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Midwives and the assault on scientific evidence

The new mantra of midwives and their advocates is “evidence based practice.” Lamaze, the childbirth education organization has changed the name of their blog to “Science and Sensibility” emphasizing the importance of science and promising:

Lamaze education and practices are based on the best, most current medical evidence available, and can help reduce the overuse of unnecessary interventions while improving overall outcomes for mothers and babies.

But midwives and childbirth educators like Lamaze have a problem. The scientific evidence often conflicts with their ideology. They could address this problem in several ways. Midwives could modify their specific ideological beliefs on the basis of scientific evidence. Childbirth educators could question whether ideology has had an inappropriate impact on the promulgation and validation of their recommendations. Both those approaches would involve a threat to cherished beliefs. They, therefore, have taken a different approach. They’ve tried to justify ignoring scientific evidence.

As midwives Jane Munro and Helen Spiby have documented in The Nature and Use of Evidence in Midwifery, the first chapter of their book Evidenced Based Midwifery, midwives were initially enthusiastic about basing clinical practice on scientific evidence. That’s because they had long told each other that midwifery was “science based” while obstetrics was not:

At the beginning of the evidence based practice movement, much of the midwifery profession responded enthusiastically to the potential for change… Evidence based practice was seen to be offering a powerful tool to question and examine obstetric-led models of care that had dominated the previous decades. The results of such examination could have meant ‘starting stopping’ the unhelpful interventions that had embedded themselves in common practice …

But it turned out that obstetrics had been based on scientific evidence all along and it was midwifery that ignored the scientific evidence in favor of ideology. Indeed, almost all practices exclusive to midwifery (as opposed to copied from obstetrics) have never been tested. They might be valuable; they might be useless; they might even be harmful. No one bothered to check before implementing them because they were based on ideology.

It has been quite a shock to midwives and childbirth educators to learn that most of their own practices have never been scientifically validated. Even worse, much of their critique of modern obstetrics flies in the face of the existing scientific evidence. As Munro and Spiby explain:

… [S]ome midwives have not been so enthusiastic [about evidence based practice], viewing the drive to create and implement evidence as a threat to their clinical freedom.

In other words, cherished ideological beliefs conflict with scientific evidence. Thus began the attack on scientific evidence.

As a first approach, midwives and childbirth educators have rejected the definition of evidence. As defined by Sackett, the founder of evidence based practice, it is “the conscientious, explicit and judicious use of current best evidence in making decisions about the care of individual patients.” That sounds objective, and evidently, objectivity is a problem. They have attempted to solve that problem by insisting that evidence can only be defined in context. “Context” in this case really means “ideology.”

Scientists see the ideology free nature of scientific evidence as one of its strengths and therefore privilege it as the ideal form of evidence. But Lomas, writing about midwifery critics of evidence, explains that they reject this privileged status:

[I]t is important that context evidence should not be viewed as any less ‘scientific’. They advocate moving forward from the epistemological argument about what is ‘best evidence’ towards a ‘balanced consensus’ …

The use of the word “consensus” is illuminating. Evidence can only be evidence if it includes the opinions of midwives and childbirth educators, whether those opinions are based on science or not. Indeed, the scientific facts are merely one aspect of evidence. “Social science oriented research” and “the views of stakeholders” are supposed to have equivalent weight.

Such is the genesis of midwifery papers like Wickham’s Evidence Informed Midwifery, and, my personal favorite, Parrat and Fahy’s Including the nonrational is sensible midwifery. When the evidence does not support your claims, the use of adjuncts, including nonrational ones, will justify any beliefs.

The Parrat and Fahy paper is particularly instructive on this point. Their central claim is that the inclusion of the non-rational is midwifery “enhances safety”:

When the concept of ‘safety’ is considered in childbearing it can illustrate how insensible rationality can be and how negative consequences can occur. Safety is an abstract concept because it is difficult to define and can only be considered in general terms. Rational dichotomous thought, however, provides ‘safety’ with the following defining boundaries:

- ‘safe’ has a precise opposite called ‘unsafe’,
- every situation/person/thing must be either be safe or unsafe,
- a situation/person/thing cannot be both safe and unsafe,and
- it is not possible for a situation/person/thing to be anything
other than safe or unsafe.

Furthermore:

…What is deemed as safe is aligned with what is rational and what is unsafe is aligned with what is irrational. As irrationality is not acceptable this essentially forces the definition of safety to be thought of as ‘true’ even though it may not fit with personal experience and all situations… As the standard birth environment is the medicotechnical environment of the hospital this is presumed to be the safest. Its ‘opposite’, the home environment, is therefore rationalised to be unsafe. To argue otherwise would define the rational person as irrational… In the purely rationalist way of thinking there is no other option except to consider that honouring the nonrational variabilities of individual bodily experience is irrational and unsafe.

The authors end with a flourish of outright stupidity:

For example, when a woman and midwife have agreed to use expectant management of third stage, but bleeding begins unexpectedly, the expert midwife will respond with either or both rational and nonrational ways of thinking. Depending upon all the particularities of the situation the midwife may focus on supporting love between the woman and her baby; she may call the woman back to her body; and/or she may change to active management of third stage. It is sensible practice to respond to in-the-moment clinical situations in this way…

This paper is but one example of a disturbing trend: many midwives and childbirth educators use the term “scientific evidence” merely as a rhetorical device, in the same way that creationism and other form of pseudoscience use the term “scientific evidence.” As Coker details in his article Distinguishing Science and Pseudoscience:

Pseudoscience appeals to the truth-criteria of scientific methodology while simultaneously denying their validity.

Similarly, midwives and childbirth educators invoke the criteria of scientific methodology while simultaneously insisting that their personal beliefs matter as much if not more.

Posted in: Obstetrics & gynecology

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107 thoughts on “Midwives and the assault on scientific evidence

  1. TimMills says:

    It is true that there is a great deal of unscientific and antiscientific thought among those who promote homebirth, as well as among those who choose it. My wife and I came across some of it here in the UK when we were exploring our options as soon-to-be-parents.

    However, as several of us pointed out in the first post on this topic, there is also good evidence from Canada and the Netherlands (full references below) that low-risk women, attended by medically-trained midwives, in the context of a health care infrastructure that accommodates home births, are at no higher risk of infant mortality or other negative outcomes at a home birth than at a hospital birth.

    The US differs from these countries in terms of access to health care (Canada and Netherlands both have universal socialized health care); it differs in terms of the medical training of midwives; and it probably also differs in terms of the criteria those midwives use to select homebirth clients.

    These differences could explain the fact that the evidence from American homebirth (discussed, for example, in the previous post on the topic) does not agree with the evidence from the Canadian and Dutch studies.

    So, having noted problems with American homebirth, what would you suggest is the best way forward?

    Is it best just to reject homebirth altogether as an option? This might keep the homebirth rate low, but it would also drive people who are determined to have a homebirth into the hands of unqualified midwives.

    Should the American obstetric profession (and the medical infrastructure more generally) work toward a more Canadian-like* or Dutch-like system where truly safe homebirth could be offered? This would seem to solve the problem of driving homebirth “underground”, and it would save women and their babies from the dangers of American homebirth as currently practiced. But it would be a huge undertaking, with many political and economic implications.

    * Note that the Canadian study is based on a new provision – homebirth (woo- or science-based) is not a commonly-available thing in Canada.

    References:

    Janssen, P. A., Lee, S. K., Ryan, E. M., Etches, D. J., Farquharson, D. F., Peacock, D., and Klein, M. C. (2002). Outcomes of planned home births versus planned hospital births after regulation of midwifery in british columbia. CMAJ : Canadian Medical Association journal = journal de l’Association medicale canadienne, 166(3):315-323.

    A. de Jonge, B. Y. van der Goes, A. C. J. Ravelli, et al. 2009. Perinatal mortality and morbidity in a nationwide cohort of 529 688 low-risk planned home and hospital births. In BJOG: An International Journal of Obstetrics & Gynaecology, Vol. 116, No. 9., pp. 1177-1184.

  2. The Canadian and Dutch homebirth studies come from systems that are very different from ours, and those conditions cannot necessarily be replicated in the US.

    In this particular post, I’m not talking only about homebirth, but about midwifery in general.

    Midwifery theorists are facing serious cognitive dissonance. After years of insisting that obstetrics is not based on the scientific evidence, they are learning that obstetrics is, of course, firmly grounded in scientific evidence.

    Now there is a backlash against the very concept of scientific evidence. The efforts include claims that provider beliefs are evidence, and (not mentioned in this post), claims that quantum mechanics (yes quantum mechanics) tells us that the entire concept of scientific evidence is fundamentally flawed.

    I don’t typically think of midwifery as being in the same category as pseudoscience, and by and large it isn’t. That’s because most of midwifery is copied directly (and appropriately) from obstetrics. But this growing effort to undermine the concept of scientific evidence does not bode well for midwifery.

  3. StatlerWaldorf says:

    I haven’t studied midwifery education in the US or elsewhere in depth yet, but if there is a trend to for modern midwifery to move towards pseudoscience – why is that? What is causing this shift?

  4. Réka Morvay says:

    “But it turned out that obstetrics had been based on scientific evidence all along and it was midwifery that ignored the scientific evidence in favor of ideology. Indeed, almost all practices exclusive to midwifery (as opposed to copied from obstetrics) have never been tested.”

    Such as? Which ones in particular? This is an incredibly misleading post; lumping together practices from midwifery care and obstetric care is if they were mutually exclusive and diametrically opposed, two sets on a Venn diagram with no overlap.

    Discussing individual practices in terms of their validity or the evidence supporting their use would be far more useful and informative, far less misleading, and far less pejorative.

    I also find the implication of this quote that NONE of the practices followed by midwives (which ones? in what setting? by whom?) are evidence-based, and yet ALL practices followed by obstetricians (which ones? in what country? by whom?) are.

    Just a few counter-examples of some practices in obstetric care in my country (Hungary) which are not evidence-based:

    1. Routine episiotomies for 70-90% of first-time mothers.

    2. Early cord clamping before the cord stops pulsating.

    3. Routine separation of mothers and infants following birth in most hospitals.

    I think (hope) we can agree that the data refuting the usefulness of the above 3 practices are very robust, but if you’d like, I can cite specific research papers.

    I would argue that aligning practices by midwifery or obstetrics is less than constructive IF the goal is to discover what yields best results for mother and baby. Obviously, some practices are evidence-based, and some are not. Some are practiced by midwives, and some are practiced by OBs. Instead of trying to besmirch one group or the other, let’s instead try to figure out what works and what doesn’t, shall we?

  5. “Which ones in particular?”

    Why don’t you name a practice or practices exclusive to midwifery (as opposed to copied from obstetrics) and present the scientific evidence for it?

