BJOG Exchange
Disclosure of interest
PMH is the co-author of Choosing Cesarean, A Natural Birth Plan (Prometheus Books 2012) and was a stakeholder for the NICE CG132 Caesarean Section Update in 2011. & References 1 RCOG statement on draft NICE caesarean section guidelines. 31 October 2011. [www.rcog.org.uk/en/news/rcog-statementon-draft-nice-caesarean-section-guidelines/]. Accessed 3 February 2015. 2 Easter A. AGAINST: Women need accessible evidence-based information on caesarean section. BJOG 2015;122:359–60. 3 BMJ 2013;347:f4649 Re: NICE says caesarean section is not available on demand unless clinically indicated. 7 August 2013. [www. bmj.com/content/347/bmj.f4649/rr/656733]. Accessed February 3 2015. 4 Caesarean section (update): consultation table with responses, 5 September 2011; Caesarean section (update): pre-publication check comments table, 23 November 2011. [www.nice.org.uk/guidance/cg132/documents]. Accessed February 3 2015. 5 New RCOG guidance urges CCGs to increase births without epidurals and reduce caesarean rates to 20%. 23 August 2012. [www.prlog.org/11953412-new-rcog-guid ance-urges-ccgs-to-increase-births-withoutepidurals-and-reduce-caesarean-rates-to20.html]. Accessed February 3 2015. 6 11 Mar 2015 UKSC 2013/0136 Montgomery (Appellant) v Lanarkshire Health Board (Respondent) (Scotland). 7 Robson S, Ellwood D. Should obstetricians support a ‘term cephalic trial’? Aust N Z J Obstet Gynaecol 2003;43:341–3.
This extremism makes three mistakes. First, it assumes that maternal rights are the only relevant ethical consideration in obstetric practice. Maternal rights are indeed an ethically important consideration but not exclusively so in professional obstetric ethics.2,3 Second, the obstetrician must, as required by professional integrity, identify and balance three ethical obligations: autonomybased (or rights-based) obligations to the pregnant woman as well as beneficence-based obligations to the pregnant woman and soon-to-be-born fetal patient.2,3 Third, given the lack of evidence of net clinical benefit and growing concern about maternal risks for current and future pregnancies and about paediatric risks, professional integrity rules out the neutral stance proposed by Ms Hull in favour of the professional responsibility to recommend against caesarean delivery that is not indicated.4,5 One-sided accounts such as the extreme version of maternal rightsbased reductionism put forth by Ms Hull distort not only the science and clinical practice of obstetrics but also its professionalism. Disclosure of interest
The authors have no conflicts of interest. Both authors wrote the letter and approve the submitted, final version. & References
Pauline M Hull Calgary, Canada Accepted 19 February 2015. DOI: 10.1111/1471-0528.13424
Authors’ reply Sir, We thank Ms Hull for her letter.1 She appears to be committed to an extreme version of maternal rights-based reductionism in obstetric ethics,2,3 in which the requests of pregnant women for caesarean delivery are in all cases final and controlling ethical considerations.
1032
1 Hull P. Re: Caesarean section should be available on request:Debate continues in 2015 – ‘Should caesarean section be available on request?’ – but if 2011 NICE recommendations were followed, it already would be. BJOG 2015;122:1031– 1032. 2 Chervenak FA, McCullough LB, Brent RL. The professional responsibility model of obstetric ethics: avoiding the perils of clashing rights. Am J Obstet Gynecol 2011;205:315.e1–5. 3 Chervenak FA, McCullough LB, Brent RL. The professional responsibility model of physician leadership. Am J Obstet Gynecol 2013; 208:97–101. 4 Chervenak FA, McCullough LB, Brent RL, Levine MI, Arabin B. Planned home birth: the professional responsibility response. Am J Obstet Gynecol 2013;208:31–8.
5 Chervenak FA, McCullough LB. Preventive ethics for cesarean delivery: the time has come. Am J Obstet Gynecol 2013;209:166–7.
