Amy Coopes writes:
Expectant mothers continue to die from preventable causes at unacceptably high rates, with “shameful” disparities affecting society’s most vulnerable groups, a summit of women’s health specialists heard in Adelaide last week.
Maternal mortality was a major theme at this year’s annual scientific meeting of RANZCOG, the Royal Australian and New Zealand College of Obstetricians and Gynaecologists, with data presented from advanced and developing economies showing there are still improvements to be made.
Obstetric physician Dr Catherine Nelson-Piercy, from London’s Kings College, set the tone for the meeting with a spirited opening presentation on the forgotten art of generalism in maternity care, in an era of “knobology”, and subspecialist “citadels”, where subspecialised Maternal-Foetal Medicine overwhelmingly focused on the unborn child.
“The mother is not just a vessel,” she told delegates.
While obstetricians are experts at managing the common complaints and complications of pregnancy, Nelson-Piercy said pregnant women in the UK continue to die from conditions like epilepsy, cancer or cardiovascular disease, with 75 percent of all maternal deaths occurring in women with comorbidities.
Australia was doing better on these measures, with lower maternal mortality than the UK (7 in 100,000 maternities compared with 9 in 100,000 and better performance on “indirect” or non-obstetric deaths), but Nelson-Piercy said this masked “shameful” discrepancies between outcomes for Indigenous and non-Indigenous mothers.
Maternal mortality for Indigenous women (13.8 per 100,000) is more than double that of their counterparts (6.6 per 100,000), with a sizeable gulf in cardiovascular deaths (3.9 vs 1.2/100,000), suicide (3.2 vs 0.6/100,000), hypertension and sepsis (2.6 vs 0.4 and 0.8/100,000 respectively).
Darwin doctor Kiarna Brown, a Yadhiagana woman and one of just three Aboriginal and Torres Strait Islander obstetricians nationwide, captivated colleagues with a powerful talk on closing the gap, which centred on the story of a teenage mother who had died following a litany of missteps in her care.
“For Aboriginal people it’s not about illness,” she said in an interview after the plenary. “It’s not about the ankle, it’s not about the kidneys, it’s not about the sugars. It’s about deep cultural strength, it’s about connection to community, it’s about connection to country. It’s about being strong within ourselves, and then the health stuff comes.”
Brown told colleagues the statistics were well known – Indigenous women faced a disproportionate burden of chronic disease, faced a 10-year life expectancy gap, and their babies were more frequently born preterm and with low birth weight “so they’re already starting 10 steps behind.”
What was less well understood was why this was the case, she said, urging delegates to educate themselves about the Aboriginal model of health (treating the person and their community in a cultural context), and the diversity of communities and inadequacy of a one-size-fits-all approach.
She also urged delegates to reflect upon and acknowledge their own privilege, and to understand the concept of remoteness – something that encompassed much more than geography and was about loneliness, loss of culture and discrimination.
“Please don’t be fooled into thinking that racism doesn’t exist,” she urged colleagues. “Almost 28 percent of Australians demonstrate racism to Indigenous Australians, and racism leads to poorer health outcomes. This is fact.”
“If you look at the historical context, Aboriginal people weren’t even allowed in hospitals one, maybe two generations ago. So our modern doctor needs to understand that, and needs to be aware that it’s their responsibility to be culturally safe and provide culturally appropriate care.”
Outgoing RANZCOG President Steve Robson said it was essential to acknowledge the lasting impacts of occupation on health outcomes for disadvantaged women, and called on the College to step up its advocacy for Indigenous, migrant and CALD populations and intensify collaboration with groups such as NACCHO, the Australian Indigenous Doctors Association and the Migrants Council of Australia to drive policy reforms.
“We are not so good at looking the broader social determinants,” said Robson. “Yet the social determinants of the conditions we treat is utterly important.”
He presented data showing stark disparities in maternal mortality by socioeconomic quintile (10 in 100,000 for the lowest, 4 in 100,000 for the highest), particularly for those deaths considered medically preventable (1 vs 0.2 in 100,000).
Though this was beyond the power of any one person to address, Robson said it was vital that each and every doctor be a strong advocate for the women they served, at all political levels.
In the UK, Nelson-Piercy said mortality had declined steadily overall in the past 20 years, but progress had been inconsistent on “indirect” deaths from things like cardiac conditions or influenza, highlighting the importance of not just multidisciplinary involvement but the need for a generalist to ”project-manage” care.
