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184 thoughts on “Is breech vaginal delivery safe?

  1. rosemary says:

    Plonit, I disagree with you about people attacking Dr. Teuter personally. I have the impression that they do. In comments on another topic they even attacked her writing style.

    I agree with you about the need to objectively review the evidence. In my glancing at comments it seems to me that that is what you have been doing, but you are in the minority.

  2. laursaurus says:

    @Fifi “And, really, it’s not about the MDs feelings when they lose a patient (not to trivialize how sad death can be) and putting patients through procedures to spare the MDs feelings. Most MDs will lose patients over the course of their careers (both my parents are doctors), it comes with the territory. It’s unrealistic for an MD, including an OB/Gyn, to think they’ll never lose a patient so I’d suggest, once again, that some of the unrealistic thinking that patients end up with actually originates with doctors who have unrealistic heroic visions of themselves.”

    The tragedy of losing a baby is a much more horrific event than losing an adult for everyone involved. The father, siblings, grand parents are devastated. It really is not comparable to other deaths. For months, the family is anticipating one of the most joyful events of their lives. Child birth is the only happy occasion to visit the hospital (if I had a nickel for everytime a visitor mumbled, “I hate hospitals!”)…. As I said before, I was an OR nurse for many years. The patients I actually witnessed dying on the table, arrived already with a grave prognosis. A somber cloud envelopes the room the moment of death. These are tragic. But the most upsetting occurrence of my career was an emergency C/S for fetal demise. Even knowing the baby was already dead, seeing the blue, lifeless body of an otherwise normal, 7+lb baby boy, was indescribable. Things got even worse, as the patient went into DIC needing an emergency hysterectomy to save her life. There was no time to grieve when the nursing supervisor had to get verbal consent for an emergency hysterectomy from the husband/father. (She had general anesthesia). Post-op, she went into renal failure and was very lucky to survive.
    Dad requested to see the baby (which is considered a healthy reaction) So one of the OB nurses wrapped up the beautiful, lifeless bundle.This was his only child (she had one from a previous marriage).
    Although this scenario is completely different from a vaginal breech delivery gone bad, it exemplifies the profoundly different impact a neonate’s death has. The news spread quickly through the hospital nursing staff. Colleagues sympathetically inquired the nurses who cared for her(this was decades before the HIPPA regulations, where you are strictly forbidden to discuss personal health info with colleagues unless they’re directly involved in that pt’s care). I think the eventual admitting diagnosis was determined to be abruptio placenta.
    In the event of a perinatal death, the feelings of the staff are much further down on the scale. Witnessing the immense pain and grief that the pt and her family had to endure was heart-breaking. When in the case of a breech presentation, a C/S seems like a no-brainer to completely avoid a well-known, significant risk. If a pt had appendicitis, cholecystitis, bowel obstruction, or even a benigh tumor, surgical intervention is medically necessary, usually on an elective basis. According to the studies Dr. Tuteur cites, C/S’s are life-saving surgical interventions. When parents refuse or neglect to seek medical treatment for religious or ideological reasons, society takes legal action in the interest of the child who doesn’t have the authority or ability to informed consent. If a mother refuses a C/S for a breech delivery, it is a practically identical situation. There is no opportunity for legal action of behalf of the child. So it’s up to the OB dr to explicitly explain that insisting on a vaginal delivery for a breech presentation is accepting a lethal risk. Where is the distinction between merely the mother’s preference and refusing medical treatment for the child? It’s ridiculous to consider the doctor’s legitimate deep concern for the infant’s survival as “bullying”.
    When a child of Jehovah’s Witness’ survival requires a blood transfusion, is it “bullying” for the pediatrician to state she’ll obtain a judicial order if they refuse? How about the 13 year old boy who was to have court-ordered chemotherapy? The mother took off with her son and a nation-wide manhunt ensued. She had decided chemo was “poison” and faith-healing/prayer was the cure. Eventually, she was caught. The boy had chemo and his cancer went into remission.

  3. rosemary says:

    Fifi, “You are aware that Dr Tuteur tries to be inflammatory on purpose and has said so?”

    Fifi, I missed that but it would not change what I’ve said. I sympathize with Dr. T because I too am very passionate when I try to communicate about a topic that I feel strongly about. I think emotions are valuable and should be used effectively rather than suppressed. I think that denying that they exist or believing that anything, especially anything as personal as medicine, can or should be practiced in a cultural vacuum is at best unrealistic. I also believe that different cultures and different individuals react to what they perceive to be a display of emotion differently. Some believe that an emotional display demonstrates a lack of rationality. Others believe it demonstrates a lack of caring.

    I know that there are people who I infuriate with my displays of emotion, but I also know that there are many, and many who are diametrically opposed to my positions, who respect me for them and conclude that I hold my positions because I really do care about human beings and many of them even agree that in spite of my passion I am rational. One quack site has actually stated that I do not go beyond the evidence regarding the dangers of silver supplements.

    I’ve had many experiences that lead me to this conclusion about how my emotional approach to communication is viewed including a confirmed alt who repeatedly tried sending me a $75 Christmas present because even though she disagreed with me and we had exchanged some very heated words, she concluded that I care very deeply and truly believe what I had stated. (She kept sending the money to my Pay Pal account. I don’t have Pay Pal account and only accept homeopathic money which can be shaken and sent on the airwaves.)

    Fifi, “As for making decisions purely on the science…that’s a snappy answer but you’re a fool if you think you have the expertise and don’t need any input from a doctor.”

    I didn’t say that I don’t think there is a need to consult and listen to the opinion of an expert. I was responding to your comment about basing your personal medical decisions on the written policies of medical boards (not sure those are the right words) in western nations other than the US.

    Fifi, “The fact remains that many people rely upon their doctors to help them make decisions.”

    Please don’t blame doctors for that. And yes I agree that many people either cannot or do not want to review medical evidence for themselves just like I have no desire to learn about computers or software and choose to rely on others for relevant information in those fields, but in doing so, I also accept the consequences. IMO, people who are for whatever reason unable or unwilling to locate and evaluate medical evidence for themselves should familiarize themselves with reputable websites like that of the Mayo Clinic and set themselves up with doctors they trust and feel comfortable with before an emergency hits. I know not everyone can do this but believe that certainly the vast majority of those in western societies at least can.

    I am very aware of the fact that people working in ERs, surgery, internal medicine, oncology and even psychiatry deal in life and death decisions. However, I think there is usually a difference in that most patients wheeled into the ER look very sick or badly injured so that if the staff can “save them”, they appear to be saviors to the general public and certainly are not often accused of causing deaths or permanent injuries to their patients when they fail to revive them. While some surgical patients are healthy going in for what seem to be minor procedures and die on the table or are seriously injured, I believe that is rather rare and quite a different experience from that of a surgeon operating on a patient everyone knows to be very sick for whom it is believed that the odds of a good outcome are not high. With other branches of medicine, aside from OS, bad things do happen, but they aren’t usually dramatic and immediate or considered unavoidable by anyone, including laypeople, watching. That is often even true for psychiatry where most observers believe that even though the patient killed himself in spite of the efforts of his therapist that he would have done so even without the intervention. None of that is true when delivering the majority of babies.

  4. Fifi says:

    Rosemary – “Fifi, I missed that but it would not change what I’ve said. I sympathize with Dr. T because I too am very passionate when I try to communicate about a topic that I feel strongly about. I think emotions are valuable and should be used effectively rather than suppressed. I think that denying that they exist or believing that anything, especially anything as personal as medicine, can or should be practiced in a cultural vacuum is at best unrealistic. I also believe that different cultures and different individuals react to what they perceive to be a display of emotion differently. Some believe that an emotional display demonstrates a lack of rationality. Others believe it demonstrates a lack of caring.”

    Yes but the point is that she’s blogging at SBM and pretending her passionate stance is purely rational (while accusing others of being emotional and irrational). That’s what I take issue with. Just so you know, I have no prejudice against emotions or passion. Quite the opposite in fact. I work in the arts because I value emotion and I have a deep appreciation for the biology and science around emotion (hence the interest in the neurobiology of pregnancy and childbirth). I’m actually passionate and curious enough about emotions that I ended up working in a pain clinic helping people understand the connection between mind/body/emotions/pain and am very highly aware of the cultural aspects of communicating about these subjects since I did it in two languages with a culturally diverse group of people. (It was a very basic education and education – based in the science and not woo! – that provided tools to help patients manage their pain and depression. I was part of a multidisciplinary team.)

    My point is that Dr Tuteur’s personal passions shouldn’t be imposed upon her patients, nor should she be trying to pass them off as SBM. If she’s emotionally attached to a certain position, she’s prone to confirmation bias. If she’s denying that she has a confirmation bias or is emotionally invested in a certain idea, she’s doing exactly what she accuses others of doing (being ideologues and not respecting SBM).

    Fifi, “The fact remains that many people rely upon their doctors to help them make decisions.”

    Rosemary – “Please don’t blame doctors for that.”

    I’m not “blaming” anyone, I’m merely talking about the reality of the doctor/patient relationship. People should be able to rely upon their doctors to help them make complicated medical decisions, that’s part of a doctors job! They should be able to rely upon their doctors to give them science-based advice that isn’t distorted by the doctor’s personal passions or ideologies – that’s the whole point of standing up for SBM so that patients truly can make informed decisions! At the very least, Dr Tuteur should be honest about her biases so that a patient can take that into consideration and decide whether she’s an appropriate doctor for them and be aware that she’s using science to support her passions or emotional bias.

    You seem to be doing a lot of special pleading for Dr Tuteur and OB/BYNs in general. You’re really off the mark if you don’t think doctors in other fields don’t get blamed when things go wrong (or dying patients aren’t saved) just as much as OB/GYNs do. To be anecdotal, it seems lots of people blame oncologists for not curing their or their loved one’s cancer (and there’s even more unrealistic expectations regarding cancer because of the anti-science propaganda and lurid promises of miracle cures). Really, I think you may be being blinded by a personal bias here. Nothing wrong with being passionate or having a bias, as long as you’re honest about it and not trying to pass it off as SBM or as being purely rational.

  5. rork says:

    Thanks, Dr. Amy, for pointers to those other studies.
    I did not read them carefully, but maybe mortality risks for two of them look closer to 1/200 or even 1/300 deaths, eh? Small detail, I grant.

    Plonit’s (and others) summary along the lines of “In the findings of the TBT, in countries with already low perinatal mortality, CS for breech at term did not reduce perinatal mortality” is not quite fair. CS did give less mortality, about 0/500 vs 3/500, it is just that this did not give p.05, barely).

