Historical controversy in health technology assessment: The case of electronic fetal monitoring

Electronic fetal monitoring (EFM) was introduced in the late 1950s as an al ternative to traditional auscultation by stethoscope or fetoscope in the ma nagement of labor and delivery. The new technology was seen as a valuable t ool in the prevention of cerebral palsy and other adverse fetal outcomes an d diffused rapidly into clinical practice. In the late 1970s, some sceptici sm began to be voiced about the evidence for the effectiveness of EFM. The authors published a systematic review of the evidence in 1979 that conclude d that there was insufficient evidence for the effectiveness of the routine use of EFM and a clear rise in the cesarean delivery rate associated with its use. The analysis was based on a thorough review of approximately 600 b ooks and articles, but focused heavily on the evidence of four randomized c linical trials (RCTs) that had been published. An economic analysis further underscored the importance of this issue. The report was met with harsh ad hominem criticism from clinicians both in public venues and in the medical literature. Subsequently, additional RCTs were conducted and other analyze s were published, and in 1987 the American College of Obstetricians and Gyn ecologists recommended that auscultation was an acceptable alternative to E FM in routine labor and delivery. Yet, today EFM continues to be the standa rd of practice, used in 80% of labors in this country. The most important c onclusion drawn from this experience is the need to evaluate new technologi es before their widespread diffusion into clinical practice. Target Audience: Obstetricians & Gynecologists, Family Physicians Learning Objectives: After completion of this article, the reader will be a ble to summarize the current state of knowledge of electronic fetal monitor ing based on the expectations for decreasing fetal morbidity and mortality.