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Worried obstetricians
1597
Environmental Epidemiology Unit, Southampton) made the startling suggestion that the critical window for cardiovascular disease could occur even in fetal life, since features of disease in middle age (eg, high blood pressure) were associated with higher placental weight relative to
birthweight. The role of
dietary programming
in later obesity was Dr Elizabeth Poskitt questioned by (University of Liverpool), who suggested that fat infants may not consume more than slim infants but have lower energy expenditure. Genetic factors, she thought, may be much more important than metabolisable energy intake in determining fatness. Dr David Forman (ICRF Cancer Epidemiology Unit, Oxford) pointed out that although it is entirely plausible that early diet could lead to later cancer, few studies have provided satisfactory supportive evidence, largely because of the numerous foods thought to be associated with cancer aetiology and because of the difficulties in obtaining reliable dietary information. An exception is the well-known association in Chinese populations of nasopharyngeal carcinoma with consumption of salted fish. Dr Andrew Cant (Newcastle General Hospital) concluded that genetic and immunological predisposition, as evidenced by family history of allergic diseases and total cord blood IgE, are the most important determinants of allergic disease, and that diet is important only in these high-risk babies. Finally, Prof Brian Wharton (Glasgow University) considered the possible role of breastfeeding on the later development of coeliac, Crohn’s, and inflammatory bowel disease. A possible mechanism is that in a genetically predisposed individual, breastmilk modifies the gut’s
experience of foreign antigens (microbiological or chemical), subsequent environmental stimulus then leading to
a
disease. The message of the day was that there is now tantalising evidence that diet in infancy could have far-reaching effects on health in adult life and important implications for the prevention and management of many diseases. The conference proceedings will be published as a supplement to the BNF Bulletin in the autumm of 1991. The Lancet
Pia Pini
Medicine and the Law Worried obstetricians Royal College of Stanley Simmons, introduced Childbirth 1991 as a symposium held in response to the Royal College’s concern about negligence claims for brain-damaged babies. The RCOG wished to have a dialogue with people outside the specialty. Its own viewpoint was that an unjustified increase in negligence claims was putting obstetrics in the UK at risk-and at a time when perinatal and maternal mortality rates had never been lower. Figures cited at the meeting indicate that perinatal mortality was 32 per 1000 in 1958 but had fallen to 8 per 1000 in 1990; maternal mortality in 1948 was 133 per 11 the president of the Obstetricians and Gynaecologists, Mr
On
June
100 000 and is now 7 per 100 000. The RCOG argument is that there is little evidence that management of labour has been responsible for most cases of cerebral palsy. Prof Geoffrey Chamberlain, chairman of the Joint Medico-Legal committee of the RCOG/Defence Societies, ascribed the
general improvement in perinatal statistics to a combination of factors-roughly two-thirds better education, nutrition, and health of mothers and one-third advances in obstetric management and medical knowledge and equipment. Yet these factors had made no impact on the numbers of babies born with cerebral palsy who survived. It should also be noted that improved neonatal care has enabled far more seriously handicapped babies and premature babies to survive than was possible 20 years ago. An RCOG survey has revealed that 85% of obstetricians in Britain have had at least one legal claim against them and that 65% have had two. There is also concern that recruitment is down because, as one student put it to Professor Chamberlain, obstetrics brings with it too much "hassle" and lawyers seem to have too great an input in obstetric practice. At the other end obstetricians are leaving the specialty early; the average retirement age has fallen from 65 to 58, possibly in part because of this medicolegal
situation. The concerns that need to be addressed include the virtually unlimited time allowed in law for brain-damaged persons to mount claims and the problems that these stale claims cause; and the adversarial system with its slowness, expense, uncertainty of outcome, and bitterness generated between parties once in so close a relationship but now adversaries. At the symposium lawyers, who had represented both sides, admitted that the system was imperfect, but one barrister thought that no-fault compensation would founder on the establishment of causation for the purposes of compensating a brain-damaged child if the criteria were error of judgment or avoidable injury. Sir Donald Acheson, from the Department of Health, said that he would like to see a change in the way that compensation cases are assessed. There was a consensus amongst doctors that some other method was needed, be it arbitration or some special scheme for babies with cerebral palsy. For many health authorities, the burden of legal claims could become too heavy and services could suffer. On the other hand, patients (and families) seriously injured as a result of negligence are entitled to compensation, which should be more readily available and accessible. Sir Donald said that Medical Defence Union figures showed that the number of files opened in respect of claims for brain-damaged babies had risen from 50 in 1982 to 150 in 1989. Asa result of a change in legal aid, enabling children to be assessed separately from their parents, the figures for 1990 could be as high as 600. Yet the proportion of babies likely to have been damaged as a result of negligent obstetric care was very small. The panel of speakers was worried that decisions made by judges would not reflect the clinical truth of the situation. Judges can work only from the evidence before them, and this is likely to conflict in important respects. If both sides remained convinced of the rightness of their cases, the loser is bound to be dissatisfied with the system.
