INFLUENCE OF MEDICAL WORK IN OBSTETRICS

Prenatal care of the mother. Influence of social service in obstetrics. Establishment in every community of a prenatal hygienic service. Duties of a medical social service in relation to obstetrics.More attention given to the teaching of obstetrics in our medical schools. Maternal mortality of childbirth.     

The general practitioner and changes in obstetric practice.

Compared with the 1960s fewer general practitioners today are obtaining a postgraduate diploma in obstetrics, and the future more stringent criteria for practitioners wishing to undertake this will probably restrict the numbers of family doctors wishing to practise in this field. More deliveries are being performed in institutions--either in consultant or general-practitioner units. Morever, within a decade probably few G.P.s will attend during normal labour or delivery, which can and should be conducted by midwives. In future, therefore, G.P.s should have a new role in obstetrics, being responsible for some antenatal supervision and postnatal care, including postnatal examinations, taking a cervical smear, and advice on birth control.     

General practitioner obstetrics in the Northern region in 1983.

In late 1983 a four page questionnaire on general practitioner obstetrics was sent to a 50% random sample of general practitioners in the Northern region of England; 84% responded. Half of them said that they had access to general practitioner facilities for delivery, and half of these used them. A quarter of all respondents had provided intranatal care previously but had given it up, most of them during the late 1970s. Younger general practitioners were more highly qualified in obstetrics than older ones but did not do more intranatal work. Isolated general practitioner maternity units were much more likely to be used than those that were alongside consultant units or integrated with them. Ninety per cent of respondents provided antenatal care, 77% of these at special clinics and 88% with midwives in attendance. Teamwork, however, was not well developed. Increasing general practitioner participation in obstetric care seems feasible but depends heavily on more appropriate training and intranatal facilities being provided for general practitioners in association with specialist units.     

SPECIALIST-GENERAL PRACTITIONER COOPERATION IN AN OBSTETRICAL DEPARTMENT

At a private hospital not affiliated with a teaching institution, a system was set up in the obstetrical department under which general practitioners carrying out deliveries had the advice and aid of specialists in obstetrics and were required to call for it in stated circumstances. General practitioners carried out about half of the 17,076 deliveries at the hospital in an eight-year period. Teamwork was stressed. Results were comparable with those reported from many of the well-known institutions.In addition, a special anesthetic service was organized for the obstetrical department. Anesthesia was administered by young physicians who not only were versed in anesthetic procedures but had special training in obstetrics.The service was available at any hour, and the physician carrying out delivery could count upon competently administered anesthesia when it was needed, as well as upon consultation and assistance should the need arise.     

Factors influencing family physicians to continue providing obstetric care.

To determine the reasons some family physicians continue to practice obstetrics when most of their colleagues do not, we surveyed family physicians in 26 counties of northern California whose practices include obstetrics and those who have recently discontinued it. In all, 70% of family physicians practicing obstetrics cited enjoying it as a reason for continuing this practice. Over a third of family physicians practicing obstetrics thought that obstetric practice was a responsibility to the community. Only 1 in 6 reported obstetrics to be important in terms of financial implications. Despite this, family physicians practicing obstetrics had a mean gross income derived from obstetric practice of $30,000 above the cost of their total malpractice premium. In contrast, a comparison group of family physicians who had recently discontinued obstetrics cited malpractice insurance costs most frequently as the reason for discontinuing it. Nearly 40% of these physicians indicated that they would be willing to return to obstetrics if circumstances were to change substantially. The most frequently cited change necessary for these physicians to return to obstetrics was a reduction in malpractice insurance rates.     

General practitioners' management of acute myocardial infarction and cardiac arrest: relevance to thrombolytic treatment.

A questionnaire was sent to 61 general practitioners who had participated 18 months previously in a study of their experience of cardiopulmonary resuscitation and defibrillation in acute myocardial infarction. Fifty (82%) replies were received. Only 16 of the 50 respondents thought that every general practitioner should have a defibrillator, but 46 thought that every group practice should have one. Most practitioners felt the need for more tuition and practice in advanced life support, but 15 did not have the practice defibrillator with them when on call. Only nine doctors normally had an electrocardiograph with them when on call, most relying on clinical acumen to make an operational diagnosis; there appeared to be reluctance to use any drugs other than opiates and atropine in the management of acute myocardial infarction. This study highlights the difficulty of maintaining readiness to deal effectively with myocardial infarction in the community and the problems of relying on the electrocardiogram in deciding who should be given thrombolytic treatment.     

