Innovation in medical practice: obstetricians and the induction of labour in Britain

Processes of change in obstetrics: a cross-national case-study of episiotomy

This article traces and analyzes the evolution of obstetric and midwifery doctrine and use of episiotomy in the United States and England. In the US, the routinization of episiotomy eventually resulted from strenuous lobbying efforts of a small group of obstetrician/gynecologists between 1915 and 1935. These physicians claimed episiotomy prevented perineal lacerations, infant morbidity and mortality, and future gynecological problems. In England, the liberal use of episiotomy came about during the 1970s from pressure from obstetricians although no overt campaigning for the practice occurred. In both countries routine episiotomy was encouraged by medical and extra medical factors which involved changes occurring in the dominant belief system in obstetrics, maternity care practices, and the obstetric and midwifery professions.

In more recent years, eventual declines in episiotomy use resulted from childbirth activists and others questioning of the practice and calling on obstetricians to produce evidence that the operation was in fact beneficial. This was facilitated, particularly in England, by midwifery interest in resisting obstetric control.

While scientific evidence showing episiotomy beneficial was not responsible for the adoption of routine episiotomy in either the US or England, the lack of evidence was central to the initial rejection of routine episiotomy in England and resulted in the launching of randomized controlled trials designed to produce evidence of the operation's effectiveness.

This case-study offers insight into some of the diverse factors implicated in bringing about change in obstetric knowledge and practice.

Achieving clinical behaviour change: a case of becoming indeterminate

This paper is based on an empirical study of attempts to achieve change in clinical behaviour across a United Kingdom National Health Service (NHS) Health Authority (HA). We suggest that the evidence based medicine (EBM) movement underpinning such attempts is premised upon a highly rationalistic conception of change. Here the generation and implementation of research findings into clinical practice is understood as movement between discrete entities. Drawing upon poststructural philosophy, social studies of science and technology, social anthropology, and gender studies, we challenge such linear perspectives through a more immanent alternative. We conceive of change as movement within indeterminate or ambiguous relationships. We then proceed to discuss the implications of this modality for the management of clinical behaviour change.

The shift from home to institutional childbirth: a comparative study of the United Kingdom and The Netherlands

The British system of childbirth with a very low rate of home childbirth is compared to that in The Netherlands, a country with a relatively high percentage of home deliveries. The analysis explores three possible explanations: the structure of the health professions in both countries, the structure of their health systems, and the use of scientific information in guiding policy decisions on birth place. Differences in the professional status and training programs of midwives between The Netherlands and the United Kingdom affected the distribution of home versus institutional deliveries in the two countries. Reimbursement schemes in The Netherlands have been important in maintaining a high percentage of births at home in this country. In the United Kingdom centralized planning and the influence of medical thinking played major roles in accelerating the shift from home to hospital deliveries in the National Health Service.

Characteristics and motives of women choosing elective induction of labour

Personal characteristics of healthy term pregnant women who chose elective induction or spontaneous onset of labour and the motives for their choice were assessed. Almost 50% of 237 women with uncomplicated pregnancies opted for elective induction when offered the opportunity. These women appeared to have had more complaints during their pregnancy and menstrual periods, more complications in their obstetrical history and to be more anxious about their labour than women who chose a spontaneous onset of labour. Predominant motives were a feeling of safety and the desire to shorten the duration of pregnancy. These characteristics and motives seem to reflect a lack of trust in physical reproductive functions. It is concluded that in evaluating effects of elective induction of labour, pre-existing differences between women who choose elective induction and women who opt for a spontaneous onset must be taken into account.

Weight of all births and infant mortality

Birth weight is the most important determinant of perinatal and infant mortality. The lowest mortality rates in the first week of life are recorded among newborn infants weighing 3500 g or more and the proportion of such infants may be regarded as a measure of optimality of the birth population. There is an inverse relationship between the proportion of heavy newborn infants in a country and its infant mortality rate. In both these respects Iceland, Norway, and Sweden have better experience than England and Wales, Denmark, and the United States of America. The effects of parity, maternal age, social class, and smoking are considered, but it appears that there are still factors that inhibit the intrauterine growth potential of American, British, and Danish fetuses. Elective delivery, use of diuretics, and restriction of diet in pregnancy have shifted the birth distribution to the left and this may have more than counterbalanced the possible beneficial effects. These other factors may adversely affect birthweight distribution in North America and Europe to such an extent as to limit or even damage the favourable position already achieved in health and social development as measured by fetal survival.

