A very obstetric issue

doi:10.1136/bmj.327.7415.0-g

BMJ 2003;327 (13 September), doi:10.1136/bmj.327.7415.0-g

Editor's choice

A very obstetric issue

A minute proportion of BMJ readers will be delivering babiesthese days, but most will vividly remember doing so as students.The first birth I ever saw caused me to burst into tears, muchto the surprise of the registrar giving a running commentary.The moment of birth is so rich with possibilities. Obstetricsis a specialty central to medicine but is wafted hither andthither by scientific, social, political, and ethical trends—asthis issue shows.

Andrew Shennan begins his review of recent developments in obstetricsby discussing one of its most difficult challenges—pre-eclampsia(p 604). It occurs in 3% of pregnant women and worldwide causes100 000 maternal deaths. Doppler ulstrasound of the uterineartery helps identify women who will develop pre-eclampsia,and low dose aspirin reduces the chance of developing the conditionby 15%. Management is complicated, particularly as controllingblood pressure does not alter the course of the disease.

One of the most contentious issues in obstetrics is the highcaesarean section rate. The rate in Britain is now 21%, twicewhat it was 10 years ago. Even elective caesarean sections doublematernal mortality, and the increased rate has not been associatedwith improved perinatal mortality or morbidity. Shennan thinksthat encouraging women who have had one caesarean section todeliver vaginally is the best option for reducing the rate."Once a caesar always a caesar" is an empty shibboleth.

Brenda Ashcroft and others have undertaken a most difficultstudy to see whether the way that midwives are deployed in labourwards affects safety (p 584). They observed practices in sevenunits and related them to one adverse event and 15 "near misses."(None of the units routinely recorded "near misses," meaningthat they couldn't learn from them.) The authors' controversialconclusion is that organising midwives into teams—as advocatedin a policy document Changing Childbirth—reduces safety.The problem is that midwives don't spend enough time in thelabour ward to develop and retain skills.

The problems in Malawi—and the rest of sub-Saharan Africa—areof a completely different order (p 587). Maternal mortalityis 10 per 100 000 in developed countries but 1120 per 100 000in Malawi. Caesarean section is the commonest operation in sub-SaharanAfrica—and is often life saving. But, Paul Fenton andothers show, maternal mortality is 1% from the operation. Threequarters of the deaths occurred on the wards, and the authorsbelieve that improved anaesthetic practices could reduce mortalityand morbidity.

A tragic outcome from birth is overpopulation and its evil twinoverconsumption. Maurice King—a great hero of the developingworld—sees demographic and environmental disaster ahead,particularly in Africa, and says so in a book he has publishedhimself (p 626). Our reviewer thinks it deserves a wide audience.

Richard Smith, editor

rsmith{at}bmj.com

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Relevant Articles

Prospective semistructured observational study to identify risk attributable to staff deployment, training, and updating opportunities for midwives: Brenda Ashcroft, Max Elstein, Nicholas Boreham, and Soren Holm
BMJ 2003 327: 584. [Abstract] [Full Text] [PDF]

Caesarean section in Malawi: prospective study of early maternal and perinatal mortality: Paul M Fenton, Christopher J M Whitty, and Felicity Reynolds
BMJ 2003 327: 587. [Abstract] [Full Text] [PDF]