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• W1965343426 abstract "Obstetricians all over the world are increasingly updating their knowledge through the internet where meta-analyzes, guidelines, and standard protocols of leading professional societies are easily accessible. As a result, treatment regimes around the world tend to become homogeneous – a trend generally considered advantageous as long as the settings are comparable. However, the economic and social conditions become homogeneous at a much slower speed in the physical world than in cyberspace, and in a number of poor countries, conditions are in fact moving toward further inequality due to differences in the access to information and thus in development. Consequently, situations might arise in which apparently evidence-based treatments are introduced under conditions that differ highly from the conditions under which the treatments were scientifically evaluated. There has always been a tendency that norms are dispersed from the affluent world to the developing countries hand in hand with aid programs and the attached ‘experts’– not necessarily because these norms were evaluated or even rational. Another factor involved is the fact that many physicians in the developing countries are partly or wholly educated in a more affluent collaborative country. An early example of direct transfer of obstetric practice was the risk screening approach in antenatal care. Formalized in the industrialized/developed countries during the 1960s, several risk-scoring systems were devised for a number of developing countries in the 1970s (1). This approach is now generally accepted as ineffective in reducing perinatal and maternal mortality (2) and displaced with initiatives to ensure all parturients a skilled attendant and possibility for transfer in case of complications. Today, all over the western world, the frequency of cesarean section (CS) is increasing steadily, and both in relation to the delivery of breeches and HIV-positive pregnancies, it is assumed that there is sufficient evidence to justify an almost 100% use of operative delivery (3, 4). At least in the USA, the idea that vaginal births after CS should be substituted by another CS is becoming still more common (5). During my visit at New Mulago Hospital, Kampala, Uganda in March 2005, several local obstetricians expressed knowledge of this evidence and stated the opinion that also physicians in Uganda should acknowledge the ‘facts’ and thus offer delivery by CS to all breeches and most women with a previous scar. The physicians at this hospital had completely abandoned the use of forceps due to reports arguing that it might hurt the baby, whereas they were still reluctant to offer sectio for HIV-positive pregnancies. Acta publishes in this issue, a study carried out at the same hospital by mutual effort of Ugandan and Swedish doctors (7). From this, it appears that the incidence of postoperative endometritis or wound infection was 11%; nearly 10 times more than in the Term Breech Trial, and if the patients are HIV positive, which is the case of more than 10% in Kampala, then 66% will get such an infection, and even worse, three out of 1500 women died during or shortly after the operation. Moreover, this is not the only consequence of a high CS rate in a hospital with limited resources. As scarce resources only allow for one operation line, operating on a para 4 with breech presentation meant waiting time for another patient with rupture or severe chorioamnionitis. While I was visiting the hospital, the wait for an ‘emergency CS’ was often 6–12 hr! – and in several cases the hospital ran out of sterile instruments, ether, or gloves which postponed all operations to the next day. Finally, the high incidence of CS today creates a population of fertile women who run a great risk if they deliver at home the next time – well illustrated by the fact that few days passed without a uterine rupture. This mixture of ‘international’ evidence and local reality invites reflection. It seems an urgent necessity to strengthen local research in developing countries to counterbalance the strong influence of ‘dogmas’ from the high-income countries. For the time being, NFOG is working on plans for the implementation of a sequence of courses in an African country, probably Tanzania. It will be a great challenge to plan these courses in such a way that recommendations given by experienced Scandinavian obstetricians and midwives will be based on the best possible local evidence and not on what is common practice in Scandinavia today. Therefore, this initiative should start with a broad expansion of what professor Staffan Bergström, in an earlier issue of Acta (6) called ‘obstetric ectoscopy’ and will, hopefully, expand into a co-operation which will also support much more research in keeping with the work of Björklund et al. (7)." @default.
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• W1965343426 date "2005-09-15" @default.
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• W1965343426 title "Just do like us … about the dispersion of ‘evidence’ from high-income countries to settings with limited resources" @default.
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