Education And Debate

Recent Advances: Obstetrics

BMJ 1995; 311 doi: (Published 04 November 1995) Cite this as: BMJ 1995;311:1209
  1. Philip Steer, professora
  1. aAcademic Department of Obstetrics and Gynaecology, Charing Cross andWestminster Medical School, Chelsea and Westminster Hospital, London SW10 9NH

    Changing Childbirth, the report of the expert committee chaired by Lady Cumberlege,1 followed the recommendations of the Winterton committee2 in emphasising choice: freedom for women to choose a home confinement, pool birth, or elective caesarean section. Choice means shifting much decision making from professionals to women, which many find challenging; it also has cost implications. The flexibility, skill, and knowledge required to give women choice demands higher standards of professional training, particularly for midwives, whose enhanced role has forced obstetricians and general practitioners to rethink their own.

    Antenatal screening

    Screening for fetal abnormality is a growth industry. Amniocentesis with karyotyping of fetal cells obtained from amniotic fluid at around 16 weeks' gestation was introduced widely in the mid-1970s and is now universal. The association of Down's syndrome with low concentrations of (alpha) fetoprotein and high concentrations of ß human chorionic gonadotrophin in maternal serum led in June 1993 to a call for providing screening for all who wanted it.3 Soon, however, concern was expressed about inadequate counselling of pregnant women,4 5 who commonly find it difficult to understand the statistical concepts of risk without a great deal of help (many professionals find it difficult, too). Since there is currently no national policy on screening, and no additional funding to pay for the extra counselling or for the scans during the first trimester that are essential to confirm gestational age, it is not surprising that nearly half of all obstetricians in Britain feel that the current service is inadequate.6 This concern is corroborated by objective surveys of the women themselves.7

    The introduction of biochemical screening is sometimes accompanied by disillusion at the relatively low sensitivity of the methods, due not just to technical problems but also to the often surprisingly high proportion of women who decline screening …

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