Frank A Chervenaka & Laurence B McCulloughb a
Weill Medical College of Cornell University, New York, NY, USA bBaylor College of Medicine, Houston, TX, USA Accepted 3 March 2015. DOI: 10.1111/1471-0528.13425
Author’s reply Sir, I would like to thank Ms Hull for her interest and response to our article— Women need accessible evidence-based information on caesarean.1,2 As stated, we believe it is fundamental that discussions with women requesting a caesarean section (CS) should be both supportive and informed by a range of relevant evidence. Women requesting CS will require differing levels of support and input from multidisciplinary teams, based on their needs and circumstances. Rather than the ‘forced NHS appointments’ described in Ms Hull’s letter, clearly a more individualised womencentred approach to care is what is needed. When a woman has a chance to discuss what she cares about, what worries her and what she wants to avoid with an experienced, woman-centred midwife, it is often possible for the midwife to address all of the woman’s concerns and aims. Working with obstetric colleagues, anaesthetists, and sometimes with perinatal mental health services, can be helpful during these discussions. As the National Institute of Health Care and Excellence guidance states, ‘if after discussion and support vaginal delivery remains unacceptable to a woman, CS should be offered’. NCT supports this approach. Ensuring that discussions are evidence-based is also essential. As highlighted in all four of the debate
ª 2015 Royal College of Obstetricians and Gynaecologists
BJOG Exchange
articles, there is limited evidence available to offer guidance to women who request a CS in the absence of any medical indication. Nevertheless, it is the responsibility of midwifery and obstetric teams to provide women who are considering CS with the best available knowledge on the risks and benefits to mother and baby, so that the decision can be an informed one. &
i.e. the same lactobacilli. This selfregulatory mechanism is designed to keep in check the growth of lactobacilli.3 Could the exogenous administration of lactic acid potentiate the vicious cycle of lactobacilli deficiency and thus in the longer term prove to be of no benefit to the patient. We would be most interested in Professor Witkin’s thoughts on this matter. &
References
References
1 Hull P. Re: Caesarean section should be available on request:Debate continues in 2015 – ‘Should caesarean section be available on request?’ – but if 2011 NICE recommendations were followed, it already would be. BJOG 2015;122:1031–1032. 2 Easter A. AGAINST: women need accessible evidence-based information on caesarean section. BJOG 2015;122:359–60.
1 Witkin S. The vaginal microbiome, vaginal anti-microbial defence mechanisms and the clinical challenge of reducing infection-related preterm birth. BJOG 2014;122:213–8. 2 Reid JN, Bisanz JE, Monachese M, Burton J, Reid G. The rationale for probiotics improving reproductive health and pregnancy outcome. Am J Reprod Immunol 2013;69:558–66. 3 Tomas M, Bru E, Nader-Macias M. Comparison of the growth and hydrogen peroxide production by vaginal probiotic lactobacilli under different culture conditions. Am J Obstet Gynecol 2003;188:35–44.
Abigail Easter Research and Quality Manager, Research and Quality Department, NCT, London, UK Accepted 15 March 2015. DOI: 10.1111/1471-0528.13426
Re: The vaginal microbiome, vaginal anti-microbial defence mechanisms and the clinical challenge of reducing infection-related preterm birth
Can too much of a good thing be bad for you? We read with great interest the most engaging and erudite review article by Professor Witkin.1 The concept of treating vaginal dysbiosis with lactic acid is a most attractive concept to supplant the current over-use of antibiotics for what is essentially a nonlife-threatening maternal condition.2 However, high concentrations of hydrogen peroxide produced in vitro by lactobacilli are bactericidal to the actual source of the hydrogen peroxide,
