Mark J. Fowler

Translation Project

Now there is ongoing project in Latvia - Williams Obstetrics translation in Latvian. The question could arise - why Latvia needs the world-wide accepted book in Latvian? Maybe initiators of this project are simply “bleeding heart” persons ? Why it is important? Why to bother to talk about this? Why to translate? And isn’t this a bit of utopia to hope that somebody will read this?  There are several propulsion ideas behind this project: 

• Williams Obstetrics is a story about how each of us was born. In this book everybody can find answers - where she/he came from, how it happened and why she/he has one or another childbirth experience. It is somehow similar to family-tree - it is not important till the moment when you are willing to understand, what are your roots, as this is the way to understand who you are. 

• The message for women: I am not a medical person, but I can read is the message which the authors of translation project are willing to send to each and every woman to encourage to take responsibility about her body, baby and about actions in which she is taking part (e.g. procedures, actions and emotions). It is true that medical staff know a lot about medicine, but only particular women knows what pregnancy and care for baby means to her. As latest trends in medical care show - as it was also discussed in eHealth Conference in Tallinn 2010 - we can talk about “Health 2.0”. It means  that “The combination of health data and health information with (patient) experience through the use of ITC (information technology and communication) enabling the citizen to become an active and responsible partner in his/her own health and care pathway.” [2] It seams it is time to change health care model from [parent-child] to [adult-adult] in which women and medical staff are equal partners and are able to cooperate. But for this idea to become true - some educational work in both sides (women and medical staff) must be done. 

• The message for professionals: If you do not want - do not read, but do not talk rubbish! It is the last thing what initiators of Williams Obstetric translation project are willing to achieve. E.g., if some women is in labor for a longer period of time as it is “usual”, and some medical staff do not intervene, initiators of translation project would be pleased if those who have not read that according to latest evidence based research it is acceptable to wait, at least - do not gabble, trying to “entertain” colleagues with their decades old “knowledge” and scare stories collected. 

Is there any chance for this idea to survive and fulfill its goal - to change birth culture in Latvia through educating women on reproductive issues and providing health professionals with worldwide accepted evidence-based literature on childbirth? Time will show.  

Why it is important? Childbirth Issues in Latvia

Studies of the Latvian authorities in obstetrics show, although the Latvian health care facilities have guidelines by which to organize their work, there are major disorders. Data on maternal and child health in Latvia has shown a positive tendency during the last decade, but they are still not satisfactory:

• Perinatal mortality – the number of stillbirths and deaths in the first week of life for the 1000 live births and stillbirths. Latvian perinatal mortality (Picture 2) still is higher than average for EU member states. The Latvian figure is also the highest among the Baltic states [3].

• Neonatal mortality – death among the life births between 0 till 27th day of life per 1000 life births. In Latvia it is still reaching much higher levels than EU member states average [3]. 

Picture 2

Perinatal mortality per 1000 live births and still births [3]

In comparison to EU Latvian infant mortality rate is approximately double that of EU average. Compared with the Baltic states, Latvia has the highest infant mortality[4].

Table 3

Delivery process and medical characteristics [3]

Significant number of childbirths are related to complicated deliveries (Table 3), like multiple births, preterm deliveries, need for urgent cesarean deliveries, where evidence based approach is crucial.

Picture 3

% of Cesarean deliveries and number per 1000 live births [5]



Dynamics of deliveries with cesarean section are described in the Picture 3.  Percentage of most common labor complications are described in the Table 4. 

Table 4

Deliveries and proportion of complications [3] 

Jaunākie dati (2006.-2011.gads) skatāmi Slimību profilakses un kontroles centra mājaslapā Statistikas gadagrāmatas sadaļā 8.Mātes un bērna veselības aprūpe.

Who will be involved? Change Participants & What They “Say”.

Professionals

Interviews and survey were done to get impression on primary participants of changes - professionals. The questionnaire was run from November 5th to December 1st, 2010. 

Total of 95 answers were received mainly covering midwifes (79%) and doctors (16%) with average age of 43.4 years. In general, most respondents claim that “Williams Obstetrics” translation in Latvian would give additional benefit/value to existing childbirth culture in Latvia - mainly respondents indicate need for renewed obstetrics literature, preferably in Latvian language (as 45.8% read most often in Latvian). Moderate use of internet and foreign literature is observed among respondents also indicating need for additional experience extending knowledge, knowing latest tendencies and switching from existing literature.

Regular Users

On-line questionnaire was performed to get impression of secondary participants of changes - regular families. There have been 175 responses collected. 

Generally there are 87% who are seeking for information of their interest regarding child birth issues. 46% do that very intensively. Women preferences for trustful information: 75% turn to medical personal; 68% search on internet; 58% read books. Most of women (72%) have not heard about the Williams Obstetrics book.

How could it be done? Comparison of Ethical Theories

Utilitarianism - Money

Utilitarianism is the idea that the moral worth of an action is determined solely by its usefulness in maximizing utility/minimizing negative utility (utility can be defined as pleasure, preference satisfaction, knowledge or other things) as summed among all sentient beings [7].

No fast money can be earned in this project and no short term gains can be calculated. It means - for utilitarianism’s point of view this project is useless.

Deontological ethics - Duty

"Duty" or "obligation" or "rule" - based ethics, because rules "bind you to your duty". Kant argues that to act in the morally right way, people must act from duty (deon) [8].

Duty to care about health and lives [16, part I / point 3] of children (born and unborn) could provide some support to childbirth culture paradigm shift in Latvia. Useful tool for government for this purpose could be concept of Social Return on Investment (SROI) as “Government can make better decisions if they have better measurement” [17]. 

