Abstract
Background
Refusal of blood transfusion by Jehovah’s Witness (JW) women poses potential problems for obstetrics worldwide as haemorrhage remains a major cause of maternal morbidity and mortality. There is a general consensus that morbidity and mortality rates in association with childbirth and gynaecological interventions are higher in these women than in the general population. We conducted a postal questionnaire survey of current practice among UK consultant obstetricians and gynaecologists to establish the practices that could contribute to poor outcomes in these women.
Materials and methods.
The main variables of interest were: use of a multi-disciplinary approach; the acceptable minimum haemoglobin (Hb) concentration before vaginal delivery and abdominal hysterectomy as low to medium risk scenarios and open myomectomy as a high risk scenario for haemorrhage; Hb concentration thresholds for iron supplementation; and the use of oral iron, intravenous iron, erythropoietin and cell salvage as potential management tools.
Results
The response rate was 28%. Sixty percent of gynaecologists and 85% of obstetricians reported having a protocol for the management of JW women. Forty-six percent of consultants adopt a multi-disciplinary approach which include anaesthetists and haematologists. A Hb concentration of >11–12g/dL is considered the minimum acceptable level by a majority (47%) prior to normal delivery and by 42% of gynaecologists prior to abdominal hysterectomy. For open myomectomy 28% of gynaecologists prefer a minimum level of 11–12 g/dL but a further 31% of gynaecologists prefer a minimum level of 12–13 g/dL.
Discussion.
A small but substantial proportion of consultants do not have protocols, operate on JW women with low Hb concentrations, do not use a lower Hb concentration threshold for supplementation, and do not adopt a multi-disciplinary approach, all of which could contribute to the reported poor outcomes in these women.
Keywords: Jehovah’s Witness, blood transfusion, questionnaire survey, obstetrics and gynaecology
Introduction
A core belief among members of the Jehovah’s Witness (JW) faith is that they will not accept blood transfusion or its primary components, including red and white blood cells, platelets and plasma, even when such transfusion could be life-saving1. This poses potential problems for obstetric services worldwide because obstetric haemorrhage remains a major cause of maternal mortality and morbidity2,3. Indeed, there is a general consensus that morbidity and mortality rates in association with childbirth are higher in these women than in the general population4–7. In the largest observational study in the USA, Singla et al. reported that JW women were at increased risk of maternal death and that blood loss was the major factor4. In the UK, the largest descriptive obstetric study of JW reported a 65-fold increased risk of maternal death compared to the national rate. In addition, there was significant haemorrhage (>1,000 mL) in 6% of all of Caesarean sections5.
More recently, a study from the Netherlands reported that compared to the non-JW Dutch population, JW women had a 6-fold higher risk of all causes of maternal death, a 130-fold increased risk of maternal death because of major obstetric haemorrhage and a 3-fold higher risk of maternal morbidity because of obstetric haemorrhage6. Other earlier studies support these views, both for obstetric and gynaecological operations7.
It is estimated that there are approximately 6 million JW worldwide, about 150,000 of whom reside in the UK. Thus JW women constitute a significant group at high surgical risk. Apart from menstrual blood loss and childbirth, the vulnerability of JW women as a group is further increased by the significant proportion of African women who are members, since these women have a high incidence of fibroid disease, and, therefore, a preponderance of menorrhagia and iron deficiency anaemia.
We conducted a postal questionnaire survey of current practice among UK consultant obstetricians and gynaecologists to establish the practices that could contribute to poor outcomes in JW women in the UK.
Methods
The Royal College of Obstetricians and Gynaecologists (RCOG) provided the postal addresses of all consultants practising in the UK and registered with the RCOG. Ethical approval was not required as the study was a questionnaire of medical professionals that did not involve patients. The postal questionnaire was sent to all the consultants in March 2010, with a stamped and addressed envelope for anonymous return.
Questionnaire
A 29-item questionnaire (Table I) was developed at St Georges Hospital, London and tested in the local hospital before being sent out to all 1,246 consultants. No reminders were sent because in our experience they do not increase the returns.
Table I.
