“The
primary objective of copyright is not to reward the labor of authors, but
"[t]o promote the Progress of Science and useful Arts." To this
end, copyright assures authors the right to their original expression, but
encourages others to build freely upon the ideas and information conveyed by
a work. This result is neither unfair nor unfortunate. It is the means by
which copyright advances the progress of science and art.” -- Justice
Sandra Day O'Connor (Feist
Publications, Inc. v. Rural Telephone Service Co., 499 US 340, 349(1991)
Dear Bob,
It seems we share a number of
attributes and interests. The most obvious is our interest in promoting
evidence-based practice in midwifery and medicine, and our “wonderment”
that factual data irrefutably identifying harmful or ineffective practices
so often does not lead to appropriate changes in regard to maternity care. A
second area of mutual interest is in the history, use, misuse and abuse of
episiotomy and our frustration that misuse and abuse far out-weighs its
“right use”.
Lastly we are both experiencing a
near total political impotence in making any kind of meaningful impact on
the “system” -- that is,
functioning as an effective change agent in regard to the misuse of an
injurious (occasionally fatal) surgical procedure that is ineffective,
painful, debilitating and to quote someone we both know well, that “women…often
reveal a startling depth of enmity for”.
To that end you embarked on an
exhaustive five-part literature review on episiotomy, four parts of which
were published in a peer-reviewed obstetrical journal 6 years ago. Woolley
RJ. Benefits and risks of episiotomy: A review of the English-language
literature since 1980. Part I. Obstet Gynecol Survey 1995; 50:806-820
Part II. Obstet Gynecol Survey 1995; 50:821-835. Of
course midwives think your work is wonderful. I’m sure a few docs have
taken the information to heart but generally, the entrenched notions of
the medical community grind onward with little or no change. I notice
that you have not been awarded the Noble prize for needed reform in
obstetrical medicine or even designated as a “Registered National
Treasure” – an honor you certainly deserve. Instead, it’s the same
old arguments between yourself and the “gang” on OBGYN.NET discussion
group. One should not confuse typing with writing.
On my part, I posted your email
of 9/13/97 (part V of your literature review) which so elegantly identified
the dimensions of the problem, speculated on its origins, proposed simple
effective remedies, and bemoaned the many “embarrassing facts” of
medical practice including the general refusal of physicians to modify their
behavior despite excellent evidence. This neglected little gem lived on my
web sites for nearly 4 years with (to my knowledge) absolutely no effect.
Nobody reads it, nobody care. Are you as sad about this as I am? Have
you noted (as I have) that nothing either of us is doing in regard to this
subject is helping? Aren’t you just a tiny bit frustrated by this
inability to make a difference in something that is so vital to the
wellbeing of childbearing women (perhaps you have a wife or a daughter or a
son that may marry). Doesn’t some part of you want to use the God-given
talent and insight so generously endowed on you to achieve a godly purpose?
Recently the problems you so eloquently described
have taken on a new urgency. In June 2000 the current ACOG president
began publicly promoting medically unnecessary cesareans as the ultimate
choice in reproductive “freedom”. The mere possibility of pelvic floor
damage subsequent to vaginal birth has become the rationale for promoting
the idea of cesarean on demand as “safer”, “better”, “maybe should
even be routine” and simply a matter of a “woman’s right to choose”.
On Good Morning America, Dr. Harer answered Diane Sawyer’s question
on relative safety between normal birth and elective CS by saying: “For
the mother, the immediate risks for a cesarean section are a little higher,
but the longer term risks of pelvic dysfunction, urinary incontinence, anal
incontinence, pelvic dysfunction -- those risks are higher for vaginal birth
and over the long time I think that the risks balance out … there
really is no big difference.” Perhaps
Dr. Harer, busy as he is representing the country’s 30,000+ ACOG
obstetricans, is even more unfamiliar with the professional literature than
most physicians.
This obstetrical romance with
prophylactic cesarean is based on the erroneous idea that damage to
the mother’s pelvic floor is an unavoidable
“collateral damage” of vaginal birth. It is intimately tied
to obstetrical profession’s historical preference for episiotomy (along
with a host of other interventions), coupled with the profession’s failure
to teach, learn or utilize physiologically effective (midwifery-based)
techniques for managing the “perineal phase” of expulsive labor and
ultimately the failure of episiotomy to “protect” against pelvic floor
damage. The obstetrical profession has never acknowledged the value (or even
the existence!) of non-medical (ie, physiological) management techniques
which historically have proven successful at preventing prolonged or
ineffective pushing (thus reducing the risk of fetal distress) and at
preventing or reducing perineal trauma during childbirth (and subsequent
pelvic floor damage)
It seems that obstetricians have
yet to discovery the laws of gravity and proudly flaunt their communal
membership in the obstetrical division of the Flat Earth Society.