    Anyway, it seems possible to quantify those risks somewhat accurately ( though experience of the docs might be hard to model without a ton of data), and those risks are comparatively easy to communicate.
    It seems a much harder part is quantifying the CS risks, and then trying to judge if for some people they will ever outweigh the mortality risks of vaginal breech birth attempts. I am open-minded (ignorant). Even with perfect knowledge, that trade-off may get very difficult to communicate (presuming it gets to be a close call for some).
    Best wishes to moms and docs out there in the trenches, you are more in my thoughts now.

  6. Fifi says:

    “The tragedy of losing a baby is a much more horrific event than losing an adult for everyone involved. The father, siblings, grand parents are devastated. It really is not comparable to other deaths.”

    Um, you’re the only one comparing deaths here and claiming one is more tragic than another. All untimely death is tragic and can be traumatic, whether it’s a baby dying during childbirth, a five year old dying of cancer, a ten year old hit by a bus, a fifteen year old dying of anorexia, a 20 year old dying of AIDS, a 35 year old mother dying of ovarian cancer, a 40 year old father dying in a car crash, etc. People have plans and look forward to enjoying time with their loved ones at all ages. Having dreams and hopes that die with your child or a loved one is tragic at any age. It’s a bit callous of you to presume to compare suffering and loss in the way you have, and to privilege one over the other.

  7. rork says:

    Crap, had editing troubles it appears:
    CS did give less mortality, about 0/500 vs 3/500, it is just that this did not give p.05, barely).

  8. rork says:

    Hells, bells, still not working.
    I was trying to say there that I actually get p=.2 for two-sided fisher’s exact, and that 500 v 500 is not enough to expect a small p. Repeat after me: Failing to get small p does not show no difference.

  9. Plonit says:

    No, it does not show no difference. However, it also does not show a statistically significant difference and it was the decision of the trial leads to stop the study earlier than planned. Vaginal birth is the physiological default (i.e. it is what will happen without intervention), it is for proponents of intervention to show that those interventions do more good than harm, on the basis of as robust evidence as possible. This goes for maneouvres to expedite delivery in vaginal birth, as well as for caesarean section. Some of these comparisons cannot feasibly and ethically be compared by RCT, but some possibly could be (burns-marshall vs. mauriceau-smellie-veit vs. forceps?) (maternal upright position vs. all fours vs. lithotomy?) and many other variables.

    The term breech trial was an opportunity to show lower perinatal mortality, but did not have sufficient power to demonstrate this in already low perinatal mortality countries, nor lower neonatal morbidity at two years. We cannot presume that had it been bigger, it would have shown a significant difference. As a result, you could say that the most honest position is ‘equipoise’ on the best mode of delivery for breech babies. But since caesarean section is the more significant intervention, you could argue that it is CS which has to make the stronger case. (The counter argument is that usual practice for vaginal breech delivery is already highly interventive, so we are really comparing to types of intervention).

  10. “Vaginal birth is the physiological default (i.e. it is what will happen without intervention), it is for proponents of intervention to show that those interventions do more good than harm”

    Proponents of vaginal breech delivery like to pretend that the PREMODA study is the last word on breech vaginal delivery, but it is just one data set among many. As I pointed out, there is copious data that show that breech vaginal delivery increases the neonatal death rate. It is disingenuous at best, and deceitful at worst to suggest that vaginal breech delivery is as safe as C-section. Even the authors of the PREMODA study acknowledge that.

    So Plonit, how many dead babies are acceptable to reduced C-sections for breech? One in a million? One in a hundred thousand? More? The refusal of vaginal breech proponents to address this issue is inexcusable.

  11. Zoe237 says:

    “The tragedy of losing a baby is a much more horrific event than losing an adult for everyone involved. The father, siblings, grand parents are devastated. It really is not comparable to other deaths.”

    Really? Come on Rosemary. The loss of a young healthy adult or an older child is devastating too. I don’t think you can compare.

    Rork is correct. The difference was not statistically significant, but only because the sample sizes weren’t large enough. I got p= .3 for the low PMR countries and perinatal mortality. However, Dr. Tuteur was the one who offered it as “proof” of her position. The onus is on her.

    It is very difficult to glean further information from Dr. Tuteur based on the evidence, because she would rather discuss anecdotes and informed consent theory (which was her response to the criticism that the providers may not have been experienced enough and that the study encouraged docs to get their breech rates up past 40% to get enough of a sample size, despite the fact that safe vaginal breech birth rates might be around 20%). In addition, she has erected a strawman claiming that VBD advocates don’t acknowledge the risk. She has admitted her non-neutrality on the subject, which I appreciate.

    The *rational* truth is that 630 dead babies means absolutely nothing without context, a denominator, how many babies die from other causes in pregnancy and birth, NNT, and a risk analysis of the alternatives. Dr. Tuteur refuses to have such a conversation, so it really leaves me with nothing more to say.

  12. Plonit says:

    “Vaginal birth is the physiological default (i.e. it is what will happen without intervention), it is for proponents of intervention to show that those interventions do more good than harm”

    ++++++++

    That statement has nothing to do with the PREMODA trial, or any particular trial. It is more a philosophical position with regard to evidence-based, science-based maternity care. Wherever we make a claim that intervention X has more benefits than harms, let’s be reasonably certain that is the case. The Term Breech Trial didn’t show this in the context of low perinatal mortality countries, though one can extrapolate from high perinatal mortality countries, or from the trend (‘nearly statistically significant’ – as rork points out), if you wish.

    To point out that there is uncertainty surrounding mode of delivery for breech birth, dependent on context ,doesn’t make one a “proponent of breech birth”. What you’re asking of me (which is that I state my own personal judgment about an acceptable NNT/NNH for perinatal mortality) is really irrelevant, since I don’t have a breech baby on board, and I don’t have to make that choice. The choice is one to be made by women who have their own values, own attitudes to risk (more tolerant or more averse to risk), own reproductive future plans – and to that end we should provide the data that exists, including being honest about uncertainty on the question.

  13. rosemary says:

    Zoe, “‘The tragedy of losing a baby is a much more horrific event than losing an adult for everyone involved. The father, siblings, grand parents are devastated. It really is not comparable to other deaths.’
    Really? Come on Rosemary. The loss of a young healthy adult or an older child is devastating too. I don’t think you can compare.”

    Zoe, I did not say that. Laursaurus did. I believe she was talking about conclusions she had drawn from her years of experience as an OR nurse. In other words she was reporting the effect such events had on her, her colleagues, and the families involved. I do not know but assume that she is talking about large numbers of people.

    Until I see evidence to the contrary, I will continue to believe that experiencing a quick, unexpected death is something most humans find very difficult to deal with emotionally, far more so for most people than experiencing the death of a person, no matter what his age, who is obviously sick and suffering. In such cases, many including the patient often consider the death “a blessing” even though the survivors miss the person and feel very sad. IMO, there is no comparison on a visceral level between that kind of death and the experience of the sudden, unexpected death of a healthy neonate.

    Healthy young people don’t usually die suddenly except in accidents and accidents are considered just that “accidents” which is quite different than the situation in which a healthy woman is giving birth to a healthy fetus when something suddenly goes very wrong which requires those attending to make instant life and death decisions that people with no experience in such things then proceed to second guess. In other words, while one has to evaluate the evidence constantly to set policies, when you are on the front line, you don’t have the luxury to spend a lot of time considering options.

    One of the points I am trying to make is that doctors are not patients’ servants. They are their partners. Both have responsibilities and obligations. Part of a doctor’s job is patient education, but part of a patient’s job is educating himself, preparing himself and finding a doctor he is comfortable with before a crisis occurs. Another point is that it is very easy to second guess people who are in professions that regularly require them to make instant life and death decisions, but you know the saying about Monday morning quarterbacking. I am a very strong proponent of evidence based medicine. However, I believe that “real world” evidence and not just the academic kind has to be considered to get the entire picture.

  14. Zoe237 says:

    Sorry Rosemary.

  15. “What you’re asking of me (which is that I state my own personal judgment about an acceptable NNT/NNH for perinatal mortality) is really irrelevant, since I don’t have a breech baby on board, and I don’t have to make that choice.”

    What? Aren’t you a midwife? What do you counsel your patients about the risk?

  16. Plonit says:

    It is one thing to *provide* information about the absolute and relative risks, the NNT, NNH (insofar as they can be calculated) and so forth, based on the current evidence – and to express this as a range, given uncertainty. This is surely within the remit of a midwife. It is even more firmly within the remit of the obstetrician to whom the midwife refers the woman (after ultrasound scan to confirm breech presentation).

    It is a different thing altogether to substitute the midwife’s or obstetrician’s judgment about what is an acceptable level of risk (in this context) for the woman’s. It is in this sense that any personal judgment about what is acceptable “One in a million? One in a hundred thousand?” (the question you put to me) is irrelevant.

    We (by which I mean the maternity care service comprising midwives and obstetricians of which I am a part) offer caesarean section for all women carrying a breech baby at term – in line with the findings of the TBT. We also ensure that women are aware that vaginal breech delivery is a genuine choice. We recommend CS most strongly where women are obviously poor candidates for vaginal delivery (explaining the reasons), and are happier to support vaginal breech delivery where women are good candidates, in line with the PREMODA study and our local audit results. These complex issues are communicated to women, supported with RCOG and hospital literature.

  17. So, Plonit, when a woman asks you to quantify the risk of a baby dying or being injured during a breech vaginal delivery, what do you tell her?

  18. laursaurus says:

    At what point would the decision to attempt a breech delivery be reckless endangerment? We have strict laws enforcing child restraint car seats. I guess the difference would be that a C/S involves surgery on the mother’s body. If you’d donate a kidney to save your child, what’s the big deal with a C/S?
    When it comes to the life of the child, one preventable death is too many.
    Yes, this is an emotional appeal supported by the studies cited in this article.
    Just a few months ago, a government-funded study found that routine mammograms for women under 50 resulted in far too many unnecessary procedures (breast biopsies) compared to the rare occasion when a woman’s life was saved because cancer was diagnosed early. They also found that monthly self-exam was producing the same outcomes. People went absolutely nuts for purely emotional reasons. If you happen to be that 1 in whatever woman who’s life was saved, that was all that mattered.
    How would morbidity rate for breech vaginal delivery compare? Clearly, as women, our emotions and ideology carry a lot more influence than the statistics. Is it because there is a sentiment that a “real” woman delivers her baby without any intervention a more noble pursuit compared with accepting appropriate medical intervention to ensure a healthy, live baby? Why accept any risk of potential death?

