More Thoughts on Research

The comments on Homebirth Research: Another Side of the Story have been interesting. Thank you to everyone who has shared your thoughts or other information you found about the study. I think the letter to the editor from De Jonge that one anonymous commenter shared was interesting, especially the point about how the methods of data collection in the study may have inflated the perinatal mortality rate in the low risk group. If she is correct in this assessment, I believe it does call the validity of the study into question.

That said, I think that the Evers study raises a lot of questions that require further research.

• is midwifery care, with referral to obstetric care if complications arise, optimal care for low risk women?
• are there specific aspects the midwifery system in the Netherlands that are suboptimal (such as, protocols for intervals to check the fetal heart rate, as mentioned in the paper, or as one response to the study pointed out, the use of midwives assistants to watch over women until close to time of birth)?
• how might midwifery care be improved to result in better outcomes?
• how might collaboration between midwives and physicians be improved to result in better outcomes?

I think that many questions such as "Is homebirth safe?" or "Are midwives or obstetricians better caregivers for low risk women?" are questions that may never be fully answered with research. There will always be people who find a flaw in a study's design or some other way to discredit it, because most people have basic beliefs about birth that are not easily changed. There will always be people who focus (some because it is their job) on the cases where things go wrong and work their hardest to save those lives. There will also always be people who want put their primary trust in either a divine design for the process of birth or its thousands of years of improvement through natural selection (whichever is their belief, mine is these former) and who prefer to use the technology of the past hundred years or so as mostly a back-up. Most people find ways to dismiss "evidence" that does not support their basic view while accepting that which is in line with it. It is human nature.

The answer to safety in maternity care is not to convince one side that the other is "right." The answer is respectful collaboration. This is not the first time I have talked about this. In October 2010, I committed to make my blog a doctor-friendly zone, and I hope that I have held true to that promise. I believe now, as I did then, that peaceful dialogue between doulas/activists/midwives and obstetricians and other hospital providers is essential for improving our maternity care system to protect the lives and and best meet the needs of mothers and babies. I believe that hospital and out-of-hospital providers could learn a lot from each other, which I think could help improve the safety of the practice of homebirth and care in transfers, as well as improve the environment and the options available to women in hospital birth. I have started to see dialogue opening up a little more in the past months, as more physicians are creating online presences and the internet is becoming a larger platform for conversation. I'm curious also, to see where the upcoming Home Birth Summit will lead.

Will We Ever Reach Peace in the OB v. NCB war?

I'm considering removing my RSS subscription to MyOBsaidWhat?!? I used to read all the comments and sometimes comment myself, but lately I've realized that it is steeped in negativity, and I'd rather focus on the positive. Reading there, it becomes easy to assume that all doctors are unhuman douchebag stabby-hands. Of course, the "Thoughtful Thursdays" are wonderful examples of what to say to a woman, but because they are featured once a week, they come across as the rare exception in a world of horribleness. If any doctors show up and make efforts to defend their profession, they are almost always met with hostility by people who know nothing about how they practice medicine or treat their own patients.

I was recently surfing a blog called OB/Gyn Kenobi, because I thought the name was really clever, written by an anonymous obstetrician who calls herself Dr. Whoo? I haven't read a lot on her blog, but I can tell that she believes in individualized patient care and recognizes that the issue of liability in the American legal system is a huge problem for her profession. I came across one post where she expressed a lot of frustration about how the natural birth community views obstetricians, automatically assuming that they are all the same horrible stereotype. She points out that in her current practice, there is a split in philosophy between the older generation and her own younger generation.

My personal experiences corroborate her observations, as the OB I saw during my first pregnancy before switching to a midwife group, was an older doctor, and he had a "my way or the high way" attitude, complete with continuous EFM, mandatory IV infusion, NPO, and pushing on your back only. He believed that episiotomy is necessary for about a third to half of all women and that all women change their minds about wanting a natural birth when they are in labor. The OB/Gyn I saw in my second pregnancy was younger and was nothing like this--she was supportive of low-intervention birth if all was going well, and had attended many unmediated labors. She almost never did episiotomies, and actually encouraged me to write a birth plan.

It is wrong to define obstetrics by extreme negative examples. There are great OB/Gyns out there. I'd like to hope that there are a lot of them.

One of Dr. Whoo?'s most compelling points is this:

Perhaps the most disheartening thing, is that there can be no real dialogue between the two philosophies, so jaded are our particular perspectives.

I appreciate that she acknowledges that the obstetric side has a jaded perspective, too. This is evidenced by some of the comments on the post:

The fan page looks good so far. You might want to include links to things like: Mothers in Medicine, pages where people can get real information about Ob/Gyn services (other than the doctor hating, "busness of being born" websites)

Condescending, much? Here is another

go to alldoula.com I went there trying to figure out what a doula was. They are very anti-OB and also are giving very bad advice to pregnant women.

That almost makes me ashamed to call myself a doula. And this one

Do any of these doctor bashing twits realize that just a few generations ago women DIED from "natural" at-home childbirth (the only kind going, back then) on a regular basis?

I would be remiss if I didn't address the fallacy of the "women used to die and now they don't" argument. You can not compare statistics from different time periods and assume that one change in that time is the determining factor in the change in statistics. Natural birth advocates know that hosptials and interventions have benefits and save lives in certain situations. That is why women who plan to birth at home have a plan for transfer to the hospital if complications arise. The burden of reaching out the olive branch of peace is really on us because we need obstetricians. Modern homebirth, though significantly safer than homebirth in antiquity (due to sanitation and better midwifery knowledge and emergency medications that can be given in the home), can never really be safe without hospital back up. All too often, women who transfer to the hospital from a planned homebirth are met with hostility for choosing not to use the hospital and then needing it after all. The truth is she needed you all along, just in a different way than you wanted her to need you.

We need to focus on what we have in common--a desire to improve birth for everyone. We may have different opinions about how that can be done, but we will never get anywhere if we keep making this a war. Division is hurting us, and hurting mothers and babies. We cannot afford to alienate all of the the obstetricians our there who care deeply about mothers and babies and make birth their life's work! Just as there are various types of natural birth advocates, each obstetrician is an individual person. Many of these people are caring and sensitive and we push them away with our belief in an extreme stereotype. It is bigotry, and I am done with it. I am committing now to make my blog a doctor-friendly zone. I want better care for pregnant women and their babies and that is only going to come about with peace and collaboration.