Letters to the Editor

Fathers Should Provide Support During Childbirth

TO THE EDITOR: The evidence-based answer to the "Cochrane for Clinicians: Putting Prevention into Practice" department in the October 1, 2002 issue of American Family Physician¹ stated that "continuous caregiver support during childbirth has a number of benefits with minimal to no risks." The Cochrane Review² and this abstract¹ serve to trivialize the role of the baby's father during the birth process and the long-term impact that the father has on the family unit.

I would like to make four points concerning the methodology of this Cochrane Review. First, the study is not blinded, because the mother would have been aware of the "continuous caregiver's" presence. Second, some of the end points measured are extremely "soft," and some of the studies used different end points. Third, "continuous caregiver support" was not defined and may have varied among the 14 studies. Fourth, the abstract states that "in one half of the trials in this review, husbands or partners were allowed to accompany women." This would imply that in the other one half of the trials, husbands or partners were not allowed to accompany women, which is hardly a "baseline" situation for expectant parents. Not to allow a father to be involved in the birth of his child for the purposes of a study would appear to be unethical. Conversely, if the mothers and fathers agreed to this artificial circumstance then there is an obvious selection bias.

There was mention of improvement of four clinical parameters; however, no mention was made of a difference in the final clinical outcome relative to the health of the mother or the baby. One less dose of pain medication, a lower score on the 5-point Apgar scale, or "slight reduction in the length of labor," while statistically significant, may not be clinically significant. The main point that is not included in the discussion is that the caregiver partly or entirely supplants the father.

The birth of a child is a unique, wonderful, emotional and, sometimes, trying experience. As such, it can be a supreme bonding experience for the parents. The memories and emotional bond created by this experience can make them a stronger couple and a stronger family. The inclusion of a third-party caregiver diminishes the opportunity for the couple to share one of life's truly unique and most precious moments.

If observation studies indicate ways to train the father to better support the mother during birth, then provide this training rather than replace the father. Whatever benefits, if any, that are provided by the presence of a "continuous caregiver" pales against the lost opportunity for the parents to share the experience of the birth of their child.

JOHN W. RICHARDS, JR., M.D.
4210 Columbia Rd., Ste. 14
Martinez, GA 20907

REFERENCES

1. Taylor JS. Caregiver support for women during childbirth: does the presence of a labor-support person affect maternal-child outcomes? (Cochrane) Am Fam Physician 2002;66:1205-6.
2. Hodnett ED. Caregiver support for women during childbirth (Cochrane Review). Cochrane Database Syst Rev 2002;1:CD000199.

Brucellar Spinal Epidural Abscess

TO THE EDITOR: Spinal epidural abscess is a rare condition that can lead to irreversible complications and death if untreated. The most common causative agent is Staphylococcus aureus, and other responsible agents include gram-negative bacteria, Streptococcus species, coagulase-negative Staphylococci, Streptococcus pneumoniae, Haemophilus aphrophilus, Nocardia asteroides, Echinococcus, Aspergillus, and Candida spp.^1,2 Chronic epidural infection may be caused by Mycobacterium tuberculosis, frequently without other evidence of infection. Rare causes include Actinomyces israelii² and Actinomyces odontolyticus.¹ In endemic areas such as South America, Central America, Mediterranean countries, Europe, and Africa, Brucella may produce spondylodiscitis, which may be complicated by spinal epidural abscesses.^3-5 The following case report is of spinal epidural abscess caused by systemic Brucella melitensis infection.

A 34-year-old Greek stockbreeder presented with a two-week history of fever, anorexia, headache, night sweats, and low back pain. The lumbar pain radiated along the S1 root and increased in intensity over four days. His medical history was unremarkable.

During examination, he exhibited tenderness to palpation of the lower lumbar spine despite having no external evidence of injury. Strength and reflexes were normal in bilateral lower extremities, but there was decreased sensation along the sciatic nerve in the left leg.

The patient was placed on intravenous ceftriaxone and dicloxacillin. A transesophageal echocardiogram was normal. A magnetic resonance imaging (MRI) of the spine showed spondylitis at L5 and a paraspinal soft tissue fluid collection at L5-S1. Three blood culture specimens yielded B. melitensis, and the Brucella seroagglutination test was positive in a titer of 1:2,560. A computed tomography-guided needle aspiration of the paravertebral collection yielded purulent material that also grew B. melitensis. The patient's antibiotic regimen was changed to streptomycin for 15 days and both doxycycline and rifampin for three months. His clinical course improved, and he recovered without neurologic sequelae.

Brucellosis is a multisystem disease caused by Brucella spp. Humans become infected from contact with infected animals and animal products, particularly milk and cheese. Neurologic involvement during the acute phase of Brucella infection affects between 2 and 5 percent of patients in the form of meningitis, encephalitis, myelitis-radiculoneuritis, brain abscess, epidural abscess, demyelinating syndromes, and meningovascular syndromes.^3,6 Epidural abscess has been reported in less than 1.5 percent of the neurologic complications, and generally this is associated with spondylitis.^3,4 Abscesses may arise from contiguity to spondylitis or from hematogenous spread. Brucellar spinal epidural abscesses commonly involve the lumbar spine, but cervical cases have recently been reported.⁵ Multidrug, prolonged treatment must be initiated quickly. One recommended regimen is doxycycline, rifampin (Rifadin), and trimethoprim-sulfamethoxazole (Bactrim, Septra) for the course that clinical, serologic, or MRI activity persist.³ Clinical response usually is satisfactory and surgical decompression is unnecessary unless there is associated medullar compression. Although rare, Brucella infection should be considered in patients presenting with signs and symptoms of spinal epidural abscess, especially in those living or traveling to endemic areas and those in close contact with infected domesticated animals and/or meat and dairy products.

DEMETRIOS PAPAIOANNIDES, M.D.,
CHRISTOS GIOTIS, M.D.
Arta General Hospital
1 Peranthis Hill
47100 Arta, Greece

PANAGIOTIS KORANTZOPOULOS, M.D.
NIKOLAOS AKRITIDIS, M.D.
"G. Hatzikosta" General Hospital
10 Makriyanni Ave.
45001 Ioannina, Greece

REFERENCES

1. Chao D, Nanda A. Spinal epidural abscess: a diagnostic challenge. Am Fam Physician 2002;65:1341-6.
2. Bleck TP, Greenlee JE. Epidural abscess. In: Mandell GL, Douglas RG, Bennett JE, Dolin R, eds. Mandell, Douglas, and Bennett's Principles and practice of infectious diseases. 5th ed. Philadelphia: Churchill Livingstone;2000:1031-4.
3. Perez-Calvo J, Matamala C, Sanjoaquin I, Rodriguez-Benavente A, Ruiz-Laiglesia F, Bueno-Gomez J. Epidural abscess due to acute Brucella melitensis infection. Arch Intern Med 1994;154:1410-1.
4. Solera J, Lozano E, Martinez-Alfaro E, Espinosa A, Castillejos ML, Abad L. Brucellar spondylitis: review of 35 cases and literature survey. Clin Infect Dis 1999;29:1440-9.
5. Pina MA, Modrego PJ, Uroz JJ, Cobeta JC, Lerin FJ, Baiges JJ. Brucellar spinal epidural abscess of cervical location: report of four cases. Eur Neurol 2001; 45:249-53.
6. Young EJ. Brucella species. In: Mandell GL, Douglas RG, Bennett JE, Dolin R, eds. Mandell, Douglas, and Bennett's Principles and practice of infectious diseases. 5th ed. Philadelphia: Churchill Livingstone;2000:2386-92.

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