    When I think of practices exclusive to midwifery, I think of the use of herbs, the use of alternative “treatments” (accupuncture, chiropractic therapy, etc.) specific positions in labor, the notion that gravity is necessary to accomplish vaginal delivery, the idea that eating during labor improves obstetrical outcomes, etc. There’s no scientific evidence to support those practices.

    “Instead of trying to besmirch one group or the other, let’s instead try to figure out what works and what doesn’t, shall we?”

    What works is adhering to the scientific evidence. What doesn’t work is substituting ideology for scientific evidence.

  6. Réka Morvay says:

    I’m not interested in what’s exclusive to midwifery or to obstetrics. I’m interested in “what works” and “what works” by my definition is a practice that is backed up by evidence, no matter who uses it.

    But I’ll bite:

    Delayed cord clamping, where I live, is primarily (can’t say exclusively) practiced by home birth midwives, not obstetricians.

    Some evidence supporting it:

    Hutton EK, Hassan ES. Late vs Early Clamping of the Umbilical Cord in Full-term Neonates: Systematic Review and Meta-analysis of Controlled Trials. JAMA. 2007;297:1241-1252.

    Strauss RG, Mock DM, Johnson KJ, Cress GA, Burmeister LF, Zimmerman MB, et al. A randomized clinical trial comparing immediate versus delayed clamping of the umbilical cord in preterm infants: short-term clinical and laboratory endpoints. Transfusion 2008 Apr;48(4):658-65.

    Kugelman A, Borenstein-Levin L, Riskin A, Chistyakov I, Ohel G, Gonen R, et al. Immediate versus delayed umbilical cord clamping in premature neonates born < 35 weeks: a prospective, randomized, controlled study. Am J Perinatol 2007 May;24(5):307-15.

    Mercer JS, Vohr BR, McGrath MM, Padbury JF, Wallach M, Oh W. Delayed cord clamping in very preterm infants reduces the incidence of intraventricular hemorrhage and late-onset sepsis: a randomized, controlled trial. Pediatrics 2006 Apr;117(4):1235-42.

    Baenziger O, Stolkin F, Keel M, von Siebenthal K, Fauchere JC, Das Kundu S, et al. The influence of the timing of cord clamping on postnatal cerebral oxygenation in preterm neonates: a randomized, controlled trial. Pediatrics 2007 Mar;119(3):455-9.

    Chaparro CM, Neufeld LM, Tena Alavez G, Eguia-Liz Cedillo R, Dewey KG. Effect of timing of umbilical cord clamping on iron status in Mexican infants: a randomised controlled trial. Lancet 2006 Jun 17;367(9527):1997-2004.

    Levy T, Blickstein I. Timing of cord clamping revisited. J Perinat Med 2006;34(4):293-7.


    If your definition of a practice exclusive to midwifery is that it is CAM that is not practiced by obstetricians, and that whatever midwives and obstetricians BOTH do has been borrowed from obstetrics, then of course you would come to your present conclusion. I would challenge your definitions, though.

  7. Pattoye says:

    @ Réka Morvay
    I don’t think Dr. Tuteur claimed that obstetrics and midwifery had no overlap. To the contrary, she stated there was an overlap and implied that the overlap they did have were practices that were evidence based and originally implimented in midwifery. She also didn’t claim that all obstetric practices are evidence based.

    “Indeed, almost all practices exclusive to midwifery (as opposed to copied from obstetrics) have never been tested. ”

    This implies that midwifery has practices that are the same or similar to ones in obstetrics and that they are evidence based. It merely claims that the practices exclusive to midwifery are nearly all untested. (I have no idea if this is true.)

  8. “But I’ll bite:”

    Where’s the evidence that midwives developed before they put it into clinical practice? There isn’t any, is there?

    In my judgment, one of the hallmarks of midwifery theory is defiance. In many cases, midwives recommend whatever is the opposite of what obstetricians are recommending without doing any research to determine what works.

    It’s not like midwives actually researched the issue. Obstetricians have used immediate cord clamping so midwives recommended delayed cord clamping. Research subsequently indicated that it may have some benefit for preterm babies, who are at particular risk for anemia. But midwives are not delivering preterm babies. They are delivering babies at term, and there the evidence for benefit is minimal, and there is a risk of polycythemia.

  9. windriven says:

    Nothing like starting off the day with a good laugh! The “flourish of outright stupidity” at the end had me chuckling out loud until I realized that these morons were talking about real mothers and real babies. I know if my wife started bleeding during delivery that I would want the care-giver to “focus on supporting love between the woman and her baby.”

    I would speculate – though I lack evidence of any sort to support my speculation – that much of the desire to birth at home stems directly from the relatively unpleasant nature of hospital delivery in some (many?) institutions. Hospitals have made great strides in the last 50 years moving from labor wards to birthing rooms that are often as comfortable and well-appointed as a mid-scale hotel.

    But despite efforts to personalize and ‘warm up’ hospital deliveries, hospitals remain complex businesses that run on their own institutional schedules. The birth of Baby Jane, while a joy to all involved, still must fit into a larger context of 300 other patients, some of whom are fighting for their lives. Shifts change, food for 300 patients comes at specific times, labs must be drawn and run; there is necessarily more regimentation in an institutional setting than in a home.

    So is this what drives people to home deliveries? Comfort and convenience? Is there some other reason that I’m missing? And is comfort and convenience worth the 1 in N chance that an unexpected event will occur that jeopardizes the life of mother or child?

    I simply don’t understand the draw. I hope someone can enlighten me.

  10. edgar says:

    Wind,
    this is a good question. I think is just isn’t for comfort and convenience, I think for many women, they think it terms of risk in the hospital vs. risk of homebirthing. And despite Amy’s claims to the contrary, the jury is still out.

    They see that there are ‘unnecessary’ interventions done. And they are afraid of that. They are also afraid of the ‘cascade of interventions’, as it is called in HB circles. They are also afraid of the lack of TRUE informed consent that goes on. I had a great hospital experience, but was given something in my IV, and I wasn’t told what it was. What gives ANYONE the right to put something in someone else’s body without asking/explaining. They also feel that while obstetrics does have something to offer in terms of complications, it over-relies on things like Friedman’s curve, CFM, lack of one-one female support (which is evidenced-based), keeping baby in the nursery, removal from observation, early cord clamping.

    Also, they see that birth is sacred event, and it isn’t JUST the birth of a child, but a trans formative event for the mother. And they feel that hospitals do not ‘get’ this, nor do they honor that. Sort of like the difference between making a baby by making love, and in-vitro would be the best comparison I would make.

    Now you can argue with this all you want, but this is where they are coming from.

  11. Both Parratt and Fahy left comments on my personal blog where I discussed the paper when it was first published, and then more recently.

    According to Fahy:

    “You seem to have a very clear view that body and mind (let alone soul) are separate. You are not up to date with the research in neurobiology and psychophysiology which demonstrates clearly the effect of thinking and feeling on human physiology. You might think it is ridiculous that skin to skin contact between a woman and her baby is seen as important in midwifery: it IS important for the woman’s natural oxytocin to be released which does at least two important physiological things; one contract the uterus and two assists with breastfeeding. Is it really your view that without the drug pitocin then women would all be having postpartum haemorrhages?”

    Fahy is co-author with Carolyn Hastied and Maralyn Foreur of the new book Birth Territory and Midwifery Guardianship, which includes such gems as:

    “During women’s experience of childbirth, midwives also have the capacity to become aware of nonrational power and knowing… Being open to the nonrational can teach midwives about trust, courage and their own intuitive abilities.”

    And (I’m not making this up):

    “Nonrational power is inexpressibly unique, diverse and whole at the experiential level…

    Spirit is power… Spirit is nonrational, ever moving, and acts in sometime idiosyncratic ways as it is free of what we rationalize as possible and impossible. The direction, force and flow of spirit extend beyond rational boundaries of time, space and matter…

    The power of the spirit is the energy underlying all that in the world and the cosmos; it has been given other names, for example Universal Energy and the subtle yet vital energy called qi…”

  12. edgar says:

    So you must be an atheist, then Amy?

  13. edgar says:

    Which is of course, fine, (I am) but it would explain your lack of understanding of other forms of knowledge.

  14. edgar says:

    Amy,
    I agree,
    her words are out of the ordinary for most of us, and strike us as…hokey. But read between the lines, in your language….You never felt the miracle of life, and felt privileged to see what you see when delivering a baby? In addition to your rational mind, focusing on doing your job?

    That is what they are talking about.

  15. “her words are out of the ordinary for most of us, and strike us as…hokey”

    That’s not the problem. Consider the following quote:

    “Depending upon all the particularities of the situation the midwife may focus on supporting love between the woman and her baby; she may call the woman back to her body; and/or she may change to active management of third stage.”

    The problem is not the New Age language; and the problem is not simply that this ignores standard of care, which is to treat postpartum hemorrhage with uterotonic agents like pitocin. The problem is that it represents an assault on the concept of scientific evidence.

    The authors appear to be claiming that although the scientific evidence supports treating postpartum hemorrhage (not simply bleeding, but an actual hemorrhage) with uterotonic agents, midwives are free to IGNORE the scientific evidence. They purportedly have “other ways of knowing” and “treatments” like supporting the love between a woman and her baby, and that’s supposedly an equally valid treatment modality.

    My main point in writing this post is to raise two issues: the fact that midwifery criticism of obstetrics as not “evidence based” is turning out to be false. And the assault on the concept of scientific evidence is an attempt to address the cognitive dissonance that arises from the recognition that midwifery ideology is not supported by scientific evidence.

  16. edgar says:

    So all obstetrical practices are evidenced based? C’mon, Amy, you know better than to make that assertation.

  17. StatlerWaldorf says:

    Amy said, “When I think of practices exclusive to midwifery, I think of the use of herbs, the use of alternative “treatments” (accupuncture, chiropractic therapy, etc.) specific positions in labor, the notion that gravity is necessary to accomplish vaginal delivery, the idea that eating during labor improves obstetrical outcomes, etc. There’s no scientific evidence to support those practices.”

    You may well be right about herbs and some alternative treatments. However, are you seriously saying that there is no evidence supporting women eating or drinking in labour to help give them energy for the birth? Is it really unreasonable for low-risk women to choose food and drink over an IV? And are you saying that scientific evidence has exclusively proven the lithotomy position is best for women to give birth as opposed to other positions? Is it really unreasonable for low-risk women to give birth in any position they feel most comfortable in?

    I’m still waiting for a thorough discussion on all the common birth practices in hospital settings and how they are evidence-based, and how any evidence to the contrary is flawed. I’m also still waiting on a detailed definition of “natural birth”.

  18. windriven says:

    @edgar

    “Now you can argue with this all you want, but this is where they are coming from.”

