Rapid Responses to:

EDITORIALS: Ana Langer and Jos Villar Promoting evidence based practice in maternal care BMJ 2002; 324: 928-929 [Full text]

Rapid Responses: Submit a response to this article

Rapid Responses published:

Ask women, not researchers, for birth's truest answers

Leilah McCracken   (21 April 2002)

Promoting evidence based practice in maternal care

Donna Young, don't know   (21 April 2002)

Demand for caesareans should be assessed rather than inferred

Joseph E Potter, Kristine Hopkins   (22 April 2002)

No change

Bernard H Fookes   (23 April 2002)

Nurses Stop Looking the Other Way

Carolyn Rafferty   (23 April 2002)

Natural function, not an illness

Bonnie B. Matheson   (24 April 2002)

Remote consequences of Caesarean section

Martin Quinn   (24 April 2002)

Financial and Non-Financial Reasons

William D. Savedoff   (24 April 2002)

Caesarean section: misinformed choice or lack of alternatives ?!

Hora Soltani, Sheila McFarlane   (25 April 2002)

The Missing link?

Jennifer s. Hall   (25 April 2002)

casarian section more misused than used

Badakere c Rao, Bangalore 560008.India   (25 April 2002)

Time for adequate counselling

Dr.Geeta.K. Tadimalla   (26 April 2002)

Paternalism and political correctness

Richard D Seigne   (14 May 2002)

Improving quality of childbirth experience may reduce demand for Caesarean sections.

Helen J Smith, Paul Garner, Kassam Mahomed, Qian Xu   (15 May 2002)

Enrich health care resources through midwifery

Laura Cao-Romero   (30 June 2002)

Spread of World Health Organization Reproductive Health Library Information to Doctors in India

Sridhar CB, Deena Suresh   (20 November 2002)

