contributor_atulgawande-new_p233In a New Yorker article (July 2013) titled Slow Ideas, the surgeon and journalist Atul Gawande asks why some innovative ideas in medicine are adopted so quickly, while others are ignored for years.  Gawande compared the cases of anesthesia (first ether, then chloroform) and antiseptics (carbolic acid), discovered at about the same time in the mid-19th century and addressing the two “great scourges of surgery,” pain and infection.  William Morton’s anesthesia was quickly adopted, but Joseph Lister’s work using carbolic acid as an antiseptic for hand-washing and instrument-cleaning was largely ignored for at least a generation, and, incredibly, it remains difficult today to get hospital personnel to wash their hands between patients and before procedures.  Why, when it so clearly prevents unnecessary patient infections and death?

“So what were the key differences?” Gawande asks.  “First, one combatted a visible and immediate problem (pain); the other combatted an invisible problem (germs) whose effects wouldn’t be manifest until well after the operation. Second, although both made life better for patients, only one made life better for doctors. Anesthesia changed surgery from a brutal, time-pressured assault on a shrieking patient to a quiet, considered procedure. Listerism, by contrast, required the operator to work in a shower of carbolic acid. Even low dilutions burned the surgeons’ hands. You can imagine why Lister’s crusade might have been a tough sell.”

The field of obstetrics has proved to be particularly prone to this puzzling phenomenon.  Gawande turns his attention to the global problem of maternal and infant mortality and morbidity, taking millions of lives every year – mothers die of hemorrhage and infection, infants die from infection and problems in adapting after birth – temperature regulation, difficulty starting to breathe.  Simple techniques and inexpensive medications could save many of these lives and have been known for years.  But they haven’t been adopted by many of the care providers in poor, remote communities in developing countries.

In Nepal, where I have worked for three years with hospital staff nurses teaching lifesaving skills to village nurses who do almost all of the maternity care in their communities, I saw nurses who were taught these skills (and some who were teaching these skills!) continue to ignore methods of care that have been proven effective and to practice others that have been shown to be useless or harmful.  For example, despite evidence that routine episiotomy is harmful, it is still performed, especially on first-time moms. I have seen synthetic pitocin given to speed up labor without first determining with a partograph if it is appropriate, and without adequate monitoring – a very dangerous practice.  “Kangaroo mother care,” or placing the baby skin-to-skin on the mother’s belly after birth, a proven way to keep them warm, is usually done perfunctorily for a minute or two, missing the whole point, to use the mother’s body heat to warm the baby for several hours (sometimes days or weeks, in the case of premature babies) while its temperature is adapting to the external environment.  The nurses don’t seem to understand the importance of staying with, comforting, and encouraging the laboring woman, a simple task that has been shown to improve birth outcomes.  They go to the bedside to perform a procedure or check vital signs, then return to the desk and sit. They have learned that position change and walking may enhance labor, but they infrequently suggest these to laboring women. It is sometimes frustrating to watch their seeming inability to understand the rationale for and importance of these simple ways of caring.

So are we doing better here in the United States, where outcomes are dramatically better than in Nepal?  We have state-of-the-art hospitals and technology, diagnostic tests, imaging studies, much more money spent on maternity care, but our outcomes aren’t so great compared to many European countries – maternal mortality and prematurity rates are rising.  We give lip service to evidence-based practice, but are we doing it?  Some simple interventions, proven to work in randomized controlled trials, are largely ignored.  The presence of a doula during labor and birth and group prenatal care are examples.  Moxibustion (a form of acupuncture) to turn breech babies is validated by a randomized controlled trial; delayed clamping and cutting of the umbilical cord after birth has been shown to decrease anemia in susceptible infants, but these interventions are rarely done.  On the other hand, continuous electronic fetal monitoring (CEFM), adopted in the 1960s without any significant research to see how it would affect outcomes, is almost universally used in hospital settings 50 years later and, despite many more studies, still hasn’t been shown to make a difference in newborn mortality and morbidity, only to contribute to an inexorable rise in the cesarean rate, in turn contributing to a rise in maternal mortality.  (CEFM has reduced neonatal seizures to a small extent, but these seizures have not been shown to have any lasting effect on the babies.)  Cesarean birth was quickly and widely adopted for women with previous cesarean births and women with breech babies after a few questionable studies in the mid-1990s ostensibly showed better Medscape: Vaginal Birth After Cesarean Delivery, Aaron Caughey, MDoutcomes.  Slowly, obstetricians and hospitals are realizing the many negative unpredicted sequelae of the dramatic rise in cesarean births, and are beginning to reconsider vaginal delivery as a possible option, particularly after a previous cesarean.  (Sadly, in the years when vaginal breech deliveries were effectively banned, obstetric providers lost the ability and the confidence to do them well.)



Frustrating, isn’t it?  But as Atul Gawande said, “Better is possible. It does not take genius. It takes diligence. It takes moral clarity. It takes ingenuity. And above all, it takes a willingness to try.”

(Graph on rate of cesareans and VBACs from Aaron Caughey, MD, Vaginal Birth After Cesarean Delivery, Medscape)

See another physician’s views on the difference between “scientific” and “technological” when it comes to birth: