812
UK
parliamentary report of maternity services
StR,—A House of Commons select committee obtains written and verbal evidence from witnesses who appear before it; it may also visit out-of-Parliament sites. Thus, although a fair account of what comes before the committee, the UK parliamentary report of maternity services1 may contain biases owing to the selection and self-selection of the witnesses. In any emotive subject people with strong opinions will have much to say and will press forward; this shows in the report, much of which relates highly biased opinions. Such people are not the ordinary providers and receivers of the maternity services. The members of the committee have tried to find their way between the warring ranks of the extremists and have produced a report with very helpful parts. The recommendations related to maternity benefits and maternity leave are sound and needed saying. The sections on antenatal care and communitybased, midwife-run antenatal clinics are useful and acceptable. With respect to place of birth, contrary to articles in the popular press, the report says nothing new about domiciliary obstetrics. Postnatal care and difficulties associated with hospital stay are clearly described. The report has the air of diji vu; much of what is recommended is already being done by the obstetric and midwifery communities. Midwives already deliver 75% of women in this country; the report underlines that they should be regarded as independent practitioners and be given their rightful authority. The division of work between midwives, some general practitioners, and obstetricians is fairly straightforward in most health authorities, without the need for firm guidelines for management. Many of the recommendations of the health service committee are already in place; the notion is becoming accepted that midwives will give their care in the most appropriate place for the stage of pregnancy or labour. The report regards the mother and her partner as the most important consideration. Women have long asked for continuity and choice of care, and some wish to have more control throughout pregnancy and labour. These are uncontentious ideas, commonly agreed, yet the committee witnessed many people dance aggressively around the arguments; we heard about large maternity units and staff being impersonal or even hostile to mothers. It is not the size of the unit but the people who work there who matter; and obstetricians and midwives do feel that women should have more say in childbirth. Ideas for the future are all important. While antenatal clinics are understaffed and labour wards are run by tired junior doctors, it will be difficult to implement the good intents of the health committee. The answer lies not in the recommendations of the committee, nor even in the attitudes of professionals, but with the chronic underfunding of the health service and the implementation of needed staff increases at all levels. It is hoped that this health committee report will be debated in the House of Commons after the forthcoming UK general election. If it is, the Departments of Health and Community Care will have to answer for many deficiencies. This is when the report will be important. Despite the publicity that the sections on home births and underwater deliveries received, these are the less substantive parts of the report. The important event was that the committee was formed in an established and public part of the government environment; the Department of Health can be now called to task over its answers to this report. Department of Obstetrics, St George’s Hospital Medical School, London SW17 0RE, UK 1. Health Committee. Second report reference:
GEOFFREY CHAMBERLAIN maternity services, vol
1. London: HM
Stationery Office, 1992.
Promoting safe motherhood SIR,-Professor Sai and Ms Measham (Feb 22, p 478) believe that people considering strategies for reducing maternal mortality have overemphasised the importance of clinical interventions. If they had ranked their own list of recommendations on the
basis of the strength of evidence that each recommendation could reduce maternal mortality, they might have reached a different conclusion. They are right to remind us of strategies outside the maternity services that are likely to be effective (such as the provision of safe abortion). Nevertheless, history suggests’ that they are wrong to imply that the other strategies they promote deserve higher priority than deployment of effective care for women presenting with obstetric emergencies such as obstructed labour, haemorrhage, and eclampsia. Sai and Measham maintain that "We need to identify all pregnant women as early as possible; provide accessible and effective prenatal care; [and] provide maternal health education". In view of the considerable uncertainties about the effectiveness of prenatal care in preventing maternal mortality,’ this is a tall order. Global provision of early and universal prenatal care presents a huge strategic challenge, which should be taken seriously only if evidence can be produced to show that this is likely to be a more appropriate use of limited resources than strategies concentrating on effective .2 treatment of complications of pregnancy and childbirth Sai and Measham are clearly ambivalent (justifiably, we believe) about the relevance of prenatal care in reducing maternal mortality. They acknowledge that "most women with pregnancy-related complications cannot be identified with certainty before the complications develop", and that "prenatal care and health education cannot prevent most complications". Instead of going on to call for research to address some of the uncertainties about the effects of prenatal care, however, they defend their advocacy of universal prenatal care from early in pregnancy by claiming, without evidence, that it is likely to have "an enormous impact on the utilisation of referral-level care". Antenatal care was introduced in the UK in the 1920s to deal with a static rate of maternal deaths.’ As the number of women receiving antenatal care increased between the mid 1920s and mid 1930s, however, so did maternal mortality. The substantial decline began only after the introduction of effective forms of clinical intervention to treat infection and haemorrhage. If Sai and Measham wish to challenge the implications of that experience, they will need to do so with evidence. National Perinatal Epidemiology Unit, Radcliffe Infirmary, Oxford OX2 6HE, UK
LELIA DULEY ADRIAN GRANT IAIN CHALMERS
1. Loudon I. Maternal mortality. 1880-1950. Some regional and international comparisons. Soc Hist Med 1988; 1: 183-227. 2. Rooney C, Graham W. Review of the evidence of effectiveness of antenatal interventions in developing countries with regard to maternal health outcomes. Geneva: WHO Maternal Health and Safe Motherhood Programme, 1991.
