Sex, suffering and silence – why peri‐operative medicine must prioritise pregnant women

1Consultant, Department of Anaesthesia, RoyalWomen’s Hospital, Parkville, Australia, 2 Departments of Pharmacology, Obstetrics andGynaecology, and Radiology andMedicine, University ofMelbourne, Parkville, Vic., Australia 3Consultant, Department of Anaesthesia,Western Health, Joan KirnerWomen’s andChildren’s Hospital, St Albans, Vic., Australia ............................................................................................................................................................................................................................................................................................................ Correspondence to: A.T. Dennis Email: alicia.dennis@thewomens.org.au Accepted: 24April 2019

Peri-operative medicine, defined as the medical care of patients from the time of contemplation of surgery through the operative period to full recovery, is being formally integrated into the care of surgical patients internationally, with large collaborative groups developing clinical and research agendas focusing on peri-operative outcomes [1,2]. This integration follows recognition by the Lancet Commission on Global Surgery that five billion people globally do not have access to safe anaesthesia and surgery, which are essential to reducing the global burden of disease [3][4][5]. An acknowledgement of this problem, which was neglected in health systems for over 50 years, was made in 2015 when the World Health Organization's Sixty-Eighth World Health Assembly passed a resolution to make safe surgery and anaesthesia an essential requirement of universal health coverage. This means that emergency and essential surgical care and anaesthesia are now embedded into the post-2015 global agenda and the sustainable development goals (SDG) [6]. Recognising the multidisciplinary, collaborative approach of peri-operative medicine and matching this with global agendas and goals will assist in enabling access to safe surgery to all.

Caesarean section surgery is an essential surgical operation
This procedure makes up approximately 30% of all operations in low middle-income countries each year [7][8][9].
Despite this, the 131 million pregnant women who might require this major abdominal surgery each year are rarely specifically highlighted in discourse on peri-operative medicine [7]. This is of concern as caesarean section surgery often occurs in an emergency setting, always involves bleeding and often a high risk of significant haemorrhage (> 500 ml), and is associated with the well-recognised postoperative complications of bleeding, infection, deep vein thrombosis and pulmonary embolism. These perioperative problems often occur on the background of comorbid conditions of hypertension (10% of pregnant women), obesity, diabetes and anaemia.
Caesarean section surgery has been identified as a Bellwether procedure by Global Surgery 2030 [4] meaning that it is an essential surgical procedure and one that should be able to be offered in all hospitals. Raising the profile of caesarean section surgery in pregnant women is necessary to enable the provision of safe peri-operative care to this often-forgotten group of surgical patients.