Questionnaire.
| N. | Questions | Options |
|---|---|---|
| 1 | Your current practice comprises: | □ Obstetrics only |
| □ Gynaecology only | ||
| □ Both Obstetrics and Gynaecology | ||
| 2 | Does your hospital have a written protocol for management of JW women in Gynaecology? | □ Yes |
| □ No | ||
| □ Don’t know | ||
| 3 | Does your hospital have a written protocol for management of JW women in Obstetrics? | □ Yes |
| □ No | ||
| □ Don’t know | ||
| 4 | If there is a protocol for either, have you read it? | □ Yes |
| □ No | ||
| □ N/A | ||
| 5 | Do you routinely discuss management of a JW patient with: | □ an anaesthetist |
| □ haematologist | ||
| □ both | ||
| □ none | ||
| 6 | Do you perform elective gynaecological surgery in JW women? | □ Yes |
| □ No | ||
| □ Prefer to opt out | ||
| 7 | How many JW women do you see in your gynaecological practice in a year? | □ 0 |
| □ 1–5 | ||
| □ 6–10 | ||
| □ 10–20 | ||
| □ >20 | ||
| 8 | What do you consider the minimum acceptable haemoglobin level (g/dL) in a JW woman undergoing major gynaecological surgery (for example abdominal hysterectomy)? | □ 10–11 |
| □ >11–12 | ||
| □ >12–13 | ||
| □ >13–14 | ||
| □ N/A | ||
| 9 | What do you consider the minimum acceptable haemoglobin level (g/dL) in a JW woman undergoing potentially complex myomectomy? | □ 10–11 |
| □ >11–12 | ||
| □ >12–13 | ||
| □ >13–14 | ||
| □ N/A | ||
| 10 | Do you have different threshold criteria for iron supplementation for your JW patients compared to the non-JW? | □ Yes |
| □ No | ||
| □ N/A | ||
| 11 | Do you routinely perform serum iron studies in JW women before commencing supplementation? | □ Yes |
| □ No | ||
| □ N/A | ||
| 12 | What is your first line iron supplementation for JW patients? | □ Oral iron |
| □ Intramuscular iron | ||
| □ Intravenous iron | ||
| 13 | What would be your indication for giving intravenous iron? (You can tick more than one option) | □ Quicker response |
| □ More reliable | ||
| □ Intolerance to oral iron | ||
| □ No response to oral iron | ||
| □ Others | ||
| 14 | Your preferred intravenous iron preparation is: | □ Iron sucrose |
| □ Iron dextran | ||
| □ Ferrinject | ||
| □ Others | ||
| □ Don’t know | ||
| 15 | What influences your choice of iron preparation? | □ Cost-effectiveness |
| □ Safety | ||
| □ Others | ||
| 16 | Have you ever used erythropoietin in JW patients? | □ Yes |
| □ No | ||
| □ N/A | ||
| 17 | What are your criteria for using erythropoietin? | □ Recipients of autologous transfusion |
| □ Poor response to oral iron | ||
| □ Concurrent renal disease | ||
| □ Others | ||
| □ N/A | ||
| 18 | How many JW women do you see in your obstetric practice in a year? | □ 0 |
| □ 1–5 | ||
| □ 6–10 | ||
| □ 10–20 | ||
| □ >20 | ||
| 19 | What do you consider the minimum acceptable (safe) haemoglobin level (g/dL) in a JW woman before delivery? | □ 10–11 |
| □ >11–12 | ||
| □ >12–13 | ||
| □ >13–14 | ||
| □ N/A | ||
| 20 | Do you have different threshold criteria for iron supplementation for your obstetric JW patients compared to the non-JW? | □ Yes |
| □ No | ||
| □ N/A | ||
| 21 | Do you routinely perform serum iron studies in pregnant JW women before commencing supplementation? | □ Yes |
| □ No | ||
| □ N/A | ||
| 22 | What is your first line iron supplementation for pregnant JW patients? | □ Oral iron |
| □ Intramuscular iron | ||
| □ Intravenous iron | ||
| 23 | What would be your indication for giving intravenous iron? (You can tick more than one option): | □ Quicker response |
| □ More reliable | ||
| □ Intolerance to oral iron | ||
| □ No response to oral iron | ||
| □ Others | ||
| 24 | Your preferred intravenous iron preparation in a pregnant JW woman is: | □ Iron sucrose |
| □ Iron dextran | ||
| □ Ferrinject | ||
| □ Others | ||
| □ Don’t know | ||
| 25 | What influences your choice of iron preparation? | □ Cost-effectiveness |
| □ Safety | ||
| □ Others | ||
| 26 | Have you ever used erythropoietin in pregnant JW patients? | □ Yes |
| □ No | ||
| □ N/A | ||
| 27 | What are your criteria for using erythropoietin? | □ Recipients of autologous transfusion |
| □ Poor response to oral iron | ||
| □ Concurrent renal disease | ||
| □ Others | ||
| □ N/A | ||
| 28 | Do you have access to cell salvage facilities in your hospital? | □ Yes |
| □ No | ||
| □ N/A | ||
| 29 | Do you use cell salvage, if available, for JW women? | □ Most of the time |
| □ Sometimes | ||
| □ Rarely | ||
| □ Never | ||
| □ N/A |
Questionnaire: Questions 1–5 were common to both obstetricians and gynaecologists, questions 6–17 were specific for gynaecologists (printed as the gynaecology section in the questionnaire), questions 18–29 were specific for obstetricians (printed as the obstetric section in the questionnaire).