Pregnant women with pre-existing medical conditions or conditions that developed during but not as a direct result of their gestation could attend multiple clinics at different sites, overseen by different doctors, with very poor communication between care providers, she said.
Few specialists were well versed in the care of pregnant women, she added, with some disciplines “cowboys” who didn’t appreciate the nuances and others overly cautious, resulting in either over or undertreatment.
What was needed was a generalist – “not instead of, as well as” – who knew how to manage pregnant patients but was also experienced in and not afraid of conditions like asthma, epilepsy, bowel and lung disease, drug use and other common and less common comorbidities, she said.
There were significant opportunities for improvement with better planning and counselling around known conditions including mental health, optimisation of medications before pregnancy, and early referral where required. There were also gains to be made in postpartum health, Nelson-Piercy said, urging that the continuum of care continue beyond the labour ward.
One of former health secretary Jeremy Hunt’s final acts in the role was to announce funding for the training of a dozen obstetric physicians and establishment of maternal medicine networks to try and combat preventable maternal deaths in the UK, said Nelson-Piercy. In the UK, the obstetric profession had also moved to split foetal and maternal medicine into distinct entities in recognition of their sometimes competing demands, she added.
The calls for more generalists and a greater focus on equity in women’s health were echoed by both Robson and outgoing AMA president Dr Michael Gannon, who said funding of public hospitals, GPs and perinatal psychiatry, and access to services were real threats to the equitable provision of maternity care.
“The move towards subspecialisation, to forming citadels of luminous brilliance in our cities, is a threat to the care we can provide in our outer suburbs, rural areas and to needy groups,” Gannon told delegates.
Oxford Professor Chris Redman offered a global perspective on the issue, sharing his experiences at the helm of CoLab, an international research consortium on adverse pregnancy outcomes funded by the Bill and Melinda Gates Foundation.
Outlining the scale of the global challenge, Redman said an estimated 350,000 expectant mothers died every year, with 2.5 million stillbirths and 2.5 neonatal deaths and 15 million preterm births, 60 percent of which occurred in low and middle income countries.
Where data was most needed, it was least often available, he told delegates, with only one of the top-ranking 10 countries in terms of maternal mortality – Cameroon – having such information available, and the remaining nine based on estimates alone.
“These are the black holes of tragedy, where no one knows what is going on,” Redman said.
He shared some of the challenges attempting to roll out large-scale data collection and standardisation in developing nations, where records were often kept on paper and authorities were suspicious of digitisation and storage of information in offshore repositories.
Unless such information was standardised and retrievable it could not be shared, said Redman, adding that “unshared data cannot serve a global vision of what is possible” in improving maternal and perinatal health.
Dr Manarangi De Silva shared her experiences of maternal mortality, following a six-month secondment to the Solomon Islands, where the death rate was 114 in 100,000 and just four consultants and six registrars serviced the whole country, delivering 5,600 babies each year.
In a country devastated by civil war and trying to find its feet after the end of a 14-year peacekeeping mission, De Silva said infrastructure remained a major issue, with the basics most doctors took for granted such as saline, antibiotics and other medicines in shortage, and two-thirds of women experiencing intimate partner violence.
Maternal deaths were commonly due to hypertensive disorders, haemorrhage and infection – causes not often seen in Australia – as well as from communicable diseases such as malaria, dengue, tuberculosis and undiagnosed Hepatitis B.
One-third of women died anaemic due to malnutrition, parasitic infections and vector-borne illness, and one in three maternal deaths had not received antenatal care, while a quarter perished due to a lack of blood products. De Silva said there was no formalised blood donation program in the Solomon Islands and patients were reliant on family to give blood if it was needed.
Five percent of women died because they couldn’t get to an operating theatre in time when complications arose, with the average waiting time for emergency surgery 170 minutes.
There was also a special session on obstetric issues in Indonesia, where the maternal mortality rate had seen an uptick in 2013 to 359 per 100,000 – a 20-year high and among the highest rate seen in Southeast Asia – with speakers presenting on management of conditions including pre-eclampsia, cardiomyopathy and placenta accreta.
Watch the interview with Dr Kiarna Brown
Tweets below by Amy Coopes for @WePublicHealth
Dr Kiarna Brown
Dr Steve Robson
Dr Chris Redman
Dr De Silva