Editor’s Choice

Does anyone know what they really really want?

In 1996, the Spice Girls singing group had their first chart success with a popular song in which the chorus went ‘I’ll tell you what I want, what I really really want’. But do we always know what we really, really want? And should we sometimes get what we really, really need rather than what we think we want? To the Western liberal clinician, giving people choice may appear to be a ‘no-brainer’. But traditionally many doctors argued that the average patient/client/consumer/pregnant woman was not equipped either by intellect, training or experience, to choose the form of medical care that was best for them. ‘The doctor is trained for many years to know what is best for people who consult them, and they should make the decisions’. On page 880, Ananda van den Heuvel and her colleagues argue that ‘political and economic changes have… propelled patient autonomy to the forefront of health care’, so that ‘the concept of informed choice has become an integral part of health care provision’. But not everywhere. They suggest that the extent to which individuals want to be involved in medical decision-making reflects a society’s orientation on the ‘individualist–collectivist dimension’. They examined this hypothesis by interviewing approximately 200 people from each of the UK, the Netherlands, Italy, Greece, China and India, about the values they attached to choice in prenatal testing decisions. It will probably not surprise readers to discover that about 85% of women in the Netherlands felt that prenatal testing was essentially a matter of parental choice; the corresponding figure in the UK was just over 70%. However, it surprised me that the most authoritarian responses were in Greece (80% felt there should be no choice: all mothers should be tested) and Italy (over 65%), rather than in China (63%) and India (58%). These results have important implications regarding, for example, the presentation of written information informing parents of the risks and benefits of prenatal screening. Van den Heuvel et al. ask whether, in culturally diverse countries such as the UK (where one in three of currently pregnant women were not born in the UK), such information should be presented according to the dominant ethical principles of the majority population or should be tailored to be ‘culturally sensitive’. Should we for example publicise the risks of consanguinity in the UK Pakistani population (60% of whom marry their first cousins) or assume that they know and accept the risks for cultural reasons?

In this month’s issue, we have three more papers on the theme of ‘choice in pregnancy’. On page 886, Kingdon and colleagues describe a longitudinal cohort study using both quantitative and qualitative methods to analyse the extent to which women in Liverpool, UK feel they have a choice for vaginal birth versus caesarean section. On page 896, Frost and her colleagues from the academic unit of primary health care in Bristol, UK report on their study of the use of decision aids to help women in southwest England decide about their preferred method of delivery following a previous caesarean section, and on page 906, Rees et al. from the same unit examine health care professionals’ views of this approach. To bring the conclusions together, we commissioned a commentary from editor Andrew Weeks and his colleague Dr Linda Watkins, which is on page 877. They address key aspects such as the amount of information that women might want, how much detail they could cope with (which of course will vary from individual to individual), who should give it and in what format. These challenging aspects of modern practice will be difficult to resolve and solutions will vary from place to place. Why not use these papers to trigger a multidisciplinary discussion and re-evaluation of the practice in your own unit?

Home birth again

Just over a year ago, BJOG published a study by Mori et al. (115:554) which attempted to obtain a ‘best estimate of intrapartum-related perinatal mortality rates for booked home births’. While emphasising that ‘the results of this study need to be interpreted with caution due to inconsistencies occurring in the recorded data’, they reported that intrapartum perinatal mortality rates for home births in the UK did not appear to have improved between 1994 and 2003, and that while those that actually delivered at home had a low intrapartum perinatal mortality rate, those that required transfer to hospital did not. These conclusions were controversial and stimulated a vigorous correspondence. We invited the most critical group, led by Gillian Gyte, to present their criticism as a formal paper on page 933, examining the assumptions made by Mori et al., and questioning their conclusions. The paper is accompanied by a Minicommentary by the authors of the original article, commenting on some of the criticisms. Gyte et al. suggest that ‘the limitations (of the Mori paper) could have been identified by the peer review process’. In fact, the Mori paper was scrutinised by three referees (a midwife, an obstetrician, and a perinatal epidemiologist) and six editors, before the decision to publish was made. All made extensive comments and none were against publication (eight were positively in favour). The paper went through five revisions before final acceptance. The limitations of the data were highlighted in the original paper, but we thought it appropriate to allow Gyte et al. to emphasise these once more.

