BJOG Editor's Choice
BJOG Editor's Choice
Article first published online: 12 FEB 2013
© 2013 The Author BJOG An International Journal of Obstetrics and Gynaecology © 2013 RCOG
BJOG: An International Journal of Obstetrics & Gynaecology
Volume 120, Issue 4, pages i–ii, March 2013
How to Cite
Marsh, M. (2013), BJOG Editor's Choice. BJOG: An International Journal of Obstetrics & Gynaecology, 120: i–ii. doi: 10.1111/1471-0528.12179
- Issue published online: 12 FEB 2013
- Article first published online: 12 FEB 2013
Although it has been recently and very controversially proposed that infanticide should be redesignated as ‘after-birth abortion’ and that ‘the moral status of an infant is equivalent to that of a fetus’ (Giubilini and Minerva. J Med Ethics 2012;April 13), it is extremely unlikely that such a view will ever gain hold, let alone prevail and influence legislature, so current energies will continue to be directed towards the prevention of such tragic events, and a paper by Klier et al. on page 428, on this issue reports the effect of one strategy.
Infanticide is the intentional killing of infants and neonaticide is the killing within 24 hours of birth. Infanticide has become less common in the developed countries and recently has been estimated to be approximately 1 in 3000–5000 children of all ages (Putkonen et al. BMC Psychiatry 2009;9:74) and 2.1 per 100 000 newborns per year (Herman-Giddenset et al. JAMA 2003;289:1425–9). The reasons for infanticide are multifactorial, but risk factors for infanticide have been clearly identified. Most mothers who kill their children have histories shaped by chaos, abuse, violence and dysfunction. A history of childhood maltreatment is the most commonly reported characteristic, as well as suicidal ideation during pregnancy and previous suicide attempts. Pregnancy denial or concealed pregnancy is a risk factor, as are unintended pregnancies in women who are young and lacking adequate support systems. Certain character traits such as aggression, isolation, suspicion, drug or alcohol abuse, and poor social supports are also indicators of potential violence against children and infanticide. Neonaticide is associated with denial of pregnancy, dissociative symptoms or hallucinations and depression. Women who commit infanticide are usually young, often fail to manifest symptoms of pregnancy and fail to attend antenatal clinics, a situation that may be complicated by their families' collusion in denying the pregnancy (Spinelli, Infanticide and Child Abuse in Psychiatric Disorders and Pregnancy, Oxford: Taylor & Francis; 2006. pp. 53–68).
A classification of types of infanticide in a contemporary setting has been described (Oberman et al. In: Spinelli M, editor, Infanticide: Psychosocial and Legal Perspectives on Mothers who Kill. Arlington: American Psychiatric Press; 2002. pp. 3–18, 209–34). They include:
- Neonaticide, typically involving young pregnant women who deny the pregnancy, who are unable or unwilling to pursue the alternatives of termination of pregnancy or adoption and feel that they would be completely cut off from their social support network were they to disclose their pregnancies.
- Women who kill their infants or children in conjunction with their male partners who are often violent and abusive.
- Mothers whose infants die as a result of neglect, i.e. a baby left alone in the bathtub, or in the care of a still-young older sibling.
- Unsupported women who suffer from severe mental illness such as a severe depressive or psychotic episode.
- Women who chronically abuse their child leading to its death, the killing often happening at mealtimes and bedtimes when efforts to discipline can become extreme.
