Shane Ridley explores the 'need for obstetric physicians’ article in the BMJ
Most maternal deaths are now caused by preventable or treatable medical conditions. This article makes shocking reading; however, it is, at the same time, heartening to see that some doctors are willing to admit this problem. It’s just a shame it didn’t hit the general press with the same force.
Saving Mother's Lives (see Nadine Edwards's article on page 4) goes into detail on the Eighth Report of the Confidential Enquiry into Maternal Deaths (CEMD). The BMJ editorial1 summarises that report, highlighting that most maternal deaths in the UK occur in women with pre-existing or new medical and psychological conditions, for example cardiac disease and neurological disease. One third of the cases are classified as having had major substandard care. Other medical conditions highlighted are epilepsy, diabetes, heart failure and asthma.
The point that the editorial is making is that obstetricians alone cannot reduce these deaths as they are not necessarily familiar with these problems. They need the support of physicians and general practitioners. The report from CEMD makes specific recommendations including pre-pregnancy counselling where women have pre-existing medical conditions; swift referral to specialist centres of expertise; and more training about pregnancy for those doctors who do not work directly with pregnant women (e.g. GPs).
The editorial makes the point that other surgical specialties have medical counterparts, for example in neurosurgery, urology and cardiac surgery. In practice this means that the clinical team will have access to a physician who is expert in the patient's medical condition in relation to the surgery about to be undertaken.
The editorial highlights that the success of obstetric anaesthesia led to a fall in anaesthesia-related deaths. As well as a recognition of the subspeciality of the obstetric physician, the editors are calling for obstetric medicine to be part of the postgraduate training curriculum of GPs and physicians.
I googled 'most maternal deaths are preventable' and the first item which came up was 'Maternal Mortality Rates Rising in California'.2 The conclusion of this report was that the number of woman who died in the state after giving birth has nearly tripled over the past decade: 'Most women died from haemorrhage, from deep vein thrombosis or blood clots, and – this is the surprise – from underlying cardiac disease'.
The rest of the list included reports from Sub-Saharan Africa, Ghana, China and Nigeria. Another report with similar details; Analysis of maternal mortality in a tertiary care hospital to determine causes and preventable factors3 came to the same conclusion in 2003: 'Obstetrical haemorrhage and hypertensive disorders are still major causes of maternal deaths. Most maternal deaths are preventable. The provision of skilled care and timely management of complications can lower maternal mortality in our setup.'
The doctors who wrote the editorial are all obstetric physicians so they are knowledgeable and convinced of the need for quality care. Why isn't their voice being heard? Why are women still dying all over the world? It may be of benefit to all women planning pregnancies that are likely to be complicated by potentially serious medical conditions to ask for pre-pregnancy counselling. Suggestions for pregnant women who have or develop an underlying medical or psychiatric condition are to:
AIMS advice to midwives and obstetricians mirrors the advice highlighted in the CEMD (see page 6) – 'listen to the woman and act on what she tells you.'
As Andrew Lansley, Secretary of State for Health, is preaching: 'No decision about me, without me' (a reference to shared decision-making).
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