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British Association of Perinatal Medicine there were only 366 consultant paedia- Arch Dis Child: first published as 10.1136/adc.88.3.181 on 1 March 2003. Downloaded from ...... tricians in the . Besides lacking an interest in the newborn, some paediatricians actively obstructed at- The British Association of Perinatal tempts to establish perinatal paediatrics. Maybe they saw their clinical workload Medicine: the first 25 years being eroded by the development of pae- diatric specialisation and were loath to (1976–2000) lose an interest in the newborn field, even though their commitment for this P M Dunn activity was inadequate. So much for the background in the ...... early 1970s. Half of all deaths from birth to 15 years were taking place in The founding, achievements, and aspirations of the British maternity hospitals within the first 3 Association of Perinatal Medicine are reviewed days of life.4 For those of us trying on a shoestring to establish and maintain a BACKGROUND as a specialty. Although stating that neonatal intensive care service, it was Although there were pioneers in the newborn care would remain the respon- most frustrating. In 1974 a leader in the 6 1930s and 1940s such as Dr Mary Crosse sibility of general paediatricians, the Lancet, “The price of perinatal neglect”, of Sorrento in Birmingham, newborn authors recommended that a total of 10 drew attention to this. But no immediate care in the United Kingdom was very perinatal paediatricians should be ap- action followed. Knowledge of what we neglected in the first half of the 20th pointed to the various major centres should be doing for newborn infants was century.1 In hospital, newborn babies throughout the country to supervise by now far ahead of what was actually were for the most part looked after by neonatal intensive care. This was to pro- provided. How best to proceed? nursery nurses, midwives, and junior vide for an annual population of new- FOUNDING OF THE BRITISH obstetricians. Two things changed this: born infants in the United Kingdom of ASSOCIATION OF PERINATAL the creation of the NHS in 1948 and the about 700 000, some 10% of which were MEDICINE (BAPM) IN 1976 introduction of the umbilical exchange anticipated to require special or intensive In 1975 June Lloyd, who was then transfusion for Rh haemolytic disease, care. honorary secretary of the British Paedi- which established an entrée for paedia- In 1971 the Government published a atric Association, asked me to find out tricians into maternity hospitals. But report on special care for newborn progress was slow and many errors in 3 for the Department of Health and Social babies. It contained the recommen- Security the number of paediatricians in management were practiced. In the dation that there should be six special nurseries of a teaching maternity hospi- the United Kingdom working mainly in care costs per 1000 births, one of which tal in 1959 where I was neonatal the newborn field. This I did by writing should be for intensive care, with a total registrar, there were no incubators, no to all the major maternity hospitals and of eight nurses per 1000 deliveries per technology, and no rooming in. universities throughout Britain and Ire- year to look after them. However, this Why had newborn care been so land, and enquiring whether there were http://adc.bmj.com/ totally inadequate nursing establish- neglected? Well, there were more babies any paediatricians spending 60% or more ment was not actually available at that than were needed and a fairly wide- of their time in newborn care. Including spread attitude of “survival of the fit- time or indeed for many years to come. eight from the Republic of Ireland, I col- test”. Obstetricians had become gynae- The state of paediatric staffing was no lected 20 names in all. Then it occurred cologists and many had lost their better. When I took up a consultant post to me to bring these 20 paediatricians interest in the newborn. Paediatricians at Southmead Hospital in the late 1960s, together and start a perinatal group. So I were few in number and were mostly there were 6000 births a year and the wrote to them early in 1976 asking them based in children’s hospitals; further- referrals from at least another 6000. The to meet at the BPA in York that April. At on September 25, 2021 by guest. Protected copyright. more few had knowledge of the new- junior paediatric staffing to meet this this point, , who was then born. case load consisted of half a registrar and secretary to the BPA Academic Board, The 1960s saw the establishment of two housemen. The annual budget for intervened. In York he put up a notice special care baby units in major equipment at that time was £500. But we inviting anyone interested in newborn maternity units. But there was little