[Editor's note: This is a guest contribution about the concurrent session at the Normal Labour & Birth International Research Conference titled Assessing Interactions Between Culture and Choice. Priscilla Hall (a second year PhD student at Emory University Woodruff School of Nursing), Esther Shoemaker (a first year PhD student in the Population Health program at the University of Ottawa), and Kathrin Stoll (doctoral fellow at the Centre for Rural Health Research) each presented their research. - AMR]
Thank you Amy and readers for allowing me the great opportunity of contributing my conference analysis to Science & Sensibility.
At no other conference has choosing between concurrent sessions been so difficult. However, from the moment the schedule was posted some weeks ago I knew there was one I had to attend. Assessing Interactions Between Culture & Choice focused on today’s generation of mothers and what shapes their perceptions, experience and consequently choices about birth.
Generation Y women are today’s young mothers and will make up the bulk of midwives’ clients in the approaching years. What shapes their perspectives on pregnancy and birth? And how will their expectations impact the way they choose to give birth?
Demographics and Influences
Generation Y is loosely made up of adults born between the mid 1980s and the mid 1990s In the conference session, we reflected on what influences this generation of women:
1. This generation is extremely comfortable with technology, having craved the “toys that make the noise” including Nintendo/Sega/Xbox game consoles, mini laptops and iPods. The toys of this generation often involve one-on-one interactions with a computer rather than a friend.
2. The “Audit Society” (Power 1997) is the norm for this generation. The 1980s saw an explosion of auditing activity in UK and American society. Teachers chart performance and activities of students, employees audited their own activities for their employers and health workers began recording up to the minute activities of their patients and one another.
3. To this generation “the most desirable women aren’t women at all – they’re girls.” The womanly shape, once held in esteem by the Greeks all the way up to pre-Twiggy models is seen as overweight to this generation. Smaller frames, straight figures and other pre-pubescent qualities are idealized by Generation Y women (or at least the media they consume). Not ironically, Gen Y has also been referred to as the Peter Pan Generation.
The first two in this hardly exhaustive list of predictors can help to explain how medicalized birth is quickly being assumed as the norm by today’s women. (And as Dr. Eugene Declercq of Boston University pointed out over lunch, the majority of U.S. women are satisfied with their maternity care.) In fact, as UBC doctoral candidate Esther Shoemaker points out from her mixed methods research of young women and new mothers, “Natural” birth to them does not equal “Normal” to us. Natural birth, to most of the women in her study, is synonymous with vaginal birth. Even if labor was induced, an epidural administered or forceps used, the women who gave birth vaginally experienced their birth as natural. I have witnessed this in my own Generation Y peer group of young mothers.
Further, the majority of those Shoemaker interviewed desired a vaginal birth in their antepartum interview, but also voiced an ambivalence about whether or not they actually would give birth that way when the time came. “If something happens I of course will have a c-section.” Oddly enough, perception of safety was not mentioned but the women said they would default to whatever their individual practitioner suggested.
In some cases reported, the practitioner suggested procedures to the Shoemaker participants that increased the degree of medicalized beyond what they expected for their birth. When this occurred, each of the participants changed their plans for their second birth. They either embraced the medical model completely or rejected the medical model in favor of a physiologic birth. So while they were ambivalent or passive first time mothers, they actively created their birth plans for subsequent children. The finding has important implications for today’s mothers as this was true for all Shoemakers’ participant’s whose birth experience was more medicalized than her birth expectation.
Intriguing findings in the studies:
1. Birth, to this generation, is, as UBC scholar Kathrin Stoll points out, a normal physiological process (71%), inherently risky and filled with “unavoidable complications” which necessitate technological interventions.
2. Of the women Stoll interviewed, 70% worried about how they and/or their partners would perceive their bodies during and after pregnancy.
3. According to Shoemaker, who studied what happened in subsequent births among women whose first births were more medicalized than expected, one of two extremes were common. The women would either fully embrace the medical model (e.g., plan a c-section with all the bells and whistles) or she planned to birth at home with no interventions.
The findings of this session’s speakers are all interesting and important for us as midwives, childbirth educators, and activists. When shaping our message about normal birth it is important to meet women where they are, use their language and respect their experience of the world and their bodies. How will we “market” normal birth as we are privileged to know it to the coming mothers?
About Katie Fulmer:
Like many of you, I have birth on the brain and care deeply about the health and wellbeing of our mommas. I am currently a student midwife with Illysa Foster, author of Professional Ethics in Midwifery Practice. My academic focus was Medical Anthropology as an undergrad at the University of Texas in Austin and I look forward to continuing my study of maternity and child care at the PhD level.
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Sign in nowAmy, that was officially the weirdest reply ever. I kind of enjoyed it’s uniqueness, though.
You: This conference has an ideological bias. Amy needs to go to conferences that do not have an ideological bias.
Me: Link to a conference about childbirth without an ideological bias.
You: ??? and no link to a conference without an ideological bias.
Me: *yawn*
“It seems to me that a “mainstream” conference would likely present only one side of the issue as well.”
I’ve been to quite a few conferences and I can assure you that is not the case. There are controversies in obstetrics just like there are controversies in any area of science. To understand what the evidence shows, you need to learn about ALL the evidence, not just the evidence you like. You can’t learn about the evidence for evolution by attending a creationism conference and you can’t learn about the evidence for modern obstetrics by attending a “normal” birth conference. You must also attend conferences that present points of view other than your own.
Or it would be like going to med school and becoming an obstetrician and thinking you know everything you need to know about birth! See — I can do it too!
Hi Amy (Romano, as opposed to A.T.),
[New thread here, since I don't want to play tag with Tuteur]:
Thanks so much for getting this info to Gene so he could talk about it and let me express much gratitude to Gene also. You are absolutely right — the internet and social media is the way people connect to each other and gain much of their information today — including women of childbearing age and the young women who will be the next generation of mothers. That’s why Amy T. lurks on the internet — so she can pop out every now and then to yell something that sounds scary to consumers.
So, as I understand it, if consumer demand is what it will take to change things, then our job is to educate consumers. And the way to educate consumers is through social media.
Look for an email from me in the next hour or so on some interesting ideas that I don’t necessarily want to share with Dr. T.
Thanks Amy Romano for spreading the news. We need to be aware of the global struggles in protecting normal birth, especially within societies that we glorify or exoticize for their dedication to physiologic, woman-centered birth.
“Evidence is not driving practice.”
Right. And I don’t even think ACOG’s latest flip-flop will have much of a trickle down effect, at least not any time soon. History has demonstrated that OBs do not generally budge from their comfort level. If ACOG wants to construct its authority over childbirth based on the “evidence” it generates, it needs to walk the talk.
What percentage of procedures, medications, and interventions in typical hospital births are truly evidence-based?
You are so right about that black hole between evidence and practice, and money and power seem to rise to the top. Only when we remove those elements from the equation will we see demonstrable birth change within the hospital system.
Well, it’s been a couple of months on the pill. Some side effects, but still pain. Having a laparoscopy in a couple of weeks.
Thanks, Amy! That’s excellent news from the conference–It’s sobering (I couldn’t help it, with all the cocktail talk!) to hear about the challenges in the Netherlands, but I am hopeful that all of the energy building from consumers who are tired of being afraid and from researchers who are getting mainstream attention will continue gaining momentum and finally get ALL women the safe and satisfying pregnancies and births they deserve.
“Science does contribute to policy and practice but the link is neither consensual, graceful, or self evident.
Love that tweet.
@Henci Goer
Thanks, Henci, for this list. Anyone who believes that “obstetricians follow the evidence” should do an environmental scan of practices across the country (even Canada) to see the wide variation in routine practices that exists. If they are all following the evidence, why is this so?
An analogue between physiologic birth and creationism is odd, indeed, as it implies that the former doesn’t really exist. As for the purpose of the conference, there is little money to be made from physiologic birth, and it’s hard to get funding for research from which there is little financial gain. I go to obstetrical conferences, too, and although there is some useful learning and research presented there which I appreciate, there are also “research” presentations from industry which has the sole purpose of promoting the product. Follow the money….
[...] danger. And the one that has been challenged by the American College of Nurse-Midwives and disputed all over the [...]
Thanks for a great article… I have often found this discrepancy between natural childbirth and what most women perceive to be natural childbirth puzzling.
Putting this in next week’s Sunday Surf
Thanks for the update. We’re pulling for you. Please keep us posted.
Katie,
Great post, Katie. Meeting your patients/clients where they’re at is so important–as is understanding how to teach to their sensibilities, biases, preferences and tendancies. I really do think this population–Gen Y moms–presents a challenge…the same challenge I am perceiving in the San Francisco Bay area where we’re currently living: folks who are intimately familiar with technology and who employ it in many ways throughout their daily lives will require extra creativity and evidence-based teaching on our part when it comes to promoting normal birth.
I think there was a session at the normal birth conference that addressed this issue of vocabulary, and that the use of ‘normal’ or ‘natural’ doesn’t mean the same thing to everyone.
Lamaze conducted a study and found that the words ’safe’ and ‘healthy’ had resonance and meaning that everyone could understand. I also like the word ‘physiological’ because I think it speaks to the intuitive hormonally driven process that is undisturbed birth. A physiological process is not a technical one, and it does not involve technology.
I am slightly older than Gen Y, and was already in university when the Internet and cell phones really got going. I think that while Gen Y women are of course going to be having babies for quite some time in the future, there are also a lot of women having babies right now who are in their 30’s and 40’s, although I don’t know what the actual statistical demographics are. So there is a mix of women who grew up without such a strong connection to technology in their childhood, but who still use computers, the internet, cell phones etc. and Gen Y who have been connected in most of their lives.
I think another aspect of this generation is that there is more awareness and more of a move towards incorporating environmentalism into everyday life, and a sense of the necessity of protecting the earth. So on the one hand there is more pervasive technology and on the other hand there is more of a trend towards green, healthy, and natural solutions. I think that this trend creates opportunity to reach a majority of women in a way that was not possible even 20 years ago, by combining the use of technology for education and the message of a ‘green’ and healthy birth.
While I agree that discouraging breastfeeding at night as a practice is emphatically *not* sound routine advice, I do think it needs to be considered on an individual basis. I personally had extremely severe PPD after my first daughter and I was not getting enough sleep. We co-slept and woke every two hours or more to nurse and my husband and I remember it as some of the worst time of our lives. I don’t have many memories of it because it was such a fog of sleeplessness and mental misery. I believe that my PPD was prolonged many months because it took so long to get to a place where I was able to get deep, healthy sleep. I clearly do not cope well with interrupted sleep and I have noted this even when I do not have a newborn, now that my children are older. My husband does the majority of the nighttime parenting and I have to sleep with earplugs.
When my second daughter was born we created a plan that we put into place when she was two weeks old. From 12 to 5am, my husband was in charge of soothing our baby, whether it was with a bottle of pumped milk or just holding her. This allowed me a period of five hours of sleep and it was just what I needed to cope. My PPD was not as severe and virtually disappeared within a month of birth. I also felt more capable of parenting both of our children during my waking hours.
As a doula, I work with a variety of moms who cope differently with sleep deprivation. I always try to help the families determine whether they are coping or not when they express that they are struggling with sleep after their babies are born. I am so grateful to have many tools to be able to recommend to help each family find their individual solution.
It is so important to not make a mother feel like a failure because she requires the help of a partner to get through difficult nights. While many mothers may enjoy co-sleeping and be able to cope with night wakings, there are many who are not. Telling them they *should* be is not helpful and may set up an adversarial situation with their baby. These moms need good, actionable plans to help them feel healthy and balanced, which is necessary for bonding and recovery.
[...] Kendall-Tackett takes on the question of whether telling women not to breastfeed overnight is good advice in combating postpartum depression on Science & [...]
How a mother nighttime nurses may have an impact too.
With my first she slept in a crib down the hall. She nursed about every 90 minutes for the first 6 months. I would get up (post C-section), walk down the hall, sit in the rocking chair in her room, nurse her, go back to bed, repeat every 90 minutes throughout the night. It was exhausting. For subsequent babies I tried having them in our bed, which didn’t work well as I was concerned about keeping my husband awake or him rolling on the baby or the baby falling off the edge of the bed.. Now my newest baby and I are in a room by ourselves, in a bed by ourselves and I’ve never been so well rested. Of course, that isn’t a possible or desireable solution for everyone but it works great for us. Until this baby, I was doing what I thought I was *supposed* to do (baby in crib in separate room, the ‘family’ bed) but not until I did what *I needed* to do, did things work well.
PS. And yes I had/have PPD/A and the absolute worst bout was when I was co-sleeping (I use that word loosely) on the couch with a newborn and a 3 year old.
[...] you to go to science&sensibility.org to read the factually sound, well-researched article Nighttime Breastfeeding and Maternal Mental Health. [...]
Thank you, Kathleen, for that fascinating information. I want to share it with my doula clients. Looking forward to seeing you this weekend at the DONA conference!
This is fantastic! I am just about to enter my senior year of college, after which I will go through nursing and midwifery school. I am planning to write my senior anthropology thesis on how young women (roughly my age, 18-25) perceive birth and what the media’s influence is in creating a culture of fear surrounding a “normal” birth. Is there someplace where I can view the whole article? So few people have done research on pregnancy and birth in the anthropology field, and I would love to use this article as some of my background research!
I breastfed exclusively all 3 of my children, I had PND with my second but I found that lack of sleep with all 3 was never a problem and all my babies slept in bed with me on my chest that is where they fed fell asleep and where I woke with all 3 of them next morning me on my back them on my chest and never did I ever had a lack of sleep problme
@Vanessa
Hi Vanessa:
Thanks so much for posting about your experiences. I’m really sorry that you had such a difficult time.
I wanted to write back and clarify a couple of points. It’s impossible to say everyone you want in a blog post. But I thought a little more info would be helpful.
My main concern is about blanket advice to new mothers about avoiding nighttime breastfeeding to lower risk of depression. Mothers with depression are frequently told that they need to give supplements. People who recommend this are trying to help. But they are likely making the problem worse because they are further compromising the mother’s sleep. Supplementation and/or avoiding nighttime breastfeeding may be the solution in some cases. But it is not always (or even usually) the answer.
Here are a couple of additional points.
1) My article does not preclude partner help and support at all. That really can be a great solution for women. In fact, in the presentation on this topic, I specifically note that if women are really having a tough time, trying to sleep for a 4-5 hour stretch can make all the difference.
2) I really wasn’t recommending that everyone bedshare. It is the easiest way to continue breastfeeding. But for some women, it is a bit too much. However, a baby alone in another room isn’t a good option either, even according to the AAP. Mainly because it is not safe and increases risk of SIDS. An adjacent sleep surface can be a good alternative.
3) It occurs to me, in reading your post, that depression itself may have had a large hand in your ongoing fatigue and sleeplessness. Unfortunately, depression wreaks havoc on sleep. So even if babycare isn’t an issue, sleep is still very much compromised in depressed people. When depression is treated, sleep tends to improve. While it may have seemed obvious that the baby was causing your sleeplessness, depression probably had a larger role.
In short, taking a thorough history and evaluating the mother’s sleep will likely be more helpful than making a blanket recommendation to avoid nighttime breastfeeding. It might be a case where the mother needs to have treated depression to improve her sleep, rather than eliminating nighttime feedings.
I hope this helps.
Kathy
I’m wearing mine right now. Otherwise, reading this would be impossible with a seven-week-old
All I have to say is if it weren’t for nighttime breastfeeding I would have been walking around like a zombie all day-of course we practice co-sleeping so that might have something to do with it!
Why are these Stanford Researchers ignoring all the studies and efforts of some many including UNICEf into Kangaroo Care – which started in Bogota in 1980’s? And I am disappointed that you did not add a link to one of the Kangaroo Care web sites like that of Nils Bergman in South Africa, especially to counter this unholistic approach to care of prem babies proposed by Stanford!!
I worked in Northern Uganda in a remote place affected by the war with the Lords Resistance Army. The local referral hospital had very limited electricity supply to run its incubators. To help to keep small/premature babies alive, they took them from their mothers and kept them warm with a heat pack. With Dr Nils Bergman’s assistance, I located two professionals who had experience of implementing Kangaroo Mother Care in the African context (one a neonatologist and the other a nurse). An intensive training was organised for the hospital staff, and Ministry of Health personnel also attended. Despite scepticism from some staff (and the organisation I was working for), the technique was implemented immediately in the maternity ward, much to the delight of the mothers and their families. The babies thrived and mortality rates fell to one quarter of the rate before this intervention. To introduce Stanford’s approach is a backward step for developing countries, and for more developed ones, too, for that matter.
I found my night time feedings the most blissful… the house was calm & quite just the baby & I were awake (or rather awake enough to get the feeding done!). I found the day time feedings to be the most stressful… my toddler wanted attention, the dog wanted out, the cat wanted in my lap for pets.
If I had ever considered supplementing my breastfed baby with formula it would have been during the day!
As a vbac mom, the dr. suggested trying cytotec if I do not want to try pitocin, as I am usually overdue with healthy babies. As an informed doula and proactive mom, I was way over stimulated by a very low dose of pitocin during my first vbac. I have every contraindication for use of cytotec and pitocin, and it is still being offered. If I were not informed they would probably just use it. And insurance companies are now being questioned on their ban of vbacs-I am currenty under review for our local hospital. The hospital seems pretty excited about this….
“Obstetricians are following the evidence? Really? Let’s just list a few routinely and commonly used obstetric management practices about which there is NO controversy in the obstetric research that they are ineffective, harmful, and generally both when used routinely or frequently and in some cases, with any use at all:”
Yes, really they are.
Henci, when was the last time anyone asked you to testify about the obstetric evidence in a court room? Never, right? And why is that? Because no one considers you an expert on the obstetric evidence except you.
Where did you get your medical degree? Oh, you don’t have one.
How about your midwifery degree? Don’t have one of those, either.
How about your PhD in a scientific descipline. No, no advanced degree in science.
How about your PhD in statistics? No, no advanced degree in statistics.
You are a woman who teaches childbirth classes who decded to make money by writing a book that grossly distorts the existing scientific research, and often making claims that are flat out false.
Only lay people think you understand the scientific research and that’s because they don’t know any better. No one who knows anything about obstetrics pays any attention to you.
I’m so thankful for ACNM’s bring-your-baby-to-work policy. Babies are allowed to come to work until they are 6 months old. You can bet I’ll be wearing my baby at work for 6 months when my time comes. My boss is doing it now, and it’s working out wonderfully.
Amy Tuteur MD, you have a medical degree, but it doesn’t make you an expert on research and statistics either. When is the last time you attended or presented at a conference, or did any collaboration with peers to improve the state of modern obstetrics and gynecology? Where are your academic journal articles and books that criticize weaknesses and misinformation in research and childbirth publications? When you can muster up more than a collection of scathing and unprofessional blog entries, come back and let us know.
“Amy Tuteur MD, you have a medical degree, but it doesn’t make you an expert on research and statistics either.”
Unlike Henci Goer, I don’t claim to be an expert on research and statistics. I simply claim to be an obstetrician, and it is part of my job to read the obstetric literature.
[...] over on the Science and Sensibility website, there’s a spirited defense of nighttime breastfeeding. The author, psychologist and [...]
This is a beautiful video and so encouraging to see. I agree Stanford’s approach is a backwards step. I’m glad to see baby-wearing picking up a bit in the U.S. We spent a little time in Burkina Faso, and everyone wears their babies there. Sometimes two at a time!
I had not heard of any bring-your-baby-to-work policies. Is this in the U.S.? How exciting! I worked in a daycare prior to my baby’s birth. I was in the infant room, but if I wanted to bring my daughter to the center for care, they would have transferred me to another room so “I wouldn’t show favoritism”. No one is allowed to work in the same room as their children. As such, I quit and now do childcare in my own home.
Thanks for this post!
B said August 4th, 2010 at 10:18 | #19 Reply | Quote Amy Tuteur MD, “you have a medical degree,….”
hey B, Big B that is. You know, as opposed to me, little b. (I think Big B is my evil twin http://childbirthtruthsquad.wordpress.com/2010/08/04/the-evil-twin-or-is-it-twin-small-t/
When was the last time you attended or presented at a genuine medical conference? Where are yours or Romano’s or anyone on the midwifery side’s great claims to a research background? Since she deletes all the criticism that shows she doesn’t know what she is talking about, it might be hard to tell. http://childbirthtruthsquad.wordpress.com/2010/07/21/things-amy-romano-of-science-fiction-and-sensibility-doesn%e2%80%99t-want-you-to-read/
Pulling out a Research For Dummies book from the Borders isn’t a ringing endorsement.
PS trying googling Amy Romano and Delete. In fact, if one googles her name or the name of this blog it is trending high.
I love wearing my daughter. It just seems so natural. I hardly ever see people in my area wearing babies- if anyone does it’s the dads with the Baby Bjorn carriers. Mothers always have strollers. Yet, I always get positive comments from people when I have on my mei tai or sling. I hope that more people will see how good it is for mom and babies to be close, and also convenient for parents who actually want to do things when their babies are tiny! I don’t know how I would have gotten laundry done without my carriers. And they are SO NICE for breastfeeding!
@Amy Tuteur, MD
Amy, is that really the best you can do to rebut Henci’s arguments?
http://www.nizkor.org/features/fallacies/ad-hominem.html
It makes sense to me that breastfeeding mothers *in general* get more sleep than bottle-feeding mothers *in general*, but only because I suspect that neither group of mothers gets much help in the nighttime feeding department. I didn’t see any of these studies (e.g. Quillin and Glenn) address WHO was doing the bottle feeding. As someone who has exclusively breastfed two children, I can see that if *I* were the one handling bottle-feeding at night, I would indeed get less sleep, because it would take longer to prepare a bottle than to breastfeed. However, bottle feeding would have allowed my husband to do night feedings, and that, I think, would have made a huge difference.
My mother, for example, bottle-fed me, and she and my father traded nights “on duty” — meaning that EVERY OTHER NIGHT she got a full night’s sleep. Compare that with my going many, many months before having a night of uninterrupted sleep. I say this as a committed breastfeeder: getting a full night’s sleep even once a week would have helped my mental health tremendously. With both my children, the fog lifted once they started sleeping through the night; I became happier, more patient, more energetic, less anxious, and overall a better mother.
For all these reasons, I find it frustrating to see this research summarized as “Breastfeeding mothers are less tired and get more sleep than their formula- or mixed-feeding counterparts.” First, could you at least say “tend to be” rather than “are”? And second, how could I possibly be more tired if I were getting to sleep soundly all night long while my husband was formula-feeding our child? The potential participation of the mother’s partner/helpers doesn’t seem to be acknowledged here.
Again, I say this as a breastfeeding advocate who has exclusively breastfed two children (and is still breastfeeding the younger of the two). I think breastfeeding is great, but in some cases I think we oversell it, to the detriment of our credibility. I know I get less sleep this way, and it’s still the choice I made and would make again.
My one and a half years old is snuggled into the improvised sling (blanket) sleeping. It’s sooo sweet
And Dr. Tuteur, reading the literature is not your job, it is your hobby, since you are a long-retired ob-gyn (who had what, only 6 years of experience before retiring?) who doesn’t teach or research. Perhaps you call blogging your profession now, but it conveniently relieves you from having any accountability with any medical boards or education/organization affiliations.
And you don’t think that a birth educator is capable of reading and understanding obstetric literature? Michaela and Augusto Odone had no medical or scientific background, but they studied and developed a useful treatment for ALD with the help of medical professionals that respected them and didn’t treat them like morons.
So, if you want to criticize Henci Goer’s assertions, then go ahead and show the data to prove her wrong, but you don’t have much of a leg to stand on if you want to squabble about credibility.
And little b, you and Dr. Tuteur enjoy treating NCB activists like morons. Despite your attitude, I agree with you that it isn’t right for NCB advocates to delete criticisms that they don’t like. They should present the counter arguments and hold their position backed by their evidence.
@b
I wrote a comment on your blog, which funnily enough is awaiting moderation. Nice conspiracy theory, but I’ve been posting as “B” for a long time on other birth blogs. Check and you will see.
Good Lord! The American Congress of Obstetricians and Gynecologists, the U.S. ob/gyn’s professional organization, is not known for publishing anything that would cramp the style of their members, but even they have a Committee Opinion going back to 1999 recommending against its use in women with previous cesareans because of the danger of scar rupture. Were I you, I wouldn’t let this doctor near me.
I’ve beeen wanting to babywear as much as possible when we have children, but worry a bit about needing my own space. Fortunately my husband really wants to babywear also, and I think splitting the time between us will be more sustainable. I don’t think I could manage my desired level of attachment parenting alone.
I guess the study was on rats, so not involving fathers/grandparents/others involvement in levels of touch, but is there support for this elsewhere?
Given that the majority of the research was done by Searle Pharmaceuticals (the original manufacturer), starting in the 80’s, how would a couple of case reports or tiny studies matter? Isn’t that just publication bias?
And if you are inducing for a reason, like pre-eclampsia, and the alternative method doesn’t work as well, don’t you get problems, much more serious problems, related to that?
Great post! I have noticed the advice often in popular culture to “let dad take a night feeding so mom can get more sleep.” It doesn’t seem to really hold up in practice.
My personal experiences as a breastfeeding mother–even of a newborn–was that I most often felt “surprisingly well-rested.” I experienced little to no of the classic sleep-deprived mother signs and I attributed this to breastfeeding. I marveled at the sense of perfect nighttime harmony that I experienced with my babies–I remember saying, “during the day, he confuses me, but at night it is like we are in perfect harmony.” The symbiosis of waking seconds before baby needed to nurse amazed me. And, since they slept right next to me it was extremely easy to not completely waken. As they got older, I would often wake in the morning not able to clearly recall whether I had woken during the night at all–and if so, how many times–though, baby would be on a different side, so I knew I must have!
As toddlers, both my boys went through a period of extra-night nursing and being very rough while nursing at night and I remember saying–hey, I’m more sleep-disrupted now with a two year old than with a two month old! What’s up! (and this was my cue that night weaning was a good idea).
Though, I will also say that have seen some pretty serious sleep deprivation cases as an LLL Leader that have made me realize that breastfeeding on demand all night CAN, individually speaking, be a link to depression in some mothers. However, I think various practitioners take anecdotal experiences too seriously in making blanket recommendations–either anecdotal from personal experience or from very serious client cases. On the flip side, this can also include me! I recognize in myself that my positive night-nursing experiences and sense of nighttime harmony and symbiosis, etc. skew my own approaches to working with breastfeeding mothers on sleep issues–I feel I have failed to take seriously several mothers’ very serious depression/night-nursing experiences, because I had personal blinders on about my own harmonious experiences and thought they must certainly be exaggerating (and/or culturally conditioned to see a “problem,” where none really existed other than popular opinion about babies being able to “sleep through the night”).
[...] Breastfeeding Week this week, it seems fitting to have a post about breastfeeding! I just read a guest post by Kathleen Kendall-Tackett at Science and Sensibility about the (flawed) recommendation that mothers avoid breastfeeding at night as a [...]
“I wrote a comment on your blog, which funnily enough is awaiting moderation. Nice conspiracy theory, but I’ve been posting as “B” for a long time on other birth blogs. Check and you will see.”
OK. Why don’t you post a few links for us, right here.
Yeah, I think this is such a hard subject because sleep is important to mothers mental health. There is such a variation in formula and breastfeeding mothers in how much sleep mothers are getting. Some breastfeeding mothers will have there baby to bed all night long by six months others will not. I think its sad for people to be against breastfeeding for the simple fact of sleep alot of factors need to be considered when determining post partum depression. For instance, heres a big one maybe, if the mother has no sense of the people or things around. Maybe cannot even figure out her own name. That would probably be an indication there is post partum depression. But not getting enough sleep is not one of them. The person whom came up with this idea probably has perfect children whom never had any issues with anything. Good for them, pin a rose on their nose and give them a million dollars for having the perfect children. Mean while quit with the puedo diagnosis which they have not idea about in the first place.
Ok, since I can’t use the direct links without the post being blocked from appearing, here are the blogs, dates, and post topics where you can find my comments. Feel free to check. It is a pleasure to bust your ridiculous conspiracy theory.
Stand and Deliver – May 30, 2009 Collaboration, transfers and attitudes
Stand and Deliver – Sept 21, 2009 Ergo Baby Carrier review
Navelgazing Midwife – May 13, 2010 Being unmidwifed
The Unnecesarean – May 20, 2010 Canadian government publishes birth intervention rates
Mom’s Tinfoil Hat – July 19, 2010 Birth plan, doulas and episiotomy nonsense
And of course my posts on Science and Sensibility. There are many more posts out there besides these.
I know that with my oldest, when co-sleeping had never occurred to me, I felt so uncomfortable with him down the hall from me. It just felt wrong. And then when he’d wake after 90 minutes of sleep, what a nightmare. I was so tired while sitting up to nurse him it was sheer misery. Finally I told my husband “just give him to me.” And we both went back to sleep while nursing. From then on, co-sleeping it was. With my youngest, my 4′th child, I’d so perfected co-sleeping and nursing lying down that I never even needed naps during the day (helped that he was a pretty good sleeper overall.) When I hear people who are opposed to co-sleeping, I just quietly feel badly for them. I would have never though I could sleep with a baby in my bed, I’m a super light, bad sleeper. But that just meant that worrying about my baby made it even worse. I underestimated both the effect of prolactin and the comfort of having my baby right there where I needed him to be. I had PPD with my oldest, and with my youngest it was better (but I also took zoloft with my youngest.) I’m a huge proponent of co-sleeping, we never even put up our crib with my youngest, no need for it.
While I know this article isn’t really about co-sleeping, I want to point out that room-sharing is unsafe if anyone sleeping in the room smokes. There’s lots of information (and misinformation) about safe bed-sharing but not so much about safe room-sharing.
However I do have to say that I think most of the “not coping” with night-wakings has to do with the unreasonable expectations placed on women during the day. Firstly, particularly in the US, women tend to have to work outside the home, but even those who stay home don’t get the kind of help that they once did. You really only have to go back 2-3 generations to get to a time when it was almost unheard of for a mom to be alone. A family member or hired help was nearly always around. Also children were expected to play outside on their own (or at the neighbours) from an early age.
If moms weren’t expected to work/do all the childcare during the day and do most of the housework (and more housework than was once done, certainly more toys to pick up these days) and provide and “educationally enriched” environment for children, etc they’d probably be more able to nap with their baby or even stay in bed all day when its a rough time.
Its easy to blame breastfeeding, its almost as easy to blame night-waking. But babies haven’t changed, their needs haven’t changed, so if depression or stress is more of a problem its pretty clear that something else is a problem. In fact in traditional cultures its common for people to nap throughout the day. Its also not so far back that it was expected that the community help each other out, whether it was making furniture for a new homestead or giving jarred foods to a newlywed couple, or taking food to a new mom.
I would bet if you went to an Amish community, you’d find really low rates of depression and tiredness. The same for other traditional societies.
Hi everyone: thanks for your great comments so far. I do want to address some of the questions Mimi raised in her post. (see below)
It makes sense to me that breastfeeding mothers *in general* get more sleep than bottle-feeding mothers *in general*, but only because I suspect that neither group of mothers gets much help in the nighttime feeding department. I didn’t see any of these studies (e.g. Quillin and Glenn) address WHO was doing the bottle feeding.
Actually Teresa Doan’s study did study this aspect and found that if dads were feeding the babies with a bottle, they got more sleep if they used breast milk vs. formula. But the moms with the most sleep were those who were exclusively breastfeeding (about a 40 difference that can make the difference between function and very fatigued).
As someone who has exclusively breastfed two children, I can see that if *I* were the one handling bottle-feeding at night, I would indeed get less sleep, because it would take longer to prepare a bottle than to breastfeed. However, bottle feeding would have allowed my husband to do night feedings, and that, I think, would have made a huge difference.
My mother, for example, bottle-fed me, and she and my father traded nights “on duty” — meaning that EVERY OTHER NIGHT she got a full night’s sleep. Compare that with my going many, many months before having a night of uninterrupted sleep. I say this as a committed breastfeeder: getting a full night’s sleep even once a week would have helped my mental health tremendously. With both my children, the fog lifted once they started sleeping through the night; I became happier, more patient, more energetic, less anxious, and overall a better mother.
KKT: But as a breastfeeding mother, a full night with no breast every other night would have dropped her milk supply down like a stone. So while that might work for an exclusively formula feeding infant, i doesn’t seem practical for an exclusively breastfed infant.
For all these reasons, I find it frustrating to see this research summarized as “Breastfeeding mothers are less tired and get more sleep than their formula- or mixed-feeding counterparts.”
KKT: What I mean by this is that overall there are striking difference in the amount of sleep moms get and how tired they feel depending on how they are feeding their babies. But as with any biomedical research, there were be patients who are exceptions to the rules.
First, could you at least say “tend to be” rather than “are”? And second, how could I possibly be more tired if I were getting to sleep soundly all night long while my husband was formula-feeding our child? The potential participation of the mother’s partner/helpers doesn’t seem to be acknowledged here.
There have been two interesting studies and sleep and women’s relationshis with their adult partners. These show that if a woman doesn’t trust her partner, she doesn’t downregulate enough to get deep sleep and is more tired. How about a new mom? Would she be able to downregulate enough to get good sleep if her infant is away. The few studies that has looked at this phenomenon suggest that they would not get good sleep when the baby is away.
Again, I say this as a breastfeeding advocate who has exclusively breastfed two children (and is still breastfeeding the younger of the two). I think breastfeeding is great, but in some cases I think we oversell it, to the detriment of our credibility. I know I get less sleep this way, and it’s still the choice I made and would make again.
Believe me, I’m not trying to oversell this. I just don’t want to see it be undersold, The first thing people assume is that breastfeeding is the cause of all these sleep problems. But what the new research is showing is exactly the opposite. Even in our survey of 6410 new moms, we found these same striking differences. Breastfeeding moms can certainly still be tired–she is still postpartum, remember. But…..the advice about giving supplements, based on several recent studies, suggests that that advice will increase sleep problems and won’t be helpful. But we always have to look at women’s experiences on a case by case basis.
I hope this helps clear things up.
Thanks for writing.
kathy
Gee, seems like everyone else has posted links. Something must have changed.
And do you have any links, or sites rather, that aren’t on blogs that are Midwifery Mind Control deletion-fests? You can see over on Skeptical OB that many people have complained that they have had posts not posted on the blogs you list. http://skepticalob.blogspot.com/
How about a neutral place like news article comment section. Although as we all know, midwife fanatics will overcome the lack of control on those boards and re-double their efforts by piling on the “flag for abuse” button. http://childbirthtruthsquad.wordpress.com/2010/07/20/can%e2%80%99t-see-the-forest-through-the-trees/
Otherwise, all you show is that there is a longer history to this. Seems like Midwifery “education” means keeping women from seeing people poke holes in their arguments. And Midwifery “choice” means which midwife do you choose.
Oops. I meant to link to the below with this comment, not the link I did. Although, if people want another look at counter-arguments that this blog wouldn’t post, that is fine too.
“Although as we all know, midwife fanatics will overcome the lack of control on those boards and re-double their efforts by piling on the “flag for abuse” button”
http://childbirthtruthsquad.wordpress.com/2010/07/23/flag-me-down/
I think I need some clarification on the statement “breastfeeding mothers who were not bedsharing got the least amount of sleep” – I took this to mean that they got even less than bottlefeeding mothers. In that case much of the impact on sleep quality for the mother seems to depend more on where the baby sleeps, not how he is fed. Or does this simply mean that they got less sleep than bedsharing, breastfeeding mothers?
This is ridiculous. I tried to post a list of links and it doesn’t work here or on your blog – check your own admin settings for allowing more than 2 links in a post. To get the info across, I wrote a new post with all the relevant blogs, dates, and subjects where you can clearly see I have posted as B for about 2 years. Now this proof isn’t sufficient for you, because I showed only links to blogs based around birth? Well, the subject and your conspiracy theory is based around my presence on birth blogs, is it not? I’ve posted on news articles, feminism sites, parenting sites, political sites etc. but sometimes I use B, or my name, or another nickname, or even Anonymous – the onus is not on me to track down everything all over the internet to prove something to you. I’ve already busted your conspiracy theory.
I’m usually just part of the peanut gallery, but I’m flattered you’ve chosen me to create such a fabulous story around. Those who know me as a semi-regular commenter on their blogs over time must also be amused too.
So that’s the end of that. You’ll have to find something else to twitch about.
http://childbirthtruthsquad.wordpress.com/2010/08/04/the-evil-twin-or-is-it-twin-small-t/
Leading by example.
Is there any place online that we can read this research?
In my opinion, 33 moms collecting five days of sleep patterns DOES NOT equal quality research. Give me a break.
Great, that was a fun detour! Now, back to the blog topic?
Thank you all for your comments. The Research is not yet published, but I have contacted Kathrin and Esther about your request.
Michelle – I would so enjoy connecting with you about our shared research interests. klfulmer at gmail
Asheya – Like you, I expected to see more green mommas in the research – Especially is gorgeous, green Vancouver! There are yoga studios on every corner, however the university students in the study did not mention green, health or natural solutions. Maybe they were mostly transplants? I don’t know, but I too hope there are more green mamas in Gen Y than the study suggests.
It’s so important that we do more of this research in other locations, and not just in university settings so we can determine how Gen Y women are framing birth. Looks like Michelle and I are ready to explore the topic further!
Thank you Mama and Kim for your professional insights into the topic. I look forward to continuing the discussion and exploration of meeting women where they are.
I’ve been thinking about this article for a while now. I have to say I’m terribly disappointed in it. Breast-feeding co-sleeping parents may be getting the most sleep (apart from formula feeding parents that share the night-time load) however, co-sleeping is NOT SAFE!!
And I must agree with JR – there really isn’t enough data to draw firm conclusions from. This is not a long-term study and the cohort groups simply cannot be big enough with just 33 participants total.
I can see how breastfeeding co-sleeping moms do get the most sleep. They can nap thru the actual feeding. However, they still need to burp their babies and change diapers. They may get that minimal bit more of sleep, but not that much and certainly not enough to avoid PPD if they are predispositioned to it. And again, co-sleeping is not recommended by the AAP and it is not safe and should not be recommended.
I’m not exactly sure what you are referring to, but Searle has NEVER conducted research into misoprostol’s use as an obstetric agent, and, as my blog post makes clear, other agents are just as effective (prostaglandin E2 results in identical cesarean rates) while carrying a lower risk profile. Specifically, with respect to pre-eclampsia, as I also made clear in my blog post, misoprostol is MUCH more dangerous than prostaglandin E2.
@Deb
There have been a few studies on co-sleeping, but they often combine unsafe and safe co-sleeping into one group, and then compare it to crib-sleeping. Some of the “co-sleeping” practices have been people falling asleep on the couch, and the baby rolling into the crevices; baby sleeping with other small children, or adults under the influence of various drugs (including illicit drugs, alcohol, and OTC meds like Benadryl); babies on water-beds; babies on very soft mattresses, and other admittedly unsafe practices. What has not been shown is that co-sleeping as recommended by such doctors as Dr. Sears and Dr. McKenna (which eliminates those things, and probably others), is actually unsafe.
Thanks Katie for your interest in my research and your thoughtful analysis of the conference session.
I have copied below the % of university students who agreed with the following statements about childbirth (N=3680).
Birth is a normal process: 97%
Childbirth is inherently risky: 66%
Technology is necessary to deliver a baby: 45%
Complications in the delivery room are unavoidable: 28%
I am afraid of what the labour and delivery process will do to my (my partner’s) body: 70%
Not all is lost: Vaginal births are an outdated method for delivery of children: 2%
These findings suggest that students’ perception of birth as a normal process is not incompatible (as we may think) with the view that birth is risky and requires technological interventions. It seems that attitudes towards ‘normal’ birth among students are a reflection of current obstetric practices and the ‘ culture of fear’ that surrounds birth.
We are in the process of preparing a manuscript based on our findings. We did publish a paper in 2009 about student’s preferences for a vaginal delivery or cesarean section which includes a comprehensive analysis of reasons for this choice (by gender). Here is the reference:
Stoll, K., Fairbrother, N., Carty, E., Jordan, N., Miceli, C., Vostrcil, Y. & Willihnganz, L. (2009) “It’s all the Rage These Days”: University Students’ Attitudes toward Vaginal and Cesarean Birth. Birth, 36(2), 133-140.
Thanks for pointing out this blog to me…
Co-sleeping is safe, all it takes is a little common sense. I keep seeing this statement about co-sleeping being dangerous, when the statistics on SIDs show it’s much more likely when a baby is alone in a room. I would love to see a decent study done on co-sleeping. As a parent of a premature infant with severe reflux and stop-breathing episodes co-sleeping was the best thing we could have done, I wholeheartedly believe that a proximity, warmth, smell and sound of mom nearby provides vital stimulation and comfort to a newborn(much as kangaroo care does). I have co-slept with both of my children, my parents co-slept with all 8 of their children … I do not believe we are the exception and somehow narrowly escaped danger!
In regards to the supplementing, honest to god – my husband did get up with the baby at night at first. It did not help, I could not rest and all that happened was we were both exhausted and stressed. I, personally, do get much more *restful* sleep by breastfeeding at night.
Thank you to all for your comments. I will respond to more directly next week, as I’m on the road and have only limited time/access to internet.
Keep up the awesome attachment parenting! Your babies (and you) will benefit greatly from it…
I was wondering what the source is for this statement:
“There is a movement afoot in childbirth education and perinatal health urging mothers to avoid nighttime breastfeeding to decrease their risk for postpartum depression.”
I want to STRESS that that is NOT part of the curriculum for a Lamaze class! As a Lamaze accredited program (Passion for Birth) that has trained over 1500 Lamaze childbirth educators, that has never been recommended, suggested, or modeled!
Night-time nursing was the easiest nursing of all – neither of us woke up completely and it was emotionally satisfying to see her filling up while asleep.
Nursing to bed was a lovely way for both of us to fall asleep too.
The blog comments topic was why does this fringe movement think its amateurish, biased, self-serving propaganda/marketing materials dressed up as so-called “research” justifies a take-over of US maternity care?
The majority of women don’t want what Lamaze and other back to nature types offer. Less medical help in exchange for what? more pain and death. They act like the average woman has to be sent off to the re-education camps for believing legit research.
Hi Teri:
I’m glad to hear that this is not part of the Lamaze curriculum. Unfortunately, it is offered as a webinar for other CE groups. And there are now hospitals that are making this a part of their efforts to prevent depression. One hospital in Toronto has published guidelines about their program. And I started hearing about similar programs at other places in the US, so I felt that it was time to address it specifically.
Thanks for asking.
Kathy
I saw different messages.
Kimmelin opined:
“Just think of the inherent message baby wearing…attachment parenting…kangaroo care…sends:
I am here for you. Always. Your well-being is so important to me that I will make sure I am close by to recognize when you need something. You are not alone.”
Maybe it says:
“You are here for my benefit. Always. Close by so I don’t have to inconvenience myself by getting up, if you need something, although even though you are I can still ignore because I tell myself wearing you is basicially all I need to do. I don’t care that you might be more comfortable and sleep better in a carrier, I will make you sleep upright and squished (would you like that by the way). Plus, you are always a readily available prop for me to use to harp on my unusual, fringe beliefs to others. I was not together enough to keep on track with the grown-up world responsibilities, before you were born. Now you are here, I am really overwhelmed. So you will be dragged along everywhere to provide me a convenient excuse. I will make you sleep on a rigid schedule because I am already a basket case and can’t manage anything more. I use you. You are my excuse. You complete me.”
Kimmelin also, no joke, came up with this one:
“I also ponder the messages being sent to a baby who spends a ton of her time in her infant car seat:
My convenience is more important than your being comforted. I hold you (literally) at arm’s length because it is easier for me. I will take you with me according to my schedule (as opposed to being home for baby’s nap time–thus avoiding the concern about removing a sleeping baby from her car seat) rather than one that is more advantageous for you.”
Well, I pondered this.
“I respond to your needs. In fact, I am so in tune with them, I realize sleeping in the recumbant position is something you might enjoy and find more comfortable than being thrown over my shoulder like a sack of potatoes. Having your tiny rib cage compressed in one of those slings can’t make it easy to breathe. I don’t confuse my needs for comfort and cuddling with yours. Even though I’d love to cuddle you all day, I realize that you need to sleep quite a bit at the beginning of this thing we call life. You are a wonderful addition to my life. Although your arrival required major adjustments on my part, I am not overwhelmed. I will make the adjustments, take care of all the details, so I can provide the best life for you. I will stay on schedule so that you don’t need to have a schedule yet! And you won’t miss any ZZZZs, in the process. There’s no “nap-time” at our house, because you sleep when you want and I will incorporate that into our lives. I’m the grown-up. I’m there for you.”
“I can see how breastfeeding co-sleeping moms do get the most sleep. They can nap thru the actual feeding. However, they still need to burp their babies and change diapers.”
Actually, as a nighttime nursing mom to three now grown babies, I quickly learned how to double diaper at night, eliminating most diaper changes (yes, you still have to do the poopy ones). Also, bf babies don’t swallow air when they feed like their bottlefed counterparts, so I didn’t burp them at most feedings, either. Nursing is the best lazy-mom tool there is! I never understand why people say bottlefeeding is easier – it never looked easier to me.
“I’m not exactly sure what you are referring to, but Searle has NEVER conducted research into misoprostol’s use as an obstetric agent”
This is completely ridiculous. Searle and its successors have about 20 re-lablings of the drug. In every single blasted one of them, as in the original research, its abortifacient/obstetrical properties must be addressed.
Your extremely limited knowledge and unscientific skills don’t allow you to know about these and access them. This is obvious plain-as-the-nose on-your-face level stuff to anyone in pharma or medicine. And you don’t even know it exists!!!
The only way anyone knows cytotec can do these things is because it was found to cause spontaneous abortions in Phase III. Searle originally explored marketing this drug as the first abortion pill, but backed away due to threats of boycott or vandelism by anti-abortion groups. Its induction properties were also investigated at the same time, which is where the OB community got the idea from!!!!!
They have to file reports. They have to keep track of adverse effects and other things, whether they are in label or not.
Searle and successors have been able to have their cake and it too by not seeking FDA approval. They avoided the anti-abortion anger and then any product liability related to for OB. Nevertheless, it is widely used for both. I mean really, who uses this drug for ulcers anymore? It would have been relegated to the generic heap a long time ago, if that was the case. They have also been accused from time to time for covertly marketing it as an OB drug. Its acquistion of Roche’s women’s health product line in the 90’s was partly motivated by the need to have an excuse for it to be doing things with OBs!!!
They have been researching this “side effect” for over 25 years.
If you disagree with the blatantly obvious facts presented here, what is your story as to how this drug came to be so widely used for these off-label uses? I can’t wait to hear the laughably implausiable “old midwives tale”. The OBs that, you know, just don’t follow the evidence, just grabbed any ol’ drug off the formulary shelf and gave it to a mom in labor…….
Bottom line is you don’t know what you are talking about because you know so little about medicine, research, and pharma. You only access data that unscientific amateurs can find through Google while watching Grey’s Anatomy.
Obviously, your comments demonstrate you know absolutely nothing about the pharmaceutical industry and its research and regulation. Your comments, like most of this forum are amateurish attempts to present your agenda, beliefs and professional self-interests as science.
Thanks for clarifying that it wasn’t Lamaze childbirth educators who were promoting this!
I do appreciate you bringing this to others awareness!
@ Denise Hynd: While I did include the link to the Kangaroo Mother Care website, here it is again for you: http://www.kangaroomothercare.com/
@ “b”: I’m curious if you are a parent and, if so, if you ever explored the practice of baby wearing? As I pointed out in my article, there likely are times when a parent who chooses to keep baby close DOES yearn for their own space, or the need to indulge in activities that would be unsafe for baby wearing (cooking, drinking a hot beverage, showering, driving, cleaning, etc.) and, when they do, they put the baby down in a safe place. In fact, baby wearers are not gluttons for punishment or psychologically unstable, needy folks as pointed out in “b”’s fabricating description, “I was not together enough to keep on track with the grown-up world responsibilities, before you were born. Now you are here, I am really overwhelmed. So you will be dragged along everywhere to provide me a convenient excuse. I will make you sleep on a rigid schedule because I am already a basket case and can’t manage anything more. I use you. You are my excuse. You complete me.”.
The truth of the matter is, most parents who choose to carry their infants/toddlers in baby carriers tend to be extremely intelligent, well-researched parents who have read numerous books and articles about the benefits of wearing their child(ren).
The infant car seat, by the way, is not necessarily the safest place for an infant to sleep (neither is a swing). Some studies have shown that when an infant (who has little-to-no trunk musculature to hold their frame upright) sleeps in one of these places,they can slowly collapse their chest cavity down onto their abdomen–effectively suffocating themselves by disenabling their lungs to fully expand.* There are even some baby slings that pose a similar (but not the same) risk***, so researching which sling/wrap you aim to use is important–as baby wearers do.
Perhaps this is the point “b” is trying to get at by saying, …”having your tiny rib cage compressed in one of those slings can’t make it easy to breathe.”
Yep. The sling style of baby carriers can pose this risk–but not because baby’s rib cage is compressed…because baby’s face can become smothered by the loose material of the sling.**
Here’s a great video demonstrating a baby placed APPROPRIATELY into an upright wrap–lungs and rib cage supported but not “compressed,” face unobstructed, baby content, parent hands-free:
http://www.youtube.com/watch?v=CamfWi0cEU8
As to your concerns regarding, “I don’t confuse my needs for comfort and cuddling with yours…” I can tell you that:
1) babies kept as close to their parents as baby wearing facilitates tend to be calmer, happier, more content, less fussy babies.**** And, yes, this also fulfills a need for the parent(s): having a less fussy baby IS comforting and calming. Hearing your own child cry is upsetting (and for good reason–nature created it that way). Being physically close to one’s child boosts Oxytocin levels in mothers–the hormone of maternal love and bonding, among other purposes. I can guarantee you that having your baby in his infant car carrier in the next room does not boost “happy” hormone levels. And, besides, why is the parent’s well-being and comfort level NOT important? A calm, comforted parent makes for a better parent.
Thank you to everyone else for your anecdotes of baby wearing!
*http://www.medpagetoday.com/Pediatrics/GeneralPediatrics/6199
**http://www.csmonitor.com/Money/new-economy/2010/0324/Infantino-baby-sling-recall-Is-your-baby-carrier-on-the-list
***http://infantstoddlers.suite101.com/article.cf/baby_wearing_facts_and_myths
****http://www.thebabywearer.com/articles/WhyTo/GreatThings.htm
Kimmelin, blissfully unaware of her double standard, proclaimed as fact without support:
“In fact, baby wearers are not gluttons for punishment or psychologically unstable, needy folks as pointed out in “b”’s fabricating description,”
So, let me see if I understand you clearly. YOU can fabricate descriptions of other people, but they may not do the same to you. Your descriptions are law, truth, etc. others’ are well, fabrications.
Nice double standard, there.
“The truth of the matter is, most parents who choose to carry their infants/toddlers in baby carriers tend to be extremely intelligent, well-researched parents who have read numerous books and articles about the benefits of wearing their child(ren).”
Too bad you don’t read your own articles.
http://www.medpagetoday.com/Pediatrics/GeneralPediatrics/6199
“Some studies have shown that when an infant (who has little-to-no trunk musculature to hold their frame upright) sleeps in one of these places,they can slowly collapse their chest cavity down onto their abdomen–effectively suffocating themselves by disenabling their lungs to fully expand.*”
Uuhhhh, I believe that is what happens more often in a sling. You know, that part I said about having baby’s chest compressed? See govenment warnings related to that above.
