Book Review

Reproductive Health Care for Women and Babies

N Engl J Med 1996; 334:868-869March 28, 1996

Article

Reproductive Health Care for Women and Babies
Edited by Benjamin P. Sachs, Richard Beard, Emile Papiernik, and Cristine Russell. 472 pp. New York, Oxford University Press, 1995. $85. ISBN: 0-19-262530-6

Reproductive Health Care for Women and Babies makes for both interesting and disturbing reading. The editors, representing the obstetrical and gynecological community, along with medical journalists, have assembled contributors who cover the wide range of challenges to the health care of women and children. As an attendee at the 1995 Asia–Oceania Congress of Obstetrics and Gynaecology in Indonesia, I heard firsthand of the dire situation faced by the majority of the world's women and of their reproductive health needs. This book covers a series of topics that logically flow from one to another: the changes in health risks for women over their life cycles, family planning and fertility, maternal health care, pregnancy and the prevention of adverse infant outcomes, the impact of adverse infant outcomes, and obstetrics and public policy. The authors touch on such hot potatoes as patient autonomy, cesarean-section rates, fetal monitoring in labor, cerebral palsy and medical litigation, and abortion.

The preface pulls no punches and may deter the more conservative reader from proceeding further. However, the message is clear and entirely appropriate for today: “Through better communication of the issues — from reproductive problems to cancer screening — we hope to empower women to take preventative steps toward health improvement, to participate in medical decision making, and to play a greater political role in the formation of health policy. We hope to stretch physicians beyond their traditional training in the diagnosis and treatment of disease into a broader role in thinking about crucial societal issues.”

Although it is not possible to detail each issue covered in Reproductive Health Care for Women and Babies, two are worthy of comment. The first is infertility, a topic that at first glance seems relevant only to developed nations with the money to afford the technology of assisted reproduction and the iatrogenically increased multiple-pregnancy rates that drain neonatal intensive care services. The issue for the developing world is not that of scarce resources, but rather the explosive increase in the prime cause of infertility: sexually transmitted diseases (causing up to 20 percent of cases of infertility in the United States as compared with 80 percent in Africa). The prevalence rates in the developing world are staggering and are often related to low socioeconomic status and being in a minority group. A combined medical–political–social approach to this problem is needed but difficult to achieve because of competing demands for diminishing resources to deal with chlamydia, gonorrhea, syphilis, and the human immunodeficiency virus. The epidemic of sexually transmitted diseases also relates to each society's perceived role of women and their control over their own fertility (including family planning and access to safe, legal means of pregnancy termination) and life expectations. Proposed strategies revolve around selective preventive measures to break the cycle of infection in the hard-core group that spreads the disease in each population and realistic priorities that take into account the fact that the more people with sexually transmitted diseases who are identified, the thinner the resources available for treatment must be spread.

The second issue, which is uncompromisingly stated in Reproductive Health Care for Women and Babies, concerns maternal mortality. Rates in rural areas of the developing world are as high as 1000 per 100,000 live births, as compared with a rate of 8 to 15 per 100,000 in the developed world. Historical data from Sweden show that dramatic reductions in maternal mortality occurred from 1861 to 1900, “long before modern obstetrical intervention was introduced.” The two interventions credited with producing this change are the use of aseptic techniques and the training and licensing of midwives. In this context, an international catastrophe — at least 500,000 women die each year — takes on a different perspective, because of the prospect of prevention with relatively inexpensive interventions that are already available. The book also points out the need for safe and legal means of terminating pregnancy, since there is a close relation between the low maternal mortality rates in most developed countries and the availability of such services. On a worldwide scale, the majority of pregnancies are unplanned, and women will seek to terminate pregnancies whether their society condemns or condones the practice.

Reproductive Health Care for Women and Babies is recommended reading for all those involved in the delivery and planning of women's health care. Its well-written messages are clear and concise and worthy of note as we approach the 21st century.

Warwick Bruce Giles, M.B., B.S., Ph.D.
University of Newcastle, Newcastle, NSW 2308, Australia