Recognised training routes are needed to sustain new maternal medicine networks

The recent Department of Health (DH) announcement of funding for training obstetric physicians to help run maternal medicine networks is a much needed initiative to address health inequalities and avoidable maternal deaths, but recognised training routes for these physicians are needed to guarantee long term sustainability of maternal networks.

In 2015, the United Nations’ fifth millennium development goal to reduce the maternal mortality ratio by three-quarters was not met.¹ Even in Britain, women die from preventable and treatable medical conditions such as asthma, epilepsy, heart disease and diabetes during and after pregnancy.

In December 2017, the annual Mothers and Babies: Reducing Risk through Audits and Confidential Enquiries in the UK (MBRRACE-UK) report into maternal mortality in the UK and Ireland was published.² As in previous years, the majority of deaths are not directly attributable to pregnancy, but to pre-existing or new onset medical or mental health conditions. The rates of these deaths have consistently remained higher than deaths from obstetric complications, and other than a decrease in deaths from influenza and other causes of sepsis, have not significantly reduced for the last 10 years despite many medical, technological and organisational advances. Reports have consistently shown that improvements in care may have resulted in better outcomes, and of paramount importance is a need to improve diagnosis, investigation and treatment of women with new symptoms. Physicians with expertise in pregnancy are a key component of the multidisciplinary team preventing future avoidable deaths. There are already geographical health inequalities for pregnant women with coexisting medical problems – provision of obstetric medicine is patchy, based on only a very few obstetric physicians working nationally.

Recently, the DH in England published ‘ambitious measures to halve the rate of maternal deaths by 2025’ as part of the Safer Births strategy.³ Funding has been committed over 3 years to train 12 consultant physicians as ‘obstetric physicians’ to establish networked maternal medicine across England. The strategy is clear that the obstetric physician will be a consultant physician working together with a consultant obstetrician (with subspecialist training in maternal medicine) to provide expert care for pregnant women with complex medical problems. The obstetric physician will also provide region-wide leadership and expertise across the whole network to help ensure there is early recognition of problems and access to the best evidence-based care. The MBRRACE-UK report emphasises that establishment of these networks is of critical importance to prevent maternal deaths and achieve the government ambition.

At present, there are not enough obstetric physicians to deliver these networks and there is no recognised training route for either current or future consultant physicians to gain expertise in pregnancy. There are currently only five full-time equivalent consultants practicing obstetric medicine in the UK and only three centres nationally where appropriate training is available. The vision is that future obstetric physicians will be trained through a recognised physician training programme combined with a medical specialty (such as acute medicine, rheumatology, endocrinology or clinical pharmacology). Obstetric medicine is not currently recognised as a specialty or subspecialty by the General Medical Council (GMC) or the Royal College of Physicians (RCP). There are only a few ad hoc routes by which a trainee physician can gain the necessary training and experience to become an obstetric physician, and only three centres nationally able to deliver this training.

Trainees on an acute medicine training programme can pursue a ‘special skill’ in obstetric medicine, which requires 12 months of trainee-organised clinical exposure to obstetric medicine. Otherwise, physicians in training must organise a clinical fellowship in obstetric medicine (either during training or after completion of training). There is no agreed curriculum or certificate to recognise this training. Options for accreditation in the absence of creation of a subspecialty include credentialing and discussions are underway. This is in contrast to obstetric training where there is a clear route for senior trainees to undertake an advanced training skills module in maternal medicine.

Without recognised training routes and recognition for physicians to gain this vital expertise in pregnancy medicine, we will not address these health inequalities and avoidable maternal deaths. These reports should provide the impetus to the RCP to establish this training as a matter of priority.