    I don’t want to argue it, only to understand it. And I agree that hospitals work by their own institutional practices. Those practices are intended to deliver quality healthcare to many patients with many different needs, all at the same time. Individual attention necessarily suffers. A buffet meal at a large function can offer very good food. But if you want your steak done extra rare you’re probably going to be disappointed.

    I can’t speak for Dr. Tuteur but I am an atheist. I nonetheless understand the splendid wonder of new life. I understand mothers wanting to bond with their babies in the immediate postpartum period. I don’t think that one’s belief or disbelief in, say, the Tooth Fairy has anything to do with this.

    “Which is of course, fine, (I am) but it would explain your lack of understanding of other forms of knowledge.”

    Other forms of knowledge????? Would this be knowledge based on crystals and intuition and auras? I don’t mean to be flippant but in my world knowledge is knowledge. Something is either true and provably so, or it is false and provably so, or it is speculative. There is no fourth option.

  19. windriven says:

    @ Statler Waldorf

    “Is it really unreasonable for low-risk women to choose food and drink over an IV?”

    Low risk is not the same as no risk. In the unlikely event that events turned horribly and surgical intervention was required, food in the stomach would potentially be very dangerous. Aspiration of stomach contents is potentially fatal. That is why pre-op patients are kept NPO.

    But in the larger sense I don’t think that anyone is arguing that hospital-based, MD assisted deliveries provide a perfect experience to the mother – only as safe an experience as medical science can offer. Hospitals have come a long way in improving the experience. Perhaps they still have a way to go. Medical doctors don’t know everything that can be known about delivering healthy babies safely. But their entire profession is focused on improving that knowledge through careful scientific investigation.

  20. edgar says:

    er, that comment was more geared toward Amy, who would undoubtedly pick it apart. Nothing to pick apart, IMO, that is what they think!

    As for the other forms of knowledge, I do think they exist, but are of course, not science-based. Intuition for one. maybe it comes from our unconscious mind trying to tell our conscious mind something. Other’s of a religious ilk might say it was from God (or crystals, which I don’t get, but that is not the point).

    Experiential knowledge, which can be a type of scientific knowledge, IMO. That soap and water (or a long time ago, some other substance) cleans wounds. Now, of course we have the mechanism to ‘prove’ that is so, but most people neither know, nor care how it works, and before we had a RCT, people knew from experience that it did work.

    We still do this in medicine. Cytotec for PPH is one example. From all accounts, it works. But I don’t believe there has been a RCT to show that it does(or if so, it was done after the fact).

  21. edgar says:

    Wind,
    :@ Statler Waldorf

    “Is it really unreasonable for low-risk women to choose food and drink over an IV?”

    Low risk is not the same as no risk. In the unlikely event that events turned horribly and surgical intervention was required, food in the stomach would potentially be very dangerous. Aspiration of stomach contents is potentially fatal. That is why pre-op patients are kept NPO.”

    But I think the question is, does denying food and drink harm more women that it helps?

  22. history punk says:

    You never felt the miracle of life, and felt privileged to see what you see when delivering a baby

    Dude, it’s all a biological process. Miracles are things that result from events that utterly suspend or break the rules of the universe.

  23. StatlerWaldorf says:

    Amy Tuteur said, “The authors appear to be claiming that although the scientific evidence supports treating postpartum hemorrhage (not simply bleeding, but an actual hemorrhage) with uterotonic agents, midwives are free to IGNORE the scientific evidence. They purportedly have “other ways of knowing” and “treatments” like supporting the love between a woman and her baby, and that’s supposedly an equally valid treatment modality.”

    So, you are saying that these authors are encouraging midwives to ignore clear evidence of post-partum hemorrhage in favour of tapping in to some spiritual beliefs they may have about the mother and baby and their own ideologies? The outcome of post-partum hemorrage is severe blood loss and/or death, and these authors have stated that “supporting love between mother and baby” is an equally valid treatment modality compared with injecting uterotonic agents like pitocin? I don’t have access to the article, so can’t read everything myself. Somehow I just can’t believe that the authors would advocate midwives to behave in that way.

  24. windriven says:

    @ edgar

    “But I think the question is, does denying food and drink harm more women that it helps?”

    No. A chocolate milkshake because it tastes better than D5W versus an orphaned newborn does not seem a reasonable exchange.

  25. Kylara says:

    Windriven,

    I’m a devout Catholic and I’m all about the miracle of life and transcendent knowledge and stuff like that, but I still wanted to give birth in a hospital with all the science and whatnot. When people set up a dichotomy like faith vs. science or “intuitive” knowledge vs. scientific knowledge, they’re either trying to take the one of the two out of its proper sphere, or they’re trying to prove an ideological point for which they have little support.

    Of course a good doctor cares for — or at least respects — his or her patient’s emotional and spiritual needs as well. But a doctor can’t ethically put those needs ABOVE clear medical needs — restricting oneself to praying for the patient’s spleen (or encouraging a love relationship between the patient and his spleen) isn’t going to help a damn thing if the spleen needs to come out.

    In my anecdotal experience, the women local to me who opt for homebirth are typically educated, but fairly unsophisticated in their dealings with the medical establishment. They seem to feel they can’t adequately advocate for themselves or make themselves heard to their doctors, they are fearful of being able to make choices for themselves, they are unsure as to how to navigate the medical bureaucracy. For them, fears of having their wishes overriden, or of being a passive entity who is acted upon without their consent are very real fears.

    Incidentally, they also tend to be the parents who don’t get wills written, I assume for much the same reason — lack of sophistication in navigating the establishment. And, for some reason, a fear of asserting oneself to learn how to do so … perhaps because they’re typically fairly successful at work and don’t like to find themselves in a position of ignorance.

    Just some amateur psychologizing to start my day. :) (Of course anecdotes aren’t data and the types of women who choose homebirth seem to vary regionally based on what I’ve read/heard.)

  26. edgar says:

    @ edgar

    “But I think the question is, does denying food and drink harm more women that it helps?”

    No. A chocolate milkshake because it tastes better than D5W versus an orphaned newborn does not seem a reasonable exchange.

    You raise a good point, but I think the idea is the lack of nourishment leads to unnecessary c-sections. At least that is the premise, which at least makes some biological sense.
    And for the record, I have heard the pros and cons of NPO during L&D. But so far, I have not seen risk numbers. Do you know?

  27. StatlerWaldorf says:

    I’m well aware that low-risk women who eat and drink and suddenly need a crash c-section are at risk of aspiration during the procedure. However, the majority of women are low-risk, and there are few crash c-sections, and even fewer women who will suffer from aspiration. So, no, it isn’t unreasonable for low-risk women to refuse IV and instead eat and drink to sustain themselves during their labour.

    windriven said, “I don’t want to argue it, only to understand it. And I agree that hospitals work by their own institutional practices. Those practices are intended to deliver quality healthcare to many patients with many different needs, all at the same time. Individual attention necessarily suffers. A buffet meal at a large function can offer very good food. But if you want your steak done extra rare you’re probably going to be disappointed.”

    If lack of consideration for one’s individual situation results in traumatic interventions or a possibly unnecessary c-section that impacts fertility and future births, how is this acceptable? This is exactly why low-risk women should have more options, including primary care by qualified midwives with co-operation with ob-gyns, and birthing in alternative settings like a birth centre or home. I’d hardly compare standard hospital birth to a buffet at a large function… price-inflated McDonald’s is more like it! ;-)

  28. edgar says:

    Ah, but the very nature of birth blends to the spheres.
    There is no other even comparable.

  29. StatlerWaldorf says:

    Why did two of my posts appear immediately, yet one is “awaiting moderation”? I’ve said nothing offensive or controversial there.

  30. Todd W. says:

    @StatlerWaldorf

    Did you include a hyperlink?

  31. “are you seriously saying that there is no evidence supporting women eating or drinking in labour to help give them energy for the birth?”

    That is precisely what I am saying.

    According to article on Oral Intake During Labor, a review article in the International Anesthesiology Clinics (International Anesthesiology Clinics: Winter 2007, Volume 45, Issue 1 – pp 133-147):

    … Many professionals argue that starvation in labor is both physiologically and psychologically detrimental for women. It is not surprising that prolonged fasting in labor is associated with an increased production of ketones …

    “A key question in labor outcome is whether there are significant improvements in women who take either calories or light diet in labor. There is a scarcity of good controlled data looking specifically at delivery outcome, but there are some randomized control trials that have evaluated obstetric end points… In 1999, Scrutton et al investigated whether a light diet would affect a woman’s metabolic profile and increase her residual gastric volume. Labor outcome was also evaluated… Glucose levels were higher in the eating group, whereas eating prevented the rise in hydroxybutyrate and fatty acids. With these numbers, there were no significant differences in other labor end points. Mothers in the eating group, however, did have significantly larger gastric volumes at the time of delivery and these women vomited larger volumes, which contained a considerable amount of solid residue.

    A further study from the same unit randomized 60 women comparing the metabolic effects of isotonic sports drink to water only during labor… [I]t was shown that these drinks prevented the rise in b-hydroxybutyrate and nonesterified fatty acids seen in the starved group. Once again, there was no change in any outcome of labor, but in contrast to the light diet allowed in the original study, there was no increase in residual gastric volume in the isotonic sport drink group…

    … Scheepers et al performed a randomized controlled trial in 200 women who received either carbohydrate solutions or placebo… The main outcomes were operative deliveries, labor duration, and need for analgesia. Again, envelopes were used for randomization and the trial was blinded. They found a 3-fold increase in cesarean section in women who received calories.

    Tranmer et al conducted a randomized trial to determine if unrestricted oral carbohydrate intake during labor reduced the incidence of dystocia … There was no significant difference in the incidence of dystocia between intervention and control group … Moreover, induction of labor, types of uterine stimulants administrated, delivery method, and indication of cesarean section were also evaluated and there were no significant difference between groups…

    The authors conclude:

    … Although a policy of ‘‘nil per os’’ may be responsible for unnecessary discomfort, there is very little evidence that it causes other harm. Current available studies suggest there is no change in the length of labor, the obstetrical outcome or neonatal outcome when parturients are fasted intrapartum compared with those who are fed.

    A more recent study, Effect of food intake during labour on obstetric outcome: randomised controlled trial, was published in the BMJ this year (BMJ 2009;338:b784):

    “Consumption of a light diet during labour did not influence obstetric or neonatal outcomes in participants, nor did it increase the incidence of vomiting. Women who are allowed to eat in labour have similar lengths of labour and operative delivery rates to those allowed water only.”

  32. Kylara:

    “When people set up a dichotomy like faith vs. science or “intuitive” knowledge vs. scientific knowledge, they’re either trying to take the one of the two out of its proper sphere, or they’re trying to prove an ideological point for which they have little support.”

    Agreed. It seems like that is what is going on here.

  33. edgar says:

    This is precisely the sort of thing HB’ers take issue with, that they are ‘not allowed.’ It seems to me that the onus is to show that NPO is beneficial.

