International differences in the use of obstetric interventions

Article Abstract:

An update of an earlier report concerning the frequency of cesarean section in different countries is provided. The current study presents information from 21 countries in Europe, North and South America, and the Pacific, covering the period from 1975 to 1986. Considerable variability in the manner in which the countries reported their birth statistics is noted. Results showed that the highest rate of cesarean delivery per 100 hospital births is in Brazil (31.6 percent); the lowest is in Czechoslovakia and Japan (approximately seven percent). In the United States, it is approximately 23 percent. No correlations were found between the rates of cesarean section and infant mortality. Although the rate of cesarean section increased steadily prior to 1980, it increased more slowly after 1980. One contributing factor to the high rate of cesarean section is a previous cesarean section. The number of vaginal births after cesarean section (VBAC) remains low in most countries (approximately seven percent in the US). Although some countries, such as the Netherlands, report that more than half the women undergo VBAC. Results for selected complications of childbirth are presented. 'Operative vaginal deliveries' (delivery by means of forceps or vacuum extraction) are performed at much lower rates than cesarean, representing between nine and 14 percent of deliveries. Again, there is little correlation between use of these approaches and outcome measures. For most countries, the operative vaginal rate has declined as the cesarean rate has risen. Overall, increasing obstetrical intervention is not associated with improved mortality. The response of different countries to birth complications that can be objectively diagnosed, such as breech presentation (baby positioned in a way that makes vaginal delivery difficult) or multiple births, provides the clearest picture of international differences. Sweden, which has stabilized its rate of cesarean section for these conditions during the past several years, could serve as a model for other countries that wish to reduce their own rate. (Consumer Summary produced by Reliance Medical Information, Inc.)

International aspects, Cesarean section, Obstetrics, Labor, Complicated, Labor complications

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Crack cocaine and cocaine hydrochloride: are the differences myth or reality?

Article Abstract:

The federal law covering conviction for cocaine possession needs to be amended. The 1986 law states that a person would have to possess 500 grams of cocaine hydrochloride to receive the same sentence as a person carrying 5 grams of crack cocaine. Researchers reviewed the literature on the various types of cocaine and found that the effects of cocaine are similar regardless of which type is used and how it is administered. Smoking crack cocaine or injecting cocaine hydrochloride appear to be more dangerous than snorting cocaine. The frequency and amount of cocaine use may be more important than the type used.

Physiological aspects, Dosage and administration, Cocaine abuse, Cocaine

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Can large-scale interventions improve care?

Article Abstract:

The value of performance information and the need for quality assessments in hospital care are generally accepted but large-scale interventions may not be responsible for the significant improvements recorded between 1987 and 1993. A study of mortality rates for coronary artery bypass graft surgery found similar improvements in states that had and had not adopted statewide quality improvement agendas. Performance information is likely to be demanded by policymakers and consumers but how to use the information to improve quality still needs to be determined.

Editorial, Mortality, Hospitals, Surgery, Quality management

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