C Griffin, J Harding & C Sutton University of Western Australia Clinical School, King Edward Memorial Hospital, Subiaco, WA, Australia Accepted 19 October 2014. DOI: 10.1111/1471-0528.13229
Author’s reply I thank Drs Griffen, Harding and Sutton for their favourable comments on my review article.1 I agree with their statement that a non-antibiotic treatment for bacterial vaginosis (BV) is highly desirable. I also concur that too high a concentration of lactic acid can inhibit growth of Lactobacilli. In fact, our recent article in BJOG provides evidence that excess L-lactic acid production in women diagnosed with cytolytic vaginosis contributes to the loss of some Lactobacillus species as well as host epithelial cells.2
ª 2015 Royal College of Obstetricians and Gynaecologists
Conversely, an article by O’Hanlon et al.3 clearly demonstrates that there are concentrations of L-lactic acid that inhibit growth of BV-associated bacteria while having no effect on Lactobacillus growth. To add a further complication, we have provided evidence that the ratio of D- to L-lactic acid isomers in vaginal fluid helps to regulate the production of mediators from vaginal epithelial cells that may differentially influence bacterial growth.4 Clearly, there remains a need to ascertain the optimal level of lactic acid, and the ratio of D- to L-lactic acid, that can be exogenously provided safely to individual women with BV. The ideal level may differ between women due to the composition of the resident vaginal microbiota. & References 1 Witkin SS. The vaginal microbiome, vaginal anti-microbial defence mechanisms and the clinical challenge of reducing infection-related preterm birth. BJOG 2014. 10.1111/14710528.13115 2 Beghini J, Linhares IM, Giraldo PC, Ledger WJ, Witkin SS. Differential expression of lactic acid isomers, extracellular matrix metalloproteinase inducer, and matrix metalloproteinase-8 in vaginal fluid from women with vaginal disorders. BJOG 2014;10.1111/1471-0528. 13072 [Epub ahead of print]. 3 O’Hanlon DE, Moench TR, Cone RA. Vaginal pH and microbicidal lactic acid when lactobacilli dominate the microbiota. PLoS One 2013;8:e80074. 4 Witkin SS, Mendes-Soares H, Linhares IM, Jayaram A, Ledger WJ, Forney LJ. Influence of vaginal bacteria and D- and L-lactic acid isomers on vaginal extracellular matrix metalloproteinase inducer: implications for protection against upper genital tract infections. MBio 2013;4:e00460–13.
SS Witkin Department of Obstetrics and Gynecology, Weill Cornell Medical College, New York, NY, USA Accepted 23 October 2014. DOI: 10.1111/1471-0528.13228
1033
Copyright of BJOG: An International Journal of Obstetrics & Gynaecology is the property of Wiley-Blackwell and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
Disclosure of interest
PMH is the co-author of Choosing Cesarean, A Natural Birth Plan (Prometheus Books 2012) and was a stakeholder for the NICE CG132 Caesarean Section Update in 2011. & References 1 RCOG statement on draft NICE caesarean section guidelines. 31 October 2011. [www.rcog.org.uk/en/news/rcog-statementon-draft-nice-caesarean-section-guidelines/]. Accessed 3 February 2015. 2 Easter A. AGAINST: Women need accessible evidence-based information on caesarean section. BJOG 2015;122:359–60. 3 BMJ 2013;347:f4649 Re: NICE says caesarean section is not available on demand unless clinically indicated. 7 August 2013. [www. bmj.com/content/347/bmj.f4649/rr/656733]. Accessed February 3 2015. 4 Caesarean section (update): consultation table with responses, 5 September 2011; Caesarean section (update): pre-publication check comments table, 23 November 2011. [www.nice.org.uk/guidance/cg132/documents]. Accessed February 3 2015. 5 New RCOG guidance urges CCGs to increase births without epidurals and reduce caesarean rates to 20%. 23 August 2012. [www.prlog.org/11953412-new-rcog-guid ance-urges-ccgs-to-increase-births-withoutepidurals-and-reduce-caesarean-rates-to20.html]. Accessed February 3 2015. 6 11 Mar 2015 UKSC 2013/0136 Montgomery (Appellant) v Lanarkshire Health Board (Respondent) (Scotland). 7 Robson S, Ellwood D. Should obstetricians support a ‘term cephalic trial’? Aust N Z J Obstet Gynaecol 2003;43:341–3.
