Concordance

One of the greatest sources of consternation for individuals receiving healthcare is to be given conflicting or contradictory advice from health professionals. Teaching interpersonal communication skills has become a key aspect of education of medical students; however, ambivalence amongst specialist providers regarding optimal communication practices continues to be a barrier to enhancing interspecialty relationships and patient care.¹ In the increasingly complex line-up of health providers, obstetric physicians are very much the new kids in town.²

Additionally, the contact we have with women is often new and relatively fleeting in comparison to the trusting relationship they may have built with other health providers over many years.

Many of us have had the experience of being contacted by a woman whose pharmacist has declined to dispense a prescription because the medication was listed as being in an ‘unsafe’ category. Similarly, many have seen a woman in preconception counselling who has been informed that she must never fall pregnant because of a pre-existing condition. Or been told emphatically by her specialist that she must have a caesarean section because a vaginal delivery would be too great a risk in the setting of her stable proliferative retinopathy, idiopathic intracranial hypertension, thrombocytopenia, heart disease or cerebral arteriovenous malformation.³

What can be done to make the course of pregnancy less fraught for women with underlying medical conditions? Is it possible to reduce the frequency with which they’re left grappling with contradictory advice?

Helping women to help themselves may be part of the answer. The LactMed website hosted by the National Institute of Health offers a wealth of information about the safety of maternal medication use while breastfeeding. A great strength of the resource is that women can access the information themselves.⁴ Similarly the MotherToBaby and BUMPS websites provide women with easy to understand information on the safety of a large number of medications in pregnancy and lactation in a user-friendly format of questions and answers.^5,6 In addition, the MotherToBaby site provides fact sheets on maternal medical conditions in pregnancy, herbal products, infections and vaccines, and substances of abuse, as well as enabling women to contact experts by telephone, email, text or web chat. For the health professional giving advice on medications uncommonly used in pregnancy, an online resource summarising the accumulated safety data of such therapies with references would be of benefit. The task of compiling such a source, the legal ramifications of accuracy of information, and the responsibility for updating entries, as novel drugs and new evidence on established medications become available, would be onerous; perhaps too much so for a single entity to manage. It could conceivably be achieved by the Obstetric Medicine societies undertaking ownership of such a resource but managing such a cooperative model effectively could also be a complex affair.

At an individual level, sharing the available literature to enable women to make an informed decision about whether to take a medication, as well as providing a printed copy for her pharmacist with contact details for further discussion, may be the best that can be done for the moment.

When it comes to patients shared with our medical colleagues, communication is all important. The kerbside consult is a time honoured means of discussing individual cases and planning future management.⁷ At an institutional level, regular multidisciplinary meetings to discuss high-risk pregnancies, with all involved parties present, and the formation of a documented management plan in the patient notes, are an excellent way of ensuring a consistent plan and communication to patients. Technology also has a significant role to play when patients and/or their treating doctors live remote to tertiary centres.

It is natural that we should seek to publish in our own Journal and present at local and international Obstetric Medicine meetings, although at times we may be preaching to the converted. Presenting the evidence regarding management of high-risk pregnancy to other health professional group meetings and publishing in their journals may be a way to deliver a message to a broader audience.

A further issue for ethnic minority pregnant women is misalignment of pregnancy-related advice from health professionals and their social networks.⁸ In a Dutch study, Scholmerich et al. proposed that increasing the health literacy of ethnic minority women and improving the communication by caregivers were not sufficient, and that involving women’s social network in intervention efforts was necessary.

Healthy pregnancy is ranked as the 12th most stressful life event on the Holmes and Rahe scale.⁹ The presence or development of an underlying medical condition is likely to increase anxiety significantly. Consistent information from health professionals is essential to prevent escalation of maternal stress.