This is accomplished by giving the mother labor-retarding narcotics and
pelvic-floor numbing anesthesia, requiring her to push lying on her back or
sitting at a 45 degree angle on her sacrum, while urging her in prolonged
breath-holding and maximally hard, prolonged expulsive efforts – all
non-physiological tactics amply identified as unnecessary, ineffective and
even detrimental. Weight bearing on the maternal sacrum closes down the
pelvic outlet by one quarter to one third while requiring the baby to
be pushed uphill at a 60 degree angle against gravity through a partially
closed door, a feat many first-time mothers cannot manage without
damage to either themselves or their babies, irrespective of the use (or
not) of episiotomy. These iatragenically-created problems are then
perceived by doctors to be proof of a fatal design flaw in normal
reproductive biology that can only be overcome by eliminating vaginal birth
all together!
An astonishing notion is now
being promoted by the obstetrical community -- that vaginal birth is so
damaging to mothers, so dangerous to babies, so “old-fashioned” and
backwards that only its total elimination will do. This is one of the most
pernicious developments in the ignoble history of the obstetrics. (see
http://www.collegeofmidwives.org/safety_issues01/rosenbl1.htm)
It would change the focus of a physician’s care from attending to the
needs of the mother during spontaneous vaginal deliveries to determining
when fetal lung maturity was achieved so that the CS could be scheduled
before the mother went into spontaneous labor by mistake and (gasp!) gave
birth naturally!
Fifteen years later the chilling
and unthinkable words of the Doctors Feldman have around again, only this
time to meet with enthusiastic acceptance:
The Drs Feldman make a statistical case for cesarean surgery as
“saving” babies with only a little “excess” or “extra maternal
mortality” and opin that the “low cost of excess maternal mortality”
may be a price worth paying. Here is a short excerpt from their article in
NEJM, May 1985 entitled Prophylactic Cesarean Section at Term?:
p.
1266 ….the number of extra women dying as a result of a complete
shift to prophylactic cesarean section at term would be 5.3 per 100,000….
This may be the proper moment to recall that the number of fetuses
expected to suffer a disaster after reaching lung maturity is between 1 in
50 to 1 in 500. … if it could save even a fraction of the babies at risk,
these calculations would seem to raise the possibility that a shift toward
prophylactic cesarean section at term might save a substantial number of
potentially healthy infants at a relatively low cost of excess maternal
mortality.
We probably would
not vary our procedures if the cost of saving the baby’s life were the
loss of the mother’s. But what if it were a question of 2 babies saved
per mother lost, or 5 or 10 or (as our calculations roughly suggest) as
many as 36 or 360? …. Is
there some ratio of fetal gain to maternal loss that would unequivocally
justify a wider application of this procedure?
p. 1267….is it
tenable for us to continue to fail to inform patients explicitly of the very
real risks associated with the passive anticipation of vaginal delivery*
after fetal lung maturity has been reached?
If a patient considers the procedure and decides against it, must she
then be required to sign a consent form for the attempted vaginal delivery?
(*emphasis mine)
My question for doctors is quite
different from the Doctors Feldman, as I want to know if it is tenable for
them to continue to fail to inform healthy women of the high risk associated
with “obstetrics as usual”, what with its high rate of risky procedures
such as induction of labor and cesarean surgery and its low or non-existent
use of effective and low-cost methods to reduce these problems, such as
routinely staffing hospitals with nurse-midwives, which, unlike
physician care providers, enjoy both a low rate of interventions (especially
induction, episiotomy and Cesareans) while having excellent perinatal
outcomes and achieving all this for a third less money? (
Midwives Deliver Healthy Babies With Fewer Interventions Dr. Roger
Rosenblatt, MD University of Washington )
In my mind the issue is not
simply that we stop this cascade of pernicious practices but also that we
employ the universally beneficial ones and I apply that idea both to
patients and practitioners. The current legal situation is hell for one and
all. In that regard the important issues are not only the physiological
management of labor versus the medical (and non-physiological!) management
but also the host of real psychological and social problems that
confronts each woman during the childbearing year. Women benefit
enormously from the opportunity to have uninterrupted, face-to-face time (30
minutes minimum) with a caring and experienced professional who will listen
to her and provide helpful guidance in the areas of PP recovery,
sleep-deprivation, breastfeeding, psychological adjustment of other siblings
and her husband to the expanded demands on her time, how the mother herself
is feeling and the level of her ability (or inability) to cope. This is the
crucial time for caregivers to pick up the early warning signs of
post-postpartum depression.
