Why I felt leaving clinical obstetrics may save more lives

A year ago, I was working as an OB/GYN resident in East London, one of the most ethnically diverse places in Europe, but it was also one of the most deprived areas of the city. East London was home to a huge refugee and immigrant population. I loved working in the area. It was exciting and rewarding to be able to treat women who had high risk pregnancies or women with severe morbidity. But I want to tell you about Mrs X.

Mrs X was a woman I met during my postnatal rounds approximately 2 years ago. She had just delivered her fourth child. The low risk vaginal deliveries were usually reviewed by a midwife. However, Mrs X was high risk. She developed gestational diabetes that required insulin during the pregnancy, and she had a caesarean section due to complications in labor. Additionally, she suffered a postpartum hemorrhage, where she bled over a 1.5 liters in the operating theatre. The beginning of the pregnancy appeared to be smooth sailing. However, after the second trimester she was diagnosed with diabetes and began to spend a lot of time at the hospital for serial fetal growth scans and diabetic checks. She was exhausted. She was caring for three young children, the youngest being just under a year old. In addition, she and her husband were financially struggling to care for their children, and this pregnancy added a lot of stress. It was not a planned pregnancy.

Mrs X’s case was not an anomaly. She was the norm.

Witnessing a series of these cases highlighted a common theme to me -  the difference between having a planned versus an unplanned pregnancy, and the differing impact this had on both maternal and fetal outcomes. The development of diabetes, the attendance of multiple hospital appointments, the administration of insulin, the caesarean section, the postpartum hemorrhage, the blood transfusion, and the birth trauma were only a few of the unintended consequences of this unplanned pregnancy. There were also other downstream effects, which included not being able to care for existing children, and not being able to go back to work. In addition, unintended pregnancies were and still are costing National Health Service millions of pounds. This is a significant problem for a health system that is constantly described as being ‘strapped for cash’. I began to realize that us as obstetricians have become really good at managing and treating failed prevention, but are pretty bad at preventive medicine. It is easy for me to look back and say Mrs X was ok - she survived and we managed her complications well. However, the scar of her caesarean section, the trauma of a difficult pregnancy and delivery, the postpartum hemorrhage, and the inability to care for her children or go to work will stay with her forever.

The simple public health intervention of contraception not only has the ability to prevent all of the above consequences of an unplanned pregnancy, but allows women to fulfil their potential in life. To me, this was why I went into obstetrics and gynecology in the first place - to allow for women to control their fertility and plan their pregnancies so they could have control over their lives. Unplanned pregnancy is not a problem that I could address by working in the operating theatre or outpatient clinic. It is a problem that is much bigger and rooted in social, economic and political factors. Therefore, I felt I had to move upstream to understand how I could transform this issue at a population level. Preventing conditions and addressing failed opportunities have a huge impact on the way women lead their lives. In addition to allowing women to plan their pregnancies, tackling unplanned pregnancy has the ability to save lives. There was a possibility that Mrs X could have died or suffered even more harm than she had done. We are just lucky in the UK that our health system has made huge advances in emergency obstetric care. But what about in places where more women die than are saved?  And so for me, this work was urgent. I decided to leave the profession for the same reason I entered it, to pursue a career in public health, hoping to make a difference to the lives of many more women.

By Shreya Patel

Photo credit: Shreya Patel, London, UK, 2017