Now that our rainy summer is over and we are all back to work, I would like to report to you on some developments, some of which could have a considerable impact on women's health care.
In 1997, the American College of Obstetricians and Gynecologists (ACOG) convened a Task Force to respond to the once again increasing incidence of cesarean delivery in the United States. The Task Force report entitled "Evaluation of Cesarean Delivery" was released this August and contains some disturbing recommendations that may adversely affect the availability of effective pain relief during labor. In this document, ACOG recommends that epidural analgesia not be initiated prior to 4 cm cervical dilation in nulliparous women and that alternative modalities of pain relief be considered because of a perceived increased risk of cesarean delivery. Unfortunately, an obstetric anesthesiologist was not consulted by the Task Force and, as a result, there are serious flaws in the process by which they arrived at this conclusion. First, the literature cited is incomplete and, by the time the report was finally published, many of the supporting studies were no longer applicable to current practice. The Task Force also considered the results of several retrospective studies, which are seriously flawed by patient selection bias, to support the notion that early epidural analgesia in nulliparous women increases the risk of cesarean delivery. The Task Force ignored several more recent studies, including an NIH metaanalysis, which demonstrate that epidural analgesia does not increase the risk of cesarean delivery in nulliparous and parous women are not cited.
Furthermore, the Task Force was unable to distinguish among the epidural techniques used in the various studies. When one considers the substantial and credible evidence available that epidural analgesia does not increase the cesarean delivery rate, the most alarming and careless recommendation is the "institutions and practitioners with high case adjusted rates of cesarean delivery in nulliparous women with term singleton fetuses with vertex presentation should be reviewed to determine how many of these patient received an epidural when cervical dilation was less than 4 cm". In my view, ACOG has put obstetricians and anesthesiologists in an impossible position between government/third party payors and the women they care for. The ASA President, Dr. Ronald MacKenzie, and I have sent a letter to the President of ACOG voicing our concern with these recommendations and asking that we jointly revisit this issue with them.
On a more pleasant note, I communicated to you in the summer that the Board of Directors had approved a motion to apply for accreditation of the annual meeting by the Accreditation Council for Continuing Medical Education (ACCME). I am happy to inform you that the application, which was filed in August, has satisfied the initial requirements of the ACCME and that the second step, an on-site visit, has just been satisfactorily completed at SOAP headquarters. I hope to be able to report back to you on a successful accreditation in the near future.
The Board of Directors is seeking professional guidance in managing the Society's monetary funds more effectively. An Ad Hoc Committee of the Executive Board met September 28th to hear proposals by fund managers from First Union Securities and Independence Advisors. The Ad Hoc Committee will select a fund manager to present to the entire Board.
The SOAP website, www.soap.org, is fully operational and an invaluable resource for information about the Society and obstetrical anesthesiology. A recent enhancement is that you now have instantaneous access to the membership roster, which will now be updated monthly. This area is password protected and, if you have not already received a user ID and password, please contact the SOAP office. Important information about the joint SOAP-ASRA meeting in Steamboat Springs, February 2001 and the SOAP Annual Meeting in San Diego, April 2001 can also be found on the website. The Board of Directors and standing committees met during the ASA and I will report on this at a future date.
Alan C. Santos, MD, MPH
President