this finding. It is just as likely to be an error of diagnosis as an indication that hypertension is ever "self terminating." It is therefore dangerous to assume that the evidence provided in this short report proves that treatment can be stopped in patients who have genuine hypertension. We agree that further, larger studies are needed, but not necessarily of stopping treatment-rather, perhaps, of when to start. The problems of overdiagnosing hypertension have been recognised for some time.5 Perhaps the criteria for making a diagnosis should be stricter. Although the British Hypertension Society has laid down some guidelines,6 including the recommendation that several readings should be taken before the diagnosis is made, the period over which these readings should be taken was left rather vague. Perhaps hypertension should not be diagnosed in anyone until the blood pressure has been persistently raised for over one year. The benefits of treatment far outlast a year or two, while there is little to be lost by delaying treatment in the short term. We would make a plea that anyone who has been diagnosed as hypertensive at some time is evaluated at regular intervals indefinitely, regardless of whether treatment is continued or not. M A JAMES T J MACCONNELL
Bristol Royal Infirmary, Bristol BS2 8HW
Society is quick to condemn women with HIV infection for having children on the grounds of irresponsibility. The argument goes that the children will be infected, and that any who are not will be orphaned early. The most recent data on transmission suggest that the risk of one of these children being infected is less than one in seven,2 lower than the risk of many serious recessive disorders. Care of the uninfected child may not be an insurmountable problem - with current medical practice, many mothers can expect to survive into the child's adolescence or longer, and extended family networks are often able to support a motherless child. A woman who is infected with HIV requires counselling so that she can make an informed choice, but if she opts to have a child we must not be surprised or disapproving. She deserves the understanding she would get if she had any other potentially terminal illness, or had chosen to take the risk of any other congenital condition. Our job is to provide support to help her to enjoy the experience of motherhood as fully and as long as
possible. M HUENGSBERG C S BRADBEER
Department of Genitourinary Medicine, St Thomas's Hospital, London SE1 7EH
would be limited by several factors, recognised since 1977.4 Most importantly, the reduction in costs will come about only if beds freed are closed and staffing levels reduced. The authors do not estimate the effect of the change on the provision of beds. Finally, the cost to the patient is not necessarily lower with attendance at a day unit. All these factors must be considered and quantified before the authors can conclude that "this is a cost effective reorganisation." SARA TWADDLE
Department of Public Health, Glasgow Royal Maternity Hospital, Glasgow G4 ONA VALERIE HARPER
Department of Obstetrics and Gynaecology, University of Aberdeen, Aberdeen I Soothill PW, Ajavi R, Campbell S, Gibbs J, Chandran R, Gibb D, et al. Effect of a fetal surveillance unit on admission of antenatal patients to hospital. BMJ 1991;303:269-71. (3 August.) 2 Haworth EA, Balarajan R. Day surgery: does it add to or replace inpatient surgery? BM3' 1987;294:133-5. 3 Rosenberg K, Twaddle S. Screening and surveillance of pregnancy hypertension -an economic approach to the use of daycare. In: Hall NH, ed. Bailliere's clinical obstetrics and gynaecology. Vol 4. Antenatal care. London: Bailliere Tindall, 1990:87-107. 4 Russell IT, Devlin HB, Fell M, Glass NJ, Newell DJ. Day case surgery for hernias and haemorrhoids. Lancet 1977;i:844-7.
J WELCH Department of Genitourinary Medicine,
1 Avlett Ml, Ketchin S. Stopping treatment in patients with hvpertension. BAI3 1991;303:345. (10 August.) 2 Kannel WB, Gordon T, Offut D. Left ventricular hypertrophv by electrocardiogram. Ann Intern Mled 1969;71:89-101.
3 Jones JV, James MA. ACE inhibitors and the heart: hypertrophy, reversal and anti-arrhythmic effects. J Hum Hypertens 1990;4(suppl 4):23-7. 4 Australian Therapeutic Trial in Mild Hypertension. Report by management committee. Lancet 1980;i: 1261-7. 5 Medical Research Council Working Party. MRC trial of treatment
King's College Hospital, London SE5 9RS 1 Craft 1, Shapland D, Al-Shawaf T. Routine testing for HIV at infertilitv clinics. BMJ 1991;303:414-5. (17 August.) 2 European Collaborative Study. Children born to women with HIV infection: natural history and risk of transmission. Lancet
1991;337:253-60.
of mild hypertension: principal results. BMIJ 1985;291: 97- 105. 6 O'Brien E, O'Malley K. Overdiagnosing hypertension. B.J 1988;297: 121 1. 7 British Hypertension Society Working Party. Treating mild
Effect of a fetal surveillance unit
hypertcnsion. BAIJ 1989;298:694-8.
