Intended for healthcare professionals

Editor's Choice

A very obstetric issue

BMJ 2003; 327 doi: (Published 11 September 2003) Cite this as: BMJ 2003;327:0-g
  1. Richard Smith, editor (rsmith{at}

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

    Andrew Shennan begins his review of recent developments in obstetrics by discussing one of its most difficult challenges—pre-eclampsia (p 604). It occurs in 3% of pregnant women and worldwide causes 100 000 maternal deaths. Doppler ulstrasound of the uterine artery helps identify women who will develop pre-eclampsia, and low dose aspirin reduces the chance of developing the condition by 15%. Management is complicated, particularly as controlling blood pressure does not alter the course of the disease.

    One of the most contentious issues in obstetrics is the high caesarean section rate. The rate in Britain is now 21%, twice what it was 10 years ago. Even elective caesarean sections double maternal mortality, and the increased rate has not been associated with improved perinatal mortality or morbidity. Shennan thinks that encouraging women who have had one caesarean section to deliver 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 difficult study to see whether the way that midwives are deployed in labour wards affects safety (p 584). They observed practices in seven units and related them to one adverse event and 15 “near misses.” (None of the units routinely recorded “near misses,” meaning that they couldn't learn from them.) The authors' controversial conclusion is that organising midwives into teams—as advocated in a policy document Changing Childbirth—reduces safety. The problem is that midwives don't spend enough time in the labour ward to develop and retain skills.

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

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


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