By Jean Robinson
Last year a study group at the RCOG recommended that the term "abortion" should no longer be used to describe early spontaneous loss of a baby. They suggested that "delayed miscarriage" should be used instead of the term "missed abortion".
Dr. David Hutchon, from Darlington, carried out a search of the two main American obstetric journals for four years, and found that the word "abortion" was six times as likely to be used as the term "miscarriage". He points out that talking about abortion to a woman who has miscarried can cause great distress, and in any case can cause confusion. There is no such problem in French and German, since they have different words for termination of pregnancy and miscarriage.
God bless you, Dr. Hutchon. Many American women may not hear of your simple, but effective, piece of research, and on behalf of them, we thank you.
A study in Liverpool looked at embryos after women had had medical terminations of pregnancy before 9 weeks. 206 embryos were studied. 63 women in fact had a non-viable pregnancy - there was no embryo present in the gestation sac or the embryo was being reabsorbed. As the authors point out, those women would not have needed a termination of pregnancy if an accurate diagnosis had been made, thus reducing pressure on the abortion services and relieving guilty or stress in the women.
However, a surprisingly high proportion of the remaining life embryos major defects - and obviously a number of those would have spontaneously miscarried if the pregnancy had continued. These included 16 with neural tube defects and 6 with abdominal wall defects. Only 121 of all the embryos appeared normal - although, of course, some them may have had abnormalities which would only become detectable later in pregnancy.
Study of embryos and fetuses from pregnancies which end early, either through miscarriage or abortion, can tell us a great deal about risks of loss and abnormality. We shall never know the full picture, because many pregnancies will end spontaneously so early that women may not even realise they are miscarrying. However, this study shows that many women having unnecessary early abortions, and that the number of initial abnormalities is surprisingly high. Most of the neural tube defects could have been prevented with folic acid. Many of the damaged babies would have spontaneously miscarried. However, the number of abnormalities in this Liverpool population seems surprisingly high, and questions should be asked about possible reasons.
Low birthweight babies have a high mortality and the specialised high tech care provided in developed countries is too expensive for the Third World. Kangaroo care, where mothers are kept next to the mother's skin between her breasts, under her clothing, has proved successful. Now we have a randomized study from three countries - Ethiopia, Indonesia and Mexico to study both effectiveness and costs of kangaroo care compared with "conventional" care.
29% of low birth weight babies died before they were eligible for the study. Mothers kept naked (apart from a nappy and a hat) babies nestled under their clothing for about 20 hours a day, including time when they were asleep. Control babies were kept in cribs in Addis Abbaba and in incubators in the other two centres.
Kangaroo babies were less likely to get hypothermia than those in conventional care. They were more likely to be breastfed when discharged (88% v. 70%). They gained more weight and were discharged early. Mothers expressed a clear preference for kangaroo care and so did health workers. However, 11% of kangaroo mothers complained about the long stay in the hospital, but 98% of the mothers whose babies had conventional care would have liked more time with them. 13% of kangaroo mothers were worried about care of their other children - this rose to 29% in Addis Abbaba.
The running costs for kangaroo care were about 50% less than for conventional care. The authors conclude this kangaroo care helps with scarce resources in poor countries.
Most low birth weight baby deaths in these studies happen before the baby is stabilised and enters the trial, so we do not have adequate information about effects on mortality. A small study from Zimbabwe where babies were entered from birth suggests that kangaroo care could reduce mortality.
Parents, doctors and nurses often have difficult decisions to make when a baby is unlikely to recover, and from time to time there are bound to be conflicts which may be difficult to resolve.
A useful and sensitive study from Scotland looks at problems within the team when continuing treatment may be pointless and even cruel. As they point out "What may be an appropriate line of management to a consultant neonatalogist may be perceived quite differently by a neonatal nurse working closely with the parents.... and the beliefs, values and expectations of parents may be very far from those of health care professionals."
The researchers studied doctors, nurses and midwives working in six neonatal intensive care units.
Doctors felt that the law gave them reasonable flexibility, but nurses thought doctors were strongly affected by legal considerations. Nurses thought doctors behaved defensively and treated aggressively. There was a clear difference in perception between doctors and nurses.
More than half the doctors and nurses (56%) thought choice should be tailored to individual cases, but whereas 60% of the doctors thought this is what actually happened, only 41% of the nurses thought it did.
Only 35% of doctors thought that treatment was started routinely and only withdrawn after re-evaluation and reassessment, but 55% of nurses thought that was what happened.
Both nurses and junior doctors were upset at incidents when they had disagreed with decisions but felt unable to speak out.
The most respected consultants were intimately involved, supported parents, supported the team and shared responsibility. Those who worked on a guided consensus were applauded by nurses. But in five of the six units there were consultants who were not seen as team players. The researchers highlighted the need for constant vigilance in order to resolve tensions before they escalate into conflicts.
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