Maternity Care in Developing Countries
Authors: Colin Bullough
Journal: Journal of the Royal Society of Medicine (2002)

This book's predecessor was Lawson and Stewart's Obstetrics and Gynaecology in the Tropics and Developing Countries. First published in 1967 it remained in print in the ELBS paperback edition until 1991. It was a book that no-one practising obstetrics or gynaecology in developing countries wanted to be without. I am confident that this long-awaited, and radical, revision will prove just as popular.

It is, however, not the same book. Gynaecology is omitted, although chapters on diseases of the trophoblast, sexually transmitted infections, childlessness and family planning have found a place. What really changed the shape of the book are the new perspectives which have emerged since the inception of the Safe Motherhood Initiative. Until then the responsibility for improving maternal health seemed to be borne by midwives and doctors alone. Although the social antecedents of poor obstetric results were known, the responsibility of health policy makers and politicians to influence the situation was almost unrecognized. When recognition did come the initial response was limited to a campaign to increase awareness of the high levels of maternal mortality. Since then, however, the remit of safe motherhood has widened. It has become a specialty of its own with epidemiologists, statisticians, public health doctors and social scientists all trying to elucidate how the maternity services should be organized and delivered.

The first 62 pages explore these issues in depth. Chapter 1 is a scholarly account of the deleterious effects of poverty, deprivation and lack of education. Clinicians would conclude that although they have no professional responsibility for these matters they do have a responsibility to press for appropriate political actions. The insights displayed here predated but concur with the recent conclusions of the WHO Commission on Macroeconomics and Health. These were that wealth results in health, and health results in wealth. Future maternal health really does depend on investment in both.

Chapters 2-4 outline what midwives and doctors can do to enhance the quality of care by going beyond clinical activities and involving themselves in organization, audit and training. As safe motherhood does not yet have a sound evidence base there is still room for debate over some of the strategies recommended. The editors admit this themselves by openly displaying their disagreements over the matter of whether responsibility for operative obstetrics should be delegated in some instances to assistant medical officers or midwives. Pragmatic decision-making based on local situation analysis is the only solution in such cases. Let us hope this stimulating account of safe motherhood will cause obstetricians and midwives to review their role and engage with other specialists to research safe motherhood issues and plan their services on the basis of such evidence as is available.

Clinicians in developing countries often suffer from a lack of books and look particularly for those that they can rely on to answer specific problems of diagnosis and management. What will this one do for them in this respect? The preface makes clear that it is intended to be a complement to, and not a substitute for, the standard textbooks of obstetrics. Looking at the text with this in mind I concluded that most sections would answer all the questions that a clinician is likely to have on the practical management of obstetric problems specific to developing countries. The sections on malaria in pregnancy and eclampsia are good examples. The chapter on HIV and AIDS in pregnancy is similarly comprehensive and would meet the needs of most obstetricians in any setting. Doctors whose responsibilities for clinical care extend to the neonate would find that the chapter on diseases of the newborn fulfils most of their needs. It is a practical exposition that includes details of the essential equipment, supplies and commonly used drugs. By contrast, the section on acute tubular necrosis would leave an isolated rural doctor short of information and does not cover all that would be needed for management in a tertiary hospital; and the section on vaginal destructive operations would leave a beginner looking for a fuller explanation of all the steps. But the contents are within the stated scope of the book and these examples merely confirm the editors' point that other books will be needed.

Any doctor practising obstetrics in a developing country should certainly read this book. Senior midwives, medical students and safe motherhood programme managers would also find it a useful source of information. But those who may value it most are doctors with obstetric responsibilities at district level who have to manage problems of which they have no experience.

One of the editors, John Lawson, did not live to see the book in print. It is certain that he would have been eager to see it readily available in all developing countries. Unfortunately, in many of the poorer countries the very reasonable price will not be affordable and a cheap edition will be needed. Anyone with the capacity to bring this about should take action.