Letters to the Editor © 2007 The Authors 153 Journal compilation © 2007 The Royal Australian and New Zealand College of Obstetricians and Gynaecologists; 47: 152 –156 second stage in the midwifery model are counter-balanced by increased interventions such as induction of labour, epidurals, episiotomies, and operative delivery as is seen in the medicalised model. The assumption that women are uninformed about the consequences of childbirth on their pelvic floor is without foundation. In general, women of this child-birthing generation have access to more information than ever before. Women who therefore choose a midwifery model may well have made an informed choice, just as it is believed that women who choose elective Caesarean section have made an informed choice on the available data with their own interpretations and judgements based on what is important to them. If vaginal birth is to be abandoned to save pelvic floors then it would be important to analyse the costs in terms of numbers needed to treat. This would include some estimate of additional costs associated with elective Caesareans, and the subsequent complications including increased risks of infertility, placental problems, infant morbidity and mortality, maternal morbidity and mortality. Just as evidence exists for increased pelvic floor injury related to increasing numbers of vaginal births so does evidence exist for increased numbers of repeat Caesarean sections, only in areas of different concern. There is no doubt that age alone is a major contributing factor to both urinary and fecal incontinence. Looking at the rates of incontinence in older age groups shows that similar rates are seen in men in the older years. 2 I would eagerly look forward to the results of a randomised clinical trial comparing ageing versus not ageing. This should probably be done before the Term Cephalic Trial. 3 I completely agree that more research is required. There is a vast amount of work to be done which looks at prevention of injury, better and earlier recognition of dysfunction and interventions that may improve outcomes. I would equally argue that calls to increase the Caesarean section rate in an attempt to rid women of pelvic floor changes is currently not sustainable until more certain evidence is available. It would be a pity to be part of a generation of maternity care providers who presided over yet another uncontrolled experiment of interventions on women and childbirth. Childbirth without the risks of long-lasting effects is an unobtainable utopia. Pregnancy and childbirth involve a compromise of consequences which women and their partners should be encouraged to understand and use to inform their choices. Just as everybody who has had a child comes to learn that introducing a child into our lives has more than one consequence and involves considerable compromise. Anne SNEDDON Department of Obstetrics and Gynaecology, The Australian National University Medical School, The Canberra Hospital, Woden, Australian Capital Territory, Australia DOI: 10.1111/j.1479-828X.2007.00705.x References 1 Lubowski DZ, Thorton MJ. Obstetric-induced incontinence: A black hole of preventable morbidity. Aust N Z J Obstet Gynaecol 2006; 46: 468–473. 2 Stenzelius K, Mattiasson A, Hallberg I, Westergren A. Symptoms of urinary and fecal incontinence among men and women 75+ in relations to health complaints and quality of life. Neurol Urodynamics 2004; 23: 211–222. 3 Robson S, Ellwood DA. Should obstetricians support a ‘term cephalic trial’? Aust N Z J Obstet Gynaecol 2003; 43: 341– 343. xxx 2007 47 2 Letters to the Editor Letters to the Editor Letters to the Editor Letters to the Editor Authors’ reply Thank you for the opportunity to respond to the two letters and one opinion article that are written in response to our article. 1 In her letter, Sneddon says that we make assumptions about the effect of the midwifery model on the pelvic floor. On the contrary, it is quite reasonable for us to enquire whether that model has been shown to be safe, and the onus rests on those practising it to prove the safety to their patients. In relation to women being uninformed, Sneddon says that women now have more access to information about the consequences of childbirth than ever before. However, access to information is wholly different from detailed informed consent, which every birthing mother has the right to expect, and as every litigant will explain. Brown and Bisits in their letter criticise the article for quoting references that are not recent. Our reasoning for this was to guide the reader through the literature that has interested colorectal surgeons, going back to the time when Parks and Swash began the process published in a number of landmark articles that defined the pathophysiology of incontinence. Brown and Bisits question the use of pudendal nerve terminal motor latency (PNTML). This is a large topic well beyond the scope of this discussion, which cannot be dismissed in their single sentence, but PNTML has been seminal in understanding the basis for neurogenic incontinence and the ways to prevent it. Our comments about potential litigation were intended to be constructive, and our admission, which Brown and Bisits quote, that ‘it is not clear who would be responsible’, is indeed factual. We believe that this should be of concern to all parties and should be addressed rather than dismissed. Brown and Bisits then criticise the Discussion by saying that we make an assumption without evidence about birth centres contributing to obstetric injury. We agree that there is a lack of evidence to analyse the problem, and that precisely is the issue in question. Our article specifically calls for ‘a comparison to be made of the risk of pelvic floor injury in conventional obstetric suites and birthing centres’. Brown and Bisits quote admirable (non-peer reviewed) rates of third-degree tears in the birthing unit of their own institution.