We accompany the Gyte paper in this issue with a paper from the Netherlands, which has the highest home birth rate in Europe. Amelink-Verburg et al. (page 923) have analysed 1 977 006 births from 1988 to 2004, looking at the referral rate from midwifery care to obstetric care. Although many of the women cared for by midwives delivered at home, their paper does not supply data on this aspect. It does, however, report that the proportion of women referred from primary midwifery care to obstetric care increased from 36.9% to 51.4% over the study period. This 14.5% increase in referrals was mainly antepartum (9%) and intrapartum (5.2%), with only a few occurring after delivery (0.3%). Much of this increase was attributed to increasing demand for pain relief and the rising incidence of previous caesarean section. Referral to obstetric care occurred in about one in four parous women and about one in two nulliparous women. One in four nulliparous women were transferred during labour. The authors highlight that ‘referral during labour has been shown to lead to more negative perceptions of birth experiences in the short term and long term compared to not being referred’. Perhaps one thing we can all agree upon is that the disadvantages of transfer during labour warrant further study, and need to be set against the undeniable advantages of successful ‘low tech birth’ in familiar surroundings.

Placenta accreta

As caesarean section rates rise, the problem of placenta accreta inevitably becomes more common in those women who go on to further pregnancies. One way of dealing with this is to leave the placenta in situ, an approach first reported in 1988. However, not removing the placenta requires long and intensive follow up, because unfortunately it is associated with a high rate of postpartum sepsis and secondary uterine bleeding. On page 915, we report the innovative suggestion by Morel et al. of destroying the placenta in situ by radio frequency ablation. They have tested their idea with human placentas in vitro and sheep placentas in vivo, with promising results. However, they suggest further evaluation in animal models before the method is tried out on humans. On page 1002, Morgan et al. suggest the alternative approach of using mifepristone and misoprostol, which resulted in expulsion of the complete placenta—although in their first case this was not done until 15 weeks after delivery, by which time presumably a plane of cleavage resulting from placental autolysis had developed. However, in the second case, the regime was successful approximately one week after delivery. While at one time hysterectomy was generally considered the only appropriate management of placenta accreta, it seems likely that strategies for conservative management will continue to improve.

Working mothers

For most women in history, reducing their workload during pregnancy has not been an option. They have continued to gather and prepare food, and generally look after their families, whether pregnant or not. As societies became more affluent, a tradition that ‘women’s place is in the home’ gradually evolved, although many women continued to work in factories, or in home-based industries, while they were pregnant. However, the perception of the male as ‘the breadwinner’ meant that by the middle of the last century, in many countries such as the UK, the majority of women did not ‘go out to work’ while they were pregnant or their children were young. Many women found this division of roles irksome, and as early as the middle of the 19th century, women such as Florence Nightingale rebelled and forced their way into positions of political influence. Many women took over men’s jobs while the men were away fighting during the First World War, and by the beginning of this century, a substantial degree of occupational parity had been achieved. However, property and cost of living prices are now based on two incomes per family rather than one, which means that women continuing to work outside the home during and after pregnancy has in many cases become a necessity rather than a choice. So it becomes particularly important to understand the role that different types of work have in relation to pregnancy outcome. On page 943, Niedhammer and colleagues report a detailed study of the link between the type of work women engage in and outcomes such as preterm birth and low birthweight for gestational age. It is perhaps not unexpected that long working hours, shift work, work requiring a lot of physical effort, and temporary contract work, were all associated with a greater risk of a poor outcome. Perhaps what is surprising, however, is that the odds ratios of preterm birth/low birthweight when women were exposed to two of these factors were as high as 5.2/4.6. Some countries, for example in Scandinavia, provide generous paid maternity leave. However, in many others, including the UK, maternity leave is relatively brief, and most women continue working during pregnancy so as to maximise the length of time they can spend with their children after the birth. This study suggests that enabling women to take adequate paid maternity leave during pregnancy, especially if their job involves the adverse factors identified by Niedhammer et al., should be an important public health priority.

And finally

It is not just in ongoing pregnancy that choice is important, there are now important choices that can be offered to women who are unlucky enough to have a miscarriage. A study from Finland on page 984 by Niinimäki et al. reports that the cost differences between surgical and medical management are small enough that the choice of management should be left to the women. Outpatient and minimal access gynaecology has increased enormously in importance since I started training, and simpler, cheaper, and safer alternatives to major surgery are constantly being developed. Reports of such developments are increasingly submitted to BJOG, and we are keen to recruit an additional editor with a special interest in this area. If you are interested, please e-mail me at [e-mail].