Life-course perspective of

women health’s care

Dr Hayder Al Shammaa

objective

• Recognize and apply the basics of clinical practice (

safe, ethical, value and prevention of disease)

• Recognize that epigenetics, adaptive developmental

plasticity , allostatic overload can have significant

impact on chronic disease in later life

• Incorporate the ethical principles of nonmaleficence,

beneficence, autonomy, justice, confidentiality and

multidisciplinary in daily practice

• Special ethical conflicts in gynecology and obstetrics

Principles of clinical practice

1. Patient safety

2. Ethical practice

3. Value

4. Patient centered prevention of disease

1- Patient safety

• Emergency preparedness

• Environmental safety

• Security

• Infection control
•

Avoidance of medical error (5th cause of death

in USA)

• Medical error:- failure of a planned action to

be completed as intended ( failure to do

cesarean section when all signs indicate

obstructive labor)

or the use of wrong plan to achieve an aim

(wrong diagnosis, wrong medications)

• Adverse drug reactions

• Are responsible for 1/5 hospital mortality and

morbidity A drug that cures one patient’s condition may be the one that causes another patient’s injury or
death owing to an adverse drug reaction (ADR). The latter may ac- count for 1 out of 5 injuries or
deaths for hospitalized patients. ADRs commonly occur from an overdose, a side effect, or an
interaction among several concomi- tantly administered drugs.

• Avoid

1. Unnecessary medications

2. Treating mild side effects with more toxic

medications Misinterpreting a drug’s side effect for a new medi-

cal problem and prescribing another medication
3. Regard side effects as new disease Prescribe another
medication

4. Prescribe medication without knowing the

dose and interactions

Surgical checklist

• To avoid surgical and anesthetic error

• A checklist to be filled by a nursessurgeon and

anesthetist

*** complications are not errors

2- Ethical practice

• Non maleficence

• Beneficence

• Autonomy

• Justice
•

confidentiality

Nonmaleficence

The principle of primum non nocere, or “first, do no harm,” originated from the Hippocratic school, and although few would dispute the basic
concept, in day- to-day medical practice, physicians and their patients may need to accept some harm from treatment (such as necessary surgical
trauma) in order to achieve a de- sired outcome. However, there is an ethical obligation to be certain that recommended medical treatment, surgery,
or diagnostic testing is not likely to cause more harm than benefit.

Beneficence

The duty of beneficence, or the promotion of the wel- fare of patients, is an important part of the Hippocratic Oath. Most would see its strict
application as an ideal rather than a duty, however. One could save many suf- fering people in a Third World country by practicing there or by giving
a large portion of one’s income in aid, but few would consider it a moral duty to do so. On the other hand, when the concept of beneficence involves
a specific patient encounter, the duty applies. A physician prevented by conscience from participat- ing in the performance of an abortion, for
example, would generally be expected to provide lifesaving care for a woman suffering complications after such a procedure—putting her welfare
first.

Autonomy

The right of self-determination is a basic concept of biomedical ethics. To exercise autonomy, an individ- ual must be capable of effective deliberation
and be neither coerced into a particular course of action nor limited in her or his choices by external constraints. Being capable of effective
deliberation implies a level of intellectual capacity and the ability to exercise that capacity. In a number of situations, it may be reason- able to limit
autonomy for the following reasons: (1) to prevent harm to others, (2) to prevent self-harm, (3) to prevent immoral acts, and (4) to benefit many others.

The concept of informed consent may be derived directly from the principle of autonomy and from a desire to protect patients and research subjects
from harm. There is general agreement that consent must be genuinely voluntary and made after adequate dis- closure of information. As a minimum,
when a patient consents to a procedure in health care, the patient should be informed about the expectation of benefit as well as the other
reasonable alternatives and pos- sible risks that are known. Table 1-1 provides a useful checklist (PREPARED) that expands on the minimum
information required.

