Professionally responsible advocacy in obstetrics and gynaecology
‘Women and children first' is certainly a familiar phrase but its origin is less well known (42, 43). In 1852, the HMS Birkenhead, with more than 600 sailors, troops, and civilians aboard, was evacuating the civilians from Cape Town, South Africa, during the Cape Frontier War (1850-1853).
At 2 am on the morning of 26 February she struck unchartered rocks near Danger Point and began to take on water and sink. The number of lifeboats was not sufficient to convey all safely off the doomed ship. Many of the troops on board drowned in their berths as the ship foundered. The remaining men and officers of the 74th Regiment of Foot were mustered on deck by their commanding officer, Lt. Colonel Seton. He realized the nature of the situation and ordered his men to stand fast while the women and children were boarded onto the lifeboats. His soldiers obeyed and went down with the ship (44). While it is not known whether Lt. Colonel Seton used the phrase, ‘women and children first', he is credited with being among the first to put it into practice. His heroism and that of his men allowed the women and children on board to be saved.The Birkenhead incident occurred during a period of British imperialism and colonialism. Any incident from such a time would seem to be out of place as an exemplar for the ethics of women's health policy today. We think otherwise: making ‘women and children first' was a defining moment in the history of world civilizations and therefore has direct relevance for healthcare today.
The reality is that women and children are not first in our world; indeed, they are often last. This is especially the case in low-resource regions, which often do not provide adequate healthcare for women and children, as reflected in perinatal mortality rates (45). International organizations, such as UNICEF (45), the World Health Organization (46), and the World Bank (47), and international associations of physicians, such as the International Federation of Gynecology and Obstetrics (FIGO) (48), Matres Mundi (49), and the World Association of Perinatal Medicine (50), have led major efforts to identify problems in obstetric and neonatal care in developing countries and have advocated for improvement.
The International Academy of Perinatal Medicine has added its voice to these advocacy efforts, with its ‘New York Declaration' on ‘Woman and Children First', which was presented at the United Nations on 7 July 2008. The Declaration defined sources of bias against the just allocation of healthcare resources for women and children in low- resource regions (42, 43).The lack of prioritization for healthcare for women and children is not confined to low-resource regions. This can also be a problem in the United States and other high-resource regions. This is not compatible with the ethical principle of healthcare justice, which requires that all pregnant patients receive treatment based on deliberative clinical judgement about the clinical management of pregnancy.
Challenges to healthcare justice in the care of pregnant, fetal, and neonatal patients arise from the self-interest of adults, age bias, and economic bias, as well as economic bias against pregnant, fetal, and neonatal patients and obstetric services.
Obstetricians' advocacy for healthcare justice for pregnant, fetal, and neonatal patients should begin with identifying and exposing allocations of healthcare resources based on these biases. Obstetricians should then advocate for highly efficient, cost-conscious obstetric care that seeks to continuously improve its quality and safety.
There is a tendency in all healthcare systems for economic values to trump or automatically override all other considerations, especially including professional integrity. By getting their own financial houses in order, and advocating for the equal importance of pregnant, fetal, and neonatal patients, obstetricians will be in a position to talk back, countering the trumping power of economic considerations.
Obstetricians are in a unique position to assume an advocacy role because they have expert scientific and clinical knowledge about how to identify and protect the health-related interests of fetal, neonatal, and pregnant patients (9). On this basis, obstetricians should advocate for healthcare priorities that create resources to support the development and global implementation of evidence-based medical care for fetal, neonatal, and pregnant patients, so that their interests are taken into account in a scientific, unbiased fashion. The goal should be the elimination, to the greatest extent possible, of national and wide area variation in the processes and outcomes of obstetric care. Ideally, where a patient lives should not make a difference to the quality of medical care that an individual receives.