Pregnant women are an integral peri-operative medicine population
The antenatal and postnatal period is also the peri-operative period for 23 million young women globally who have caesarean section surgery each year (18.6% of pregnant women globally) [9]. The global maternal mortality ratio (MMR) in 2015 was 385 deaths per 100,000 women giving birth [10]. Given the number of women who undergo caesarean section surgery, the global problem of maternal mortality is intimately linked with a solution offered by the framework of peri-operative medicine. In the African Surgical Outcomes Study, maternal mortality after caesarean section surgery in Africa was 50 times higher than in high-income countries, with the main causes being perioperative haemorrhage and anaesthetic complications [11].
Optimisation of maternal health is essential to reduce both maternal and neonatal morbidity and mortality, particularly in areas where access to caesarean section surgery is limited. In these areas, key focuses for improvement are: the education of women regarding the importance of seeking help for pregnancy problems early; developing transport routes that are easily accessed to travel to hospital; and, once in hospital, prioritisation of pregnant women in the healthcare facility.
Global mortality data suggest that the overall rate of caesarean section surgery is too low and aiming for a 20% caesarean section surgical rate is ideal [7]. Suboptimal utilisation of caesarean section surgery results in increased maternal and perinatal mortality and morbidity, predominantly in low middle-income countries, whereas liberal use, in high-income countries, has not shown benefits and may lead to harm [12]. These disparities in global rates of caesarean section surgery reflect inconsistent care in the peri-operative period.
In high-income countries, maternal mortality is low; 10 deaths per 100,000 women giving birth. Morbidity, however, is still high in these settings and improvements in care are needed, especially in the management of haemorrhage, where almost 90% of women may have benefitted from better care [13]. Therefore, in both high and low middleincome countries, morbidity and mortality from perioperative haemorrhage remains a serious and neglected area [14,15]. This is due in part to a lack of defined optimal pre-operative haemoglobin levels in pregnant women, sexbased negative biases in determining haemoglobin reference ranges in women in general, and the long-standing global problem of normalising anaemia in women [14].
In countries with strong health systems, a woman having caesarean section surgery is 30% more likely to die than a woman having a vaginal birth [16]. Women having caesarean section surgery are also at a greater risk of complications including postpartum haemorrhage, chronic anaemia, infection, anaesthetic complications, embolism and longer term complications such as placental adhesion disorders, ectopic pregnancy, preterm birth and uterine rupture [12]. There are also emerging data to suggest that postoperative mental health problems are significant in this patient group, including postpartum depression, posttraumatic stress disorder and anxiety [13]. In high-income countries, the median maternal age is increasing, with data from the National Health Service UK Hospital Maternity Activity, 2015-2016, showing the number of births in women aged 40 years and older growing by nearly 22% in the last decade. Pre-existing comorbid conditions are also increasing in pregnant women. These include increased body mass index of greater than 35 kg.m À2 , hypertensive disorders of pregnancy, endocrine disorders and cardiovascular disease, with cardiac disease now the leading cause of maternal death [17]. Assuming that mortality is the tip of the iceberg of maternal morbidity, a formalised approach to maternal peri-operative cardiovascular research, then clinical evaluation and management is needed to improve outcomes after caesarean section surgery [18].
The growth of peri-operative medicine within other surgical fields has enabled recognition and risk stratification of the high-risk patients; development of peri-operative risk scoring systems; collaborative decision making; pre-operative optimisation; standardisation of in-hospital care and enhanced recovery and rehabilitation [2]. It has also facilitated research and data collection to increase the evidence base for peri-operative medicine and the implementation of protocols which ultimately improve patient outcome. Application and expansion of peri-operative medicine principles to pregnant women, including the development of specific peri-operative scoring systems for pregnant women to compliment the neonatal Apgar score, is needed so that this group of patients also benefit from advances in this field [19].
The PARRCEL approach to maternal peri-operative medicine Maternal peri-operative principles include: pre-pregnancy counselling (including contraception and family planning) [20]; antenatal care; recognition of higher risk pregnant women, risk stratification and modification [18]; resuscitation; collaborative decision making; enhanced recovery and rehabilitation [21]; and linkage to community support networks. The acronym of PARRCEL, developed by the authors, can be used as an approach to peri-operative care of pregnant women ( Table 1).
The Lancet Commission on Global Surgery recommends that to achieve the goal of safe surgery and anaesthesia, six indicators for surgery need to be adopted: timely access to essential surgery; specialist surgical workforce density; surgical volume; peri-operative mortality; protection against impoverishing expenditure; and protection against catastrophic expenditure [4].
Maternal programmes based on the aforementioned multipronged solution approach should include these indicators so that assessment of the interventions to solve the problem of the lack of safe surgery and anaesthesia for pregnant women can be made [22] ( Table 2). Adoption of these indicators for pregnant women also allows benchmarking and comparison with other countries in the region and internationally, which can be fed back into the health programmes leading to further refinements or improvements, as well as collaboration between countries.
The importance of integrating the principles of perioperative medicine into the care of pregnant women cannot be overstated. We propose that adoption of the PARRCEL approach to peri-operative medicine for the care of pregnant women, which can also inform peri-operative data sets and outcome measures, will reduce maternal mortality and significantly contribute to the achievement of the SDG 3 to achieve a global MMR of less 70 deaths per 100,000.
Goldkind et al., in the wake of the H1N1 influenza pandemic where pregnant women were disproportionately affected, wrote that pregnant women are a marginalised population and need to be included in clinical studies of drugs used in pregnancy [23]. Nine years later, in 2019, there is again an urgent need to advocate for the inclusion of pregnant women and sex equity in peri-operative medicine research and clinical practice [24]. As a collaborative team with obstetricians, midwives and physicians, anaesthetists need to change our thinking from the antenatal period being one of passive bystanding, to it being a crucial peri-operative period in which we are active participants in the peri-operative management of pregnant women [25]. As a collaborative group we also need to change our approach to childbirth in the light of caesarean section surgery being an essential surgical operation. A caesarean section should not simply be viewed as an alternative, lesser mode of birth or a lesser form for surgery.
It instead needs to be considered a significant abdominal surgical procedure where clinical advances in perioperative medicine, anaesthesia and surgery, pain medicine, research, and quantity and safety, need to be routinely embedded so that pregnant women and their  Catastrophic expenditure is defined as direct out-of-pocket payments that are greater than 40% of annual household income. a Impoverishing expenditure is defined as entering into poverty or progressing further into poverty by out-of-pocket payments.
babies are not left behind. There is an urgent need to standardise end-points in peri-operative trials specifically involving pregnant women undergoing caesarean section surgery so that a core and extended outcome set can be developed. In peri-operative medicine, pregnant women should not be a silent population and caesarean section surgery should not be a forgotten operation.