Editorial: Obstetrics and culture

August 1, 2007

American physicians view disease as an alien invader that must be defeated at all costs-thus phrases like "beating cancer" and "the war on cancer" capture the public's imagination.

Key Points

BUT BEFORE YOU GET TOO SMUG about the plight of our internist colleagues, consider just how enthusiastically American obstetricians have embraced expensive technologies without substantial supportive clinical trials. Take for example, antenatal fetal testing. The use of nonstress tests (NSTs) in patients considered to be at increased risk for stillbirth has been almost universally accepted by American obstetricians without any substantial evidence of efficacy. Indeed one meta-analysis of four studies involving 1,588 at-risk pregnancies found a trend toward increased perinatal deaths in the cardiotocography group (OR 2.85, 95% CI; 0.99–7.12)!3 Similarly, most obstetricians order at least one ultrasound scan on low-risk patients, and many order several. Yet the only US randomized trial found that universal ultrasound screening did not significantly reduce adverse perinatal outcomes.4

WE ALSO OVERUSE MEDICATIONS. Many US obstetricians still employ maintenance tocolytics despite compelling evidence of its futility in preventing prematurity and/or reducing perinatal mortality.5 Appreciating that a single course of corticosteroids given within 7 days of a preterm delivery reduced the sequelae of prematurity, we rushed into providing weekly courses in women at more marginal risk only to discover they don't help.6 Between 1990 and 2004, the induction of labor rate in the US increased from 9.5% to 21.2% without clear evidence of benefit to mother or child.7 Then there is our national cesarean delivery rate. In less than a decade, from 1996 to 2005, rates climbed nearly 50% from 20.7% to 30.2%, again without strong evidence of improved maternal or fetal outcomes.8

SOME OBVIOUS EXPLANATIONS come to mind. Since we are paid per procedure, we are more likely to perform them. The more CPT codes we can ring up, the bigger our paychecks. In addition, our "customers" generally do not directly pay for each service and so are fully incentivized to want the latest and best diagnostic tests, medications, or interventions, regardless of cost. Then there is the professional liability insurance crisis. We are less likely to be sued for "doing" something than for failing to do something. How many US obstetricians are sued for unnecessary cesarean deliveries, ordering too many ultrasounds or NSTs, or for prolonging tocolysis?