begged, borrowed, and stole and estab- care to come to the meeting that I had equipment, and paediatric cover was lished an intensive care service in 1970. arranged. After opening the meeting, he poor. The perinatal mortality of 35 per Everyone worked all hours, and in no then left me to chair it. However, my 1000 births at the start of the decade fell time we were rewarded by a falling mor- intention had been to create a pressure only slowly. Progress, however, was being tality. Between 1970 and 1973, the group from among those actually facing made in , and in Peter neonatal mortality for non-malformed the problems of providing a neonatal Tizard had created a training ground for infants over 1000 g birth weight fell by intensive care service. As this was now neonatologists at The Hammersmith 74% in the university service.4 However, no longer possible, the meeting closed Hospital.1 However, as there were no although such a fall may have been tak- without making significant progress. consultant posts in neonatal medicine, ing place in a few neonatal units around My next move was to invite those most of his trainees returned to general the country, it was not happening in same 20 neonatal paediatricians to con- paediatrics. In 1968, I think I may have general.4 tribute to a neonatal symposium in Bris- been the first person (certainly south of Apart from the lack of finances gener- tol in November 1976. This they agreed the border) to be appointed to a consult- ally available to the NHS, paediatrics had to do, and after the conference we ant perinatal/neonatal post. received a particularly raw deal, receiv- formed the British Paediatric Perinatal In 1972, , chairman of ing possibly a third of the financing to Group (fig 1) and celebrated the event the BPA Academic Board, wrote a book- which child health was entitled as its with a dinner in the cellars of Foster’s let with Tony Jackson entitled Paediatrics share of the medical budget5; and such Rooms. Our declared aim was “to im- in the seventies.2 It contained the first offi- money as was available was badly prove the standard of perinatal care in cial recognition of perinatal paediatrics needed for older children. At the time, the British Isles”.

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became members of our council, which Arch Dis Child: first published as 10.1136/adc.88.3.181 on 1 March 2003. Downloaded from met each year for a day’s debate before our annual scientific meeting. These annual perinatal symposia, a continua- tion of the Bristol series, went peripa- tetic, visiting in turn most of the major cities throughout the British Isles and Ireland.

PROGRESS IN PERINATAL CARE As the pace of work quickened, it was found necessary in 1980 to create an executive committee and the secretary became its chairman. For some time we used to meet in my home in Bristol. In 1982, who gave our first founders’ lecture, then pointed out that the correct term for a presiding officer was president, not chairman, and so we changed that title. We also changed our name from a perinatal group to British Association of Perinatal Paediatrics and Figure 1 Founding meeting of the British Association of Perinatal Medicine, Bristol, 1976. Left to right: standing: Niall O’Brien, Roger Harris, David Davies, George Russell, Colin registered ourselves as a charity. Walker, David Harvey, Brian Wharton, , Cliff Roberton, John Maclaurin, In 1984, Cliff Roberton took over as Richard Orme, Mark Reid, David Baum, Garth McClure; sitting: Pamela Davies, Osmund president (fig 2). Cliff in turn was Reynolds, Peter Dunn, Margaret Kerr, Brian Speidel (in absentia: Malcolm Chiswick and succeeded in 1987 by Forrester Cock- Harold Gamsu). burn. Then followed Richard Cooke in 1990 and Garth McClure in 1993. Next, My idea had been that there should obstetric view at that time was that all in 1996 Phil Steer became our first also be a twin group, the British Obstet- gynaecologists were perinatologists, and “obstetric” president. From the start we ric Perinatal Group and that together we that it was diversive to suggest that some had welcomed obstetricians to join our would create the British Association of were more perinatal than others. In paediatric group and, in fact, in 1980 Phil Perinatal Medicine with combined meet- addition, the RCOG, unlike the BPA, did had become a valued member of our ings. I approached Richard Beard of St not agree to our new group becoming executive committee. In 1982 the RCOG Mary’s Hospital in London with this affiliated with their College. This was recognised maternal and fetal medicine suggestion and the hope that he would disappointing as it seemed obvious that as a subspecialty of obstetrics and organise the obstetric group. He was perinatal medicine could only be fully gynaecology. The chairman of the RCOG enthusiastic until senior colleagues at effective if the two disciplines most con- working party that made that rec-

