Oxfam’s Development Resources Review
This book provides a detailed and comprehensive description of the major aspects of maternity care in developing countries. It begins with a description of the links between poverty, deprivation and unsafe motherhood, and outlines the organisation of maternity care in developing countries. Then, it offers criteria for the evaluation and assessment of the quality of maternity care. This is supplemented by an outline of the processes whereby professionals can be trained in the Safe Motherhood Initiative(WHO). The book then turns to an examination of the pregnant women herself. It begins with nutrition and lactation during pregnancy, and then focuses upon the major illnesses and diseases to which pregnant women are subject. Then, it focuses upon the birth itself, and the major types of potential complication. Next, it concentrates upon the new born child, and its common diseases. Finally, it deals with abortion, ectopic pregnancy, diseases of the trophoblast, sexually transmitted diseases, HIV infection and AIDS in pregnancy, childlessness, family planning and blood transfusion facilities.
Journal of the Royal Society of Medicine 2002;95:215
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 confidant 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 changes 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 developed.
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 actins. 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 addition will be needed. Anyone with the capability to bring this about should take action
Colin Bullough
The Dugal Baird Centre for Research on Women’s Health, Department of Obstetrics and Gynaecology, University of Aberdeen
Irish Journal of Medical Science 2001;170:268
The first time I came across the name Professor John Lawson I was working as a young doctor in a mission hospital in a remote part of East Africa in the late 1970s. He had co-edited with EB Stewart a text book entitled Obstetrics and Gynaecology in the Tropics and Developing Countries in 1967. This was truly the bible of obstetrics for practising doctors in the developing world. Professor Lawson died in 1997 after a lifetime dedicated to the improvement of maternity care. His co-authors, Professors Harrison and Bergstrom, have produced a worthy revision of the original masterpiece.
This book is intended primarily for those wishing to practice obstetrics and care for mothers in developing countries. However, it is also a useful read for practising obstetricians in the developed world. It cannot fail to remind us how our local problems should be seen against a wider, more global perspective.
The early chapters outline the epidemiological background of the enormous challenges posed by poverty. We are reminded that over half a million women die in pregnancy every year and 99% of those are in developing countries. Obstetric problems are directly related to poverty and in the poorer countries women fare far worse than men when it comes to the allocation of resources. On the political level, the cost of Third World debt servicing exceeds all the funds available to health and education combined. The need for political intervention and social change are discussed. The importance of the maternity care organisation is outlined including the role of training doctors and paramedical workers. The clinical conditions that are common to the developing world are dealt with in some detail and practical advice is given on how to deal with such problems. This is always done in an easy-to-read manner. The emergence of new problems such as HIV infection and AIDS merits particular attention.
Throughout the whole book the preventability of serious clinical conditions that besiege the doctor in the developing world is emphasised. The treatment of life threatening complications is, of course, the immediate challenge for most, but prevention and elimination are undoubtedly bigger challenges.
I would recommend this stimulating book as an essential read to anybody interested in the practice of obstetrics world-wide.
P Lenehan