SiR,—Professor Sai and Ms Measham bring the safe motherhood initiative from theory to practice on several relevant points but they end up adhering to an irrelevant and unnecessary argument for this initiative-ie, comparison of ratios of child and maternal deaths in poorer and wealthier countries. Mortality due to pregnancy has been brought to almost zero in industrialised countries, but so has mortality due to tuberculosis, cardiovalvular diseases, and many other disorders. All such disorders will yield high mortality ratios when comparing poor with wealthy countries; ratios will approach indefinite values when the denominator gets close to zero. Such comparison ratios are of no use for setting priorities in less developed countries. Moreover, the ratio between child and maternal mortality for less developed and developed countries will be in the same range if children with malformations and preterm births are excluded. The fact that half a million reproductive deaths take place each year in developing countries makes this one of the major health problems of the world and Sai and Measham rightly emphasise the need to show how motherhood can be made safe in these countries. Support for interventions against this, as well as other global health problems, should be based on the effectiveness and efficiency of the interventions rather than on confusing slogans about occurrence. International Child Health Unit, Department of Paediatrics, Uppsala University, S-751 85 Uppsala, Sweden
HANS ROSLING THORKILD TYLLESKAR
UK
parliamentary report of maternity services
StR,—A House of Commons select committee obtains written and verbal evidence from witnesses who appear before it; it may also visit out-of-Parliament sites. Thus, although a fair account of what comes before the committee, the UK parliamentary report of maternity services1 may contain biases owing to the selection and self-selection of the witnesses. In any emotive subject people with strong opinions will have much to say and will press forward; this shows in the report, much of which relates highly biased opinions. Such people are not the ordinary providers and receivers of the maternity services. The members of the committee have tried to find their way between the warring ranks of the extremists and have produced a report with very helpful parts. The recommendations related to maternity benefits and maternity leave are sound and needed saying. The sections on antenatal care and communitybased, midwife-run antenatal clinics are useful and acceptable. With respect to place of birth, contrary to articles in the popular press, the report says nothing new about domiciliary obstetrics. Postnatal care and difficulties associated with hospital stay are clearly described. The report has the air of diji vu; much of what is recommended is already being done by the obstetric and midwifery communities. Midwives already deliver 75% of women in this country; the report underlines that they should be regarded as independent practitioners and be given their rightful authority. The division of work between midwives, some general practitioners, and obstetricians is fairly straightforward in most health authorities, without the need for firm guidelines for management. Many of the recommendations of the health service committee are already in place; the notion is becoming accepted that midwives will give their care in the most appropriate place for the stage of pregnancy or labour. The report regards the mother and her partner as the most important consideration. Women have long asked for continuity and choice of care, and some wish to have more control throughout pregnancy and labour. These are uncontentious ideas, commonly agreed, yet the committee witnessed many people dance aggressively around the arguments; we heard about large maternity units and staff being impersonal or even hostile to mothers. It is not the size of the unit but the people who work there who matter; and obstetricians and midwives do feel that women should have more say in childbirth. Ideas for the future are all important. While antenatal clinics are understaffed and labour wards are run by tired junior doctors, it will be difficult to implement the good intents of the health committee. The answer lies not in the recommendations of the committee, nor even in the attitudes of professionals, but with the chronic underfunding of the health service and the implementation of needed staff increases at all levels. It is hoped that this health committee report will be debated in the House of Commons after the forthcoming UK general election. If it is, the Departments of Health and Community Care will have to answer for many deficiencies. This is when the report will be important. Despite the publicity that the sections on home births and underwater deliveries received, these are the less substantive parts of the report. The important event was that the committee was formed in an established and public part of the government environment; the Department of Health can be now called to task over its answers to this report. Department of Obstetrics, St George’s Hospital Medical School, London SW17 0RE, UK 1. Health Committee. Second report reference:
GEOFFREY CHAMBERLAIN maternity services, vol
1. London: HM
Stationery Office, 1992.