the Royal College of Obstetrics and cerned worked closely together. ommendation was Charlie Whitfield, http://adc.bmj.com/ Gynaecology (RCOG) dissuaded him. I Meanwhile, I became secretary to the and indeed it was he who, in 1985, then approached Charlie Whitfield of group and also honorary treasurer with suggested that the time had come to . Exactly the same happened, as the £100 I had raised from the Bristol rename our association the British it did with my third approach to Knox- Neonatal Symposium. All the founding Association of Perinatal Medicine. This Ritchie, then in Belfast. The official members, along with later recruits, we did in 1987 and at the same time acquired a logo, designed by a young lad from Ulster. So at last perinatal medicine

had been established in this country on September 25, 2021 by guest. Protected copyright. with its own representative association. In fact many disciplines contribute to perinatal care, and from the early days we have had at our meetings members and representatives from pathology, an- aesthetics, midwifery, radiology, paediat- ric surgery, family and community prac- tice, epidemiology, neonatal nursing, and administration—the Department of Health. In particular, we invited from 1978 onwards two neonatal nurses, the late Jean Boxall of Exeter and Paula Hale of Nottingham, to become members of our council. It was they too who together helped to create that same year the Neo- natal Nurses Association with a constitu- tion very similar to our own. Both of these splendid nurses were later made honorary members of our association. The BAPM has many activities and functions: as a pressure group to improve Figure 2 Presidents of the British Association of Perinatal Medicine (BAPM), 1976–2000. perinatal care; to audit facilities and Standing, left to right: Clifford Roberton, Forrester Cockburn, Andrew Wilkinson, Garth workload; to define standards for staff- McClure, Peter Dunn; kneeling: Philip Steer, Richard Cooke. ing, cots, and equipment; to train staff; to

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undertake postgraduate education; to quarter of what it was in 1976. The work has threatened to undermine this Arch Dis Child: first published as 10.1136/adc.88.3.181 on 1 March 2003. Downloaded from act as a scientific forum; to organise BAPM made its contribution thanks to important strategy. multicentre trials; and to promote col- the efforts of many, especially the honor- Another way of focusing on and laboration and good fellowship. Al- ary secretaries. Harold Gamsu took over improving the perinatal training of ob- though many of the BAPM’s achieve- from me in 1980, followed by David Har- stetricians and paediatricians may be to ments are listed in its handbook,7 it is vey (1983), Malcolm Chiswick (1986), prepare a syllabus of knowledge basic to worth mentioning one in particular. This Malcolm Levene (1989), Andrew Wilkin- the care of the fetus and newborn and was obtaining formal recognition for son (now our president) (1992), Neil award a diploma to those reaching an perinatal paediatrics with its own train- Marlow (1995), and, at present, Janet appropriate standard. I very much hope ing programme from the Royal Colleges Rennie (1998). Mention should also be that this will indeed be achieved within and BPA. It proved difficult because of made of our honorary treasurer, David the coming decade under the general the many professional bodies involved Lloyd, who took over the management of auspices of the two parent Royal Col- and the prejudice of some senior col- our financial affairs from me in 1988 and leges. leagues; indeed it took years of negotia- has done a magnificent job. The fourth The importance of perinatal audit is tion. In 1977 I started with an approach officer, the honorary archivist, is plan- self evident, and the BAPM has already to the BPA Academic Board. Ross Mitch- ning to retire later this year and to hand made considerable progress in this area. ell was then the chairman of the board his baton on to David Harvey. Nor should If we professionals fail to take a lead in and was more sympathetic to our cause we overlook the splendid achievements this matter, others such as administra- than most. However, the correspondence of our Multi-centre Trials Group led since tors and politicians may pre-empt us that I had with him in 1977 makes inter- 1991 by Henry Halliday and more re- with systems less likely to meet our esting reading 23 years later. In short, he cently by Steve Walkinshaw. This group needs. It is important too that our audit stated that was likely to has worked closely with Iain Chalmers, should include all babies, and not just remain largely in the hands of general previously of the National