  19. “Why accept any risk of potential death?”

    The issue, though, is that proponents of vaginal breech delivery are not honest about the risk of neonatal death. Within the comment thread there has not been one person willing to quantify the risk or explain how they might counsel a patient about the risk she faces. They’d prefer to be vague about the risk and emphasize a woman’s right to make an informed decision.

    Of course every woman has the right to make her own decision, but it can’t be an informed decision if no one will honestly inform her of the risks.

  20. Fifi says:

    Laursaurus, do you believe that c-sections are risk free? Or do you understand that there is also a risk of complications both during the operation and long term for future pregnancies?

    Dr Tuteur – “Of course every woman has the right to make her own decision, but it can’t be an informed decision if no one will honestly inform her of the risks.”

    Agreed, the issue here has been whether you’re actually doing that or are instead operating from a personal and emotional bias in both the way you present the risks of vaginal breech birth and the way you have avoided discussing the risks of c-sections. Honestly informing women of the risks of having a c-section is just as much part of any honest, evidence based discussion regarding this issue. And, obviously, while statistics are nice we’re all an N of 1 and the risk is going to be different depending on the specifics of each woman’s situation.

  21. Fifi says:

    Plonit – Sounds like a very sane and respectful approach, that actually gives women an informed choice without pressuring them. But, then again, it sounds like you work somewhere where it’s not about promoting an ideology or some ego driven midwives vs doctors competition.

  22. “Agreed, the issue here has been whether you’re actually doing that or are instead operating from a personal and emotional bias in both the way you present the risks of vaginal breech birth and the way you have avoided discussing the risks of c-sections.”

    What has bias got to do with it? Vaginal breech delivery increases the risk of neonatal death. You may not like that; you make wish it weren’t so; you may try to pretend that the risk is so small that it doesn’t count. None of that changes the fact that there is a real risk and it is difficult to communicate that risk to women.

    I haven’t noticed anyone offering alternate figures. Indeed I haven’t noticed anyone willing to address the fact that promoting vaginal breech delivery means consigning some babies to a preventable death. That doesn’t mean that women shouldn’t be offered the choice, but it does mean that we need to be explicit about the dangers.

    As far as the risks of C-section are concerned, they pale in comparison to the risk of death from vaginal breech delivery. C-section is almost always safer than vaginal delivery for the baby, and it is an remarkably safe procedure for the mother (not perfect, but remarkably safe).

    All childbirth is inherently dangerous. The risk can be apportioned between mother and child in differing ways, but the overall risk remains. A C-section shifts more of the risk onto the mother. A vaginal delivery shifts more of the risk onto the baby.

    In breech delivery of any kind, the total risk is increased over that of a vertex delivery. There’s no questions about that. The only question is how to apportion that increased risk.

  23. Fifi says:

    Dr Tuteur – Once again you’re erecting strawmen, I’ve never been promoting vaginal breech birth, I’ve been promoting the right of women to be properly informed about their choices and the consequences of those choices so they can make up their own mind. My objection is to your pretense that you’re practicing SBM when you’re actually using science to promote a personal bias. The fact that you have talked so much about how it effects you and how victimized you feel is an indicator of how personal this is for you. As is the fact that you seem to think everyone who doesn’t fall into lockstep behind your highly emotionally charged bias is promoting vaginal breech birth. It’s not having a personal bias that’s the problem here, it’s that you’re not being honest about it and pretending that you’re simply promoting SBM (and have been called out by others more into statistics than me about the statistics).

    It’s pretty clear that your bias means you minimize and apparently totally ignore some of the consequences of having a c-section can have for future pregnancies. You obviously didn’t include it in your initial blog and haven’t actually said you do inform patients about these risks. Not that I expect much from someone who wants the authority of being under the SBM umbrella but who consciously tries to be as inflammatory as possible and cherry picks evidence about controversial topics. Seriously, for those of us from countries where these things are publicly discussed quite rationally (and women’s health issues are a bit more advanced and much less controversial than in the US), you’re coming off as an attention seeking ideologue and not someone who actually cares about SBM or women’s health and freedom to choose.

  24. Fifi,

    I must say, this is not the discussion I was anticipating when I wrote the post. I was anticipating a discussion of the relative merits of the studies, and a comparison of the risks of breech vaginal delivery vs. the maternal risks of C-sections. In other words, I was anticipating a relatively dispassionate discussion of the facts.

    Instead the discussion has recapitulated the typical discussions with patients who don’t understand the risks.

    Breech vaginal delivery increases the risk of neonatal death. If that is acceptable, then all those who favor a more liberal policy toward breech vaginal delivery merely need to acknowledge that a few hundred preventable neonatal deaths is an acceptable exchange for tens of thousands of fewer C-sections. I certainly could accept that argument.

    Instead, I’ve gotten all the usual accusations and evasiveness that one typically hears from patients who are convinced that vaginal breech delivery is safe and those evil obstetricians merely want to deprive women of their empowering “birth experience.”

    We’ve seen the entire gamut including:

    You ought to minimize the risk when counseling patients;
    Telling a woman that her baby has a nearly 1% chancy of dying is too scary and manipulative to boot;
    Obstetricians just want to protect themselves;
    Obstetricians value the life of the baby over the life of the mother;
    And so on …

    Everyone refuses to confront the real issue: some babies will die.

    It’s a cop-out to kick the can down the road to the mother. Obviously it is her decision and no one else’s. However, from a policy point of view, we are obligated to recognize when people have difficulty understanding scientific information and giving informed consent. Everyone is hiding from that issue either by pretending that the risk is too small to matter, or that we don’t need to think about it because it’s the mother’s decision, or hoping that no babies will die and we then don’t need to think about it at all.

    In my view, it bears a lot of similarities to counseling patients about vaccinating their children. Sure, it’s ultimately the parents’ decision, but we know that people who are choosing not to vaccinate their children don’t really understand the risks. In some cases it is because they are literally unaware of the risks. In other cases it is because they have difficulty evaluating relative risk.

    We don’t simply throw up our hands and say: “just give them a description of the data, without any bias toward vaccination, and let them decide.” Why don’t we do that? Because more is at stake than exercising personal freedom to make parenting decisions. The health of children is at stake and that means we need to make our best efforts to insure that parents understand.

    If you think it is biased and overly emotional to feel strongly about preventing neonatal deaths than I am proudly guilty as charged. That doesn’t mean that I wouldn’t step back and let a mother take steps that might or even will kill her baby, as long as she understands what’s at stake. Indeed, I have gone along with a patient who refused pregnancy interventions to save the baby because she was ambivalent about the pregnancy and wanted the baby to die. It’s her right to make that choice, and I have no ethical or legal basis to stop her.

    On the other hand, I have seen patients make decisions that they have been told are dangerous and then observed the tragic outcome. In not one case have parents accepted responsibility for their own decisions. Zip, zero, nada. Every single time the parents cried out in their grief: “I didn’t understand that this could happen.” Women who chose homebirth, women who refused induction for medical indications, women who refused to comply with medical advice, all responded in exactly the same way when confronted with the ultimate loss: “I didn’t understand. I didn’t realize. I never knew this could happen.”

    Doctors know, and most patients realize, that there is more at stake than a dispassionate discussion of the data and the exercise of personal autonomy. Real lives are at stake and that requires taking all steps necessary to insure that decisions are informed.

  25. SunkenShip says:

    [quote]I hope Dr. Tuteur remembers to inform her patients when discussing or before doing a circumcision that every year some boys die from the complications of this surgery and that this circumcision might be the next death. Seems in her recent circumcision post she forgot to mention the possibility, or thought it too negligible to consider seriously.[/quote]

    I too found Dr. Tuteur’s whole stance on here completely contradictory to what she was espousing when it came to circumcision. With circumcision, she poo poos the risks of death, infection and other complications as being rare and not worthy of discussion. If you bring it up, you’re fear mongering, or a foreskin fetishists. But here, Dr. Tuteur launches into the details of the INHERENT RISKS, even though she admits they’re rare.

    In this case I actually agree with, patients should be informed that if they choose vaginal birth, their child may not make it. Likewise for circumcision. As Dr. Tuteur astutely pointed out, when you tell parents that complications are “rare” or less than 1 percent, no one ever imagines their child being that rare case.

  26. Zoe237 says:

    “That doesn’t mean that I wouldn’t step back and let a mother take steps that might or even will kill her baby, as long as she understands what’s at stake. ”

    Oops, Dr. Tuteur must not have gotten enough “hits” on this particular blog post, so she’s again pulling out the “mothers/ care providers/ commenters who choose vaginal breech delivery (or believe in informed consent) are baby killers.” She would also like to shift the burden of proof on non-obs to quantify the risks, after a sound criticism of her “630 babies will die.” Surprise, surprise.

  27. Plonit says:

    We recommend caesarean section for breech at my hospital and discuss the option of vaginal breech delivery. We discuss the risks and benefits of each and, as I’ve said before on several occasions, we are honest about the uncertainty that exists.

    The excess risk can’t be easily quantified in a single headline figure because a) our knowledge is inadequate (due to inadequacies with the largest trial, and counterveiling information from other sources) and because every woman’s situation is individual (parity, estimated fetal weight, type of breech, previous obstetric history, and so on).

    So, we share and discuss the information that exists, which includes the TBT and Cochrane review as well as the Premoda trial and others. The RCOG green top guidelines are very useful for framing this discussion.

  28. BillyJoe says:

    rosemary,

    “BillyJoe, if your estimates about women are correct, and if the other side of the coin is also correct, that doctors are highly intelligent almost always right superior beings…”

    The problem, rosemary, is that you think you are average. Or that all obstetric patients are as informed amd motivated as you are. The average obstetric patient is far less motivated, far less intelligent, and far less attuned to the evidence and what it means than the average ostetrician, and by a large margin. If that is not so, there is something wrong with the education of our obstetricians.

    “then in the interest of society, I think we had better return immediately to the old paternalistic society of our ancestors.”

    That’s such an obvious strawman I’m surprised you made it.
    You might hope to get a great deal of information via the iternet, but what you cannot get is expertise. Sorry, democracy has its limits.

    “If your estimates about women are correct, but you do not believe that doctors are all knowing, then I think instead of fighting with doctors and demanding that they hand feed and take responsibility for the total education of their patients as I feel people here are doing, I think we should just give up on women and let them suffer the consequences of their inferiority.”