Presently the public erroneously
assumes that detection and prevention of PPD are an important aspect of
standard obstetrical care but you and I know that is not so (with the
possible exception of Minnesota and its routine use of the Edinburgh PPD
scale). With the exception of a single 6 weeks check-up, obstetricians
don’t provide any kind of follow-up care (especially not
psychologically-orientated) to a new mother nor does the baby’s
pediatrician, despite a PPD rate of 12 to 20%. (Predictors,
prodromes and incidence of postpartum depression. Chaudron LH, J Psychosom
Obstet Gynaecol 2001) Except for
community-based midwifery, there is no continuity of care for
childbearing women or functional safety net to prevent PPD or to catch it
early on, before it damages the parent-child bond, the woman ’s
relationship with her husband or results in harm to herself or others.
(Do not minimize signs
of postpartum depression! Early intervention essential to prevent negative
consequences for the child. [Article in Swedish] Wickberg B, Hwang P. 2001).
I’ll
bet that Andrea Yates received the best medical care that obstetrics had to
offer during each of those five labors & births (continuous EFM,
epidural & episiotomy!) but ultimately society and the medical
profession drastically failed each of her five children when it failed to
detect and respond to her PPD five times in a row. Apgars of ten and ten for
a child at birth are wonderful but floating face down in the bathtub each
child was left with apgars of zero and zero.
Necessary Change
There are three areas of maternity care reform crying
out here at the cusp of the 21st century. The first is the continuing
absence of the “right stuff”, i.e. the failure of contemporary
maternity care to utilize the midwifery model of care as the standard for
normal birth. Midwifery principles and practices are only conspicuous by
their absence. Approximately 70% of childbearing women are healthy and have
normal pregnancies and yet 95% of them are simultaneously denied the
cesarean-reducing benefits of midwifery management (which can be employed by
physicians as well as midwives) while being subjected to
cesarean-increasing, “business as usual” interventist obstetrics.
(Peter Schlenzka thesis) This is to
say that labor was “managed” by a busy L&D nurse who was out of the
labor room 79% of the time (Gagnon, & Waghorn, 1996 “Supportive Care by Naternity
Nurse: A Work Sampling in an Intrapartum Unit” Birth, 23:1; 1-6)
and a physician who was not even present in hospital until the last few
minutes before the birth or who only came in to perform the Cesarean after
things began to go awry. (Dr
Rubsamen, MD, LL.B The Obstetrician’s Professional Liability --
Awareness and Prevention, 1993)
The second category of concern is the legal
consequences of the absent-obstetrician syndrome, which shows up as a
vastly increased rate of malpractice claims and litigation, making the
profession of obstetrics disproportionately expensive (and way more
defensive!) than it need be. Dr. David Rubsamen, MD, LL.B., an expert in the
field of obstetrical liability and author of the Professional
Liability Newsletter, has collected a sample set of 63
obstetrical malpractice cases involving permanent brain damage and
subsequent litigation. In his book The
Obstetrician’s Professional Liability -- Awareness and Prevention
he presents these cases as "instructive" and "cautionary
tales" designed to acquaint readers with the malpractice traps that
have made obstetrics a "loss leader" for liability carriers
throughout the US.
The absence of an awake, decision-making,
practitioner at or near the bedside of the laboring mother played a
central role in approximately 2/3s of these malpractice cases, particularly
those which necessitated telephone conversations between nurses at the
hospital and the doctor who was not. This gave rise to various forms of
misunderstanding or miscommunication between those present at the bedside
(non-practitioners who don’t have the necessary training to intercede on
their own authority) and those absent from the scene (who have both training
and responsibility but are not present to use them). An “absent
obstetrician”, combined with an unexpected medical situation (the basic
reason families choose hospital care!), results in an adverse outcome for
mother or baby far too often, followed by a malpractice lawsuit for the
physician. Litigation occurs in regard to what was said by whom, whether or
not a phone call was made by the nurse to the doctor or the exact timing of
the call as the hospital nurse and independent obstetrician each blame the
other for the unfortunate outcome.
