Maternal mortality in the UK and the need for obstetric physicians

Sir,

I must lead a sheltered life as I must confess that I had not heard
of obstetric physicians until I read the BMJ Editorial by Nelson-Piercy et
al on "Maternal mortality in the UK and the need for obstetric
physicians"[1]. The authors make a cogent argument for a selective
expansion of obstetric medicine in the UK.

I note with interest that the authors declared no conflict of
interest in writing this editorial. Yet they are calling for a significant
n expansion of their own sub-specialty. This seems to me to be a potential
"competing interest".

The BMJ's criteria for competing interests does include non-financial
interests. I would suggest that (presumably) leading members of a small
sub-specialty calling for an expansion of their numbers could be seen as a
"non-financial association(s) that may be relevant or seen to be relevant
to the submitted manuscript"[2].

Any resulting expansion of obstetric medicine would see an increase
in membership, recognition and resource allocation to this nascent medical
field.

This potential competing interest does not necessarily diminish the
strength of their argument per se. However, the non-recognition of a
potential conflict of interest takes some of the shine off an otherwise
reasonable editorial, in my personal opinion.

References:

1. Nelson-Piercy C, Mackillop L et al. Maternal mortality in the UK and
the need for obstetric physicians. BMJ 2011 343:d4993doi:10.1136/bmj.d4993

2. BMJ competing interests guidance. BMJ website
http://resources.bmj.com/bmj/authors/editorial-policies/competing-
interests (accessed 6/9/11)

Even in the Western world, maternal mortality remains an obstetric
challenge. Although few would argue that Nelson-Piercy et al.'s (2011)
suggestions are not within the scope of desired approaches to lowering
maternal mortality rates, it could be argued that the discussion
characterizes a relatively micro and individualistic analysis- one that
tends to block structural thinking and structural, policy-based
solutions.Yes, we can develop more points of intervention for maternal
obstetric care and for keeping pre-term and underweight newborns alive,
but what is causing these mothers and babies to be vulnerable in the first
place? Similarly, improving optimal maternal and newborn care is surely
important, but what factors are placing these mothers and babies "at risk"
in the pre-conception years? There is now robust evidence that structural
or societal causes of ill health are the most reliable predictors of
health outcomes across the lifespan (Raphael, 2009; Navarro, 2004).

These structural causes are best articulated within the realm of the
political economy of health. Authors such as Navarro (2007) and Esping-
Anderson (2002) have, over the past decade, provided detailed discussions
of the ways that a political economy approach can provide solution-focused
insights regarding how to tackle health inequities and their genesis in
material and social deprivation. Although individual mothers require the
best perinatal care to ensure the best birth outcomes, it is imperative
that we also consider the societal context within which women live and
hence the societal causes of maternal mortality- the 'causes-of-the-
causes' of maternal mortality. A political economy lens is central to
modern efforts to understand and tackle these causes-of-the-causes of
growing inequities in health outcomes related to intersections of
classism, racism, and sexism, to name a few. These are the structural
determinants of health. They are called structural because "they are part
of the political, economic, and social structure of society and of the
culture that informs them" (Navarro, 2007. p. 2).

In a political economy of health approach, emphasis is directed to
the role of the economic organization of society in the production and
distribution of disease and burden of illness, and the ways that disease
and illness are framed and treated (McGibbon, 2009). Materialist
perspectives on health and health care direct our attention to questions
about how some groups of people persistently have worse health than
others, and how some countries have different kinds of health care systems
and decidedly different health and well being outcomes for their citizens.
The focus is on the structural links between health and economic,
political, and social life (Coburn, 2001). Structural causes of maternal
and infant mortality have been found to involve the following factors:
racism-related stress and socioeconomic hardship during pregnancy and in
the pre-conception years (Giscombe & Lobel, 2005), high prevalence of
low income among women who experience serious hardships during pregnancy
(Braveman et al., 2010); high poverty rates and lack of access to a
socialized health care system, as is the case on the United States
(Tillet, 2010); significant correlation of high poverty rates with infant
mortality rates among minority and White mothers in the US (Simms, Simms,
& Bruce, 2007); significant correlation among poverty level, racial
composition of geographic areas, and infant mortality rates (Eudy, 2009);
and high correlation of inequality and maternal-child child relative
poverty with infant mortality rates in rich societies (Pickett &
Wilkinson, 2007).

