We appreciate your considerations to the article. Our aim was to debate how the evolving
medical knowledge, now supported by the digital revolution, has challenged some long-standing,
classic definitions. We discussed data from the former Medical Insurance Association
of America, from January 1985 to December 2001, referring to malpractice charges to
the birth attendant physician in cases of obstetric paralysis.[1] Since the publication of the study by Jennett et al.,[2] in 1992, we believe that publications from the last 20 years or so have been changing
how brachial plexus injury at birth is viewed; in our opinion, this is a better denomination
than obstetric paralysis.
Regarding the title, a systematic literature review is defined as a secondary study
with the aim of grouping similar studies, published or not. It critically evaluates
the methodology of these studies and, whenever possible, includes a statistical analysis,
in a so-called meta-analysis. Since it synthesizes data from similar primary studies
of relevant scientific quality, it is considered the best level of evidence to make
therapeutic decisions and establish medical management strategies.[3]
[4]
To avoid an analysis bias in a systematic review, data selection and assessment methods
are defined beforehand in a well-defined, rigorous process. Initially, a clinical
hypothesis is elaborated to define the focus of the study. Next, a wide literature
search is carried out to identify the largest possible number of studies related to
the subject. Papers are selected, and then their methodological quality is assessed
based on the original study.[5]
Therefore, we partially agree with the criticism regarding the title and classification
of our study. The study was called “systematic review of literature”, and not just
“systematic review”, because it uses all the elements required to make a classic systematic
review, which assesses primary studies, that is, randomized clinical trials, summarizing
findings from systematic review articles alone. Thus, we used only outcomes from these
systematic reviews that are important for evidence-based medicine, obtained from the
primary studies previously evaluated by these reviews. Such (systematic) organization
assures the same technical-scientific quality for our study, since several primary
studies were indirectly evaluated.
Although systematic reviews of randomized clinical trials are more frequent, there
is an increasing number of reviews based on observational investigations, such as
case-control, cross-sectional, cohort, report, and case series studies, in addition
to qualitative studies and economic assessments.[6] For this reason, we believe in the validity of our study, whose methodolgy contained
a detailed explanation of how the study was produced, strictly following the steps
of a good systematic review: 1) development of a research hypothesis; 2) active literature
search; 3) selection of articles of interest; 4) data extraction; 5) assessment of
methodological quality; 6) data synthesis/meta-analysis (the only step not performed
in our article); 7) evaluation of the quality of the evidence; and 8) writing and
publication of theg findings.[7]
Our review demonstrates a change in the main etiology of obstetric paralysis, removing
the high burden of malpractice from the attending physician and his/her team.[8]
[9] In addition, we also argue that shoulder dystocia is not the main cause, as previously
described.[10]
[11]
[12]
[13]
[14]
[15]
[16]
A paradigm shift has been indicated by the literature. For more than 100 years, since
Duchenne (1872) and Erb (1874), the person responsible for childbirth was deemed guilty
of the obstetric paralysis. Our intention is to review who is to blame, which is certainly
not just the doctor or any professional delivering the child.
