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Advice on oxytocin use may be premature
- Jennifer Ball (11 May 2000)
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Jennifer Ball, Medical Student Newcastle University Medical School
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Dear Editor, Ellis et al. report the risk factors for neonatal encephalopathy in Nepal. We admire the pioneering nature of this case-control study in a country with limited resources. However, we have a few concerns. Firstly, an objective of the study was to identify variations in risk factors between high and low income populations. However, we suspect that the lowest income mothers were excluded from the study due to the user charge of the maternity unit and because the hospital served the urban area and not the outlying rural areas where the poorest people live. Therefore, the results of the study may not apply to the poorest populations in Nepal. Secondly, it is not clear whether doctors were blinded to intrapartum events. This could introduce bias when grading encephalopathy, for example if a doctor was aware of a difficult birth, he/she may be more inclined to diagnose encephalopathy. This could create a spurious association. We commend the testing of interobserver reliability but note only five doctors were assessed. Also, it appears that the assessment was only performed at one point in time, yet the study took place over 18 months. For these two reasons we question whether this was a sufficient assessment. Finally, the study concludes that "the use of oxytocin in low income countries …. presents a major risk to the foetus". We question this conclusion because of the lack of statistical adjustment for other intrapartum risk factors. For example, oxytocin may have been used during pregnancies which were already high risk and it may have been this and subsequent foetal distress that was associated with neonatal encephalopathy, rather than the oxytocin per se. To resolve this problem, we suggest multivariate adjustment to demonstrate the independent effect of intrapartum variables. We conclude that further research is needed before clinical recommendations are proposed. Yours sincerely, Jennifer Ball, Caroline Flisher, Gemma Jones, Julia Rahman
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