Physician experience in performing embryo transfers may affect outcome

The distribution of six physicians' pregnancy rates with cycle and patient demographics was investigated for 2,212 transfer cycles. The results indicate that when the patient and cycle characteristics are compromised, the level of physician experience may determine the outcome of embryo transfers.     

Do Physicians and Their Relatives Have a Decreased Rate of Cesarean Section? A 4‐Year Population‐Based Study in Taiwan

ABSTRACT: Background: The increased rate of cesarean deliveries may be partly due to a lack of consumer knowledge. Assuming that physicians and their relatives are well informed of the risks and benefits associated with the different methods of delivery, our goal was to compare cesarean rates between female physicians, female relatives of physicians, and women with high socioeconomic status in Taiwan. Methods: Two subgroups of 588 female physicians and 5,021 relatives of physicians aged 20 to 50 years were compared with 93,737 pregnant women with a monthly wage $40,000 New Taiwan (NT) dollars or more as identified in nationwide National Health Insurance databases of Taiwan from 2000 to 2003. Results: Female physicians (adjusted odds ratio 0.66; 95% CI 0.47, 0.93) and female relatives of physicians (adjusted odds ratio 0.84; 95% CI 0.74, 0.95) were significantly less likely to undergo a cesarean section than other high socioeconomic status women, adjusted for clinical and nonclinical factors. Conclusions: In this study, the cesarean delivery rate was lower among women who may have greater access to medical knowledge. However, the lower rates observed among female physicians and physician relatives in Taiwan are still considerably higher than the national averages of many countries. This finding suggests that other than information, practice patterns, and social and cultural milieu may play a role. (BIRTH 33:3 September 2006)     

Lowering the cesarean section rate in a private hospital: Comparison of individual physicians' rates, risk factors, and outcomes

Objective: Our purpose was to compare the practice patterns and outcomes of physicians delivering in our institution to identify risk factors and management techniques that could explain the differences in individual cesarean section rates. Study Design: We retrospectively reviewed detailed computerized delivery records (n = 16,230) collected from May 16, 1988, to July 30, 1995. We excluded physicians who had <100 deliveries at our institution during the study period. The physicians were divided into two groups depending on whether their individual cesarean section rates were greater than (control group) or less than 15% (target group). Various cesarean section rates, risk factors for abdominal delivery, labor management techniques, and neonatal outcome parameters were calculated for each group. The cesarean section rates of the two groups were analyzed by year to assess changes. Results: As expected by study design, the overall cesarean section rate was markedly different between the two groups (13.8% vs 23.8%). In addition, the primary, repeat, primigravid, and multiparous cesarean section rates were all lower for the target group. The rates of cesarean section for fetal distress (1.5% vs 3.3%) and cephalopelvic disproportion (5.3% vs 8.5%) were also significantly less in the target group. The rates of breech presentation, third-trimester bleeding, and active herpes cesarean sections were not lower. The control group had more postterm (8.6% vs 14.7%) and >4000 gm infants (12.0% vs 13.7%) but similar numbers of low birth weight, multiple gestation, and preterm infants. The target group used more epidural anesthesia, oxytocin induction, and trial vaginal births after cesarean delivery and more successful trial vaginal births after cesarean sections. Over the study period the cesarean section rate in the target group remained unchanged, whereas it steadily declined in the control group. Conclusions: Individual physician's lower cesarean sections are primarily obtained by labor management and attempting vaginal birth after cesarean delivery. These practice patterns did not appear to lead to any increase in perinatal morbidity or mortality. Efforts to lower cesarean section rates of individual practitioners should focus on the areas of fetal distress, cephalopelvic disproportion, and repeat cesarean section. (Am J Obstet Gynecol 1998;178:1207-14.)     

Variations in individual physician success rates within an in vitro fertilization program might be due to patient demographics

OBJECTIVE: To determine whether there are variations in individual physician success rates in an IVF program, even with uniform laboratory and treatment protocols. DESIGN: Retrospective analysis. SETTING: Boston IVF, a private practice. PATIENT(S): Patients <38 and 38-40 years of age who underwent non-donor egg, fresh embryo transfer (ET). INTERVENTION(S): Retrospective analysis of IVF success rates for Boston IVF for the year 1999, as reported to the Society of Assisted Reproductive Technology. MAIN OUTCOME MEASURE(S): Each individual physician's clinical pregnancy and live birth rates for patients aged <38 and 38-40 years for the year 1999. Pregnancy rates were also obtained for an "ideal patient group." RESULT(S): Among 13 physicians, the clinical pregnancy rate in the <38-year age group ranged from 20.5% to 35.1% and the live birth rates from 17.8% to 31.1%. For the 38-40-year age group, the clinical pregnancy rate ranged from 10.6% to 29.8% and live birth rates from 7.0% to 25.5%. There was no statistical difference in the clinical pregnancy rate for the ideal patient group. CONCLUSION(S): In the ideal patient group, in which patient demographics are uniform, there are no statistical differences in individual physician performance within the same IVF program. Variation exists in the success rates between the physicians in the <38- and 38-40-year age groups. Possibly this is owing to patient demographics.     

The Great Canadian Rural Obstetrician Meltdown

Fewer and fewer family physicians are delivering babies in rural Canada. Due to a serious shortage of obstetricians, general surgeons and rural physicians with advanced operative skills, some community hospitals have been forced to discontinue these operative services. In some instances, they have been obliged to close their maternity units entirely. Women must then deliver far from home in unfamiliar regional facilities. Two solutions to this provider access crisis have been suggested.It has been proposed that certain rural physicians be trained in advanced operative obstetric skills (chiefly the performance of Caesarean sections) for those community hospitals which require these skills. Candidates for a programme of this sort would be drawn from graduating family practice residents and from the ranks of practising rural physicians returning for reinforcement of this operative experience. This emerging initiative raises important questions about training, the scope of practice, specialist backup and maintenance of competence.An alternative remedy would stress much broader exposure to obstetrics in family practice residencies, the opportunity for additional training in more advanced skills, rural practice experience for senior residents in obstetrics and gynaecology, equitable alternative funding for consultant obstetricians in regional facilities and considerable strengthening of regional links for perinatal care delivery.The short-and long-term consequences of this crisis must not be underestimated by the profession, by regional health boards and particularly not by government.     

Impact of the International Term Breech Trial on Clinical Practice and Concerns: A Survey of Centre Collaborators

Objective: The purpose of this study was to determine what impact the International Term Breech Trial had had in different settings and to elicit any concerns among collaborators regarding the implementation of a policy of planned Caesarean section for term breech babies.Methods: We mailed a questionnaire to all Term Breech Trial collaborators. The questionnaire asked 3 open-ended questions about the impact of the trial, about concerns with implementing planned Caesarean section for term breech babies, and about whether information as to the relative costs of planned Caesarean section versus planned vaginal birth would be helpful. Frequencies of responses were calculated for centres in countries classified as having a low or a high national perinatal mortality rate (≤ 20/1000 vs. > 20/1000, respectively) according to the figures published by the World Health Organization in 1996.Results: We received responses from 80 centres in 23 countries. Most centres (92.5%) stated that clinical practice had changed to planned Caesarean section for most or all term breech babies. The majority of centres 66.3 had no difficulties or concerns with implementing a policy of planned Caesarean section for term breech babies. Most centres (85.0) indicated that an analysis of relative costs would not affect clinical practice in their setting.Conclusion: Clinical practice has changed to planned Caesarean section in most collaborating centres, given the results of the Term Breech Trial.