Mid-arm circumference at birth as predictor of low birth weight and neonatal mortality

In Bangladesh, like other developing countries, most births occur at home or in the community, so logistic problems and taboos prevent the weighing of every newborn child. This study was performed to see whether other simpler measurements could be substituted for weight to identify neonates of low birth weight. A total of 1676 live births at the Chittagong Medical College Hospital constituted the study sample, and this showed a high correlation between mid-arm circumference and birth weight (r=0.792, p<0.000). A mid-arm circumference of <9.0 cm had the best sensitivity and specificity for identifying newborns with a birth weight of less than 2500 g. These neonates were followed up to record neonatal deaths. Neonatal mortality showed an inverse relation with mid-arm circumference. A mid-arm circumference of <9.0 cm and a birth weight of <2500 g were equally useful in predicting neonatal outcome. Mid-arm circumference is a simple, quick and reliable indicator for predicting low birth weight and neonatal outcome, and can be easily measured by medical practitioners and traditional birth attendants (TBAs) in the community of developing countries like Bangladesh.     

Obstetrics and Gynecology: Diabetes Mellitus in Pregnancy

The Council on Scientific Affairs of the California Medical Association presents the following inventory of items of progress in obstetrics and gynecology. Each item, in the judgment of a panel of knowledgeable physicians, has recently become reasonably firmly established, both as to scientific fact and important clinical significance. The items are presented in simple epitome, and an authoritative reference, both to the item itself and to the subject as a whole, is generally given for those who may be unfamiliar with a particular item. The purpose is to assist busy practitioners, students, researchers, or scholars to stay abreast of these items of progress in obstetrics and gynecology that have recently achieved a substantial degree of authoritative acceptance, whether in their own field of special interest or another.The items of progress listed below were selected by the Advisory Panel to the Section on Obstetrics and Gynecology of the California Medical Association, and the summaries were prepared under its direction.     

Obstetrics and gynecology: AIDS and pregnancy

The Scientific Board of the California Medical Association presents the following inventory of items of progress in obstetrics and gynecology. Each item, in the judgment of a panel of knowledgeable physicians, has recently become reasonably firmly established, both as to scientific fact and important clinical significance. The items are presented in simple epitome and an authoritative reference, both to the item itself and to the subject as a whole, is generally given for those who may be unfamiliar with a particular item. The purpose is to assist busy practitioners, students, research workers, or scholars to stay abreast of these items of progress in obstetrics and gynecology that have recently achieved a substantial degree of authoritative acceptance, whether in their own field of special interest or another.The items of progress listed below were selected by the Advisory Panel to the Section on Obstetrics and Gynecology of the California Medical Association and the summaries were prepared under its direction.     

Obstetrics and gynecology: avoiding pregnancy in isotretinoin users

The Scientific Board of the California Medical Association presents the following inventory of items of progress in obstetrics and gynecology. Each item, in the judgment of a panel of knowledgeable physicians, has recently become reasonably firmly established, both as to scientific fact and important clinical significance. The items are presented in simple epitome and an authoritative reference, both to the item itself and to the subject as a whole, is generally given for those who may be unfamiliar with a particular item. The purpose is to assist busy practitioners, students, research workers, or scholars to stay abreast of these items of progress in obstetrics and gynecology that have recently achieved a substantial degree of authoritative acceptance, whether in their own field of special interest or another.The items of progress listed below were selected by the Advisory Panel to the Section on Obstetrics and Gynecology of the California Medical Association, and the summaries were prepared under its direction.     