    In either case, what the mother does or doesn’t do, should be up to her after proper BRAIDED informed consent.

  34. windriven says:

    @StatlerWladorf

    I misspoke if I gave the impression that hospital deliveries meant “…lack of consideration for one’s individual situation…” I believe that every MD obstetrician and every L&D nurse thinks carefully about each patient’s individual situation. I was only talking about the vicissitudes of the institutional environment.

  35. edgar says:

    No,
    Wind ask for reasons, and for different types of knowledge. I gave them to him, to the best of my ability.
    My question to you, Amy, every decision you make as a doc is evidence-based? Every one?

  36. edgar says:

    No,
    Wind ask for reasons, and for different types of knowledge. I gave them to him, to the best of my ability.
    My question to you, Amy, every decision you make as a doc is evidence-based? Every one?

    And there are people, who, believe it or not, are incapable of separating these two spheres. And that is OK, and their prerogative. Kylara, you have never heard of anyone asking a doc to pray with them? What’s the difference, then?

  37. windriven says:

    @ edgar

    Sorry, I don’t know and cannot point to any evidence either way. I am simply going on the assumption that D5W is adequate to the caloric needs of a laboring mother without the potentially negative consequences of food in the stomach.

  38. edgar says:

    SO then,
    I think the ones that are pushing for removing NPO are using the following logic:

    “A crash is rare. A crash calling for a general is rarer, Aspiration under the rare crash necessitating a rare general is not common, And if I do aspirate, death is rare under the rare crach calling for the rare general and anyway, what do they do during emergency unplanned surgeries, can’t they do that?”
    It seems logical in the absence of hard numbers (which most people do not look at anyway).

  39. windriven says:

    @Kylara

    Can you explain ‘transcendent knowledge?’ How does transcendent knowledge differ from ordinary knowledge. How does transcendent knowledge differ from transcendent belief?

    And thanks for the insights into HBers. I have met some, also generally unsophisticated people, who eschew any responsibility for their own health deferring any and all decisions the their physicians. Apparently some HBers take the opposite track, trying to take complete responsibility despite not necessarily having the appropriate tools to do that.

  40. Harriet Hall says:

    Amy has never suggested that every decision obstetricians make is evidence based. Her point is that scientific obstetrics values evidence and tries to implement it whenever possible, whereas some midwives have a completely different approach that values personal experience and ideology over the scientific method. The midwives I worked with in the Air Force were firmly on the scientific bandwagon, but it appears that other midwives operate from a different paradigm. The idea of “calling the woman back to her body” is sheer poppycock and can only delay appropriate treatment.

  41. Calli Arcale says:

    Edgar

    So all obstetrical practices are evidenced based? C’mon, Amy, you know better than to make that assertation.

    Not to speak for Amy, but my perception is that one of the big problems in obstetrics (whether the mainstream kind that is an actual accepted medical specialty or the spectrum of practices that fall under the rubric of “midwifery”) is that much of it is not based on evidence. Much of, across the board, whether MD or not, hospital or home, it is cargo cult science — it is how it has been done, and we don’t have a good reason to turn away, and we are dearly afraid of losing mothers and babies. One can argue about how much of it is cargo cult in which setting, of course, but there is some even in the hospital setting.

    Some of this is unavoidable. There is a limit to the kinds of scientific research that can be used to evaluate various practices when you cannot contemplate the idea of allowing babies and/or mothers to die or suffer serious complications. So barring the advent of another Nazi regime, willing to conduct that sort of research, we have to make do with other, less rigorous forms of evidence. And more often than we’d like, doctors/nurses/midwives/EMTs/etc have to make rapid decisions when they don’t have much data to go on.

    I don’t think Amy would deny that there are practices within mainstream obstetrics which are not entirely evidence based. The problem isn’t that. The problem is that there is a homebirth/midwifery movement which seems to be responding to that deficiency by celebrating it. If c-sections are sometimes done when they don’t need to be, it doesn’t mean it’s a good idea to give birth in a wading pool. Yet most of the evidence in favor of home birth seems to consist of pointing at problems in hospital births. What’s more, just because it’s not easy to know the right thing to do doesn’t mean we should give up. Just because it’s hard to choose the best way doesn’t mean we should consider all “ways of knowing” as equivalent.

  42. Calli Arcale says:

    windriven:

    Sorry, I don’t know and cannot point to any evidence either way. I am simply going on the assumption that D5W is adequate to the caloric needs of a laboring mother without the potentially negative consequences of food in the stomach.

    It is, but there are adverse effects associated with intravenous nutrition too. Edema, in particular; you get bloated. And it’s not fun to have a growly stomach.

    Some hospitals are starting to allow laboring patients to eat at least a limited diet, depending on the circumstance. It will be interesting to see if any useful data comes out of that. The thinking is also beginning to change about food after surgery, so this is an area where the answers aren’t entirely clear and doctors/midwives/etc have to do their best. I can certainly see a hospital not wanting to allow a patient to eat if there is any chance of having to intubate them (e.g. for emergency c-section). And at present, there is really no way for hospitals to know for sure that a particular laboring patient *won’t* need a c-section.

  43. Calli Arcale says:

    windriven:

    Sorry, I don’t know and cannot point to any evidence either way. I am simply going on the assumption that D5W is adequate to the caloric needs of a laboring mother without the potentially negative consequences of food in the stomach.

    It is, but there are adverse effects associated with intravenous nutrition too. Edema, in particular; you get bloated. And it’s not fun to have a growly stomach.

    Some hospitals are starting to allow laboring patients to eat at least a limited diet, depending on the circumstance. It will be interesting to see if any useful data comes out of that. The thinking is also beginning to change about food after surgery, so this is an area where the answers aren’t entirely clear and doctors/midwives/etc have to do their best. I can certainly see a hospital not wanting to allow a patient to eat if there is any chance of having to intubate them (e.g. for emergency c-section). And at present, there is really no way for hospitals to know for sure that a particular laboring patient *won’t* need a c-section. Their practice doesn’t revolve around limiting a patient’s options ahead of time.

  44. edgar says:

    SO then,
    I think the ones that are pushing for removing NPO are using the following logic:

    “A crash is rare. A crash calling for a general is rarer, Aspiration under the rare crash necessitating a rare general is not common, And if I do aspirate, death is rare under the rare crash calling for the rare general and anyway, what do they do during emergency unplanned surgeries, can’t they do that?”
    It seems logical in the absence of hard numbers (which most people do not look at anyway).

  45. edgar says:

    “. Her point is that scientific obstetrics values evidence and tries to implement it whenever possible, whereas some midwives have a completely different approach that values personal experience and ideology over the scientific method.”

    This makes no sense, you are saying the practice of scientific obstetrics as compared to some midwives.

    What kind of a comparison is this?

  46. galway says:

    If I may:

    Did anybody see the study posted in the BMJ?

    “Dr Geraldine O’Sullivan from the Department of Anaesthesia, St Thomas’ Hospital, and colleagues from King’s College London and the Guys’ and St Thomas NHS Foundation Trust, carried out this research.

    The study was funded by a grant from the Obstetric Anaesthetists’ Association and the Special Trustees of the St Thomas’ Hospital. One of the authors was also supported by Tommy’s, the baby charity.
    It was a randomized controlled trial designed to investigate whether eating during labor has any effect on labor and birth outcomes.
    Between June 2001 and April 2006, researchers recruited 2,426 women who were at the end of their first pregnancy. All women were over 18, non-diabetic, had had an uncomplicated pregnancy, were more than 36 weeks pregnant with a single baby, and were currently in labour with cervical dilation of less than 6cm. Women having induced labour were also included. Women who had medical or pregnancy complications that could increase the risk of operative delivery were excluded, as were those who were in severe pain or intended to use intravenous or intramuscular opioid analgesia during delivery”

    The authors conclude that their study demonstrates that a light diet during labor has no effect on labor and birth outcomes, and neither does it increase the risk of vomiting.
    Essentially, it’s not going to make things better, but it is not going to make things worse.
    Personally, I’d prefer not to have stomach pains in addition to labor pains should I choose no drugs in labor.

    Aside from that, I know of three large studies conducted in the U.S., women who ate freely during labor had no choking problems. In 78,000 cases, not a single case of aspiration occurred.
    Frustratingly, I haven’t been able to find the specific studies for this, but here’s a press release: http://www.riskworld.com/PressRel/2000/PR00a022.htm
    Henci Goer is quoted, which I’m sure Dr. Amy will find issue with.

  47. Harriet Hall says:

    It’s a comparison between a profession that is solidly committed to science and a profession that isn’t. I think that was Amy’s point.

  48. edgar says:

    I would disagree that obstetrics is solidly committed to science. They do things all the time that are not evidence-based. i think this is changing, for all medical practices, though.

    That it is the dominant culture of baby-having does not make it as a profession ‘solidly based in science’ any more than midwifery as a profession NOT being based in science.

  49. windriven says:

    edgar, how can you say that? While obstetrics may not have solid scientific evidence for each and every step in the process it is nonetheless ‘solidly committed to science.’ There is a constant flow of scientific research in every branch of medical science.

    Midwifery simply cannot make that statement and that, I believe, was the entire point of Dr. Tuteur’s post.

  50. annabelle says:

    I read this article with interest but feels a little confused. Having just moved from the UK I’m used to midwife led care in pregnancy unless there are problems at which point the obstetrician steps in (at this point I should also say that unfortunately the two obstetricians I had dealings with were not very forward with informations and very evasive when asked direct questions). It is my understanding that midwives in the UK are medically trained. You can have a home birth and indeed they are getting more popular but most people still choose to give birth in a maternity hospital. The birth will be helped by a midwife unless there are problems and the obstetrician will intervene. From my experience there doesn’t seem to be the opposition obstetrician v midwife mentionned in the article. I don’t understand the focus of all of the OB gyn articles on the blog seem to have a slant on either hyper medicalised birth versus home birth. Why does it have to black and white? In the US can you not elect to give birth in a hospital but not have an epidural and be mobile rather than on a bed?
    I agree that everything should be reviewed and policies made based on the strongest evidence but I do not get the constant attacks on the idea of a slightly less medicalised birth… Also looking at the WHO data for neonatal death and maternal death rates bewteen the UK and the US (I think it was 2004 I couldn’t find more recent) they were more or less in the same ballpark (I think 4/1000 for the US and 3/1000 for the UK for neonatal). So surely midwife led care at least in the Uk is doing something right?

  51. “The midwives I worked with in the Air Force were firmly on the scientific bandwagon”

    As were the midwives (CNMs) I worked with during my training and throughout my years of practice. As far as I can tell, this drive to discredit scientific evidence is coming from midwives in the UK and Australia as well as “natural” childbirth educators and advocates.