What you cited really it wasn’t a study at all. It is a news article about a study. It reports that some of infants who died in carseats had congential deformities that blocked the upper airway and the others were under a month, but unknown.
The original abstract’s results section says this:
http://adc.bmj.com/content/93/5/384.abstract
“Of the 508 deaths reviewed, 409 were unexplained and 99 were explained after investigation. Seventeen deaths occurred in a sitting device, of which 10 were unexplained. There was no excess of premature infants dying. However, there was an excess of infants of less than 1 month of age found to have died in a sitting position in the unexplained death group. In addition, three infants who died in a sitting position had an increased risk of upper airway obstruction.
What a joke these comments are! Amy Tuteur makes a povocative statement that obstetricians are following evidence but can’t back it up. Henci throws out a few examples and Amy rebutts it by crying about how everyone likes Henci’s book but she has no advanced degree.
Baby b is whining about how capital B is such a name thief and does the ultimate in sleazy self promotion– posting multiple links to their own blog. Baby b’s emotional rants are getting old.
I’m not sure what the problem is, little b. If the majority of women don’t want Lamaze, then they won’t attend Lamaze-related classes or pay for Lamaze-related material. Why block whatever percentage of women who DO want that information?
Much to the discontent of some family and friends, my husband and I decided to co-sleep with our first child. I also chose to exclusively breastfeed. Our son, now 9 months old, is healthy, happy, and quite beyond his counterparts developmentally. All three of us get between 12 and 14 hours of sleep each night. My son also takes three naps a day. I am sure our relationships with one another are stronger because of co-sleeping and breastfeeding. During the night, my son just latches himself on and off…no one loses sleep. Why is it that these practices are so frowned upon? They are the most natural things to do. I find it incredibly sad that mothers are brain-washed into thinking our motherly instincts are wrong; that society knows best. And yes, co-sleeping and breastfeeding are not acts that every mother can do. However, society need not discourage women from these acts. Cultures all over the world embrace them- it is our misguided culture that wishes to avoid collectivism and train people to thrive on an individualistic way of life. Let’s start trusting ourselves and providing our children with what they need. Mother knows best.
@Jennifer
Maybe if the Deletion Squad here would post the factual responses on the discussion with the links and quotes from academic journals, then we wouldn’t seem so to the crowd that never ventures far from the safety of like-minded blogs.
But, much like they posture that they know statistics and research, and delete comments that show they don’t, they selectively delete blog comments to exclude real, hard evidence presented that shows they are completely wrong about their claims, and their (unlinked) alleged citations don’t come close to supporting their points. Embarrassing isn’t it?
http://childbirthtruthsquad.wordpress.com/2010/08/12/keeping-baby-close-the-importance-of-high-touch-parenting-and-deleting-correct-information/
Don’t worry. In a week or so, if you search for these people, the posts, or their blogs, it comes up pretty high.
“What a joke these comments are!” “Baby b is whining about how capital B is such a name thief and does the ultimate in sleazy self promotion”
Was your sense of humor surgically removed, or is this a congenital problem? Everyone else thought it was funny. Whatever. Of course, I could have insisted she was wrong because, you know, because it was a one million possibility that all those posts really followed mine.
Sort of like the way NCBers insist that a homebirth study showing higher deaths rates that are limited to full-term births, that take place in the home (not on the way to the hospital), and have a midwife or doctor attending aren’t valid. There’s a one in a bazillion chance that a few of the homebirth deaths were really mistaken accidental homebirths that are so precipitous (like 10 minutes or so) that they can’t get out the door and they happen to have a midwife over for coffee when it happened and the baby died.
Henci Goer doesn’t even know where the bulk of data for Cytotec is and forms her “opinon” on a few blippy case reports.
Goer (on comments on other posts on this blog)
“I’m not exactly sure what you are referring to, but Searle has NEVER conducted research into misoprostol’s use as an obstetric agent”
b
“This is completely ridiculous. Searle and its successors have about 20 re-lablings of the drug. In every single blasted one of them, as in the original research, its abortifacient/obstetrical properties must be addressed.”
Or maybe we are all whining babies because we think a drug that has been on the market for 25 years, might have some data of its own and at the FDA.
Whining baby @ SS = people who know medicine, reseach and pharma, as characterized by those who don’t want to hear about it.
http://childbirthtruthsquad.wordpress.com/2010/08/12/keeping-baby-close-the-importance-of-high-touch-parenting-and-deleting-correct-information/
Oh, yeah, right Searle NEVER did research on cytotec for obstetrics. Geez.
http://www.nytimes.com/1988/10/29/world/us-may-allow-anti-ulcer-drug-tied-to-abortion.html
“Ms. Bruno said the drug’s abortion-inducing effects were tested only to assess the dangers to patients taking it for other reasons.”
“To test the drug’s hazards in pregnancy, Ms. Bruno said, Searle gave Cytotec to a small group of women in their first trimester of pregnancy who planned on having abortions. The tests, conducted in West Germany in the early 1980’s, showed that the drug caused ”uterine expulsion and bleeding,” Ms. Bruno said.”
“Dr. Richard Glasow, another official of National Right to Life, said the group had not yet decided what actions to take against Searle, but that a boycott of Searle products, including Nutrasweet, was a possiblity.”
I’m reading this with interest as due to being type 2 diabetic and on insulin, I’m facing an induction next Tuesday. The CNM and OB both want to use Cytotec… or as the CNM said, “just a little pill.” I said…”What Cytotec? Doesn’t that have an increased risk of uterine rupture and meconium-staining?” She replied, “Not more than any other induction method.” Not true–as far as I can tell. I’ve had insulin-dependent GD for three prior pregnancies, so induction isn’t new to me–but in previous inductions, have used Pitocin. My HbA1c is 5.1%, baby is in the 53rd percentile for growth. My MFM is comfortable with my going to 40 weeks–and all of the BPPs and NSTs have been fab. Well, now I’ll be 40 weeks on Monday. I’m tempted to skip my induction. I’m tempted to push for another week and maybe ask if we can do three NSTs rather than two. I.do.not.want.Cytotec. Yet, it seems like I don’t have much choice with this group–which is supposed to be so natural birth friendly. Argh.
My son has been carried since birth. We have a wide variety of carriers, from a MeiTei, to a wrap, to an ergobaby carrier. My husband and I both enjoy carrying him and when we do need our own space, we just swap. Our son gets carried borth front and back and because we researched thouroughly how to carry babies in a secure way, he never had any issues. We always get comments on how calm and smiling he is and people actually ask us if he ever cries… It’s actually very convenient too. I use public transportation a lot and those huge strollers take up a lot of space on the bus. Wearing baby just makes it much more convenient for everyone, and he feels more secure that way.
Babies have been worn for centuries in many different cultures and I haven’t yet heard of a study that links those practices to rib cage collapse. I’m aware of some deaths related to babies in bag-type slings but I think they have more to do with our society having forgotten the way to properly carry babies…I think we need to rethink the way we consider touch. Touch is not inappropriate with young babies, it’s vital.
Elodie: A beautiful example of baby wearing! And yes, babies have been carried/worn for centuries (and still are in many cultures). Going back to the basics is not always a bad thing.
b- You could divide that into chapters. Settle down, there.
“In a week or so, if you search for these people, the posts, or their blogs, it comes up pretty high.”
So your goal is to whore for traffic? Hey, whatever gives you a boner over there in Maryland. You have a friend in Sharon, MA that gets off on the same thing.
This was supposed to have been comment 13. It shows that studies indicate any more upright positioning in any type of baby gear could cause breathing problems. Baby wearing is non-stop as opposed to occasional sub-optimal positioning.
Plus, case reports have shown the curled position that can be caused by slings alone has caused some deaths. No studies — most people don’t wait for stuff like that to not do things that could kill their babies — the govt. issued warnings on slings. The facts are the opposed of what was proffered by this author on her blog and her comments.
Well, I don’t know if I can compete with high-powered medical journals such as The Christian Science Monitor and Baby Wearer.com.
http://pediatrics.aappublications.org/cgi/content/full/110/2/401
“Positioning young infants in devices such as swings, infant carriers, backpacks, or slings may have similar physiologic effects in susceptible infants to positioning semireclined in car safety seats, and consideration should also be given to limiting the use of these devices as well.”
Meaning there’s been no direct research on these (obscure fringe practices don’t get studied much), but they share the salient feature of carseats — upright positioning. Obviously, the bio-physics of being more vertical verses semi-reclined are worse and the support (or lack thereof) of a soft backing leads to suffocation from rib cage/airway compression from the curved positions the soft back can cause doesn’t register here.
Here’s a news article about those light-weight government officials issuing formal warnings. I mean, not as good a source as suite101.com, but ya know.
http://www.king5.com/health/childrens-healthlink/Govt-to-warn-on-baby-slings-because-of-deaths–87144607.html
“It’s the “C-like” position that causes safety advocates to shudder. They say the curved position can cause the baby, which has little head and neck control in the early months, to flop its head forward, chin-to-chest — restricting the baby’s ability to breathe.
Another concern: that the baby can turn its face toward mom’s chest or belly and smother in the parent’s clothing.”
There’s no studies, because the common-sensy type folks just react to the case reports and take action. Silly us.
Kimmelin who never gives up on this non-sense continues:
“Being physically close to one’s child boosts Oxytocin levels in mothers–the hormone of maternal love and bonding, among other purposes. I can guarantee you that having your baby in his infant car carrier in the next room does not boost “happy” hormone levels.”
Even better sources. None and your guarantees.
I can guarantee that “happy hormones” are not increased if the baby dies from being a in a sling. I can also guarantee that “natural” fanatics will say “yeah, but the experience was worth it.”
It may feel like you have no choice, but you do. All people, pregnant women not excepted, have the right to make informed decisions about their medical care, and while that doctrine is termed “informed consent,” the concept is meaningless unless it also incorporates informed refusal. So you have the right to refuse induction until such time as you are convinced that inducing labor would be in your baby’s best interest, and you have the right to refuse Cytotec as a method of induction.
As long as I’m at it, I’ll add some advice about induction as well because I’m just finishing up the chapter on it for the new edition of Obstetric Myths Versus Research Realities. Based on the research:
(1)Unless there is compelling reason to do otherwise, wait for cervical ripening. Even women with prior births and no cesareans are at increased risk for cesarean if they are induced with Bishop scores less than 6 REGARDLESS of whether cervical ripening agents have been used. And, of course, if the cervix is ripe, there is no need for cervical ripening agents; you can go straight to oxytocin.
(2)Insist on a low-dose oxytocin (Pitocin) regimen where doses are increased at no less than 30 minute intervals. (The oxytocin package instructions describe this regimen.) Labor takes longer, but cesarean rates are similar and there is less uterine hyperstimulation with accompanying abnormal fetal heart rate. Insist, too, that the oxytocin drip be turned off once you are in active labor. In the majority of cases, women continue under their own steam with their own natural contractions. For those who don’t, no big deal, the drip can be turned back on.
(3)Refuse membrane rupture as part of the induction process. There is NO evidence that it decreases likelihood of cesarean, AND it has harms, which makes breaking the bag of waters a “batting 0 for 2″ proposition. First and foremost, unlike any other agent or technique, it commits to delivery. With intact membranes, if the induction doesn’t “take” you can quit and try another day. In addition, rupturing membranes opens the door to ascending infection; removes the protective cushioning of the amniotic fluid, which makes contractions more stressful on the baby; and creates the potential for umbilical cord prolapse (the umbilical cord comes down ahead of the baby), an obstetric emergency requiring cesarean surgery.
I’d love to hear what you decide to do and how it goes.
[...] on disaster preparedness efforts for childbearing women and newborns. I was happy to see this since I wrote recently that this topic has gotten too little attention. One of the articles, titled Targeting Prenatal Emergency Preparedness Through Childbirth [...]
An extraordinary thing happens when you are in constant contact with your baby, your devotion and attachment and love grows. My 4th child has been almost constantly with me since birth, and unlike my emotions with my more traditionally raised children, I’ve never been consumed with the idea that I need “me” time, space, relief. In fact, it feels wrong without her in my arms.
I love to read Michel Odent’s work along this line…
If I remember correctly, the sling deaths were one kind of sling that places the baby down around the mother’s waist. When properly placed, the baby’s face is not covered by the sling or the mother’s clothing and their airway is not constricted. They baby will also be in a position very close to the mother (not way down by her waist) where she can feel every breath. If the baby stops breathing, she’ll feel it and rouse the baby. With the baby way down by the waist (and padding in between the baby and mother’s body), the mothers could not feel that their baby had stopped breathing.
well this is nice. i feel like im on death row or something. im scheduled for an induction (GD) on the 22nd of august (this sunday/saturday) the ob plans to start me on 25 mg every three hours—orally. then in the morning pitocin. i was measured at 1.5 cm dilated this past friday. my ob is on vacation until sunday when i go in, so i have no one else to re-discuss this with. reading all these posts is scaring me…and i dont know what to do. i guess if i survive it, ill let all of you know.
I am so glad you’re enjoying my film — you all are using it in just the way I intended! Let me know how I can be of service to you — events? screenings? articles? You can contact me at birth-media.com.
Thank you all so much for the excellent work you’re doing — it’s never been more important than it is today!
[...] Keeping Baby Close: The Importance of High-Touch Parenting [...]
[...] flawed (an assessment with which I agree), I still keep coming back to the question I asked in my earlier post – did we need a meta-analysis to establish the neonatal outcomes of planned home birth? We [...]
Congratulations Amy for a very clear, succinct and compelling review of the Wax meta-analysis. Shoddy research seems to be the hallmark of a section of the medical profession. The breech trial, the anaesthetist who falsified data … The list goes on … and now this!! My esteemed medical friends are, understandably, horrified. Thanks for your rigor and dedication. We are fotunate to have you shining the light on the truth.
Who is this Wax person, anyway, with all of the comparisons of apples to hippopotamuses?
“Study size (home birth group):
* Wax: 9,811
* de Jonge: 321,307″
That’s completely wrong. According to the Wax study:
“A total of 342,056 planned
home and 207,551 planned hospital deliveries
were available for analysis.”
The Wax study INCLUDES the de Jonge study!
No, the neonatal mortality analysis does not include de Jonge. de Jonge data is included for other outcomes, for which no significant differences were found.
@Amy Tuteur, MD
I suggest you reread this article more carefully as it says:
I completely missed the fact that while the de Jonge study was “included” in the meta-analysis, it was excluded from the analysis of neonatal mortality, which was the major finding given so much attention by the media.
</quote.
“No, the neonatal mortality analysis does not include de Jonge. de Jonge data is included for other outcomes, for which no significant differences were found.”
But the deJonge paper does not measure neonatal mortality (death from birth to 28 days). So a more accurate representation of the study size for measuring neonatal mortality is:
* Wax 9,811
* deJonge: 0
The Wax paper clearly shows how many studies of the 12 eligible study are include in measuring each variable. For example, when analyzing maternal complications, different studies measured different things. So in looking at specific complication (tears, etc.) only the subset of studies that ACTUALLY MEASURED the specific outcome were included. This procedure was followed for EVERY variable in the study.
de Jonge did not include neonatal mortality (death from birth to 28 days) so it was literally impossible for Wax to include it.
The Wax study is far from perfect, and I myself have criticized it. But what you have written is a misrepresentation of the study.
The implication of your claim is that IF de Jonge had looked at neonatal mortality, homebirth would have had as low or lower neonatal mortality than hospital birth, but you don’t know that; you CAN’T know that. It is entirelly possible that de Jonge left neonatal mortality (birth to 28 days) out of the study because it was much higher.
Soooo was the reason that they didn’t include the deJonge data on neonatal mortality because they classified it as a shorter time window?
It’s too bad because with the number of homebirths there, it would definitely be good data to look at. I just don’t see how you can compare the US to the Netherlands because the systems are so different, which is also why I can’t fathom looking at a meta-analysis of homebirth as the end-all be-all study. And I like you Amy, would just like to optimize our options and care in this country! So frustrating!
@Amy Tuteur, MD
“It is entirely possible that de Jonge left neonatal mortality (birth to 28 days) out of the study because it was much higher.”
Always hunting for the nefarious evil motivations of home birth researchers?
As Amy R recounted from her personal contact with the co-author, the reason that late neonatal mortality was not included in the original de Jonge publication is that it is not collected in the same perinatal statistics registry, and is collected elsewhere in a fashion that is not as reliably complete. It’s not like they had all the neonatal (0-28 day) data in one collection, and they intentionally “excluded” it.
Even so, from published data we know that about 86% of all neonatal deaths in the Netherlands occur in the early neonatal period (0 – 7 days). So in effect, the figures on early neonatal mortality in the de Jonge study represent a rather comprehensive part of total neonatal mortality. It is indeed *possible* that this ratio may vary somewhat when considering only the low-risk pregnancies in the de Jonge study; it’s also *possible* that it may vary somewhat between the planned home and hospital group. But while it MIGHT be true that including the deaths from 8 – 28 days could possibly affect the results of the de Jonge study (in either direction!), it’s not very likely that it would change it by much.
It’s really not a huge leap to assume that the de Jonge results for early neonatal mortality are a close approximation for total neonatal mortality. Not a sure thing, but still a rather safe bet.
my source for the 86% calculation:
http://www.europeristat.com/bm.doc/european-perinatal-health-report.pdf
see figure 7.4 on page 119.
6/7 of all neonatal deaths in the Netherlands take place in the early neonatal period.
From the DeJonge/Netherlands study
“All neonatal care data from academic hospitals and about 50% of other paediatric data are entered in
the paediatric register. Recently, these databases have been combined into one national perinatal database via a validated linkage method.22” See abstract of said alleged “validated linkage method”, below.
In plain English, probably about half their baby death data is missing. The rest is not directly counted by place of intended birth at all, but rather guessed at by some poorly described modeling technique to link databases without unique identifiers.
This isn’t a study at all!!! It is playing with SPSS waaaay too much. Can someone buy these guys a Wii?
It is incredibly biased and hypocritical to spread propaganda that the Pang/Washington study (which showed at least twice the death rate) was invalid for allegedly having unplanned home births. A birth had to be full-term, occur at home (as opposed to on the way to the hospital or elsewhere) and with a licensed doctor or midwife, as per the study’s criteria and Washington State law regarding birth certificates. Unattended accidental births could not possibly meet this criteria, unless they just happened to have a midwife hanging around the house.
Yet, this Grand Canyon sized flaw in the Netherlands goes without comment.
http://www.ncbi.nlm.nih.gov/pubmed/19538407
J Clin Epidemiol. 2007 Sep;60(9):883-91. Epub 2007 May 17.Probabilistic record linkage is a valid and transparent tool to combine databases without a patient identification number.Méray N, Reitsma JB, Ravelli AC, Bonsel GJ.
Academic Medical Centrum (AMC), Department of Medical Informatics, Amsterdam, The Netherlands.
Abstract
OBJECTIVE: To describe the technical approach and subsequent validation of the probabilistic linkage of the three anonymous, population-based Dutch Perinatal Registries (LVR1 of midwives, LVR2 of obstetricians, and LNR of pediatricians/neonatologists). These registries do not share a unique identification number.
STUDY DESIGN AND SETTING: A combination of probabilistic and deterministic record linkage techniques were applied using information about the mother, delivery, and child(ren) to link three known registries. Rewards for agreement and penalties for disagreement between corresponding variables were calculated based on the observed patterns of agreement and disagreements using maximum likelihood estimation. Special measures were developed to overcome linking difficulties in twins. A subsample of linked and nonlinked pairs was validated.
RESULTS: Independent validation confirmed that the procedure successfully linked the three Dutch perinatal registries despite nontrivial error rates in the linking variables.
CONCLUSIONS: Probabilistic linkage techniques allowed the creation of a high-quality linked database from crude registry data. The developed procedures are generally applicable in linkage of health data with partially identifying information. They provide useful source date even if cohorts are only partly overlapping and if within the cohort, multiple entities and twins exist
“Even so, from published data we know that about 86% of all neonatal deaths in the Netherlands occur in the early neonatal period (0 – 7 days).”
But that, of course, tells us nothing because most neonatal deaths occur in high risk groups (such as premature birth) that are explicitly excluded from the deJonge study.
The point of my comment was to show that Amy Romano has deliberately misrepresented the Wax study. The numbers she quoted for neonatal mortality show that the deJonge study, far from including hundreds of thousand of women in calculating neonatal mortality (0-28 days), actually included ZERO!
There is simply no excuse for making patently false claims like the deJonge study is 32 times larger than the Wax study. When it comes to the analysis of neonatal mortality (0-28 days), the deJonge study contains ZERO cases.
@b
“Unattended accidental births could not possibly meet this criteria,…”
So, you’re making claims about the Pang study that go beyond even the authors’ own claims?
“This study has several limitations that are related to the reliance on birth certificate data. These include the potential for misclassifying unplanned home births as planned home births and for misclassifying various outcomes and covariates.”
“We sought to minimize misclassification of intended location of delivery in this study…”
That’s *MINIMIZE* not *eliminate*. Even the authors admit that their methodology cannot categorize intended place of birth with absolute certainty. What do you know that they don’t?
@Amy Tuteur, MD
“because most neonatal deaths occur in high risk groups (such as premature birth) that are explicitly excluded from the de Jonge study. ”
Sure.
Yes, we know that a very small percentage of neonatal deaths occur among low-risk pregnancies.
And we know that only a small percentage of all neonatal deaths are late neonatal deaths.
So the likelihood that there exists a significant number of late neonatal deaths among low-risk pregnancies is a very very small likelihood.
And if you had access to cause of death to eliminate late neonatal deaths related to accidents, respiratory and other infections acquired after 7 days, and other non-birth-related causes, that very very small likelihood becomes even smaller.
I would still stand by my statement that
“It’s really not a huge leap to assume that the de Jonge results for early neonatal mortality are a close approximation for total neonatal mortality. “
Indianafanny:
“6/7 of all neonatal deaths in the Netherlands take place in the early neonatal period.”
That’s unstandardized, (didn’t we talk about this before?)try page 32 here. I’m glad you are using some of the links I gave you though.
http://whqlibdoc.who.int/publications/2006/9241563206_eng.pdf
Since the midwife databases (home or hospital), the OB databases, and the baby databases aren’t linked in the first place, and a lot of the baby data isn’t even in them in the first place, it has to be awfully hard to tell what perinatal factors are related at all by using those as this so-called “study” did.
Oh, but they have a lot of subjects, so will ignore the fact the fact that they have no actual data. ; )
Amy Romona opined:
“de Jonge: midwives routinely record the planned place of birth in a national perinatal database that covers 99% of births and is linked to another database of neonatal deaths by a validated method.”
There’s no “perinatal database” RTFM. The entire thing was through statistical guessing linking Midwife to OB and then peds databases. There’s no actual data in this so-called study!! Where babies that died were intended to be born in this is no more than a guess.
From the J Clin Epidemiol. 2007 Sep;60(9):883-91. Epub 2007 May 17.Probabilistic record linkage is a valid and transparent tool to combine databases without a patient identification number.Méray N, Reitsma JB, Ravelli AC, Bonsel GJ.
Academic Medical Centrum (AMC), Department of Medical Informatics, Amsterdam, The Netherlands. (document listed by DeJonge as the method they used)
“All four perinatal caregivers create records in one of four independent registries: the registry of midwives (LVR1 or MR), of general practitioners (LVR-h), of obstetricians (LVR2 or OR), and of pediatricians (LNR or PR), respectively, with partial records in case of transfer. Because of privacy laws of the Netherlands, no unique personal identifier (of the mother or child) is available to combine records.”
And in case you weren’t aware, there’s no way to definitive validate anonymous databases, otherwise, ya know, they wouldn’t be anonymous. Only a small percentage matched on a small set of variables, and only a very small percent of those were unique.
The full text is up at science direct http://www.sciencedirect.com/
J Clin Epidemiol. 2007 Sep;60(9):883-91. Epub 2007 May 17.Probabilistic record linkage is a valid and transparent tool to combine databases without a patient identification number.Méray N, Reitsma JB, Ravelli AC, Bonsel GJ.
Academic Medical Centrum (AMC), Department of Medical Informatics, Amsterdam, The Netherlands.
“In absence of a large sample of validated pairs to independently estimate the awards and penalties, we used standard maximum likelihood techniques to estimate these weights from the data itself and to estimate the threshold”
In other words, they guessed.
@b
The funny thing is that the 2006 WHO document you reference is exactly the same one I used as a source a few weeks ago to show that there are many other countries “in Europe” which have perinatal death rates greater than the Netherlands.
And Dr T said that this information was “erroneous and out of date”.
So I guess now it is a reliable source after all…..
And anyway, the data in that table is rounded up to the whole digit (per thousand), so it really doesn’t contradict the numbers from the Peristat report (which is, incidentally, more recent, being based on 2004 birth data, as opposed to the WHO report which is based on data from the year 2000). And they both confirm that late neonatal mortality is a relatively small component of total neonatal mortality. And so does the updated WHO report using 2004 birth data which can be found at
http://whqlibdoc.who.int/publications/2007/9789241596145_eng.pdf
She also said that Wax could have but did not attempt to get the 0-28 data from deJonge, and that such data is in the publication pipeline so we will have to wait and see what it says. Could you be any more uncharitable in your comments?
Ehhh, no it is about 3/4s in there vs. 6/7s.
Since the DeJonge “study” is really based on statistical guessing as to which deaths were home vs. hospital, as opposed to anything that comes close to resembling real data, I don’t think the the timeframe of follow-up matters anymore.
To invent bizarre unlikely scenarios to suggest that studies unfavorable to midwives might have miscategorized some data and then embrace something like this that didn’t even categorize data in the first place…..unbelievable.
