Caring for pregnant women for whom transfusion is not an option. A national review to assist in patient care

Abstract

Postpartum haemorrhage (PPH) is the leading cause of maternal mortality and morbidity globally. Obstetric bleeding can be catastrophic and management is challenging, involving a coordinated multidisciplinary approach, which may include blood products. In settings where blood transfusion is not an option, either because of patient refusal (most commonly in Jehovah Witnesses) or because of unavailability of blood, management becomes even more challenging. Observational studies have demonstrated an association between refusal of blood products in major obstetric haemorrhage and increased morbidity and mortality. This review draws upon evidence in the literature, physiological principles and expert opinion for strategies and guidance to optimise the outcomes of pregnant women in whom blood transfusion is either refused or impossible. The importance of a multidisciplinary antenatal and perinatal management plan, including optimisation of haemoglobin and iron stores pre-delivery, blood loss minimisation, early haemorrhage control and postpartum anaemia treatment, is discussed.

The Jehovah’s Witness obstetric patient – a literature review

“…and Deuteronomy ("Just be firmly resolved not to eat the blood, because the blood is the life, and you must not eat the life with the flesh."). The faithful see refusal of blood transfusion as an act of obedience to God, which will guarantee them eternal life [3,5,11,12].…”

“…Some medical professionals might not be aware of the selectivity of blood product refusal in JW patients, but such refusal is obligatory for red blood, platelets and plasma [2-4, 8, 10, 11] (Table 1). Since 2000 the governing council of the congregation has allowed the faithful to independently decide about the use of so-called "small fractions of blood" with, inter alia, fibrinogen, albumins, clotting factor concentrates, as well as on the use of intraoperative blood salvage or erythropoietin administration [3,4,7] (Table 2).…”

“…On the other hand, the patient's resistance to the most effective and, sometimes, the only indicated treatment, causes disapproval amid medical professionals. Due to various medical, ethical and legal problems arising from blood refusal, JW patients are considered demanding and difficult, especially in urgent situations [3,5,8,12,18,19]. The medical staff often struggle with cognitive dissonance because, despite having a diagnosis, and adequate knowledge, skills and tools, they must remain passive while the patient is getting worse, yet still opposing treatment [3-5, 7, 8, 10, 11, 19, 20].…”

Getting the ‘Comfortable’ to listen: a mixed methods study of refusal of recommended maternity care

“…Several other papers focus on the care of women who refuse blood products on religious grounds (Belaouchi et al, 2016;Braithwaite et al, 2010;Gupta et al, 2012;Kidson-Gerber et al, 2016;Mahoney & Valenti, 2004;Zeybek et al, 2016). However, most of these focus on the clinical management of such women.…”

“…A PACT could, therefore, be initiated whenever the women signalled her intention to decline recommended care. In some cases, this would also allow proactive steps to be planned and undertaken antenatally to maximise the chances of good outcomes, such as in the care of women who decline blood products (see Belaouchi et al, 2016;Kidson-Gerber et al, 2016;Queensland Maternal and Perinatal Quality Council, 2012). As discussed in Chapter Four, some women may signal their intention to decline recommended care as early as their booking visit.…”