Letters to the Editor

Trained Caregivers Provide Valuable Role in Childbirth

TO THE EDITOR: In a letter to the editor¹ of American Family Physician, Dr. Richards responded to a Cochrane Review² of caregiver support for women during childbirth that was abstracted in American Family Physician.³ He makes several excellent points about the invaluable role that fathers can play in supporting mothers during labor. However, he has several misconceptions that warrant further clarification.

Dr. Richards expresses concern that the caregiver providing labor support "partly or entirely supplants the father," thus diminishing the couple's ability to share in the experience of childbirth. The Doulas of North America, a national certifying organization for labor support caregivers, states that the doula's role is to "provide physical, emotional, and informational support to women and their partners during labor and birth."⁴ The doula organization adds, "the doula is there in addition to, not instead of, the partner. Ideally, the doula and the partner make the perfect support team for the woman, complementing each other's strengths."

The doula is not intended to replace the supportive partner. Doula support can alleviate the anxiety of both parents by helping the father and other family members support the laboring mother. Dr. Richards states, "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."¹ Providing this training is exactly what intrapartum caregivers do.

Dr. Richards also misunderstands some of the details of the clinical trials included in the Cochrane review.² He comments that in one half of the trials evaluated, women's partners were not allowed to be present for the delivery, raising a potential ethical dilemma of excluding fathers from their children's birth for the purposes of a study. The trials included in the review were conducted in diverse locations, including North America, Europe, Central America, and Africa. Hospital policies differ internationally, and some of these hospitals did not admit fathers as a matter of policy. Therefore, not admitting these fathers was standard care where these trials were conducted, rather than a condition artificially induced by the investigators.

Dr. Richards criticizes the Cochrane review² for not defining "continuous caregiver support." The review² included trials that compared usual care with "continuous labour support by either a familiar or unfamiliar professional (nurse or midwife) or lay person (paid or volunteer)," providing one-to-one support. Dr. Richards also comments on the lack of blinding in the trials. Although the majority of trials were not blinded, one trial attempted blinding, by using a "sham" doula who did not actually provide support for control patients.⁵ For many medical interventions, trials cannot be adequately blinded. However, this does not obviate the need for careful evaluation of such interventions in the context of a randomized clinical trial. Finally, although doulas have not been documented to improve final clinical outcomes for mothers or infants, reductions in pain, operative vaginal deliveries, and cesarean deliveries are far from trivial clinical outcomes. Family physicians who provide obstetric care should consider using doulas in the intrapartum care of their patients.

AMY C. DENHAM, M.D.
University of North Carolina
Department of Family Medicine
CB# 7595 Manning Dr.
Chapel Hill, NC 27599-7595

REFERENCES

1. Richards JW Jr. Fathers should provide support during childbirth [Letter]. Am Fam Physician 2003;67:2071.

2. Hodnett ED. Caregiver support for women during childbirth (Cochrane Review). Cochrane Database Syst Rev 2002;1:CD000199.

3. 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.

4. Simkin P, Way K. Position paper: the doula's contribution to modern maternity care. Accessed January 29, 2004 at http://www.dona.org/ConsumerInformation.html.

5. Kennell J, Klaus M, McGrath S, Robertson S, Hinkley C. Continuous emotional support during labor in a US hospital. A randomized controlled trial. JAMA 1991;265:2197-201.

Psychosocial Counseling May Be Best Treatment for Hair Loss

TO THE EDITOR: I enjoyed the article on hair loss disorders in the July 1, 2003 issue of American Family Physician.¹ However, I was surprised that the authors' discussion of androgenetic alopecia (male-pattern baldness) excluded an important alternative to surgery and pharmacologic therapy: no medical treatment.² Certainly, the safest and least invasive way to address the psychosocial impact of hair loss is through psychosocial counseling. An earnest conversation about body image and reassurance that hair loss is a normal part of life might help some patients avoid the costs and risks of pharmacologic therapy or surgical intervention, and those associated with the quack remedies hawked for this medically benign condition.

JONATHAN U. PELED
Second-year Medical Student
Albert Einstein College of Medicine
1300 Morris Park Ave.
Bronx, NY 10461

REFERENCES

1. Springer K, Brown M, Stulberg DL. Common hair loss disorders. Am Fam Physician 2003;68:93-102.

2. Drake LA, Dinehart SM, Farmer ER, Goltz RW, Graham GF, Hordinsky MK, et al. Guidelines of care for androgenetic alopecia. American Academy of Dermatology. J Am Acad Dermatol 1996;35:465-9.

Question of Consent for Image Used in 'Photo Quiz'

TO THE EDITOR: I was taken aback when reading the Photo Quiz in the July 1, 2003 issue of American Family Physician,¹ which featured a full-frontal nude picture of a 17-year-old woman with Prader-Willi syndrome. Several things about this bothered me, including referring to her as a "girl" (had she been male, would the reference have been to a 17-year-old boy?), describing her as "mentally retarded," and picturing her entirely naked. Certainly, there is a place for photography such as this in the medical literature. However, in this instance, I was concerned about how a young woman with significant disabilities could have reasonably given consent for such a photograph.

JIM ANDERSON, PA-C
Harborview Medical Center
325 9th Ave.
Seattle, WA 98101

REFERENCE

1. Baumgart DC, Gerl H. Obesity and daytime sleepiness. [Photo Quiz] Am Fam Physician 2003;68: 151-2.

EDITOR'S NOTE: For questions of terminology, American Family Physician policy is to follow the standards of the American Medical Association Manual of Style: a Guide for Authors and Editors. According to the AMA Manual of Style, this person should have been described as a "teenager" or an "adolescent girl."

Written consent was obtained from the patient's guardian for use of the photograph.

REBECCA POAGE, M.D.
Medical Editing Fellow
American Family Physician

Correction

The article "Management of Gestational Diabetes Mellitus" (November 1, 2003, page 1767) contained an error in the values of whole blood glucose. On page 1768, in the third paragraph, the last sentence should have stated "Whole blood glucose values are approximately 10 to 15 percent lower than serum or plasma values." The online version of this article has been corrected. *

Send letters to Jay Siwek, M.D., Editor, American Family Physician, 11400 Tomahawk Creek Pkwy., Leawood, KS 66211-2672; fax: 913-906-6080; e-mail: afplet@aafp.org. Please include your complete address, telephone number, and fax number. Letters should be submitted on disk, double-spaced, fewer than 500 words, and limited to one table or figure and six references. Please submit a word count. Letters submitted for publication in AFP must not be submitted to any other publication. Possible conflicts of interest must be disclosed at time of submission. Submission of a letter will be construed as granting the AAFP permission to publish the letter in any of its publications in any form. The editors may edit letters to meet style and space requirements.