This is how a self-interested professional guild acts, and a guild that doesn’t know much about science and research to boot.
For some reason Amy Romano keeps repeating this even though it isn’t true:
“In Pang et al., which contributed 63% of the home birth data and accounted for 12 of the 18 neonatal deaths in normally formed newborns, researchers relied on birth certificate data that did not differentiate between planned and unplanned home births, and assumed that any birth certificate for a baby born at home at or beyond 34 weeks, signed by a midwife, nurse, or doctor was a planned home birth, a method that has not been scientifically validated and has been widely criticized.”
They didn’t assume it, it is Washington state law. Maybe not perfect, but a bit better than trying to match up anonymous records two database away don’t you think? Since only 5% of births didn’t have APGARs, it is unlikely that there is much possibility for unattended births.
http://apps.leg.wa.gov/RCW/default.aspx?cite=70.58.080
RCW 70.58.080
“1) Within ten days after the birth of any child, the attending physician, midwife, or his or her agent shall:
(a) Fill out a certificate of birth, giving all of the particulars required, including: “
“6) If there is no attending physician or midwife, the father or mother of the child, householder or owner of the premises, manager or superintendent of the public or private institution in which the birth occurred, shall notify the local registrar, within ten days after the birth, of the fact of the birth, and the local registrar shall secure the necessary information and signature to make a proper certificate of birth.”
Docs and midwives can’t cert for births they don’t attend. It might surprise some, but there are a number of people in this world who actually pay much more attention to the details and rules, and master and follow them.
@b
I am kinda thinkin’ I am gonna regret jumping in here as “b” seems to have strong opinions and exhibits some proficiency in torturing studies. Nevertheless, I suppose trading rocks in the blogosphere is just as useful as anything else I might do just now.
“b” – thanks for the link to the Washington statute language regarding the execution of the birth certificate. My personal opinion is that statute language means precisely bupkiss in assuring quality control over data collection when irregularities on the order of 0.001 can affect the outcome of a retrospective study and those filling out the birth record do not know it will be used for evaluation in the future. Pang is flawed and… your argument is irrelevant.
You seem to criticize de Jonge as unreliable given the difficulty in using multiple databases and then assert that Pang must be considered good because you don’t like de Jonge. I confess this line of reasoning might be too complex for me, but it is safe to say…your argument is irrelevant. In any event, if you are inclined to dismiss de Jonge, then we do not have much of a meta-analysis from Wax (with hundreds of thousands of births, albeit not associated with the subject neonatal mortality rate parameter in Wax that is the meat of this discussion) and we should just withdraw Wax Paper from the archive (and I agree with you on this).
The only thing that Wax did was to breath new life into Pang which objective folks have judged as flawed.
Your faithful midhusband,
Russ
@Amy Tuteur, MD
Greetings Amy,
Boy, it feels like old times. I hope all is well with you and yours.
I see in subsequent comments how your defense of the study size is defeated given that de Jonge is used for the perinatal mortality rate and not the neonatal mortality rate (which is the point of contention). Clearly, it is at best misleading to associate a study size containing hundreds of thousands of births with an elevated neonatal mortality rate in this study as AJOG has done in celebrating Wax Paper.
You know, Amy, it does not bother me when a researcher makes an honest technical mistake, or fails to identify a shortcoming. I am really struggling to give Wax, et. al., the benefit of making an honest mistake.
Cheers,
Russ
@Amy Tuteur, MD
Actually, Amy, asserting that de Jonge had 0 neonatal mortality rate data is incorrect. The 0-7 day data is clearly important and part of the neonatal period.
Russ
Good job people; other than one comment from b, this discussion has been entirely on topic and civil! Nice to see actual evidence rather than pointless jabs.
The authors of the study admitted that they could have included unintentional homebirths. Not sure what you’re even arguing about there. In fact, Dr. Amy has often bemoaned the use of birth certificate data in studies of elective cesarean section. She knows darn well that b.c. data is notoriously inaccurate.
I am actually rather suprised to see Dr. Amy defending Wax, she’s usually pretty honest re: the shortcomings of studies. All of the media reports quoted the 500,000 subject number, then the neonatal mortality data. When in fact the neonatal mortality data was based on about a tenth of the original, or 50,000. What a bait and switch.
The really bizarre thing is that every single one of the included 12 studies besides Pang showed no statistical difference between hospital and home. So yes, this meta is a regurgitation of Pang.
Here’s what the 12 studies conclusions in their abtracts show (and I’ve read about half of the studies in full):
(the first six listed here were used in the neonatal analysis that showed the alleged doubling of mortality, while all 12 were used in the perinatal.)
4.Ackermann-Liebrich U, Voegeli T, Günter-
Witt K, et al. Home versus hospital deliveries:
follow up study of matched pairs for procedure
and outcome. BMJ 1996;313:1313-8.
CONCLUSION: Healthy low risk women who wish to deliver at home have no increased risk either to themselves or to their babies
7. Lindgren HE, Radestad IJ, Christensson K,
Hildengsson IM. Outcomes of planned home
births compared to hospital births in Sweden between
1992 and 2004: a population-based register
study. Acta Obstet Gynecol 2008;87:751-9.
CONCLUSION: In Sweden, between 1992 and 2004, the intrapartum and neonatal mortality in planned home births was 2.2 per thousand. The proportion is higher compared to hospital births but no statistically significant difference was found. Women in the home birth group more often experienced a spontaneous birth without medical intervention and were less likely to sustain pelvic floor injuries.
10. Woodcock HC, Read AW, Bower C, Stanley
FJ, Moore DJ.Amatched cohort study of planned
home and hospital births in Western Australia
1981-1987. Midwifery 1994;10:125-35.
KEY CONCLUSIONS: Planned home births in WA appear to be associated with less overall maternal and neonatal morbidity and less intervention than hospital births. IMPLICATIONS FOR PRACTICE: whether these observed differences in intervention and morbidity have any relationship to the small, non-significant increase in perinatal mortality could not be determined in this study. Continuing evaluation of home birth practice and outcome is essential.
17. Janssen PA, Lee SK, Ryan EM, et al. Outcomes
of planned home births versus planned
hospital births after regulation of midwifery in
British Columbia. CMAJ 2002;166:315-23.
INTERPRETATION: There was no increased maternal or neonatal risk associated with planned home birth under the care of a regulated midwife. The rates of some adverse outcomes were too low for us to draw statistical comparisons, and ongoing evaluation of home birth is warrant
15. Pang JWY, Heffelfinger JD, Huang GJ,
Benedetti TJ, Weiss NJ. Outcomes of planned
home births in Washington State: 1989-1996.
Obstet Gynecol 2002;100:253-9.
CONCLUSION: This study suggests that planned home births in Washington State during 1989-1996 had greater infant and maternal risks than did hospital births.
13. Koehler NU, Solomon DA, Murphy M. Outcomes
of a rural Sonoma county home birth
practice: 1976-1982. Birth 1984;11:165-9.
Of the 273 who delivered at home, including 10 unplanned births, two were transferred to hospital for postpartum hemorrhage. One neonate was hospitalized for complications. The results of this study, as well as a review of the relevant literature, illustrate that, for a selected population, home birth is a reasonable alternative to hospital.
5. Shearer JML. Five year prospective survey of
risk of booking for a home birth in Essex. BMJ
1985;219:1478-80.
A higher rate of episiotomy and second degree tears and more Apgar scores of 7 or below were found in those who were booked for hospital. There were no perinatal deaths in either group. The results of this study showed no evidence of an increased risk associated with home confinements but indicated that there were fewer problems than were encountered in the deliveries in mothers confined in hospital.
6. Wiegars TA, Keirse MJNC, van der Zee J,
Berghs GAH. Outcome of planned home and
planned hospital births in low risk pregnancies:
prospective study in midwifery practices in the
Netherlands. BMJ 1996;313:1309-13.
RESULTS: There was no relation between the planned place of birth and perinatal outcome in primiparous women when controlling for a favourable or less favourable background. In multiparous women, perinatal outcome was significantly better for planned home births than for planned hospital births, with or without control for background variables. CONCLUSIONS: The outcome of planned home births is at least as good as that of planned hospital births in women at low risk receiving midwifery care in the Netherlands.
11. Hutton EK, Reitsma AH, Kaufman K. Outcomes
associated with planned home and
planned hospital births in low-risk women attended
by midwives in Ontario, Canada, 2003-
2006: a retrospective cohort study. Birth
2009;36:180-9.
CONCLUSIONS: Midwives who were integrated into the health care system with good access to emergency services, consultation, and transfer of care provided care resulting in favorable outcomes for women planning both home or hospital births.
12. Janssen PA, Saxell L, Page LA, Klein MC,
Liston RM, Lee SK. Outcomes of planned home
birth with registered midwife versus planned
hospital birth with midwife or physician. CMAJ
2009;181:377-83.
INTERPRETATION: Planned home birth attended by a registered midwife was associated with very low and comparable rates of perinatal death and reduced rates of obstetric interventions and other adverse perinatal outcomes compared with planned hospital birth attended by a midwife or physician.
14. Dowswell T, Thornton JG, Hewison J, Lilford
RJL. Should there be a trial of home versus
hospital delivery in the United Kingdom? BMJ
1996;312:753-7.
Although the trial was too small to draw any conclusions about the effect of homebirth, the recruitment rate of 11 out of 71 women offered entry to the study, or 11 out of 500 women booking for delivery, shows that the trial is theoretically possible.
16. deJong A, van der Goes BY, Ravelli ACJ, et
al. Perinatal mortality and morbidity in a nationwide
cohort of 529,688 low-risk planned home
and hospital births. BJOG 2009;116:1177-84.
CONCLUSIONS: This study shows that planning a home birth does not increase the risks of perinatal mortality and severe perinatal morbidity among low-risk women, provided the maternity care system facilitates this choice through the availability of well-trained midwives and through a good transportation and referral system.
In addition, Wax says this:
“The analysis excluding
studies that included home births attended
by other than certified or certified
nurse midwives had findings similar to
the original study, except that the ORs
for neonatal deaths among all (OR, 1.57;
95% CI, 0.62–3.98) and nonanomalous
(OR, 3.00; 95% CI, 0.61–14.88) newborns
were not statistically significant.”
@b- “Docs and midwives can’t cert for births they don’t attend. It might surprise some, but there are a number of people in this world who actually pay much more attention to the details and rules, and master and follow them.”
Very interesting comment that implies either that this “professional guild” is unethical or alludes to intent of a certain population to commit fraud. I’m not sure exactly to whom b is addressing this sideways accusation.
Birth certificate verification is of particular interest to the government right now with all of the controversy over illegal immigration, identity theft and terrorism. I would like to read more about birth certificates, birth certificate verification, data collection and the like, especially how it relates to out of hospital birth and concerns that the citizenry “pay[s]… attention to the details and rules, and master[s] and follow[s] them.” b, do you know anyone else like you who could speak to this?
Am I the only person who seems to think that a decent study on the safety of homebirth will remain elusive because of so many important variables and difficulties gathering accurate data using a more effective research design.
“My personal opinion”
Such an objective reliable source. Let’s make public health policy based on it.; )
“ is that statute language means precisely bupkiss in assuring quality control”
If you value your license and your livelihood the statutes that govern it are not bupkiss. Perhaps you think the people of Washington State are so dysfunctional that their police, social service and medical service people don’t mount a rather significant investigation as to the circumstances of a baby that dies outside a medical setting. Perhaps midwives who believe “they do everything the same as a doctor would” actually don’t even know about a all the rules and regs doctors have to apply in everyday practice. Maybe doctors have a lot more street cred with mothers because they can and do manage lots of very complicated information.
I remember a “study” where midwives thought they had “proved” birth certs were inaccurate as to provider. When you read, you see that midwives simply don’t know basic federal guidelines about who get credit for the delivery. If the OB is physically present in the same room, it is considered theirs by law, even if a midwife catches. But, the midwives, were whining about how they didn’t get credit for THEIR deliveries. Too funny.
“over data collection when irregularities on the order of 0.001 can affect the outcome of a retrospective study and those filling out the birth record do not know it will be used for evaluation in the future”
No, the errors would have to be in the classification of deaths. There’s only a few dozen of those. The denominator has to be waaaay, waaaay, waaaay off to make a difference. If people on the midwifery side knew anything about math, science, or research that would be obvious. But, they don’t which is why they don’t see the problems in their so-called arguments and they can’t figure out why the average woman rejects midwifery.
Most of the wrong classification would likely be in favor of the midwives — not knowing an ambulance patient had really been an attempted homebirth with a midwife (because, ya know, I have heard they take off on you), a mom starts at home but the delivery actually happens in the hospital, it could be missed as homebirth.
For errors you imply to be present and make a difference, there would have to be doctors and midwives all over Washington who go searching for dead babies outside the hospital. They would have to be stepping up to the plate, pushing police investigators and social workers out of the way to take credit for the death that was really an accidental home delivery that came faster than a pizza. They would have to lie on an official document and claim that THEY delivered them in the home and hang a sign on their backs saying “Sue Me and Take My License, Please!”. S’yeah right.
“You seem to criticize de Jonge as unreliable given the difficulty in using multiple databases”
Yes, I tend to think when the association between the cause (home vs. hospital) and the effect (death vs. living) was a complete and total fabrication and an invention and really just made-up data by the researchers, that’s a bit unreliable. I’m funny that way.
@Jennifer “I would like to read more about birth certificates, birth certificate verification, data collection and the like, especially how it relates to out of hospital birth and concerns that the citizenry “pay[s]… attention to the details and rules, and master[s] and follow[s] them.” b, do you know anyone else like you who could speak to this?”
Read all you want. It is the midwives that a history of falsifying birth certs for a price. Don’t worry about your data. These kids were all alive and well and when the midwives committed fraud on their birth certs. Actually, one midwife could change the data in Texas in midwives favor by being such a big fraud that she affected the denominotor (ie she claimed to have delivered thousands of kids that were already alive and well).
See too all the problems they cause for innocent Americans who had nothing to do with them.
http://www.dshs.state.tx.us/midwife/mw_enforce.shtm
http://www.texasobserver.org/cover-story/born-to-be-barred
http://www.latinalista.net/palabrafinal/2009/09/tx_mexican-americans_birthed_by_midwives.html
“there was a time when midwives were falsifying birth records — saying Mexican-born children were born in the U.S. — for a price, it is assumed.”
http://www.chron.com/CDA/archives/archive.mpl/1996_1382428/birth-certificate-fraud-booms-at-border-midwives-o.html
They’ve dubbed her the “”mother of all midwives,” and authorities believe she may have filed more phony birth certificates than anyone in Texas history.
Brownsville midwife Margarita Garcia-Rojas, 61, filed 3,400 birth certificates between 1985 and 1996. The Immigration and Naturalization Service says that is an unbelievable number, and suspect that many of those certificates are fraudulent.
“”That’s almost like delivering a baby a day for 10 years,” said Gilbert Trevino, the special agent who headed a four-year investigation into the matter for the INS. “
“who do we believe”. that’s right. many of us believe what we want to believe. we trust women’s bodies ~ or not. and even in front of all the evidence in the world, we may not change our views. but through educating young women, and telling them the TRUTH, that MOST of the time, birth is NOT a medical event, maybe there’s a glimmer of hope that they will learn to trust their bodies, which will be the best outcome for them. AND perhaps, through teaching them their RIGHTS (my body, my birth, my baby), we will empower them to say NO to birth attendants of ANY KIND who just need to control.
thank you for your highlights, and pointing out this and that. it will make sense for whomever wants to read it, and it won’t for whomever doesn’t want to believe it. that’s fine. it’s part of our freedom: to believe the truth or to keep on with the lies. blessings on your work.
@aly
“Good job people; other than one comment from b, this discussion has been entirely on topic and civil!”
Midwifery definition of uncivil = showing that your data was fabricated.
“The authors of the study admitted that they could have included unintentional homebirths.”
But it has a snowball’s chance in hades.
“Not sure what you’re even arguing about there. In fact, Dr. Amy has often bemoaned the use of birth certificate data in studies of elective cesarean section. She knows darn well that b.c. data is notoriously inaccurate”
So how does birth certificate data compare to blind matching of records in anonymous databases (aren’t those, you know, just a compliation of birth certificate like data collected in much the same way?) where your cause and effect variables are in different databases and can’t be matched definitively?
Discuss
Actually, as a nighttime nursing mom to three now grown babies, I quickly learned how to double diaper at night, eliminating most diaper changes (yes, you still have to do the poopy ones). Also, bf babies don’t swallow air when they feed like their bottlefed counterparts, so I didn’t burp them at most feedings, either. Nursing is the best lazy-mom tool there is! I never understand why people say bottlefeeding is easier – it never looked easier to me.
I’m currently nursing my 3rd (he’s 2 months) so I do know a thing or two about night-time nursing.
This one poops with every feed. There is no avoiding the diaper issue. And he also always has a burp… as did my others.
Kudoz to those of you who were able to do the family bed thing safely, but it doesn’t work for everyone.
Also, I still believe that co-sleeping isn’t a safe choice for most people. Those who have a desire to do so do the research and make their beds safe for this practice. However, if it was recommended to all new nursing moms as a way to get a bit more sleep, I’m not convinced that many people would take the time/effort to do the research to make the arrangement safe.
Personally, if I co-slept, I would get less sleep from being stuck in one position all night. As well, my newest is a very noisy and wiggly sleeper! Getting up for 15-30 minutes once or twice a night is much more ‘restful’ for me.
Quote:
Actually, as a nighttime nursing mom to three now grown babies, I quickly learned how to double diaper at night, eliminating most diaper changes (yes, you still have to do the poopy ones). Also, bf babies don’t swallow air when they feed like their bottlefed counterparts, so I didn’t burp them at most feedings, either. Nursing is the best lazy-mom tool there is! I never understand why people say bottlefeeding is easier – it never looked easier to me.
—————————————–
I’m currently nursing my 3rd (he’s 2 months) so I do know a thing or two about night-time nursing.
This one poops with every feed. There is no avoiding the diaper issue. And he also always has a burp… as did my others.
Kudoz to those of you who were able to do the family bed thing safely, but it doesn’t work for everyone.
Also, I still believe that co-sleeping isn’t a safe choice for most people. Those who have a desire to do so do the research and make their beds safe for this practice. However, if it was recommended to all new nursing moms as a way to get a bit more sleep, I’m not convinced that many people would take the time/effort to do the research to make the arrangement safe.
Personally, if I co-slept, I would get less sleep from being stuck in one position all night. As well, my newest is a very noisy and wiggly sleeper! Getting up for 15-30 minutes once or twice a night is much more ‘restful’ for me.
@b: “If people on the midwifery side knew anything about math, science, or research that would be obvious. But, they don’t which is why they don’t see the problems in their so-called arguments and they can’t figure out why the average woman rejects midwifery.”
Could you be any more rude or condescending toward midwives and the women who choose to see them for care? I was reading your comments with interest, your obvious bias against midwives notwithstanding, but this level of personal attack is completely uncalled for and only undermines your contributions to the discussion. Tsk tsk.
As an aside, it is my personal observation (so take it for what it’s worth) that many of the women in my community who seek maternity care with out-of-hospital (LDM) midwives are highly educated, and choose to have home births after doing considerable research and investigation. I myself have a Ph.D. in a science field, and while it doesn’t make me an expert on birth studies, I believe that I have a firm grasp on math, science, and various research methods. I am an average (albeit highly educated) woman, and I reject obstetric care for my normal, low-risk pregnancy (currently 38 weeks along). You may disagree with my reasons for making this choice, or believe that I made the decision based on flawed data, but I take exception to your assertion that midwives and their clients aren’t intelligent enough to “figure out” the medical literature. That’s patently false, and in my opinion just plain rude.
Lastly, I wanted to point out your wording on something: “people on the midwifery side.” Isn’t it better if we try to avoid picking sides? I’m not on anyone’s side but my own. I approach research with objectivity, as everyone should. Your clear lack of objectivity severely undermines your credibility on this topic, at least with me…
I ‘wore’ both my girls, and recommend the sling (when worn properly) to everyone I meet with infants or pregnant. It’s pretty easy to recommend, especially when I have my 2 1/2 year old in it!
I’m so glad to see that this discussion has focused on the data and its validity rather than degenerating into something else. Maybe its the cool lime green colored background
Clearly the De Jonge data, which was collected in a country with a large organized homebirth system, cannot be extrapolated to the United States.
Clearly the fact that De Jonge left out days 8-28 deaths is an issue, and very likely explains the difference between De Jonge and Pang. Many babies with hypoxic injuries die after 7 days. In my experience this has been the rule rather than the exception, when neonatal resucitation is available. Modern pediatric technology can keep an infant alive for just about as long as the parents care to continue. The death of these infants is usually because support is withdrawn, and in many cases it takes more than 7 days to reach that point.
Clearly Pang’s methodology also has some problems.
The most important line in the whole piece is this ““Is home birth safe?” is a bogus question to which there is no answer.”
I could not agree more. The whole concept of safety of childbirth, in any environment, is flawed. Bad things can happen in childbirth, just as they can happen crossing the street. The question is whether birth environment has a clinically important impact on outcomes in low risk pregnancies. This will always be hard to answer, as to the 99.9% that do fine the difference wasn’t significant, but if there is an attributable risk, the 0.1% that hits it will see that risk in special significance that cannot be described in mathematics.
Wax has published a meta analysis which has some strengths and weaknesses. It does show an increased neonatal death rate for homebirth. Those that are against homebirth will taut it, those that support homebirth will attack it. This is nothing new. This type of post-hoc research commentary is part of the process of scientific discovery, and has gone on with every major paper that anyone ever cared about.
The most important part of all of this is that both Wax and DeJonge showed that homebirth is largely safe. There may be a few more bad outcomes in the homebirth groups depending on how you look at the data, but when you consider the number of births we are looking at, the absolute number is so very few that the argument is a little ridiculous.
@Amanda- You might expect this kind of bias from someone with an interest in the collection and analysis of birth data. Before 1986, people didn’t get a Social Security number until around age 14. By 1990, the age was lowered to 1 year and now parents apply for Social Security numbers for their children at birth. Giving birth in an institution allows for cleaner data and facilitates tracking, which helps prevent fraudulent claiming of dependents. Which, of course, helps our country’s bottom line financially.
The idea that women who give birth outside of institutions and the notion that midwives are lawless rule-despisers working off-the-grid is old. Really old. Birth moved from the home to hospitals around the time that the Social Security Act of 1935 was enacted. The act was passed in 1935 and between 1938 and 1948, the hospital birth rate went from 55% to 90%. Social security taxes were collected for the first time in January 1937 and, obviously, the point of the SS number was to track individual’s accounts within the Social Security program and has become the de facto identifier of U.S. tax payers.
The tracking of maternally-linked perinatal data would be much easier if everyone just gave birth in the hospital. Out of hospital births are seen as potentially fraudulent and off-the-grid and midwives are viewed by statisticians as a potentially dishonest disruption in the production of clean, uncorrupted data.
Right, b?
I thought the meta-analysis was supposed to be published in Sept….have you read the whole thing yet?
@Nicholas Fogelson, MD
Thank you! You put things in perspective quite perfectly!
@Katrina
:like:
@Nicholas Fogelson
“Clearly the fact that De Jonge left out days 8-28 deaths is an issue, and very likely explains the difference between De Jonge and Pang. “
This criticism was originally raised by yours truly and is out of date, my friend. The biggest problem of DeJonge is the cause and effect variables came from different unlinked databases!!!! The researchers can get any results they want because they are fabricating the association between birthplace and outcome, themselves.
Their pediatric database has a 40% drop-out rate and it isn’t linked to birth place data either. So, 8-28 days will be even worse quality data. I, for one, have never heard of asking people for more of their data before a meta-analysis of what they published. But, I guess this “oh my God, look what they didn’t do, that makes their study terrible” is the Forest Plot of this do-over of the prior debate .
Thanks to LaMaze and this blog for harping on this study as the gold standard of maternity research. This fatal flaw would not have been noticed otherwise. But, at least they got the consolation prize. It makes their nemesis, the Wax meta, partially flawed for the part that included it. But, oops, all those parts were the ones they liked.
“Clearly Pang’s methodology also has some problems.”
Yeah, they bent so far over backwards to avoid capturing unintended home births, that they missed a good portion of midwifery deaths. That’s probably why they get only two times as deady, when most people get 3-5 X as deadly.
“Giving birth in an institution allows for cleaner data and facilitates tracking, which helps prevent fraudulent claiming of dependents. Which, of course, helps our country’s bottom line financially.”
LOL. I will file that in the same file as fallacy “hospitals make more money from c-sections”.
No, there is no Federal Bureau of Unclaimed Tax Deductions. The government doesn’t fly around in its black helicopters looking for families that didn’t get a social security number for junior and therefore can’t claim him as a deduction.
And since Medicaid pays for half of births, wouldn’t the govt. look in to saving money by pushing homebirth? Since midwives can only convince a teeny, tiny fraction of women to fall for their deception, in fact, they have turned their focus to government officials. They are trying to highlight the cheaper rates and hide the ultimately higher costs of later medical care from the disasters they cause and intangible human costs that women will bear.
But, wow. LMAOROTF That’s the most entertaining conspiracy theory I’ve heard in a long time. The Social Security Pension Fund and the math geeks starting in the 1930’s have been conspiring for decades to make women birth at hospitals. Today, I would think they would just be conspiring to make them birth — anywhere, since it will go broke soon without tons more taxpayers. Next Lamaze will be warning pregnant women about the hidden dangers of retirement communities and nerd glasses. Tell me please, is the Illuminati in this story, somewhere? How about the AARP? Keep baby close….BUT AWAY FROM GRANDMA!!!! The Industrial-Medical-Geezer-Geek complex. The Business of Being Old.
“The idea that women who give birth outside of institutions and the notion that midwives are lawless rule-despisers working off-the-grid is old. Really old.”