  52. edgar says:

    Because, as it has been shown, there are many interventions that are used that are not evidence-based, at all. It seems to me as a profession for them to make that claim, they would not continue any practice that is not evidence-based. But they do. And they continue to use practices that are NOT based in science are have proven to be no more effective that alternatives (EFM vs. intermittent auscultation for one), while increasing harm of unnecessary c-sections. I don’t mean to beat up OB, because I think that all medical professionals do this to some degree, midwifery included. But to point fingers and say “you are not science-based, but we are,” is ludicrous, because it just isn’t so.

    I agree that there is research being done in every branch of medicine, and that is important, and that needs to continue, including midwifery practice. That there has been little comparatively within midwifery practice(and there should be more) isn’t any different to me that OB practice using untested methods.

  53. The issue of eating in labor is a good example of how the anti-science paradigm in midwifery works.

    Obstetricians tell women that they can’t eat in labor.

    Therefore, midwives insist that women can and should eat in labor to “keep up their strength.”

    First, the anti-science midwives insist (erroneously) that obstetricians never “tested” restricting food in labor, so they don’t have to adhere to that guideline. At no point, however, do they conduct any research on eating in labor; they simply put it into practice.

    Second, they are shocked to learn that there is copious scientific evidence on the subject of eating in labor, particularly in the anesthesiology literature (midwives, of course, never bothered to look.) It is well known that aspiration is a risk for pregnant women, that pregnant women have delayed gastric emptying, and that an ileus (cessation of gastro-intestinal activity) is common in labor and probably physiologic.

    Third, they claim that “studies show” or will show that eating in labor is beneficial. They are completely unaware that the most recent scientific evidence (in keeping with the older scientific evidence) demonstrates no benefit to eating in labor.

    Finally, they insist that restricting food in labor shows that obstetrics is not based on the scientific evidence, even though it has been based on the evidence all along.

  54. edgar says:

    That is just the issue HB’ers take issue with Amy. In order to have true evidence-based practice and true informed consent , NPO must be agreed to by the patient. But it isn’t.

  55. edgar says:

    What are the risks of eating, crashing, getting general, aspirating, and dying.
    Specifically, how many mother per 1000 die due to this?

  56. “In order to have true evidence-based practice and true informed consent , NPO must be agreed to by the patient. But it isn’t.”

    That’s ridiculous.

    1. One or not the patient gives informed consent tells us nothing about the quality of the evidence.

    2. By your reasoning, all surgery of any kind violates informed consent because patients don’t explicitly and separately consent to being NPO before surgery. Is that really the claim you want to make?

  57. edgar says:

    If it’s an intervention unto itself, that MAY cause harm then it needs consent. According to Cochrane the effects of ketosis are unknown.
    As for a planned surgery no, the risks of aspiration is covered in the surgical informed consent, as is (I hope) the risk reduction strategy (NPO).

    But during labor is different altogether, it is a ‘precaution’ for something that probably won’t happen. It is not your decision to make, its the patient’s. With proper informed consent.

  58. Todd W. says:

    @edgar

    Gotta go with Dr. Tuteur on this one. Whether or not the patient consents to the procedure has no bearing on whether the procedure is science- or evidence-based. Past studies investigating the procedure, on the other hand, make the difference. No past studies, no science-base.

    By your logic, a procedure could have thousands of studies supporting its safety and efficacy, but if the patient doesn’t consent, then it isn’t an evidence-based practice?

  59. rachelleavitt says:

    Just thought all might be interested in this link about NPO during labor….

    http://www.acog.org/from_home/publications/press_releases/nr08-21-09-2.cfm

    If you want more references on NPO status during labor, let me know. I’ll find some for you all.

  60. “As for a planned surgery no, the risks of aspiration is covered in the surgical informed consent”

    I doubt it, since it is an anesthesia complication, not a surgical complication. Similarly, the decision to make labor patients NPO comes from the anesthesiologists, not the obstetricians.

  61. “What are the risks of eating, crashing, getting general, aspirating, and dying.”

    You’ve now shifted the ground for discussion. Instead of claiming that the recommendation to remain NPO during labor is without any basis in science, you’ve acknowledged that there is scientific evidence on the topic and it shows that aspiration is a real risk.

    In fact, aspiration has been identified as one of the leading causes (if not the leading cause) of death in obstetric anesthesia.

    This raises an important philosophical question. The risk of dying from aspiration is higher than the risk of dying from an epidural. So if you think that women should forgo epidurals because of the “risks” and because women don’t “need” pain relief, why aren’t you opposed to eating in labor, since the risks are higher and there is no benefit at all to eating in labor.

  62. rachelleavitt says:

    Amy-our anesthesiologists at the hospital are looking at this right now since ACOG came out with their statement. At two of the hospitals, they already allow women clear liquids and have for a while. At a third one, they are looking more into it. It is up in the air right now.

    I don’t see this as an indictment against the medical community. I see it as a good thing that you can say you were wrong sometimes. I have seen this happen with both midwifes and obstitritions. From my experience working with both, they both equally are stuck to their ways, but they both look for research to improve their practice and change when needed. I do think it is a bit unfair of you to make it seem as if midwifes don’t do this.

    Obviously, there are extremes in both camps. But I think the best care taker is one who is willing to change their minds. And I have seen this done in both camps also. I have also seen some very stubborn doctors and midwifes who refuse to acknowledge that new research suggests other ways to practice. I think it goes both ways.

  63. windriven says:

    “What are the risks of eating, crashing, getting general, aspirating, and dying. Specifically, how many mother per 1000 die due to this?”

    Is one in a million enough? This isn’t a question of a choice between a 1:1000000 chance of dying of starvation vs. a 1:1000000 chance of crashing and subsequently dying of aspiration. It is a choice between a 0:1000000 chance of aspirating and a 1:1000000 chance of aspirating. If you’re that ’1′ it is a life or death decision.

    And before I get beaten to death the numbers that I quoted are entirely a creation of my imagination and have no basis in fact. The numbers, like the not-statistically accurate life/death thing, are intended only as illustrative rhetorical devices.

    The point is we are talking about a spurious choice.

  64. Zoe237 says:

    “As were the midwives (CNMs) I worked with during my training and throughout my years of practice. As far as I can tell, this drive to discredit scientific evidence is coming from midwives in the UK and Australia as well as “natural” childbirth educators and advocates.”

    I am very glad to at least hear you admit that. Yes, there are flaky midwives, for sure. There are also obs who tied women up without informed consent 50 years ago. There are obs today who believe that informed consent is threatening bodily harm to a woman or telling her to shut up. That doesn’t mean that OBs or obstetrics as a whole are evil. Pregnancy and birth, for sexist reasons, have been a battleground for extremists on both sides for a hundred years.

    The discussion about not eating and drinking leading to c-section is interesting, because the avoidance of a 30% c-section rate (and much higher at some hospitals) is the main reason that many women homebirth. Pain medication that is too strong or given too early, inductions, lithotomy position, and CEFM are all routine interventions that have been shown to (at least possibly)increase c-sections.

    I know some people don’t understand why I would rather avoid a c-section if at all possible, but I rather enjoyed going home after 24 hours and back to school at 48. I’m a very active person and hate being bedridden. I’d rather avoid the moderate risk of breathing problems in my newborn and the risk of placenta problems with any future pregnancies. Of course, I would have had one, zero guilt, if it had been shown to be truly necessary (breech, pree, whatever). And of course I’m fine with any woman who would prefer an elective c-section.

    My three pregnancies, three labors, and three recoveries, for me and my children, were without interventions (the only one I can think of is a hep lock), thanks in part to an incredible doctor who believed in evidence based medicine, that positive experiences and healthy babies/moms are not mutually exclusive, and in women’s choices. She also works with amazing midwives who believe the same. While homebirth isn’t something I would do, it is a choice I support fully and understand if a woman has had a previous bad hospital experience or can’t find a good OB. I don’t know any homebirthers who don’t accept the fact that there is a very small possibility that something like amniotic fluid embolus may happen and they may not be able to make it to the hospital in time. There are women who have an elective c-section knowing very well there is a very small possibility the doctors may be unable to stop the bleeding (as possibly happened in the link I posted in the last thread about two friends who both died from c-sections within two weeks of each other, same hospital).

    I also have friends who didn’t interview docs and ended up with c-sections for big baby “diagnosed” via ultrasound who ended up being eight pounds. I have another friend who baby ended up in the NICU from breathing problems as a result of an unnecessary c-section (done at 12 hours after the ob broke her water without permission, even though ACOG gives women something like 36 hours). These women aren’t upset because they missed some experience. They’re upset because they feel like they were tricked and lied to and manipulated by the “dead baby” card that passes for informed consent by some (not all) OBs. I also have a friend who was hospitalized for 12 days because of an incision infection (this was a necessary c-section however, 2nd baby transverse). Of course anecdotes don’t prove anything, but they do show that jackass OBS exist (just like hokey midwives). To villify ALL obs or ALL midwives based on the actions of a few is reprehensible. (And the title of the post makes me slightly suspicious that this is Dr. Tuteur’s goal in life).

    I know for me that I had to interview many doctors to find one who was fine with me eating and drinking in labor, pushing in the position I felt most comfortable, not cutting an episiotomy, and letting my baby nurse right after birth rather than take him to the nursery. I didn’t feel like battling for my rights in the midst of labor pains, and I shouldn’t have to. It’s also almost impossible for a woman to say “don’t cut me!” while she’s crowning. Thank goodness it wasn’t even an issue for me. I got lucky.

  65. ” I see it as a good thing that you can say you were wrong sometimes.”

    Wrong about what? ACOG is still opposed to eating in labor for precisely the reason that I explained.

  66. “there are flaky midwives”

    I suspect that Professors Parratt and Fahy would take exception to your characterization of them as flaky.

    This is not about flaky behavior. This is about attempting to discredit the principle of scientific evidence specifically because the scientific evidence does not support their beliefs. It is a tactic borrowed directly from pseudoscience.

    That’s the real issue, here, and it’s an issue that midwives must address if they expect to be taken seriously.

  67. “manipulated by the “dead baby” card”

    I find that expression a particularly offensive characterization.

    “Natural” childbirth advocates generally lack an understanding of statistics and risk. If they are told that a particular condition increases the risk of neonatal death (postdates, for example) and the baby does not die, they like to pretend that they’ve been misinformed. Rather, they’ve simply misunderstood.

    When a condition “increases the risk of neonatal death” that does not mean that the risk is 100%. It only means that the risk is greater than it would be without the condition. That is an accurate representation of the facts.

    Consider breech vaginal delivery. Breech vaginal delivery increases the risk of neonatal death (from trapped head and asphyxiation). The increased risk of neonatal death is in the range of 6 excess deaths/1000. If you elect to have a vaginal breech delivery and the baby does not die, that does not mean that there was no increased risk.