These studies all provide evidence that persistent poverty, and
resulting material and social deprivation for families and communities,
has a strong negative impact on maternal-child birth outcomes. Despite
these important studies, there is relatively little literature regarding
the structural causes of maternal and infant mortality, pre-term birth,
and neonatal medical complications in the West, and there is a disturbing
lack of academic published literature about the relationship between
public policy, material deprivation, and maternal-infant mortality. For
example, a PubMed search for articles between 2000-2010 with 'poverty' and
'infant mortality' in the title or abstract, produced 72 articles. Only 12
of these articles directly connected structural causes, such as poverty
and racism, with infant mortality- a remarkable deficit in the medical
literature. The same search, with 'poverty' and 'maternal mortality' in
the title or abstract, produced 57 articles. All but five of these
articles reported results or discussions about countries in the global
south. A notable exception, and what appears to be one of the few articles
of its kind reported in PubMed over the last 10 years, was Barker &
Lackland's (2003) study of prenatal influences on stroke mortality in
England and Wales. The researchers found that areas of England and Wales
with high stroke mortality were characterized by poor living standards and
high infant and maternal mortality rates. In contrast to this dearth of
PubMed cited articles about the structural causes on of infant and
maternal mortality, there is a copious literature regarding the individual
-based, pathophysiological causes of infant and maternal mortality in
Western countries.

The ready availability of largely individualistic, biophysically-
based analyses regarding maternal health outcomes provides a stark
contrast with the dearth of quantitative and qualitative evidence about
the structural causes of poor health. This situation is a reflection of
the strong presence of neoliberal ideology that permeates conventional
health thinking, health care and hence health policy. At the heart of this
ideological bent lies not only an emphasis upon the individual and
equality of opportunity, rather than equality of condition, but also, as
Banting (2005) has noted, a difficulty or an unwillingness to tackle
societal-based preventative approaches, and the recognition that health
and well-being often have their roots beyond the health policy domain. As
a result, there is a very real reluctance to link social and economic
policies to the systemic, policy-created poverty at the heart of material
deprivation and its sustained erosion of the health and well-being of
citizens, including expectant mothers. Hence, political economy of health
considerations are a much neglected aspect of public policy in 'rich'
countries, such as the UK, the USA, and Canada, to mention a few. High
quality, high-end care provision in obstetric care is necessary. However,
tackling maternal and infant mortality requires sustained and close
attention to the 'causes-of-the causes' of maternal mortality.

References

Banting, K. (2005). Canada: Nation-building in a federal welfare
state. In Obinger, H., Stephan Leibfried, S., & Castles, F.G.
(Eds.).Federalism and the Welfare State: New World and European
Experiences. Cambridge: Cambridge University Press. (pp. 89-137).

Barker, D.J., & Lackland, D.T. (2003). Prenatal influences on
stroke mortality in England and Wales. Stroke, 34(7), 1598-602.

Braveman, P., Marchi, K., Egerter, S., Kim, S., Meltzer, M., Stancil,
T., & Libet, M. (2010). Poverty, near poverty, and hardship around the
time of pregnancy. Maternal and Child Health Journal, 14(1), 20-35.

Coburn, D. (2001). Health, health care and neo-liberalism. In D.
Coburn (Ed.). Unhealthy times: The political economy of health and care in
Canada. Toronto: Oxford University Press. (pp. 45-65).

Esping-Anderson, G. (2002). Why we need a new welfare state. Oxford:
Oxford University Press.

