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107 thoughts on “Midwives and the assault on scientific evidence

  1. pmoran says:

    Amy, I also see no problems with the format of the Cochrane systematic review, and the licensed midwives involved in those studies are entitled to be proud of their work.

    There are still some questions. All these studies were carried out within the PUBLIC hospital systems of Australia, Canada, New Zealand and the United Kingdom. It is not at all clear what what “non-midwife-led” care consisted of this environment, but it would seem able to include any kind of less organized, less continuous form of care with diffusion of responsibilities, potentially biasing this group towards unfavorable outcomes in some respects. We would need to examine the studies in detail to be sure that one group was also not exposed to less experienced obstetric care in some public hospitals (all births were hospital-based).

    The study thus does not even reflect outcomes within the usual patterns of PRIVATE obstetric care in those countries. For all I know that care may be even MORE interventional during labour, but the point is that these results cannot be easily applied to different systems and different countries.

  2. “Actually, the authors do set out their reasons for excluding 20 studies in the characteristics of excluded studies”

    I understand the criteria they used. For example, I know that they excluded studies that didn’t investigate antenatal care. What I don’t understand is why they chose those specific criteria. After all, the 11 studies included were very different from each other in important ways, yet they decided to lump those together.

    Why, for example, did they include studies from different countries whose system are not comparable? They could have used that as an exclusion criterion, yet they chose not to do so.

  3. Plonit says:

    Why, for example, did they include studies from different countries whose system are not comparable?

    +++++++++++

    Because it is a systematic review, and they felt that the basic question that interested them (concerning the outcomes of midwifery-led care – i.e. midwives as primary care professional for pregnant women) had been ‘tested’ in a variety of different systems – all of which were relevant to the basic question.

  4. David Gorski says:

    Why, for example, did they include studies from different countries whose system are not comparable? They could have used that as an exclusion criterion, yet they chose not to do so.

    This isn’t really a particularly good objection to the study. It’s a systematic review. When doing a systematic review you go with the literature that is available; sometimes that means including studies that may not be as clearly comparable as you would like. It’s always a balance between being inclusive and limiting heterogeneity of studies. If the investigators had decided to exclude studies from different countries, that would have opened up a whole new can of worms as far as interpretation goes. Moreover, study design is more important in constructing inclusion and exclusion criteria than study characteristics like this. Other than that, Plonit’s comment is correct regarding meta-analyses and systematic reviews. It is normal in any meta-analysis to exclude studies that do not address the research question of the meta-analysis or systematic review.

    I frequently criticize meta-analyses myself (in fact, my post on Monday will do just that for a specific meta-analysis–how’s that for a shameless plug?), but your complaint in this instance strikes me as off base.

  5. MOI says:

    rachelleavitt – “If you want to talk about the research surrounding these issues, that’s fine, but that would be best to do in another post.”

    I can’t wait!!!!!!!!!!!

  6. Bevans says:

    I’d love to see an overview of the techniques of midwives and obstetricians, and which are and aren’t supported by evidence, because I know almost nothing about these subjects.

    I don’t have to worry about it yet myself, but I do have a few friends now who are, and they tend to lean toward “alternative” treatments often, so it’d be great to have a guide to refer them to.

  7. franny234 says:

    I stumbled across this post and hope that I can make some thoughtful remarks. I had a homebirth and perhaps can offer a perspective there. Please note that I am (almost!) a scientist, so I am familiar with research and analysis. I am almost obsessive in this pursuit, actually. I chose to have a home birth with my daughter, and it was based on a very reasoned decision process, not anything “whoo-ey”.
    First, I live in a rural area with an abysmal hospital. Although they won’t release the C-section rate, nurses I and other mothers spoke to estimate it at higher than 40%. This is a hospital with such high rates of MRSA infection it has made the news. So right there, if you’re a women with no health issues and a perfectly progressing pregnancy (as I was), it seems ridiculous not to at least explore birth alternatives. I decided to work with a midwife alongside of an OB, in order to help me make my birth decision as my pregnancy progressed.

    I was unable to find an OB who would take me, because we have such a dearth of MDs in our area (not uncommon in rural parts of the US), so I was assigned an OB by my insurance. The experience was horrible. The doctor (or any assistant in his office) failed to spend more than 5 minutes with me at any appointment. There were lots of little issues I had with his “care” but the main driver in my decision to step away from the “medical model” came when he misread ultrasound results, told us our baby was horribly brain-damaged and asked if we wanted to terminate the pregnancy (all in the space of 5 minutes). My husband told him we needed more information and he referred us to a specialist. We spent 3 horrible weeks waiting to see the specialist…who reiterated the assessment of the ultrasound our midwife had given (totally different – and nothing to worry about).

    My midwife was completely different. She spent an hour with me at every appointment, discussed exercise, my diet, my general well-being, my mental state. I never waited more than 5 minutes in her waiting room. She gave me 4 phone numbers to reach her any hour of the day – no “here’s the 7 possible people who might attend your birth” kind of thing. During the home birth, she was there for over 10 hours, right by my side, talking to me, focusing only on me. She was calm and encouraging. She did follow up appointments at my home and her check-ups included looking for signs of post-partum depression. The total cost was under $2500 (which we gladly paid out of pocket).

    I know I would never have gotten this treatment from a “traditional” OB/hospital birth, at least not in my area. The ten or so friends I know who have had home births regard their birth experiences with pride, fondness, and joy. Those who have had traditional hospital births generally speak of the things that were “done” to them, instead of the thing they did. I had friends who got pregnant without insurance. The hospital gave them a sheet of the charges they would likely incur, assuming the birth went smoothly. When my friends told them they had no insurance, the staff told them oh! then you don’t need all this stuff,and crossed off a bunch of “medical treatments” off the list to reduce the cost by thousands (still in the $6000 range.) That’s a real ding in the confidence meter for me.

    Having said all this, I am also aware that there are some really unqualified women out there practicing midwidfery. There is a certain “hippie” population where I live and I have heard of so-called midwives allowing their patients to give birth in the ocean, on the beach, siting around chanting, etc. I would bet that this faction contributes to those numbers listed by the CDC. But for a competent, medically trained, experienced midwife- who actually remembered my husband’s name!- to attend my birth was much preferable to me than the situation the medical field in this country pushes. I think the issue should not be home birth vs. hospital or midwife vs. OB, but rather making sure that practicing midwives are trained, licensed, and competent. the health care system is such a mess, it seems logical to me that it would take a lot of burden off strained MDs and hospitals to allow women in low-risk situations to birth at home with qualified attendants.

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