    Goddamn, I count about three strawmen here.

  29. BillyJoe says:

    rosemary,

    “I am a very strong proponent of evidence based medicine. However, I believe that “real world” evidence and not just the academic kind has to be considered to get the entire picture.”

    What exactly is “real world” evidence?

  30. “The RCOG green top guidelines are very useful for framing this discussion.”

    Here’s what the guidelines say:

    “Women should be informed that planned caesarean section carries a reduced perinatal mortality and early neonatal morbidity for babies with a breech presentation at term compared with planned vaginal birth.”

    “Women should be advised that planned caesarean section for breech presentation carries a small increase in serious immediate complications for them compared with planned vaginal birth.”

    Regarding the criticism of the Term Breech Trial, the RCOG guideline states:

    “However, multiple subgroup analyses failed to identify any group for which the benefit of planned caesarean section was eliminated.”

  31. “I hope Dr. Tuteur remembers to inform her patients when discussing or before doing a circumcision that every year some boys die from the complications of this surgery”

    This is what I mean about lay people having trouble understanding relative risk.

    The death rate from breech vaginal delivery is 1/110. The death rate for circumcision is 1/500,000. So the death rate from breech vaginal delivery is 5000 times higher.

    In the case of breech vaginal delivery, neonatal death is common. In the case of circumcision, neonatal death is rare. That doesn’t change the need to include it in obtaining informed consent, but the risks aren’t remotely comparable.

  32. Plonit says:

    On the RCOG guidelines…your quotes are accurate but do not adequately represent the careful discussion of the issues in the document overall, I would suggest that people read for themselves

    http://www.rcog.org.uk/files/rcog-corp/uploaded-files/GT20bManagement_ofBreechPresentation.pdf

    By the way, did I mention that we *recommend* caesarean section for breech at my hospital and discuss the option of vaginal breech delivery.

  33. edgar says:

    You did mention it.
    Amy just wants you to tell your clients “630 babies will die if birthed vaginally. 630. 630.”

    “DID YOU HEAR ME? 630!”

    630!!!!!

    Unless you are doing this exactly as written, you are negligent!

  34. “DID YOU HEAR ME? 630!”

    Do you think hundreds of dead babies is some sort of joke worthy of your contempt? I can assure you they’re not.

  35. edgar says:

    Of course not, but your ham handed attempt at ‘informed consent’ is.
    Plonit has a good approach.

  36. Zoe237 says:

    The RCOG guidelines seem very reasonable, no mention of 630 dead babies. Not only do they support the option of planned vaginal birth, but if the facility OBs are not experienced enough, they recommend referral to another. Also, they mention the risk to mothers and future pregnancies.

    Btw, are baby killers worse or the same as Nazis? Pretty common tactic for those without a leg to stand on fact wise. Just curious.

    You are the one using the inflammatory language to further your own ideological agenda, not any obstetrical organization in the world. You have a long history of *using* the tragedy of the death of an infant to further your own position. Some find this tactic reprehensible.

  37. “The RCOG guidelines seem very reasonable, no mention of 630 dead babies.”

    That’s hardly surprising since the 630 deaths would occur in the US. The UK has a much lower number of births. If 50% of women with breech babies opted for vaginal delivery, the number of deaths would be 117.

    I did notice that RCOG also elided the issue of quantifying the risk. How can women make an informed decision if they don’t know the magnitude of the risk?

  38. “In the case of breech vaginal delivery, neonatal death is common. In the case of circumcision, neonatal death is rare. That doesn’t change the need to include it in obtaining informed consent, but the risks aren’t remotely comparable.”

    Neither are the benefits remotely comparable in low HIV/AIDS prevalence areas. Any risk needs to be weighed against a benefit; any benefit needs to be weighed against the risk.

    This conversation could be better grounded if you could quote a common “natural birth” reference that obscures the risk of neonatal death in vaginal breech delivery. You attack Plonit, who recommends cesarian delivery for breech presentations. Is your goal to attack people who recommend cesarian delivery for breech presentations? Or is your goal to attack people who do not? Perhaps you could identify these other people and explain what is wrong with what they are saying?

  39. rork says:

    I was also shocked that the RCOG document did not seem to be offering advice quantifying the absolute risk of breech deliveries.
    So I’m agreeing with Tuteur that that’s bad, though I am probably not agreeing about the estimate of the risk to give exactly. I also agree not much has been said about the breech vaginal delivery benefits – I do not think Tuteur is obliged to spoon feed me that, though I wish someone would have, and if I were a patient I hope you would feel so obliged. The RCOG did give me some idea about that.

    Missionary work: I sure hope docs do get quantitative when the patients can follow it and not just act as if “patients do not understand probabilities” (Mayer,D “Evidence-based medicine”, Epilepsia, Vol 47). I live in a college town. For just a few of us, there is concern about 1) whether our doctors really understand the evidence, and 2) if they understand decision theory.

  40. “not just act as if “patients do not understand probabilities”

    I’m not sure why this is such a controversial point. My point is not that probabilities should be omitted from counseling. Patients have a right to know. My point is that providers must be aware that a straightforwardly quoting statistics is not enough to ensure that the patient understands.

    Similarly, patients don’t understand medical terminology, so telling a patient that the risks of C-section include a subsequent increased risk of placenta accreta would not be a valid way to obtain informed consent for a C-section. It is the provider’s obligation to present the information in a way that the average person can understand it.

    Patients are not incapable of understanding probabilities, just like they are not incapable of understanding medical terminology. Nonetheless, the provider is still obligated to explain risks in a way that the average person can understand and to be sure that the patient understands it.

  41. rosemary says:

    BillyJoe, if you want me to comment about my 3 strawmen, please define the term for me. Yes. I did learn it in philosophy class about 40 or so years ago but have forgotten it although I know that Skeptics use it often. And no I’m not going to look it up for the simple reason that I strongly believe discussions like these opened to the general public should speak the vernacular rather than using terms only Skeptics and academics are likely to understand. (When discussing medicine with the general public, I think that part of the discussion should include teaching the medical terms relevant to the discussion.)

    I made statements that you call strawmen in response to your statement, “What percentage of woman, when they decide they will have children, have the inclination, intelligence, wisdom, and investigative skill to do this. My estimate is <10%
    Of those, what percentage could attain a level of knowledge to be able to effectively argue against what their obstetrician recommends. Again, my estimate is <10%
    So we effectively have <1% of mothers who have anything that could reasonably be called 'informed choice'."

    Perhaps I should have asked if you think that the same percentages apply to men understanding medical information given by a doctor.

    I find your figures incredible, but that is based on my personal experience, which includes translating for illiterate people. Without knowing where you got your figures, or if they are based on personal experience, what that experience is, I don't really have a clue which one of us is correct. However, if you are a doctor and use terms like strawmen when talking to patients, I believe that may be part of the comprehension problem you are speaking about.

    But really if in fact less than 1% of patients are incapable of understanding well enough to make an informed choice, do you really believe that trying to provide them with the relevant information required to make those choices makes any sense? Don't you think that if that is the case, the health care practitioner should be able to quickly determine if he is talking to one of the rare creatures capable of doing it and only bother to give the relevant information to that person?

    IMO, people including patients have to take responsibility for themselves or else accept the consequences. To put it another way, if you aren't going to try to learn the risks involved in a specific procedure and find a doctor you are comfortable with before you need him, then if things go wrong, don't simply blame the doctor. At the very least, share the blame.

    BillyJoe, "You might hope to get a great deal of information via the iternet, but what you cannot get is expertise."

    I didn't say that you can get expertise from the Internet. I said, "IMO, people who are for whatever reason unable or unwilling to locate and evaluate medical evidence for themselves should familiarize themselves with reputable websites like that of the Mayo Clinic…" I meant that is the very least they should do and I think it is something that the majority of people can do.

    You asked what I mean by "real world evidence". That actually touches on expertise. I find that many academics and intellectuals, highly educated people, are very critical of Dr. Tuteur. They sound as if they are brilliant and caring, but they also sound, to me at least, as if they have no practical experience, just "book knowledge", and some sound as if they would faint at the sight of blood and oppose, or at least be very leery of, any surgical intervention no matter what the benefits and risks.

    I don't think "book knowledge" alone is sufficient to evaluate the safety and efficacy of drugs or therapies. I think to do that also requires hands on experience or at least close observations. I think that is true when it comes to educating laypeople about medicine too. I think that both high quality studies and experience have to be weighed although I do realize that I am walking a thin line between subjective and objective evidence. However, I think it is a line that always has to be walked when treating real people in the real world.

    Now let me try to explain with examples, I was asked to present testimony to an FDA advisory committee on pharmacy compounding. The pharmacists wanted Mild Silver Protein put on the list of bulk drugs they could compound. It was to be used in ophthalmology. I know a great deal about silver and have almost all the Eng. lit on it. I wrote up my report based on that then brought it to my mother's ophthalmologist and asked him to check it for accuracy. Another example. I have a good friend who is retired after a career developing drugs who has told me that in Scandinavian countries they do some very good research but because of the homogeneity of the population, it is impossible to extrapolate the findings to other countries. Today when it is relatively easy for laypeople to find medical journal articles someone with a PhD in English may come up with many studies showing one thing which he believes should apply in his society or to his case whereas a practitioner may have a feeling something is wrong. He may or may not know what, but I think that his feelings must be given weight.

    Sorry. These examples are obviously oversimplifications, but I have no idea if I'm clearly expressing a concept that I believe is important or not, and I don't have any more time to spend trying.

  42. Zoe237 says:

    Rork, that would seem to be because we don’t really know the increased absolute risk, and that it is dependent on many factors, also listed. The RCOG statement quantified the increase risk from several studies, but they varied. But yes, most moms who you handed that would look at you like you had two heads. This is unfortunate, because people like certainty. There is certainly increased risk, the question is “how much” and what are the possible benefits.

    “On Tuteur’s point that “the most severely injured babies were already dead, and therefore were not included in a study of outcomes at 2 years of age.””

    Is this factually true? I can’t access the study on mdconsult right now for some reason. Were the dead babies (vaginally- or c-section born) not included in the analysis at two years? That would seem to invalidate some of the results.

    http://www.ajog.org/article/PIIS0002937804006568/abstract

    This quote from RCOG made me question that:

    “A 2-year follow-up was conducted at the Term Breech Trial centres which expected to be able to
    achieve follow-up rates of about 80%.15 The primary outcome, death or neurodevelopmental delay
    at age 2 years, was similar between the two groups (RR 1.09, 95% CI 0.52–2.30). The smaller
    number of perinatal deaths with planned caesarean section was balanced by a greater number of
    babies with neurodevelopmental delay.”