Statistics
Categorical responses are presented as percentages.
Results
Response rate
Twenty-eight percent of the 1,246 consultants responded. Of these 349 respondents, 323 (93.4%) consultants were accepted for the analyses, while 23 were excluded for the following reasons: 13 (3.7%) were either retired or no longer in clinical practice, 3 (0.9%) were genitourinary consultants, 1 (0.3%) was a fertility consultant, 1 (0.3%) was a sexual health consultant, 2 (0.6%) were community gynaecologists and 3 (0.9%) did not enter responses to the questions or their responses were invalid. Forty-three (13%) of our respondents practised obstetrics exclusively, 56 (17%) practised gynaecology only and 227 (70 %) practised both. In other words, 270 (83%) of the respondents practised obstetrics and 283 (87%) practised gynaecology.
Number of Jehovah’s Witness women seen
Table II shows the estimated number of JW patients seen by each consultant per year. The majority of consultants in both obstetrics and gynaecology (76.7 and 78.9% respectively) see only one to five JW women per year. Three percent of obstetricians and 10% of gynaecologists see no JW patients at all, while approximately 2% and 1% of obstetricians and gynaecologists see more than 20 in a year.
Table II.
Number of JW seen per year, availability and familiarity with a protocol, performance of elective gynaecological surgery on JW women, and practice of multidisciplinary approach in the care of JW women.
| Number of JW women seen by each consultant per year | |||||
|
| |||||
| (Responses) | 0 | 1–5 | 6–10 | 10–20 | >20 |
| In Gynaecology (266) | 28 (10%) | 220 (78.9%) | 25 (9%) | 4 (1.4%) | 2 (0.7%) |
| In Obstetrics (279) | 8 (3%) | 204 (76.7%) | 36 (13.5%) | 13 (4.9%) | 5 (1.9%) |
|
| |||||
| Availability of protocol for management of JW women | |||||
|
| |||||
| Yes | No | Don’t know | |||
| In Gynaecology (326) | 192 (58.9%) | 76 (23.3%) | 58 (17.8%) | ||
| In Obstetrics (326) | 276 (84.7%) | 15 (4.6%) | 35 (10.7%) | ||
|
| |||||
| Familiarity with protocol and performance of elective gynaecological surgery | |||||
|
| |||||
| Yes | No | Not applicable | Prefer to opt out | ||
| Have read existing protocol (In total 311 consultants had access to a protocol, either in Obstetrics or Gynaecology or both) |
265 (85.2%) | 15 (4.8 %) | 31 (9.9 %) | Not applicable | |
| Perform elective gynaecological surgery on JW women (282) | 255 (90.4%) | 22 (7.8%) | 5 (1.8%) | ||
|
| |||||
| Multidisciplinary approach in JW women | |||||
|
| |||||
| Anaesthetist | Haematologist | Both | None | Multiple responses | |
| Multi-disciplinary member (326) | 130 (38.2 %) | 3 (0.9 %) | 158 (46.3 %) | 35 (10.3 %) | 52 (19.5%) |
A protocol for the management of Jehovah’s Witness women
In the setting of gynaecological care, 59% consultants reported that their hospital had a protocol, 23% said there was none, and 18% said they did not know whether one existed. The corresponding figures for obstetrics were approximately 85%, 5% and 11%, respectively. About 85% percent of the consultants whose hospital had a protocol had read it in gynaecology and/or obstetrics (Table II).
Performing elective gynaecological surgery on Jehovah’s Witness women
Ninety percent of gynaecologists perform elective surgery on JW women while less than 2% stated that they would prefer to opt out of such surgery (Table II).
Multi-disciplinary approach
We sought to establish the extent to which a multi-disciplinary approach which included a gynaecologist/obstetrician, an anaesthetist and haematologist, was taken by obstetricians and gynaecologists. We found that 46% had a multi-disciplinary approach involving anaesthetists and haematologists while 10% did not routinely discuss management with either anaesthetists or haematologists. A further 38% of consultants routinely discussed the care of JW women with anaesthetists but not haematologists.