The RCOG and the Government could do worse than consider the proposals from the Royal College of Physicians Working Party on Compensation for Medical Injuries, published last year. The Conservative Government, having dismissed a private member’s compensation bill, did agree that change was necessary, and a consultative document is thought to be in preparation. No-fault compensation is now Labour Party policy. Relations between obstetricians and their patients could be improved now if obstetricians were to speak more freely and frankly; some responsibility for patient dissatisfaction, manifesting itself in negligence suits, must be laid at the doctors’ door. If medical, nursing, and other staff come over as unhelpful, evasive, and unsupportive of a family into which a seriously handicapped baby has been born, this is likely to suggest that there is something to hide. The public need to be educated that a perfect outcome to pregnancy cannot be guaranteed. Diana Brahams
Environmental Epidemiology Unit, Southampton) made the startling suggestion that the critical window for cardiovascular disease could occur even in fetal life, since features of disease in middle age (eg, high blood pressure) were associated with higher placental weight relative to
birthweight. The role of
dietary programming
in later obesity was Dr Elizabeth Poskitt questioned by (University of Liverpool), who suggested that fat infants may not consume more than slim infants but have lower energy expenditure. Genetic factors, she thought, may be much more important than metabolisable energy intake in determining fatness. Dr David Forman (ICRF Cancer Epidemiology Unit, Oxford) pointed out that although it is entirely plausible that early diet could lead to later cancer, few studies have provided satisfactory supportive evidence, largely because of the numerous foods thought to be associated with cancer aetiology and because of the difficulties in obtaining reliable dietary information. An exception is the well-known association in Chinese populations of nasopharyngeal carcinoma with consumption of salted fish. Dr Andrew Cant (Newcastle General Hospital) concluded that genetic and immunological predisposition, as evidenced by family history of allergic diseases and total cord blood IgE, are the most important determinants of allergic disease, and that diet is important only in these high-risk babies. Finally, Prof Brian Wharton (Glasgow University) considered the possible role of breastfeeding on the later development of coeliac, Crohn’s, and inflammatory bowel disease. A possible mechanism is that in a genetically predisposed individual, breastmilk modifies the gut’s
experience of foreign antigens (microbiological or chemical), subsequent environmental stimulus then leading to
a
disease. The message of the day was that there is now tantalising evidence that diet in infancy could have far-reaching effects on health in adult life and important implications for the prevention and management of many diseases. The conference proceedings will be published as a supplement to the BNF Bulletin in the autumm of 1991. The Lancet
Pia Pini
Medicine and the Law Worried obstetricians Royal College of Stanley Simmons, introduced Childbirth 1991 as a symposium held in response to the Royal College’s concern about negligence claims for brain-damaged babies. The RCOG wished to have a dialogue with people outside the specialty. Its own viewpoint was that an unjustified increase in negligence claims was putting obstetrics in the UK at risk-and at a time when perinatal and maternal mortality rates had never been lower. Figures cited at the meeting indicate that perinatal mortality was 32 per 1000 in 1958 but had fallen to 8 per 1000 in 1990; maternal mortality in 1948 was 133 per 11 the president of the Obstetricians and Gynaecologists, Mr
On
June
100 000 and is now 7 per 100 000. The RCOG argument is that there is little evidence that management of labour has been responsible for most cases of cerebral palsy. Prof Geoffrey Chamberlain, chairman of the Joint Medico-Legal committee of the RCOG/Defence Societies, ascribed the
general improvement in perinatal statistics to a combination of factors-roughly two-thirds better education, nutrition, and health of mothers and one-third advances in obstetric management and medical knowledge and equipment. Yet these factors had made no impact on the numbers of babies born with cerebral palsy who survived. It should also be noted that improved neonatal care has enabled far more seriously handicapped babies and premature babies to survive than was possible 20 years ago. An RCOG survey has revealed that 85% of obstetricians in Britain have had at least one legal claim against them and that 65% have had two. There is also concern that recruitment is down because, as one student put it to Professor Chamberlain, obstetrics brings with it too much "hassle" and lawyers seem to have too great an input in obstetric practice. At the other end obstetricians are leaving the specialty early; the average retirement age has fallen from 65 to 58, possibly in part because of this medicolegal
situation. The concerns that need to be addressed include the virtually unlimited time allowed in law for brain-damaged persons to mount claims and the problems that these stale claims cause; and the adversarial system with its slowness, expense, uncertainty of outcome, and bitterness generated between parties once in so close a relationship but now adversaries. At the symposium lawyers, who had represented both sides, admitted that the system was imperfect, but one barrister thought that no-fault compensation would founder on the establishment of causation for the purposes of compensating a brain-damaged child if the criteria were error of judgment or avoidable injury. Sir Donald Acheson, from the Department of Health, said that he would like to see a change in the way that compensation cases are assessed. There was a consensus amongst doctors that some other method was needed, be it arbitration or some special scheme for babies with cerebral palsy. For many health authorities, the burden of legal claims could become too heavy and services could suffer. On the other hand, patients (and families) seriously injured as a result of negligence are entitled to compensation, which should be more readily available and accessible. Sir Donald said that Medical Defence Union figures showed that the number of files opened in respect of claims for brain-damaged babies had risen from 50 in 1982 to 150 in 1989. Asa result of a change in legal aid, enabling children to be assessed separately from their parents, the figures for 1990 could be as high as 600. Yet the proportion of babies likely to have been damaged as a result of negligent obstetric care was very small. The panel of speakers was worried that decisions made by judges would not reflect the clinical truth of the situation. Judges can work only from the evidence before them, and this is likely to conflict in important respects. If both sides remained convinced of the rightness of their cases, the loser is bound to be dissatisfied with the system.
The RCOG and the Government could do worse than consider the proposals from the Royal College of Physicians Working Party on Compensation for Medical Injuries, published last year. The Conservative Government, having dismissed a private member’s compensation bill, did agree that change was necessary, and a consultative document is thought to be in preparation. No-fault compensation is now Labour Party policy. Relations between obstetricians and their patients could be improved now if obstetricians were to speak more freely and frankly; some responsibility for patient dissatisfaction, manifesting itself in negligence suits, must be laid at the doctors’ door. If medical, nursing, and other staff come over as unhelpful, evasive, and unsupportive of a family into which a seriously handicapped baby has been born, this is likely to suggest that there is something to hide. The public need to be educated that a perfect outcome to pregnancy cannot be guaranteed. Diana Brahams