Education in developing countries and reducing maternal mortality: a forgotten piece of the puzzle?

Despite substantial improvement in reducing maternal mortality during the recent decades, we constantly face tragic fact that maternal mortality (especially preventable deaths) is still unacceptably too high, particularly in the developing countries, where 99% of all maternal deaths worldwide occur. Poverty, lack of proper statistics, gender inequality, beliefs and corruption-associated poor governmental policies are just few of the reasons why decline in maternal mortality has not been as sharp as it was wished and expected. Education has not yet been fully recognized as the way out of poverty, improvement of women's role in the society and consequent better perinatal care and consequent lower maternal mortality. Education should be improved on all levels including girls, women and their partners, medical providers, religious and governmental authorities. Teaching the teachers should be also an essential part of global strategy to lower maternal mortality. This paper is mostly a commentary, not a systematic review nor a meta-analysis with the aim to rise attention (again) to the role of different aspects of education in lowering maternal mortality. The International Academy of Perinatal Medicine should play a crucial role in pushing the efforts on this issue as the influential instance that promotes reflection and dialog in perinatal medicine, especially in aspects such as bioethics, the appropriate use of technological advances, and the sociological and humanistic dimensions of this specific problem of huge magnitude. The five concrete steps to achieve these goals are listed and discussed.

Fetal medicine specialist experiences of providing a new service of termination of pregnancy for fatal fetal anomaly: a qualitative study.

OBJECTIVE: To explore fetal medicine specialists' experiences of caring for parents following a diagnosis of fatal fetal anomaly (FFA) during the implementation of termination of pregnancy (TOP) for FFA for the first time. DESIGN: Qualitative study. SETTING: Fetal medicine units in the Republic of Ireland. POPULATION: Ten fetal medicine specialists from five of the six fetal medicine units. METHODS: nvivo 12 assisted in the thematic analysis of semi-structured in-depth face-to-face interviews. MAIN OUTCOME MEASURES: Fetal medicine specialists' experiences of prenatal diagnosis and holistic management of pregnancies complicated by FFA. RESULTS: Four themes were identified: 'not fatal enough', 'interactions with colleagues', 'supporting pregnant women' and 'internal conflict and emotional challenges'. Fetal medicine specialists feared getting an FFA diagnosis incorrect because of media scrutiny and criminal liability associated with the TOP for FFA legislation. Challenges with the ambiguous and 'restrictive' legislation were identified that 'ostracised' severe anomalies. Teamwork was essential to facilitate opportunities for learning and peer support; however, conflict with colleagues was experienced regarding the diagnosis of FFA, the provision of feticide and palliative care to infants born alive following TOP for FFA. Participants reported challenges implementing TOP for FFA, including the absence of institutional support and 'stretched' resources. Fetal medicine specialists experienced internal conflict and a psychological burden providing TOP for FFA, but did so to 'provide full care for women'. CONCLUSIONS: Our study identified challenges regarding the suitability of the Irish legislation for TOP for FFA and its rapid introduction into clinical practice. It illustrates the importance of institutional and peer support, as well as the need for supportive management, in the provision of a new service. TWEETABLE ABSTRACT: The implementation of termination services for fatal fetal anomaly is complex and requires institutional support.

Violence against trainees: urgent ethical challenges for medical educators and academic leaders in perinatal medicine.

Objectives Violence against medical trainees confronts medical educators and academic leaders in perinatal medicine with urgent ethical challenges. Despite their evident importance, these ethical challenges have not received sufficient attention. The purpose of this paper is to provide an ethical framework to respond to these ethical challenges. Methods We used an existing critical appraisal tool to conduct a scholarly review, to identify publications on the ethical challenges of violence against trainees. We conducted web searches to identify reports of violence against trainees in Mexico. Drawing on professional ethics in perinatal medicine, we describe an ethical framework that is unique in the literature on violence against trainees in its appeal to the professional virtue of self-sacrifice and its justified limits. Results Our search identified no previous publications that address the ethical challenges of violence against trainees. We identified reports of violence and their limitations. The ethical framework is based on the professional virtue of self-sacrifice in professional ethics in perinatal medicine. This virtue creates the ethical obligation of trainees to accept reasonable risks of life and health but not unreasonable risks. Society has the ethical obligation to protect trainees from these unreasonable risks. Medical educators should protect personal safety. Academic leaders should develop and implement policies to provide such protection. Institutions of government should provide effective law enforcement and fair trials of those accused of violence against trainees. International societies should promulgate ethics statements that can be applied to violence against trainees. By protecting trainees, medical educators and academic leaders in perinatology will also protect pregnant, fetal, and neonatal patients. Conclusions This paper is the first to provide an ethical framework, based on the professional virtue of self-sacrifice and its justified limits, to guide medical educators and academic leaders in perinatal medicine who confront ethical challenges of violence against their trainees.

