiotic therapy, and training transport teams. With the spike in the use of various video-conferencing platforms in medicine, it may be possible to use them effectively for education by local and international experts.

Though resection of the bowel, when primary closure is not possible, has been reported with some success, it is a difficult concept. Shortening an underlying dysmotile gut can complicate short- and long-term management resulting in the anastomotic leak, feeding issues, and growth failure. In such a setting, surgical care could be provided by expanding the abdominal opening (a mini-laparotomy) instead of bowel resection. In absence of spring-loaded silos, the use of blood bags or urine bags is a better option where primary closure of a defect is not possible.

As you say and we agree that it is a long journey to embark on however, we must start taking steps to provide these newborns with gastroschisis a better chance, with an ‘all-hands-on-deck’ approach that values the contributions of obstetric staff, neonatal nurses, neonatologists, and surgeons.