Book Review

Obstetrics in the 1990s: Current Controversies

N Engl J Med 1993; 329:514-515August 12, 1993

Article

Obstetrics in the 1990s: Current Controversies
(Clinics in Developmental Medicine. Nos. 123/124.) Edited by T. Chard and M.P.M. Richards. 249 pp. London, Mac Keith, 1992. $54.95. ISBN: 0-521-41282-X (Distributed in the U.S. by Cambridge University Press, New York.)

The practice of reproductive medicine is inherently controversial. This is a function not only of the accelerating pace of technological advances and their rapid assimilation into clinical practice, but also of the conflicts encountered in a discipline in which the distinction between physiology and pathology is often unclear. Fifteen years after the publication of Benefits and Hazards of the New Obstetrics (London: Heinemann Medical, 1977), the original editors have assembled a new panel of distinguished commentators to provide another snapshot of contemporary obstetrical practice in Obstetrics in the 1990s.

The British collection of essays is not an encyclopedic management textbook but, rather, a thoughtful discussion of many topics that are currently being vigorously debated among health care providers. Of particular interest in this book are the extraordinary breadth of issues and the multidisciplinary authorship. As the epidemiologist Iain Chambers notes in his foreword, “The book is a celebration of the value of considering many different kinds of evidence -- research based in laboratories, letters written by individual women to newspapers and voluntary organisations, formal sociological and psychological investigations, randomised trials involving anything between a handful and tens of thousands of participants, and analysis of vital statistics.”

It is impossible to characterize a “typical” chapter or style of presentation in this compilation. Some authors have adopted the traditional format of a relatively nonjudgmental review of the current literature (predominantly British). Advances in techniques of assisted reproduction, contemporary methods of prenatal diagnosis, and an examination of the efficacy of antenatal tests of fetal well-being are handled in this manner. A less objective analysis of the increase in the rate of cesarean delivery is foreshadowed by an introductory sentence that says “ . . . too many Cesarean sections are performed.” Not surprisingly, the essays “The Midwife in the 1990s” and “Women's Views of Childbirth” are pointedly opinionated (and none too charitable in their portrayal of traditional obstetrical practice). Whether one agrees or disagrees (on the basis of either the author's obvious bias or the content of the essay), virtually all the chapters are provocative and worthwhile to dissect. U.S. readers may be startled by the lack of parallels between the British system of litigation related to obstetrics and the current U.S. quagmire. The chapter examining decision-making theory and its application is filled with practical tips applicable in clinical practice. The authors of this chapter also highlight a crucial teaching point that is far too often overlooked when they declare that “the outcome . . . is irrelevant since decisions are right or wrong in prospect not retrospect.”

This book presents a final conundrum: What is the target audience? It is certainly not an appropriate textbook for students (either medical or nursing), and although some residents in obstetrics and gynecology may find several chapters of interest, it cannot be viewed as a primary textbook. Medical academicians will probably find the treatment of their particular areas of expertise less than revealing. Yet this is not a work geared toward the lay public. I must confess ignorance about the target audience. However, most health care providers familiar with the searing controversies inherent in the practice of reproductive medicine will find some, if not most, of this work engaging and stimulating.

Gregory L. Goyert, M.D.
Sinai Hospital, Detroit, MI 48235