Perinatal Epi- those requiring special and intensive paediatricians and that therefore the demiology Unit in Oxford. Some 17 care. board would not press for perinatal or multicentre trials are in progress. The BAPM has always been a pressure neonatal paediatrics to be recognised as Since the first annual founders’ lec- group, and its political clout has been a paediatric subspecialty for the pur- ture by Sir Peter Tizard in 1982, we have steadily increasing. However, there re- poses of accreditation. In fact, the break- listened to many distinguished speakers, mains some confusion stemming from through took six years to achieve. Our some 20 in all. All have become honorary the fact that our discipline lies halfway cause was helped by the publication of members. There are now 45 such mem- between the two Royal Colleges. Hope- Donald Court’s child health report Fit for bers; but, alas, eight are no longer with fully, the day will arrive when we become the future,8 which labelled the unneces- us: Peter Tizard, Alec Turnbull, Jean formally affiliated with the RCOG as we sarily high perinatal mortality as a holo- Boxall, Kenneth Cross, Geoffrey Dawes, are already with the RCPCH and when caust, and then in 1980 by the massive Leonard Strang, Jon Scopes, and David our executive committee then becomes 9 the source of advice on perinatal matters five volume “Short report” of the House Baum. David, a founder member, became to both Colleges. This will I am sure come of Commons Social Services Committee, President of the Royal College of Paediat- about in due course, but is likely to be which emphasised the gross neglect of rics and Child Health (RCPCH) in 1997. hastened if we increase our membership, perinatal medicine in this country, and He was an inspiration in so many ways especially of obstetricians, and if we have urged the recognition of the specialty and his death is a great loss to paediat- http://adc.bmj.com/ our own independent base. As long as and the immediate appointment of 50 rics as well as to perinatal medicine and the BAPM administrative office is consultant neonatologists. Officially to all of us personally. Some years ago he housed in the College of Paediatrics, as it there were still only 12 in the United wrote: “Perinatal medicine is the biggest is at present, we will be seen by obstetri- Kingdom at that time.9 Many gave most rapidly growing and effective spe- cians as a mainly paediatric organis- evidence to that committee and in cialty in paediatrics”. ation. So a major initiative in fund particular the BPA/RCOG Liaison Com- We have come a long way since our raising is required with a view to mittee prepared a discussion document Perinatal Group first met at the Bristol purchasing or renting our own accom- entitled “Recommendations for the im- Maternity Hospital (now St Michael’s modation. on September 25, 2021 by guest. Protected copyright. provement of infant care during the Hospital) just half a mile away. We now 5 We have moved into bewildering times perinatal period”, which had a major have some 550 members including 62 of high technology,11 but we must be very impact. But special credit must go to professors. Eight of the original 20 careful not to allow our clinical skills to who represented founder members are here today and atrophy as a result. The art of medicine neonatology on Reneé Short’s com- most of the remainder have sent their must not be submerged by science. Each mittee. apologies and their good wishes. As I will individual patient is unique and does not Another most important advance was be retiring shortly, I hope you will permit necessarily obey the dictates of a meta- 10 the Körner report in 1982. It gave me me to tell you of some of my hopes for analysis. Also we must never lose sight of particular satisfaction by recommending our Association in the years to come. those two cardinal precepts in medicine: that every newborn infant should in “Prevention is better than cure”, and future be identified as a patient from THOUGHTS ON THE FUTURE “First of all, do no harm”. Parturition is a birth and that there should be a mini- One of my keenest concerns is that we particularly fertile ground for iatrogen- mum data set for the baby as well as for all—obsetricians, midwives, paediatri- esis. For example, there is the rising the mother. At last, the 90% so called cians, and neonatal nurses—continue to prevalence of iatrogenic multiple preg- “normal” newborn babies not receiving work closely as a team.11 I believe we are nancy, the many routine interventions special or intensive care emerged from only likely to achieve this if we under- during labour, and the ever rising caesar- what John Ballantyne1 described in 1916 stand and share each other’s problems. ean section rate. We must, I believe, get as the “no-man’s land” between obstet- Joint clinics