Old? Not to the scores of Americans that had their right to unrestricted foreign travel taken from them until recently because of the massive fraud of some midwives. Not to the kids who grow up with druggie mothers because they birthed with a midwife they knew she would not report them to social services, the way the hospital would. Not to the kids with non-fatal handicaps who die because their moms birthed with a midwife to prevent medical care that would save them, so they didn’t have to raise a handicapped kid.
@Nicholas Fogelson, MD
Greetings Nicholas,
I appreciate your thoughtful remarks. This is more of a management problem than a problem in evaluating the studies. A comprehensive safety assessment of these two different models of care (the setting is just one attribute) would need to include maternal mortality in addition to perinatal mortality, peripartum hysterectomy, hypoxic events leading to long term disability, bad outcomes in future pregnancies associated with uterine scars, postpartum depression and a whole host of relevant dependant variables. What we know is that planned home birth, attended by a skilled midwife, is a valid choice and we should manage it.
You pointed out that extending de Jonge to the U.S. may not be appropriate because the Netherlands has a long history of supporting home birth and I agree with you. In the U.S., we have made every effort to marginalize women who would make this choice by denying them access to care and disenfranchising the midwives who serve them. We might very well expect to see a slightly higher risk of a bad outcome in the U.S. as compared to the Netherlands because of this.
Here are actionable steps we can take to fix the situation and achieve the same outstanding performance as the Netherlands:
1) License and regulate Certified Professional Midwives in all 50 states, the District of Columbia and Puerto Rico as the CPM is the primary care giver to women who choose the home setting for birth in the U.S. The CPM is authorized to practice in 26 states (licensed and regulated in 24) and regulatory oversight is key to assure access and performance. I should say here, and this is important, that regulatory oversight must not be used as a means to deny women autonomy in their birthing decisions.
2) Retire mandatory written practice agreements between Certified Nurse Midwives and physicians as a condition to practice. In addition, intentionally produce CNMs with the training they need for the home setting and autonomous practice.
3) Assure reimbursement for planned home birth (Medicaid and private insurance).
4) Standardize guidelines for intrapartum transports and assure that all members of the healthcare team are trained to understand how to manage these events.
5) Cultivate liability options such as a) no fault remedies, b) binding arbitration, c) limits of liability, etc…by installing pilot programs in every state as the Childbirth Connection suggests in their Blueprint for Transforming Maternity Care document. I would also hope that successful programs could be enlarged to improve the environment for physician led care in the hospital setting. I would hope that managing the medico-legal environment better would reduce interventions and improve safety. This might actually moderate the accelerating rates of planned home birth.
6) Engineer systems to monitor performance of planned home birth and adopt best practices as they are identified and confirmed.
We have some work to do, Nicholas, and much of it needs to be done in each state’s General Assembly.
Best,
Russ
Russ Fawcett
Vice President & Legislative Co-Chair
North Carolina Friends of Midwives
@b- I was baiting you with SSA history from your web site. This is more than I could have asked for:
“Not to the scores of Americans that had their right to unrestricted foreign travel taken from them until recently because of the massive fraud of some midwives. Not to the kids who grow up with druggie mothers because they birthed with a midwife they knew she would not report them to social services, the way the hospital would. Not to the kids with non-fatal handicaps who die because their moms birthed with a midwife to prevent medical care that would save them, so they didn’t have to raise a handicapped kid.”
This, combined with your previous comment about border midwives, shows that you believe that midwives are out to commit fraud and they’re in collusion with those dirty, sneaky WOMEN. I don’t know how a person gets to a point where they no longer trust women and assume that, if they prefer midwifery, they are just trying to hide that they have dark desires to abuse their children and or let them die. Not only that, but they’re stealing the right to travel abroad from good, law abiding citizens.
You want a good conspiracy theory? Look at what you just wrote!
It was one thing to rant about how nobody understands science and statistics as well as you do, but this entire thread has shown that you have no understanding of midwifery and zero trust for women. Someone with deep hatred like you’ve shown above will never listen. Why would you? You think women and midwives are out to kill babies.
@Jennifer
Wow. It was clear that ‘b’ was clearly losing his/her composure over the course of these posts, but holy smokes …
@Midhusband
Russ, thank you for this comment. Probably the most useful one of the whole lot.
Please read the previous post to yours (# 23). It is my response to another woman in a similar position to yours and applies to you as well.
“Brownsville midwife Margarita Garcia-Rojas, 61, filed 3,400 birth certificates between 1985 and 1996.”
I’ve always wondered if the paranoid rantings against midwives on Dr. Amy’s site and elsewhere were related to racism and stereotypes of granny midwives. b is confirming that for me a little bit. I can certainly understand being against homebirth, but the frenzy of some of these anti-midwife screeds is just wierd, and interesting in a historical context.
@ Nicholas Fogelson
“The most important line in the whole piece is this ““Is home birth safe?” is a bogus question to which there is no answer.”
I could not agree more. The whole concept of safety of childbirth, in any environment, is flawed. Bad things can happen in childbirth, just as they can happen crossing the street. The question is whether birth environment has a clinically important impact on outcomes in low risk pregnancies. This will always be hard to answer, as to the 99.9% that do fine the difference wasn’t significant, but if there is an attributable risk, the 0.1% that hits it will see that risk in special significance that cannot be described in mathematics.”
You’ve hit the nail on the head. Do many of your ob-gyn colleagues agree? It doesn’t seem that Dr. Amy Tuteur does.
@ Midhusband
You make some great points, but I would like to add a few points.
1) Midwifery education should be as good as what is received in the countries showing better homebirth outcomes with homebirth midwives, e.g. UK, Canada, Netherlands In the US, only CNMs have similar education backgrounds to midwives in other countries. The bar should be set high, because women and babies deserve the best care, no matter where they birth. If new educations standards are set by the US government and existing CPMs will not retrain and therefore not longer be able to practice, so be it.
2) Midwifery organizations need to be free of conflict of interest and make public all data, just as obstetrics and gynecology organizations need to. Credibility and professionalism all around.
3) The US (and any other medium to large country with people living spread out) likely needs more birth centres. Why? Because many US residents don’t live in the same proximity to hospital as would be found by citizens in the Netherlands for example. An emergency transport to hospital from a rural home far from the local hospital could result in bad outcomes. There may be many women who want to homebirth but feel safer birthing at a birth centre near a hospital.
Of course, the other crucial factor is that there needs to be more cooperation between midwives, ob-gyns and nurses in the event of transfer. You addressed this in point 4.
I completely agree with point 5 as well.
Both hospital birth and homebirth could be improved, and there should be less time spent on demonizing one side or the other and more time spent studying the flaws and implementing crucial changes.
I really enjoyed this and think it’s so important to draw attention to the fact that breastfeeding mothers aren’t just a self-sacrficing bunch– we may actually be doing this to get some sleep. I have written about your article– links below– hoping to help further the discussion. Many thanks, Ceridwen Morris
http://blogs.babble.com/being-pregnant/2010/08/04/could-breastfeeding-at-night-actually-mean-more-sleep-for-mom/
http://blogs.babble.com/being-pregnant/2010/08/17/debating-nighttime-breastfeeding-no-formula-for-success/
@jennifer
“@b- I was baiting you with SSA history from your web site.”
So, in other words, you are now claiming you were doing something sneaky to victimize women. And then you rant for an entire post that midwives are falsely accused of doing sneaky things to victimize women?!!!
ROTFLMAO!!!! And you wonder why most women don’t want you. Remember, actions speak louder than words. You guys (sorry, gals) are your own worst enemies.
Or maybe you really were a conspiracy theorists and are changing your story, because you are embarrassed when things are pointed out like this one. http://skepticalob.blogspot.com/2010/08/uks-leading-midwife-caught-using-make.html Either way, it’s bad for you and your so-called cause.
I must have really struck a nerve to elicit the hat trick of posts deleted again . http://childbirthtruthsquad.wordpress.com/2010/08/20/home-birth-and-neonatal-death-who-do-we-believe/ , the patellar reflex “witchhunt” accusations and the other Groupthink defensiveness.
“This, combined with your previous comment about border midwives, shows that you believe”
No, I think it shows what you believe and what you are like:
Since no one can respond to main topic here, the cheerleading about a midwifery study that has turned out to have completely fabricated data, you changed topic and solicited comments on midwifery bad behavior. Then, you complain “how dare someone have heard about patterns of midwifery bad behavior”. I believe you have called that derailing in another post.
The only thing midwives want to censor more than data that shows they are deadly is evidence of bad behavior. Patterns (not isolated l incidents of individuals) of dishonesty (like fabricating your supporting facts or data, admitting you were trying to deceive women), patterns of criminal behavior, evidence that they are aware deaths are higher but value midwifery birth more, and mostly patterns of being really, really mean to pregnant women that they screw up on to name a few.
They don’t want people to know about all the collateral damage they cause in the lives of other people.
But, your sexism is really showing here.
Fraudulent birth certificates don’t require a conspiracy between a midwife and a sneaky *woman*. The dad or some male relative could have done it. And they could have been desperate or deceived, by the midwife for all we know. The parents were not accused of any wrongdoing. But, the innocent victims are all those babies, now middle aged. Regardless of whether some adults did something wrong on their behalf or not, they were all victims because could not get passports and denied other rights we enjoy, for a long time, because of midwifery criminal activity.
Drug addicted moms? Since drug addicts really don’t have full control of their faculties, they are hardly some “sneaky woman” who can “conspire”. Again, they are desperate and disabled….and taken advantage of by midwives. A health professional that sees them and knows, has an obligation to them to address this, not enable it by giving the drug addict whatever she asks for, because the midwife can’t attract enough patients. Again, she is really a secondary victim.
And the rest – those reports comes from the horse’s mouth.
http://blogs.babble.com/famecrawler/2010/07/22/mayim-bialik-childbirth-home-birth/
“There are those among us who believe that if the baby can’t survive a home labor, it is OK for it to pass peacefully,” she writes. “I do not subscribe to this, but I know that some feel that … if a baby cannot make it through birth, it is not favored evolutionarily.”
BMJ 2005;330:1416 (18 June), doi:10.1136/bmj.330.7505.1416 “Outcomes of planned home births with certified professional midwives: large prospective study in North America” Kenneth C Johnson, senior epidemiologist1, Betty-Anne Daviss, project manager2
“and three babies with fatal birth defects”
Lethal congenital anomalies (n = 3): Dwarf and related anomalies, Acrocallosal syndrome, Trisomy 13 “
Except, only one of these is considered a lethal anomaly.
The other two should have the majority survive.
@Midhusband
“August 19th, 2010 at 17:40 | #39 Reply | Quote @Nicholas Fogelson, MD
Greetings Nicholas,
I appreciate your thoughtful remarks. This is more of a management problem…. Here are actionable steps we can take to fix the situation and ….”
Hey, great. Not only to do midwives deceive and victimize women, but the men are in charge of everything!! ; )
@b- Keep backpedaling, please. I do feel bad about baiting you and I’m sorry. Amanda is right. You’ve been losing your composure and now you’re dropping anecdotes as your proof. Why is someone from the Social Security Administration running around all over the internet to scream about how midwives are criminals who seek to commit fraud, which harms the U.S. population as a whole?
Are you really ROTFLYAO? Glad you’re getting your jollies from this. Please keep it up. The “I know you are but what am I” response worked for Pee Wee Herman, but it’s not doing it for you.
What makes this extra interesting is your claim that midwives are part of a big lying conspiracy and your claim that you have The Truth (the name of your blog). Face it. You’re not going to “convert” people here to your hatred because most people are rational enough to accept that some women like midwifery care and others like medical care. Even Amy Tuteur accepts that- she just likes to fight. You make her look supportive of a woman’s right to choose midwifery care.
You are saying such basic things it seems like it would be obvious right? Sadly I see EVERY woman and girl around with a baby – still packing that infant seat around rather than being in contact with the baby in it. I practiced attachment parenting without realizing it was called that or that anyone else did it. And yes, I do believe the bond between my children and I is stronger than what I typically see. I did it 25 years ago with my first two children, and did it again with my second family twenty years after the first. The second time around, I had to work full time, so as soon as I got the babies(then toddlers, now big boys)home I would put them in the sling or otherwise carry them. My sons are now 4 and 5 and as soon as I get home, I physically carry them. Because I am gone so many hours a day (necessity) I make sure they still get skin to skin contact. When I walk in the door they are whining and complaining. After skin to skin contact, they are calmer and seem reassured and not so anxious or grouchy. It works!
I found gas and air very helpful during my lovely home birth, but I think I would have hated a mask. I had a mouthpiece that I held between my lips/teeth – not claustrophobic at all.
@B
Thanks B,
Yes, I think we will agree on many things and below are a few thoughts.
Training – I think it is best to establish training requirements based upon the scope of practice and the job description as opposed to what other countries do that intentionally produce credentialed home birth midwives within the bricks and mortar university setting. I really can’t speak to the scope of practice for midwives in the UK or the Netherlands, but I think we can discuss the CNM & the CPM.
A key thing to understand is that the CNM has a much broader scope of practice than the CPM and the CNM is designed to operate in the hospital setting with all the associated complexities. The CNM provides primary care for women, primary gynecological care, she has prescriptive authority, she may provide primary elder care – she does many things in addition to providing care for women during the childbearing year. Indeed, she may be the primary care provider for women from their first cycle to their dying day. The CPM scope of practice is limited to maternity care for healthy women experiencing normal pregnancies during the childbearing year, and so it is not justified to simply hold all midwives to the same training requirements when they do not have the same scope of practice.
It is interesting, here in my state, we have CNMs with Associate Degrees in nursing and the CNM certificate, 3 year RN degrees and the CNM certificate, and now a Masters degree in nurse-midwifery will be required for entry into the CNM profession.
Shall we require that all CNMs who do not hold a graduate degree (with decades of experience) return to school? Clearly, the answer is no.
One thing to keep in mind is that the CPM credential is accredited by the National Commission for Certifying Agencies (irrespective of pathway) which also accredits the CNM credential. In judging the adequacy of the credential and pathways to achieving it, I submit it is best to look at performance metrics such as outcomes and maternal satisfaction as opposed to what might be considered customary for CNMs, engineers and attorneys. We are comfortable with performance, and the credential, as evidenced by the results of the CPM2000 study (Johnson & Daviss) and many years of experience.
As we are talking about the adequacy of the Portfolio Evaluation Process (P.E.P.) pathway to obtaining the CPM, which is a very formal apprenticeship program, let me draw your attention to many other apprenticeship programs registered with the Department of Labor in the Tar Heel state:
http://www.nclabor.com/appren/trades/apprenticeable_occupations_900.pdf
Note how many specialized jobs of moderate scope in the healthcare fields are produced via an apprenticeship model.
Now we need to put our manager’s hat on for a minute. As PEP trained CPMs are the primary caregiver to women who choose a home birth in the U.S., states that do not license and regulate PEP trained CPMs for home birth will then have elevated rates of planned unattended home birth, they will not manage intrapartum transports, continuity of care is compromised, the midwives will not be regulated and consumers will not be protected from a midwife who does not maintain the standard of care. It is clear that we need to address today’s problems today, and install increased requirements when there is justification in the context of a multi-generational program plan.
Free-Standing Birth Centers – I agree with you. Unfortunately, the trend in my state is to close small facilities in favor of concentrating maternity care in large facilities with increased capability. There seems to be a lot of consolidation going on and there are many obstacles in front of a midwife of any credential who considers such a venture.
All the best to you, B,
Russ
@russ
“4) Standardize guidelines for intrapartum transports and assure that all members of the healthcare team are trained to understand how to manage these events.”
What exactly are you looking for here? This shows a lot ignorance of the health care system again and women’s rights. Women and their babies and their fetuses already have rights to health care under US law when they come to the hospital from outside. Women don’t want to sacrifice their rights to treatment for the career ambitions of midwives.
The more important is the underlying issue of denial of the problems inherent in homebirth with a midwife embodied in the call for this so-called solution.
Midwives are slow to recognize problems, because those who train in “normal birth” and are so unpopular they have few patients aren’t familiar with them. When they recognize problems, they make things worse by delaying medical help as long as possible (and often, in their inexperience and philosophy of birth overestimate how long they can) because their goal is their version of “normal birth”.
This leads to a midwife-created 5-alarm emergency that then has to overcome a time and distance barrier to boot. A hospital’s emergency response that complies with the above laws and other relevant standards of care is already doing all it can.
Essentially, you are demanding that other enable the dysfunctional strategies of midwifery.
“5) Cultivate liability options such as a) no fault remedies, b) binding arbitration, c) limits of liability, etc”
You sound like the people who work for public relations for British Petroleum.
Victims can’t have the damage they suffer limited, why should those responsible get limits?
Limits on intangible damages have been criticized as sexist, so no surprise they are embraced here. http://papers.ssrn.com/sol3/papers.cfm?abstract_id=898863 “Limits of liability” is a code-word for saying a woman’s pain and suffering, her unpaid domestic work, her loss of future childbearing don’t have a tangible dollar amount attached to them, so she doesn’t have to be compensated.
Women’s very lives are devalued in these tort reform schemes. Work as a homemaker and mother is devalued. Wage discrimination makes a working woman’s loss of her life or disability devalued, as well. The loss of her baby’s life is devalued.
So once again, men in charge. Once again, women’s rights sacrificed to benefit the career ambitions of a few who want to be midwives.
“) License and regulate Certified Professional Midwives in all 50 states, the District of Columbia and Puerto Rico as the CPM is the primary care giver to women who choose the home setting for birth in the U.S. …..I should say here, and this is important, that regulatory oversight must not be used as a means to deny women autonomy in their birthing decisions.”
In Oregon, this seems to have morphed into “have your cake and eat it too”. In other words, they licensing to get access to insurance and to help get the patients via the impression of the state’s seal of approval. They want all the benefits. But, they don’t people to actually be able to complain about them to the state licensing board!!
More sacrifice of women’s rights to midwives.
http://www.oregonlive.com/news/index.ssf/2010/07/homebirth_conflict_escalates_o.html
[...] Planned home birth and neonatal death: Who do we believe? by Science & Sensibility. [...]
@b
Greetings Anony-b,
Well…it looks like it is just you and me now.
I confess that I had resigned myself that I was not going to respond to you as your inflammatory remarks are actually helpful to me as folks who might casually wander upon this thread would likely favor our more temperate words. As I was cutting the grass yesterday (something we XY types are fond of doing when there is not much on ESPN or the beer inventory is low and in between telling women how to give birth), I decided it is time to engage you.
I must point out that there is a bit of a mismatch in this contest. You are entirely anonymous, b, and free to say whatever you like with no accountability, while I am accountable for my words. Why don’t we make it more fun and you can tell us who you are with all of your outstanding credentials. What do say, b? Amy was never anonymous.
Anyway, here are my thoughts on your most recent remarks…
Anony-b said – “You sound like the people who work for public relations for British Petroleum. Victims can’t have the damage they suffer limited, why should those responsible get limits? Limits on intangible damages have been criticized as sexist, so no surprise they are embraced here. ”
Nope, I don’t work for BP and I am not in Public Relations. Clearly, you did not understand the message I sent. Let me suggest you read it again. I am not advocating for limits of liability, or any other model, but rather I am suggesting we do what the Childbirth Connection suggests and deploy pilot programs to cultivate options that may provide improvement. My personal opinion (FWIW) is that there is indeed a crisis in the medico-legal environment in maternity care that needs attention. Defensive medicine has resulted in 1 of 3 women concluding her pregnancy in abdominal surgery. While I am thankful that the OBs are as good as they are at C/S (and this procedure does save lives), I am in the camp that believes this elevated rate is a problem. Also, tort based remedies are only 60% efficient in distributing funds to families awarded a judgement, while administrative programs are 90% efficient. I tend to believe we can better support the families in crisis, and reduce the pressure on the good folks working in maternity care, with alternative models all at the same time.
Perhaps you think the existing tort based model is perfectly fine, but I think you are in the minority on this.
Anony-b said – “In Oregon, this seems to have morphed into “have your cake and eat it too”. In other words, they licensing to get access to insurance and to help get the patients via the impression of the state’s seal of approval. They want all the benefits. But, they don’t people to actually be able to complain about them to the state licensing board!!”
First of all, let me suggest you slow down and review your posts more carefully before releasing them. You make a lot of mistakes in putting your words together which does not help you develop credibility. This is true in your comment posts and your blog as well.
As for the Oregon issue, the experience from around the country is that the vast majority of complaints against licensed midwives arise from healthcare providers in the hospital who are hostile to home birth after an intrapartum transport. It is very rare (but it does happen) in which a client/consumer enters a complaint. Nevertheless, the fundamental purpose of licensure is to protect consumers from midwives who do not maintain the standard of care and so processing complaints is a key part of regulation (which is why every state has a Board of Medicine to address issues with incompetent physicians). I don’t have enough information to know if the midwives’ suit is correct, but I do know that harassment exists, and so I am looking forward to knowing the results of this litigation.
Take care, Anony-b, and I look forward to your response.
Russ
Midhusband>> As for the Oregon issue, the experience from around the country is that the vast majority of complaints against licensed midwives arise from healthcare providers in the hospital who are hostile to home birth after an intrapartum transport.
And why do you think that is? It usually because the transport happened way too late and put the woman and fetus are far more risk than the OB felt was justified. Some of this comes from differing expectations of what is appropriate, but a lot of it comes from completely screwed up transfers.
In my career, I would say that at least 25% of hospital transfers were associated with some sort of negligent practice on the part of the midwife. I don’t take it personally, as they have a different training than I, but it does make for some bad feelings. Some OBs do take it personally, and try to fight back.
Here’s just a few examples
1) Midwife transfers patient postpartum, saying she is bleeding postpartum and she can’t stop it. She has been massaging the uterus and it stops for a bit but it keeps coming after that. The patient is in hypovolemic shock and is pouring blood from her vagina. Exam shows she has a massive sulcus tear up to her cervix with an arterial bleeder. Pt requires many units of blood and general anesthesia to repair the tear, which was completely missed by the midwife.
2) Midwife sends a patient in in her husband’s car, saying she has been 8 cm for 12 hours. On exam the baby is frank breech. Midwife didn’t come with the family, and told the husband it was because “she was just going to stay at the house and clean up.”
3) Midwife brings in patient with huge posterior laceration saying she can’t fix it. Exam shows that she has sewn the vagina nearly shut and still has not encircled the bleeders. Entire ‘repair’ is removed and fixed. Midwife watched the repair, and based on comments clearly had no idea what the anatomy was that needed to be repaired. The ‘repair’ she tried to do also was with the completely wrong type of suture.
4) Midwife transfers a patient who has been complete for 6 hours without descent. By leopold’s the baby is huge and the patient’s blood sugar is 180. Midwife and patient insist that she she is not diabetic because a fingerstick blood sugar early in the pregnancy was normal (rather than a far more sensitive glucose challenge test). Midwife actively influences the mother to not accept an insulin drip to control her sugars prior to delivery, says it will hurt the baby. Baby eventually delivered by cesarean, 11.5#.
5) Midwife transfers a mother with a stuck breech with head entrapment. Baby has an agonal rhythm and cannot be resucitated postpartum. Infant dead in labor room.
Ask any OB and they can give you more examples.
I try not to bring these up because there are midwives that do a good job and make appropriate transfers. But many don’t, and many don’t accept what they do not know. They transfer too late, and sometimes don’t even come with the patient to give a proper report. By doing this they undermine any good feelings between midwivery and obstetrics, and turn some OBs into absolute midwife haters. If CPM are ever going to get real acceptance, this kind of shit needs to stop, or the people who do it need to be pushed out of practice.
Great Day in the Morning, Nicholas !!!
I sense some frustration here…
First of all, as long we are telling stories, let’s talk about gross negligence for a minute. Check this out…
http://fayobserver.com/Articles/2010/03/31/987295
I must confess that I have never heard of a midwife inducing a non-gravid woman and then sectioning them only to find out the uterus is without the products of conception (because there never were any). To be fair, this spectacular event also illustrates the systemic problems with maternity care these days in addition to real issues of human performance with physicians.
I can produce hundreds of women who will describe significant deficiencies in the practice of obstetrics. Does that mean obstetricians are incompetent as a profession given that 80% will be sued for malpractice during their career? Of course not.
This does bring up an important aspect of the dynamics here. The hospitalists only see the transports and while most of them are not urgent, some of them are. I tend to agree that there are different thresholds for escalation of intervention (which is why there is a dramatic difference in C/S rate), and that is why the studies are useful in counting outcomes.
You seem to have passed judgement on the CPM and I am sad for that. The vast majority of CPMs are competent and maintain the standard of care, day-in and day-out, (just like you do). Just like there are incompetent physicians, there are midwives who should not be practicing, and that is why regulation is so important.
Russ
“But many don’t, and many don’t accept what they do not know. They transfer too late, and sometimes don’t even come with the patient to give a proper report. By doing this they undermine any good feelings between midwivery and obstetrics, and turn some OBs into absolute midwife haters.”
Gee, maybe it’s because they get treated like shit when they get there, get threatened, sued, and even *jailed.* I have NEVER heard of a midwife sexually assaulting a patient, getting a court order to FORCIBLY cut a woman open for cesarean section, or threatening a woman bodily harm if she does not cooperate. Does this excuse the midwifery behavior you mention? Absolutely not, particularly the dumping of patients that generally happens in states ACOG has worked to keep ooh midwifery illegal. Besides that, the other behaviors are from lack of training, not malice, as obs do. And don’t tell me Obs don’t screw up, or cause dead or brain damaged babies. Better training, more regulation, I agree. But obstetricians absolutely cannot ignore their own culpability here. There will always be women who want to homebirth for whatever reason, whether you like it or not. We need 1)better training of cpms, no doubt. 2) formal obstetrician backup in hospital. 3) careful screening of homebirthing mothers 4) informed consent.