    Telling women about increased risk is exactly like telling them about the increased risk of letting your infant ride in the car without being in a car seat. Would you boast that you don’t strap your child in and she isn’t dead yet? Would you parade your living child as evidence that people are wrong about the protective effects of carseats? Would you claim that those who warn you to put your infant in a carseat are “playing the dead baby card”?

  68. rachelleavitt says:

    “In fact, aspiration has been identified as one of the leading causes (if not the leading cause) of death in obstetric anesthesia.”

    References please. If this is the case, I find it odd that three of the hospitals I work in find if perfectly acceptable to have at least clear liquids instead of NPO.

  69. Zoe237 says:

    manipulated by the “dead baby” card”

    “I find that expression a particularly offensive characterization.

    “Natural” childbirth advocates generally lack an understanding of statistics and risk. If they are told that a particular condition increases the risk of neonatal death (postdates, for example) and the baby does not die, they like to pretend that they’ve been misinformed. Rather, they’ve simply misunderstood.”

    Why would it be offensive when you just purported that it is *necessary* to use scare tactics with dumb women who don’t understand risk and statistics?

    Breech and postdates weren’t the two examples I gave. *Some* obstetricians are so close to the anecdotes and so bent on proving their necessity in ALL childbirth cases that they make hysterical arguments not proven by research at all. They go against the guidelines of ACOG.

    It’s the same arguments that those heavily involved in mammography are making about the new guidelines… “the USPTSF is going to kill women of breast cancer.” This is an emotional argument, not a scientific one. It also presupposes there are no risks to the alternative, and that mortality is the only thing worth considering. For example, all women should be sectioned at 39 weeks or you’ll kill your baby. These are scare tactics, not science. And it is possible to both overstate and understate risks.

    *Some* midwives can be extreme on that side as well- 43 weeks, or 36 weeks will be just fine at home, e.g.

    Would you support an ob saying “you eat that cracker, you’re going to kill yourself and leave your baby an orphan when I have to section you!”?

    That’s why we need oversight organizations and peer review.

  70. edgar says:

    Amy,
    please show me where I say that NPO is not evidence based? I believe I askeed for over and over again to be shown the numbers, you have not been able to do so. I believe my post to Wind specifically said that I have not seen any numbers to support this.
    Why is it such a problem to ask for hard data? “one of the leading causes’ does not cut it for me, it it shouldn’t be for anyone else who is interested in learning more.

    Wind, no actually, that 1 in a million is not enough for me personally (as a patient as opposed to a policy). But I find it surprising that you use that argument here (preventing one death is enough, when you support the new mammogram recc’s. Which I do as well, but let’s be consistent here).

  71. edgar says:

    Thank you for raising that point, Zoe and Amy, which is the presentation of risk and informed consent to the patient. This is woefully neglected the majority of time I have seen a provider, and I believe it is something all providers (not just midwives Amy) are terrible at doing. Lets take the breech birth example. 6/1000? I will take your word for it.

    “6 out of every thousand breech babies will die. while, x out of 1000 who are not breech will die.”

    “There is a .6% of breech babies will die”

    Or in a fictitiously busy hospital the delivers 1000 breech a week “We see about 1 death a week.”

    And Amy, the dead baby card is a very real feeling. If you find it offensive maybe you should work toward improving informed consent.

  72. edgar says:

    Oops that should read 6 deaths, sorry.

  73. MOI says:

    Interesting but I’m still waiting for you to dispel many of the supposed myths that midwives and homebirth advocates like to shout from the rooftops. To be honest this post is a bit tiring. All you’ve stated is that OBs practice with science based medicine and *some* midwives like to use the word without it really meaning anything to them. Awesome, but how ’bout some examples, please.

    So far you have used this platform only to inform us of the wacky (and sometimes dangerous) culture that is the American Home Birth Movement and the seemingly sub-par training of many midwives.

    This still doesn’t tell me the real risks of an epidural, just what interventions can lead to other inventions (and the risks involved with those), if women really should wait until they are 10cm to push, why we lay down to give birth, if squatting really is better, what the science says about episiotomies, benefits of fetal monitoring, pro vs cons of pitocin and the various other drugs given to women for a variety of reasons, VBACs, ultrasound safety, etc.

    All of your posts have been in the context of the HB movement and mid-wifery. It’s already getting stale. I want information on the science that backs the procedures given to women during prenatal care and delivery. I want to see where there is room for improvement, just what we know and what we don’t know, how to best use the technology available to us (for instance, the “optimal” timeframe to give an epidural), and just what questions women should be asking their OBs/GPs/mid-wives.

  74. MOI says:

    I realize that some in my above list have been covered in part in the comments. I would like a post dedicated to many of these topics. This will provide more time to discuss the topics and it will be much easier to search out the information.

  75. rachelleavitt says:

    “I want information on the science that backs the procedures given to women during prenatal care and delivery. I want to see where there is room for improvement, just what we know and what we don’t know, how to best use the technology available to us (for instance, the “optimal” timeframe to give an epidural), and just what questions women should be asking their OBs/GPs/mid-wives.”

    Agreed!

    And here’s just a few examples that shows that the natural birthing/midwifery community is interested in using research. I don’t know that their research is always sound, but it does show that they understand the need to use it.

    http://www.scienceandsensibility.org/…this is a website that is sponsered by lamaze.
    http://www.awhonn.org/awhonn/…this is a nursing organization that has won awards for the work in research they have done. And a lot of the research is done by….midwifes.

    From this same organization is a wonderful guide to second stage management..http://www.awhonn.org/awhonn/store/productDetail.do?productCode=EML-2

    And yes, it uses research done by midwifes to show that how we currently manage the second stage may not be optimal.

    http://www.awhonn.org/awhonn/content.do?name=03_JournalsPubsResearch/3G2_Mgmtof2ndStageLabor.htm

  76. rachelleavitt says:

    “While obstetrics may not have solid scientific evidence for each and every step in the process it is nonetheless ’solidly committed to science.’ There is a constant flow of scientific research in every branch of medical science.”

    I agree that obstetrics is committed to science. Midwifery, I think is just barely starting to stick their feet in the water. I don’t think this has to do with them not wanting to use science, I think it has to do with the fact that they don’t have the money that medicine does.

    A truly good study takes a lot of money. Midwifery just simply has not had the organization or the money to do many research studies on their own.

    I really haven’t seen any prove of them wanting to outright reject scientific evidence. But this is just speaking of my own experience. I have associated with CNM. DEM, and LDEM’s and I have never seen this. Some are skeptical of obstetrics because of some reasons mentioned above. What I have seen, though, is that they do use or implement different ways of intervening without research to back it up. But, as has also been pointed out before, so has obstetrics.

    Really what is happening, is that this is a clash between two different cultures. Midwifes are not used to having to deal with research and are floundering a little bit(not rejecting it, just not sure how to deal with it). And the medical community is not used to anyone outside their culture, questioning what they are doing.

    But this is all just from my own observations working in the field.

  77. I’m mystified by many of the recent comments.

    This post is about the fact that midwifery professors have ACKNOWLEDGED that the scientific evidence does NOT support their ideological beliefs and DOES support modern obstetrics. Therefore, they are questioning the entire concept of evidence.

    Insisting that the scientific evidence does support your beliefs and claiming that modern obstetrics is not supported by scientific evidence seems to ignore this central reality. Your “leaders” (the professors of midwifery and midwifery theory) admit that the evidence does not support their beliefs. It’s a little late for you to claim that it does.

  78. rachelleavitt says:

    “Insisting that the scientific evidence does support your beliefs and claiming that modern obstetrics is not supported by scientific evidence seems to ignore this central reality. Your “leaders” (the professors of midwifery and midwifery theory) admit that the evidence does not support their beliefs. It’s a little late for you to claim that it does.”

    Amy, I am assuming you are addressing this to me…

    Quite frankly, you don’t know what my personal “believes” are. Nor who my “leaders” are. In my own personal practice, I just want to give the care as supported by research, no matter where it comes from.

  79. rachelleavitt says:

    But maybe it’s not:) So, if it’s not, forget that last comment:)

  80. Joe says:

    @rachelleavitton 11 Dec 2009 at 3:09 pm wrote “Midwifery just simply has not had the organization or the money to do many research studies on their own.”

    So, you think it should proceed as if such knowledge has been acquired? That is nonsense.

    @rachelleavitton 11 Dec 2009 at 3:09 pm wrote “Really what is happening, is that this is a clash between two different cultures.”

    “Cultures”?? Reality is what remains regardless of your beliefs, or your “cultures.”.

    @ rachelleavitton 11 Dec 2009 at 3:22 pm “Quite frankly, you don’t know what my personal “believes” are.”

    Again, your “beliefs” are irrelevant. You may “believe” in the Flying Spaghetti Monster or the Invisible Pink Unicorn; but they are jokes.

    This is how you compare to chiropractors, homeopaths, and “water cure” believers. You have no reliable data, just cult status.

  81. rachelleavitt says:

    Joe- I’m not trying to say that midwives shouldn’t be using research, I’m just trying to explain why they are having a hard time using it. It isn’t in their culture. I;m not even trying to prove anything. Just explaining things as I see it as people did earlier with the mentality of people who choose home births. I think it is becoming more a part of their culture and down the road we may see more research being used by this culture. And I agree, I think your believes are irrellevant. Amy just appeared to think she understood what my believes are when I have stated nothing about that.

    This is where I am coming from as I said before….In my own personal practice, I just want to give the care as supported by research, no matter where it comes from. That’s why I decided to start looking at this website in the first place.

    Do I really need to go into who I am and what my objectives are? That all seems irrelevant, but if you all seem to think that I belong to a cult I’ll tell you. I just think it might bore every one else. So let me know if anyone really wants that info because it appears that some believe that I belong to a cult, that doesn’t believe in scientific evidence.

    So, back to midwifery practices that are researched backed and being implemented due to that research. I will get the research for you if you all want, so let me know about that, but currently these are the practices that are now being instituted in the three hospitals I work at due to research.

    First off, I’ve already mentioned that NPO status is not used at two of them, and is being questioned at a third. Being able to have some form of nutrients has been mostly a midwifery practice.

    Physicians are now being encouraged to institute late cord clamping. This is also something that is considered a midwifery practice(btw, there is a great review on this at this site…www.academicobgyn.com/2009/12/03/delayed-cord-clamping-should-be-standard-practice-in-obstetrics/)

    Early skin to skin is also being taught and encouraged for physicians to implement as long as baby is ok. They are also encouraged to do as much newborn resuscitation on the mom’s belly or chest. This is also considered a midwifery practice.

    Let me be straight before anyone accuses me of being in a cult again. I’m not defending any practices that is held by midwifes that I feel is concerning or against current research. Just to give an idea, I do not hold the believe that we should let women stay pregnant forever. I have seen the research that women over 41-42 weeks have more complications. I do like to follow research.

