Wednesday August 10 2011
Chronic health problems can influence pregnancy
BBC News has reported “a call for more maternity doctors” by a group of six UK obstetricians who said that most maternal deaths are now caused by treatable medical conditions.
In a British Medical Journal editorial, the doctors discussed trends in maternal deaths in the UK over the last several years. The authors said that while deaths during pregnancy continue to fall, most maternal deaths are now due to indirect causes such as medical and psychiatric conditions that develop before or during pregnancy. They said that improved training for doctors could prevent many of these deaths.
This editorial reflects the views and recommendations of the authors. While it is based on a long-running effort to track maternal deaths in the UK, the editorial opens up a debate and does not provide firm evidence on the potential impact of the recommendations made. However, changing patterns of disease (in this case, disease occurring during pregnancy) often require policy adjustments in order to keep people healthy. This editorial should spur discussion on how best to care for pregnant women in the UK and how to prevent any avoidable deaths.
Where did the story come from?
This editorial was written by several consultant obstetric physicians and professors of obstetric medicine from St Thomas’ Hospital, John Radcliffe Hospital, University College Hospital, and Queen Charlotte’s and Chelsea Hospital.
The piece was published in the British Medical Journal, and was not peer reviewed.
Several of the news headlines misrepresented the editorial, with The Daily Telegraph reporting that “childbirth deaths rise as women delay pregnancy”. This headline is inaccurate, as childbirth deaths have in fact been falling in the UK for several decades, and the editorial focuses on complicated medical conditions leading to maternal deaths, not the mother’s age. The Telegraph also ran a photo caption regarding toxic pesticides and their impact on mother and foetus, which was unrelated to the editorial’s topic. The Independent similarly reported a rise in deaths during pregnancy and childbirth.
What kind of research was this?
This was an editorial written by obstetric physicians and professors of obstetric medicine. They wrote it following the eighth and most recent “Confidential Enquiry into Maternal Deaths”, a regularly published report investigating the background of every case of a maternal death in the UK. The most recent report was published in March 2011 and covered the years 2006 to 2008. This article was not a systematic review of the literature, but an opinion piece based on trends the authors observed in the report.
The authors discussed trends in the total number of maternal deaths, as well as in the underlying causes of these deaths. They further discussed recommendations laid out by the report and offered their own recommendations on ways to reduce maternal mortality in the UK.
What did the editorial say?
The authors said that maternal deaths have dramatically declined since the 1950s, largely due to reductions in the number of women who die due to direct obstetric causes, such as haemorrhage and other complications of pregnancy and childbirth. They also said that most maternal deaths today are due to indirect causes, mainly related to chronic medical conditions such as:
- heart disease
- asthma or psychiatric conditions
They said that these medical conditions are preventable or treatable, and that the trend in maternal death due to indirect causes has been increasing over the last 20 years (although maternal deaths have fallen overall).
The authors discussed their growing concern that many of today’s maternal deaths could have been prevented had adequate healthcare been provided. They said that sub-standard care led to many deaths, and that many of the deaths could have been prevented if proper training had been provided.
The authors said that the increase in maternal deaths due to indirect causes is due to both an increase in the number of pregnant women with complicated medical problems and to healthcare professionals not being given appropriate training to diagnose and treat these medical problems within the specific context of pregnancy.
The authors considered this rise in maternal deaths from underlying indirect medical causes to be treatable and preventable. They supported several recommendations laid out in the “Confidential Enquiry into Maternal Deaths”, including:
- offering pre-pregnancy counselling for women with potentially serious medical conditions such as heart disease, diabetes or asthma
- giving specialist referrals to women with pregnancies complicated by serious medical conditions
- training doctors who do not specialise in pregnancy on the potential interaction between pregnancy and other medical conditions
How did the author interpret the findings?
The authors concluded that the UK needs to increase the number of obstetric physicians (doctors who specialise in treating pregnant women with pre-existing and new medical problems). They said that such an expansion would “be a positive step towards reducing deaths from medical disorders during pregnancy”. They also thought that this expansion would not require a specialist in each obstetric unit, but that a well-developed network would be sufficient to ensure access to a specialist when needed. Finally, they concluded that physicians and GPs should be trained in obstetrics, so that complications are detected early, assessed correctly and referred appropriately.
This was an editorial written in response to the recently published “Confidential Enquiry into Maternal Deaths”. The authors described a decrease in the total number of maternal deaths in the UK, but also an increase in maternal deaths due to indirect causes, primarily through preventable or treatable chronic conditions. They went on to make recommendations for how to prevent maternal deaths from indirect causes such as heart disease, diabetes, epilepsy and asthma.
It is important to note that while deaths due to these indirect causes may be increasing, in absolute terms maternal deaths are decreasing, and are currently quite low in the UK. According to the 2011 report on which the editorial was based, the UK maternal mortality rate between 2006 and 2008 was 11.39 per 100,000 pregnancies, or approximately 0.01%.
It is also important to remember that this editorial is intended to provide a commentary on a regularly produced report by the Centre for Maternal and Child Enquiries (CMACE), a nationwide survey of deaths during pregnancy. As an expert commentary this academic paper does not feature systematic examinations of the evidence to back up the recommendations it makes – for example, whether an increase in training or numbers of midwives, obstetric physicians or obstetricians would improve obstetric care. Instead, this editorial, along with the CMACE report, opens up an important debate on how to reduce indirect maternal deaths, rather than providing systematic proof that the outlined measures should be implemented. That said, the article did highlight important areas for future policy discussions on how the UK’s health system can adapt to the changing landscape of illness, especially as it relates to pregnancy.
Pregnant women who have a pre-existing medical condition should discuss this with their midwife and GP, and should clarify whether treatment of this condition will need altering during their pregnancy.