Would keep the knife away

Papers pp 942, 945

In maternal health care there is a recognised gap between evidence of effectiveness and clinical practice. Indeed, too often routine care is not evidence based and there is strong resistance to stopping harmful or useless procedures.1 Unnecessary caesarean section and episiotomy are good examples of the mismatch between evidence and practice and of the complexities that change entails, as two articles in this issue illustrate. 2 3

Unnecessary caesarean section is known to increase health risks for both mother and newborn child and adds burdens to healthcare budgets. There has been a sustained growth in caesarean section rates worldwide that has reached epidemic proportions in Latin America. A combination of factors contributes to this trend: providers' views on the safety of caesarean section,4 obstetricians' convenience,5 and the configuration of healthcare systems.6 A fourth element is patients' demand for surgical delivery, a hotly debated issue, especially in Brazil. …