Do demographic and socio-economic characteristics of women with epilepsy influence contact with joint obstetric/neurology services in Northern Ireland?
Introduction from Dr Markus Reuber, editor-in-chief of Seizure
About one quarter of people with epilepsy are women of childbearing age and one in 300 pregnancies involve active maternal epilepsy . Uncontrolled convulsive seizures are a significant risk factor for epilepsy-related mortality, and pose a risk to the fetus. For women with epilepsy (WWE) who are free of seizures, pregnancy is a time where full control of seizures should be maintained if at all possible, while exposure to those antiepileptic drugs (AEDs) that pose a risk to fetal health should be minimised. When seizures continue during pregnancy, the risks associated with using AEDs potentially harmful to the fetus must be balanced against the need to minimise seizure frequency and severity. Striking this balance requires a degree of expertise so joined-up obstetric-epilepsy care makes a lot of sense.
In the UK the optimal care of WWE in pregnancy has attracted particular attention since the publication of the latest report by MBRRACE-UK (Mothers and Babies: Reducing Risks through Audits and Confidential Enquiries across the UK). This report demonstrated that, between 2009 and 2012, neurological disorders comprised the second most frequent cause of maternal mortality during pregnancy. Over 3 years, 14 deaths during pregnancy were recorded in WWE. Whilst this number is small given a UK population of 64 million, closer analysis suggests that two thirds of these pre-partum deaths may have been prevented by better care .
My editor’s choice article in the current issue of Seizure by Damian Bennett examines clinical, demographic and socioeconomic factors that determine whether WWE access a specialist obstetric-epilepsy service in a regional centre or whether they use local and less specialised obstetric care . Health care is provided free at the point of use in the UK and there are no health insurance limitations to patients accessing optimal care in a regional centre. However, patients would have to bear travel costs and, in most cases, arrange their own transport to hospital for out-patient visits or immediate perinatal care. The results of Bennett’s analysis are mixed: Most importantly, only 48% of WWE accessed optimal joint specialist care. While deprivation or employment status had no impact on the proportion of women from outside the local catchment area of the specialist centre benefiting from optimal care, distance from the regional centre had a marked effect.
On the one hand, it is great to see that, for once, deprivation did not seem to diminish the chances of WWE to access optimal care. On the other, the fact that this form of obstetric care was only accessed by a minority of WWE and that WWE – quite understandably- did not appear to like having to travel a long distance to access obstetric care means that service designers have more work to do if they want to ensure best possible pregnancy outcomes.
(1) Olafsson E, Hallgrimsson JT, Hauser WA, Ludvigsson P, Gudmundsson G, Pregnancies of Women with Epilepsy: A Population-Based Study in Iceland. Epilepsia 1998; 39: 887–892.
(2) Kelso A, Wills A. 2014. On behalf of the MBRRACE-UK neurology chapter writing group. Learning from neurological complications. In Knight M, Kenyon S, Brocklehurst P, et al (eds) on behalf of MBRRACE-UK, Saving Lives, Improving Mothers’ Care – Lessons learned to inform future maternity care from the UK and Ireland Confidential Enquiries into Maternal Deaths and Morbidity 2009–12 (pp. 73–9). Oxford: National Perinatal Epidemiology Unit, University of Oxford.
(3) Bennett D. Do demographic and socio-economic characteristics of women with epilepsy influence contact with joint obstetric/neurology services in Northern Ireland Seizure 2016:40;127-132 DOI: 10.1016/j.seizure.2016.06.012 PII: S1059-1311(16)30075-9.