  82. IndianaFran says:

    “the fact that midwifery criticism of obstetrics as not “evidence based” is turning out to be false.”
    ++++++++++++++++++++++++++++++++++++++

    You have asserted this over and over, without ever actually “showing” that it is true.

    In fact, researchers inside the medical profession are asking many of the same questions that consumers and birth activists have been asking for decades:

    http://jdc.jefferson.edu/cgi/viewcontent.cgi?article=1001&context=obgynfp

    The purpose of this study was to review the American College of Obstetricians and Gynecologists practices
    bulletins to quantify the type of recommendations and references and determining whether there are any
    differences between obstetric and gynecologic bulletins

    Conclusion
    Only 29% of the American College of Obstetricians and Gynecologists recommendations are level A, based
    on good and consistent scientific evidence

    (and the result for the recommendations related only to obstetrics is even worse at 23%)

    http://jdc.jefferson.edu/cgi/viewcontent.cgi?article=1001&context=obgynfp

  83. IndianaFran says:

    “Why don’t you name a practice or practices exclusive to midwifery (as opposed to copied from obstetrics) and present the scientific evidence for it?”
    +++++++++++++++++++++++++++++++++++++++++++

    Continuous support in labor:

    Am J Obstet Gynecol. 1999 May;180(5):1054-9.
    A comparison of intermittent and continuous support during labor: a meta-analysis.

    Scott KD, Berkowitz G, Klaus M.

    Continuous support, when compared with no doula support, was significantly associated with shorter labors (weighted mean difference -1.64 hours, 95% confidence interval -2.3 to -.96) and decreased need for the use of any analgesia (odds ratio.64, 95% confidence interval.49 to.85), oxytocin (odds ratio.29, 95% confidence interval.20 to.40), forceps (odds ratio.43, 95% confidence interval.28 to.65), and cesarean sections (odds ratio.49, 95% confidence interval.37 to.65).

    ++++++++++++++++++++++++++++++++++++++++

    Alternative positions for birth:

    Gupta JK, Hofmeyr GJ, Smyth RMD. Position in the second stage of labour for women without epidural anaesthesia. Cochrane Database of Systematic Reviews 2004, Issue 1. Art. No.: CD002006. DOI: 10.1002/14651858.CD002006.pub2.

    Use of any upright or lateral position, compared with supine or lithotomy positions, was associated with: reduced duration of second stage of labour (9 trials: mean 4.28 minutes, 95% confidence interval (CI) 2.93 to 5.63 minutes) – this was largely due to a considerable reduction in women allocated to the use of the birth cushion; a small reduction in assisted deliveries (19 trials: relative risk (RR) 0.80, 95% CI 0.69 to 0.92); a reduction in episiotomies (12 trials: RR 0.83, 95% CI 0.75 to 0.92); an increase in second degree perineal tears (11 trials: RR 1.23, 95% CI 1.09 to 1.39); increased estimated blood loss greater than 500 ml (11 trials: RR 1.63, 95% CI 1.29 to 2.05); reduced reporting of severe pain during second stage of labour (1 trial: RR 0.73, 95% CI 0.60 to 0.90); fewer abnormal fetal heart rate patterns (1 trial: RR 0.31, 95% CI 0.08 to 0.98).

    +++++++++++++++++++++++++++++++++++++++++

    Skin-to-skin contact:

    Cochrane Database Syst Rev. 2007 Jul 18;(3):CD003519.
    Early skin-to-skin contact for mothers and their healthy newborn infants.

    The intervention may benefit breastfeeding outcomes, early mother-infant attachment, infant crying and cardio-respiratory stability, and has no apparent short or long-term negative effects

    +++++++++++++++++++++++++++++++++++++++++++

    I’m sure that you will argue that these practices are not “exclusive” to midwifery. But they generally developed and spread first through the “alternative” birth practitioners, and were largely resisted (for the most part) by obstetricians and hospital protocols.

  84. “I’m sure that you will argue that these practices are not “exclusive” to midwifery”

    No, I will ask you whether you read these papers in their entirety and reviewed the data to see whether it supports the claims in the abstracts. If you didn’t read the papers, then you don’t know what they said or whether the claims are true.

  85. Joe says:

    rachelleavitt on 11 Dec 2009 at 6:15 pm “Joe- I’m not trying to say that midwives shouldn’t be using research, I’m just trying to explain why they are having a hard time using it.”

    That is the argument of all quackery that I have encountered over 30+ years. “Allow us to practice as if we have evidence because it is so hard to obtain … it’s just fair.” That is just nonsense. Some people still think the Earth is flat, others (notably David Icke) think it is hollow. Should I be “fair” and teach that in science classes? I don’t think so.

  86. IndianaFran says:

    Twice on this thread you have made the same bizarre claim about perverse motivations:

    “In my judgment, one of the hallmarks of midwifery theory is defiance. In many cases, midwives recommend whatever is the opposite of what obstetricians are recommending …………Obstetricians have used immediate cord clamping so midwives recommended delayed cord clamping. ”

    And

    “The issue of eating in labor is a good example of how the anti-science paradigm in midwifery works.
    Obstetricians tell women that they can’t eat in labor.
    Therefore, midwives insist that women can and should eat in labor to “keep up their strength.””

    ++++++++++++++++++++++++++++++++++++++++++++

    This is a totally irrational and ahistorical interpretation of reality. As MDs took over the supervision of birth from traditional midwives, they borrowed and adopted the strategies that worked, discarded others, and eventually grew into a (somewhat) science-based model. As midwifery was reignited in the US during the 60′s and 70′s, they borrowed back and readapted techniques as well. I know that you are aware of Ina Mae Gaskin’s biographical data; she and the original midwives at The Farm were trained by a local doctor. They did not reject all of his techniques, they adopted, modified, and used these techniques, and passed them on to subsequent generations of midwives. And of course in Europe, both medical obstetrics and midwifery matured in parallel across the last couple of centuries, both adopting useful discoveries such as antibiotics and oxytocic agents, with (mostly) mutual respect for their counterparts. Only in Amy’s mind does there exist an incarnation of “midwifery” that is the perfect ideological antimatter to “modern obstetrics.”

    ++++++++++++++++++++++++++++++++++++++++++++

    As far as the two practices mentioned above, the much more understandable reason for midwives’ recommendations in these cases is about the same: they respect normal physiological processes.

    It is reasonable to presume that a normal newborn possesses internal physiological mechanisms to optimize hematological status before the umbilical vessels naturally close. It is reasonable to allow that process to proceed without interruption except when there are signs of abnormality.
    This view is not held only by “irrational” midwives, but an increasing number of mainstream practitioners as well. (I believe someone provided references upstream). I predict that within a decade or so, immediate cord clamping will be seen in much the same way that episiotomy is today.

    As far as eating and drinking in labor, it is reasonable to presume that if a woman is perceiving feelings of hunger or thirst during labor, their physiological meaning is the same as it would be in a non-laboring person: a self-regulating feedback that there is a metabolic need for water and/or calories. In a setting where every laboring woman is assumed to be a pre-operative patient, those needs are allegedly met by a replacement IV fluid (although many women would experientially claim that this substitution is not always adequate). The standard hospital NPO orders may have been science-based fifty years ago, when the use of general anesthesia, inhalation analgesics, and behavior-altering narcotics were common. Here again, as anesthesia methods improve, attitudes are (slowly) changing. It is reassuring that the most current recommendations are taking at least baby steps toward a more humane approach.

    For women who choose to labor in a non-hospital setting, or a hospital where a heplock is an acceptable substitute for an IV, oral hydration and nutrition are simply a practical recognition of normal physiological needs.

    There is absolutely no reason to impute a theory of “naughty defiance” in either case.

  87. IndianaFran says:

    “No, I will ask you whether you read these papers in their entirety and reviewed the data to see whether it supports the claims in the abstracts. If you didn’t read the papers, then you don’t know what they said or whether the claims are true.”

    You asked for
    “Why don’t you name a practice or practices exclusive to midwifery (as opposed to copied from obstetrics) and present the scientific evidence for it?”
    You didn’t ask for a doctoral dissertation.

    If it is hopelessly naive for me to assume that the researchers who publish the Cochrane reviews are doing a fine job of reviewing the original work and summarizing the results, then I plead guilty. But then so would 98% of practicing physicians, who share my judgment of the credibility of this source.

  88. “who share my judgment of the credibility of this source.”

    What do you mean they share your judgment? Anyone with training in science knows that you have to read the paper.

    For example, I just read the doula paper, and it has some very surprising results. For many of the parameters, the control group for the intermittent doula support (in other words, women who had no doula support) had better results than the group that had continuous doula support.

    Moreover, the paper on position in the second stage basically shows that position makes no difference.

    And the paper on skin to skin contact shows nothing.

  89. fitzerald says:

    “It’s a comparison between a profession that is solidly committed to science and a profession that isn’t. I think that was Amy’s point.”

    “Her point is that scientific obstetrics values evidence and tries to implement it whenever possible, whereas some midwives have a completely different approach that values personal experience and ideology over the scientific method.”

    - Harriet

    “This makes no sense, you are saying the practice of scientific obstetrics as compared to some midwives.

    What kind of a comparison is this?” – Edgar

    Well Edgar, it’s pretty clear from all of Amy’s posts that she is comparing certain scientific obstetric practices with certain non-scientific midwifery practices. What kind of a comparison is this? An unfair one, of course! You have to understand that Amy’s motivation is not to discuss the science of common practices during childbirth, but she wants to be the Joseph DeLee of blogosphere (since she’s not actually practicing medicine). Her goal is to discredit the profession of midwifery and all midwives based on certain midwives’ philosophical arguments, while praising a falsely defined “obstetrics” for “being committed to science” despite unscientific practices taking place. In her own blog, she talked about a Dutch study that found no difference between overall expenditure on home births vs. hospital births, and concluded that “if home births aren’t cheaper in Netherlands, they’re not cheaper anywhere.” Why did Amy ignore the obvious reasons why this Dutch study can’t be too generalized? Because her aim was to discredit that American HBers are wrong when they say HB is cheaper for them.

    If you present Amy with studies that show a light diet during labor doesn’t affect the obstetrical outcomes, she’ll argue that a light diet has no value, instead of realizing that a light diet to hungry laboring mothers in absence of definite risks would be comforting. There are subjective outcomes that these studies have not measured, like whether the mom feels better about her labor if she’s allowed to eat. Those feelings are important to many laboring women.

    I don’t know what is wrong with Dr. Hall that she could say this: “It’s a comparison between a profession that is solidly committed to science and a profession that isn’t.”

    Are you kidding me? Have you forgotten that midwives attend the majority of labors in almost all developed countries? Midwives and doctors are both involved in modern obstetrics. Why are you perpetuating this false dichotomy Amy invented between midwifery and obstetrics? Even in America it would be wrong to generalize that way, since midwives have variable training, degrees, and beliefs.