    That can sound pretty scary.

    http://www.rcog.org.uk/files/rcog-corp/uploaded-files/GT20bManagement_ofBreechPresentation.pdf

    “A study from the Netherlands estimated that, in the 4 years following
    publication of the Term Breech Trial, the increase of approximately 8500 elective caesarean sections
    probably prevented 19 perinatal deaths. However, it also resulted in four maternal deaths that may
    have been avoidable. It is estimated that, in future pregnancies, nine perinatal deaths can be
    expected as a result of the uterine scar and 140 women will have potentially life-threatening
    complications from the uterine scar.21″

    This would indicate 447 c-sections for every one infant saved, not 111. And 4 maternal deaths. Like I said, uncertainty.

  43. BillyJoe says:

    rosemary,

    A strawman argument is one in which you mischaracterise a person’s argument by using parody or exaggeration in order to either to refute or dismiss it. It is most often done unconsciously, as in your case, but can be done deliberately.

    You were effectively characterising my argument as being anti-feminist, authoritarian, and paternalistic. However, nothing in what I said could possibly indicate that those descriptions characterise my views.

    I used the words “women” amd “mothers” because I consider that it is women and mothers who are being expected to make the informed choice about their pregnancies (although the father would be expected to have some input, the final decision, in my opinion, lies with the pregnant woman – so you see I am clearly no anti-feminist).

    In the case of prostate cancer I would make the same comments about men. In Australia, the media has already decided that all men should have prostate tests (although the commencement age is often left unstated, as a result of which men in their 20s and 30s are fronting up for tests!). Most men who present for a test are actually blindly follow that media advice unquestioningly.

    Talking generally now, my point was simply that the average person is simply not suffiuciently motivated, or intelligent, or educated to make an informed choice against the advice of experts in the field.
    And, when I used the figure of <1%, I was being generous.

    I am totally ignorant about cars and I am not motivated to find out. I chose a mechanic recommended by friends because of his reputed expertise and trustworthiness.
    On the other hand, because my father died of prostate cancer, and because I just happened to read an interesting article on the testing and treatment of prostate cancer at the time of his death, I was sufficiently motivated to educate myself about the pros and cons of testing and had fully made up my mind about this before even seeing a GP.
    I could not possibly do this for every condition from which I could possibly suffer, or in every field in which there are people with expertise.

    Finally, to your point about "real world evidence":

    This is more commonly known as "anecdotal evidence" or "the evidence of personal experience". It may interest you to know that it was the realisation that this sort of evidence is so unreliable as to be almost no better than a coin flip that gave rise to the scientific method and "Evidence Based Medicine" (though I also much perfer the term "Science Based Medicine").

    I would stay clear of any expert who presumes to make decisions based on "personal experience" and seek out one whose decisions are based on "the evidence of properly controlled clinical trials".

    regards,
    BillyJoe

  44. “Were the dead babies (vaginally- or c-section born) not included in the analysis at two years? That would seem to invalidate some of the results.”

    You are correct; the dead babies were included in the subgroup analysis at 2 years.

    The paper on outcomes at 2 years does not include all of the more than 2000 deliveries in the original paper. Only some centers participated in the 2 year follow up and 20% of patients in each group were not evaluated. Less than half the participants from the original study were evaluated.

    There was no difference between the two group. I wouldn’t say that the smaller number of perinatal deaths was balanced by the increased number of neurodevelopmental delays, since the two outcomes are very different.

    The authors acknowledge that the study at 2 years is underpowered:

    “if a policy of planned cesarean birth for breech presentation at term is to have a beneficial effect on the long-term outcome of children, it is likely only through an ability to reduce the risk of perinatal asphyxia and/or trauma. The risk of cerebral palsy that is due to perinatal asphyxia is exceedingly low, probably approximately 1 in every 1000 births, which increases to approximately 1% to 7% if the Apgar score is <4 at 5 minutes.10., 11., 12. In retrospect, the Term Breech Trial had far too small a sample size to be able to assess the effect of planned cesarean birth on abnormal outcomes of children at 2 years of age."

    "A study from the Netherlands"

    The study is in Dutch so we can't evaluate the claims. Moreover, the authors are claiming an exceedingly high maternal death rate for C-sections. Multiple large studies with thousands of women in each arm have showed no difference in maternal deaths (indeed they have shown no maternal deaths) in C-sections done on a non-emergency basis in women without medical problems.

    Interestingly, a very large Dutch study (Rietberg CC, Elferink-Stinkens PM, Visser GH. The effect of the Term Breech Trial on medical intervention behaviour and neonatal outcome in The Netherlands: an analysis of 35 453 term breech infants. BJOG 2005;112:205–9.) reported very different results, claiming that 60 lives had been saved. They calculated an NNT of 175.

  45. Zoe237 says:

    Thanks Dr. Tuteur.

  46. Fifi says:

    Dr Tuteur – “I must say, this is not the discussion I was anticipating when I wrote the post. I was anticipating a discussion of the relative merits of the studies, and a comparison of the risks of breech vaginal delivery vs. the maternal risks of C-sections. In other words, I was anticipating a relatively dispassionate discussion of the facts.”

    Considering that you have stated elsewhere that your intention when writing about controversial issues is to be inflammatory, that you didn’t actually discuss the maternal risks of c-sections in your initial blog and then continued to ignore them, that you’ve consistently erected strawmen and essentially accused anyone who doesn’t agree with the way you want to deliver your message as being a pro-vaginal breech delivery baby killer, and that you’ve resorted to emotional appeals of quite a personal nature over and over again, that claim seems less than honest. (Particularly in light of your previous circumcision post.) Or you could really believe you’re engaging in a SBM discussion and just be entirely unaware of how you’re communicating and your own rather obvious and very personal biases in this and the circumcision posts. (I haven’t read any of your other ones here so I don’t know if your approach was the same in other posts.) I get it that you want to be seen as promoting SBM and undertaking a dispassionate discussion of the facts. However, how and what you actually communicate contradicts the image you’d like to promote of yourself and your stated intention.

    I find it particularly silly since you’re actually alienating all kinds of very reasonable people (who want to have a rational discussion) with your presumption that anyone who doesn’t uncritically accept your position is the enemy or anti-SBM. In my case, I’m actually very sympathetic to the pressures that doctors face from anti-medicine propaganda since my mother is a doctor (hey, it’s a personal bias towards people not hurting my mom’s feelings or insulting her when she’s given so much of herself both professionally and socially). That said, since my mother is now 70 I’m also aware of the historical prejudices in medicine (and society) that were based in religion/ideology (and the historical sexism). Science, along with ethical pressure and activism, has been instrumental in making the practice of medicine more ethical and evidence-based. This is one reason I find it quite objectionable that you’ve been promoting personal beliefs/ideology/prejudices – which you may quite honestly be unaware of – using the cloak of SBM to try to claim you’re above reproach and that anyone who questions your authority or position is on the other side of the ideological fence that you seem to have erected. Why not tear down the fence, put aside your ideology and personal axe grinding (or simply be honest about your personal bias)?

    SBM needs as many feet on the ground as it can get – particularly in the US where science has become an ideological battleground (as well as a corporate interest vs public health good one) – please think a bit more deeply and critically about what and how you’re communicating. The recent discussion regarding abortion was a good example of how controversial topics can be managed in a way that dampens ideological fires and supports SBM rather than simply inflaming passions (be they your own or others). There’s nothing intrinsically wrong with passion or even having an emotional bias, it’s simply not SBM and it disrespects SBM and science to use/abuse them to promote an undeclared personal bias or ideology. (And, sorry, but retreating into “just talking about the science” now when that hasn’t been what you’ve been doing from the beginning also seems a bit dishonest at this point in the discussion. To be honest, you seem to use a lot of the same communication tactics as the anti-science/medicine crowd.)

  47. “Considering that you have stated elsewhere that your intention when writing about controversial issues is to be inflammatory”

    No, I never stated anything of the kind.

    “I find it particularly silly since you’re actually alienating all kinds of very reasonable people”

    All kinds of people? A brief perusal of the comments on my posts in the past 3 months shows that it is the same few people who comment over and over again saying essentially the same thing.

    Moreover, the people who comment are a small fraction of the people who read the posts (usually in the range of 1% of readers) and they are non-representative fraction. People are more likely to comment if they disagree than if they agree.

  48. micheleinmichigan says:

    FIFI” I find it particularly silly since you’re actually alienating all kinds of very reasonable people (who want to have a rational discussion) with your presumption that anyone who doesn’t uncritically accept your position is the enemy or anti-SBM.”

    Dr. Tutuer “Moreover, the people who comment are a small fraction of the people who read the posts (usually in the range of 1% of readers) and they are non-representative fraction. People are more likely to comment if they disagree than if they agree.”

    Just want to point out the alienated people don’t necessarily continue reading or commenting so basing your estimate on how many people you alienate on repeat commenters numbers isn’t realistic.

    Also, you can not expect a standard percentage of readers who agree with a writer. It is going to vary. I would estimate that David Brooks of the NYT has a much higher percentage of disagreeing readers than Peggy Noonan of WSJ. (I could be wrong, don’t know their numbers).

    I myself feel that you tend to stir the pot, then act the injured party. I don’t feel I learn a lot from your posts, but I do find it interesting reading the comments. Generally the comments on SBM are quite interesting and thought provoking (if somewhat needlessly sarcastic). It’s why I keep coming back.

  49. Fifi says:

    Dr Tuteur – Um, yes, you did indeed say that you like to stir the pot (on Open Salon not here).

    http://open.salon.com/blog/amytuteurmd/2009/10/17/dr_amy_was_mean_to_me

    Your assumption that you’re not alienating readers who don’t comment is silly. How can you even know that? (Not that I’m claiming to know what readers who haven’t commented think either, I’m sure there’s a diversity of opinions.) For someone who wants to claim the authority of SBM, you’re clearly reaching beyond the realm of evidence here yet again. It’s clear that you’re alienating all kinds of people who do care enough to comment, including people who support SBM and even people in this particular thread that actually do recommend c-sections for breech birth but also support informing women about vaginal breech birth. It’s just weird the way you go out of your way to write about obviously controversial topics, do so in an inflammatory and biased/ideological way, attack anyone who doesn’t automatically agree with you (and in this case paint us all as baby killers), and then claim to be being victimized when called on it. It’s certainly not indicative of someone who actually has a genuine interest in SBM. Really, it seems like attention seeking behavior and abusing science for personal/ideological ends. I find that offensive in arena that’s about SBM and damaging to rational discussion of controversial topics.