Obstetrics and gynecology-important advances in clinical medicine: exchange transfusion in pregnant women with sickle cell disease

The Scientific Board of the California Medical Association presents the following inventory of items of progress in obstetrics and gynecology. Each item, in the judgment of a panel of knowledgeable physicians, has recently become reasonably firmly established, both as to scientific fact and important clinical significance. The items are presented in simple epitome and an authoritative reference, both to the item itself and to the subject as a whole, is generally given for those who may be unfamiliar with a particular item. The purpose is to assist busy practitioners, students, research workers or scholars to stay abreast of these items of progress in obstetrics and gynecology that have recently achieved a substantial degree of authoritative acceptance, whether in their own field of special interest or another.The items of progress listed below were selected by the Advisory Panel to the Section on Obstetrics and Gynecology of the California Medical Association and the summaries were prepared under its direction.     

The views of singlehanded general practitioners: a qualitative study.

OBJECTIVES--To examine the concerns of singlehanded general practitioners working in an inner London area and to compare the views of general practitioners in partnerships. DESIGN--Qualitative analysis of semistructured interviews with a random sample of singlehanded general practitioners and a sample of general practitioners from partnerships matched for age and sex. SETTING--The area covered by Lambeth, Southwark, and Lewisham Family Health Services Authority. RESULTS--The singlehanded general practitioners were more likely to be older, male, and first qualified abroad than general practitioners in partnerships. Their major concerns were inadequate premises, maintaining their singlehanded status, and coping with recent changes to their contract. Most were very satisfied with their solo status and did not see the provision of 24 hour care as stressful. CONCLUSION--Singlehanded general practitioners saw themselves as providing a unique service for patients, and their status as an alternative for general practitioners who were unhappy in partnerships. Such practices are unlikely to wither away as a pattern of provision. Any comprehensive development of primary care must take their needs into account.     

FORENSIC OBSTETRICS

Some of the more important and current aspects of forensic obstetrics are, broadly,1. Fulfillment of basic criteria in all cases of alleged traumatic abortion.2. Utilization of therapeutic abortion review boards, as well as sterilization committees, in all hospitals, with the active support of such committees by all those physicians interested in advancing the art and practice of obstetrics.3. Early and active joint study of professional liability problems by combined groups of physicians and lawyers in every community.     

General practitioner obstetrics in Bradford.

The standard of obstetrics care by general practitioners in Bradford was assessed by reviewing the case records of all women who in 1988 were booked for delivery under their general practitioner but subsequently required transfer to consultant care. A total of 5885 women were delivered in Bradford during 1988. Of 1289 booked under their general practitioner, 637 required transfer to consultant care. In 259 cases transfer occurred during labour; only 37 of these women were visited by their general practitioner. Many of the problems that precipitated transfer were predictable and some were considered preventable: 263 of the women transferred were considered unsuitable for booking by general practitioners. The perinatal mortality among women booked under their general practitioner was 10.1/1000 and the stillbirth rate 7.8/1000. These figures are high and suggest a need for tighter controls over the qualifications and experience of doctors participating in a fully integrated system of obstetric care.     

Family Practice: A Proposed Solution to the Problem of Meeting the Medical Needs of the Community

Difficulties in meeting today''s community medical needs are outlined, followed by a proposed solution in which the first-contact physician is the trained family physician. The McMaster Family Practice Course is described. The potential research contribution of a Department of Family Medicine is stressed.     

Demand for patient care.

A study was performed to determine the extent to which patients of all types were receiving inappropriate levels of care. The needs of patients in acute and supporting hospitals, people in residential homes, and patients cared for at home were assessed. A sixth of the hospital inpatients did not need hospital care, while 5% of those in residential homes and 5% of those at home did need hospital services. These findings indicate that a realistic provision of hospital beds would be 4 per 1000 population for all specialties except regional specialties, psychiatry, mental subnormality, obstetrics, and paediatrics. About a third of these beds need to be acute, while the rest may be in supporting or community hospitals. Thus the current provision of acute beds (2-0 to 2-5 per 1000 population) exceeds actual need.     

Explanatory Models and Mental Health Treatment: Is Vodou an Obstacle to Psychiatric Treatment in Rural Haiti?