This extremism makes three mistakes. First, it assumes that maternal rights are the only relevant ethical consideration in obstetric practice. Maternal rights are indeed an ethically important consideration but not exclusively so in professional obstetric ethics.2,3 Second, the obstetrician must, as required by professional integrity, identify and balance three ethical obligations: autonomybased (or rights-based) obligations to the pregnant woman as well as beneficence-based obligations to the pregnant woman and soon-to-be-born fetal patient.2,3 Third, given the lack of evidence of net clinical benefit and growing concern about maternal risks for current and future pregnancies and about paediatric risks, professional integrity rules out the neutral stance proposed by Ms Hull in favour of the professional responsibility to recommend against caesarean delivery that is not indicated.4,5 One-sided accounts such as the extreme version of maternal rightsbased reductionism put forth by Ms Hull distort not only the science and clinical practice of obstetrics but also its professionalism. Disclosure of interest
The authors have no conflicts of interest. Both authors wrote the letter and approve the submitted, final version. & References
Pauline M Hull Calgary, Canada Accepted 19 February 2015. DOI: 10.1111/1471-0528.13424
Authors’ reply Sir, We thank Ms Hull for her letter.1 She appears to be committed to an extreme version of maternal rights-based reductionism in obstetric ethics,2,3 in which the requests of pregnant women for caesarean delivery are in all cases final and controlling ethical considerations.
1032
1 Hull P. Re: Caesarean section should be available on request:Debate continues in 2015 – ‘Should caesarean section be available on request?’ – but if 2011 NICE recommendations were followed, it already would be. BJOG 2015;122:1031– 1032. 2 Chervenak FA, McCullough LB, Brent RL. The professional responsibility model of obstetric ethics: avoiding the perils of clashing rights. Am J Obstet Gynecol 2011;205:315.e1–5. 3 Chervenak FA, McCullough LB, Brent RL. The professional responsibility model of physician leadership. Am J Obstet Gynecol 2013; 208:97–101. 4 Chervenak FA, McCullough LB, Brent RL, Levine MI, Arabin B. Planned home birth: the professional responsibility response. Am J Obstet Gynecol 2013;208:31–8.
5 Chervenak FA, McCullough LB. Preventive ethics for cesarean delivery: the time has come. Am J Obstet Gynecol 2013;209:166–7.
Frank A Chervenaka & Laurence B McCulloughb a
Weill Medical College of Cornell University, New York, NY, USA bBaylor College of Medicine, Houston, TX, USA Accepted 3 March 2015. DOI: 10.1111/1471-0528.13425
Author’s reply Sir, I would like to thank Ms Hull for her interest and response to our article— Women need accessible evidence-based information on caesarean.1,2 As stated, we believe it is fundamental that discussions with women requesting a caesarean section (CS) should be both supportive and informed by a range of relevant evidence. Women requesting CS will require differing levels of support and input from multidisciplinary teams, based on their needs and circumstances. Rather than the ‘forced NHS appointments’ described in Ms Hull’s letter, clearly a more individualised womencentred approach to care is what is needed. When a woman has a chance to discuss what she cares about, what worries her and what she wants to avoid with an experienced, woman-centred midwife, it is often possible for the midwife to address all of the woman’s concerns and aims. Working with obstetric colleagues, anaesthetists, and sometimes with perinatal mental health services, can be helpful during these discussions. As the National Institute of Health Care and Excellence guidance states, ‘if after discussion and support vaginal delivery remains unacceptable to a woman, CS should be offered’. NCT supports this approach. Ensuring that discussions are evidence-based is also essential. As highlighted in all four of the debate
ª 2015 Royal College of Obstetricians and Gynaecologists
BJOG Exchange
articles, there is limited evidence available to offer guidance to women who request a CS in the absence of any medical indication. Nevertheless, it is the responsibility of midwifery and obstetric teams to provide women who are considering CS with the best available knowledge on the risks and benefits to mother and baby, so that the decision can be an informed one. &
i.e. the same lactobacilli. This selfregulatory mechanism is designed to keep in check the growth of lactobacilli.3 Could the exogenous administration of lactic acid potentiate the vicious cycle of lactobacilli deficiency and thus in the longer term prove to be of no benefit to the patient. We would be most interested in Professor Witkin’s thoughts on this matter. &
References
References
1 Hull P. Re: Caesarean section should be available on request:Debate continues in 2015 – ‘Should caesarean section be available on request?’ – but if 2011 NICE recommendations were followed, it already would be. BJOG 2015;122:1031–1032. 2 Easter A. AGAINST: women need accessible evidence-based information on caesarean section. BJOG 2015;122:359–60.