I do believe midwives might even be more scorned and hated than Muslims, by people who have no concept that there are moderates and extremists in EVERY group. (That’s true of obs-moderates and extremists-, but there’s no movement to eliminate them either, unless you count malpractice insurance skyrocketing!).
Sigh.
@Midhusband
>> You seem to have passed judgement on the CPM and I am sad for that.
Not really, but I can see from an OB’s perspective how so many OBs can be so anti-midwifery. Even if only 1 in 50 transfers are like this, its enough to hurt relations terribly.
I agree that regulation is necessary and there needs to be standards of education that CPMs should meet. Right now its far too fractured, and in many states completely unregulated.
>> We need 1)better training of cpms, no doubt. 2) formal obstetrician backup in hospital. 3) careful screening of homebirthing mothers 4) informed consent.
Agreed
>> I do believe midwives might even be more scorned and hated than Muslims
Its interesting that you compare midwives to a religious affiliation.
Trying to post without links (besides one, these are all non birth/midwife websites):
Did I mention I hate anecdotes? It’s not right to condemn all obs
based on these stories anymore than it is to do the same against
homebirth midwives. But as long as we’re sharing horror stories, I know you have wondered why some women are scared to death of obstetricians. The funny thing is, it’s obs who are getting sued right and left for killing babies, and lawyers claim it’s because doctors refuse to police themselves and get rid of the bad apples. Sound familiar?
Chicago police officer versus fired and fined obstetrician:
Refusal of cesearean, has vaginal delivery, woman loses her baby for 3
years after hospital calls cps:
Obstetrician disappears after ordering pitocin, baby dies:
Two teachers die, 15 days apart, same hospital, after c-sections:
Medical Kidnapping: Rogue Obstetricians vs. Pregnant Women:
ob/gyn sexual assault:
Comments from physicians:
Physician (to a patient who was expressing discomfort over a vaginal exam): “Come on, now, you’ve had something a lot bigger than my finger in there! How’d you ever manage to get pregnant if you can’t put up with this?”
So, Nicholas, do you know why CPMs remain unregulated in about half of the US?
That’s right!! You guessed it – the leadership of each state’s medical society exerts their considerable political leverage in the General Assembly objecting to it. They cannot separate their objections to planned attended home birth from the need to regulate the midwives.
We just completed a substantial project at the request of the General Assembly for the stakeholders to propose a licensing methodology to regulate CPMs in our state. Just about everybody (and their lobbyist) was there. The fundamental message from the Medical Society was…
Home birth is a bad idea and don’t do anything to make anything other than a bad idea.
I found it remarkable. Our argumentation was compelling and the physician participants even acknowledged it, but nevertheless they ignored the request of the General Assembly and elected not to participate.
The irony is profound.
Russ
Profound, indeed. I am always shocked by physicians who stand against midwifery presumably because it makes women babies less safe. Yet when you start talking about ways to make it safer, they do not want to participate. The argument always comes back to, “We want women to have choices and participate in their healtcare, so long as they choose hospitals and physicians.” Do they want women to be safer or not?
Sorry for the typos.
>> I do believe midwives might even be more scorned and hated than Muslims
DR. F:
Its interesting that you compare midwives to a religious affiliation.
Sure, there are some midwives with religious like philosophical beliefs. I’ve made clear in the past that I don’t agree with ideological commitment to either extreme. Some obstetricians have an equally tenacious ideology that pregnancy is a disease and technology is supreme. The only difference is that midwives don’t try to force their beliefs on anybody else, while obstetricians have taken a political and medical policy of forcing their “religion” on society as a whole. In addition to forcing individual women to undergo surgery with court orders. Kind of like the difference between Unitarians and fundamentalist Christians.
My only philosophy is evidence based medicine and that benefits and risks of medications and procedures should be weighed objectively based on science and not anecdotes (on either side). That’s about medicine and health in general, not birth specifically. And that no matter how misinformed I personally think unassisted birth or elective cesareans are, women ultimately have complete control over their bodily integrity.
@ Midhusband
“Training – I think it is best to establish training requirements based upon the scope of practice and the job description as opposed to what other countries do that intentionally produce credentialed home birth midwives within the bricks and mortar university setting.”
But the scope of practice is the same for any midwife working in a hospital or in a home – they must be able to provide high standard pre-natal care and assess risk for labour, they must be expert in low-risk physiological birth, and expert at recognizing medium and high-risk situations that need transfer to hospital, as well as providing top-notch transfer care and excellent communication and co-operation with attending ob-gyns. I hope you aren’t suggesting that the high standard university-level midwifery education, including practical training components, that midwives receive in Canada, UK, Netherlands etc. is over-kill for their scope of practice.
@ Aly
“My only philosophy is evidence based medicine and that benefits and risks of medications and procedures should be weighed objectively based on science and not anecdotes (on either side). That’s about medicine and health in general, not birth specifically. And that no matter how misinformed I personally think unassisted birth or elective cesareans are, women ultimately have complete control over their bodily integrity.”
Well said!
Hi B,
The assertion that the scope of practice of the US CNM & the CPM is not the same originates from testimony given by the Director of our university based nurse-midwifery program as she argued for the adequacy of apprentice trained CPMs for their scope of work. I agree that a normal prenatal exam delivered by a CPM may be considered as identical to that delivered by a CNM, in addition to many other tasks. The point here is that the CNM has a much broader scope of practice than the care of healthy women during the childbearing year (not to belittle this aspect in any way – we think it is of prime importance).
Of course I am not criticizing the training requirements established in the countries you site. I have no basis to criticize them nor intention to do so. I think it is terrific that the infrastructure exists there to actually produce credentialed midwives to meet the home birth demand (more or less) with that pathway as we don’t here. Producing home birth midwives is something that the architects of the training program need to be intentional about, and we don’t tend to do that in the university setting here. My argument is against the bias that says university training is the only confident training. This is not true for professions of moderate scope – particularly when they are specialized. Did you review the link to the registered apprenticeship programs I provided? I suggest embracing the notion that apprenticeship training is adequate for specialized professions of moderate scope, or don’t think about it very much the next time you get on an airplane…
I have no objection to producing midwives of any credential. I would have no objection to requiring a Doctor of Nursing for midwives as long as we produce enough of them (but I would wonder about the motivation for doing that). When we have serious issues with access to care (and all the associated implications), we need to focus on the fundamentals of adequacy of training and then assure performance through regulation.
Russ
@ Midhusband
I think the university is exactly the right place to teach midwifery including a long practical period for hands-on experience. University midwifery programs do not contain only academic courses and there should not be a stereotype that they are theory only programs.
How strange that teachers from primary school to college and university-level are expected to study at university-level, but midwives who may deal with life and death situations where some medical knowledge is necessary are only expected to have high school diplomas and a certificate from a midwifery school below university-level, especially ones that teach pseudoscience like homeopathy, aromatherapy, reiki etc.
I don’t think anyone needs a Masters degree to be a midwife, but they certainly should have a Bachelors degree with excellent academic and practical skills upon completion of the program. You’d likely find that nurses and doctors would be more cooperative working with midwives if they had at least the same education and qualification level as nurses.
Lay midwives scare the wits out of me. I read Gloria Lemay’s site and she implied that one young woman died from post-partum hemorrhage because her baby was not with her nursing right after birth. I tried to comment how ridiculous that was but it was never published. Midwives who can spout such nonsense are a danger to birthing women. We all know that nipple stimulation triggers uterine contractions, but serious pph cannot be solved by a breastfeeding baby! Complete ignorance about medical facts.
“I don’t think anyone needs a Masters degree to be a midwife, but they certainly should have a Bachelors degree with excellent academic and practical skills upon completion of the program. You’d likely find that nurses and doctors would be more cooperative working with midwives if they had at least the same education and qualification level as nurses. ”
I agree, but don’t necessarily think it has to be a nursing degree. The CM route available in one or two states seems to be enough. A college degree, hospital training, low and high risk training, etc, are a must., as well as a strict midwifery board for oversight.
Thanks for this post – this certainly seems to be an exciting set of initiatives. There is definitely room for improvement in second stage management!
I agree too, not a nursing degree, but I just meant similar standard of education.
As a university educated midwife in Ontario, I’d like to make a couple of comments. One is that a university midwifery program needs to be built from the ground up. One of the issues that we saw with a CM educated midwife that moved up here was that the program she went through appeared to be a condensed nursing program with midwifery crammed into the second half or so, which seemed to leave some gaps. The program here (which is responsive to external input regarding its functioning) has a core academic program with sciences (a & p, repro, pharmacology, etc) and then extensive clinical placement (over 50% of the program, with a minimum requirement for births attended in both home and hospital settings). Midwives are expected to be competent in both hospital and home settings, and competence includes extended skills like managing women with epidurals and induction/augmentation. Midwives are expected to have entry-level competence upon graduation (something that is also different from other jurisdictions), but there are restrictions in their first year of practice regarding requirements to work only with experienced midwives for mentoring purposes.
Re: the conversations around transfer. I believe that one of the reasons that our outcome data in Ontario and BC regarding homebirth are so good is because midwives must, by regulation, function in both settings — there is no home/hospital birth midwife divide. Because we can still look after women post-transfer (and most often do) at the hospitals where we are privileged, we are less reluctant to transfer if we (or the woman) need or want to. Further to that, even if a transfer is for a more emergent reason, we are, by and large, respectfully received, and so there’s little fear of hostile reception. Because our consultants know us (and I think this is *so* important), they have far more trust in our clinical skills/knowledge and that we are not bringing in disasters to dump on their doorstep. When the impediments to good transfers are reduced or eliminated, then it’s less likely that bad ones are going to occur.
I’m curious to know what improvements will be part of the “second-stage safety” package. Do you know?
And I must say I am less than impressed that the “induction safety” package stopped at eliminating elective induction before 39 weeks instead of eliminating elective induction, or at the very least, eliminating it, period, in first-time mothers and in women with an unfavorable cervix. Electively inducing labor in these subgroups increases the risk of cesarean surgery, and the use of cervical ripening agents does not do away with the excess, so it is far from safe.
Henci,
Thank you for your on target comments. In the current obstetrical environment, we decided to start where we were which meant that we focused on the safe use of oxytocin first, knowing that changing the current practice of elective inductions would require cultural and practice changes that involve not only health care providers, but women as well. As the organizations learn at a different level what is happening to all patients in their care, it becomes more evident and intuitive that the next focus is why is this patient here to begin with? In the work, we all agree with the outcomes associated with elective induction. As part of the second stage safety work, we began with understanding the current patient populations in individual organizations using the NQF, now JCT endorsed measure for Cesarean Section (Nulliparous women with a term, singleton baby in a vertex position delivered by cesarean section). The first surprise in the data was the actual number of women who did NOT make it to second stage, and I encourage all to study this group to understand how our systems and processes contribute to the outcomes. We all may know what we should do, the truth is unless we change our systems we will not change our outcomes and the cesarean rate will continue to increase. Thank you for all your work in this area.
My question- How can we mobilize women to partner with us to make this shift in care? Social movements are needed and many leaders have done this- you, Polly Perez, Penny Simpkin, and others. Is it time again?
I think Neal hit on it with both conclusions: Either many nulliparous women are admitted prior to progressive (active) labor yet held to dilation expectations of “active‟ labor and/or common expectations of active labor dilation rates (e.g. 1 cm/hr) are unrealistically fast.
This post betrays two very serious misunderstandings. The first is a misunderstanding of the Friedman curve. The second is a profound misunderstanding of standard deviation.
I know a bit about the Friedman curve because I trained with Dr. Friedman himself. He was the chief of my department at Beth Israel in Boston for the four years of my residency. He was an extremely difficult man to work with, but he was brilliant and a strong advocate for women.
The Beth Israel Hospital OB-GYN department was one of the first to invite fathers into the delivery room and had strict rules banning elective induction and C-section for non-medical reasons. He reviewed every case and Lord help you if you so much as tried to book an induction before 42 weeks. And you need to understand that although we graphed every labor, Dr. Friedman himself did not believe in rigidly adhering to the curve.
It helps to understand how and why Dr. Friedman defined the curve:
Dr. Friedman did his residency in the 1950s. He was not a man to suffer fools gladly and he considered a lot of his superiors to be fools. He felt that they made medical judgments based on their intuition and not on science, and he set out to accumulate the research data necessary to give the profession a firm scientific foundation.
During his residency, when he was on call every other night, he used his “spare” time to compile detailed observations about every laboring woman who came through the hospital. The goal was no less than to find out what normal labor looked like. Using observations from tens of thousand of women, he created a curve. Women who followed the curve were almost certain to have a vaginal delivery. Women who fell off the curve were more likely to need a C-section.
Dr. Friedman was the first to say that you should not section a woman in latent phase because a long latent phase was not a sign that the baby doesn’t fit. He insisted that you should not section a woman in the active phase of labor unless she failed to make a certain amount of progress in a certain amount of time. Dr. Friedman used to express the utmost disgust for doctors who would say, “she looks like a C-section to me”, instead of adhering to established criteria.
Dr. Friedman conducted his research before the advent of the epidural. It is worth investigating whether epidurals affect the curve, but the basic idea behind the curve is brilliant and he created precisely to avoid unnecessary C-sections.
The concept of standard deviation has been egregiously misrepresented. NCB advocates like to claim that medical definitions of “normal” are utterly arbitrary and exist merely for the convenience of doctors. Nothing could be further from the truth. Often, “normal” is based on knowing the outcomes from previous experience. We can confidently say that having an Apgar score of 1 at 5 minutes of life is not normal, because babies who have Apgar scores of 1 at 5 minutes always have serious medical problems of one kind or another.
Sometimes “normal” is defined as a range. That is not an accident, and it does not mean that a range was chosen arbitrarily. A normal range in medicine is almost always based on a basic and widely accepted form of statistical analysis, the standard deviation.
There is an excellent simple explanation of standard deviation on SensibleTalk.com. It is written for journalists who have no background in statistics:
“Let’s say you are writing a story about nutrition. You need to look at people’s typical daily calorie consumption. Like most data, the numbers for people’s typical consumption probably will turn out to be normally distributed. That is, for most people, their consumption will be close to the mean, while fewer people eat a lot more or a lot less than the mean.
When you think about it, that’s just common sense. Not that many people are getting by on a single serving of kelp and rice. Or on eight meals of steak and milkshakes. Most people lie somewhere in between.”
When you graph the data with calories on the x-axis and numbers of people on the y-axis, you will get a bell shaped curve. The curve is a graphical representation of all the possible things that can happen. The important point, though, is that every possible thing that can happen is not necessarily normal. How do we tell the difference between normal and abnormal? We start by calculating the standard deviation. The formula for calculating the standard deviation is complicated, but the result is relatively simple to understand. The standard deviation is a reflection of distribution of all possible outcomes.
Mathematically, one standard deviation on each side of the mean (the average) encompasses 68% of individuals. Two standard deviations encompasses 95% of individuals. Therefore, only 5% of individuals will be outside of two standard deviations from the mean. This is always true, regardless of whether the bell curve is tall and narrow or short and extended. “Normal” is usual defined as within two standard deviations. That means that “normal” is a range, but the range is hardly arbitrary. It reflects the actual distribution of results among large populations of human beings.
So when we look at how long a first labor lasts, for example, we can graph the labors of large numbers of women and we will get a bell curve. Ninety-five percent of women will fall within two standard deviations of the mean. It is only those women who are outside of two standard deviations that are considered abnormal. That does not mean that a woman whose labor is lasting longer than two standard deviations from the mean cannot possibly have a vaginal delivery, but it does mean that a woman whose labor is lasting longer than two standard deviations from the mean is far less likely to have a vaginal delivery.
The bottom line is this: defining normal as a range is not arbitrary. It is a reflection of what we know about human variation. The range of normal accounts for most of human variation. Anything that lies outside the range of normal is very unlikely to be normal.
Dr. Tuteur,
Thanks you for the wonderful backstory on Dr. Friedman and the importance of the Friedman curve. Unfortunately, many of us know from personal experience that the Friedman curve is *actually* used to determine when a labor should be augmented. Changing the limits to reflect this new mis-usage of the Friedman curve seems very appropriate to this end.
As for the “profound misunderstanding” of standard deviation, the author made no such error. Her comment was that, statistically speaking, the curve provides a label of abnormal that could be translated to mean “baby in danger.” The author’s comment that a standard deviation analysis in this situation has “no clinical significance” is related to her previous comment that there is no information on whether these babies/mothers are in a higher risk category of perinatal mortality/morbidity. The standard deviation cutoff is indeed clinically useless if it is being used to claim these mother/babies are in danger without that known link.
Thanks for taking the time to explain the statistics, though, and thanks for your comments.
Thanks for this thoughtful analysis, as ever! The thing I want to know is: how often are laboring mothers subjected to vaginal exams to determine their “progress”? I suspect vaginal exams themselves actually slow labor’s progression! It seems to me the only useful data to collect on a laboring mother are her blood pressure and the baby’s heart rate. When she’s ready to birth, she’ll know!
“Her comment was that, statistically speaking, the curve provides a label of abnormal that could be translated to mean “baby in danger.” The author’s comment that a standard deviation analysis in this situation has “no clinical significance” is related to her previous comment that there is no information on whether these babies/mothers are in a higher risk category of perinatal mortality/morbidity.”
I understand and she’s quite wrong about that.
The Friedman curve has NOTHING to do with morbidity and mortality. That wasn’t its purpose when it was developed and it is not its purpose today. It is, however, quite important clinically because it tells us the likelihood that woman will deliver vaginally.
A few additional thoughts:
1. The Friedman Curve was developed in the 1950s and thus, during a time when women had begun to labor and birth in hospital, and therefore in a supine/inactive position (not to mention the use of Scopolomine and other sedative/amnesic agents). This certainly would have affected the curve’s outcomes and, therefore, does not represent what is “normal” for physiologic labor and delivery.
2. Regarding the debate over significance of standard deviations: the mere fact that we, as human beings, decided that two standard deviations away from the mean = the range of normalcy when it comes to childbirth (and those people/numbers falling outside that range represent “abnormal”) is where the arbitrary nature comes in. So what if some women experience labor that lasts 1, 2, 3, 4 or 5% longer (or shorter) than the other 95% of their cohorts? Why does that occurrence necessitate the title of “abnormal”–particularly when there are no studies linking maternal/fetal safety or lack-there-of to labors sitting in the outlying time lines? It is only by our saying so, that makes those women statistically abnormal. Dr. Tuteur makes the comment that the Friedman curve has NOTHING to do with m/m. If this is the case, why does a woman’s labor falling outside the curve prompt her provider to intervene? Because of the fear of danger to mom/baby, right?
3. I can’t help but relate the points made in this analysis to the question of prodromal labor–another sticking point during which I have seen a lot of potentially unnecessary intervention occurring. How do we define a “normal” complete length of labor and birth when early labor can last anywhere from hours to days? I believe that because we are an impatient society with many quick fixes available to us, many have lost their ability to truthfully judge “normal” from “abnormal”–whether discussing active labor, prodromal labor, second or third stage, etc.
As I go along in life, I believe more and more that stopwatches are better saved for the kitchen when baking bread and the gym when working out…not in the labor and birth setting.
@Kathi Wilson
Thanks for explaining the system in Ontario and British Columbia Kathi. It sounds fantastic to me!
@Allison
The thing I want to know is: how often are laboring mothers subjected to vaginal exams to determine their “progress”?
From what I’ve read and heard, most women have VEs every hour while in labor, although the World Health Organization’s “Safe Motherhood” standards say that mothers shouldn’t be checked more often than every 4 hours.
My perspective on the progress of labor changed when I began attending homebirths. For the first time I saw a woman move freely throughout labor. The mothers position changes, intuitive desire to stand and rock her hips affected the postion and angle of the baby moving down and into position for birth. Some babies need to adjust their position. Sometimes the circumference of the baby’s head ( a larger head) takes longer to find that right angle. My daughter labored at home with home birth attendants and stalled at 5-6 cm for six hours. Her bag of waters was still intact when she transferred to the hospital. At the hospital she was given intravenous fluids (no pitocin) and allowed to continue in labor while the baby was monitored. Six hours later she gave birth vaginally to a baby with 9/9 apgars and 14 and 1/4″ head circumference.
I agree with Kimmelin–Dr. Friedman’s observations were limited and skewed by viewing labor within hospital practices.
Dr Tuteur, and Mrs Hyde http://skepticalob.blogspot.com/2010/08/anatomy-of-natural-childbirth-smear.html
“No study links a cut point for “abnormally slow” with an increase in perinatal morbidity, but averting adverse outcomes should form the basis for intervening medically because of the risks of intervention. ”
I’m simply a mother of five (all birthed in the hospital with no interventions, with carefully chosen, patient doctors), so I’m hesitant to jump into these deep waters, but this topic is of particular interest to me. The above point is frustrating to me; I cannot understand why this hasn’t been studied, especially when doctors DO, most certainly, use the Friedman Curve. Its usage has become so standard that when a doctor chooses to deviate from it, it’s cause for celebration from the natural-birthing world! Virtually all of my friends who have labored & delivered in a hospital setting, and three of my friends who are L&D nurses, agree that mothers are, indeed, bullied with the standard of 1cm/hr.
I’m not nulliparous, obviously, but to my surprise, the birth story of my youngest was recently chosen by the Mother’s Advocate blog as anecdotal support, I suppose, of how avoiding unnecessary interventions very often has a positive result. I was “failure to progress”, staying at 7cm for nearly seven hours, before spontaneously entering transition and birthing a healthy baby in 15 minutes’ time. http://mothersadvocate.wordpress.com/2010/08/16/the-birth-of-baby-fiala/
@B
I need to ask a favor of you. It is really easy and not very complex. It doesn’t cost anything and it is the right thing to do…
Please don’t use the words “Lay Midwife”.
There is no place for those words in professional conversation – particularly in reference to CPMs. The word “Lay” means untrained and so using it in reference to midwives who invest 3-5 years in a clinical setting learning their trade, and whose credential is accredited by the National Commission for Certifying Agencies (who also accredits the CNM credential) is not only incorrect, but is really offensive. To make the distinction between a credentialed and non-credentialed midwife, the appropriate and respectful words to use are “Traditional Midwife” when referring to the latter.
I trust this is not a big inconvenience for you.
Now, on to the few things we disagree on…
B said – “I think the university is exactly the right place to teach midwifery including a long practical period for hands-on experience. University midwifery programs do not contain only academic courses and there should not be a stereotype that they are theory only programs. ”
OK. I respect your opinion. I am not of the opinion that a university based program is a theory only program. I do believe an apprentice trained CPM is likely more capable of managing a home birth operation upon entry than a CNM, simply because she has been doing the specific job for a number of years.
B said – “How strange that teachers from primary school to college and university-level are expected to study at university-level, but midwives who may deal with life and death situations where some medical knowledge is necessary are only expected to have high school diplomas and a certificate from a midwifery school below university-level, especially ones that teach pseudoscience like homeopathy, aromatherapy, reiki etc.”
Well, I think I will just refer you back to the many professions in which an apprenticeship program is considered adequate, many of which have safety significance. My concern, which you kind of touched upon, is performance variability among preceptors. Recently, NARM increased requirements to be a preceptor that equates to an additional 2 years of practice after being credentialed before being qualified to serve as preceptor. In any event, requirements will continue to evolve, but, at the end of the day, it is licensure and regulation that assures performance and protects consumers.
B said – “I don’t think anyone needs a Masters degree to be a midwife, but they certainly should have a Bachelors degree with excellent academic and practical skills upon completion of the program. You’d likely find that nurses and doctors would be more cooperative working with midwives if they had at least the same education and qualification level as nurses.”
I agree that a graduate degree is not required to produce high quality midwives. I am not so confident that university degrees will improve the relationship between the hospital staff and the midwives as home birth CNMs also struggle in this regard. Please note that there are many CPMs who hold undergraduate degrees, graduate degrees, nursing degrees, associates degrees… in addition to the CPM credential. So, many conform to what you have described as your preference, yet it seems judgement has been passed.
B said – “@&$ (offensive language deleted) midwives scare the wits out of me. I read Gloria Lemay’s site and she implied that one young woman died from post-partum hemorrhage because her baby was not with her nursing right after birth. I tried to comment how ridiculous that was but it was never published. Midwives who can spout such nonsense are a danger to birthing women. We all know that nipple stimulation triggers uterine contractions, but serious pph cannot be solved by a breastfeeding baby! Complete ignorance about medical facts.”
OK. I don’t judge OBs by the spectacular few, but if those concerns are paramount for you then you must be a strong advocate for regulation as the CPM is indeed the primary care provider to women who choose home birth in the US whether they are regulated or not.
Can we produce credentialed home birth midwives better than we in the US produce them today? Sure we can. The best we can do today to manage planned home birth is to regulate CPMs irrespective of pathway. Ten years from now it may be different.
Russ
@Kathi Wilson
Hi Kathi,
The Ontario program sounds terrific (I travel there on occasion and I adore the people). I have a few questions for you…
1) From the time folks first started working on developing the program, how long did it take until it was active?
2) What did you do in the interim until the program was in place?
3) Do you produce enough home birth midwives from the program to meet the need?
4) Prior to the training program and licensure, what was the environment like?
5) Can you describe how many midwives are practicing who were not trained in the program?
Best,
Russ
It was actually a very fast (relatively speaking) turnaround from the universities being granted the program to its inception. I don’t know precisely, but I’m thinking not much more than a year. The program actually began prior to legislation (it started in 1993 and midwifery was not formally enshrined in legislation and funded by the province until Jan 1 1994). All midwives who had been practicing prior to legislation had to undergo a program of evaluation and upgrading in order to become registered (there were about 60 midwives in that group). I, personally, was apprenticing at the time that the program for “grandmothering” began, but did not have the numbers needed to do that, so applied to the first university class and was accepted.