Minimum acceptable haemoglobin concentration
Table III shows that one third of gynaecologists (31%) would accept a minimum Hb concentration >12–13 g/dl prior to an open myomectomy for JW women. For abdominal hysterectomy, the largest group of gynaecologists (42%) would accept a minimum of >11–12 g/dl. Similarly the largest group of obstetricians and gynaecologists would accept a minimum of >11–12 g/dl for normal vaginal delivery.
Table III.
Minimum acceptable haemoglobin prior to normal delivery, hysterectomy and myomectomy, performance of iron studies, thresholds for and first choice iron supplementation, indication for using intravenous (IV) iron, preferred IV iron preparation and factors influencing its choice.
| Minimum acceptable levels of haemoglobin concentration at normal vaginal delivery and major abdominal surgery | |||||
|
| |||||
| Haemoglobin g/dL (responses) | 10–11 | >11–12 | >12–13 | >13–14 | Not applicable |
| Normal vaginal delivery (257) | 98 (38.1%) | 121 (47.1%) | 32 (12.5%) | 6 (2.3%) | 0 |
| Abdominal hysterectomy (276) | 86 (31.2%) | 116 (42%) | 47 (17%) | 8 (2.9%) | 19 (6.9%) |
| Open myomectomy (269) | 25 (9.3%) | 74 (27.5%) | 84 (31.2%) | 26 (9.7%) | 60 (22.3%) |
|
| |||||
| Iron studies in JW women | |||||
|
| |||||
| Types of responses | Routinely study iron | Do not routinely study iron | NA | ||
| Gynaecology (278) | 88 (31.7%) | 176 (63.3%) | 14 (5%) | ||
| Obstetrics (267) | 123(46.1%) | 142 (54%) | 2 (0.8%) | ||
|
| |||||
| Threshold for iron supplementation in JW women | |||||
|
| |||||
| Same threshold as general population | Lower threshold than general population | Not applicable | |||
| Gynaecology (280) | 114 (40.7%) | 155 (55.4%) | 11 (3.9%) | ||
| Obstetrics (263) | 87 (33.1%) | 173 (65.8%) | 3 (1.1%) | ||
|
| |||||
| First choice iron supplementation in JW women | |||||
|
| |||||
| Oral iron | Intravenous iron | Intramuscular iron | |||
| Gynaecology (279) | 274 (98.2%) | 5 (1.8%) | 0 | ||
| Obstetrics (268) | 260 (97%) | 7 (2.6%) | 1 (0.4%) | ||
|
| |||||
| Indications for use of intravenous iron | |||||
|
| |||||
| Quicker response | More reliable | Intolerance to iron | No response to oral iron | Other indications | |
| Gynaecology (283) | 85 (30%) | 40 (14.1%) | 213 (75.3%) | 159 (56.2%) | 9 (3.2%) |
| Obstetrics (263) | 91 (34.6%) | 44 (16.7%) | 210 (79.9%) | 188 (71.5%) | 8 (3%) |
|
| |||||
| Preferred intravenous iron preparation in JW women | |||||
|
| |||||
| Type of preparation | Iron Dextran | Iron sucrose | Iron carboxymaltose | Others | Don’t know |
| Gynaecology (270) | 64 (23.7%) | 67 (24.8%) | 25 (9.3%) | 30 (11.1%) | 83 (30.7%) |
| Obstetrics (265) | 65 (24.5%) | 84 (31.7%) | 31 (11.7%) | 31(11.7%) | 53 (20%) |
|
| |||||
| Factors influencing choice of type of intravenous iron | |||||
|
| |||||
| Cost effective | Safety | Patients’ intolerance | Other factors | Multiple responses | |
| Gynaecology (267) | 58 (21.7%) | 135 (50.6%) | 79 (29.6%) | 66 (24.7%) | 52 (19.5%) |
| Obstetrics (267) | 66 (24.7%) | 137 (51.3%) | 80 (30%) | 62 (23.2%) | 49 (18.4%) |
Pre-operative iron studies in Jehovah’s Witness women, thresholds for iron supplementation and choice of first line treatment
JW women’s refusal of blood places them at an extra high-risk when undergoing major surgery. We asked whether consultants used different Hb concentration thresholds for deciding when to start iron supplementation in these women compared to non-JW women. Fifty-five percent of gynaecologists and 66% of obstetricians used a lower Hb concentration threshold for iron supplementation in JW women (Table III). Interestingly too, approximately 32% of gynaecologists and 46% of obstetricians would routinely perform iron studies prior to iron supplementation in JW women, although the majority of gynaecologists (63%) and obstetricians (54%) would not do so (Table III).
