Article first published online: 22 DEC 2003
BJOG: An International Journal of Obstetrics & Gynaecology
Volume 109, Issue 11, pages xv–xvi, November 2002
How to Cite
Grant, J. M. (2002), Editor's Choice. BJOG: An International Journal of Obstetrics & Gynaecology, 109: xv–xvi. doi: 10.1046/j.1471-0528.2002.51011.x
- Issue published online: 22 DEC 2003
- Article first published online: 22 DEC 2003
The oldest profession
It is not prostitution that is the oldest profession, argues Karen Rosenberg and Wenda Trevathan (pages 1199–1206), but midwifery. The authors are anthropologists who have studied closely the evolution of childbirth in our ancestors, the earliest Hominidae, and have compared human childbirth with parturition in monkeys and the great apes. Several characteristics distinguish human beings from other primates, including a bipedal gait, a large brain, the use of tools, development of language and assisted childbirth. Bipedalism was the first of these characteristics to appear about five million years ago, and it was associated with assisted childbirth. Thus, assisted birth is as old as the family Hominidae itself. Rosenberg and Trevathan describe parturition in monkeys and the great apes, showing clearly that the infant is always delivered in an occipito-posterior position, facing its mother. This allows the mother to guide her infant out of the birth canal towards her nipples and wipe mucus away from its mouth to assist breathing. The monkey does not require assistance, and generally gives birth alone, away from predators. The evolution of a bipedal gait and a large brain has brought about adaptations in the shape of the pelvis, which result in the human infant being born in an occipito-anterior position, facing away from its mother. This creates difficulty for the mother, as attempts to guide her infant out of the birth canal may result in extension of the head and damage to the infant. It is this disadvantage that has resulted in the involvement of others to assist childbirth. Contemporary anthropological studies of aboriginal cultures confirm that assistance during childbirth is universal. Thus, midwifery has developed not as a result of conscious endeavour on the part of human beings; rather, its origin is in the evolution of human beings, where by a process of natural selection women who were more likely to accept assistance during childbirth were more likely to withstand the rigours of a long labour, and survive. The presence of a known and trusted companion will reduce the pain and fear experienced by the woman during labour, and this companion will also carry out the necessary practical procedures to assist delivery of the infant. In a difficult labour, the presence of a companion is more likely to ensure survival of the mother and her infant.
Rosenberg and Trevathan show how the evolution of the large brain in humans has brought about reproductive disadvantages, as the size of an infant's head is only slightly smaller than its mother's pelvis. This implies that slight variations in the shape of the pelvis will cause mechanical difficulties in labour, resulting in damage to the pelvic floor. Andrea Frudinger and her colleagues (pages 1207–1212) investigated the effects of a narrow subpubic angle on anal incontinence after childbirth. The authors measured the subpubic angle in 134 women and, after delivery, performed endoanal ultrasound to identify damage to the anal sphincter. Women who had a narrow subpubic angle were eight times more likely to suffer anal incontinence, but were no more likely to have a damaged anal sphincter on ultrasound examination than women with a wide subpubic angle. The reason for this paradox may be that women with a narrow subpubic angle had longer labours, and that a prolonged second stage may result in damage to the innervation of the pelvic floor. This hypothesis should be tested in future studies.
Rosenberg and Trevathan suggest that the evolution of a companion in human labour has resulted in easier labour and delivery, and there is evidence from randomised trials to support this practice. Why is it then that many women undergo childbirth attended by unfamiliar people, obstetricians and midwives, who collectively may counteract the beneficial effects of a trusted companion? In the 21st century, the prevailing mood in many labour wards is fear—fear experienced by women of the outcome of labour, and fear experienced by obstetricians and midwives lest they will be blamed for an adverse outcome of labour. We are criticised for high rates of caesarean section, and perhaps, it is fear experienced by women which largely accounts for slow labour and emergency caesarean section. Fear of childbirth is the subject of the study by Rebecca Johnson and Pauline Slade (pages 1213–1221). The authors tested the hypothesis that fear of childbirth is associated with emergency caesarean section. They measured fear of childbirth by a specific dimension of anxiety, the Wijma Delivery Expectancy Scale, in late pregnancy in 443 women. Emergency caesarean section was associated with the age of the woman, medical complications of pregnancy, previous caesarean section and primiparity, but not with fear of childbirth. However, the amount of fear experienced by primiparae was much greater than that experienced by multiparae, and it is possible that the association of primiparity with emergency caesarean section concealed an association of fear of childbirth with emergency caesarean section.
