Diuretics in pregnancy: a case study of a worthless therapy

A survey on the use of alternative drugs during pregnancy

OBJECTIVE

To describe the use of alternative drugs during pregnancy.

DESIGN

A trial including 3 surveys on drug use during pregnancy in maternity centers in one area of Finland in 1985-86 (study 1), and a retrospective survey in 2 maternity hospitals in Finland in 1988 (study 2).

PATIENTS AND METHODS

Study 1: 2912 pregnant women (about 94% of pregnant women in the area during the study period); 97-88% returned questionnaires. Study 2: 180 out of 181 consecutive women giving birth. In study 1, drug use (including drug-like products) in the last two weeks was asked by questionnaires around 12th, 28th, and 36th gestation weeks. In study 2, women were interviewed 2-3 days after birth asking about any drugs used during pregnancy. Due to the method of asking, our studies underestimate the level of using alternative drugs.

RESULTS

In study 1, a total of 97 (3.6%) pregnant women reported use of alternative drugs. Most drugs were dietary supplements, and by current knowledge harmless. But a few women had used (potentially) dangerous drugs. The users were from the higher social class and they had also used pharmaceutical specialties more often than non-users. In study 2, 14% had used alternative drugs at some time during pregnancy.

CONCLUSION

Because our surveys showed that alternative drugs are used, possibly with increasing frequency, during pregnancy, further studies on safety are needed.

Prenatal care in Finland: from primary to tertiary health care?

Traditionally, the Finnish prenatal care system has been based on special maternity centers outside hospitals. In recent years, however, the use of hospital outpatient clinics has increased. The purpose of this study was to describe the use of the clinics and to see whether clinics serve as an addition or as an alternative to maternity centers. We used several different data sources (statistics, documents, interviews, questionnaires). The main source was data on visits for all women who gave birth in Helsinki in a five-week period in 1987. The content of care and means of care delivery differ between clinics and maternity centers. Clinics are technologically and provider-oriented without continuity of care. Clinics are not just referral centers for high-risk mothers; at least half of pregnant women visit them. Ultrasound screening is an important reason for use of the clinic. Background characteristics as well as the outcome of pregnancy were similar among women visiting a hospital clinic a maximum of one time (low users), two to three times, or four times or more (high users). Standardizing for the length of gestation, high users made fewer visits to maternity centers than did low users. Hospital clinic care now seems to replace care in maternity centers, and we found a weak trend toward a pluralistic prenatal care.

Identification of meta-analyses. The need for standard terminology

Our efforts to identify published articles describing meta-analyses of clinical trials illustrate the need for standard terminology to facilitate retrieval. We found 119 articles describing meta-analyses and eligible for inclusion in MEDLINE, and yet when we searched MEDLINE, using strategies based on textwords and medical subject headings (MeSH), only 48% of the 119 articles were identified. Sixty-eight (57%) of the 119 articles contained at least one of the terms "meta-analysis," "pooling," or "overview" in the title or abstract. The importance of meta-analyses in the evaluation of medical treatments argues for more disciplined use of a specific term in order to facilitate identification of articles. The fact that the National Library of Medicine has started in 1989 to index articles describing meta-analyses using the MeSH META-ANALYSIS underscores this argument.

The use of ultrasound examinations, intrapartum fetal heart rate monitoring and beta-mimetic drugs in France

We conducted a survey of French obstetricians to document their attitudes towards routine ultrasound, intrapartum fetal monitoring and beta-mimetics in 1987. A questionnaire was sent to 582 obstetricians or gynaecologists who were members of two French medical associations. The response rate was 85%. Of the respondents 92% prescribed two or three routine ultrasound examinations; only one doctor did not use electronic fetal monitoring and 99% of the respondents prescribed beta-mimetics to prevent preterm delivery. Some obstetricians reported a decrease in their use of ultrasound and more dramatically in the use of beta-mimetics. Side-effects were reported to be the major reason for the change in beta-mimetic use. Obstetricians who read English language journals were more likely to have reduced their use of ultrasound and beta-mimetics than those who read only French language journals.

Is it any good? The evaluation of therapy by participants in a clinical trial

Research into patients' perspectives on treatments, in concentrating on their compliance with medically prescribed regimens, have taken bio-medicine's evaluation of therapeutic efficacy and benefit for granted. This paper suggests that the clinical trial, the predominant method of evaluation, should become the object of research attention. Clinical trials of hyperbaric oxygen therapy for multiple sclerosis have failed to show any therapeutic benefit: people who themselves have the disease have however continued to employ it, arranging its delivery for themselves. This study focuses on the decision by a small number of participants in one such clinical trial whether or not to continue using the therapy afterwards. On the basis of in-depth interviews, concerning how the participants evaluated the therapy and came to their decision, it is suggested that at least in the case of this therapy and this condition, the assumptions inherent in the trial method, and its concept of genuine therapeutic benefit, structures the conclusions of the trial in a way that is profoundly at variance with the participants' own methodological assumptions and concept of benefit. Inter alia, the study challenges the view of patients as being inevitably driven by their disregard of proper scientific method to an unreasoning optimism in their assessments of possible treatments.

Commercial Information on Drugs: Confusing the Physician?

Physicians' drug prescribing habits are not adequate. This paper gives examples from Finland suggesting that information given by drug industry is likely to create and reinforce poor prescribing. Results from four different studies looking at the content of the Finnish commercial drug catalogues suggest that physicians relying on them may be led astray. Studies on drug representatives' presentations in 1975 and 1986 showed that negative aspects of drugs were often omitted. The confusion created by the double name system (trade names and generic names) is illustrated by a survey, showing that physicians did not often know the generic equivalents of the trade names and vice versa. At the end, predictions of possible changes in commercial drug information are presented.

Meta-analysis of clinical trials as a scientific discipline. II: Replicate variability and comparison of studies that agree and disagree

The replicate variability of meta-analyses of controlled clinical trials has been assessed as a measure of scientific precision. 46 of 91 known meta-analysis papers were divided into 20 cohorts of studies of the same therapies. Ten cohorts contained meta-analyses with different statistical conclusions; 14 contained differing clinical conclusions with a wider spread than the statistically differing studies. Possible causes of variability, such as different trials included, different policies regarding the inclusion of non-randomized and unpublished trials, and different statistical methodologies, were not obvious causes of differing conclusions. Further work in this area should include multivariate analyses in order to explore possible interactions in the factors accounting for the variability found in replicate meta-analyses.