Ask women, not researchers, for birth's truest answers 21 April 2002
Leilah McCracken, childbirth writer/researcher Vancouver, Canada Send response to journal: Re: Ask women, not researchers, for birth's truest answers	Thank for addressing the incredibly important issue of the general obstetrical tendency toward violence against women. The overwhelming "answer" for so many childbirth challenges and questions has been "let's cut her"- cut a perineum, cut a c-section incision- touch warm flesh with surgical steel rather than with compassion and humanness. The pain and disability resulting from surgical birth is breathtaking; and women's pain must be realized, and understood. Thank you for taking the first steps in that. It is my wish though that women themselves will be talked to regarding what they experience in their births, rather than having researchers go through endless erudite, academic loops. Birth is a simple, basic human issue- and one that is most logically addressed in the warm, elemental way that it is best given. Medicalizing birth, as you have shown, is not the evidence-based answer to all childbearing questions- nor is the medicalization of the discussion of birth issues. Talk to the women themselves for the answers you seek- mothers know more than anyone about birth. If one wants to hear women's own voices regarding their birth experiences, they can go to www.birthlove.com and read hundreds of birth stories from women having all sorts of birth experiences- from elective c-sections to unassisted home births. Women, not evermore researchers and physicians, hold birth's truth: between their legs, in their hearts and in their minds. Please stop looking beyond them for childbirth answers. Leilah McCracken
Promoting evidence based practice in maternal care 21 April 2002
Donna Young, don't know V1G 4H4, don't know Send response to journal: Re: Promoting evidence based practice in maternal care	Hi, please visit these web sites. From my own research doctors do NOT want to communicate with any persons' investigation or research on their practice or knowledge. My web site of concerns of practices done in secret, hidden possible motives, and failure to keep records of treatments, such as the timing of the clamping of the infant's lifeline and how much blood was deprived the baby go along with failure to research best practice possible. My web site is: www.123babybirth.com This following is a medical web site by research and knowledge and personal experience of the doctor trying to re-educate other doctors. see: www.cordclamping.com Thank you for a reply. Sincerely, Donna Young Box 504 Dawson Creek, BC V1G 4H4 Canada
Demand for caesareans should be assessed rather than inferred 22 April 2002
Joseph E Potter, Professor Population Research Center, 1800 Main Building, University of Texas, Austin, Texas 78712 USA, Kristine Hopkins Send response to journal: Re: Demand for caesareans should be assessed rather than inferred	In several recent papers, we and others have presented evidence that in Brazil consumer demand for caesarean sections is much lower than previously assumed and that most caesarean sections are unwanted.(1-4) Langer and Villar (5) state the results reported by Behague, Victora and Barros (6) contradict these findings. We are surprised by this assertion. First, Behague et al. make no reference to our papers. Second, despite using the term consumer demand in their title, Behague et al. (6) do not actually present an estimate of the demand for caesarean sections in the population they studied, that of mothers giving birth in 1993 in a medium sized city in the very southernmost state of Brazil. The only statistic they present that relates to demand is the proportion of a sub-sample of 80 mothers who in retrospective interviews stated that when they went to the hospital, they expected to deliver by caesarean section. A woman's expectation of type of delivery may have little to do with the type of birth she would prefer. This is especially true in the private sector where, typically, the majority of caesareans are scheduled, and the decision to operate is taken some time before the woman departs for the hospital to give birth. Also puzzling is Behague et al.'s failure to distinguish their sample according to sector of care. Studies in Brazil and elsewhere (7) have shown the dramatic differences in caesarean section rates depending on whether the woman delivered in the public (25%-30% c-section rates) or private sector (70% rates). Our most striking finding was that despite these large differences in rates, there were no significant differences in women's preferences for vaginal delivery, about 80% across the board. (3) While the remaining 20% who prefer caesarean section certainly represents many women in Brazil, they are by no means the majority. We commend Behague et al. (6) for giving voice to the women who prefer caesarean section and for unpacking some of the reasons for why they may actively seek them out. Notably absent from their discussion, however, is tubal ligation, one of the primary reasons women, especially poor women, actively seek to deliver by caesarean section in Brazil. Among the majority of the approximately 3000 women in the new studies who stated their