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EDITORIALS: James F King Obstetric interventions among private and public patients BMJ 2000; 321: 125-126 [Full text]

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Money,private sector and corrupt Obstetricians

Jayantha Ilangaratne   (21 July 2000)

Bumblebees do fly

Malcolm John Dickson   (26 July 2000)

Money,private sector and corrupt Obstetricians 21 July 2000
Jayantha Ilangaratne, Doctor Send response to journal: Re: Money,private sector and corrupt Obstetricians	Many will find it hard to disagree that surgical interventions in Obstetrics are commoner in the private sector.As this editorial confirms[1],there is good evidence that non-clinical indications account for a considerable amount of such interventions.Based on Australian evidence[1],probably it is reasonable to conclude that same pattern of private Obstetric interventions prevails elswhere,including the UK private sector.The pressure put upon by some patients on clinicians must be a reason for such surgical intereventions during pregnancy;'too posh to push' must be included in this category.Also there must a group of corrupt Obstetricians in the private sector who collude with others(including Anaesthetists), knowing the financial rewards that come with such surgery.We all know the 'additional bonuses' that the private sector offers.In fact,such corrupt practices do not just involve doctors in the developed world.A little known medical journal from India,Issues in Medical Ethics[2] gives a succinct account of 'medical corruption' in the Indian private-medical sector,and the inducements offered to doctors.Do similar things happen in the UK?. REFERENCES [1]Obstetric interventions among private and public patients James F King BMJ 2000; 321: 125-126. [2] http://www.healthlibrary.com/reading/ethics/april- june2000/campaign.html
Bumblebees do fly 26 July 2000
Malcolm John Dickson Send response to journal: Re: Bumblebees do fly	Editor - I read with interest King's editorial (1) regarding the higher rate of caesarean sections in women having private obstetric care when compared to women having public obstetric care (2) . He concludes that any benefit from these those interventions is not supported by reliable evidence. This implies that women and their babies with private obstetric care are disadvantaged, compared to women having public obstetric care. If is the case, it is surprising to learn that 31.6% of the population studied still pay for private obstetric health care. Evidence based medicine (EBM) has brought great advances in clinical practice. In circumstances where there are hard outcomes to measure against a limited set of variables, EBM reigns supreme. A striking example of this is the reduction in vertical transmission rates of HIV from an infected mother to her child if she has a caesarean section prior to the rupture of membranes, takes antiviral medication and does not breastfeed, when compared to an infected mother who has a vaginal delivery, doesn't receive antiviral medication and breastfeeds. Substantial benefit is clearly demonstrated by controlled trials. When softer and more intangible variables are introduced to an equation, firm answers are harder to arrive at. A woman who has had an unexplained stillbirth at term has no evidence to contradict her going 10 days overdue in her next pregnancy and aim for a spontaneous vaginal delivery. And yet, despite whatever any evidence is presented to that woman, she will not rest easily in her next pregnancy until the baby is born. If offered the choice, she may well wish an elective caesarean section as soon as she has gotten to her 38th week of pregnancy. And willingly accept the drawbacks of this decision. Similarly, a woman who has had a previous unpleasant vaginal delivery may well request an elective caesarean section as the mode of delivery in her next pregnancy. Despite there being reliable evidence that subsequent deliveries are quicker, and associated with reduced perineal trauma, it is not unreasonable to accede to her wishes so that the nine months of her pregnancy are not marred by the dread of labour. Perhaps these are extreme examples. Practicing obstetricians are, and should be interested in information presented to them that demonstrates practice that may confer benefit to their patients. As medical practitioners they are also aware that accepted clinical practice is dynamic and changes year by year. As clinicians they are aware that scientific observations recorded from a large cohort may not necessarily translate well to the individual persons. James mentions that the Cochrane systematic review indicates that vacuum extraction is associated with less perineal trauma than forceps delivery (3) . That may be so, but that is only one of many aspects to consider when comparing different modalities of assisted vaginal delivery. That is why those familiar and skilled in the use of the obstetric forceps would be better advised to continue their use of the forceps rather than changing to a new technique such as vacuum extraction with which they are unfamiliar and inexperienced. It is said that in theory bumblebees should not fly. In reality, they do. Clinicians are well advised to remember this. So too, should commentators when urging changes in others clinical practice. All the more so when evidence used to support their arguments is not necessarily as complete or comprehensive as it could be. Malcolm John Dickson 1. King F J. Obstetric intervention among private and public patients. BMJ 2000;321:125-6 2. Roberts CL, Tracy S, Peat B. Rates for obstetric intervention among private and public patients in Australia: a population based descriptive study. BMJ 2000;321:137-41 3. Johanson RB, Mennon BK. Vacuum extraction versus forceps delivery for assisted vaginal delivery. In:Cochrane Collaberation. Cochrane Library. Issue 2. Oxford: Update Software, 2000