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Monday
Aug222011

A Midwife and an OB Walked Into a Blog...

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By Jill Arnold

 

One of my favorite discussions of all time on this blog occured on the post, Defensive Medicine is a Symptom of a Risk Society, in January 2011 as part of the Defending Ourselves against Defensive Medicine series. It veered off in multiple directions and stayed pretty interesting from start to finish. 

I plucked two comments and my response to them in case you’re not up for meandering through nine pages of comments. Obviously, you will find context in the whole discussion in the link above.

 

Ina May Gaskin wrote:

Many interesting exchanges have taken place since I’ve been able to contribute anything more to this interesting discussion/debate. I understand now that one reason that Dr. Tuteur has objected so strenuously to my ideas comes from the helplessness she and other staff members felt during her residency when those three mothers who did need obstetrical intervention refused it, unaware that their babies really could (and did) die for lack of it. I don’t think she made up that incident.

She doesn’t think that I have been truthful in recounting some experiences I had during the early part of my career. That’s unfortunate, because I make it a point not to exaggerate. I didn’t make up the incident (it was the eighth birth I witnessed, by the way), in which repeating the traditional wedding vows made it possible for my friend’s cervix to dilate fully after she had been stuck at 7 cm for more than a day. She gave birth about an hour and a half after that impromptu ceremony. I realize, of course, how hard it can be for anyone who prides herself on being “rational” and skeptical to accept this, but I’m stuck with what did happen. There were witnesses.

Regarding Grantly Dick-Read, I think it’s better to read him before swallowing whole the ways his critics have picked at him. I think it’s unfair to a writer to quote his critics without reading his primary material. I haven’t read his book about his experiences in Africa (though I did order it today), but it will take more than the article abstract that Amy posted to convince me that he was a racist.

I don’t find it at all hard to believe that he encountered tribal people whose experience told them that a labor could be prolonged when a mother had a sexual secret that she was keeping. It doesn’t mean that will happen with everyone, but it does happen sometimes. And no randomized controlled trial will ever demonstrate this. Niles Newton did some interesting research in this area, but like many other rigorous scientists, her work has largely been ignored by technophilic feminists.

Judith Goldsmith (author of Childbirth Wisdom from the World’s Oldest Societies), who did read No Time for Fear wrote: “One thing he [Dick-Read] found was that ‘the more urbanized natives who lived in the town brought their wives into the hospital, and it should be noted that they had more discomfort and made more noise than the village women at home.’”

After noting another writer who observed the same phenomenon among the Pima of Arizona, Goldsmith notes: “It would seem, therefore, that easier natural childbirth is made possible by the attitudes, ways of life, and other intrinsic practices of the material minimal lifestyle, and not by the physical (racial) characteristics of non-Western women.”

Here’s another wise observation she made:

“….nowhere in the tribal world did a woman give birth among strangers. She carried out this intimate act among relatives and friends whom she knew well and trusted.”

“Down on biology” feminist academics can argue all they want about whether certain things happen or not. Hopefully, all will be curious enough to investigate farther than the academics who used to sit in rooms in cities, arguing about how many teeth horses (or women) had, without bothering to count any.

In case no one has ever seen this method for having a baby with an intact perineum, try this:http://www.youtube.com/watch?v=9bF_T3wBE14

G’night for now.

 

Amy Tuteur’s response:

” I understand now that one reason that Dr. Tuteur has objected so strenuously to my ideas comes from the helplessness she and other staff members felt during her residency”

You don’t have to conjure up any secret motivations. I’ve explained why I object strenuously to your ideas: I find your philosophy of biological essentialism and anti-rationalism completely unpersuasive, and I have pointed out ad nauseum that most of your empirical claims are factually false. That’s more than enough reason to explain why I disagree with you.

In recounting those anecdotes, I was not describing my “helplessness” since I did not feel helpless. I recounted those anecdotes specifically to illustrate my claim that homebirth and NCB advocates don’t understand the risks of their choices because the NCB literature is silent or lies about those risks.