preference for vaginal delivery, the most frequently expressed reason from both rich and poor women was that vaginal delivery affords a faster recovery (followed by "it's more natural"). (1-4) A faster recovery is especially important for poor women who, medicalized attitudes or not, know they would have little support to look forward to if they were to be recovering from a caesarean section. Perhaps the most troubling aspect of the analysis by Behague et al. is that, lacking a direct assessment of demand for caesarean delivery or information on how and when the decision to operate was taken, they proceed to infer demand on the basis of differentials in caesarean rates according to different characteristics of the women in their sample. Recent research has shown that such differentials can be seriously misleading. (1-4, 7) 1. Hopkins K. Are Brazilian women really choosing to deliver by caesarean? Soc Sci Med 2000; 51: 725-40. 2. Perpétuo IHO, Bessa GH, Fonseca MC. In: Parto cesáreo: uma análise da perspectiva das mulheres de Belo Horizonte. XI Encontro Nacional de Estudos Populacionais da Associação Brasileira de Estudos Populacionais (ABEP), Caxambú, MG (1998), pp. 95-119. 3. Potter JE, Berquó E, Perpétuo IHO, Leal OF, Hopkins K, Souza MR, and Formiga MCC. 2001. Unwanted caesarean sections among public and private patients in Brazil: prospective study. BMJ 2000; 323: 1155-1158. 4. Osis MJ, Pádua KS, Duarte GA, Souza TR, Faúndes A. The opinion of Brazilian women regarding vaginal labor and caesarean section, Int J Gynecol Obstet 2001; 75 (Supplement 1): S59-S66 5. Langer A, Villar J. Promoting evidence based practice in maternal care would keep the knife away. BMJ 2002; 324: 928-929. 6. Béhague DP, Victora CG, Barros FC. Consumer demand for caesarean sections in Brazil: population based cohort study linking ethnographic and epidemiological methods. BMJ 2002; 324: 942-945 7. Murray SF. Relation between private health insurance and high rates of caesarean section in Chile: qualitative and quantitative study. BMJ 2000; 321: 1501-1505.
No change 23 April 2002
Bernard H Fookes, Retired Send response to journal: Re: No change	In Medicine it is all change: & sometimes not! At the time of the controversy between Professor Savage & her colleagues, I spent some time, while waiting for a meeting to start, browsing through copies of "The Lancet" for the year of my birth, 1932. Much was devoted to discussing the rival merits of different spa waters, though there was no mention of a control group offered distilled water! The rest described the high inidence of maternal mortality at the two ends of the socio- economic scale. The poor had no ante-natal care, & died; the rich had Caesarian sections, & died, death being attributed to anaesthesia.
Nurses Stop Looking the Other Way 23 April 2002
Carolyn Rafferty, Executive Director ANACS,Inc 20901 Send response to journal: Re: Nurses Stop Looking the Other Way	Every nurse on a labor and delivery unit sees first hand the practice gaps that exist. Why not look at them closer? Why not be a patient advocate? Why is it that we just follow the orders, in many cases without questioning? If nurses, as a profession, desire to be seen as colleagues and fellow scientists then we must take responsibility for our actions. If we all know that the unneeded interventions in maternal child health are increasing and the evidence suggests the opposite of our protocols in any instance why are we not forming groups to look at this in every hospital? When the doctor sends us an induction at 37 weeks for "impending labor" why don't we scream...WHAT!! you can't be serious. MD's still have tremendous political power within the workplace( hospitals)and they are the revenue source for the hospitals. "Women", they say, "are begging for inductions" and though this may be the case..what are the OB's doing to teach the women that this isn't in their best interest? "We try to tell them" I have been told... "but they keep asking...like a broken record. "This is consumer driven" I am told by OB's. Well, you know if the OB didn't get anything out of the interventions being performed on women routinely the rate of intervention in low risk birth would decline. It is a conflict of interest for those that benefit from the interventions either financially or by the predictability in scheduling, or management of labor to be the ones teaching the women or emphasizing the need to learn about labor intervention risks and benefits. The Association of Nurse Advocates for Childbirth Solutions (ANACS) challenges nurses to find solutions to the practice gaps and to teach women in every conversation you have with a childbearing age woman to think about these issues. We believe nurses have a responsibility to reach out to other nurses and talk about what is happening in childbirth today. We believe women need to take more responsibility for what happens to them by learning more about pregnancy and childbirth. Invest in the process like they would a large financial purchase! The Thinking Woman’s Guide to Better Birth by Henci Goer should be every woman’s first purchase when contemplating or achieving pregnancy.
Natural function, not an illness 24 April 2002
