"Shooting the Messenger if You Don't Like
the Message"
The following ran in the Midwifery
Today E-News- Volume 4 Issue 16 April 18,
2002.
"I am an obstetrician/gynecologist seeking
info on collaborative practice/midwifery. Our
goal is to work on establishing this in our area.
However, upon reading the article by Dr. Wagner
[What Every Midwife Should Know About ACOG and
VBAC, available online at Midwifery
Today] I am appalled at the tone of the
content. It is very antagonistic and inflammatory.
As a physician who is actively seeking info I
feel turned off by the message given by your publication.
There has to be a moderating influence in your
editorial board. How can you expect to breech
the divide between the disciplines if you publish
extremist material? To imply that rising maternal
death rates are due to rising c-sections and epidural
rates undermines your credibility. It makes you
seem as dogmatic as old-style MDs who say you
must have an episiotomy WITHOUT any evidence to
support the claim. I will look elsewhere for a
source that is supportive of a true collaborative
and truly progressive style of medicine."
-Parke Hedges, MD San Antonio, TX
Marsden Wagner responds:
"This obstetrician has labeled me antagonistic
and an extremist -- another example of shooting
the messenger if you don't like the message. I
fear that obstetricians have been in a position
of power for so long that some are unable to take
criticism -- a dangerous attitude to say the least.
My credibility is challenged because I suggest
that the rising maternal mortality rate in the
US the past 15 years (a fact) may be related to
the rising rates of c-section and epidural. In
fact, good data in the literature shows c-section
has a rate of maternal mortality 6 times higher
than vaginal birth. Even if you eliminate emergency
c-section and consider only elective c-sections,
the maternal mortality rate is just under 3 times
higher than vaginal birth. (Hall M, Lancet, 354,
776, 1999).
Good scientific data in the literature reveals
that the maternal mortality rate is higher if
epidural block is used for the pain of normal
labor -- ask any anesthesiologist.
Since the rate of c-section and the rate of epidural
block for normal labor pain both have been shown
to be increasing in the US, it is not extremist
but logical to suggest the rising maternal mortality
is likely related to the increasing rates of c-section
and epidural block.
The tone in the message from this obstetrician
is a familiar one -- it represents what I call
"tribal loyalty." Since I am a member
of the tribe -- a medical doctor -- I must never
say anything that might be considered critical
of the practice of other doctors. But tribal loyalty
is a self-defeating strategy because it eliminates
the possibility for doctors to admit they make
mistakes and therefore improve their practice.
An example: Between 1990 and 1999 many women having
VBAC in the US were given Cytotec induction. Finally
in 1999 published papers proved that Cytotec induction
with VBAC markedly increases the risk of uterine
rupture, and ACOG finally said don't do it. So
we now know that during these years many women
had uterine rupture because obstetricians were
making a mistake. But I have never heard a single
obstetrician admit to making this mistake, much
less express remorse.
Obstetricians and midwives will collaborate well
together only when there is mutual respect in
an egalitarian professional relationship."
-Marsden Wagner MD, MSPH
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