Perinatal palliative care: a developing specialty.

Neonates and babies have the highest death rate in the paediatric population. Perinatal palliative care aims to enhance the quality of life of babies with a life-limiting condition and their families. However, very little data is available on perinatal palliative care and its impact on babies and families along their journey. End-of-life decision-making for babies with an adverse prognosis also remains ethically challenging. This paper provides an overview of perinatal palliative care and its development, and then considers some of the issues affecting this field by looking at single national, institutional, and patient case studies.

Ethics of resuscitation at different stages of life: a survey of perinatal physicians.

OBJECTIVE: We surveyed US neonatologists and high-risk obstetricians about preferences for resuscitation in ethically difficult situations to determine whether (1) their responses adhered to traditional ethical principles of best interests and patient autonomy and (2) physician specialty seemed to influence the response. METHODS: In an electronic survey, we presented 8 vignettes with varying prognoses for survival and long-term outcome. Respondents were provided outcome data for mortality and morbidity in each vignette. We asked whether resuscitation was in the patient's best interest and whether the physician would accede to requests for nonresuscitation. RESULTS: We analyzed surveys for 587 neonatologists and 108 high-risk obstetricians (15% overall response rate, 75% of web site visitors). There were no statistically significant differences in responses between the 2 physician subspecialty groups. As expected, in most cases there were inverse relationships between valuation of best interest and deferred resuscitation at the family's request. For example, for the oldest patient (an 80-year-old), 9.9% found resuscitation to be in the patient's best interest and 94.3% would allow nonresuscitation; for a 2-month-old, 93.9% found resuscitation to be in the patient's best interest and 24.5% would allow nonresuscitation. However, this pattern was not observed in the 2 newborn cases, in which resuscitation and nonresuscitation were both acceptable. In the triage scenario, the 7-year-old with cerebral palsy and acute trauma was consistently resuscitated first despite others having equivalent or better short- and long-term prognoses. CONCLUSIONS: On the basis of our results, physicians' decisions to resuscitate seem to be context-specific, rather than based on prognosis or consistent application of best-interest or autonomy principles. Despite their different professional perspectives, neonatologists and high-risk obstetricians seemed to converge on these judgments.

Ethical charter of Union of European Neonatal and Perinatal Societies.

The Union of European Neonatal and Perinatal Societies, worried for the lack of unanimous guidelines in the ethical domain, propose a 10-point charter about the ethical rights of the newborns. It is complementary to other charters, such as the United Nations charter of children's rights, but it adds some specific and debated points, to find a common denominator, hopefully useful to the ongoing debate.

Ethics education in neonatal-perinatal medicine in the United States.

Neonatology is one of the specialties that has immensely benefited from advances in medical technology in the last few decades. These advances have paralleled the rise of the civil rights movements and wider recognition of individual rights. As a result, ethical decision-making has become more complex, involving patients, parents, members of the health care team, and society in general. This has created a need for formal ethics education in neonatal-perinatal medicine fellowship programs. In this article, we briefly explore the current published data on ethics education in pediatric residency and neonatal-perinatal medicine fellowship programs. Then, we discuss the questions an academic educator may face while developing an ethics curriculum in his/her medical institution. Finally, we present the ethics curriculum that we developed in our neonatal-perinatal medicine fellowship program.

Limit of viability in Japan: ethical consideration.

Viability means "the quality or state of being able to live, grow and develop." Limit of viability has been changed along with the advancement of perinatal and neonatal medicine. The viability limit defined in the Japanese Motherhood Protection Act was amended from 24 to 22 completed weeks of gestation in 1991 based on the survival rate of extremely preterm infants. Survival rates of infants at 22 and 23 weeks' gestation born between 2002 and 2004 in Japan were 31% and 56%, respectively. Though medical data are the most important means to define viability, socio-economical and ethical factors should be also considered, especially when we discuss the group of marginally viable infants. We think there are two different categories of viability limits, one from biological survival limit and another from social agreement of providing active medical intervention. Currently in Japan, the former viability definition based on purely medical data is 22 completed weeks and the latter definition is the social consensus of about 24-28 weeks' gestation.

Ethics of fetal surgery.

This article provides a comprehensive approach to the ethics of clinical investigation of fetal surgery. Investigators should address the initiation and assessment of clinical trials to determine whether they establish a standard of care and use an appropriate informed consent process to recruit and enroll subjects, consider whether selection criteria should include the abortion preferences of the pregnant woman, and consider whether physicians have an obligation to offer referral to such investigation. This approach is comprehensive because it takes account of the physician's obligations to the fetal patient, the pregnant woman, and future fetal and pregnant patients. The comprehensive approach to the ethics of fetal surgery is applied to the example of in utero surgical management of spina bifida.