  50. Fifi says:

    Also, your assumption that people only comment when they disagree is bogus and self serving (do you actually know what a confirmation bias is?). It may make you feel better to assume that there’s an invisible army out there that agrees with you and all negative commentary is simply because people disagree with an ideological stance you’ve taken. Is this why you’re so reactionary and automatically assume that anyone who calls you on anything is anti-SBM and your ideological opposition? All that does is indicate you’re actually arguing ideology and not actually discussing the science. I’m just as likely to comment on or defend posts here that I agree with (or that I think are presenting the science without being ideological) as I am ones that I don’t.

  51. “Um, yes, you did indeed say that you like to stir the pot (on Open Salon not here).”

    Did you read it? If so, then you would know that I was responding to people who complained that among the thousands of weekly posts on the Open Salon blog aggregator, mine were routinely chosen to be featured and had thousands of readers.

    “For someone who wants to claim the authority of SBM, you’re clearly reaching beyond the realm of evidence here yet again”

    With the possibly exception of the circumcision post, all my posts are the standard mainstream view of obstetricians. Indeed, a lot of what I do is explain why obstetricians practice the way they do.

    I realize that this is not the received view among some lay people, but that’s why I write: Much of what “natural” childbirth advocates and some midwives criticize about modern obstetrics reflects the fact that they don’t know what the scientific evidence shows.

  52. Fifi says:

    I did read it. I see you’re still totally focused on how much attention you get as the most important thing!

    Dr Tuteur – “With the possibly exception of the circumcision post, all my posts are the standard mainstream view of obstetricians.”

    That’s not at all true as evidenced by the recommendations of the Canadian professional body. It’s pretty narcissistic to claim that you’re speaking for all obstetricians when you’ve self appointed yourself in this role and professional bodies around the world clearly indicate that you don’t. Once again this seems to be more about your ego than it is about reality. Also, your claim that everyone that agrees with you is “mainstream” and inference that anyone who doesn’t is some kind of radical is the same kind of supercilious ad hominem as the way you try to paint anyone who questioned you in this thread as being pro-vaginal breech birth baby killers. It’s becoming quite clear why you’re unable to actually acknowledge or even see how your own ideological biases taint the way you use science and claims to be presenting SBM. Really, own your own opinions rather than claiming to speak for all obstetricians and various other arguments from authority (or presumed popularity).

  53. “That’s not at all true as evidenced by the recommendations of the Canadian professional body”

    The SGOC does not speak for obstetricians in any other country besides Canada, and it’s not clear that it even speaks for them. Their recommendations are new, and have not yet been tested in practice, and it isn’t even clear that obstetricians will follow them.

    In the US, C-section is still the standard recommendation for breech delivery for the reasons that I have discussed.

    Besides, I never claimed to speak for Canadian obstetricians or even all US obstetricians. I’m merely articulating the mainstream view of American obstetricians. You may not like it; you may disagree with it; but among obstetricians it would not be considered remotely provocative.

  54. Zoe237 says:

    ACOG and RCOG also have changed their guidelines back to “vaginal breech birth should be an option.” But I agree, you do represent mainstream obstetricians (maybe not the nastiness towards people though, not sure about that). I don’t know why mainstream obstetricians don’t often agree with or follow their own trade organizations, or what the politics is there.

    The RCOG guidelines also made the point that vaginal breech techniques still need to be taught and practiced because a significant minority of planned c-sections are vaginally delivered, I’m assuming because labor went too fast. It was 10% in the TBT.

  55. Zoe237 says:

    Hmm, I just posted, not sure why it didn’t show up.

    FWIW, ACOG (US) and RCOG (UK) also recommend that breech vaginal delivery should be an option. I seriously doubt that ACOG’s policy statement recommends informed consent as describing the population based risk of “babies killed” argument advocated here.

    I agree though, Dr. T does represent mainstream obstetrical thought (maybe not the nastiness towards other people though, I don’t know). I’m not sure why mainstream obstetricians seem to often disagree or not follow their own trade organizations or their own research, or what the politics is there.

    Also, RCOG points out that obs still need to be trained and practiced at breech vaginal deliveries because a significant minority of planned c-sections will be delivered vaginally, I’m assuming because the labor went too fast. 10% of planned c-sections in the TBT were vaginally born.

  56. Fifi says:

    Dr Tuteur – The point is that you’re claiming that you speak for “mainstream obstetricians” when you haven’t been appointed to do so and have just presumed the authority to do so. It’s highly questionable if all your opinions do actually reflect what the majority of American obstetricians think or how they’d approach discussing breech birth with their patients even if they agree about c-sections. This isn’t just about your opinions regarding breech births but the way you present science and your opinions in both this post and discussion and the one regarding circumcision, which you’re now trying to make an exception so you can claim to speak for “mainstream” obstetricians.

    It’s interesting how you keep trying to pretend that nowhere in the world is relevant except America when it suits your purposes – this is the internet and you were quite happy to make claims about Uganda and AIDS that were totally irrelevant to medicine in America when it served your ideological stance masquerading as SBM regarding circumcision.

    Really, just have the honestly to claim your own opinion as your own instead of trying to hide behind the authority of SBM or making appeals to populist authority by claiming to speak for “mainstream obstetricians”. Your inability to identify or own your personal opinions, or recognize when you’re being ideological and not scientific, is an indication of just how blind to your personal confirmation biases you are. Really, you’re using science in exactly the same way anti-science ideologues do…to support ideological positions and confirmation biases that you refuse to recognize and continually defend by appeals to populism and manipulative emotionalism. I have no doubt you CAN do better, the question is whether you’re willing to be honest and own your own opinions so you can actually deal with the science in the detached way for you to be truly supporting SBM and not abusing it.

  57. “The point is that you’re claiming that you speak for “mainstream obstetricians” when you haven’t been appointed to do so and have just presumed the authority to do so.”

    Get a grip. I did not say that I speak for American obstetricians in an official capacity. I said that the positions I articulate are the positions of mainstream obstetricians and would not be considered remotely provocative by them.

    “It’s highly questionable if all your opinions do actually reflect what the majority of American obstetricians think or how they’d approach discussing breech birth with their patients even if they agree about c-sections.”

    Really? The C-section rate for breech in the US approaches 100% and ACOG recommends C-section as the preferred mode of delivery for breech.

    Moreover, breech delivery is not the only topic I’ve written about. I’ve also written about homebirth, waterbirth, the C-section rate and midwifery. In all those cases, my positions are consistent with both mainstream obstetrics and ACOG (to the extent that ACOG has specific policies on these topics).

    Please, stop talking about me and let’s get back to the issues at hand.

  58. SimonH says:

    I have not read all the comments above (too many), but have a few points to mention. As a paediatrician I would point out that the end-point for research into outcomes should not just be mortality, but long-term morbidity – and significant long-term neurological impairment at that. This is a difficult area to research due to (1) long follow up required ie until 6-8 years of age, (2) what is considered “significant” impairment, & (3) a large number of infants required to be enrolled to detect small but statistically significant results.

    I have unfortunately been present at difficult vaginal breech deliveries where the head is delivered after a considerable delay and the infant needs significant resuscitation… with less vaginal breech deliveries being performed the younger ObGyns have less experience and hence potentially higher complication rates.

  59. rosemary says:

    BillyJoe, “This is more commonly known as ‘anecdotal evidence’ or “the evidence of personal experience”. It may interest you to know that it was the realisation that this sort of evidence is so unreliable as to be almost no better than a coin flip that gave rise to the scientific method and ‘Evidence Based Medicine’ (though I also much perfer the term ‘Science Based Medicine’).”

    I am very aware that evaluating the safety and efficacy of a drug or therapy based on personal experience alone is useless. I am also aware that you can’t teach surgery from a book alone. To develop surgical skills, you need hands-on practice and to evaluate many published studies you need knowledge or expertise in the field being studied, the study methods used and even the equipment and what it can and cannot do to actually be able to evaluate the studies themselves.

    I believe that the hands-on experience of practitioners is a part of the body of evidence that has to be weighed when trying to reach a conclusion about which drugs and therapies to use in individual cases. However, the point I was trying to make in previous posts on this thread is that I see a red flag when I notice people with no hands-on experience, no expertise in a field, using published studies alone to criticize someone with the expertise and experience.

    I prefer the term “evidence-based medicine” to “science-based medicine” because I fear that people who promote SBM may be so in love with logic and science that if solid evidence is consistently presented that contradicts one of their scientific theories that they will disregard the evidence rather than their theories, something very unscientific that scientists have been known to do in the past.

    While I consider this very important, it is way off topic. If anyone is interested, I’d be happy to continue the discussion privately. You can write to me here:
    rosemary@rosemaryjacobs.com

  60. Fifi says:

    Dr Tutuer – Once again you erect strawmen. You were the one claiming to speak for “mainstream obstetricians” – I pointed out that this was an appeal to populist authority.

    Essentially you’ve been critiqued by a number of people for how you communicate and propose communicating with patients regarding the risks of both breech births and circumcision. In regards to breech births it is in a sensationalized way that includes fearmongering and emotional bullying to convince patients (and leaving out information of the potential long term consequences of c-sections) while claiming to be merely presenting the evidence and representing SBM. In regards to circumcision it was minimizing and ridiculing to promote an ideological position that’s really not supported by the majority of doctors around the world. Meanwhile, you accuse everyone who doesn’t support your position as being emotional, ideological and even pro-vaginal breech birth baby killers (when they’re no such thing). You’re abusing science and using SBM as a shield. I probably wouldn’t be so offended if both my parents weren’t doctors. However, because my mother is a doctor (the only woman in her graduating class and someone who fought for our right to informed choice as women), I find your abuse of science and inability to discern your own confirmation biases while using SBM as a soapbox pretty sketchy and self-serving. And, yes, fairly or not, I expect better from women – particularly women in medicine and science. That’s a personal bias I have and can freely admit.

  61. You’re still talking about me and not the science.

  62. micheleinmichigan says:

    Amy Tuteur, MDon 21 Jan 2010 at 6:44 pm

    You’re still talking about me and not the science.

    You say that like it’s a bad thing. One of the reasons there are comment boxes on blogs is so that people can voice their agreement or opposition to the writer’s approach, style OR factual content.