Bonnie B. Matheson, CEO & President of ChildbirthSolutions, Inc. ChildbirthSolutions, Inc. PO Box 1023 Marshall, Virginia 20115 Send response to journal: Re: Natural function, not an illness	Childbirth deserves our respect and awe not "Management". It is a natural function that has been medicalized to the point of danger for both mother and child. Induction is rampant and wrongheaded. Nature has a plan for birth that does not have a time table we can depend on or second guess. Just as spring can be early or late and still be spring, birth timing is completely individual and unique to each baby and mother. Of course there is variety. It is not to be feared but rather to be embraced and calmly anticipated. Women who want to experience birth in all of its miraculous eventualities tell of wondrous tales with very, very different sets of circumstances. No two births are alike. Just as no two babies or mothers are. Why has it become necessary to try to standardize this most miraculous event? It does not better the outcome. Listen to women when they talk of their birth experiences. So many have no feeling of empowerment. Their experiences were orchestrated by the caregivers whose ideas superceded their own. Many times births are managed in such a way that the needs of the caregiver are met, not those of the mother and least of all the baby. I have devoted my life to trying to wake women up to the fact that it is their choice. Women must educate themselves. Caregivers do not necessarily give them all the facts nor tell them about all their options.My company ChildbirthSolutions, Inc. has a website at www.childbirthsolutions.com full of information and stories for women who want to learn all their is about birth options. Options in childbirth are essential. Birth is far too individual an act to standardize. There is NO "one size fits all" type of birth experience. Many women insist on knowing about all that is available to them. Many women orchestrate their own birthing experiences. But too few know enough to do this with the first baby. Often it is an angry response to some horrible experience of disempowerment that occurred during the birth of their first child that leads a woman to seek something better with her next and succeeding babies. It is my hope that in the 21st Century women will reclaim birth. This is entirely up to them. If enough women decide they have had enough of unempowered birth, they will be able to make sweeping changes in the way birth is perceived and carried out. Let's hope they do this soon!
Remote consequences of Caesarean section 24 April 2002
Martin Quinn, Cons Obstetrics & Gynaecology Hinchingbrooke Hospital PE29 6 NT Send response to journal: Re: Remote consequences of Caesarean section	Any uterine incision that extends to interrupt the lateral neurovascular bundle threatens the innervation of the anterior uterine wall above this level. Recurrent, preterm and late Caesarean section may be frequent causes. Focal, hyperechoic changes of the anterior uterine wall may reflect disruption of the normal vascular patterns. Severe adenomyosis is strongly associated with uterine denervation (1) and may require hysterectomy in later life (another denervatory event). Disruption of myofascial pelvic supports during labour inevitably damages branches of the inferior hypogastric plexi (denervation) and may create the conditions for reinnervation. Collateral sprouting and chaotic, small-diameter nerve fibres have been identified in uterus, vagina, vulva, uterosacral ligaments and bladder (2). Chronic pelvic pain, menstrual dysfunction, dysmenorrhoea, dyspareunia, irritative bladder and bowel symptoms are the contemporary labels for these consequences. Both abdominal and vaginal delivery carry clear though unquantified threats to the pelvic innervation. The epidemic of teenage pregnancy is bringing serious gynaecological problems to the clinic in women under the age of twenty five. What happens to a woman during her first delivery (abdominal or vaginal) may place her on a trajectory of pain and misery for the rest of her life. If Brazilian women were aware of these concerns would they submit themselves to Caesarean section in their present numbers (3) ? Obstetric fashion needs to be replaced by robust facts about the remote consequences of different patterns of labour and delivery. Comprehensive and appropriate datasets are available; some better questions may have to be asked ? MJ Quinn, MD, MRCOG, Hinchingbrooke Hospital, Huntingdon, PE29 6NT. martin.quinn@hbhc-tr.anglox.nhs.uk (1) Differences in uterine innervation at hysterectomy. MJ Quinn, N Kirk, MC Slack, MD Harris. Presented at Society of Gynecological Surgeons, Dallas, March 2002. (2) Obstetric denervation – Gynecologic reinnervation MJ Quinn, N Kirk, MC Slack, MD Harris. Am J Obstet Gynecol 2002;, Jan; 186(1):168. (3) Consumer demand for caesarean sections in Brazil: population based birth cohort study linking ethnographic and epidemiological methods. Behague DP, Victora CG, Barros FC, BMJ 2002; 324:942-945.
Financial and Non-Financial Reasons 24 April 2002