    @ IndianaFan
    “If it is hopelessly naive for me to assume that the researchers who publish the Cochrane reviews are doing a fine job of reviewing the original work and summarizing the results, then I plead guilty. But then so would 98% of practicing physicians, who share my judgment of the credibility of this source.”

    Again, Dr. Tuteur has an agenda. If Cochrane reviews conclude uncertainty about any aspect of birthing midwives tend to use, she’ll interpret that uncertainty as being “proof” that midwives use techniques that don’t work. If, however, the uncertainty is about something specific to obstetrics, she’ll conclude that obstetricians are scientific. And if you remember her previous posts, she’ll critique published studies for various limitations (which is fine), but then use similarly limited data to make her own conclusions.

    I’m not sure why SBM welcomes such unscientific posts, but I guess it’s because Dr. Amy’s unscientific posts valorize the medical profession, and when it comes to that, scientific discussions become less important.

  90. Zoe237 says:

    “Moreover, the paper on position in the second stage basically shows that position makes no difference.

    And the paper on skin to skin contact shows nothing.”

    Well, if you *say* so…

    It must be a giant midwife conspiracy between the Cochrane reviewers AND the BMJ editors lol.

    I wouldn’t bother IndianaFran, there’s no point (although you and Plonit are clearly the most informed about these issues). It’s a circular argument on Dr. Tuteur’s case. Midwives are *part* of obstetrics, unless I missed an exclusivity clause. And they have published research in leading scientific journals.

    Yes, women shouldn’t have skin to skin contact with their newborns, should be flat on their backs for pushing, should have no emotional support, and have immediate cord clamping. All because of your dismissal of research for the oh so scientific reason of “midwives once practiced it.” Seriously, if Dr. Tuteur were still practicing, she’d be an OB straight out of the 70s.

    Here’s an article from QuackWatch on Dr. Tuteur’s silly assertions about cesarean sections, CEFM, and midwives.

    http://www.quackwatch.com/04ConsumerEducation/crhsurgery.html

    ACOGs new position on episiotomy (that midwives have been advocating for for years)

    http://www.guideline.gov/summary/summary.aspx?ss=15&doc_id=10926&nbr=5706#s23

    With that, I’m done. In hopes that SBM will include in the future the views of a more middle of the road, evidence based OB. I’m not sure why the editors here don’t understand why it might be offensive and unscientific to lump midwives in with chiropractors, naturopaths, etc.

  91. Joe says:

    fitzerald on 12 Dec 2009 at 12:38 am “… Well Edgar, it’s pretty clear from all of Amy’s posts that she is comparing certain scientific obstetric practices with certain non-scientific midwifery practices. What kind of a comparison is this? An unfair one, of course!”

    Well, Fitzerald, science is not about “fair.” When you deviate from current, science-based practice you need new facts; not mere argument.

    “@ IndianaFan “If it is hopelessly naive for me to assume that the researchers who publish the Cochrane reviews are doing a fine job of reviewing the original work and summarizing the results, then I plead guilty.”"

    One hopes that is still true for medicine; but their reviews of “alternative medicine” are often performed by incompetent proponents these days.

  92. rachelleavitt says:

    This discussion here has shown that midwifery practices have indeed influenced how obstectics have practiced. Amy has also not provided any conclusive evidence that there is an “assault” on scientific evidence by midwives in general. I find her arguments poorly constructed and they lack scientific evidence. I’m sure you find instances where midwifes disregard science(ie waiting post dates is the major one I can think of) but as has been previously stated here, so do physicians(episiotomies, the use of EFM on every patient).

    If you want to talk about the research surrounding these issues, that’s fine, but that would be best to do in another post. For this post, though, your theories don’t hold up.

  93. Harriet Hall says:

    “women shouldn’t have skin to skin contact with their newborns, should be flat on their backs for pushing, should have no emotional support, and have immediate cord clamping.” Straw man. No one even suggested that, and the evidence doesn’t support it.

  94. rachelleavitt,

    It’s fine if I haven’t convinced you. If you learned something that you didn’t know before, and if the post made you think, I’m satisfied.

  95. rachelleavitt says:

    “It’s fine if I haven’t convinced you. If you learned something that you didn’t know before, and if the post made you think, I’m satisfied”

    Well, I’ll grant you that:) Any post I’ve read of yours has made me think.

  96. IndianaFran says:

    Well, Harriet, if pointing out the straw man argument is your specialty here, what are your feelings about this one:

    “In my judgment, one of the hallmarks of midwifery theory is defiance”

    You have told us that your personal experience includes working with reasonable, well-trained, and competent midwives. Don’t you agree that Amy’s statement above is an unfounded overstatement?

    I think that a reasonable person would agree with the following:
    The practice of mainstream obstetrics includes a mix of procedures and policies that are science-based and customary-tradition-based, with additional limitations based on institutional factors (like nursing ratios and shift changes) and legal considerations (which do not always align with science).

    The practice of midwifery also includes a mix of procedures and policies which are science-based and customary-tradition-based, which are sometimes supplemented (not replaced) by additional factors like religious beliefs and a greater degree of client (rather than patient) autonomy.

    It is true that there are *some* midwives who practice imprudently and stretch the philosophy of normalcy beyond what might be considered reasonable. But it is also true that there are *some* obstetricians whose practices (like routine elective induction, early amniotomy, and routine episiotomy) are not scientifically supported.

    On the whole, as midwifery is actually practiced in the real world, its results are not inferior:

    Hatem M, Sandall J, Devane D, Soltani H, Gates S. Midwife-led versus other models of care for childbearing women. Cochrane Database of Systematic Reviews 2008, Issue 4. Art. No.: CD004667. DOI: 10.1002/14651858.CD004667.pub2.

    Midwife-led versus other models of care for childbearing women

    “Midwife-led care confers benefits for pregnant women and their babies and is recommended.”

  97. “Midwife-led versus other models of care for childbearing women.”

    I know I sound like a broken record, but you have to read the paper in order to know what it says.

    That paper is NOT about midwife care vs. physician care. The study compared midwifery-LED team care with other forms of team care.

    This paper is instructive on two levels. First, it is an excellent example of why systematic reviews are NOT the gold standard of scientific evidence. Second, it shows how midwifery and “natural” childbirth advocates don’t bother to read the scientific papers they cite, don’t understand what they say, and promptly disseminate misinformation to others.

    First, let’s look at what the study was trying to investigate. According to the authors:

    “Midwife-led care has been defined as care where “the midwife is the lead professional in the planning, organisation and delivery of care given to a woman from initial booking to the postnatal period”. Some antenatal and/or intrapartum and/or postpartum care may be provided in consultation with medical staff as appropriate. Within these models, midwives are … the lead professional …”

    Here’s how the authors describe the other models of care that served as the comparison group:

    “Care is often shared by family doctors and midwives, by obstetricians and midwives, or by providers from all three groups. In some countries … the midwifery scope of practice is limited to the care of women experiencing uncomplicated pregnancies, while in other countries … midwives provide care to women who experience medical and obstetric complications in collaboration with medical colleagues. In addition, maternity care in some countries … is predominantly provided by a midwife but is obstetrician-led, in that the midwife might provide the actual care, but the obstetrician assumes responsibility for the care provided to the woman throughout her pregnancy, intrapartum and postpartum periods.”

    In other words, this study compared two different MODELS of team care. This study did not compare midwife care to doctor care. Virtually every woman in both arms of the study was cared for by midwives AND doctors. The study only looked at the role of the midwife within the team.

    Let’s look at the problems within the study itself. As I mentioned above, systematic reviews are not the gold standard of scientific evidence. That’s because they depend entirely on what studies are included, and which are excluded. How did the authors determine which studies to include in this review?

    “Our search strategy identified … 31 studies for potential inclusion. Of those, we included 11 trials involving 12,276 randomised women in total … Included studies were conducted in the public health systems in Australia, Canada, New Zealand and the United Kingdom with variations in model of care, risk status of participating women and practice settings…

    Seven studies compared a midwife-led model of care to a shared model of care, three studies compared a midwife-led model of care to medical-led models of care and one study compared midwife-led care with various options of standard care including medical-led care and shared care.”

    Note that not a single study compared midwife care with doctor care.

    How did the authors decide that only 11 of the 31 studies should be included, and the other 20 excluded? The authors never say. This review contains 130 pages of text and tables, and as far as I can determine, the authors offer no justification or even explanation for their decision to use only 11 of the 31 studies. It seems that they simply picked the studies they liked and excluded the ones they didn’t like.

    I’m rather surprised that the editors of the Cochrane Review were willing to accept this review. It conclusions are essentially useless because studies were included and excluded on an arbitrary basis, and the 11 studies that were included had wide variations in the comparison group. So this study tells us nothing about anything.

    The bottom line is that is a poorly done study that is designed to compare midwife led team care with other forms of team care. Did it show that midwife-led care is superior to other forms of team care? The authors think that it did, but that may be simply because the data selection was biased.

    One point, though, is undeniable. The study NEVER compared midwife care to doctor care. Therefore, midwifery advocates who use the study to show that midwife care is superior are only demonstrating that they never even bothered to read the study.

  98. IndianaFran says:

    “I know I sound like a broken record”

    Actually, you sound like a person whose mind is made up, who picks and chooses what items meet your standards of “scientific evidence” based on whether or not they meet your own ideology.

    In other words, you sound just like the caricature of midwifery researchers whose approach to evidence-based practice that you initially chose to criticize.

  99. IndianaFran says:

    It’s interesting that you seem to have overlooked or chosen not to respond to this paper:

    http://jdc.jefferson.edu/cgi/viewcontent.cgi?article=1001&context=obgynfp

    Conclusion
    Only 29% of the American College of Obstetricians and Gynecologists recommendations are level A, based
    on good and consistent scientific evidence

    (and the result for the recommendations related only to obstetrics is even worse at 23%)

  100. Plonit says:

    How did the authors decide that only 11 of the 31 studies should be included, and the other 20 excluded? The authors never say.

    ++++++++++++++

    Actually, the authors do set out their reasons for excluding 20 studies in the characteristics of excluded studies, and they boil down to:

    * Not RCTs

    * Not designed to address the comparison of midwifery-led vs. shared or physician-led care (e.g. comparing setting as a surrogate for lead professional)

    * Not addressed to the entirety of care (antenatal, intrapartum, postnatal) but to only one element (some just address intrapartum and some just address antenatal).

    It is normal in any meta-analysis to exclude studies that do not address the research question of the meta-analysis. The alternative is hopeless heterogeneity, attempting to smoosh together studies that address cognate but different questions. It is obvious that if you do a search in the literature on a number of terms you will find many studies which on closer inspection do not address the question you set out to answer.

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