    There are many controversies in science. Some of them are not about the science themselves. They are about how science is communicated to the public, the patient, the student.

    The recent “Climategate Scandal” is an illustration of that.

  63. Zoe237 says:

    Okay, trying again to post this while my other one is awaiting moderation.

    FWIW, it’s not just the Canadians. ACOG (US) and RCOG (UK) also recommend that breech vaginal delivery should be an option, as a 2006 *revision* of their 2000 policy of “no vaginal breech delivery.” I seriously doubt that ACOG’s policy statement recommends informed consent as describing the population based risk of “babies killed” argument advocated here.

    I agree though, Dr. T does represent mainstream obstetrical thought (maybe not in her nastiness towards other people though, I don’t know). I’m not sure why mainstream obstetricians seem to often disagree or not follow their own trade organizations or their own research, or what the politics is there.

    Also, RCOG points out that obs still need to be trained and practiced at breech vaginal deliveries because a significant minority of planned c-sections will be delivered vaginally, I’m assuming because the labor went too fast. 10% of planned c-sections in the TBT were vaginally born.

    Communication about science and medical issues can be a touchy thing, and obviously I’m the last one to be able to recommend how to do so. I do however know demeaning when I hear it. There are lots of OBs who can say “I can understand surgery can be really scary when you’ve not gone through it. IT’s hard to take care of a toddler (or several) when you’ve had a c-section and you don’t have a lot of help. There is an increased risk of serious maternal morbidity, as well as a possible risk to future pregnancies and deliveries. C-sections should only be done in necessary circumstances and breech is one of those circumstances, in my professional opinion. There is an XXX increased risk of neonatal mortality and/or serious morbidity, as shown by research and my experience, and it’s a significant risk. Yes, babies can and have died, and it could be yours. ACOG supports vaginal breech delivery in some very limited circumstances. Here’s some more reading you can do. Ultimately it’s your body and your choice.” (assuming ECV has failed). And referral if needed.

    Rather than, “if you have this baby vaginally, you are possibly going to kill your baby!!! And if other moms do it too, you’ve killed 630 babies THIS YEAR ALONE!!! Suck it up because you are seriously selfish if you *for one second* think about your own bodily integrity *in addition to* your baby’s LIFE.” Moms are a lot more likely to trust the former OB, and not only that, but “owning” the decision no matter what the outcome. I know if my OB had talked like the latter, I’d have been out the door, even if I was scrambling to find someone at 36 weeks. I don’t like to be bullied, not even by an MD, and I’m pretty good at standing up for myself and my babies. (Didn’t have to though, because when I interviewed doctors, I asked those questions. Particularly when do you recommend c-sections and what is your philosophy regarding them.)

    Since half of the original blog post was about informed consent, I think communication about that in relationship to the topic is fair game. I don’t think anything Dr. Tuteur is advocating even resembles informed consent and respect for mothers. Not to mention, maybe 10% of the time, her facts are just plain wrong. Possibly because she hates “natural” childbirth advocates so much, she goes too far to the other extreme, I honestly don’t know.

    Finally, Dr. T’s blogging style has been discussed ad nauseum over on Open Salon, for years, and MUCH more nastily than on this site (by both her and her… non fans- and over on OS these non fans are not birth advocates of any kind). She’s not going to change or be kind or nuanced, so it’s kind of a waste of time. It’s more a distraction, and since reading over on OS a little bit, I regret my participation in criticism of said vitriol. There’s plenty of logical and factual errors abound without having to go into blogging style, especially since the latter is subjective. But of course comments are open and I appreciate that on SBM.

  64. Zoe237 says:

    “You’re abusing science and using SBM as a shield. I probably wouldn’t be so offended if both my parents weren’t doctors. However, because my mother is a doctor (the only woman in her graduating class and someone who fought for our right to informed choice as women), I find your abuse of science and inability to discern your own confirmation biases while using SBM as a soapbox pretty sketchy and self-serving. And, yes, fairly or not, I expect better from women – particularly women in medicine and science. That’s a personal bias I have and can freely admit.”

    Okay, Fifi, this is going a little far. She’s some random online blogger, not the downfall of modern medicine or women’s rights. Unfortunate SBM endorses it, but I’m still reading, so I can’t complain too much. ;-) Now I’m done.

  65. BillyJoe says:

    rosemary,

    “I see a red flag when I notice people with no hands-on experience, no expertise in a field, using published studies alone to criticize someone with the expertise and experience.”

    If Dr Tuteur was presenting evidence based on her personal experience of treating women with breech presentation, I would have been long gone, because that sort of evidence is almost totally unreliable and totally anaethema to “Science Based Medicine”

    “I prefer the term “evidence-based medicine” to “science-based medicine” because I fear that people who promote SBM may be so in love with logic and science that if solid evidence is consistently presented that contradicts one of their scientific theories that they will disregard the evidence rather than their theories, something very unscientific that scientists have been known to do in the past”.

    Okay short reply as it is off topic: “Science Based Medicine” considers BOTH prior probability AND evidence; the point being that if the prior probability is low then the evidence has to be correspondingly high; and if the prior probability is almost zero, then the evidence has to be extraordinary.

    BJ

  66. “As a paediatrician I would point out that the end-point for research into outcomes should not just be mortality, but long-term morbidity – and significant long-term neurological impairment at that. This is a difficult area to research due to (1) long follow up required ie until 6-8 years of age, (2) what is considered “significant” impairment, & (3) a large number of infants required to be enrolled to detect small but statistically significant results.”

    Absolutely!

    I wonder if the PREMODA team is planning to study the long term effects of vaginal breech delivery.

  67. Fifi says:

    zoe – “Okay, Fifi, this is going a little far. She’s some random online blogger, not the downfall of modern medicine or women’s rights. Unfortunate SBM endorses it, but I’m still reading, so I can’t complain too much. ;-) Now I’m done.”

    Hmmm, well she’s not a “random blogger”, she’s being promoted here as an advocate of SBM and given the blessings/conferred authority of this collective that purports to be a superior source of science-based medical information and a defender of SBM. The other bloggers here generally do present SBM and very good discussions around SBM, the attacks on SBM by anti-science ideologues, the difference between science and pseudoscience, and so on. So, in many ways being a blogger here gives someone a certain amount of authority and credibility. Certainly I advocate a reader/buyer beware approach and for people to think critically, however that doesn’t change the fact that being supported/presented by this blog does lend the bloggers a certain amount of credibility.

    I don’t think she’s about to bring down medicine or destroy women’s rights, I was simply explaining why I find her abuse of science and SBM so personally appalling and worth commenting upon (aka what my own personal bias is in this matter and why I’ve been passionate enough to keep commenting). Dr Tuteur keeps trying to paint anyone who calls her out as being some kind of ideological proponent of pseudoscience. I’m quite the opposite. I was raised by two doctors and with science as the best means to understand the world. I grew up around medical research so also understand that being able to say “we don’t know” is integral to good science. I also worked briefly in a clinical setting where a great deal of what I did was helping people understand the mind/body connection in lay terms (in two languages and with people from a very diverse range of cultures). I have a very deep respect for the scientific method as the best way to discern, explore and understand objective reality (subjective experience is another thing, there’s plenty of room for that too). I understanding confirmation bias and how ideology can interfere with science, I’m aware of my own biases and the difference between objective reality and subjective experience (and how one can inform the other and the traps our cognition can lay for us). I also understand how hurtful and insulting all the anti-medicine and anti-doctor propaganda can be for people who’ve dedicated their lives to medicine, science and helping others (once again, this is personal because it’s my mom who gets angry, hurt and frustrated).

    While Dr Tuteur is just one more person abusing science for ideological/personal ends, the whole point of the SBM blogging group (supposedly anyway) is to call out people who abuse science for ideological or commercial ends. The other purpose seems to be to present good science and further understanding of science. It doesn’t seem to me that Dr Tuteur is doing either.

    I had absolutely no idea who Dr Tuteur was before I ran across her here – despite her seeming previous notoriety and reading Salon sometimes. I’ll just avoid her posts from this point in (which I’m sure she’ll appreciate) but I’m pretty disappointed that the SBM blogging collective is supporting and promoting this kind of thing. Why? Because I do think the battle between science/reality-based thinking and pseudoscience/unreality-based thinking is a defining battle of our times and has all kinds of very potent real world repercussions. From my perspective, someone like Dr Tuteur does more harm than good because she makes any accusations that SBM is as equally ideological as any other group that is pseudoscientific and ideological true (and uses the same kinds of sketchy and dishonest tactics as those she claims she’s against). The very least I can do is to speak up. I’ve done that but, like trying to discuss anything with the ideologues that Dr Tutuer considers her enemy, to continue doing so is obviously fruitless because Dr Tuteur doesn’t seem to even respect science enough to be honest about her own biases. C’est la vie, but I can’t say I’m not disappointed and don’t expect better from the SBM blogging group (and, personal bias alert, women in medicine and science).

  68. StatlerWaldorf says:

    Good points Fifi, especially this, “From my perspective, someone like Dr Tuteur does more harm than good because she makes any accusations that SBM is as equally ideological as any other group that is pseudoscientific and ideological true (and uses the same kinds of sketchy and dishonest tactics as those she claims she’s against).”

    I’m starting to wonder, what is the point of discussing risks stats in obstetrics and gynecology when the discussion is so limited? From the way that Dr. Tuteur presents her articles, everything done in maternity wards is based on scientific evidence, and the proof is that 1 in x thousands of babies could die because y wasn’t done. Anyone could be that 1 in x thousand, so everyone should accept the practices in maternity wards for their births. Parents aren’t educated enough to give informed consent and it is best left to the doctors to make decisions. The only consideration in childbirth is having a live baby, nothing else is involved in decision-making.

    There we go, done and dusted!

  69. “From the way that Dr. Tuteur presents her articles, everything done in maternity wards is based on scientific evidence, and the proof is that 1 in x thousands of babies could die because y wasn’t done.”

    I’m glad that came through to you since I have been pounding on that point in almost every post.

    The canard of the moment in the “natural” childbirth community is that obstetrics is not based on scientific evidence. That claim, like so much of “natural” childbirth advocacy, is simply fabricated. Obstetric recommendations on breech birth, “natural” childbirth, homebirth, waterbirth, C-sections, etc. ARE based on the scientific evidence. It is it TRUE that the scientific evidence shows that obstetric recommendations and technology save lives.