The law concerning infanticide varies across the developed world. In the UK the Infanticide Act of 1922 (amended 1938) states that if a mother can be shown to suffer from a postpartum mental ‘disturbance’ she can be charged with manslaughter rather than murder. As this is common in such women and often easy to demonstrate, most women convicted of infanticide in the UK receive sentences associated with manslaughter, most commonly probation, undergo psychiatric treatment, and do not serve time in prison. The British statute has been replicated in slightly varying forms in more than 20 nations around the world (Oberman, 1996 Am Crim Law Rev 34:17). In the USA there is reliance on the safe-haven laws (known in some states as ‘Baby Moses laws’). These were first introduced in Texas in 1999 and are statutes that decriminalise the leaving of unharmed infants with statutorily designated private persons so that the child becomes a ward of the state. The parents usually remain nameless to the court. The upper age limit to which these statutes apply varies between states. Police stations, hospitals and fire stations are all typical locations to which the safe-haven law applies. (www.childwelfare.gov/systemwide/laws_policies/statutes/safehaven.cfm)
In Europe the two chief preventive strategies to reduce neonaticide and child abandonment are ‘anonymous delivery’ and ‘baby hatches’. The anonymous delivery law allows a woman to give birth in a hospital anonymously and free of charge if she gives her child up for adoption. Anonymous delivery was implemented in France during the French Revolution in 1793, and enacted again in 1940. Luxemburg followed in 1993, Italy in 1997 and Austria in 2001. To date, there is no statute in European law concerning anonymous delivery. Baby hatches are incubators in the walls of hospitals and religious buildings where mothers can safely abandon their babies. The incubator signals staff when a baby is placed inside. Almost 200 have been installed across the continent in the past decade in nations as diverse as Germany, Switzerland, Poland, Czech Republic and Latvia. Since 2000, more than 400 children have been abandoned in the hatches. However, there are inadequate data to determine whether the introduction of baby hatches has resulted in changes in the numbers of killed or abandoned newborns. The baby hatch system does not ensure support for the woman during pregnancy, delivery and postpartum. In addition, any person could place a newborn baby in a baby hatch, potentially without the consent of the mother, and the baby hatch system prevents investigation if the baby might be the result of rape or incest. Aside from these problems the legality of baby hatches as a method of preventing infanticide has recently become uncertain. In June 2012 the UN Committee on the Rights of the Child expressed concern that baby hatches violated Article 7 of the UN Convention on the Rights of the Child, which states that children must be able to identify their parent, and even if separated from them the state has a ‘duty to respect the child's right to maintain personal relations with his or her parent’. The committee is taking the issue to the European parliament.
Returning to the paper of Klier et al. on page 428, they examined the effect of the introduction of the anonymous delivery law in Austria on neonaticide. They demonstrate a significant decrease in neonaticide after the implementation of the statute (Figure 1).
It is also of note that this study also demonstrates that Sweden and Finland have much lower neonaticide rates than Austria, even after the intervention. Within the discussion the authors consider possible reasons for this, including the influence of abortion laws and incidence of sex education.
Statins and pregnancy
Statins are used successfully in the treatment of hypercholesterolaemia by interrupting liver cholesterol synthesis through inhibition of 3-hydroxy-3-methylglutaryl coenzyme-A reductase, leading to a decrease in plasma cholesterol levels. They also increase the expression of low-density lipoprotein receptors in hepatocytes, causing a fall in circulating low-density lipoprotein cholesterol. These effects result in reductions in cardiovascular risk by reducing atherosclerosis in all major arterial trees. Statins are among the most extensively investigated and prescribed pharmaceutical agents in current clinical use. Atorvastatin was the best selling drug in pharmaceutical history, and topped the list of best-selling branded pharmaceuticals in the world for nearly a decade (Crain's New York Business. 28 November 2011). In 2010, atorvastatin was the biggest-selling drug in the world ($US10.73 billion).
Increases in the average age of pregnant women and in the prevalence of obesity have led to increasing exposure to statins in women during the first trimester of pregnancy, so data about their safety is of obvious importance. In addition, there is increasing interest in the idea that statins could be useful in the management of pre-eclampsia.
Several potential indications have been proposed (Lecarpentier et al. Drugs 2012;72:773–88) including primary or secondary prevention early in pregnancy and for the treatment of established pre-eclampsia. It has recently been hypothesised that placental dysfunction during pregnancy is an indicator of the mother's underlying risk of developing cardiovascular disease in the long term, so statins may limit later vascular complications in women with a history of pre-eclampsia. A randomised, placebo-controlled, double-blind trial (http://www.clinicaltrials.gov/ct2/show/NCT01278459?term=NCT01278459&rank=1 identifier NCT01278459) is currently assessing the postpartum utility of atorvastatin on endothelial function.
On page 463 Winterfeld et al., in a multicentre observational prospective controlled study using the European Network of Teratology Information Services, collected observations from 249 exposed pregnancies and 249 controls and compared rates of major birth defects, live births, miscarriages, elective terminations, preterm deliveries and gestational age and birthweight at delivery. The study did not demonstrate any significant differences between outcomes in exposed or nonexposed women, with the exception of an increased rate of premature birth in exposed pregnancies (16.1% versus 8.5%). This study did not detect a teratogenic effect of statins. The miscarriage rate was (nonsignificantly) higher in exposed women (Figure 2), although this finding could be explained by the greater age of the treated women.
The authors acknowledge that the statistical power remains insufficient to challenge current recommendation of treatment discontinuation during pregnancy. Taken as a whole the results provide more evidence for reassurance in cases of inadvertent exposure and perhaps add weight to the arguments for randomised studies of statins and pre-eclampsia.