The exercise of autonomy may cause considerable stress and conflict for those providing health care, as in the case of a woman with a ruptured
ectopic pregnancy who refuses a lifesaving blood transfusion for religious reasons and dies despite the best efforts of the medical team. More
complex questions may be raised by court- ordered cesarean births for the benefit of the fetus.

Justice

Justice relates to the way in which the benefits and bur- dens of society are distributed. The general principle that equals should be treated equally was espoused by Aristotle and is
widely accepted today, but it does require that one be able to define the relevant differ- ences between individuals and groups. Some believe all rational persons to have equal rights;
others em- phasize need, effort, contribution, and merit; still oth- ers seek criteria that maximize both individual and social utility. In most Western societies, race, sex, and religion are
not considered morally legitimate criteria for the distribution of benefits, although they too may be taken into account to right what are perceived to be historical wrongs, in programs of
affirmative action. When resources are scarce, issues of justice become even more acute because there are often competing claims from parties who appear equal by all relevant
criteria, and the selection criteria themselves become a moral issue. Most modern societies find the rational rationing of health-care resources to be appropriate and acceptable (Figure
1-2).

Confidentiality is a cornerstone of the relationship between physician and patient. This duty arises from considerations of autonomy but also helps promote beneficence, as is the case
with honesty. In obstetrics and gynecology, conflicts can arise, as in the case of a woman with a sexually transmitted disease who refuses to have a sexual partner informed, or a school-
aged child seeking contraceptive advice or an abortion.

There are many other situations in which conflicting responsibilities make confidentiality a difficult issue. The U.S. Health Insurance Portability and Account- ability Act (HIPAA) mandates
strict rules that physician practices and health-care facilities must adhere to regarding the confidentiality and security of patient health-care records. Some are concerned that these
regulations could restrict the flow of information about patient care and may hinder efforts to improve overall performance.

Caring for a pregnant woman creates a unique maternal-fetal relationship because the management of the mother inevitably affects her baby. Until recently, the only way by which an
obstetrician could produce a healthy baby was by maintaining optimal maternal health, but as the fetus becomes more accessible to di- agnostic and therapeutic interventions, new
problems emerge. Procedures performed on behalf of the fetus may violate the personal integrity and autonomy of the mother. The obstetrician with a dual responsibil- ity to mother and
fetus faces a potential conflict of interest. Most conflicts will be resolved as a result of the willingness of most women to undergo consid- erable self-sacrifice to benefit their fetus. When a
woman refuses consent for a procedure that presents her with significant risk, her autonomy will generally be respected. However, there may be cases in which an intervention that is likely
to be efficacious carries little risk to the mother and can reasonably be expected to prevent substantial harm to the fetus. These have oc- casionally ended in a court-ordered intervention.

Special obstetrical and gynecological

situations representing ethical

conflicts

• Cesarean section for fetal distress

• Unwanted pregnancy request for abortion

• Pregnant with medical condition and pregnancy threatened the life of the mother .

• Illegal abortion with complications (perforation of the uterus and bowel)

• Young unmarried girl with pregnancy

• Unmarried woman requesting hymen repair

• Sexual abuse

invitro
• IVF, surrogate mother, ovum downer, sperm bank

fertilize

• Reduction fetecide

• Woman with sexually transmitted infection refuse to inform her sexual partner.

• Fetal disease amenable to intrauterine treatment

• Too many women competing on treatment in depleted resources

3- value health care quality improvement

• Value :- is the clinical outcome considering

resources…(result/cost)

• Effectiveness and efficacy of health care

4- patient centered prevention

• the importance of preventive part of practice

is often overlooked but it certainly increase

the value of health care by promoting health

and reduce the cost of treatment example is

the prevention of cervical cancer CA cervix by

screening program and vaccination

Life-course perspective women health

• Genetic factor(1/3 of diseases as a direct cause )