Even when the doctor is asleep
in the call room of the hospital, communication breakdowns occur as nurses
may be inexperienced (or a “temp” from another floor or an agency) and
not recognize a serious situation or are hesitant to wake the doctor for
what may seem like a "trivial" reason. This break in the
continuity of care may cause other kinds of problems, as the doctor
doesn’t actually know what has and has not been tried or exactly how long
a situation has persisted. It is the usual malpractice nightmare, but unique
in this respect -- it is the one malpractice risk that is the most
predictable and most preventable. “As a result of nail the
rider was lost”. One of the reason that approximately 10% of obstetricians
get sued each year is bBecause doctors do not “do” labor. The rest of us
pay the bills. The “absent obstetrician” is a preventable accident
waiting to happen. However, problem would disappear overnight if labor and
delivery units were staffed by professional midwives who were continually
present during active labor and who routinely delivered all healthy
women with normal pregnancies and spontaneously progressive normal
labors (unless the mother requested to be attended by a physician). The
economic advantage is this would be astounding.
Episiotomy
and Right Management of
Physiological Perineal-Phase – a good place to begin
Of course, item number three is the issue of episiotomy
and physiological perineal-phase by physicians. As you know so well, these
desired changes in physician behavior have two distinct parts – doctors
must stop doing the wrong thing (episiotomy) and must start doing the right
thing – use of traditionally successful physiological management of 2nd
stage labor employed world wide with excellent results. Simply not doing
episiotomy is not enough, especially if that translates into preventable
perineal trauma caused by extreme efforts of pushing the baby uphill against
a closed door or if fear of pelvic floor damage results in increased
use of medically-unnecessary Cesarean surgery. How are we to bring the
necessary changes? In answer to my own question I would say “one step at a
time”.
A very good first step would be for you to actually
publish Part V, chronicling the reluctance of your fellow physicians’ to “adopt
a more scientific view of the evidence available on the subject of
episiotomy, disclose this information to our patients, listen to their
perspective, and, when the moment comes, choose to heed the evidence over
our prejudices, we could hardly fail to reduce dramatically the use of this
injurious procedure”.
It has now
been 4 years since you circulated Part V of your literature review on the
OBGNY.NET discussion group and 6 since part I-IV were published. With a
current episiotomy rate of 56% and annual birth rate of approximately
4,000,000, and assuming a truly “necessary” episiotomy rate is only
about 6% (the rate of midwives in Holland), that means that 50% or about 2
million medically-unnecessary “injurious procedures” are performed
annually by uninformed doctors each year. Multiplied by 6 years that equals
12 million unnecessary episiotomies over the course of just a few years ~
that’s a lot of avoidable loss of maternal blood and a lot of pain and no
doubt, a lot of significant complications, all for no good social or medical
purpose.
Frankly, I think the time for waiting is long past. It
seems unlikely that any peer review journal would be willing to print such
astute observations that are critical of physicians as communicated in Part
V. However, Midwifery Today, the Birth Gazette, the Journal of
Midwifery and Lifelines, the journal for AWHONN, are all
good choices. Any one of them would gladly breathe new life into your prose
and enable us to elevate the quality of the public and professional debate.
In the mean time, I am writing an article for
publication on these topics and the relationship between the misuse and
abuse of episiotomy and the many negative consequences, including its
association the institutionalized lack of physician training in
physiological management of labor and price paid by us all for such
deficiencies in medical education and practice such as the
“prophylactic” cesarean epidemic and return to “once a Cesarean,
always a Cesarean” for VBAC moms. I intend to publish in one of the
national ‘mother-baby-midwife-friendly’ magazines. It will include an
extensive commentary and critique of the ideas in your published literature
review, including Part V, which technically (for purposes of
copyright law) has already been published on the OBGYN.NET discussion group.
A critique of part V falls squarely under the “fair use” doctrine. I
have spoken to a lawyer, researched relevant laws and been in contact with
the friendly folks at the Electronic Frontier web site. They have provided
the following quotes, explanations of copyright law and the fair use
doctrine.