Anal incontinence and fear of childbirth are major concerns in obstetric and midwifery practice in the 21st century, and we investigate these disorders by sophisticated physical and psychometric measurements, analysed by complex statistical techniques. By our better understanding, we hope to assist women in childbirth to avoid these problems. We may be humbled by the realisation that the concept of assistance in childbirth did not arise from human intellectual endeavour, but is a basic evolutionary process, brought about by natural selection, on the plains of Africa, in the Pleistocene epoch of geological time.
Counting the cost of treating uterine fibroids
Hysterectomy is becoming increasingly unfashionable. In women with excessive menstruation who have no uterine pathology, the levonorgestrel intrauterine system and endometrial ablation are preferred, hysterectomy being a last resort. So too in women with excessive menstruation due to uterine fibroids, new treatments are emerging. Walker and Pelage (pages 1262–1272) report the largest uncontrolled case series to date of embolisation of the uterine arteries for the treatment of fibroids, in which 400 women were treated. In four women out of five, excessive menstruation diminished, and other symptoms such as swelling of the abdomen and frequency of micturition were similarly improved. The procedure was not pleasant, and was accompanied by post-operative pain which was classified as ‘more than labour pain’ or the ‘worst ever’ pain in one in five women. Many women had a persistent post-operative vaginal discharge, some expelled the fibroid spontaneously and a few required hysteroscopic resection of fibroids for pain due to infarction of the fibroids. Three women developed septicaemia due to Escherichia coli or the streptococcus. Twelve women became pregnant after the procedure, with eight successful term pregnancies. The authors conclude that although complications may be serious, they are uncommon, and that uterine artery embolisation is a successful treatment for uterine fibroids.
Twenty-one randomised trials attest to the effectiveness of gonadotrophin-releasing hormone analogues before hysterectomy or myomectomy for uterine fibroids. This treatment will result in reduction in the size of the fibroids, such that vaginal hysterectomy can be performed instead of abdominal hysterectomy, and a transverse abdominal incision can be performed instead of a midline incision in myomectomy. Gonadotrophin-releasing hormone analogues are clinically effective, but are they cost effective? This was the question asked by Cynthia Farquhar and colleagues (pages 1273–1280). The authors initially performed a systematic review to measure the effectiveness of this treatment, and then compared the cost of hysterectomy or myomectomy with and without gonadotrophin-releasing hormone analogues. There was a net increase in costs if gonadotrophin-releasing hormone analogues were used. The authors then performed a study of the amount women were willing to pay to have a vaginal hysterectomy instead of an abdominal hysterectomy, or a transverse abdominal incision instead of a midline incision in myomectomy. The amount women were willing to pay was far less than the increased cost incurred by the administration of gonadotrophin-releasing hormone analogues. Farquhar et al. conclude that gonadotrophin-releasing hormone analogues are not cost effective. One limitation of the study was that the randomised trials were too small to take into account rare but very serious consequences of hysterectomy and myomectomy resulting in litigation, which, if they occur in women not given gonadotrophin-releasing hormone analogues, may displace the results of the cost effectiveness analysis in the opposite direction.
These studies ask fundamental questions about how we decide upon treatments in obstetrics and gynaecology. We need to know more about embolisation of the uterine arteries before we can make a judgement about the place of this procedure in treating fibroids. There should be some formal measurement of the degree of reduction of menstruation following uterine artery embolisation. When is the post-operative pain felt, for how long does it last and what are the recommendations for its treatment? Above all, the effect of the treatment should be assessed by formal measurement of quality of life. A cost effectiveness analysis to compare embolisation of the uterine arteries and hysterectomy should be carried out. It may be tempting to suggest a randomised trial to compare these two procedures, but conceptually, this may not be justified, for they are quite different operations. Hysterectomy is carried out under general anaesthesia, usually involves an abdominal incision and requires a stay in hospital for several days. Uterine artery embolisation is carried out under local anaesthesia, there is no abdominal incision and requires a much shorter stay in hospital. These major differences in technique will exert an undue influence on the measurement of the relative success of the procedures, for there will be a bias in favour of embolisation. Randomised trials of surgical treatments will be successful only if the surgical operations have some similarities. The place of embolisation of the uterine arteries compared with hysterectomy in the treatment of fibroids will be established only by uncontrolled case series such as this one, where the embolisation is carried by interventional radiologists who are fully trained in the technique, where the outcome is formally measured by quality of life, and where the clinical and financial costs of the procedure are fully described. By adding the experience of several uncontrolled case series to a national database, the place of uterine artery embolisation for fibroids will be established.