    Indeed, the fact that obstetrics is based on the scientific evidence has become obvious in some quarters of the midwifery community, much to their disappointment. As I pointed out in another post, they are clamoring for a “redefinition” of evidence so that they can justify ignoring the actual scientific evidence.

  70. Zoe237 says:

    “From the way that Dr. Tuteur presents her articles, everything done in maternity wards is based on scientific evidence, and the proof is that 1 in x thousands of babies could die because y wasn’t done.”

    “I’m glad that came through to you since I have been pounding on that point in almost every post.”

    I hope the SBM editors who defended Dr. Tuteur by saying “I’m sure Dr. Tuteur is not defending every practice in maternity wards” will take note. She is indeed as extreme as others have been saying all along, without the goods the back it up.

    Otherwise, Dr. Tuteur might want to check the ACOG policy statements versus what is being done in maternity wards. A lot has changed since the early ’90s in terms of recommendatons.

    http://www.acog.org/navbar/current/publications.cfm

    See committee opinions.

    Love the newest midwife dig in there at the end too. ;-)

  71. “I hope the SBM editors who defended Dr. Tuteur by saying “I’m sure Dr. Tuteur is not defending every practice in maternity wards” will take note.”

    I am not defending EVERY practice in maternity wards. I am specifically defending and explaining the practices that I write about. How about addressing what I actually say instead of erroneously insisting that I said something entirely different?

  72. Amy,

    What part of …

    ‘From the way that Dr. Tuteur presents her articles, everything done in maternity wards is based on scientific evidence, and the proof is that 1 in x thousands of babies could die because y wasn’t done.’

    I’m glad that came through to you since I have been pounding on that point in almost every post.”

    … did you not say? You quoted someone saying “everything.” You agree with their statement. This seems very clear to me.

    “How about addressing what I actually say instead of erroneously insisting that I said something entirely different?”

    Amy, you are the one who persistently says things and later complains that’s not what you meant. And that we should talk about what you mean instead of what you say.

    Can you explain exactly how we are supposed to know what you mean if it’s different from what you say?

  73. “Amy, you are the one who persistently says things and later complains that’s not what you meant”

    Hardly.

    I am addressing a common fallacious argument.

    I present evidence that various obstetric recommendations (like C-section for breech) are based on the scientific evidence. Invariably someone claims: So you are saying every obstetrical practices that exists and ever existed is based on scientific evidence?

    No, that’s not what I said, but it is ever so much easier to argue against the absurd absolute than to address what I actually said.

    That’s what’s happening here and the same thing is happening on the Big Placebo thread. I said that contrary to the claims of Big Placebo, most illness and death is not caused by lifestyle factors. Of course someone immediately claimed that I was insisting the lifestyle factors never cause disease. Once again, that’s not what I said.

  74. Amy, if someone says,

    “From the way that Dr. Tuteur presents her articles, everything done in maternity wards is based on scientific evidence, and the proof is that 1 in x thousands of babies could die because y wasn’t done.”

    … and you want to communicate that this is a fallacious argument of the straw man variety, you should say something like, “No, that is a straw man. I present evidence that various obstetric recommendations (like C-section for breech) are based on the scientific evidence.”

    What you said instead was, “I’m glad that came through to you since I have been pounding on that point in almost every post.”

    If you want us to understand what you mean, you should say what you mean and not something else.

  75. “you should say something like, “No, that is a straw man. I present evidence that various obstetric recommendations (like C-section for breech) are based on the scientific evidence.”

    Oh, you mean I should have interpreted the “everything” in her statement “everything done in maternity wards is based on scientific evidence, and the proof is that 1 in x thousands of babies could die because y wasn’t done.’ as “everything in the history of obstetrics”? You mean I gave her more credit than she deserved since I assumed she meant “everything I wrote about” instead of “everything in the history of obstetrics.”

    Alison, why do you nitpick about irrelevant details? Does it make any difference to the claims in this post? Why not address what I wrote about instead instead of anything else but?

  76. Plonit says:

    Obviously, “everything done in maternity wards is based on scientific evidence” should be interpreted as “everything done in maternity wards is based on scientific evidence.” A plain reading of the text is called for here!

    I would probably presume (in the context of the discussion) that the maternity wards being cited were contemporary US maternity wards. But I might clarify that if that were ambiguous.

    I wouldn’t assume that the Zoe237 was referring to “everything in the history of obstetrics” since that is not what is written.

  77. Zoe237 says:

    Statlerwaldorf: “From the way that Dr. Tuteur presents her articles, everything done in maternity wards is based on scientific evidence, and the proof is that 1 in x thousands of babies could die because y wasn’t done.”

    Dr. Tuteur: “I’m glad that came through to you since I have been pounding on that point in almost every post.”

    Me: “I hope the SBM editors who defended Dr. Tuteur by saying “I’m sure Dr. Tuteur is not defending every practice in maternity wards” will take note.”

    Dr. Tuteur: “I am not defending EVERY practice in maternity wards. I am specifically defending and explaining the practices that I write about. How about addressing what I actually say instead of erroneously insisting that I said something entirely different?”

    _______________________________

    Um, I’ll take your word for it, but for the life of me I can’t figure out why you would then agree with statlerwaldorf rather than calling her observation a strawman.

    However, I’m glad you can’t defend every maternity ward practice as based on scientific evidence. Because some are not.

  78. StatlerWaldorf says:

    Amy, the point you have missed is that just because 1 death in x thousands of births may occur, it does not justify all labouring women being coerced or forced into accepting maternity practices for their individual pregnancy and taking into consideration their own bodies and future fertility.

    You have presented here the statistical risk of a bad outcome when attempting vaginal breech birth. (Well, another poster gave a more reasonable way to present the stats to parents.) As anyone can see, there is risk; however, it should not be standard that all women with babies in breech position are c-sectioned (especially court-ordered!), or told that if they don’t consent to a c-section they will kill their baby. You argue that women who don’t consent to a c-section aren’t educated enough on the issue and have no concept of the risk (and brainwashed by the evil natural childbirth folks!). Maybe you think that the evidence shows that everyone should opt for the c-section, but as has been discussed here, c-sections have their own risks for mother, baby and future pregnancies and therefore parents might want to take the chance that they will not be the 1 in 111 that will see a bad outcome.

    I’m wondering if one of your main unstated beliefs is that parents essentially are incapable of informed consent and all decisions should be left to the expert ob-gyn.

    It’s tricky out there, on one hand you have extreme NCBers that say “Trust nature, trust birth.” and on the other hand you have some ob-gyns well versed in “You are going to kill or brain damage your baby!”. Neither side is discussing the risks adequately, nor respecting parents’ choices.

  79. “the point you have missed is that just because 1 death in x thousands of births may occur, it does not justify all labouring women being coerced or forced into accepting maternity practices for their individual pregnancy and taking into consideration their own bodies and future fertility.”

    That is a different issue entirely.

    The threshold issue is: what does the scientific evidence show? After determining that, women can address how they wish to use that evidence.

    It is perfectly reasonable for a woman to say that she’d rather incur a small increased risk of neonatal death than have abdominal surgery. That is something altogether different than claiming that the recommendation for C-section to deliver a breech baby is not based on the scientific evidence.

  80. BillyJoe says:

    Amy,

    You are starting to make a lot more sense to me (though I think you have not clarified you position on “informed choice”). Perhaps your original article should have been a lot more pointed, or a lot more detailed.

    Someone complained about David Gorski’s long posts a while back, but I think that is preferable to all the misunderstanding that has occurred here.

    Maybe a good compromise is a detailed article covering a sinle or a limited number of points for those keen on commenting on the subject, together with a summary at the beginning for those who don’t want so much detail and are not interested in commenting on the article.

    Just a suggestion.

  81. “I assumed she meant “everything I wrote about” instead of “everything in the history of obstetrics.””

    Ok, that’s interesting and maybe very relevant to why you have so much difficulty communicating.

    Why would you assume she meant everything you wrote about? She said “everything done in maternity wards is based on scientific evidence,” and I assume she meant “everything done in maternity wards.” If she wanted to say “all the practices Amy writes about,” I assume she would have written “all the practices Amy writes about.” She wrote in the present tense, so was not referring to the thousands of years of obstetric history.

    There is no reason for anyone to assume that StatlerWaldorf meant anything different from what she wrote. And yet you did just that.

    I assume that if you write something, you must mean it. You call that nitpicking, but I have no alternative.

    “Alison, why do you nitpick about irrelevant details? Does it make any difference to the claims in this post?”

    If you cannot communicate your claims, and if you cannot interpret questions and comments, then it makes a difference to whether you should be an SBM blogger. After 180 comments, BillyJoe is starting to understand what you might be talking about. It shouldn’t take 180 comments to begin to understand a post.

    As I have said before, I want you to be a better writer. I want you to understand that accuracy matters.

    “Why not address what I wrote about instead instead of anything else but?”

    I did. I defended your use of the statistically meaningless 630 dead babies on the grounds that human beings generally have a hard time with probability.

  82. StatlerWaldorf says:

    I did mean everything done currently in maternity wards, not what was done through obstetric history.

    I think Amy believes that everything done currently in maternity wards is science-based because of her writings on her own blog and here. The only thing I’ve seen her mention is episiotomy as an exception.

    Amy said, “The threshold issue is: what does the scientific evidence show? After determining that, women can address how they wish to use that evidence.”

    I agree. My argument is that stats on infant mortality or brain damage from head entrapment during a vaginal breech birth are not the only stats used in the decision making. It would have been interesting to see some stats on risks for baby, mother and future pregnancies after c-section to get a good picture of which stats should be more persuasive in informing women’s decisions.

    Amy says, “It is perfectly reasonable for a woman to say that she’d rather incur a small increased risk of neonatal death than have abdominal surgery. That is something altogether different than claiming that the recommendation for C-section to deliver a breech baby is not based on the scientific evidence.”

    I haven’t heard anyone claim that vaginal breech birth has the same risk level as vaginal vertex birth, nor that a c-section is not a valid medical recommendation. This topic is not a good example of “things NCBers say is not evidence-based”. Where is the post on continuous vs. intermittent fetal monitoring if you want to get into something juicy.

  83. Plonit says:

    brain damage from head entrapment during a vaginal breech birth are not the only stats used in the decision making.

    +++++++++

    Just to be clear, no one has actually given those stats. The perinatal deaths in the Term Breech Trial were not all from difficult deliveries.

  84. StatlerWaldorf says:

    Plonit you are correct. Those would be useful stats to see.

Comments are closed.