William D. Savedoff, Health Economist WHO, Geneva, Switzerland Send response to journal: Re: Financial and Non-Financial Reasons	I was also surprised by the assertion in the editorial that Béhague, et al, "contradict" studies that indicate most cesareans are unwanted. The way that I interpret Béhague, et al, is quite consistent with the other studies. Béhague, et al, show that in a social context in which rich woman overwhelmingly have cesareans, poor women interpret cesareans as "better medical care" and therefore actively seek it out. But this doesn't answer why the prevalence of Cesarean sections is there in the first place. Financial incentives are the most logical explanation for huge gaps between private hospitals (with generally wealthier lower risk mothers) and public hospitals (who admit mothers with less income and are reimbursed less for Cesareans). Once patterns are established for the wealthy, it is not surprising to see a shift in preferences in the rest of the population. Most of the literature on how financial incentives (and doctor's convenience) affect cesarean rates comes from the United States and Brazil. However, a recent study in Peru confirms that after controlling for a variety of risk factors, hospital ownership and payment mechanisms have a statistically significant impact on the decision to do a cesarean. See Lorena Alcázar and Raúl Andrade "Induced Demand and Absenteeism in Peruvian Hospitals", Ch. 5 in R. Di Tella and W. Savedoff, *Diagnosis Corruption: Fraud in Latin America's Public Hospitals*, Inter-American Development Bank, Washington, DC, 2002.
Caesarean section: misinformed choice or lack of alternatives ?! 25 April 2002
Hora Soltani, Lead Research Midwife Derby City General Hospital, Uttoxeter Road, Derby, DE22 3NE, Sheila McFarlane Send response to journal: Re: Caesarean section: misinformed choice or lack of alternatives ?!	It is encouraging to see such reports are published to address true challenges in maternity care. The misuse of power, authority and knowledge by some health care providers are real issues which have not even been considered as a problem in some developing countries. All the issues raised in the above paper such as the social gap between the consumers and providers, poor labour care (e.g. lack of access to effective pain relief) leaves women to accept or even to choose the most invasive methods of labor. Anecdotally, the caesarean section mode of delivery is sold to women as a cosmetically superior option to the normal labor! As sad as it looks in some countries, the choice of caesarean section is followed as a fashion and in public belief it is used as a measure of one’s wealth and fortune! The informed choice is not even an option for many women attending overcrowded clinics. The financial gains and convenience of an elective caesarean section as opposed to a demanding, unpredictable sometimes sleep disturbing labor and delivery care for some health professionals may outweigh a conscious and just choice for mothers. This also highlights the inherited dangers of private health system where the health care professionals directly benefit from consumer’s choices of treatment and allows opportunities to exploit vulnerable groups! We welcome the authors’ suggestion in integrating developing countries publications and introducing rigorous changes to improve women’s condition and health worldwide. It certainly is time for World Health Organisation to take a more proactive role in introducing more systematic approaches to promote evidence based practice and informed choice globally.
The Missing link? 25 April 2002
Jennifer s. Hall, Visiting Lecturer, Midwifery and Clinical Editor, The Practising Midwife University west of England BS16 1DD Send response to journal: Re: The Missing link?	It is pertinent that there should be a continued effort to reduce Caesarean section rates worldwide. It was surprising however to find the authors had missed a key factor in reducing caesarean section rates- something that was highlighted recently in the journal (Has the Medicalization of birth gone too far? Johansson R Newburn M MacFarlane A BMJ 2002 324 892-895). That is the contribution of one-to-one support in labour- ideally a relationship between caregivers that has developed during the antenatal period. Of course if women have devloped this relationship with an Obstetrician and built up trust she will listen to him when he sugggests she pays for a caesarean section as well. Where women have bulit up relationships with midwives they are more likely to end up with a normal birth.
casarian section more misused than used 25 April 2002
Badakere c Rao, General practitioner Apoorva diagnostic centre,CMH Road,Indiranagar,, Bangalore 560008.India Send response to journal: Re: casarian section more misused than used	OVER YEARS IN URBAN INDIA THE CONFINEMENT HAS SHIFTED FROM HOME TO THE HOSPITAL WHERE THE PREGNANT WOMAN WHO IS MIDDLE CLASS AND SOME TIMES BELONGING TO UPPER ECONOMIC GROUP GENERALLY OPTS FOR ONE OR TWO CHILDERN, IT IS EASY TO MOTIVATE THEM TO HAVE SESARIAN SECTIONS. sUCH SUREGERIES EVEN IN WOMEN WHO WOULD HAVE DELIVERED NORMAL BABIES IS ON THE INCREASE.In one recent study it is more than 40% The reasons are obious apart from definite indications the main indication is money. The sad part of it IS THAT no body seem to protest much less the hapless patienT. The community doctors have no say as these deliveries occur in the institutions. IT IS DIFFICULT TO REVERSE THIS TREND IN THE PREVAILING SOCIO ECONOMIC SCENARIO AND FALLING ETHICAL STANDARDS IN THIS COUNTRY,
