[ozmidwifery] WV Based med rejected

[Mary Murphy]

This is part of the text of the last article.  Isn’t it amazing that individualization is O.K for obstetricians, but not for women wanting normal births? MM   The recent emphasis on evidence-based medicine has tended to overshadow the need for individualization in obstetrics. RCTs provide information about populations, but cannot replace clinical judgment. Even if it is true, for example, that cesarean section is generally safer for babies in breech presentation, neither mother nor child would be well served by emergency surgery performed when the breech is on the perineum. Although RCTs provide the highest level of evidence, their external validity is often limited by small sample size and the recruitment biases inherent to the research process. Furthermore, investigators are not a random sample of providers. In the statistical spirit of our time, it is probably fair to say that clinical judgment and technical ability are normally distributed within the profession. These attributes are not often equally developed in the same individual, nor is there any evidence that academic achievement correlates positively with clinical excellence. In light of such confounding factors, it is prudent to maintain a degree of skepticism about the conclusions of any study. The future of cesarean section ‘‘.we have all regretted that we have not done a cesarean in certain cases, but I have yet to regret one that I have done.’’23 Few obstetricians would disagree with this sentiment, expressed by a prominent New York obstetrician in 1920. Given this attitude, is there an upper limit to the cesarean rate? As the obstetric population becomes older, heavier, and increasingly primiparous, the cesarean rate in the US will continue to rise. This trend will be accentuated by the reluctance, or inability, of obstetricians to perform 934 Cyr