In this issue investigators and commentators from Australia, the United Kingdom, the Netherlands, Sweden, and the United States consider some of the many issues being studied and discussed by advocates of appropriate technology in obstetrics.

This article describes one approach to assessing the effects of perinatal care–that adopted by the National Perinatal Epidemiology Unit in Oxford, England. The unit's research has been based primarily on a combination of simple, descriptive analyses of observational data and statistically robust analyses of evidence derived from randomized controlled trials.

In the past decade the prevention and management of prematurity have begun to be addressed with more appropriate designs. A few strategies—very few—can now be recommended. A few, some widely implemented, can be abandoned. The risks and benefits of most interventions still require clarification.

Both observational studies and nonrandomized controlled trials have found the presence of support during pregnancy to be associated with superior outcomes in terms of preventing abortion, extending the length of gestation, and reducing interventions in labor. However, randomized controlled trials of supportive interventions in pregnancy have not demonstrated any physical benefits from the interventions. It is also unlikely there are any significant adverse effects. Psychological benefits do appear to result from supportive interventions, including better enjoyment of the pregnancy and better postnatal status.

Comparison of assisted conception in Australia, the United Kingdom, and the United States indicates that further rapid growth in services is likely in many countries. Better data on pregnancy rates and the outcome of pregnancy, as well as standardized reporting of national results, are needed to monitor the effectiveness of treatment.

Cooperation in midwifery research between Zambia and Sweden is ongoing. Joint studies on gastric suctioning and maternity routines are used as examples, and breastfeeding is discussed from a global perspective. The midwife, who also interprets responses from mothers, is an important member of an assessment team. Cooperation over cultural boundaries is feasible and mutually rewarding.

More and more medical technologies are becoming available for the early detection of congenital abnormalities, such as amniocentesis, chorionic villus sampling, and ultrasound scanning. Recent research has shown that maternal serum can provide a wealth of information on the unborn fetus and that the testing method lends itself to mass screening. Although screening will prevent a great deal of grief, such developments also lead to extreme medicalization of pregnancy. However, owing to the fact that people show a strong desire to avert every possible approaching calamity, the “tentative pregnancy” seems to be unavoidable.

Beginning in the 1960s, the maternity patients' movement in the United States was joined by lay, medical, and political critics who protested the escalating cost, poor and inequitable distribution, and overspecialization of medical care. During the 1970s some goals of the maternity patients' movement were met, including fathers' attendance at birth, care in low intervention birth centers, and keeping the newborn baby with the parents immediately after delivery. At the same time, however, perinatal care became ever more based on new technology, tests, and procedures, some of which were promoted by doctor-developers in continuing education courses and in expert witness testimony at malpractice trials. Primary obstetric units closed while urban and suburban centers advertised new services to people who could pay. In the 1990s the maternity patients' advocates have most of the same complaints as in 1970, as well as many new ones.

In an attempt to establish the extent to which patients and doctors agree on the outcome of health care, the pre- and postoperative states of health of 388 men undergoing transurethral resection of the prostate for benign disease were studied. Generally, high levels of concordance (>70%) were obtained. The strongest agreement was for clearly defined events, such as episodes of acute retention (95%); the weakest agreement occurred over the most subjective symptoms, prognostic expectations, and ambiguous terms (around 60%). The level of agreement was not associated with any characteristics of the patient, surgeon, or treatment.

The objective of the study was to ascertain the extent of utilization of medical technologies (defined as equipment) used in various health care institutions in Nigeria. The study also investigated the factors accounting for use of and under- and nonutilization of this equipment. Sixteen major and minor health care institutions were surveyed. The outcomes of the study indicate that not less than a third of the equipment was out of order at the time of the study. A number of factors are responsible for nonutilization of this equipment. They include lack of infrastructural facilities such as piped water, storage, and power supply; poor handling by badly trained staff; and the low priority that is accorded to maintenance. The study leads to the important conclusion that the local culture is unable to sustain the technologies that are procured.

This paper examines how the decision-making process and its consequences affect medical technology transfer in major Chinese medical schools. Data are from a 1987 survey of 13 key medical universities, directly supervised by the Ministry of Public Health in the People's Republic of China. This paper limits itself to four types of laboratory equipment — electron microscopes, UV/VIS spectrophotometers, high-performance liquid chromatographs, and polygraphs. Decisions on the transfer of medical technology have been more decentralized in China since the economic reform in 1978. The major reason for schools to import these four types of equipment is their dissatisfaction with the quality of domestic products. Chinese medical schools depend heavily on the information provided at medical equipment exhibits and their neighboring schools. Their decisions to acquire the equipment are based more on the quality and service available than on the prices. Chinese medical schools face serious infrastructure problems in acquiring and maintaining these pieces of equipment. A number of suggestions are made for improving the efficiency of medical technology transfer in China.

Controlled clinical trials are recognized as the best source of data on the efficacy of health care interventions and technologies. Because economic evaluation is dependent on the quality of the underlying medical evidence, clinical trials have increasingly been viewed as a natural vehicle for economic analysis. However, the closer integration of economic and clinical research raises many methodological issues. This paper discusses these issues in trial design, collection of resource use data, collection of outcome data, and interpretation and extrapolation of results. Some guidelines are suggested for economic analysts wishing to undertake evaluations alongside clinical trials.

In-vitro fertilization (IVF) is a relatively recent approach to overcoming human fertility problems. This study explored factors in the diffusion of IVF in England and in the Netherlands. Many factors were common to the two countries. Governments in both countries have been passive, apparently wishing to avoid entering a controversial field. Technology assessment has played little part in the diffusion process in these two countries.

The decision whether to enhance diffusion and to reimburse for the fertility treatment in-vitro fertilization (IVF) was postponed in the Netherlands until the results of a cost-effectiveness analysis were known. IVF appeared to be as cost-effective as its most important alternative, tubal surgery. But policy decisions still were not straightforward, obscuring important social and ethical issues.

Evaluating the use of resources as well as outcomes in cancer therapy is increasingly becoming recognized by both clinicians and others as a legitimate and indeed even desirable activity. While this trend is to be welcomed if it facilitates the efficient use of resources for cancer care, there are dangers in applying estimates of unit costs, in particular average costs to the evaluation of trends in practice in cancer therapies. This article examines the use of appropriate measures of average and marginal cost in the economic evaluation of developments in cancer therapy, taking illustrations from radiotherapy and chemotherapy.

Breast cancer is the second leading cause of death by cancer among women in the United States. The total cost of illness for breast cancer has been estimated to be $3.8 billion, of which $1.8 billion represents medical care costs. It has been estimated that breast cancer detected early is considerably less expensive than when the tumor is discovered at a later stage. Mass screening using mammography can improve early detection by as much as 15–35%. Cost-effectiveness studies have estimated that the costs of breast cancer screening range between $13,200 and $28,000 per year of life saved. The cost-effectiveness of breast cancer screening in the 40–49-year-old age group is controversial. Mass screening for breast cancer will probably increase total health care costs, but when all economic costs are included, screening appears to be more cost-effective than not screening.

Methods of meta-analysis, computer modeling, and issue analysis are used to answer four key questions related to efficacy, cost, and political feasibility of legislating insurance coverage for mammography. The findings are presented, and the strengths and weaknesses of the combined use of these methods to inform policy debate at the regional level are discussed.