Routine testing for HIV at infertility clinics SIR,-Ian Craft and colleagues discuss the reasons for HIV testing in infertility clinics.' It appears from this letter that they believe that a woman who knows she has HIV infection would not want to conceive. We have not found this to be the case; indeed, some women have told us that knowing that they have HIV infection has made them decide to have children before it is too late. Currently 91 women with HIV infection are attending our two clinics in south east London. Although they knew their HIV status, 15 women had a total of 18 pregnancies resulting in nine babies, one miscarriage, and eight terminations. These terminations were predominantly for reasons unrelated to the women's HIV status. All the women who attend our clinics receive counselling about the risk of vertical transmission but, despite this, we find that many choose to have children; indeed, four more have sought medical help to become pregnant. Other workers have also found that HIV infection seems to play little part in decisions about pregnancy. (BJ Datel et al, seventh international conference on AIDS, Florence, 1991).
Women infected with HIV are usually in their peak reproductive years, their peers will be having children, and they will be expected to have children too. The pressures are often great, especially for those from cultures where a large number of children is the norm (demographic and health survey 1988-9, Ugandan ministry of health). Seven out of 15 (46%) of our women who have become pregnant are from Africa.
BMJ VOLUME 303
14 SEPTEMBER 1991
SIR,-We have been assessing the effects of a day care unit in the management of hypertension in pregnancy. Our work has shown that while there are considerable financial benefits from its use only in some groups of women, there are no detrimental effects on outcome and the clients of the system prefer day care to inpatient care. Mr P W Soothill and colleagues report a reduction in antenatal bed occupancy rates after the opening of a fetal surveillance unit. ' They conclude that this change in practice will result in substantial financial and social benefits and improve organisation, audit, teaching, and research. Evaluation of alternative forms of care is methodologically difficult, but this paper fails to address important issues. The patients were not shown to be similar in the two periods of study. The 22% reduction in bed occupancy rates was not shown to be significant. The antenatal admission rate remained stable even though on 85 occasions the referring doctor stated that the availability of the unit had prevented an admission (330 patients were referred). The unit may be generating its own demand, and this effect has been well documented.2" Teaching, research, and audit can be organised effectively from an antenatal ward and ultrasound department, and the authors fail to show how they will improve these objectives in comparison with
their previous organisation. The authors conclude that "the savings to be gained from a fetal surveillance unit are clear," calculating that a saving of £456 000, minus the unspecified cost of the unit, would be possible each year in a maternity unit with 4000 deliveries. Our work found that the average cost per inpatient day was £93.79 and that the cost of attendance at the day unit was £45.87 (in 1989 prices, excluding costs of tests and capital charges). The ability of the hospital to save the difference of £47.92 a day
AUTHORS' REPLY,-We are grateful for Drs Twaddle and Harper's interest in our paper on the value of a fetal surveillance unit and pleased that they report similar findings in their hypertension in pregnancy day care unit. There is no evidence of a change in the obstetric population in Camberwell over this period. The appropriate analysis for investigating the change in bed occupancy is comparison of the distributions of the lengths of individual admissions before and after the opening of the unit. This comparison was found to be highly statistically significant, and this is reflected in the 22% fall in the overall rates of bed occupancy per 100 deliveries. The failure to detect a reduction in the incidence of antenatal admissions, despite the statements of the referring doctors that admission had been deferred on 85 occasions and the decrease in antenatal bed occupancy, was explained in the paper. The patients were still admitted at some point in the pregnancy but for a shorter time (for example, closer to the time of delivery). The suggestion that the unit was simply generating extra work overlooks the reduction in antenatal bed occupancy and admission length. Improvements in the quality of teaching, research and audit