Time for adequate counselling 26 April 2002
Dr.Geeta.K. Tadimalla, Reistrar Obstetric and Gynaecolgy. Saudi Arabia Send response to journal: Re: Time for adequate counselling	Though it is a well noted fact that women's request for a caesarean delivery is one of the contributing factors in the increasing caesarean rates world over, it is definitely surprising to know about the underlying reasons for such requests. However in my own place of work we face a totally different kind of problem. Here women insist on vaginal birth in the face of well recognised medical or obstetric indications for ceasarean birth. There are incidences where we were helpless in the face of a woman's consent for a caesarean delivery with previous two caesarean deliveries , and had to be mute observers of vaginal delivery, anticipating the dreaded complication of a uterine rupture. Most of these obsessive women belong to lower educational status and grandmultiparity. Does it all go to emphasise that lack of education makes them endanger their lives with dogmatic decisions, just as a higher education too makes them take an irrational decision? In the light of the above facts I feel the health care providers have a great role in adequate counselling regarding the indications for caesarean birth.
Paternalism and political correctness 14 May 2002
Richard D Seigne, Consultant Anaesthetist Christchurch Hospital, Christchurch, New Zealand Send response to journal: Re: Paternalism and political correctness	We are often reminded by the BMJ to loosen our paternalistic grip on the patient, to put patients first and to encourage patients to make informed decisions about their care. The editorial by Langer and Villar1 suggests that when women make decisions that do not conform to the evidence as we perceive it that they must be making this decision for the wrong reason - "to avoid negative side effects" rather than "from a positive attitude based on accurate information...". They imply the women's choice is therefore incorrect and we should attempt educate the women to choose the correctly. Perhaps in Brazil the quality of care for a caesarian section is better than that for other methods of delivery and the women are making a valid informed decision whether we like it or not. Of course this may not be the case. In either scenario unfortunately the human mind does not conform to the logic that given certain information we will all choose the "right" answer, assuming there is a body of opinion that can decide exactly what the "right" answer is! When patients make the "wrong" informed choice then out of the swirling mists of political correctness appears paternalism, it had never left us. Reference. 1. Langer A, Villar J. Promoting evidence based practice in maternal care. BMJ 2002; 324: 928-929 Yours sincerely Dr. Richard Seigne
Improving quality of childbirth experience may reduce demand for Caesarean sections. 15 May 2002
Helen J Smith, Research Associate International Health Research Group, Liverpool School of Tropical Medicine, L3 5QA, UK, Paul Garner, Kassam Mahomed, Qian Xu Send response to journal: Re: Improving quality of childbirth experience may reduce demand for Caesarean sections.	Sir-Béhague and colleagues found that women want Caesarean sections in developing countries partly to avoid pain (1). We have some data that show severe pain during childbirth is common in developing country institutional deliveries. We believe this is a large, unmet need. In 1998, with Kassam Mahomed from the University of Zimbabwe, we measured current practice at Harare Hospital. We extracted information on use of enema, amniotomy, pethidine and episiotomy from 501 patient notes. At this busy hospital where resources are limited, we found that pethidine was given to 75/501 women during vaginal delivery; other forms of pain relief were rarely provided because of shortage of anaesthetic and nursing staff. We conducted exit interviews on a sample of women by visiting on selected days. From the 62 postnatal women identified, we asked them to categorise the severity of pain with these options: tolerable without pain relief, tolerable with pain relief, not tolerable with pain relief, and not tolerable and no pain relief given. Forty percent of women said the pain during childbirth was not tolerable and no pain relief was available for these women. (Mahomed K, Smith H, Garner P. Quality of childbirth care in a government hospital in Harare. Unpublished report). In 1999, with Qian Xu from Fudan University, we used a similar survey in four hospitals in Shanghai. We used a structured interview with 150 postnatal women per hospital to document practices used during childbirth. We asked women if pain relief was given during labour and to describe pain using a scale of options: lumbago or slight discomfort, tolerable pain and sleeping undisturbed, obvious pain and sleeping disturbed, and severe intolerable pain. Acupuncture, epidural anaesthesia, abdominal massage, diazepam and pethidine are the most commonly used methods. Pain relief was provided for less than 27% of women at all four hospitals, yet over half of the women who delivered