With regards to the choice of first-line iron supplementation, at least 97% of gynaecologists and obstetricians chose oral iron (Table III).
Indications for use of intravenous iron, preferred preparations and factors influencing choice
Table III shows that the two commonest indications for intravenous iron for obstetricians and gynaecologists were “intolerance to iron” and “no response to oral iron”.
The two most preferred intravenous iron preparations amongst gynaecologists (combined 48.5%) and obstetricians (combined 56%) are iron sucrose and iron Dextran, perhaps because they are the established preparations. Only one in ten gynaecologists and obstetricians preferred to use iron carboxymaltose (Ferinject, ViforPharma), a newer preparation. Interestingly 30% of gynaecologists and 20% of obstetricians do not know what intravenous iron preparation they preferred (Table III).
With regards to the factors that influenced the choice of intravenous iron preparation, one in two gynaecologists and obstetricians chose patients’ safety as the most important factor, followed by patients’ intolerance to oral preparations (Table III).
Indications for use of erythropoietin
Eighty-five percent of gynaecologists and 87% of obstetricians had never used erythropoietin in JW women (Table IV). The two commonest indications for using erythropoietin among gynaecologists and obstetricians were “poor response to oral iron” and “concurrent renal disease”.
Table IV.
Experience of using erythropoietin, indications for using erythropoietin; availability and utilisation of cell salvage.
| Experience of using erythropoietin in JW women | ||||||
|
| ||||||
| (Responses) | Have used | Never used | Not applicable | |||
| Obstetrics (267) | 33 (12.4%) | 233 (87.3%) | 4 (1.5%) | |||
| Gynaecology (281) | 35 (12.5%) | 241 (85.8 %) | 5 (1.8 %) | |||
|
| ||||||
| Indications for using erythropoietin in JW women | ||||||
|
| ||||||
| Indications | Autologous transfusion | Poor response to oral iron | Concurrent renal disease | Other factors | Multiple responses | Not applicable |
| Obstetrics (33) | 0 | 7 (21.2%) | 3 (9.1%) | 12 (36.4%) | 7 (21.2%) | 4 (12.1%) |
| Gynaecology (35) | 2 (5.7%) | 10 (28.6) | 3 (8.6%) | 13 (37.1%) | 7 (20%) | 0 |
|
| ||||||
| Availability of cell salvage to obstetricians | ||||||
|
| ||||||
| Available | Not available | Don’t know | ||||
| Availability (270) | 209 (77.4%) | 55 (20.2%) | 6 (2.9%) | |||
|
| ||||||
| Utilisation of available cell salvage | ||||||
|
| ||||||
| Most of the time | Sometimes | Rarely | Never | Not applicable | ||
| Utilisation (209) | 126 (60.3 %) | 51 (24.4 %) | 22 (10.5 %) | 9 (4.3 %) | 2 (0.9 %) | |
Use of cell salvage
Cell salvage facilities were available to 77% of obstetricians (Table IV). With regards to actual use of cell salvage, 60% of those who had the facility used it most of the time. Interestingly 17 respondents stated that they would either hire the facility or send patients to places where a salvage facility was available if they anticipated a complex Caesarean section in a JW.
Discussion
All available research evidence suggests that JW women experience high morbidity and mortality in association with obstetric and gynaecologic interventions, and this is thought to be linked to their refusal of blood and blood products. So far there is no research evidence to show that any specific interventions or practices would reduce the morbidity and mortality rates to those of their non-JW counterparts. However, it is logical to suppose that a number of measures could do so. These might include written protocols that emphasise a multi-disciplinary approach to the management of these women, aiming to optimise the Hb concentration in clinical situations in which significant blood loss is anticipated, and recourse to iron supplementation at lower Hb concentration thresholds, using effective agents such as intravenous rather than oral iron, and the deployment of strategies such as the use of cell salvage, erythropoietin and factor VII in appropriate circumstances. This view prompted us to survey consultants to establish whether there are current practices that could contribute to the poor outcomes in JW women. We acknowledge the weaknesses inherent in questionnaire studies and have endeavoured to interpret our findings with caution.