Let me make myself very clear, Ms. Gaskin, so you cannot twist or misinterpret what I mean. I disagree with almost everything you say because I think you are wrong. The scientific evidence does not support your claims, and your invocations of non-rational forces and energies is nothing more than quackery.

 

My attempt to sum up the entire thread:

Amy has more or less placed the OB philosophy in the science category and NCB philosophy in the mysticism (or non-rational) category. Scientism holds science as superior and therefore will always trump any non-empirical philosophical explanations for phenomena.

If we’re talking about the philosophy of OB vs. NCB, as Amy has framed it, we’re not speaking about how it is practiced. Courtroom Mama had an interesting point about many women opting for “not obstetrics”, which I suspect in most cases is not a knee-jerk act of defiance but simple psychology— aversion as a result of an unpleasant, distressing or extremely difficult experience within the health care system. I would also guess that most women choosing “not obstetrics” never really knew there was anything besides the OB philosophy, so the insistence of framing this as OB vs. NCB seems short-sighted and borders on a false dilemma.

One thing that has been fascinating has been watching the discussion between Amy and Susan, a proud, religious biological essentialist and supporter of the NCB philosophy. It feels like something that could have taken place half a century ago. Thanks again for your time in constructing your comments.

I agree wholeheartedly that NCB philosophy, at its purest and as I understand it, is biological essentialism. It ranks unmedicated, vaginal birth as superior to all other ways to become a mother.

The “feminist non-rationalist” framework is not quite as clearly argued here because the examples given seem to connect the mystical explanation of phenomena (anti-scientism) to a social group which endorses choice. The mysticism connection to NCB philosophy is well cited, however.

The source of contention seems to be whether or not there is a psychosomatic aspect to pregnancy and labor, and really, whether there is a psychosomatic aspect to anything. This is the classic debate between the Cartesian view of the patient (edit: the patient’s body) and what psychosomatic medicine refers to as the “body-mind.” It bleeds through into discussions about alternative medicine, which I guess is why Amy has named her blog the Skeptical OB. And if there’s anything on science blog (Amy, yours is sort of a sociological/science/activist/politics blog, no?) that will drive scientists and doctors up the wall, it’s claiming that a treatment works based solely on a personal experience.

Research on birth in the fields of psychology, psychiatry and neuropsych appears to be scant at best, so anything beyond birth being a just a parasympathetic event that requires oxytocin to cause uterine contractions, etc., (Unless, of course, this process is preempted with surgery and the construct of birth is changed.) will always lose the research battle. It doesn’t mean that in 30 years we’ll all be looking at this from a completely different perspective, but as of now the connection is unproven and therefore unscientific (says this lay person).

For further reading, this 2009 paper about psychosomatic medicine (found on the Columbia University site at http://www.columbia.edu/cu/psychology/tor/Papers/Lane_2009_Neuroscience_Psychosomatic%20Medicine_Part2.pdf) explains a bit about neuroscience in psychosomatic medicine. Here are a few excerpts:

One of the primary goals of research in psychosomatic medicine is to delineate the biological mechanisms whereby psychological, behavioral, and social factors influence disease outcomes, and to use this information in the service of optimizing medical care

[A]pplying current methods in human neuroscientific investigation in psychosomatic research would greatly enhance our ability to identify causal mechanisms that underlie mind-body linkages to disease pathogenesis

This work constitutes an outstanding foundation for “brain-body” research because we are now able to study how different mental processes are instantiated in the brain.


Within the framework that Amy is working, I’d have to say (as a layperson, so who cares, right?) that most non-biological (i.e. psychological) claims about birth are unscientific, as they are yet unproven. Neuroscience appears like it might someday bridge that gap, but as of yet, it hasn’t.

As far as correctness and being right is concerned, a cultural relativist (like me) will hold that separate philosophies are equal and can both lay moral claim to rightness, with none being superior to the other. The moral of that story is that moral/cultural relativists are a pain in the ass.

Thanks for the discussion.