[Perinatal bioethics: euthanasia or end-of-life decisions? Analysis of the Groningen Protocol]. / Bioética perinatal: eutanasia o decisiones sobre terminación de la vida? Análisis del Protocolo de Groningen.

The so called "Groningen Protocol" was conceived as a framework to discuss the euthanasia in neonates. Originally, it presents three groups of babies who might be candidates to this option. We analyzed the protocol in its original context and that of the Dutch society in which it was created. The analysis started with a careful reading of the protocol in both English and Dutch versions, translated later into Spanish. The medical and nursing staff participated in discussing it. A final consensus was reached. The Institutional Ethics Committee at our hospital discussed it freely and made recommendations for its application as a guideline to honestly discuss with parents the clinical condition of their babies, without permitting the option included literally in the word euthanasia. We selected four extremely ill infants. Their parents were interviewed at least twice daily: three stages were identified: the initial one of promoting all possible treatments; a second one of guarded and cautious request for the staff to evaluate "suffering", and a last one where requests were made to reduce therapeutic efforts to provide dignified death. A week after the death of their infants, they were presented with the facts of the protocol and the limits of our legal system. In all four cases the parents suggested that they would have chosen ending the life of their infants, in order to avoid them undue suffering. They clearly pointed out that this option emerged as a viable one to them once the ultimate outcome was evident. The protocol must not be viewed as a guideline for euthanasia in newborns, but rather as a mean to discuss the critical condition of an infant with the parents. Its direct implementation in our setting remains difficult. As a clear limitation for its overall application remains the definition of what is considered "unbearable suffering" in newborns, and how to certify when the infant has "no prospect". We emphasize the benefits of securing the help of the Ethics Committee and of "second opinions" from authorized physicians.

[Question raised by the limits of viability in extremely preterm infants]. / La question des limites dans la prise en charge de la grande prématurité.

Recent advances in perinatology allow to take care routinely of extremely preterm babies. Medical problems as well as ethical questions raised by initiation and withdrawal of intensive care of these infants are discussed here. Successively are considered what population is concerned by the so-called limits of viability, the long-term results of the medical interventions and the ethical questions resulting of them.

O cuidado à saúde materno-infantil e a psicanálise: uma interseção possível / Weight reduction for primary prevention of stroke

O presente trabalho procurou analisar a inserção da psicanálise nas novas formas de cuidado terapêutico em perinatologia, mais precisamente, no domínio que envolve os acontecimentos que ocorrem entre a concepção e os 36 meses de vida da criança. Para tanto, inicialmente foi apresentada a área da saúde materno-infantil no Brasil e as políticas públicas que a sustentam. Em seguida, delineou-se o funcionamento do campo escolhido, no caso uma maternidade de alto risco. Tendo em vista, a construção de uma rede de atenção tecida a partir de diferentes olhares, se procurou enfocar os impasses da interseção entre o discurso biomédico, o da educação em saúde e o da psicanálise. Nesse ponto, foi utilizada como referência principal a contribuição de D. W. Winnicott sobre a teoria do amadurecimento pessoal. Com a finalidade de circunscrever o crescente interesse pela primeira infância, procedeu-se a um mapeamento do estudo psicanalítico dos primórdios do psiquismo, após uma breve incursão pelo texto freudiano. Promoveu-se ainda uma discussão sobre o encontro das hipóteses psicanalíticas com as novas descobertas científicas sobre as potencialidades do bebê, ressaltando as conseqüências possíveis de tal intercâmbio. Por fim, foram destacadas algumas concepções que fundamentam a importância do olhar psicanalítico para o cuidado integral à saúde materno-infantil, enfatizando autores como Lebovici, Cramer, Bydlowski e Golse. Aqui as discussões teóricas entrelaçaram-se com observações de campo e vinhetas clínicas.

The following work's intent was to analyze the insertion of psychoanalysis in the new forms of therapeutic care in perinatology and, more specifically, in the domain involving the events occurring between conception and the child's first 36 months of life. To do so, the area of maternal and child health in Brazil and public politics supporting it were initially presented. Afterwords, the functioning of the chosen field was delineated, the present case being a high-risk maternity. Considering theconstruction of an attention network built on and from different perspectives, we focused on the deadlocks of the intersection between the biomedical, the education in health and the psychoanalytical discourses. Here, the main references were the contributions of D.W. Winnicott on the theory of personal maturity process. In order tocircumscribe the increasing interest in early childhood, a mapping of thepsychonalitycal study of the beginnings of psychic life was undertaken after a brief incursion in the freudian text. A discussion was still promoted on the meeting of psychanalytical hypotheses with new scientific discoveries on babies potential, pointing to the possible consequences of such interchange. Finally, some conceptions pointing to the importance of the psychanalytical point of view for the comprehensive health-care of maternal-child health were underlined, emphasizing authors such as Lebovici, Cramer, Bydlowski and Golse. Here the theoretical argument were interlaced with field observation and clinical vignettes.