And now 2020…

Abstract

Here in the northern hemisphere, the days of December are darkening, heralding the end of 2019. Time, perhaps, to reflect on the past year, and look forward to the future. One positive thought is the progress that is being made, year on year, in reducing child and maternal mortality. Since 1990, deaths of children younger than 15 years has more than halved – from 14.2 million deaths to 6.2 million in 2018. From 2000 to 2017, the maternal mortality ratio (MMR) declined by 38% (WHO et al. 2019 Maternal mortality: Levels and trends 2000 to 2017; UNICEF et al. 2019 Levels and trends in child mortality report 2019). Of course, this is still far too many. Each of the 2.5 million – mostly preventable – annual newborn deaths is an individual tragedy, but also a huge loss of human talent; think that any of the lost children could change the world for the better. It is thought that a similar number of stillbirths occurs, and they often do not even figure in statistical reports. In addition, there were about 295 000 maternal deaths in 2018; while this was 35% lower than in 2000 (when there were 451 000) and while the global MMR has decreased from 342 to 211 per 100 000, the combined numbers mean that a pregnant woman or newborn dies somewhere in the world every 11 seconds. This terrible burden is concentrated in the poorest countries: maternal mortality in sub-Saharan Africa is 50-times higher compared with highincome countries, while their babies are 10-times more likely to die in their first month of life. As a ‘human family’ (apologies to Maya Angelou), we have set ourselves ambitious targets through the United Nations Sustainable Development Goals (SDGs). One of these is to reduce the global MMR to less than 70 per 100 000 live births by 2030. At the current pace of progress, we will fall short of this target by more than 1 million lives. The SDG target (3.2) for reducing neonatal mortality is 12 per 1000 live births, and 25 per 1000 live births for under-5 mortality. Though 121 countries have already achieved this, 53 countries will need to accelerate progress to reach the SDG target on child survival by 2030. One of the most common causes for maternal death globally is severe bleeding after childbirth. As estimated blood loss is notoriously unreliable, it is actually quite difficult to estimate the incidence of major haemorrhage. Most obstetricians will – at some point – have used some kind of balloon device in atonic postpartum haemorrhage (PPH) as an adjunct to uterotonics to achieve control of bleeding. As a trainee, my preference was a Sengstaken–Blakemore tube; originally designed for the management of bleeding oesophageal varices, this could always be found in the ‘gastro’ ward, which was right next door. Since that time, lower cost balloons designed specifically for obstetric haemorrhage have been designed. Cohort studies have suggested these are very effective in controlling bleeding when medical management fails (Doumouchtsis et al. Obstet Gynecol Surv 2007;62:540–7; Georgiou BJOG 2009;116:748–57). In low-income settings, the condom-catheter is the cheapest option and in the December issue of BJOG, Anger and colleagues (pages 1612–21) report a stepped-wedge cluster randomised trial of condom balloon tamponade. The results are counter-intuitive; not only did the introduction of condom-catheter tamponade in these settings not improve maternal outcomes, but it also increased the rate of PPH-related surgery and death. So should we abandon this procedure owing to lack of effect? The thoughtful mini commentary by Andrew Weeks on page 1622 tries to put this study into context, look for reasons that could explain these findings and discusses the dilemma for those of us who use balloons in practice. In another relevant study, Thurn and colleagues (pages 1577–86) cross-linked births over 20 years in Stockholm, Sweden, to the transfusion database. Massive blood transfusion – defined as the transfusion of more than 10 units – was rare in this setting at 5.3 per 10 000 births. The authors usefully separated those risk factors that were present beforehand (abnormal placentation, pre-eclampsia, placental abruption and previous caesarean birth) from those that occurred at time of birth (uterine rupture, atonic uterus and caesarean delivery). Perhaps these findings are not surprising, but the ability to provide accurate estimates for the incidence and risk factors is extremely relevant, and the rising incidence – this rose by 30% between the first and second 10-year period of the study – is an important observation that warrants further investigation. On page 1641, Mark Ranasinghe and Arunaz Kumar reflect on their experience as medical students and how effective simulation training in obstetrics helped to provide more effective emergency care during a haemorrhage. As we see day to day, clinical opinions vary widely – between countries, neighbouring hospitals or even clinicians working in the same unit. While we all like to think that our medical opinion is formed only by hard evidence, we often use intuition, experience or perceived logic. This is illustrated by Bonet and