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much progress has been made in making health care safe. Institutions across the country have focused on improving quality and patient safety through standardization of practices. In a follow-up publication in 2005, Drs Leape and Berwick
commented on the progress made after the original report and future expectations. They predicted that the pace of change would accelerate with implementation of electronic medical records, coupled with more widespread adoption of best practices to improve patient safety and outcomes. They also surmised that access to more reliable data will allow us to weed out unwarranted variability in care and reduce waste.
The jury is still out on how well the health care system has kept these promises twenty years later. Indeed, it is far from clear if pesky old controversies that impact day-to-day management are being resolved expeditiously and new ones contained to a manageable pace. In a recent article on quality of care and disparities in obstetrics, experts paint a worrisome picture.
They contend that even though the United States spends more on maternity care than any other country in the world, the extra spending has not translated into improved outcomes, and our maternal and infant mortalities continue to be among the highest in the industrialized world. Not just that, according to them, data suggest that quality of obstetric care continues to vary widely across the country. Unresolved controversies and variability of care persist in some of the most used interventions, such as use of oxytocin, timing of delivery, episiotomy, and general anesthesia.
It is not surprising that these uncertainties translate into wide variation in care provided to patients and result in equally unpredictable outcomes.
Such is the case in neonatal care as well. From use of oxygen, feeding practices, to adequate level of analgesia, challenges persist in nearly every area of the discipline. Clinicians struggle when there are no evidence-based recommendations. However, randomized controlled trials are hard to conduct, and meaningful data trickle in at an even slower pace to impact change. There is also the culture of medicine we are all so familiar with, which relies on high standards of autonomous individual performance but struggles with the complexity of medicine and propensity for errors.
Let us also not forget the racial and ethnic disparities in care and outcomes. Variability in care is magnified in care delivered to underserved and ethnically diverse populations and correlates well with poorer outcomes. This is important since half of all US births are to minority women. A study from a few years ago showed that women who delivered in hospitals with a high number of black patients had higher rates of severe morbidity compared with women who delivered in hospitals with a low number of black patients.
In this issue of the Clinics in Perinatology, Drs Cohen and Kliegman have collated an important set of articles on current controversies in neonatal-perinatal medicine. Despite the challenges posed by the pandemic, this has been an outstanding year for the Clinics in Perinatology, and I am grateful to you for making us your trusted source of state-of-the-art information. I am also thankful to the publishing staff at Elsevier, including Kerry Holland and Karen Justine Solomon, for their support in bringing this wonderful publication to you.
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