 

 

 

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Reader Comments (61)

Moreover, you seem to have misunderstood the point of this post. Jill is acknowledging that when it comes to scientific accuracy, I am right and Ina May just ignores science altogether.

ha ha ha ha ha
Sorry, trying to construct a thoughtful post of how off the mark this is, but I just keep reliving arguments with my 4yo where he twists something I've said to his benefit.

August 22, 2011 | Unregistered Commenterlarissa

Off topic but...

Amy says:
"If by psychosomatic you mean the idea that the mind impacts the body, that is a concept firmly embedded in science."

aka Hypnosis for birth.

August 22, 2011 | Unregistered Commentermommymichael

Hi Amy. It's a bit frustrating to engage in argument with you when you level unfounded accusations and twist the argument to make the point you want rather than one that addresses the post. I am going to respond anyway, less because I expect that we can have a rational discussion than because I think others may benefit from reading the information.

So first of all, I did read the article in question (Scientific Evidence Underlying the American College of Obstetricians and Gynecologists’
Practice Bulletins), and if anyone else wants to, she can find a link to it at the bottom of this blog post from empowered birth doulas (this source does not require specialized access):
http://www.empoweredbirthdoulas.com/blog/2011/08/15/23-OBGYN-Clinical-Guidelines-Not-Evidence-Based.aspx

I am a PhD public health researcher who works with a world-renowned maternal-child health MD (I myself am not world renowned, nor even country or state renowned, but maybe I will be one day). My mentor is still actively practicing both research and medicine. Among the areas of expertise that I bring to our research group is research methodology, and I have taught graduate level methods classes for nearly a decade.

The article makes some interesting points, including that much of contemporary obstetric care is based on personal feelings, biased studies, and poor evidence, and that many findings are overgeneralized:
"Although guidelines provide useful information for clinicians, they have limitations. First and foremost, guidelines are only as good as the evidence that underlies them. Evaluations of a number of guidelines have found that many recommendations are based on low-quality evidence and expert opinion. This is particularly problematic as expert opinion is subject to bias, either implicit or subconscious. Other limitations have also been noted. Some authors have suggested that guidelines are too narrowly focused and often lack the flexibility to address patient-specific issues."
Because patients are specific individuals, it may be that there are a variety of practices that may be appropriate in specific situations. One thing that non-reserachers do not always understand is that when there are two alternatives and one is ranked as better or more effective, that does not necessarily mean that it is better or more effective for all people all of the time. It may only mean that given no knowledge whatsoever of the individual situation, if you have to choose one, you are more likely to have success with one over the other. For instance, Motrin may be better than Tylenol on average for bringing down a fever. However, a particular individual may respond better to Tylenol, or be allergic to Motrin, or the particular illness the person has may respond better to Tylenol. A good practitioner will investigate the individual situation, and not just say, "Motrin is scientifically proven to be better."

Here is a point that you, Amy, may want to take to heart:
"Despite the limitations of guidelines, adherence to these recommendations is often used as a benchmark for quality."
I realize that there may not be other useful benchmarks, but if the benchmark itself is bogus, then an Ina May approach is just as valid. In fact, it may be MORE valid because it hasn't been tested, so we don't actually KNOW that her approach is bogus. Medicine often has the problem of assuming that because it holds a hammer, every problem it confronts is a nail. Before I get accused of not understanding that OBs do not actually practice medicine with hammers, I would like to point out that the previous sentence is metaphorical.

The article goes on to say that "Our findings suggest that only a third of the recommendations put forth by the College in their practice bulletins are based on high-quality, consistent scientific evidence." This is not to say that any OBs actually follow these practice bulletins. It only says that if all OBs followed the advice of the bulletins all of the time, that about a third of what they did could be scientifically justified as good practice. Homebirth midwives may or may not practice some of the A level guide lines. Many of the recommendations are related to births that should not occur at home or be attended by midwives, and I would agree that in such cases, homebirthing would be in direct violation of such guidelines. I myself would never consider homebirthing under such circumstances.

