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.

Video of an OBGYN speaking on timing of cord clamping

I wanted to share the link to the video Dr. Nicholas Fogelson posted on his blog of him speaking at a Grand Rounds on the topic of Delayed Cord Clamping. It is a 50 min talk shown in four parts, check it out if you can make the time.

Delayed Cord Clamping Grand Rounds--Academic OB/GYN

From Dr. Fogelson's conclusion:

Delayed cord clamping clearly increases fetal hemoglobin, blood volume, and iron stores. The evidence supports a clinical benefit of delayed clamping. There’s really no strong evidence against delaying the cord clamping. When we talk about interventions in medicine, really, the burden of evidence is on the intervention. And I think people say. “Delayed cord clamping, you can't prove that that’s an intervention that helps.” And I’m like, oh, no, no, no, no. Delayed cord clamping is what we evolved to do. We evolved to get the blood that’s in the placenta. I don’t have to prove that that’s right. You need to prove to me that phlebotomizing the baby of forty percent of its blood volume is right."

I personally would see it from a perspective of God's design, and not evolution, but I think his point about the burden of evidence is spot-on. I think it would make sense to look the same way at a lot of other common routine maternity care practices.

Joseph B. DeLee: Obstetrics that Sucks

My first baby being suctioned with a DeLee Mucus Trap
Joseph B. DeLee, inventor of the suctioning device still commonly used in American hospitals today (though routine suctioning might actually be harmful), was an obstetrician in the early 1900s. In my Childbirth International workbook, I came across this lovely quote from him:

Obstetrics has a great pathologic dignity. Even natural deliveries damage both mothers and babies, often and much. If childbearing is destructive, it is pathogenic, and it if is pathogenic it is pathologic

If the profession would realize that parturition viewed with modern eyes is no longer a normal function, but has imposing pathologic dignity, the midwife would be impossible even of mention.-Dr. Joseph DeLee, 1915

Sometimes the words of Dr. DeLee are so extreme they sound like satire. They're not. The guy was serious. I first read about him in Tina Cassidy's book Birth, the Surprising History of How We are Born, which is a very easy-to-read tracing of the history of obstetrics and midwifery in the U.S.--The author of which, who had a standard hospital birth-turned-cesarean for her first birth, came out of the writing of the book a believer in midwifery, and had a HBAC with her second child (you can find the story if you dig around the archives of her blog). It was also in Cassidy's book that I first learned that a large percentage of women in the late 19th and early 20th century, including the population DeLee would have treated, were afflicted with rickets, a bone softening disorder caused by Vitamin D deficiency that often caused people to have severely deformed pelvises.

With a quick googling his name, I found that Jill at the Unnecessarian has already posted a whole series on the writings of Joseph B. DeLee:

• Joseph Bolivar DeLee and the Prophylactic Forceps Operation
• Joseph DeLee's 1915 Campaign to Eliminate the Midwife
• Joseph DeLee Warns Colleagues in 1940 About "Streamlined Labors"

Dr. DeLee was a very influential figure of his time, and his ideas were very shaping of the course maternity care in this country. The influence of DeLee resulted a wiping out of nearly all of the traditional body of knowledge about birth (luckily, a few "grand midwives" survived, mostly in the South, allowing one unbroken link to the midwifery past), and replaced it with an ideology that was not founded in science, but the belief that birth was a problem, and technology was the solution.

Obstetricians, as members of society, tend to blind faith in technology and the mantra: technology = progress = modern. The other side of the coin is the lack of faith in nature, best expressed by a Canadian obstetrician: 'Nature is a bad obstetrician.' So the idea is to conquer nature and results in the widespread application of attempts to improve on nature before scientific evaluation. This has led to a series of failed attempts in the twentieth century to improve on biological and social evolution. Doctors replaced midwives for low risk births, then science proved midwives safer. Hospital replaced home for low risk birth, then science proved home as safe with far less unnecessary intervention. Hospital staff replaced family as birth support, then science proved birth safer if family present. Lithotomy replaced vertical birth positions, then science proved vertical positions safer. Newborn examinations away from mothers in the first 20 minutes replaced leaving babies with mothers, then science proved the necessity for maternal attachment during this time. Man-made milk replaced woman-made milk, then science proved breast milk superior. The central nursery replaced the mother, then science proved rooming-in superior. The incubator replaced the mother's body for care of low-weight newborns, then science proved the kangaroo method better in many cases.
-Marsden Wagner, MD, MSPH, Fish Can't See Water: The Need to Humanize Birth in Australia

...Routine pitocin and cord traction replaced physiological delivery of the placenta, then science found a natural third stage superior for low risk women.

Science has helped American maternity care come a long way from DeLee's time, but the fact remains that the roots of our obstetric system are in the ideas of people who had a lot of things about birth wrong, at least when applied to a population of women with normally developed pelvises. I also believe he was wrong about midwives. Obstetrics (speaking of the profession generally and not of specific members) will continue to be at odds with those who support the midwifery model as long as it continues to dismiss the value of childbirth knowledge gathered by those who learn by being with woman.

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.