Morality -  Consensus Ethics

Consensus is defined in English as, firstly, general agreement and, secondly, group solidarity of belief or sentiment. It has its origin in a Latin word meaning literally to feel together [9]. The most common and most successful model of consensus is called the prisoner's dilemma [10]. Consensus upon a particular formal model of consensus can lead to groupthink, by making it harder for those who reject any that formal model to have their case heard out in informal terms or using a different model [10].

There is consensus (more precisely - groupthink) about childbirth issues in Latvia already. Still this consensus in within “old” - tradition and routine-based childbirth - paradigm. New consensus should be created and practiced - evidence-based medicine in practice as a norm. However, taking in account history of evidence-based medicine concept [18], most probably, it will take years.

Virtue Ethics

Virtue ethics is an approach to ethics that emphasizes the character of the moral agent, rather than rules or consequences, as the key element of ethical thinking [11, 12].

Medical ethics is strongly related topic to childbirth - obstetrics, which is the branch of medicine dealing with childbirth and care of the mother. As medical situations quite often are related to decision making, we can agree that virtue ethics approach to moral dilemmas in medicine [19]. In the case of paradigm shift and changes in childbirth culture in Latvia we can address this theory in the context of individual decision-making process. 

Game theory - Precedents

The ethical decisions we make form a set of precedents that inform subsequent ethical decisions [13]. And people’s expectations are conditioned by precedent [20]. 

The practice of evidence-based medicine means integrating individual clinical expertise with the best available external clinical evidence from systematic research. In this context evidence-based childbirth care could be collected and communicated as precedents.  

How will it be done? Feasible Solution for Paradigm Shift

In the context of this paper Williams Obstetrics can be perceived as a tool for paradigm shift implementation in Latvia. It will be paradigm shift from tradition & routine-based to evidence-based childbirth care. 

Concept of “evidence-based” in Latvia can not be described as intrinsic value. Still intrinsic value should be present “in order to function successfully” and are build through education [14, pp.19]. Two paradigms cannot be reconciled with each other because they cannot be subjected to the same common standard of comparison. No meaningful comparison between them is possible without fundamental modification of the concepts that are an intrinsic part of the paradigms being compared.  This aspect lead us following decisions for “introducing / participating” in paradigm shift: 

• Building trust. Forward planning - goal of paradigm shift and metrics should be defined and gradual forward planned actions should be performed to build trust in participants of these changes. 

• Building intrinsic values and new consensus. Introducing evidence-based medical care in education (starting from secondary schools till medical high-schools). Advertising editions of Williams Obstetrics (4 selected chapters can be introduced as the first material for this purpose).

• Using the most appropriate ethical theory - game theory. List of precedents - as from all previously described ethical theory game theory with precedents seemed the most appropriate, all precedents should be documented, analyzed and documented to set new expectation in society related to childbirth care. 

• Using supportive ethical theory - deontological ethics:
  • Social return of investment should be calculated to show impact of changes in childbirth culture on society. 
  • Empowering evidence-based medical care with the power of law - e.g. Home-birth midwives in Latvia will have separate certificate of working in out-of-hospital environment. This certificate  is required by law, is going to be included as part of particular Cabinet regulations and are developed based on Williams Obstetrics - the leading obstetrics reference for more than a century.  

• Strengthening medical ethics issues in Latvia to encourage changes in individual decision-making process.  

In description of paradigm shift it is said: “When enough significant anomalies have accrued against a current paradigm, the scientific discipline is thrown into a state of crisis, according to Kuhn. During this crisis, new ideas, perhaps ones previously discarded, are tried. Eventually a new paradigm is formed, which gains its own new followers, and an intellectual "battle" takes place between the followers of the new paradigm and the hold-outs of the old paradigm” [21]. 

And let me finish this paper with a quote from Max Planck used by Th.Kuhn: "A new scientific truth does not triumph by convincing its opponents and making them see the light, but rather because its opponents eventually die, and a new generation grows up that is familiar with it." [22].

References

• 1. F. Gary Cunningham, Kenneth J. Leveno, Steven L. Bloom, John C. Hauth, Dwight J. Rouse, Catherine Y. Spong . Williams Obstetrics. McGraw-Hill, 2010

• 2. eHealth Conference in Tallinn 2010 materials

• 3. Veselības ekonomikas centrs. Statistikas dati par dzemdībām un jaundzimušajiem no 2007.gada līdz 2009.gadam

• 4. Māmiņu Klubs E-žurnāls. Joprojām satraucoši augsta perinatālā mirstība Latvijā

• 5. Latvijas veselības aprūpes statistikas gadagrāmata 2009: Mātes un bērna veselības aprūpe. 

• 6. Group project in the course: Integrated marketing Communications. IMC plan for launch of new product – Williams Obstetrics translation in Latvian. Project’s Authors: Kļaviņš Pēteris, Krūmiņa Liene, Martinsone Līga, Nītiņa Kate, Roze Ģirts, Vītuma Linda. Fall, 2010

• 7. Utilitarianism

• 8. Deontological ethics

• 9. Consensus decision-making

• 10. Consensus

• 11. Virtue Ethics

• 12. Virtue ethics

• 13. Laws, Rules, Precedents, Ethics and Speeding Tickets: A Table

• 14. Th.Donaldson “The Ethical Wealth of Nations”.

• 15. SROI Methodology: an introduction

• 16. LR Konstitucionālais likums. Cilvēka un pilsoņa tiesības un pienākumi.

• 17. SROI and Public Policy.

• 18. A very short history of Evidence Based Medicine (EBM) with a special look at surgery

• 19. P. Gardiner. A virtue ethics approach to moral dilemmas in medicine.

• 20. Excerpt from H. Peyton Young's interview: Question 4 & 5

• 21. Paradigm shift

• 22. Paradigm