Faculty Bibliography

OBJECTIVE:To examine trends in electronic fetal monitoring (EFM) use and quantify the extent to which such trends are associated with changes in rates of primary cesarean delivery and neonatal morbidity and mortality. METHODS:We carried out a retrospective study of more than 55 million nonanomalous singleton live births (24-44 weeks of gestation) delivered in the United States between 1990 and 2004. Changes in the risks of neonatal mortality, cesarean delivery, and operative vaginal delivery for fetal distress, 5-minute Apgar score lower than 4, and neonatal seizures (at 34 weeks of gestation or after) were examined in relation to changes in EFM use. RESULTS:Electronic fetal monitoring use increased from 73.4% in 1990 to 85.7% in 2004, a relative increase of 17% (95% confidence interval 16-18%). This increase was associated with an additional 5% and 2% decline in early and late neonatal deaths, respectively, at 24-33 weeks of gestation as well as a 4-7% additional decline in the 5-minute Apgar score lower than 4 at 24-33, 34-36, and 37-44 weeks of gestation. Increasing EFM use was associated with a 2-4% incremental increased rate of both cesarean delivery and operative vaginal delivery for fetal distress at 24-33, 34-36, and 37-44 weeks of gestation. Increasing EFM was not associated with any temporal changes in the rate of neonatal seizures. CONCLUSIONS:The temporal increase in EFM use in the United States appears to be modestly associated with the recent declines in neonatal mortality, especially at preterm gestations. LEVEL OF EVIDENCE/METHODS:II.

OBJECTIVE:To assess the role of the referees in assisting the peer review process of systematic reviews and meta-analyses. METHODS:A one-page questionnaire was mailed to 1391 referees of two journals, the American Journal of Obstetrics and Gynecology and Obstetrics and Gynecology. The referees were asked how often they verified by their own independent analysis 11 key items related to the methodology and statistical analysis of systematic reviews and meta-analyses. Response categories included "always", "frequently" (>50% of the time), "infrequently" (≤ 50% of the time) and "never". A second and a third mailing was sent to the non-respondents. RESULTS:42 mailings were returned because of change of address. Of the remaining 1349 referees, 272 responded (response rate 20%). Of the 272 respondents, 159 (58%) had previously reviewed articles dealing with systematic reviews or meta-analyses. The responses varied according to the key items in the questions but the referees used their own independent analyses "always" in only 2%-17% of the time. The rates of "infrequently" or "never" responses combined together ranged from 51% to 86% for the various key items. CONCLUSION/CONCLUSIONS:The overwhelming majority of the referees do not verify, by their own independent analysis, key items related to methodology and statistical analysis of submitted systematic reviews and meta-analyses.

OBJECTIVE:To estimate the degree of association between body mass index (BMI) and some of the most common adverse outcomes and conditions in obstetrics and gynecology, and to compare it with the traditional descriptors such as age, gravidity, parity, history of preterm births, history of abortions or miscarriages, and race and ethnic status. METHODS:Using a PubMed search, abstracts were identified that dealt with the associations between each of the descriptors (age, gravidity, parity, history of preterm births, history of abortions, racial and ethnic identification, and BMI) and a variety of adverse outcomes and conditions in both obstetrics and in gynecology. RESULTS:Body mass index had the highest association with the most common adverse outcomes and conditions in obstetrics and in gynecology (53 of 57 [93%]) as compared with the traditional descriptors (age, 39 of 57 [88%]; gravidity, 19 of 57 [33%]; parity, 24 of 57 [42%]; previous preterm births, 22 of 57 [39%]; abortions, 14 of 57 [25%]; and race and ethnic status, 26 of 57 [46%]). CONCLUSION/CONCLUSIONS:This study underscores the prominence BMI plays regarding its frequently cited associations with an array of obstetric and gynecologic conditions. Body mass index should be included in the opening statement of the history of present illness and in all communications of health care providers regarding obstetric and gynecologic patients.

Obstetricians often rely on the results of randomized studies and other medical evidence to guide them in treating patients. However, not infrequently, there are problems with the manner in which we communicate medical evidence to our patients and the public. For instance, we often rely almost exclusively on relative risks without discussing absolute risks. This has the potential to cause undue anxiety, misinterpretation, unrealistic expectations, and problems with clinical decision making. This commentary encourages a more critical look at the way we interpret data and communicate medical evidence to our patients and the public.