We further acknowledge that a significant limitation of the study was the low response rate of 28%, which might question the validity of the findings if the population of responders is not representative. We could have taken measures to try to improve this, such as sending reminders, but a recent published survey in which the response rate was 9.4% 8 found that sending reminders made only a marginal difference. This was also our personal experience with a previous questionnaire survey and that of our colleagues with separate surveys (Thakar et al., personal communication). We looked at response rates in surveys published over the past 5 years and found a great deal of variation, with rates as low as 9.4% being reported13, the majority lying between 20–60%9–17, and occasional surveys having a response rate of 70–80%18–19. It is unclear what determines the response rate. We had thought that there could be generalised apathy in a very busy specialty whose staff are frequently bombarded with questionnaires, but the high response rates in some surveys argues against this. Although the morbidity and mortality associated with JW patients is an important issue, our survey showed that few consultants see large numbers of such patients, and interest in this topic could be very low. Yet another possibility is that a long questionnaire might lead to lower response rates. We had considered that our questionnaire [of 480 words] struck the right balance. Our principal finding that the overall care of JW women could be improved is consistent with the consensus that these women suffer increased morbidity and mortality. We do not, therefore, believe that our low response rate has affected the key issues of interest. We also acknowledge that we did not touch on issues such as the use of haemoglobin-based oxygen carriers, isovolumic haemodilution and blood-less surgery, but we were minded to keep the questionnaire brief, and these practices are uncommon in the UK. For the same reason we did not investigate issues such as anaesthetic techniques which have been demonstrated to modify the amount of blood loss and the risk of blood transfusion.
Although nearly 85% of obstetric respondents said that their unit had a written protocol for the management of JW women, in gynaecology this figure was only 60%. The relatively small number of JW in the general population is reflected in the number seen by each consultant, with more than three-quarters in obstetrics and gynaecology reporting that they see only one to five JW women per year. This has a number of important implications: firstly for utilisation of management protocols in their units and secondly for a “multidisciplinary approach to care”. Forty-six percent of consultants reported that they used a multidisciplinary care team involving an anaesthetist and haematologist. A significant proportion (38%) would involve an anaesthetist. Three consultants stated that they involve the haematologist only. However 10% would not involve either a haematologist or an anaesthetist, thereby ignoring professionals who can advise on methods of optimising a woman’s Hb concentration, give practical advice on alternatives to blood products such as factor VII and supervise cell salvage.
It seems logical to assume that a JW woman who starts with a higher Hb concentration, for example 12–13 g/dL will fare better than one with a Hb concentration of around 10 g/dL or less in the event of significant blood loss. Indeed, maintaining a Hb concentration above 12–13 g/dL and a haematocrit above 40% enables a woman to withstand a peripartum blood loss of 2 litres without requiring a blood transfusion20. Therefore optimisation of the Hb concentration at all stages in the clinical care of JW patients could logically be a key factor in the reduction of morbidity and mortality. Thus, although there is no evidence-base for “acceptable” levels of Hb, we nevertheless sought to establish whether our respondents had levels which they considered acceptable in a number of scenarios such as vaginal delivery and gynaecological operations. We note that 38% of obstetricians would deliver JW women with a Hb concentration of 10–11 g/dL, a level that is just above the cut-off for the definition of anaemia in pregnancy21. Similarly 9% of gynaecologists were prepared to perform open myomectomy, an operation considered at high risk for excessive blood loss, in JW women with a Hb concentration of 10–11 g/dL. One study found that about a quarter of women undergoing myomectomy lose over 1,000 mL of blood22.
With regards to optimisation of the Hb concentration we found that between 30% and 40% of consultants would manage iron deficiency in JW women in a similar fashion to the way they manage non-JW women in that they do not adopt a lower threshold for iron supplementation. The vast majority of obstetricians and gynaecologists (97–98%) would consider oral iron as the first choice for supplementation. The largest group of obstetricians and gynaecologists (75–80%) would consider intravenous iron because of intolerance to oral iron, 56–71% because of absence of response to oral iron and 30–35% because of a quicker response. However, only a small proportion (14–17%) used intravenous iron because it was more reliable than oral iron, although there is level I evidence that subjects treated with iron sucrose have an more rapid improvement in Hb and ferritin than do those treated with oral iron23–25. It is also surprising that more than 50% of obstetricians and gynaecologists do not routinely perform serum iron studies, although obstetric patients and women in child-bearing age and with fibroids have a high incidence of iron deficiency.