Eudy, R.L. (2009). Infant mortality in the Lower Mississippi Delta:
geography, poverty and race. Maternal Child Health Journal, 13(6), 806-
813.

Giscombe, C.L. & Lobel, M. (2005). Explaining disproportionately
high rates of adverse birth outcomes among African Americans: the impact
of stress, racism, and related factors in pregnancy. Psychological
Bulletin, 131(5), 662-683.

McGibbon, E. (2009). Health and health care: A human rights
perspective. In D. Raphael (Ed.) The social determinants of health. 2nd
Edition. Toronto: Canadian Scholar's Press. (pp. 319-339).

Navarro, V. (2007). What is national health policy? International
Journal of Health Services, 37(1), 1-14.

Navarro, V. (2004). The political and social contexts of health. New
York: Baywood Publishing Company.

Pickett, K.E. & Wilkinson, R.G. (2007). Child wellbeing and
income inequality in rich societies: Ecological cross sectional study.
British Medical Journal Online, 24;335(7629):1080.

Raphael, D. (2009). Social determinants of health. (2nd ed.).
Toronto: Canadian Scholar's Press.

Raphael, T. Bryant, & Rioux, M. (2006). Staying alive: Critical
perspectives on health, illness, and health care. Toronto: Canadian
Scholar's Press International. (pp. 35-57).

Sims M., Sims, T.L., & Bruce, M.A. (2007). Urban poverty and
infant mortality rate disparities. Journal of the National Medical
Association, 88(4), 349-356.

Tillett, J. (2010). Global health and infant mortality: Can we learn
from other systems? Journal of Perinatal and Neonatal Nursing, 24(2), 95-
97.

Sir,

Leaving aside the grating juxtaposition of "general practitioners" and "doctors" (as if we GPs were no real doctors), the article jumps to a conclusion without any real analysis and contributes therefore little to the future welfare of pregnant mothers with chronic health problems.

Given the utter horror and devastation caused by each maternal death, this is very frustrating.

So, to offer some suggestions for further debate, I recommend a short look at what actually has changed in the way antenatal care is done in the UK between - say - 2000 and now? What could possibly contribute a rise in deaths of chronically ill mums?

In the year 2000 it was routine for most mums-to-be to be seen in an antenatal clinic in their doctors' (GPs) surgeries. Midwives attended and jointly or sequentially saw with the GP every mum, rather frequently.

We GPs had much exposure to normal pregnancies and were - hopefully - able to spot the "not normal" pregnancy from afar. We (GPs and midwives) complemented each other and learned from each other. We had much exchange, both formal and informal. Patients clearly profited from this.

Fast forward to today - GPs are essentially squeezed out of the antenatal care. Midwives have acquired a near-monopoly over all antenatal care and have largely dispensed of sharing information and requesting medical advice from GPs. Often we GPs are nowadays unaware who of our patients is pregnant or who has developed medical problems in pregnancy.

In early 2011 the Scottish Government sent out a letter to GPs advising them of a current poster campaign in community pharmacies telling mums-to-be, that it is not any more necessary to see their GP when pregnant, but they could directly go to see midwives. Midwives in turn would, if mothers wished so, share info back to the GP.

Now, who would think such an arrangement up, removing the one person with good and direct knowledge of the patient and their health and keeping them routinely in the dark?

This is just one example of a vast systemic change which has had likely severe impact. Dr Hogg points at another, when relating his experiences in GP obstetric training.

Maybe Professor Nelson-Piercy should have looked first at the complete picture before making a plea for more recognition (and presumably funding) for her sub-speciality. And maybe Doctors Falconer and Cardigan could have directed her in that direction, instead of jostling which specialist should get the lead in antenatal care

The bulk of mothers-to-be with chronic health problems will benefit from their own GP being closely involved, contributing directly and confidently to a shared care model. Only a small minority will hopefully ever need sub-speciality services. And even those would likely benefit from their GPs having direct input into their care.