All midwives in Ontario are “homebirth” midwives. Our regulatory college requires that all midwives attend and be competent at births both at home and in hospital — midwives cannot choose to be one or the other. We are required to submit “active practice” reports every 5 years that demonstrate minimum numbers attendance in each setting. It’s difficult to assess how many women who want homebirths are unable to access midwifery care, although in most places demand exceeds supply. We are roughly capped in the numbers of women each full-time midwives provides care to in a year — usually each midwife has 40 – 50 primary clients/year. Approximately 2% of babies in Ontario are currently born at home (overall, not just midwifery clients, and the rates within practices varies. My practice runs at about a 20% homebirth rate.
Midwifery in Ontario was never illegal, but rather alegal. Prior to legislation in 1993, there was no legislated midwifery in Canada; however that has changed over the last decade and a half, with only a couple of remaining Atlantic provinces not having regulation (which will likely change). Although midwives never faced prison in this province, there was certainly a good deal of suspicion and hostility, but there was also a very active consumer lobbying group that arose in the early 80’s that worked alongside some sympathetic high-profile supporters to accomplish legislation. That was also spurred by a couple of coroner’s inquests in midwifery baby deaths that led to recommendations that midwifery be regulated and legislated.
Don’t know how many precisely who are currently practicing who have not gone through the university program. Many of the original 60 have retired, but we do have a very active “bridging” program to evaluate and integrate midwives who have had formal training in other jurisdictions, which is a year-long program administered by one of the universities. There are currently about 500 midwives now practicing in Ontario, and I would hazard a guess that maybe 1/4 of them have come through the bridging program. Many of those have trained in the Middle East (many from Iran), UK and the USA (both CNMs and CPMs).
Hope that answers your questions!
Kathi
@Karen Joy
Enjoyed your birth story. It was great to read about your persistence and prayer–and the patience of your doctors!
I would like a good video to help teach nurses and/or parents about techniques to help open glottis pushing/non-directed pushing during second stage. I saw the webinar on AWHONN and would like a different option and have it discuss more about prevention of tears.
@Carol Van Der Woude
Thank you, Carol! I realized, at the time, that my doctor was patient (even the impatient nurse assured me that he was, indeed, likely the most patient doctor with whom she was familiar). But, the more I study about natural birthing, and the better I acquaint myself with standard birthing practice in the U.S., the more I am thankful that he was my doctor.
(By the way, I just subscribed to your blog, and put a request for your novel via inter-library loan, as my library does not have a copy. I’m always on the hunt for books that are good art + good message — it’s hard to find that combination!)
Midhusband (Russ) said, “B said – “@&$ (offensive language deleted) midwives scare the wits out of me.”
Lay midwife is not an expletive just because you don’t like the term. Please do not edit my comments to imply that I was using an expletive. I’d expect a professional not to play such games.
Russ, I certainly hope that you take a look at midwifery programs worldwide, especially in other countries with successful homebirth infrastructures and outcomes and see what the gaps are between current CPM training and that midwifery training. A large gap in curricula and apprenticeship should tell you something.
Well, B, we certainly have managed to push each other’s buttons, haven’t we…I do regret that. Maybe we should walk a mile in each other’s moccasins for perspective.
I am simply arguing from a perspective similar to this recent, and outstanding, Time article.
http://www.time.com/time/magazine/article/0,9171,2011940,00.html
Unfortunately, the entire article is not yet available online, but the fundamental message is go license CPMs.
If I could snap my fingers and install the Ontario program, with regulation, and sufficient quantities of midwives, I would do it in a heartbeat. If I think about what it would take to do that, I think of the following process steps…
1) advocate until a target university is charged with designing a program and activating it (3-5 years)
2) activate the program (1 year, but I think that is extraordinary)
3) graduate the first class (2-4 years depending…)
4) continue to produce midwives until the production rate offsets the attrition rate and growth in demand (2-4 years?)
Note that we would also have to assure that the licensing statute does not require a written practice agreement with a physician – the CNMs have been trying to change that for decades.
At this point, we can establish the new program as minimum required for entry.
So, if we start today, maybe we could achieve the transition in 8-14 years depending upon success. We need to address the safety issues today by regulating CPMs which is what every state that manages midwifery care in the home setting has done. We know the training model is adequate, even if others may be evaluated as better. Evolving to a university based program should be put in the context of a Multi-Generational Program Plan.
We should not let the perfect be the enemy of the good.
Russ
@mystic_eye
AMEN SISTER!
@Amy Tuteur, MD
It’s seems you have chosen to interpret this post as a “smear” on the reputation of your former colleague. It’s clearly nothing of the sort.
In the context of the contemporary practice of obstetrics (and midwifery), Dr Friedman’s original motivations in researching and developing his “curve” are quite irrelevant. (just like Margaret Sanger’s motivations and Dr Dick-Read’s motivations are irrelevant to a contemporary discussion of birth control or physiologic birth).
If the original purpose of the Friedman curve was to prevent unnecessary cesareans, then over the decades of its use, it has clearly failed in execution, if not in principle.
@Amy Tuteur, MD
As far as the standard deviation discussion, the statistical definition of normal (within 2 standard deviations of the mean) may or may not have any actual clinical significance.
Ask your primary care provider whether your blood pressure is normal, and I doubt that s/he would use a definition that includes 95% of the population. Instead, the range of normal is defined by its clinical significance – the threshold where blood pressure impacts the likelihood of having an adverse affect on health. That threshold is somewhat arbitrary (and has been revisited several times), but it is at least based on actual observed outcomes.
As far as labor observation and management, what is needed is not a more recent estimate of where the 95% cutoff lies, (since this has nothing to do with mortality or morbidity), but evidence-based guidelines based on outcomes.
When a clinician recommends either augmentation or surgical delivery, that recommendation ought to be based on clear evidence that such action is likely to have a better outcome than no intervention.
@Karen Joy
My daughter-in-law’s recent story was very much on my mind as I wrote my blog post. Her first baby, she was induced at 42 weeks for postdates. She hung up at 6 cm for many, many hours. Thanks to the watchful patience and excellent care by the staff at Kaiser Santa Clara–which included taking a break from the Pitocin for a shower and a rest (which allowed a restart at a lower dose), an epidural eventually, time to “labor down” before beginning pushing–and the knowledgeable assistance and support of her doula, my daughter-in-law gave birth spontaneously to an 8 lb 15 oz boy in the occiput posterior position. I am sure that at any hospital adhering to the conventional cookbook approach, she would now be recovering from her cesarean surgery. In fact, that would probably have been true a few years ago at this same hospital, but a new, progressive ob who graduated from resident to attending physician has been influential in changing the culture.
@b
“I mean, c’mon, why doesn’t any one address this”
because your argument contains so many falsehoods that it is hardly worth it.
“There’s no “perinatal database” RTFM.”
Yes, there is:
http://www.perinatreg.nl/home_english
“The LVR1, LVR2 and LNR registries are linked to one combined PRN-registry.”
You are trying to make an argument regarding the methodology by which the registries were linked. However, making the claim that the linked registry does not exist is an argument not worth having.
“There’s no actual data in this so-called study!! ”
Again, of course the data exists. The existence of the data does not depend on your acceptance of the way the linkage was accomplished.
“It is a couple of midwives that used a completely invented connection between homebirth and its outcomes.”
No, it’s not. The data linkage was performed by a different group of researchers, including epidemiologists and statisticians. One of the co-authors of the de Jonge paper was also involved with the data linkage project (ACJ Ravelli). She is an epidemiologist, not a midwife. Her contribution to the de Jonge paper was most likely related to her knowledge of the creation of the data linking methods.
And then there are your repeated disparaging references to “they just guessed”, “invented connections”, “fabricated links”.
A group of specialists in epidemiology, medical informatics, and public health developed a sophisticated method for linking the Dutch obstetrics, midwifery, and pediatrics registries. They published their methods and results in several papers in peer-reviewed journals of epidemiology and medical informatics.
Their primary result and conclusions:
“Independent validation confirmed that the procedure successfully linked the three Dutch perinatal registries despite nontrivial error rates in the linking variables.
Probabilistic linkage techniques allowed the creation of a high-quality linked database from crude registry data. The developed procedures are generally applicable in linkage of health data with partially identifying information. They provide useful source date even if cohorts are only partly overlapping and if within the cohort, multiple entities and twins exist.”
The linked registry has been used by other groups of researchers as the basis for a number of other peer-reviewed publications, besides the de Jonge study.
So, on the one hand, we have the opinions of a wide range of specialist professionals, who submit their work to peer review, whose product is considered to be a high-quality database suitable for further peer-reviewed work.
On the other hand, we have a random internet individual who disagrees with their methods and results.
I submit that if you want to undertake a serious criticism of the combination of probabilistic and deterministic record linkage techniques used to create the Dutch Perinatal Registry, this is probably not the right forum. And I’m afraid that “in other words, they just guessed” does not constitute a serious criticism. And your approach is certainly not strengthened by the inclusion of outright falsehoods.
I’m all for changes, even if they take time, as long is isn’t a case of maintaining the status quo because it is easier and pisses less CPMs off.
@Henci– Congrats to your family, and Kudos to that doc/staff! I hope this amount of patience will become the norm! How wonderful!
That’s a good size baby for an OP one! 
That pesky meta-analysis
That was supposed to be a trackback.
“My daughter-in-law’s recent story was very much on my mind as I wrote my blog post. Her first baby, she was induced at 42 weeks for postdates. She hung up at 6 cm for many, many hours.”
Why?
Do you suggest that people stop wearing seat belts because your daughter-in-law drove cross country without one and didn’t get hurt? Do you suggest that people refuse breast biopsies because your friend ignored a lump for 3 years and it turned out to be benign?
The recommendation to wear a seatbelt and the recommendation to biopsy all breast lumps are based on statistical analysis. Sure, you can get away with not wearing a seatbelt or with ignoring a breast lump. But that doesn’t mean it’s a good idea. Similarly, you can get away with a protracted labor, but that doesn’t mean it’s a good idea.
Telling “just-so” stories tike that of your daughter-in-law, and pretending that medical management should be based on them is just the kind of scientific nonsense that leads people to ignore NCB advocates.
I just read the Neal article in the July/August issue of the Journal of Midwifery and Women’s health in its entirety. I think some of the salient points that Ms. Goer does allude to include a) many labors will stall for greater than or equal to 2 hrs in the active phase and b) As dilation is progressively closer to 10 cm, the rate of dilation speeds up. So yes, labor does not typically proceed in a linear fashion and doing interventions in the 4-6 cm range in particular may not take into account a potentially normal physiologic variation in many nulliparous women.
I would comment, in regard to the penultimate paragraph, I don’t think that it can be assumed to be clinically insignificant when a woman’s labor length is in the far reaches of the norms despite the lack of a cutoff point at which is is known a poor outcome would result should labor continue. When a labor is truly prolonged, with or without intervention, there is often an identifiable reason. For example a larger baby, poor fetal positioning, dehydration or fatigue may be at the root. A prolonged labor demands that the provider look more closely to discover what might be holding up progress, and interventions may take many forms including or not including pitocin augmentation.
Finally, in regard to Ms. Tuteur’s comments, I did go to your blog to read the full flesh of your comments that you posted here. I found your tone to be spiteful and ill-willed when I read your posts in entirety. I would prefer a kinder approach in these professional discussions and debates.
Your analogy doesn’t work. From my perspective the seat belt is careful observation of mother and baby. Fetal heart tones are a measure of the baby’s tolerance of labor. The Friedman curve cannot be compared to a seat belt. If I followed your logic and fear-mongering I would never get in a car.
@Amy Tuteur, MD
[...] fallen on deaf ears among physicians, their trade union ACOG, and hospitals. In light of the solid new research of the past few years clearly demonstrating the safety of homebirth, how likely is it that [...]
A perspective from another OB –
The Friedman curve was the product of some brilliant research from a dedicated man, who put a great deal of work into defining the norms of term active labor. The data did show us 5th and 95th percentiles for typical labor, for term spontaneous labor. There is nothing wrong with this data, and it is somewhat useful, but one needs to consider changes that have occurred since Friedman collected his data.
Since that data two major things have changed:
1) inductions have become common, and Friedman looked at only term spontaneous deliveries
2) average BMI has increased substantially, and obesity is associated with slower labors (and shoulder dystocias)
Subsequent data to Friedman has been published has suggested that a ‘modern’ labor curve may be slower than what Friedman described, likely for the reasons noted above.
In my opinion, we must individualize care. If a patient is way off the curve, it may be that she truly will not deliver the infant vaginally, but if the strip is reasurring and the mother wants to continue the labor, it is in the best interest of the mother to give her more time.
A number of comments have taken issue with the idea of someone being at the 5th or 95th percentile being ‘abnormal’. I think these folks need to note take these terms so personally. Ultimately we are trying to identify women who will not deliver vaginally, or who will not deliver vaginally without injury to baby or mother. Most likely, all of these mothers will eventually be contained within the 5% outside of two standard deviations of the mean(true positives), but some of the women two standards from the mean will go on to deliver a healthy infant if given enough time (false positives). The concept of ‘abnormal’ or ‘normal’ in this case is purely a statistical definition, not a value judgement.
As for statistics being a creation of man, I would argue that if anything is a creation of something other than man, it would be the truth of mathematics. We didn’t create mathematics, we discovered it.
I think Henci’s example is a good one of how the Friedman curve can lead us astray. Her daughter in law had two issues that might push her off the curve 1) she was an induction and 2) her infant was OP. The patience of her physician, the staff, and the mother allowed the ‘false positive’ to be revealed and for the baby to deliver vaginally. As long as the fetal heart rate strip was reasurring, waiting that situation out did not bring additional risk, and ultimately was crucial in allowing a vaginal delivery. I disagree with Dr Tuteur here, in that this story illustrates good and patient labor management, rather than flaunting of some proven rules.
I agree with you Dr. Fogelson. There are so many factors that can influence how quickly or slowly labors progress, and Henci’s example was perfect… and I don’t believe that she was giving that example so that we can all forget about wearing “seatbelts”. Duh. Caregivers need to take these factors into consideration when using the curve and making decisions, and not use them as excuses to immediately jump to a c/s. This is also the reason that as patients, we need to explore these factors and how they can affect labor so that we can advocate for ourselves if needed. There may be women who don’t know that they may have a stalled/slow labor if baby is OP for example.
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Thanks for this! I had three friends link to that study from facebook saying “See? epidural’s AREN’T bad!” I agree with your *headdesk* sentiment. The study defies all logic.
The whole premise of this finding seems wrong on its face. Isn’t immobility and the supine position for the second stage the biggest contributor (after forceps, of course) to pelvic floor damage? And don’t epidurals nearly always result in immobility and supine delivery? Of course, hospitals do have other ways to get women to lay on their backs in bed, but it seems that the relevant comparison would be pushing position.
Once again you’ve utterly misrepresented a study. There are so many things wrong with your assessment that it’s difficult to know where to begin.
Let’s start with the most egregious. You claim:
“there is absolutely no data whatsoever linking the author’s definition of microtrauma to pelvic organ prolapse …”
That is flat out false.
The authors were attempting to determine why vaginal delivery increases the risk of pelvic organ prolapse and related symptoms in older women. Some women sustain visible damage to the levator ani muscles (macrotrauma) resulting in a gap between the muscles that the pelvic organs can fall through. However, many women who have no evidence of mactrotrauma go on to develop pelvic organ prolapse. The mechanism seems to be damage to the substance of the muscle itself (microtrauma) that leads to weakening and stretching of the muscles. That can also lead to widening the gap between the muscles, a weakening that may only be noticeable when the intraabdominal pressure is increased, such as when the woman coughs or sneezes.
Muscle microtrauma can occur in any muscle, is widely mentioned in the scientific literature and has been mentioned in connection with the levator ani muscles in previous scientific papers. No one knows exactly how the levator ani muscles weaken in the aftermath of childbirth, but microtrauma is a very plausible explanation.
Levator ani microtrauma is not a surrogate outcome since the study was designed specifically to look at all possible ways that the levator may be damaged by vaginal delivery.
The authors then looked at the factors that seemed to be associated with macro and micro trauma to the levator muscles. Operative vaginal delivery seemed to be the biggest risk factor. The authors noted in passing that epidural anesthesia appeared to be protective. It was a tangential observation, mentioned along with all the other associations.
The study is not about epidurals, has nothing to do with epidurals and makes no specific claims about epidurals. In your zeal to dismiss the possibility that epidurals might have any beneficial effects, you’ve trashed a study that mentioned epidurals only in passing. You’ve made accusations that are completely false. Levator microtrauma is real, accepted and potentially involved in pelvic organ prolapse. Microtrauma is not a surrogate endpoint, but a real and meaningful endpoint.
The gap between the study and the headlines was ridiculous. Thanks for clearing it up, Romano.
Thanks for this analysis! Urinary incontinence is a scary thing so stories like this are powerful.
I think the best (recent) historical example of misuse of unvalidated surrogate endpoints guiding clinical practice is in the Term Breech Trial, where the surrogate endpoints seemed to indicate additional neonatal morbidity with planned attempts at vaginal birth. However, follow-up with the actual clinical indicators showed no difference. However, clinical practice changed significantly and 10 years of experience and training with vaginal breech delivery was lost in the US.
I’m the senior author of the study discussed by you. After 25 years of research in this field it still depresses me how excited people get when it comes to research that may affect the choices made by women in childbirth. There is way too much ideology and zealotry out there for a rational discussion. Amy Romano, you seem to intuitively know what’s right- saying: “Maybe doing away with coached pushing, fundal pressure, episiotomy, and supine positioning might be the better strategy. ” How do you know? Where is the data?
And how do you know what ‘pelvic floor damage’ is? By all means do check my website if you really want to know:
http://web.mac.com/hpdietz1/iWeb/Site/Welcome.html
It seems you’re interested in those issues, and good on you for that. I’d be happy to answer any questions you may have, and I promise not to be prejudiced in any way. We all want the same: healthy mums and healthy babies. Just try and avoid the zealotry please.
And good on you for being suspicious about industry links. I’ve written about these issues (Dietz HP. Bias in research and conflict of interest: why should we care? Int Urogynecol J 2007; 18 (3): 241-243) and share your concerns. However, this study was not sponsored by industry, and I assure you that I do not currently receive any money or other benefits from any device or pharmaceutical company.
And thanks, Amy Tuteur, for your contribution. I agree with everything you said.
All the best
Prof HP Dietz MD PhD
Sydney
What an honor to have the author of the study write to you. That is pretty cool. I respect that you left his and Dr Tuteur’s comments and criticism up. I am hoping you make a statement correcting your representation of the study so that we don’t spread false information since all of us are simply promoting science and patient safety through patient education. You have a large audience and I would not want them to get the wrong idea. I like this paper because it was simply thought provoking. I do a lot of pelvic reconstruction surgery. More papers like this looking at the basic science underlying pelvic floor damage will help us improve our understanding and surgical techniques in the future. That is how I will apply the paper in practice. It didn’t really speak to me about labor management.
It’s always an honor when researchers come to this blog to discuss their research, so thank you Dr. Dietz. As I said in this post, my issue was more with the BJOG press release and related media attention than with the study itself. I think the study is useful, but that the headline in the press release that epidurals may be protective is premature based on this data. I assume you would agree with that statement. I worry, too, that since we know epidurals are associated with operative vaginal deliveries and prolonged second stage and appear to be associated with OP fetal position, too, and all of these are associated with pelvic floor problems, recommending epidurals as a strategy to reduce pelvic floor trauma based on this study may actually turn out to do more harm to the pelvic floor than good.
Where are the data on the alternative strategies I suggested? Fundal pressure is rarely documented and when it is long-term studies reporting its effect are unlikely, so we don’t have much data. But we know it is highly associated with anal sphincter injury, especially when used in combination with episiotomy. See the link in my post for more info on that. For coached pushing, see Schaffer’s work http://www.ncbi.nlm.nih.gov/pubmed/15902179. It also relies on surrogate outcomes, but the mechanism whereby a longer duration of more forceful valsalva pushing might lead to muscle injury and weakness is pretty clear (which stregthens the possibility that a surrogate outcome may be a good predictor of clinical outcomes). As for supine positioning, I don’t believe there is any data that supports or refutes an association with pelvic floor strength and function, because maternal position during second stage and the moment of birth itself isn’t reliably or consistently documented and long-term studies that look at outcomes (surrogate or clinical) relative to birth position are nonexistent as far as I know. The Cochrane reviewers who looked at position in the second stage in women without epidurals found no data on long-term outcomes but reported a small decrease in instrumental vaginal births as well as a reduction in second stage duration and use of episiotomy. Seems plausible that there may be a protective effect, then, on the pelvic floor. Like I said, though, I don’t know for sure, which is why I said “maybe”.
Another issue about advising epidurals to protect the pelvic floors is that there are many different types of epidurals, different ways of managing labors with epidurals, and lots of other covariables. Like you said in your paper, you have no data on the duration of active pushing versus laboring down in the women in your study (do you know if laboring down is the usual practice in the setting?). There are still many places where women are valsalva pushing from the moment they’re 10 centimeters with an epidural and instrumental delivery is done routinely if the baby isn’t out after 2 hours. In that setting is an epidural good for the pelvic floor? Probably not, but for a woman (or her provider, anestesiologist, etc) who has only read the headlines or the study abstract, they may well conclude the opposite.
Yes, I care about pelvic floor outcomes in women and like I said I think this data may prove useful for understanding pelvic floor issues and for that matter epidurals – especially if other research follows up on some of clues and inferences in your data. But I honestly think the media attention, which started with the BJOG release, should be considered malpractice.
As for Dr. Tuteur’s assertion that microtrauma is not a surrogate outcome, I stand by my assertion that it is, using the definition that tells us that surrogate endpoints are substitutes for “how a patient feels, functions, or survives.” And the idea that epidurals were mentioned only “in passing” in the study is absurd. Why was it in the abstract, keywords, 12 times in the manuscript itself including a whole paragraph devoted to it in the discussion, in the headline of the journal press release, and in the headline of countless media stories? Far more women have read or heard in the past week that epidurals protect the pelvic floor than will ever read this post or any other criticism of the study or the media management of it. I saw a comment on a newspaper web article yesterday from a first time mom saying she is fearful of giving birth and ending up peeing in her pants and now after reading the story is more inclined to get an epidural. Should she not be exposed to another point of view about the strength and usefulness of that data, or told of other low- to no-risk strategies that *might* (or in some cases *will*) protect her pelvic floor?
@Jeff Livingston, MD
Thanks for your comment. I’m not sure what you think I misrepresented. I stated, “there is absolutely no data whatsoever linking the author’s definition of microtrauma to pelvic organ prolapse or other important pelvic floor problems such as incontinence or sexual dysfunction” This is relevant to how useful a surrogate endpoint microtrauma will turn out to be. I think you and I see this similarly – that this was a useful study for showing the prevalence of this type of muscle injury and proposing a definition based on serial ultrasound measurements that can be used to diagnose microtrauma. It seems the next study should be to use that definition of microtrauma and see if it correlates with clinical outcomes such as pelvic organ prolapse, incontinence, etc. As far as I can tell, no one has done that, which is why I made that statement. Another way it might be useful is to measure the effects of treatments for muscle injury (not my area of expertise.)
If it’s another thing in my post that you want me to clear up, let me know. But as of now I stand by everything I wrote.
To anyone with a background in normal physiological birth, studies like this are just depressing because it is not that they are comparing “normal” birth to birth with an epidural… they are comparing normal *interventive and managed birth* in a hospital setting, with normal interventive and managed birth with an epidural. To me all this study suggests is that when birthing in a managed hospital scenario, it is possible that an epidural may result in less damage overall.
Call me when there is a study comparing epidural use to self-directed natural pushing in woman-led positions, and I’ll get excited.
A key characteristic of science, as opposed to pseudoscience, is that all possible outcomes are allowed. That’s why “intelligent design” is not science; there is no evidence that would lead it’s advocates to announce that there is no “intelligent designer.” The conclusion is predetermined.
This analysis of a scientific paper veers perilously close to pseudosciece. It starts with an unalterable conclusion – under no circumstances can epidurals be beneficial. It then precedes to trash the study, making demonstrably false claims about microtrauma and negative insinuations about the authors’ integrity, for the SOLE purpose of insuring that no one credits the observation that epidurals may be protective. Finally, with absolutely no data, it asserts that the current recommendations of NCB advocates would surely be protectve.
Frankly, I think you owe the authors of the study an apology and a correction. You deliberately mischaracterized their work and impugned their integrity to fufill a private agenda of demonizing epidurals.
I’m not going to comment on the research because I have not read it. However, I can theoretically see how an epidural could relax the pelvic floor muscles and allow greater stretch for those women who do achieve a vaginal birth with an epidural. Unfortunately most women with or without an epidural are subjected to a number of interventions that increase the risk of perineal trauma during birth. I conducted an extensive literature review for my PhD and in summary practices associated with increased risk of perineal trauma are: directed pushing; the use of analgesia and anaesthesia; an instrumental birth; hands on techniques; squatting, supine or lithotomy position. If you want the references and full literature review you can download it here:http://www.box.net/files/0/f/0#/files/0/f/0/1/f_474591782
There is also a study by Professor Hannah Dahlen in press which found an increased risk of perineal trauma associated with: obstetrician care vs mw care; land birth vs waterbirth. I bet the media do not pick up on this research when it is published. Can you imagine the headline “Waterbirth with a midwife protects the pelvic floor!” – no chance.
What we need is further research into physiological birth (ie. birth where women are left to get on with it). In addition it would be nice if the media reported research in a non-biased and non-sensationalist way so that women could have access to all information (from both sides of the birth divide). It would be even nicer if midwives and obstetricians could work together to provide the best possible maternity care for women. If we shared knowledge and respect we could revolutionise maternity care and outcomes.