• Barker hypotheses (intrauterine stress can affect future

adult disease)

intra uterine growth restriction( IUGR) due to placental

insufficiency may cause future insulin resistance, diabetes and

obesity when become adult by 3 mechanisms

• Epigenetics (environmental factors and stresses affect the

The process whereby hu- man cells can have the same genomic makeup
expression or blockade of genes) but dif- ferent characteristics is referred to as epigenetics.
factors obesity1
behavioral inact Smoking Env
Physical factors

• Adaptive developmental plasticity (intrauterine stress can to exposure

switch on survival adaptations which alter the growth and metals a

solvent

development to prevent fetal death may become Pesticid

Endocrine
disruptor

permanent ). Ree toxicant

• Allostatic overload

 in human biology, a phenomenon called adaptive developmental plasticity plays a very im- portant role in helping to adjust behavior to meet any
environmental challenges. To understand human development over time (a life-course perspective), one must first understand what is normal and
what adverse circumstances may challenge and then change normal development in the fetus. These protective modifica- tions of growth and
development may become perma- nent—programmed in utero to prevent fetal death. The price the fetus may pay in the long run, however, for short-
term survival is a vulnerability to conditions such as obesity, hypertension, insulin resistance, atheroscle- rosis, and even a chronic disease such as
diabetes.

This se- ries of initially protective but eventually harmful de- velopmental changes was first described in humans by David Barker, a British
epidemiologist, who care- fully assessed birth records of individuals and linked low birth weight to the development of hypertension, diabetes,
atherosclerosis, and stroke later in life. The association among poor fetal growth during intrauter- ine life, insulin resistance, and
cardiovascular disease is known as the Barker hypothesis. The process whereby a stimulus or insult, at a sensitive or critical period of fetal
development, induces permanent alterations in the structure and functions of the baby’s vital organs, with lasting or lifelong consequences for health
and disease, is now commonly referred to as developmen- tal programming.

another important concept in the life- course perspective is allostasis, which describes the body’s ability to maintain stability during physi- ologic
change. A good example of allostasis is found in the body’s stress response. When the body is un- der stress (biological or psychological), it activates
a stress response. The sympathetic system kicks in, and adrenalin flows to make the heart pump faster and harder (with the end result of delivering
more blood and oxygen to vital organs, including the brain). The hypothalamic-pituitary-adrenal (HPA) axis is also activated to produce more cortisol,
which has many actions to prepare the body for fight or flight.

But as soon as the fight or flight is over, the stress re- sponse is turned off. The body’s sympathetic response is counteracted by a parasympathetic
response, which fires a signal through the vagal nerve to slow down the heart, and the HPA axis is shut off by cortisol through negative feedback
mechanisms.

This stress response works well for acute stress; it tends to break down under chronic stress. It works well for stress one can fight off or run from, but
it doesn’t work as well for stress from which there is no escape. In the face of chronic and repeated stress, the body’s stress response is always
turned on, and over time will wear out. The body goes from being “stressed” to being “stressed out”—from a state of allostasis to allostatic overload.
This describes the cumulative wear and tear on the body’s adaptive systems from chronic stress.

The life-course perspective synthesizes both the developmental programming mechanisms of early life events and allostatic overload mechanisms of
chronic life stress into a longitudinal model of health development. It is a way of looking at life not as discon- nected stages but as an integrated
continuum. Thus, to promote healthy pregnancy, preconception health must first be promoted. To promote preconception health, adolescent health
must be promoted, and so forth. Rather than episodic care that many women re- ceive, as a specialty we must strive toward disease pre- vention and
health promotion over the continuum of a woman’s life course.

According to the above principles

• Antenatal care now should start before

1 conception

As pre-pregnancy counseling and care

• Screening program for ca cx ( PAP smear)

• Screening and management of IUGR

Reference

• Hacker and Moore’s Essentials of Obstetrics

and gynecology. Sixth edition.

• Ethical issues in obstetrics and gynecology by

the FIGO committee for the study of athical

aspects of human reproduction and wome’s

health. October 2012