vaginally (157/303) said they could not tolerate labour pain and 34% (103/303) said they could not sleep because of the pain. Episiotomy was used routinely, with rates above 85% in three hospitals, and half the deliveries were by caesarean section (296/599). Excluding the women who had clear medical indications for caesarean section, in-depth interviews revealed that women frequently preferred a caesarean section, and their reasons were for the good of the child, and fear of pain during vaginal delivery (2). Making childbirth less painful might include better quality health services, which can be achieved by encouraging use of specific interventions that are beneficial and assist women during childbirth. Allowing lay companions to be present reduces the need for medication for pain relief and the likelihood of caesarean section (3); where this is not possible, ensuring access to an appropriate form of analgesia will help. As Langer and Villar point out (4), promoting evidence-based practice in maternal care is not easy. We have recently tried this by targeting a few simple changes that will reduce pain and improve women’s experience. Simply reducing the use of enemas, perineal shaving, and routine episiotomies will do a lot to reduce unnecessary pain and discomfort during childbirth. The Better Births Initiative (5) is proving successful in pilot studies in South Africa; it helps improve the quality of childbirth experience and hence may help reduce the demand for Caesarean sections. 1. Béhague DP, Victora CG, Barros FC. Consumer demand for caesarean sections in Brazil: population based cohort study linking ethnographic and epidemiological methods. BMJ 2002;324:942-5. 2. Qian X, Smith H, Zhou L, Liang J, Garner P. Evidence-based obstetrics in four hospitals in China: An observational study to explore clinical practice, women's preferences and provider's views. BMC Pregnancy and Childbirth 2001, 1:1. 3. Hodnett ED. Caregiver support for women during childbirth (Cochrane Review). In: The Cochrane Library, Issue 2, 2002. Oxford: Update Software. 4. Langer A, Villar J. Promoting evidence based practice in maternal care. BMJ 2002;324:928-9. 5. http://www.liv.ac.uk/lstm/bbimainpage.html
Enrich health care resources through midwifery 30 June 2002
Laura Cao-Romero, Director of Parteras Ticime Mexico, D.F. 01030 Send response to journal: Re: Enrich health care resources through midwifery	Dear Ana and Jose: I enjoyed reading your article and entirely agree in that informed choices is the strategy to raise awareness in women and their families for improving normalcy, thus safety, in birth. I strongly believe that the implementation of non exisiting models, specially those trained in the physiology of birth, such as holistic midwifery should be established, as part of the resources in public health teams. I specifically refer to the case of Mexico, where I work, and also to other countries. Last week, six midwives from Argentina, Chile, Urugay and Bolivia met in our workplace. Together, South American and Mexican midwives discussed a schema of why women are allowing themselves and their babies to have so much technological intervention. The similarity of concepts was amazing. Ana, we need people like you participating in a recent launching of a national network for the Humanization of Birth: REMEXHUPAN, part of a Latin American and Caribbean network RELACAHUPAN. Thanks in advance for you contacting us at: lauracao@att.net.mx or ticime@laneta.apc.org
Spread of World Health Organization Reproductive Health Library Information to Doctors in India 20 November 2002
Sridhar CB, Senior Medical Advisor; and Prof. & Head Medicine & Diabetes, MVJ Medical College Research Hospital , 2/2, South Cross Road, Basavanagudi, Bangalore 560004, Deena Suresh Send response to journal: Re: Spread of World Health Organization Reproductive Health Library Information to Doctors in India	In this article there is mention of health providers needing to identify ways to make updated evidence available to practitioners in a user-friendly format such as the World Health Organization's reproductive health library. Towards this we have established Recon Healthcare Bangalore Model (RHBM) through which within a period of 7 months, 1346 doctors have been given the information they need pertaining to women's heath care from WHO- RHL in a cost ineffective manner. The expense incurred has been Rs. 46 per doctor (0.604 GBP). The existing organisation infrastructure was used for this purpose. This service has been offered to doctors free of cost. In a country as vast as India, spread of communication regarding latest health information to doctors is difficult. Through our RHBM it has been shown this is possible and achievable by linking academia with the industry. From an expected response of 3130, we have received 1346 responses (43%) for one-time questionnaire. 88.87% of doctors found the write-up useful and 83.73% stated that this helped in improving patient care. To the best of our knowledge, such an activity has not been carried out anywhere in the world. The WHO has a wonderful opportunity to take up such models and spread the knowledge relating to women’s healthcare all over the world very rapidly. Competing interests:   None declared