@Amy Tuteur, MD
A key characteristic of science, as opposed to pseudoscience, is that all possible outcomes are allowed. That’s why “intelligent design” is not science; there is no evidence that would lead it’s advocates to announce that there is no “intelligent designer.” The conclusion is predetermined.
I am LOLing at this!! Your blindness on this point is staggering. I’m not trying to derail the comment thread, and I do hope that I don’t, but I had to take this up. What you say of “intelligent design”, and what you have previously said of creationism is exactly what you should also say about the belief in evolution. I will not derail the thread but cannot allow this point to pass unchallenged.
There is no evidence that would lead the advocates of evolution to announce that blind, purposeless chance did not bring about this universe and everything that is in it.
As long as modern obstetrics continues its assault on women through the use of practices that are based in $$ rather than in evidence-based medicine, I am thankful that we have well-trained home birth midwives available. For those women that are unlikely or unwilling to go to the hospital, I am thankful that we have the same. For those women that have precipitous labors and refuse induction, ditto…
Life is not perfect. Planning is not perfect. While I support those that find the hospital their most comfortable place for birth, we must take care not to alienate those that find otherwise — at the risk of creating more of a problem than we solve. And certainly OBs cannot at this time claim to be problem free, what with all the absolutely unnecessary c-sections, epis, inductions, managed labors and tests that do not have reasonable research evidence to back them up.
That said, I also support excellent training for home birth attendants — ideally a combination of coursework and hands on practice. That is what we have in the CPM credential. In my state, a vast majority of the CPMs have BA/BS degrees or higher. And most have years of observation and hands-on work before they attempt the credential process.
Just like any medical personnel, it makes sense to shop around. I will certainly point out that it is way more likely to have an OB with serious issues still practicing, since there is no required reporting that the consumer has access to. The anecdotes of negativity can go both ways, from the woman who dies of intestinal perforation from her c/s to the postpartum hemorrhage. It would be so nice if people could step back and realise that women are people who deserve choices, not just vessels for a child. PTSD and trauma can be avoided in all settings, when care is appropriate for each individual, and guided by a combination of empathy, compassion, caring, and evidence-based medicine. Demonizing either side, or deciding that one side is somehow intrinsically of more value or has intrinsically better outcomes is childish.
” I conducted an extensive literature review for my PhD and in summary practices associated with increased risk of perineal trauma”
You are talking about damage to the superficial tissues of the perineum. We are talking about damage to the deep musculature, an entirely different issue.
@Amy Tuteur, MD
The media does not make this distinction in it’s reporting. I’m sure women are interested in all areas of their perineum and how to avoid damage. Why report one study and not the others?
@Amy Tuteur, MD
This analysis of a scientific paper veers perilously close to pseudosciece. It starts with an unalterable conclusion – under no circumstances can epidurals be beneficial.
On the contrary, Amy Romano admits the possibility that an epidural may be protective, but wonders aloud if it is the best protection of pelvic floor trauma, when you consider that epidurals increase the likelihood of the need for forceps. In fact, I know that most NCB advocates will say (perhaps not every time they use the word “epidural,” but with some regularity) that they know of instances in which an epidural was either beneficial or necessary; including many times in which an epidural was the key in a woman ending up having a vaginal birth, instead of a C-section. But it still doesn’t change the fact that epidurals have downsides and negative side effects. Nor does it change the fact that epidurals are associated with greater use of forceps, which definitely leads to greater pelvic trauma than an unassisted vaginal birth.
In a similar fashion, proponents of circumcision can point to certain studies that seem to demonstrate that cutting off part of a penis may lead to a reduction in the transmission of HIV/AIDS; yet intactivists can show that condom usage and monogamy (or abstinence) are far better methods of reducing the spread of diseases including HIV/AIDS, and that even if circumcision provides some protection against the transmission of AIDS to or from the man, that it still leaves a man very vulnerable to AIDS, when compared to intercourse using a condom.
“The media does not make this distinction in it’s reporting.”
Regardless of what the media does, you, as a midwife, should be cognizant of the difference.
@Amy Tuteur, MD
I am thanks.
I have read the post, the criticisms of the post, and your replies, Ms. Romano.
I don’t have anything to add, as assessing studies is not my gifting. I can say that I appreciate how respectful your tone always is, and how much you simply make sense. I’m reasonably certain you don’t think epidurals are “bad.” I certainly didn’t take it that way…I understood you to be saying that all the hooplah around this was unjustified. From all I can gather from this discussion, this is basically a study that tells us we should study this more…
Do I have that right?
[...] the study itself, only representations of the story in various places. I know that Amy Romano at Science and Sensibility is sceptical, and I think she is a pretty trustworthy source of information. It has been [...]
I talked to a nursing Ph.D. candidate who’d dissertation was research on women and kegels. 96 woman, early 20’s to mid 60’s none could kegel properly. Some had been instructed by physicians, some had read about it, some had never heard of it. This candidate also quoted a doctor as saying “I can talk any woman into surgery.” There is no meaningful reason for anyone but the woman to know how to do a proper kegel.
This relates to the pelvic floor discussion in that we cannot work/exercise, protect, recover what we do not know. All women need to know their bodies better.
Nice. my thoughts exactly!@Krista
>> There is no evidence that would lead the advocates of evolution to announce that blind, purposeless chance did not bring about this universe and everything that is in it.
I can’t quite decipher this, but it sounds like you are saying that evolution has as little evidence for it as creation. If so, that would be a staggeringly incorrect statement, as there is really no question that the variation of species on this earth is due to evolution. From phylogeny to DNA evidence to fossil record, everything is absolutely consistent with evolution of species over the millions of years that life has existed on this planet.
Amy – I’m pretty surprised at your post here. It seems like a lot of your followers and fans got wind of this article and wanted to see it trashed, and you did it to please them. I have to agree with Amy T that your criticism of this article is not justified. The idea that they are using surrogate outcomes is incorrect. The point of the paper is the identification of microtrauma. That is the outcome they are measuring. If it were a surrogate, they would be making claims about epidurals and some other downstream outcome, which they are not.
The idea of microtrauma of muscles is a well documented idea, and is the basis of much if not all muscle remodeling. The soreness one feels after working out is the results of this microtrauma, for example.
To me it feels like you started out with the desire to deny the results of this study, rather than looking at it from an objective point of view.
Amy, thanks for taking this up. I do hope this study leads them into further studies. Unfortunately the conjecture about the possibility of epidural protecting the pelvic floor seems to have been hijacked by the media, and is what potential mothers are reading. These simplistic conclusions don’t usually end up carrying much weight in six months’ time. This conclusion does not appear to be the main aim of the research.
I have read their responses on their Blog. Academic discussion so easily turns into mud-slinging. It is not possible for an ordinary woman like me to critically appraise either side. Unfortunately, this rhetorical nitpicking overshadows the benefits of La Maze’s methods, which are almost totally at odds with the degree of intervention these obstetricians are talking about. They are trying to perfect intervention, and work out ways of repairing the damage they cause, which is the only moral path for them. At least they admit that there is a lot they do not know, but at the same time they seem to be saying that Lamaze knows nothing, which is clearly untrue. This discredits them in my eyes.
I have been fortunate to benefit greatly from Christine Kent’s work with non-surgical management of pelvic organ prolapse so the quest for better surgical repairs is a bit like the quest for a better designed machine gun, as far as I am concerned – totally irrelevant.
I can read. I have education. I have internet access. These factors did not prevent my first labour being fully-managed. I will never know how medically necessary it all was. These factors have given me a means of living an energetic and normal life despite the prolapses. It is the millions of women throughout the world who do not have these advantages who are vulnerable to saying yes to all these fixes which may improve their lives in the short term, but multiply the risks to their bodies when they start the surgical repairs treadmill.
My second and third labours and births were much less medicalised, thanks to Lamaze and his followers. Macrotrauma? Microtrauma? Phooey! To me, it doesn’t matter what caused it. What is important is how women like me respond to it.
@Nicholas Fogelson, MD
I’m saying that evolution is not falsifiable. There is no evidence that would lead its advocates to announce that evolution is not the cause of everything we see today or in the past. You bring up phylogeny and the similarity of DNA as a proof of evolution; I say it is a proof of a common Designer. You bring up the fossil record, I say it is merely millions of dead things buried in rock layers laid down by water all over the earth. Charles Darwin believed that his lack of proof for his hypothesis of evolution was due to the fossil record not being very well studied. He said that there should be innumerable transitional forms, and that if they were not found, then it would show that he was incorrect. They have not been found, and nobody has a reasonable explanation of finding them… yet it is not seen as disproving evolution.
Now, here I am derailing the thread. Sorry.
Dr. Fogelson, Dr. Amy, or anyone else, if you really want to take this up, you can go to this post I just published and have at it. I won’t think anything negative if you don’t feel like taking me up on it; I really don’t feel like the time either, but we can discuss it if you have the time and inclination.
Would love to read your article, but the link doesn’t seem to be working…
Here’s a quick primer on the falsifiability of evolution, Kathy:
http://atheism.wikia.com/wiki/Disproving_Evolution
Is there no micro or macro trauma (in general, obviously not lavator) associated with cesarean section? Does microtrauma lead to some sort of clinical problem? Where’s the evidence? If there is no proof that microtrauma leads to health problems, what’s the point in even looking at it? The “downstream outcome” Dr. Fogelson mentions is prolapse. Are the authors claiming that epidurals may prevent future pelvic organ prolapse, because that’s what the press release says:
BJOG release: The use of epidurals may help prevent future pelvic organ prolapse
Why bother to look at microtrauma without the assumption that it leads to permament problems? Here’s what the study says. Why the disconnect? Yikes.
“Intrapartum epidural appeared to have a protective effect (P = 0.03; OR 0.42; 95% CI 0.19–0.93).
Conclusion Levator trauma at the time of first delivery is associated with vaginal delivery, forceps and a longer second stage. Epidural pain relief may exert a protective effect.”
An honest obstetrician would admit that the press release, and the RCOG overreached from the study itself. That’s not just the media.
It’s certainly plausible that epidurals relax the pelvic floor enough to prevent damange. It’s also plausible, and falsifiable, that epidurals could cause an increase in forceps deliveries, and have the opposite effect. That puts the discussion firmly in the realm of science rather than pseudoscience. Unlike creationism vs evolution. Creationism/intelligent design is an argument based on faith rather than evidence.
First, no more talk of creationism or intelligent design on this blog. Please follow Kathy’s link if you want to get involved with that. I will delete or edit any further comments that weigh in on that “debate”.
No, I shared with my readers a degree of skepticism about the study’s findings because of what I’ve said here already many times – there is ample evidence that epidurals are associated with outcomes such as instrumental delivery, OP delivery, prolonged second stage, and excess perineal trauma that all seem like they would, if anything, weaken the pelvic floor. Any time a new scientific finding is published that refutes conventional wisdom or other science, it deserves scrutiny. I did not set out to trash epidurals or this study because it dared to say something good about epidurals. I set out to sort out what was behind the disconnect – a real protective mechanism or science that may be flawed or limited? Or some other factor? I admit openly to being “biased” at the beginning of my quest, but I was biased because of the large body of *science* showing that epidurals have real, measurable adverse effects, including several that have potential significance for pelvic floor strength and function. They also have a very significant benefit – excellent pain relief, which is why I would never judge a woman for weighing the pros and cons and choosing one. But let’s do our best to give her solid evidence that helps her understand the likelihood of the real outcomes she cares about (peeing in her pants, needing future surgery for prolapse, etc.) Surrogate outcomes, by definition, don’t do that. More specifically, this novel surrogate outcome (a method of ultrasound measurement defined and described for the first time by these authors) does not and cannot do that.
And while I don’t argue with your assertion that the authors were looking specifically at microtrauma and so it was appropriate for them to measure microtrauma, it is still a surrogate endpoint for pelvic floor function and strength. And the press release made claims about pelvic floor function and strength which is why it is appropriate to ponder whether the ultrasound findings described in the study are a useful surrogate.
My main key message I was trying to get across by writing this post was this: please use caution when applying research on surrogate outcomes to patient care. History shows it can backfire.
And let’s talk for a moment about bias. The profession of obstetrics has offered women three strategies for protecting the pelvic floor: routine episiotomy, elective primary c-section, and now epidurals. Oops, after decades of blind faith and routine use it turned out that episiotomy isn’t effective. So cross that one off the list. That leaves two options. And they have some things in common: they give doctors (rather than women) more control over the birth process, doctors and hospitals get major revenue from their use, and they have documented risks so any real or perceived pelvic floor benefit is a trade-off from the woman’s perspective. Also, some women have pelvic floor problems despite their use – so they’re no panacea. The idea that no one but obstetricians (who understand the science of muscle physiology better than lay people or midwives) may offer any ideas as to how to prevent pelvic floor problems when OBs are offering only risky and costly interventions is absurd and elitist. In any area of health there are prevention strategies that don’t involve doctors. In fact, most of the best prevention strategies don’t involve doctors, but no one gets paid for them so they don’t get used, except by those few engaged, motivated, health-conscious people. And, because industry funds so much of our research and there are few devices or machines that help with prevention, research on low-tech or behavioral prevention strategies is underfunded. Any one of us may have our individual biases and manage them well or poorly, but clearly our system is biased toward offering women doctor-controlled high-tech interventions over women-led, low-tech options.
Happy Labor Day, everyone! May every woman have an opportunity to labor in health and safety!
@tanya@motherwearblog
I just checked the URL in multiple browsers and it seems to work for me. The design of the page is markedly different from last time I saw it, though, so I wonder if the page was inactive for a period of time while they upgraded. Let me know if you continue to have problems. http://www.ingentaconnect.com/content/lamaze/jpe/2010/00000019/00000003/art00009
Amy,
Four different doctors have already explained to you that you are wrong in your invocation of surrogate endpoints and you won’t admit it and apparently don’t understand it, so let me try again:
There is a difference between basic research and clinical research. Basic research, as the name implies, is research on a scientific phenomenon that may or may not have clinical implications. So, for example, when Alexander Fleming noted and then researched a mold that killed the bacteria in his petri dishes, he was doing basic research. He announced that the mold made a substance that killed bacteria (an “antibiotic”) and speculated that the substance (named penicillin) might kill bacteria that were making people ill.
His research on penicillin reported bacteria kill rates. That was not a “surrogate endpoint” for lives saved, because he was looking at the actual action of penicillin. The fact that he speculated that penicillin might save lives does not make the bacteria kill rates a “surrogate endpoint.”
Similarly Shek and Dietz are doing basic research on levator trauma that may or may not have clinical implications. They were looking at what happens to the levator muscles in the wake of childbirth. They found that there could be macro trauma (such as avulsion) and microtrauma. They also reported on factors that increased or decreased the risk of these changes. They were not researching prolapse. They did not clan that muscle injury leads to or is the cause of prolapse; they merely speculated that it might be related.
Interestingly, you gave the authors a pass on their claim that forceps increases the risk of levator trauma. You could have made an impassioned argument that forceps might be beneficial and that the authors used a “surrogate endpoint” of levator trauma to unfairly malign forceps. You ignored that entirely.
So let me ask you directly: Do you believe that the authors observation that forceps increases levator trauma should be ignored because it is a “surrogate endpoint”?
@aly
Please come to my blog post.
[...] Goer provides a top-notch (as always) review of research on dilation for first-time moms on Science and [...]
And you certainly can have pelvic floor damage and incontinence problems without EVER having been pregnant, let alone birthed a baby.
@Amy Romano
Not having read the study yet, I wonder what kind of care the women without epidurals received. With all due respect, most doctors I have worked with do not know how to support a woman in natural labor. If the women in this study who had a drug free birth were like most of the women I work with, and received no help or care to work through a natural birth, this could make a difference.
For example, if the women who received no epidural, were encouraged to push the way women with an epidural were, I would not be surprised if they were to recieve more perineal trauma. It makes sense to me that women who feel the urge to push and are encouraged to push as hard as women who have epidruals, are putting a lot more force behind that push.
On the other hand, if they have a competent practitioner that knows and understands how to support a physiological birth, they may push a different way that might help to preserve the perineum better. (This is of course not proven by research, but it would be interesting to see this done).
In the case of this study, I’m guessing, it is comparing a group of women who receive epidurals and are cared for my doctors that know how to care for them well, to a group of women who don’t receive epidurals and are cared for providers that don’t know how to best support them in their pushing efforts.
Something that makes me think that the outcomes would be different if these two groups of women were treated differently, are the homebirth studies done. Whatever you want to say about the safety of homebirth, I think that most studies show that there is less perineal truama in a homebirth-obviously these are done without epidurals by providers that know and understand how to support woman in natural labor.
But I do think this should also make us, as natural birth advocates, look at this and ask ourselves the question, “why would an epidural help protect the perineum”? If it does, how can be best help those who wish to not have an epidural, receive the same degree of protection? If this research does pan out, then we should be looking at how best to help women achieve the same results who choose to go without drugs.
Just a thought, and before Amy jumps down my throat, yes more research would need to be done on this hypothesis, and as I have not read all the research on homebirth or this paper, these are just my own thoughts and opinions, and recognize them as such. Also, I am not trying to debate the effectiveness or safety of homebirth….does that rule out everything Amy? I guess I’ll see:)
Cutting to the chase. There is an excellent meta-analysis indicating that immediate directed pushing is the culprit, even with an epidural!
See: Brancato et al. A Meta-Analysis of Passive Descent Versus Immediate Pushing in Nulliparous Women With Epidural Analgesia in the Second Stage of Labor. JOGNN, 37 , 4-12; 2008. DOI: 10.1111/J.1552-6909.2007.00205.x
More back up evidence…
Less Pelvic Floor Damage Associated With Uncoached Than Coached Pushing During Labor, AUGS/SGS 2004 Joint Scientific Meeting: Abstract 14. Presented July 30, 2004.
“…no evidence that bearing down during contractions helps either the mother or the child…” Bloom et al. The American Journal of Obstetrics & Gynecology (Jan. 2006).
I just found this blog and found it very interesting. I apologize for coming so late to the discussion!
My first is 15 months old now, and I wore her very, very often as a newborn. We had a Maya wrap first and then a Mei Tai-style carrier. We just got a stroller for her last week, and that mainly because (1) she now weighs 21 pounds, and even in the Mei Tai that can be a challenge over long distances, and (2) we are about to get a replacement for our infant (bucket) seat, so no more Snap ‘n’ Go. So, yes, I think babywearing is incredibly valuable and I’m glad for that time I get to spend in skin-to-skin contact.
However. There is not a dichotomy here. It is not babywearers versus infant-car-seat users; any one set of parents can balance both. To characterize people who let the child sleep in the infant car seat (as opposed to taking them out and waking them up? is that really better for the infant?) as selfish is not fair, and more practically, contributes to the off-putting stereotype of babywearers/breastfeeders/natural-childbirth advocates as Holier Parents Than Thou. (And as far as “being home for baby’s nap time” — if you know the secret for keeping my kid from falling asleep during a 5-minute car ride to the park or playgroup, please do share it with me. Otherwise we’re stuck at home as she transitions from two naps to one, and it’s driving me nuts.)
I like babywearing. I like keeping my girl near me. I don’t like using babywearing as an excuse to consider myself superior to other parents, because I know I’m not.
I am a G2P2, 1st baby c/s for breech, 2nd baby vbac (proud to say). About 2 1/2 yrs after my c/s I begain to notice a large lump at the c/s incision. There had always been a knot there but over the 2yrs became larger. My doctor performed an ultra sound & diagnosed me with endometriosis. I also had other symptoms prior to that for about a yr of pain during intercourse, painful and long cycles and pain during bowel movements. I had never had any problems prior to my section. I had an ablation soon after the diagnosis and my doctor said there was minamal endometrium growth elsewhere but a moderate amout of course at the incision. My doctor was easy to say that I would have a hysterectomy as an end result over the course of the next few years. I was 34 at the time & this did not set well with me. Shortly after the surgery I was put on birth control for 4 months & stoped to try to get pregnant, which I did immediately. I gave birth 3 months ago & have already started back with long periods of bleeding (34days so far) while on birth control. My doctor has put me on estrace for 30days every day along with the birth control. I have attempted several conversations with my OB about this being a direct result of the C/s but he is not responsive. I would love to see this topic studied more. This could maybe lessen the amount of “elective” or unnecessary c/s from happening. I am a postpartum nurse that sees a lot of unnecessary sections performed. For me it was necessary, but I never knew that endometriosis was a risk. Thank you for having this topic discussed. I think it may help people understand what perhaps they may be going through.
“There is an excellent meta-analysis indicating that immediate directed pushing is the culprit, even with an epidural!”
That study doesn’t even address the issue of levator damage or pelvic organ prolapse, let alone identify the culprit.
Thank you for sharing your story. It makes me feel good to know that women have found my blog post helpful. Perhaps the reference list that accompanies the post might convince your OB that endometriosis can arise as a result of cesarean surgery.
>>although many physicians would agree in theory that honesty, transparency, and disclosure are all good and right things to do for patients in the aftermath of a serious adverse event, it was unlikely to happen unless a business case could be made and it could be shown that such an approach would not put hospitals and clinicians in further financial or legal jeopardy.>>
I don’t believe him.
90%+ of the malpractice cases that actually go to trial result in a win for the physician, though it’s time-consuming and expensive for personal injury attorneys to prepare these cases. That’s why most are settled or abandoned entirely rather than going to trial. For physicians, the risk of losing is relatively small, and of being ruined financially, negligible. The real fear (and dread) for physicians is simply of being sued, no matter how small the lawsuit, and no matter the degree of fault on the part of the physician. Physicians don’t want to be sued, ever. Why? Because it’s human to be reluctant to admit one’s imperfections. Physicians are human, no different and no better than attorneys, mechanics, or waitresses.
Our society in general is reluctant to admit fault; we’ve become increasingly rude and selfish over the last fifty years or so. Our great-grandparents would likely be appalled at our behavior. No one wants to be accountable for his or her shortcomings, even those in a position to cause great harm.
(For context: I’m an equine veterinarian. We’re the most frequently sued specialty in veterinary medicine.)
Side note: I’m so happy to see you posting. I am very interested in your thoughts on practical steps the medical profession can take to change the current poisonous culture, which is unhealthy not only for patients who have been harmed, but for healthcare workers including physicians.
All I want is an apology. I want the doc and nurses to realize how they treated me (and most likely other woman) is unacceptable and make efforts to change for the better.
Some people tend to be sue happy but really no amount of money will make them (or me) feel better (not talking about covering medical expenses for mistakes that lead to needing on going medical care). I realize docs are only people and people make mistakes…but that is no excuse to be rude and uncaring because you are afraid of being sued… no reason to lie to patients and not document things that happened because of fear of being sued….suck it up, own up, apologize, or change professions
interesting information about infant development (spinal, hip, respiration, etc.)and upright position
http://www.sleepywrap.com/Research/uprightposition.pdf
yes, the sleepywrap is a baby carrier, but the product they are selling is essentially a long piece of fabric (anyone can make one cheap).
safety and babywearing
addresses sling recalls, and give safety tips
http://www.undercovermother.net/2010/03/babywearing-real-deal-on-safety.html
things babies shouldn’t sleep in:
http://www.idph.state.ia.us/hcci/common/pdf/sleep_positioning.pdf
second page is a list of examples of babies who died of strangulation or asphyxia while sleeping in various pieces of equipment.
bottom line is, be constantly aware of your infant. what better way than having her right on your chest?
My husband’s grandmother was killed through a medical error. She probably would have lived another 6 months – 1 year otherwise. (She was taking a blood thinner that was not stopped before surgery and bled out, the physicians did not communicate about her meds – and she was an inpatient at the time).
His family never thought of suing; they just wanted an apology. Fortunately, because her daughter (husband’s mom) worked at the hospital, they got it. And the family was given an update about 6 months later concerning new safeguards installed.
It seems like most people want an apology and to know what is going to be done to prevent it. If the medical community cannot do this (because it admits fault) then people will sue to make sure their experience was not for nothing.
Of course, concerning pregnant women/new mothers, suing isn’t usually an option if you end up with a “healthy baby.”
[...] and Sensibility blog explains what’s misleading about last week’s headlines proclaiming epidurals protect the pelvic floor. Is science reporting always so [...]
@chukwumaonyeije
Hello, I am writing you with a concern that i have. I am 33 and have 3 living childern, 3 repeat sections being atleast 3 years apart and the last over 6 years ago. I was told by my DR during my 3rd that i should tie my tubes, as more then 3 sections was a very high risk. During the 3rd section, my DR noted very thin uterin window (said that he could see the baby), also lots of scare tissue and the bladder was adheared to the uterus. He also notice a “runt” in the bladder that had to be reparied. Well, Needless to say he did tie my tubes that day… It is 6 years later and I want another child. Other than the noted problems with my 3rd section, i have no health issues at all.. i do not drink, smoke or have any other issues that i see a Dr for. I am wondering WHAT the chances are that I could carry another child? Thanks so much for youe time!
Ps, I do understand that I would need to have IVF completed if i were able to carry another child.
Thanks again,
Carrie
I came out of hospital one month ago, i went in with what was thought was a hernia. Turned out to be Endometriosis, on my c section scar. I had my last child 5 nearly 6 six years ago and have been suffering
since his birth.
Carrie, I could have written your post aside from having my tubes tied, because I refused. The doctor doing my c-section talked about my uterine window while operating, but refused to discuss it with me afterward. I was patted on the hand and congratulated. He continued to patronize me throughout my stay in the hospital. I have not had a chance to discuss it with my family doctor yet (she was the one taking care of me during my last pregnancy), and probably need to discuss it with an OB as I’m not satisfied with why. I was told to seriously reconsider my desire for more children because of a uterine window. I’m very disappointed with the lack of communication from either of the doctors. I will certainly weigh the risks, but as a patient I expect to have more of a conversation about why my dreams for a big family are not going to happen than, “well, you had a uterine window, so you should probably not have any more children.” To have such important dreams potentially snatched away in a conversation that lasted a minute and half is just really disappointing.