Re: Use of a postoperative pad test to identify continence status in women after obstetric vesicovaginal fistula repair: a prospective cohort study

Sir, We wish to thank Matsubara et al. for their comments relating to our article. We agree wholeheartedly that risk needs to be communicated to the patient and her partner whether she is undergoing surgery for AIP or considering pregnancy with underlying complex maternal heart disease. A recent UK ruling from the Supreme Court has brought this to the forefront and clearly demonstrates that we can no longer practise medicine in a paternalistic fashion. All the authors of our paper have had individual experience counselling women undergoing very high-risk pregnancies, and we feel that women must to be provided with clear, accurate information that includes all aspects, even when that might cause anxiety. Nothing less than this is acceptable. Ultimately, whatever our personal choices would be, it is the prerogative of the woman to decide her future, and she must then be supported positively no matter what decision she decides to make. Occasionally this will lead to maternal mortality but it is not for the attending doctor to make value judgments about an individual woman’s own decisions. Working in highly collaborative multi-disciplinary teams helps to ensure that the management of these challenging cases is in line with best international standards, and the psychological burden to the individual of managing such cases is reduced by being shared. We are reminded by a recent high profile case in the UK that maternal death from obstetric haemorrhage still continues, and will do so despite the best interventions from medical staff. Nevertheless, we appreciate that the media and society often look to apportion blame even when the judicial ruling is that there is none to be allocated. We must therefore make every effort to support staff who are ‘caught up’ in such circumstances so that they themselves do not become victims.