Our findings have a number of implications for the clinician. The absolute numbers of JW women are small, and centralisation of care for these women could improve outcomes, although we hasten to acknowledge that there is no evidence to support this statement. Interested clinicians in designated centres could develop and adhere to protocols, advance relevant research, and only a few units would need to invest in facilities that could optimise the care, including cell salvage, an outpatient intravenous iron service and access to recombinant erythropoietin and factor VII. Our own unit already receives referrals of JW women from local hospitals, especially those needing treatment for massive symptomatic fibroids. Our approach is multi-disciplinary and includes haematologists who will conduct iron studies and optimise Hb concentration prior to surgery; interventional radiologists who may perform premyomectomy uterine artery embolization, if indicated, to minimise blood loss at open myomectomy26, and anaesthetists who are involved in the measures to minimise blood loss at surgery including the use of tranexamic acid, vasopressin27 and supervision of cell salvage. Of course, any such centralisation would need the acquiescence of the JW community, who may resist being treated differently or having their choice of hospital being apparently curtailed.
This survey shows that a small but substantial proportion of consultants do not have protocols for the management of JW women, operate on JW women with a relatively low Hb concentration which could lead to rapid development of acute anaemia in the event of significant blood loss and do not adopt a multi-disciplinary approach. Whether all these contribute to the reported poor outcomes in this vulnerable group of women is a matter for conjecture, but it seems logical to suppose that changing practices could translate into improvement of outcomes.
Acknowledgments
We are grateful to all the consultant colleagues who graciously gave up time to complete the questionnaire.
Footnotes
Authors’ contributions
All authors were involved in the development of the questionnaire, analysis of the results and writing of the manuscript.
The Authors declare no conflicts of interest.
References
- 1.Watchtower Bible and Tract Society Rightly value your gift of life. Watchtower. 2004;15:14–6. [Google Scholar]
- 2.Schuitemaker N, van Roosmalen J, Dekker G, et al. Confidential enquiry into maternal deaths in the Netherlands 1983–1992. Eur J Obstet Gynecol Reprod Biol. 1998;79:57–62. doi: 10.1016/s0301-2115(98)00053-0. [DOI] [PubMed] [Google Scholar]
- 3.Zwart JJ, Richters JM, Ory F, et al. Severe maternal morbidity during pregnancy, delivery and puerperium in the Netherlands: a nationwide population-based study of 371,000 pregnancies. BJOG. 2008;115:842–50. doi: 10.1111/j.1471-0528.2008.01713.x. [DOI] [PubMed] [Google Scholar]
- 4.Singla AK, Lapinski RH, Berkowitz RL, Saphier CJ. Are women who are Jehovah’s Witnesses at risk of maternal death? Am J Obstet Gynecol. 2001;185:893–5. doi: 10.1067/mob.2001.117357. [DOI] [PubMed] [Google Scholar]
- 5.Massiah N, Athimulam S, Loo C, et al. Obstetric care of Jehovah’s Witnesses: a 14 year observational study. Arch Gynecol Obstet. 2007;276:39–43. doi: 10.1007/s00404-007-0346-0. [DOI] [PubMed] [Google Scholar]
- 6.Van Wolfswinkel M, Zwart J, Schutte J, et al. Maternal mortality and serious maternal morbidity in Jehovah’s Witnesses in the Netherlands. BJOG. 2009;116:1103–10. doi: 10.1111/j.1471-0528.2009.02191.x. [DOI] [PubMed] [Google Scholar]
- 7.Bonakder MI, Echous WW, Bacher BJ, et al. Major gynecologic & obstetric surgery in Jehovah’s Witnesses. Obstet Gynaecol. 1982;60:587–90. [PubMed] [Google Scholar]
- 8.Sharma A, Walker D-M, Atiomo W. National survey on management of weight reduction in PCOS women in the United Kingdom. Eur J Obstet Gynecol Reprod Biol. 2010;152:181–5. doi: 10.1016/j.ejogrb.2010.07.015. [DOI] [PubMed] [Google Scholar]