Promoting safe motherhood SIR,-Professor Sai and Ms Measham (Feb 22, p 478) believe that people considering strategies for reducing maternal mortality have overemphasised the importance of clinical interventions. If they had ranked their own list of recommendations on the
basis of the strength of evidence that each recommendation could reduce maternal mortality, they might have reached a different conclusion. They are right to remind us of strategies outside the maternity services that are likely to be effective (such as the provision of safe abortion). Nevertheless, history suggests’ that they are wrong to imply that the other strategies they promote deserve higher priority than deployment of effective care for women presenting with obstetric emergencies such as obstructed labour, haemorrhage, and eclampsia. Sai and Measham maintain that "We need to identify all pregnant women as early as possible; provide accessible and effective prenatal care; [and] provide maternal health education". In view of the considerable uncertainties about the effectiveness of prenatal care in preventing maternal mortality,’ this is a tall order. Global provision of early and universal prenatal care presents a huge strategic challenge, which should be taken seriously only if evidence can be produced to show that this is likely to be a more appropriate use of limited resources than strategies concentrating on effective .2 treatment of complications of pregnancy and childbirth Sai and Measham are clearly ambivalent (justifiably, we believe) about the relevance of prenatal care in reducing maternal mortality. They acknowledge that "most women with pregnancy-related complications cannot be identified with certainty before the complications develop", and that "prenatal care and health education cannot prevent most complications". Instead of going on to call for research to address some of the uncertainties about the effects of prenatal care, however, they defend their advocacy of universal prenatal care from early in pregnancy by claiming, without evidence, that it is likely to have "an enormous impact on the utilisation of referral-level care". Antenatal care was introduced in the UK in the 1920s to deal with a static rate of maternal deaths.’ As the number of women receiving antenatal care increased between the mid 1920s and mid 1930s, however, so did maternal mortality. The substantial decline began only after the introduction of effective forms of clinical intervention to treat infection and haemorrhage. If Sai and Measham wish to challenge the implications of that experience, they will need to do so with evidence. National Perinatal Epidemiology Unit, Radcliffe Infirmary, Oxford OX2 6HE, UK
LELIA DULEY ADRIAN GRANT IAIN CHALMERS
1. Loudon I. Maternal mortality. 1880-1950. Some regional and international comparisons. Soc Hist Med 1988; 1: 183-227. 2. Rooney C, Graham W. Review of the evidence of effectiveness of antenatal interventions in developing countries with regard to maternal health outcomes. Geneva: WHO Maternal Health and Safe Motherhood Programme, 1991.
SiR,—Professor Sai and Ms Measham bring the safe motherhood initiative from theory to practice on several relevant points but they end up adhering to an irrelevant and unnecessary argument for this initiative-ie, comparison of ratios of child and maternal deaths in poorer and wealthier countries. Mortality due to pregnancy has been brought to almost zero in industrialised countries, but so has mortality due to tuberculosis, cardiovalvular diseases, and many other disorders. All such disorders will yield high mortality ratios when comparing poor with wealthy countries; ratios will approach indefinite values when the denominator gets close to zero. Such comparison ratios are of no use for setting priorities in less developed countries. Moreover, the ratio between child and maternal mortality for less developed and developed countries will be in the same range if children with malformations and preterm births are excluded. The fact that half a million reproductive deaths take place each year in developing countries makes this one of the major health problems of the world and Sai and Measham rightly emphasise the need to show how motherhood can be made safe in these countries. Support for interventions against this, as well as other global health problems, should be based on the effectiveness and efficiency of the interventions rather than on confusing slogans about occurrence. International Child Health Unit, Department of Paediatrics, Uppsala University, S-751 85 Uppsala, Sweden
HANS ROSLING THORKILD TYLLESKAR