Vodou as an explanatory framework for illness has been considered an impediment to biomedical psychiatric treatment in rural Haiti by some scholars and Haitian professionals. According to this perspective, attribution of mental illness to supernatural possession drives individuals to seek care from houngan-s (Vodou priests) and other folk practitioners, rather than physicians, psychologists, or psychiatrists. This study investigates whether explanatory models of mental illness invoking supernatural causation result in care-seeking from folk practitioners and resistance to biomedical treatment. The study comprised 31 semi-structured interviews with community leaders, traditional healers, religious leaders, and biomedical providers, 10 focus group discussions with community members, community health workers, health promoters, community leaders, and church members; and four in-depth case studies of individuals exhibiting mental illness symptoms conducted in Haiti's Central Plateau. Respondents invoked multiple explanatory models for mental illness and expressed willingness to receive treatment from both traditional and biomedical practitioners. Folk practitioners expressed a desire to collaborate with biomedical providers and often referred patients to hospitals. At the same time, respondents perceived the biomedical system as largely ineffective for treating mental health problems. Explanatory models rooted in Vodou ethnopsychology were not primary barriers to pursuing psychiatric treatment. Rather, structural factors including scarcity of treatment resources and lack of psychiatric training among health practitioners created the greatest impediments to biomedical care for mental health concerns in rural Haiti.     

Meeting the challenge: providing anesthesia services in rural hospitals.

Although the volume and intensity of surgery done in rural hospitals are not sufficient to support a fully trained staff anesthetist, it is not practicable for all surgical, anesthesia and obstetric services to be provided by specialists in referral centres. As the study reported by Chiasson and Roy in this issue shows (see pages 1447 to 1452), general practitioners (GPs) with limited additional training in anesthesia already play an important role in the provision of these services in rural areas. To ensure that there is a continued supply of physicians prepared to meet the needs of small communities, funding and opportunities for supplemental training in surgery, anesthesia and obstetrics must be made available to GPs.     

Interactions among ecosystem stressors and their importance in conservation

Interactions between multiple ecosystem stressors are expected to jeopardize biological processes, functions and biodiversity. The scientific community has declared stressor interactions—notably synergies—a key issue for conservation and management. Here, we review ecological literature over the past four decades to evaluate trends in the reporting of ecological interactions (synergies, antagonisms and additive effects) and highlight the implications and importance to conservation. Despite increasing popularity, and ever-finer terminologies, we find that synergies are (still) not the most prevalent type of interaction, and that conservation practitioners need to appreciate and manage for all interaction outcomes, including antagonistic and additive effects. However, it will not be possible to identify the effect of every interaction on every organism''s physiology and every ecosystem function because the number of stressors, and their potential interactions, are growing rapidly. Predicting the type of interactions may be possible in the near-future, using meta-analyses, conservation-oriented experiments and adaptive monitoring. Pending a general framework for predicting interactions, conservation management should enact interventions that are robust to uncertainty in interaction type and that continue to bolster biological resilience in a stressful world.     

Opinions of general practitioners in Nottinghamshire about provision of intrapartum care.

OBJECTIVE--To examine the beliefs of general practitioners concerning intrapartum care. DESIGN--Postal questionnaire survey. SUBJECTS--All general practitioners with patients in Nottinghamshire Family Health Services Authority in September 1993. MAIN OUTCOME MEASURES--General practitioners'' current involvement in maternity care, and beliefs on intrapartum care. RESULTS--Of 694 general practitioners sent questionnaires, 550 (79.2%) replied. 529 of these were on the obstetric list; 437 had not attended a delivery in the past 12 months; 36 had attended two or more; 358 general practitioners did not wish to provide more intrapartum care; 349 did not feel competent to do so. Reasons for not wanting to provide intrapartum care included current workload (453), disruption to personal life (407), and the fear of litigation (377). General practitioners who already booked women for home delivery were more likely to wish to do more deliveries (62/42 v 61/316, chi 2 = 85.3; P < 0.0001) and to have more positive attitudes towards increasing women''s choice in maternity care (90/22 v 195/151, chi 2 = 227; P < 0.0001). CONCLUSIONS--The involvement of general practitioners in intrapartum care in Nottinghamshire is low, and most general practitioners are unwilling to increase their role. However, general practitioners who already book for home delivery are keen to do more.