Medical writers have recently turned to the opening line of Charles Dickens's A Tale of Two Cities to describe these prevailing times in medicine and obstetrics as "the best of times. . . the worst of times. . ." (Grumbach, 1999; Morrison, 2000). Why are these times at once the best and worst of times for obstetrics? There are many reasons for this, and some are now considered.
[...] WORST OF TIMES Among the most pressing challenges facing obstetrics and gynecology is that of epidemic human immunodeficiency viral infection (HIV). But there is even some good news here. Specifically, in 1995, according to the Centers for Disease Control and Prevention (1996), HIV infection was the leading cause of death in women 25 to 44 years old. By 1998, however, HIV-infection had dropped to the fifth leading cause of death in all 25- to 44-year-old Americans (Martin and colleagues, 1999). [...]
[...] There is a similar deleterious effect on efforts to conduct the research necessary to move obstetrics forward (Weissman and colleagues, 1999). As Kuttner (1998) aptly described the situation, there are " . too many promoters, marketers, attorneys, underwriters, consultants, reviewers, and shareholders—all taking too big a cut of the premium dollar . " PORK BELLIES VERSUS PEOPLE. Dr. Marcia Angell, editor emeritus of the New England Journal of Medicine, summarized the current state of American health care in 1999: "The hallmark of the system is its reliance on the private market to deliver and, to a lesser extent, to fund health care. [...]
[...] The contingency-fee system continues to offer personal injury attorneys the perverse incentive that encourages mendacity and promotes the "sleaze factor." Nowhere in obstetrics is this more prevalent than in "birth injury" litigation (Chap p. 1048). According to Collins (2000), in such cases it is not uncommon that obstetricians are expected to prove that their (in)actions did not cause neurological injury. Attempts to mitigate some of these contentious issues have been only partially successful because of watered-down versions of legislations engineered by the plaintiffs bar. [...]
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