1 Witkin S. The vaginal microbiome, vaginal anti-microbial defence mechanisms and the clinical challenge of reducing infection-related preterm birth. BJOG 2014;122:213–8. 2 Reid JN, Bisanz JE, Monachese M, Burton J, Reid G. The rationale for probiotics improving reproductive health and pregnancy outcome. Am J Reprod Immunol 2013;69:558–66. 3 Tomas M, Bru E, Nader-Macias M. Comparison of the growth and hydrogen peroxide production by vaginal probiotic lactobacilli under different culture conditions. Am J Obstet Gynecol 2003;188:35–44.
Abigail Easter Research and Quality Manager, Research and Quality Department, NCT, London, UK Accepted 15 March 2015. DOI: 10.1111/1471-0528.13426
Re: The vaginal microbiome, vaginal anti-microbial defence mechanisms and the clinical challenge of reducing infection-related preterm birth
Can too much of a good thing be bad for you? We read with great interest the most engaging and erudite review article by Professor Witkin.1 The concept of treating vaginal dysbiosis with lactic acid is a most attractive concept to supplant the current over-use of antibiotics for what is essentially a nonlife-threatening maternal condition.2 However, high concentrations of hydrogen peroxide produced in vitro by lactobacilli are bactericidal to the actual source of the hydrogen peroxide,
C Griffin, J Harding & C Sutton University of Western Australia Clinical School, King Edward Memorial Hospital, Subiaco, WA, Australia Accepted 19 October 2014. DOI: 10.1111/1471-0528.13229
Author’s reply I thank Drs Griffen, Harding and Sutton for their favourable comments on my review article.1 I agree with their statement that a non-antibiotic treatment for bacterial vaginosis (BV) is highly desirable. I also concur that too high a concentration of lactic acid can inhibit growth of Lactobacilli. In fact, our recent article in BJOG provides evidence that excess L-lactic acid production in women diagnosed with cytolytic vaginosis contributes to the loss of some Lactobacillus species as well as host epithelial cells.2
ª 2015 Royal College of Obstetricians and Gynaecologists
Conversely, an article by O’Hanlon et al.3 clearly demonstrates that there are concentrations of L-lactic acid that inhibit growth of BV-associated bacteria while having no effect on Lactobacillus growth. To add a further complication, we have provided evidence that the ratio of D- to L-lactic acid isomers in vaginal fluid helps to regulate the production of mediators from vaginal epithelial cells that may differentially influence bacterial growth.4 Clearly, there remains a need to ascertain the optimal level of lactic acid, and the ratio of D- to L-lactic acid, that can be exogenously provided safely to individual women with BV. The ideal level may differ between women due to the composition of the resident vaginal microbiota. & References 1 Witkin SS. The vaginal microbiome, vaginal anti-microbial defence mechanisms and the clinical challenge of reducing infection-related preterm birth. BJOG 2014. 10.1111/14710528.13115 2 Beghini J, Linhares IM, Giraldo PC, Ledger WJ, Witkin SS. Differential expression of lactic acid isomers, extracellular matrix metalloproteinase inducer, and matrix metalloproteinase-8 in vaginal fluid from women with vaginal disorders. BJOG 2014;10.1111/1471-0528. 13072 [Epub ahead of print]. 3 O’Hanlon DE, Moench TR, Cone RA. Vaginal pH and microbicidal lactic acid when lactobacilli dominate the microbiota. PLoS One 2013;8:e80074. 4 Witkin SS, Mendes-Soares H, Linhares IM, Jayaram A, Ledger WJ, Forney LJ. Influence of vaginal bacteria and D- and L-lactic acid isomers on vaginal extracellular matrix metalloproteinase inducer: implications for protection against upper genital tract infections. MBio 2013;4:e00460–13.
SS Witkin Department of Obstetrics and Gynecology, Weill Cornell Medical College, New York, NY, USA Accepted 23 October 2014. DOI: 10.1111/1471-0528.13228
1033
Copyright of BJOG: An International Journal of Obstetrics & Gynaecology is the property of Wiley-Blackwell and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