and ward rounds help. Even back to first principles and study the rics and paediatrics. better though would be the inclusion of wonderful physiology of childbirth and Tremendous progress has been made some obstetrics in the training of perina- fetal adaptation to extrauterine life, and in newborn care during the last 25 years. tal paediatricians and vice versa, as was do everything possible to avoid interfer- Smaller and smaller infants have sur- originally proposed 20 years ago. Alas, ence with normal mechanisms. vived with the help of intensive care, and the truncated Calman training pro- Once the baby is delivered, we must the perinatal mortality has fallen to a gramme and the current pressure of seize the opportunity to screen both

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4 Dunn PM. Perinatal statistics. In: House of

mother and baby for medical pathology, It is time for me to end. Perinatal Arch Dis Child: first published as 10.1136/adc.88.3.181 on 1 March 2003. Downloaded from for socioeconomic problems, for psycho- medicine is, I believe, the best of all the Commons Social Services Committee Session, 1979–1980. Second report: perinatal and logical stress, and for ignorance on medical disciplines. Of course it is stress- neonatal mortality. London: HMSO, parenting.12 Birth provides the most ful and of course there are problems at 1980;2:256–67. wonderful opportunity for screening a times, but there are also tremendous 5 British Perinatal Association/Royal College of Obstetrics and Gynaecology population and getting families off to rewards, and we should consider our- Liaison Committee. Recommendations for the best possible start. Every baby has selves very privileged to call ourselves the improvement of infant care during the the right to a skilled examination on the perinatal physicians. perinatal period. Discussion document. first day of life,13 and every mother has London: British Paediatric Association and Arch Dis Child 2003;88:181–184 Royal College of Obstetricians and the right to know at once the results of Gynaecologists, 1978. such an examination. As a discipline, it 6 The price of perinatal neglect [editorial]. is essential that paediatricians do not ...... Lancet 1974;1:437. 7 Dunn PM. The history of the British withdraw into their intensive care units. Authors’ affiliations Association of Perinatal Medicine, Equal attention and care should be P M Dunn, Emeritus Professor of Perinatal 1976–1999. In: British Association of given to all babies, wherever they are Medicine and Child Health, University of Bristol, Perinatal Medicine handbook, 2000–2001. Southmead Hospital, Bristol BS10 5NB, UK London, BAPM, 2000:9–11. born and however normal they may 8 Committee on Child Health Services. Fit appear to be. This paper was read at the BAPM 25th Jubilee for the future. London: HMSO, 1976. (Cmnd And if I may have one last wish it Scientific Meeting, Bristol, 8–9 September 6684, vols I and II).. 2000. 9 House of Commons Social Services is that we will, in future, take more Committee Session 1979–80. Second advantage of the school years to educate Correspondence to: Professor Dunn, Department report: perinatal and neonatal mortality. children on how best to live healthy of Perinatal Medicine and Child Health, London: HMSO, 1980. University of Bristol, Southmead Hospital, Bristol 10 National Health Service/Department of lives, how to prepare for pregnancy and BS10 7AD, UK; [email protected] Health and Social Security Steering Group childbirth, and how to bring up their on Health Service Information. First report of the Secretary of State, 1982. London: own families when the time comes. REFERENCES There are so many important lessons to HMSO:1–41. 1 Dunn PM. The development of newborn care 11 Dunn PM. Perinatal reflections. Prenatal and be learnt, the most important of which in the UK since 1930. American Academy of Neonatal Medicine 1998;3:367–70. are to avoid smoking, drugs, and pro- Pediatrics Thomas E. Cone Jr Lecture on 12 Dunn PM. Examination of the newborn infant miscuous sex, and the great advantages Perinatal History. J Perinat 1998;18:471–6. in the UK: a personal viewpoint. Journal of 2 Court D, Jackson A (eds). Paediatrics in the Neonatal Nursing 2002;7:55–7. of breast feeding. And in this task we seventies. Developing the child health 13 International Federation of Gynecologists need to enlist the help of the teachers services. London: , and Obstetricians (FIGO) Committee for and give them the necessary infor- 1972:45. the Ethical Aspects of Human 3 Expert Group on Special Care for Babies. Reproduction and Women’s Health. Ethical mation to pass on to children from a Reports on Public Health Medical Subjects no aspects of newborn care. London: FIGO, young age. 127. London: HMSO, 1971. 2000:43.

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