The article comes right out and says that many standard obstetrical practices are NOT based on sufficient scientific evidence. Perhaps this is true of midwives as well, but much of standard OB practice is NOT based on sound science. Apparently, not having any actual evidence to back their claims does not stop them from making the claims anyway:
"A major issue faced by the College and other professional societies is the role of guidelines in areas of relative uncertainty. Many experts have pointed out the problems that arise when guidelines rely on expert opinion that is subject to bias. Some organizations, such as the U.S. Preventive Services Task Force, do not issue guidelines when evidence is insufficient."
In other words, many guidelines are basically made up so that there will be a guideline, even if it is at best meaningless and at worst outright harmful. Mysticism does not seem any different except that it may involve better informed consent. In any case, even if midwives completely disregard many of the practice guidelines, they may be practicing medicine that is as good or better than what the guidelines suggest. Their practices may also be worse. However, we don't know which is the case because NEITHER SET OF PRACTICES HAS BEEN SUFFICIENTLY TESTED.

The authors of the article conclude by saying
"There is an urgent need to continue to conduct high-quality research in obstetrics and gynecology and to provide the funding to undertake such research."
Perhaps such research could include the benefits of individualized approaches. Even mysticism.

August 22, 2011 | Unregistered Commenterpraminthehall

praminthehall,

You seem very confused on a variety of points.

You seem to think that the only guidelines that are useful are those that are Level A guidelines.
You seem to think that in the absence of Level A guidelines, no guidelines should be issued.
You seem to think that if we don't have evidence that meets Level A guideline critieria, we don't have evidence.

But:

NCB and homebirth midwifery have NO Level A guidelines.
NCB and homebirth advocacy have NO scientific evidence, let alone evidence that meets Level A criteria.

And your apparent conclusion is absolutely mystifying:

Obstetrics isn't always based on perfect evidence
and NCB and homebirth advocacy are based on NO evidence,
therefore,
it's perfectly reasonable to substitute principles based on NO evidence for those based on less than perfect evidence.

That is entirely illogical.

I'm curious why you seem so discomfited by the idea that obstetrics doesn't always have perfect evidence available for guidelines, but are remarkably blase about the fact that NCB and homebirth midwifery never have any evidence.

Could you explain that?

August 22, 2011 | Unregistered CommenterAmy Tuteur, MD

Praminthehall,

The point you are missing is that obstetrics (and all other branches of medicine) rely on the best evidence AVAILABLE. It's not all the gold standard randomized controlled trials, because that would be impossible. But relying on the next best thing is better than just doing whatever the heck you want with no evidence at all to back it up.

It does bear pointing out that, while ACOG bases it's recommendations on the best available evidence, certainly not all doctors follow those recommendations, and are thereby not practicing based on the best evidence. Unfortunately, there's not much punishment for that unless those doctors actually kill a patient, which is rare (an unindicated* c section sucks and is an example of bad medicine, but it doesn't often kill anyone). I get incredibly pissed off when I see doctors doing things for their own convenience or best interests (where I work, we have both ends of the spectrum-the best obs and the worst). I see several solutions to this: patients not giving business to bad doctors being number one (which would of course take some insurance and healthcare reform).

What is NOT a solution is to run away from the healthcare system into the arms of uneducated "midwives" who ignore scientific evidence just because you had a bad experience with a doctor. All that leads to is tragedy, as we've seen recently with some of the widely publicized home birth deaths that pretty clearly wouldn't have happened in a hospital. If you want change that doesn't lead to putting people in dangerous situations (even more dangerous than bad doctors), then don't patronize those doctors. Tell your friends which doctor sucked and find the best OB or CNM in town, and recommend them to everyone. Ask l&d nurses who delivers their babies. I realize insurance and other factors don't always allow people to change providers, so fight for healthcare reform. Better yet, go to school and become a real midwife (CNM) or OB and practice unbiased evidence based medicine yourself.

To sum up: even the worst doctor still has the training and resources to keep you alive when needed, which aren't available at home with unlicensed and untrained midwives (and sometimes with well trained midwives). That doesn't excuse practicing bad medicine, and we should be doing what we can to encourage doctors to practice good, evidence based medicine by not patronizing the ones that don't.