“The primary objective of copyright is
not to reward the labor of authors, but "[t]o promote the Progress of
Science and useful Arts." To this end, copyright assures authors the
right to their original expression, but encourages others to build freely
upon the ideas and information conveyed by a work. This result is neither
unfair nor unfortunate. It is the means by which copyright advances the
progress of science and art.” -- Justice Sandra Day O'Connor (Feist
Publications, Inc. v. Rural Telephone Service Co., 499 US 340, 349(1991)
“The genius of United States copyright
law is that, in conformance with its constitutional foundation, it balances
the intellectual property interests of authors, publishers and copyright
owners with society's need for the free exchange of ideas”
“Fair use refers to a privilege in
those other than the copyright owner to use the copyrighted material in a reasonable
manner without the consent of copyright owner. At its core is a
fundamental conviction that not all copying should be banned, particularly
in socially important endeavors.”
“Some examples listed in the statute that would generally be
considered a fair use to copy copyrighted material include: Criticism,
comment, parody, news reporting, teaching, scholarship, research.”
“Several important limitations
to the author's exclusive rights exist under copyright law to encourage
citizens to fully and openly exchange and build upon information to
increase the public's knowledge.”
“Taken together, fair use and other public rights to utilize
copyrighted works, as confirmed in the Copyright Act of 1976, constitute
indispensable legal doctrines for promoting the dissemination of
knowledge.”
“The factors to consider include:
1.The purpose and character of the use, including whether such use is
of a commercial nature or is for nonprofit educational purposes --
Courts are more likely to find fair use where the use is for
noncommercial purposes. 2. The nature of the copyrighted work -- A
particular use is more likely to be fair where the copied work is factual
rather than creative.”
Certainly we both were always aware that I had (and
have) the legal authority to “critique, comment, parody, report, teach”,
engage in “scholarly dissertations” and other similar “fair use” for
the express purpose of this socially important endeavor.
Until now I have chosen not to exercise that right. It
seemed to me that what would best honor your work was for you to state
you ideas in your own voice. Ideally that would come about by
publishing your original work in all five parts. For whatever reason,
that did not happen and Part V has taken on a life of its own, published as
it was on the OBGYN.NET (distribution of 1000+) and then posted by me on www.GoodNewsnet.org
and www.CollegeofMidwives.org
. I have been (and remain) willing to do what ever I could/can to make this
work for you – leave your name off, put your name in, identify the article
posted as an “unauthorized reprint” so as not to damage your changes of
independent publication or expose you to charges of plagiarism of another
physicians writings, etc. Taking the ‘blame” for a theoretical copyright
violation was a strategy to balance your personal and professional desires
with the absolute need of women to have this dangerous and dysfunctional
system fixed before another 10 or 20 million unnecessary procedures are
performed.
Sadly it seems that the only avenue for a full and open
exchange of these ideas and the opportunity to build upon information that
will increase the public's knowledge in the right use, misuse and abuse of
episiotomy will have to come from my voice, not yours. As I was
walking in the park this evening at sunset, musing on the Eternal Verities
of God, life, love and human endeavors and praying for inspiration, an
additional possibility came to me. It seems to me that the most appropriate
and dignified conclusion to this current controversy would be to give your
work a forum for publication in its entirety ~ that is, to repatriate part V
with parts I-IV on Ronnie Falcao’s web site and/or the www.collegeofmmidwives.org.
Please consider these options carefully and contact me
as to your preference. Your voice is a good one and should not be silenced,
muted or diluted.
I leave you with one additional thought:
“Now,
if Plato was the proverbial Johnny Appleseed of ideas for having written
them down and dispersed them, Socrates, his friend and mentor, is the
midwife for having exercised their birth. A passion for the delivery of
ideas was what both of these two ancients shared in common. Far from seeking
to quell the transmission of ideas, laws of copy protection seek mostly to
encourage their continued creation and expansion. That much seemed evident
from the start. In this respect, Socrates and his art of the dialectic throw
into relief the importance of a healthy and vibrant relationship between the
creators/providers and the enlightened self-interested as benefactors and
patrons.” Gerald Martin, gmartin@well.com
Warm regards,
faith ^^O^^
650 / 328-8491
Pacific Daylight Savings Time
PS it would be best to postpone
future phone conversations until I am awake. Last time I had been up most of
the night with a Gr 8 that I transferred to a hospital in San Francisco with
PPROM and a slight temp. Baby NSVD at 2:11 AM, all WNR except for long drive
home, did not get to bed til after 5 am.