are difficult to quantify. Although we agree that these objectives can be achieved within the previous system, our experience is that centralisation of investigation and concentration of high risk pregnancies into a fetal surveillance unit allows these to be more effective and efficient. We agree with Drs Twaddle and Harper that the financial costs to the patient and her family should be considered and disruption should not be underestimated. We also agree that the full potential financial savings will be difficult to achieve within the structure of the NHS for the reasons they describe. Our obstetric unit has, however, lost about 10% of its beds and the reduction in length of antenatal admissions described in the paper is likely to be an important reason for this having been possible. STUART CAMPBELL PETER SOOTHILL RICHARD AJAYI KYPROS NICHOLAIDES Department of Obstetrics and Gynaecology,
King's College Hospital, London SE5
FIONA REID Department of Public Health, King's College Hospital, London SE5
645
Bristol Royal Infirmary, Bristol BS2 8HW
Society is quick to condemn women with HIV infection for having children on the grounds of irresponsibility. The argument goes that the children will be infected, and that any who are not will be orphaned early. The most recent data on transmission suggest that the risk of one of these children being infected is less than one in seven,2 lower than the risk of many serious recessive disorders. Care of the uninfected child may not be an insurmountable problem - with current medical practice, many mothers can expect to survive into the child's adolescence or longer, and extended family networks are often able to support a motherless child. A woman who is infected with HIV requires counselling so that she can make an informed choice, but if she opts to have a child we must not be surprised or disapproving. She deserves the understanding she would get if she had any other potentially terminal illness, or had chosen to take the risk of any other congenital condition. Our job is to provide support to help her to enjoy the experience of motherhood as fully and as long as
possible. M HUENGSBERG C S BRADBEER
Department of Genitourinary Medicine, St Thomas's Hospital, London SE1 7EH
would be limited by several factors, recognised since 1977.4 Most importantly, the reduction in costs will come about only if beds freed are closed and staffing levels reduced. The authors do not estimate the effect of the change on the provision of beds. Finally, the cost to the patient is not necessarily lower with attendance at a day unit. All these factors must be considered and quantified before the authors can conclude that "this is a cost effective reorganisation." SARA TWADDLE
Department of Public Health, Glasgow Royal Maternity Hospital, Glasgow G4 ONA VALERIE HARPER
Department of Obstetrics and Gynaecology, University of Aberdeen, Aberdeen I Soothill PW, Ajavi R, Campbell S, Gibbs J, Chandran R, Gibb D, et al. Effect of a fetal surveillance unit on admission of antenatal patients to hospital. BMJ 1991;303:269-71. (3 August.) 2 Haworth EA, Balarajan R. Day surgery: does it add to or replace inpatient surgery? BM3' 1987;294:133-5. 3 Rosenberg K, Twaddle S. Screening and surveillance of pregnancy hypertension -an economic approach to the use of daycare. In: Hall NH, ed. Bailliere's clinical obstetrics and gynaecology. Vol 4. Antenatal care. London: Bailliere Tindall, 1990:87-107. 4 Russell IT, Devlin HB, Fell M, Glass NJ, Newell DJ. Day case surgery for hernias and haemorrhoids. Lancet 1977;i:844-7.
J WELCH Department of Genitourinary Medicine,
1 Avlett Ml, Ketchin S. Stopping treatment in patients with hvpertension. BAI3 1991;303:345. (10 August.) 2 Kannel WB, Gordon T, Offut D. Left ventricular hypertrophv by electrocardiogram. Ann Intern Mled 1969;71:89-101.
3 Jones JV, James MA. ACE inhibitors and the heart: hypertrophy, reversal and anti-arrhythmic effects. J Hum Hypertens 1990;4(suppl 4):23-7. 4 Australian Therapeutic Trial in Mild Hypertension. Report by management committee. Lancet 1980;i: 1261-7. 5 Medical Research Council Working Party. MRC trial of treatment
King's College Hospital, London SE5 9RS 1 Craft 1, Shapland D, Al-Shawaf T. Routine testing for HIV at infertilitv clinics. BMJ 1991;303:414-5. (17 August.) 2 European Collaborative Study. Children born to women with HIV infection: natural history and risk of transmission. Lancet
1991;337:253-60.
of mild hypertension: principal results. BMIJ 1985;291: 97- 105. 6 O'Brien E, O'Malley K. Overdiagnosing hypertension. B.J 1988;297: 121 1. 7 British Hypertension Society Working Party. Treating mild
Effect of a fetal surveillance unit
hypertcnsion. BAIJ 1989;298:694-8.