Mothers' views of care in labour

The management of labour was the main focus of interest in this study of mothers' views of their obstetric care. Most of the mothers, 63 per cent, were satisfied with their care by both the doctors and midwives during labour and delivery. Those who were not satisfied rarely questioned the technical competence of the staff but were more concerned with the manner in which care was provided. Thirteen per cent stated that they were not attended by a doctor at any stage during labour or delivery and 43 per cent said they were left alone for at least five minutes; both groups of mothers were more anxious during labour and delivery and were less satisfied with their overall care than those who did not have such experiences. The mothers' feelings about the various procedures which they had during labour and delivery, including induction, were generally favourable. Although overall satisfaction with care was expressed by 77 per cent of the mothers, the findings suggest that obstetricians and midwives need to give greater consideration to the social and psychological aspects of patient care.

A randomized clinical trial of the Leboyer approach to childbirth

To examine the effects of the Leboyer method of delivery, we randomly assigned 56 women to either a Leboyer or a conventional delivery and used a variety of clinical and behavioral measures to assess the outcome in mother and child. No differences were noted in maternal or newborn morbidity, in infant behavior in the first hour of life, at 24 or 72 hours post partum, or at eight months of age; or in maternal perceptions of her infant and the experience of giving birth, except that eight months after delivery, mothers who had used the Leboyer method were more likely to say that the event had influenced their child's behavior (P = 0.05). Women who expected a Leboyer delivery had shorter active labors (P = 0.03), suggesting that psychologic factors (expectations) influence physical outcomes in perinatal medicine. Our results suggest that the Leboyer procedure has no advantage over a gentle, conventional delivery in influencing infant and maternal outcomes.

Convenience and the occurrence of births: induction of labor in the United States and Canada

This paper, using data for the United States and Canada on number of births by day of the week, presents indirect evidence for the widespread incidence of the practice of elective induction. For both the United States and Canada, it is found that substantially fewer births occur on Saturdays, Sundays, and holidays than on weekdays. Controlling for such factors as prenatal care, race, education, legitimacy, birth weight, and time trend strongly suggests that the induction of labor is responsible for the patterns found. The paper concludes by discussing the framework within which the practice of elective induction of labor should be evaluated and justified.

A critique of Priorities for Health and Personal Social Services in England

Priorities for Health and Personal Social Services in England was prepared by the Department of Health and Social Security (DHSS) as a basis for consultation about its intended policies during the period 1975–1976 to 1979–1980. The decision of the DHSS to engage in consultation with interested parties is, of course, to be welcomed. However, the Priorities document leaves much to be desired both in terms of the quality and quantity of information provided and in its treatment of the pressing issues affecting the health and personal social services. Many of the areas labeled as priorities show no increase in the proportion of the budget devoted to them; some, in fact, show a definite reduction. Other so-called “growth areas” show such low rates of expansion that they will barely keep pace with the needs of the increasing number of elderly in the population.

Many Area Health Authorities are reducing services in acute specialties, despite long waiting lists and the fact that over 80 percent of admissions of elderly patients are to acute wards. Thus, such cuts are likely to increase even further the demand for geriatric facilities. Many of the areas designated for expansion by the DHSS are largely under the financial control of local government, which is in many cases reducing these services. The most rapid rise in expenditure will be on pharmaceuticals. This will account for the largest increase within the primary care system, leaving little room for any improvements in the service.

In an associated document, Prevention and Health: Everybody's Business, the DHSS attempts to demonstrate that specific preventive measures have been the most important factors in major changes of disease patterns and ignores the importance of secular changes. There is no discussion of the relationship between social structure and both disease and delivery of care; instead, the focus is on individuals changing their life-style as a result of being provided with the appropriate information. There is already evidence that this approach yields poor results and that alternative strategies are needed. Unfortunately, the DHSS seems unable to provide leadership for their development.

These two documents give little hope that genuinely new initiatives will come from the DHSS. Whatever the initial intentions behind their publication, it now seems unlikely that “consultation” will prove to be anything more than a smokescreen behind which cutbacks in services can occur. True consultation implies availability of accurate information about the health and personal social services, together with a program of public education far more comprehensive than that which is currently envisaged.

Evaluation of different approaches to obstetric care: Part 1

The obstetric management and results obtained by two obstetric teams working in the Cardiff Maternity Hospital over a five-year period are compared. One team had a more active approach to induction of labour and antepartum monitoring with urinary oestrogen assay and serial ultrasound cephalometry than the other. After controlling for differences in the attributes of the two groups of patients treated, it was not possible to show any striking advantage or disadvantage of the more active approach.

Evaluation of different approaches to obstetric care: Part II

The obstetric management and outcome of normal patients presenting to two obstetric teams working in the Cardiff Maternity Hospital are compared over a five-year period. One team induced labour with amniotomy and oxytocin infusion three times more frequently than the other. No advantage or disadvantage of this practice was demonstrated using various measures of perinatal morbidity and mortality. The implications of these findings are discussed together with those of two previously reported observational studies. The need for experimental research in perinatal medicine is stressed.