- 9.Alfhaily F, Ewies AA. Postcoital bleeding: a study of the current practice amongst consultants in the United Kingdom. Eur J Obstet Gynecol Reprod Biol. 2009;144:72–5. doi: 10.1016/j.ejogrb.2009.01.014. [DOI] [PubMed] [Google Scholar]
- 10.Driscoll DA, Morgan MA, Schulkin J. Screening for Down syndrome: changing practice of obstetricians. Am J Obstet Gynecol. 2009;200:459. doi: 10.1016/j.ajog.2008.12.027. [DOI] [PubMed] [Google Scholar]
- 11.Power ML, Leddy MA, Anderson BL, et al. Obstetrician-gynecologists’ practices and perceived knowledge regarding immunization. Am J Prevent Med. 2009;37:231–4. doi: 10.1016/j.amepre.2009.05.019. [DOI] [PubMed] [Google Scholar]
- 12.Gorti M, Hudelist G, Simons A. Evaluation of vaginal pessary management: a UK-based survey. J Obstet Gynaecol. 2009;29:129–31. doi: 10.1080/01443610902719813. [DOI] [PubMed] [Google Scholar]
- 13.Deb S, Flora K, Atiomo W. A survey of preferences and practices of endometrial ablation/resection for menorrhagia in the United Kingdom. Fertil Steril. 2008;90:1812–7. doi: 10.1016/j.fertnstert.2007.08.052. [DOI] [PubMed] [Google Scholar]
- 14.Farrell SA, Baskett TF, Baydock S. The use of intraoperative cystoscopy by general gynaecologists in Canada. J Obstet Gynaecol Can. 2009;31:48–53. doi: 10.1016/s1701-2163(16)34053-1. [DOI] [PubMed] [Google Scholar]
- 15.Paschall S, Kaunitz AM. Depo-Provera and skeletal health: a survey of Florida obstetrics and gynecologist physicians. Contraception. 2008;78:370–6. doi: 10.1016/j.contraception.2008.07.022. [DOI] [PubMed] [Google Scholar]
- 16.Sedlecky K, Rasevic M. Are Serbian gynaecologists in line with modern family planning? Eur J Contracept Reprod Health Care. 2008;13:158–63. doi: 10.1080/13625180802012433. [DOI] [PubMed] [Google Scholar]
- 17.Subramanian S, Desai A, Joshipura M, Surani S. Practice patterns of screening for sleep apnoea in physicians treating PCOS patients. Sleep Breathing. 2007;11:233–7. doi: 10.1007/s11325-007-0120-3. [DOI] [PubMed] [Google Scholar]
- 18.Bimbashi A, Ndoni E, Dokle A, Duley L. Care during the third stage of labour: obstetrician’s views and practice in an Albanian maternity hospital. BMC Pregnancy Childbirth. 2010;10:4. doi: 10.1186/1471-2393-10-4. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 19.Wedisinghe L, Macleod M, Murphy DJ. Use of oxytocin to prevent haemorrhage at caesarean sectiona survey of practice in the United Kingdom. Eur J Obstet Gynecol Reprod Biol. 2008;137:27–30. doi: 10.1016/j.ejogrb.2007.04.007. [DOI] [PubMed] [Google Scholar]
- 20.Gyamfi C, Berkowitz RL. Management of pregnancy in a Jehovah’s Witness. Obstet Gynecol Clin N Am. 2007;34:357–65. doi: 10.1016/j.ogc.2007.06.005. [DOI] [PubMed] [Google Scholar]
- 21.Nice Guidelines. Antenatal care: routine Care for the healthy pregnant woman. Nice. 2008. [PubMed]
- 22.Fletcher H, Frederick J, Hardie M, Simeon D. A randomised comparison of vasopressin and tourniquet as haemostatic agents during myomectomy. Obstet Gynecol. 1996;87:1014–8. doi: 10.1016/0029-7844(96)00071-3. [DOI] [PubMed] [Google Scholar]
- 23.Perewusnyk G, Huch A, Breymann C. Parenteral iron therapy in obstetrics: 8 years experience with iron-sucrose complex. Br J Nutrition. 2002;88:3–10. doi: 10.1079/BJNBJN2002577. [DOI] [PubMed] [Google Scholar]
- 24.Danielson BG. Intravenous iron therapy - efficacy and safety of iron sucrose. In: Huch A, Huch R, Breymann C, editors. Prevention and Management of Anaemia in Pregnancy and Postpartum Haemorrhage. Zurich: Schellenberg; 2008. pp. 93–106. [Google Scholar]
- 25.Al AR, Unlubilgin E, Kandemir O, et al. Intravenous versus oral iron for treatment of anaemia in pregnancy. Obstet Gynecol. 2005;106:1335–40. doi: 10.1097/01.AOG.0000185260.82466.b4. [DOI] [PubMed] [Google Scholar]
- 26.Ngeh N, Belli A-M, Morgan R, Manyonda I. Premyomectomy uterine artery embolisation minimises operative blood. BJOG. 2004;111:1139–40. doi: 10.1111/j.1471-0528.2004.00239.x. [DOI] [PubMed] [Google Scholar]
- 27.Mukhopadhaya N, De Silva C, Manyonda IT. Conventional myomectomy. Best Pract Res Clin Obstet Gynaecol. 2008;22:677–705. doi: 10.1016/j.bpobgyn.2008.01.012. [DOI] [PubMed] [Google Scholar]