Routine testing for HIV at infertility clinics SIR,-Ian Craft and colleagues discuss the reasons for HIV testing in infertility clinics.' It appears from this letter that they believe that a woman who knows she has HIV infection would not want to conceive. We have not found this to be the case; indeed, some women have told us that knowing that they have HIV infection has made them decide to have children before it is too late. Currently 91 women with HIV infection are attending our two clinics in south east London. Although they knew their HIV status, 15 women had a total of 18 pregnancies resulting in nine babies, one miscarriage, and eight terminations. These terminations were predominantly for reasons unrelated to the women's HIV status. All the women who attend our clinics receive counselling about the risk of vertical transmission but, despite this, we find that many choose to have children; indeed, four more have sought medical help to become pregnant. Other workers have also found that HIV infection seems to play little part in decisions about pregnancy. (BJ Datel et al, seventh international conference on AIDS, Florence, 1991).
Women infected with HIV are usually in their peak reproductive years, their peers will be having children, and they will be expected to have children too. The pressures are often great, especially for those from cultures where a large number of children is the norm (demographic and health survey 1988-9, Ugandan ministry of health). Seven out of 15 (46%) of our women who have become pregnant are from Africa.
BMJ VOLUME 303
14 SEPTEMBER 1991
SIR,-We have been assessing the effects of a day care unit in the management of hypertension in pregnancy. Our work has shown that while there are considerable financial benefits from its use only in some groups of women, there are no detrimental effects on outcome and the clients of the system prefer day care to inpatient care. Mr P W Soothill and colleagues report a reduction in antenatal bed occupancy rates after the opening of a fetal surveillance unit. ' They conclude that this change in practice will result in substantial financial and social benefits and improve organisation, audit, teaching, and research. Evaluation of alternative forms of care is methodologically difficult, but this paper fails to address important issues. The patients were not shown to be similar in the two periods of study. The 22% reduction in bed occupancy rates was not shown to be significant. The antenatal admission rate remained stable even though on 85 occasions the referring doctor stated that the availability of the unit had prevented an admission (330 patients were referred). The unit may be generating its own demand, and this effect has been well documented.2" Teaching, research, and audit can be organised effectively from an antenatal ward and ultrasound department, and the authors fail to show how they will improve these objectives in comparison with
their previous organisation. The authors conclude that "the savings to be gained from a fetal surveillance unit are clear," calculating that a saving of £456 000, minus the unspecified cost of the unit, would be possible each year in a maternity unit with 4000 deliveries. Our work found that the average cost per inpatient day was £93.79 and that the cost of attendance at the day unit was £45.87 (in 1989 prices, excluding costs of tests and capital charges). The ability of the hospital to save the difference of £47.92 a day
AUTHORS' REPLY,-We are grateful for Drs Twaddle and Harper's interest in our paper on the value of a fetal surveillance unit and pleased that they report similar findings in their hypertension in pregnancy day care unit. There is no evidence of a change in the obstetric population in Camberwell over this period. The appropriate analysis for investigating the change in bed occupancy is comparison of the distributions of the lengths of individual admissions before and after the opening of the unit. This comparison was found to be highly statistically significant, and this is reflected in the 22% fall in the overall rates of bed occupancy per 100 deliveries. The failure to detect a reduction in the incidence of antenatal admissions, despite the statements of the referring doctors that admission had been deferred on 85 occasions and the decrease in antenatal bed occupancy, was explained in the paper. The patients were still admitted at some point in the pregnancy but for a shorter time (for example, closer to the time of delivery). The suggestion that the unit was simply generating extra work overlooks the reduction in antenatal bed occupancy and admission length. Improvements in the quality of teaching, research and audit are difficult to quantify. Although we agree that these objectives can be achieved within the previous system, our experience is that centralisation of investigation and concentration of high risk pregnancies into a fetal surveillance unit allows these to be more effective and efficient. We agree with Drs Twaddle and Harper that the financial costs to the patient and her family should be considered and disruption should not be underestimated. We also agree that the full potential financial savings will be difficult to achieve within the structure of the NHS for the reasons they describe. Our obstetric unit has, however, lost about 10% of its beds and the reduction in length of antenatal admissions described in the paper is likely to be an important reason for this having been possible. STUART CAMPBELL PETER SOOTHILL RICHARD AJAYI KYPROS NICHOLAIDES Department of Obstetrics and Gynaecology,
King's College Hospital, London SE5
FIONA REID Department of Public Health, King's College Hospital, London SE5
645