*by unindicated I mean done for no reason at all-no signs of fetal distress, no medical condition, simply doctor wanting to be done. It's not the majority of sections, but it does happen, unfortunately. I'm not talking about ones that may have been unnecessary in retrospect, as usually there's no way to know for sure.

August 22, 2011 | Unregistered CommenterHeidi RN

Heidi RN, I agree with you about a lot of what you have said but think that the ideal situation you've outlined is pretty difficult to achieve. I definitely struggled with my decision about how and where to birth after seeing a lot of hospital births and watching the way practice varied among OBs (hard to guarantee a good fit with an evidence-based OB when there are so many group practices) and even with the same OB from day to day (hearing about a bad outcome or a friend getting sued can make one a bit quicker to pull the trigger on pit or a C-section). And, as you already certainly know, nurses really direct a lot of your care in labor and on the postpartum floor and one has little or no control over which nurses care for you in the hospital. Hospital policies and even that day's patient census also have a big impact on care.

I'll admit that I also have a tendency to shake my head at those who decide that the appropriate response to hospitals and OBs refusing to do VBAMCs, vaginal twins and vaginal breeches is to do these at home with lay midwives. But changing policy to allow more women to get guaranteed evidence-based care with OBs or CNMs in hospitals (or perhaps at home) is probably more effective than either of our disapprovals at changing those choices. What are some of the other ways that we can improve women's access to evidence-based care with trained medical personnel besides informally directing women to the best OBs we know?

August 22, 2011 | Unregistered CommenterChristie B

Hey Praminthehall - Thanks for posting that link to the article. It is a point of infinite frustration for me that my university does not get the Green Journal and if I want anything, I have to go up the hill to the local med school and read it there or print it out for 10 cents a page.

August 22, 2011 | Unregistered CommenterLarissa

I agree that psychosomatic things can affect labor. Sure, our minds can affect our bodies. I've experienced that.

But the NCB's emphasis on the power of the mind can be cruel. I went through a difficult non-progressing labor because of a big-headed posterior baby and a small pelvis. In addition to dealing with the pain and exhaustion and distress that things weren't progressing normally--the mos difficult experience in my life up to that point--I ALSO had to deal with a head trip from the midwife who asked me if I had any fears about the baby coming. Luckily I had enough sense to know that she was full of crap and I didn't let it get to me, and luckily my midwife dropped it. But if I had trusted her more and worried myself about this "fear" of a wanted second baby coming into my home, or if that had been the midwife's only trick for dealing with nonprogressive labor, it would have distracted us from looking at the real physical causes, and could have put us in danger. And it's just plain cruel to blame a laboring woman for complications outside of her control.

Since then I've read about more dangerous mind-control ideas, such as telling the mother to stop bleeding in case of a post-partum hemorrhage.

August 23, 2011 | Unregistered CommenterSara

The link didn't work: an example of a midwife recommending to tell the mother to stop bleeding in a hemorrhage: http://blogs.babble.com/being-pregnant/2011/04/05/homebirth-interview-with-a-certified-professional-midwife/. That's just plain dangerous and desperate, and leaves the woman feeling at fault if she does not have Jedi mind power over her body.

August 23, 2011 | Unregistered CommenterSara

Christie B,

"OB's refusing to do VBAMC, vaginal twins and vaginal breeches"

That's just it, though. Advocates of NCB constantly claim that all those things are based on evidence, when that's not the case. To my knowledge, ACOG has never endorsed more than VBA2C, because evidence doesn't support VBA3+C. Also, the best available evidence tells us that for breech, c section is safer (there is a case to be made that in certain circumstances, the risk is low enough that vaginal can be considered, but that doesn't mean that most breeches should be delivered vaginally). As for twins, many OBs will deliver them vaginally, and I agree with you that it's unfortunate that some won't under any circumstances.

The point is that the evidence doesn't always say what many NCB advocates would like to think it does. I'm glad we're in agreement that the solution is not to turn to lay midwives at home.

August 23, 2011 | Unregistered CommenterHeidi RN
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