Intended for healthcare professionals

Rapid response to:


Maternal mortality in the UK and the need for obstetric physicians

BMJ 2011; 343 doi: (Published 09 August 2011) Cite this as: BMJ 2011;343:d4993

Rapid Response:

Re: Maternal mortality in the UK and the need for obstetric physicians

Dear Editor

Professor Nelson-Piercy and colleagues (BMJ Online, 10 July 2011)
draw attention to the challenges of medical care and supervision for an
obstetric population that has increased by 22% and by an equal degree in
complexity over the last 20 years in the UK1. The increase in maternal
deaths due to co-morbidities and worsening of underlying medical
conditions should be a warning sign to the increasing ill-health of the
nation and the inadequate quality of service provision2. We must focus on
solutions. Obstetricians have successfully reduced the traditional direct
causes of death, such as haemorrhage, hypertension, thrombosis and ectopic
pregnancy, by focussing on the causes and developing solutions in the form
of training and clinical guidelines.

We believe that, to make further improvements, women's health should
focus on the duration of the life-course3. We strongly support the concept
that pregnancy is an opportune moment to focus on this with pre-conception
planning and advice for all women with significant medical disorders for
pregnancy and beyond. Indeed, we would go further than this and suggest
that such a strategy would be helpful for all women. Prevention and
counselling, forward planning and embracing a life-course approach to
women's healthcare are mandatory if we are to improve clinical outcome not
only for pregnancy but for later life. Pregnancy is a significant
predictor of future medical morbidity for both the mother and her baby and
medical and midwifery services must capitalise on such information. The
inclusion of these fundamental elements in the provision of the life-
course of women's healthcare will need careful modelling within the
proposed new commissioning arrangements.

The provision of comprehensive medical services for women should be
network based. However, within such a structure, the provision of all-
embracing care for pregnant women with significant risk should be the
responsibility of the suitably trained obstetrician, working within the
framework of a multi-disciplinary team including suitably trained
physicians. Specialised training should underpin such arrangements. The
current training of obstetricians and gynaecologists includes medical
disorders in pregnancy, with an advanced training module in maternal
medicine and subspecialty options in feto-maternal medicine for a few
trainees, but this should be enhanced. Additionally, there is a need for
more specialist provision delivered in collaboration with specialised
physicians in a few centres providing unique experiences and skills. Such
clinicians should receive appropriate training and recognition.

This high quality, high-end care provision should be delivered by
either physicians or obstetricians with a subspecialist interest in
maternal medicine. The RCOG and the RCP should work jointly to guarantee
appropriate training for obstetricians and physicians to provide quality
care for mothers with medical complications of pregnancy, so that we can
reduce avoidable maternal deaths.

Dr Anthony Falconer, President, Royal College of Obstetricians and

Dr Patrick Cardigan, Registrar, Royal College of Physicians


1 Office for National Statistics (July 2011) Births and Deaths in
England and Wales, 2010

2 Centre for Maternal and Child Enquiries (CMACE). Saving Mothers'
Lives: reviewing maternal deaths to make motherhood safer: 2006-08. The
Eighth Report on Confidential Enquiries into Maternal Deaths in the United
Kingdom. BJOG 2011;118 (Suppl. 1):1-203.

3 RCOG Expert Advisory Group Report (July 2011) High Quality Women's
Health care: A proposal for change

Competing interests: No competing interests

10 August 2011
Tony Falconer