Scientific studies

In a previous post, I wrote about a woman who attended one of my readings who wanted to discuss why there are so many contradictory studies regarding labor and delivery. She suggested ethical and legal constraints get in the way of doing really good work. I talked to professionals who do such studies to try to learn more about this. While it is true that anyone conducting a trial that directly involves patients (in this case pregnant women) must past the muster of a hospital's ethics panel and must use standard legal waivers and obtain full consent of the patients who participate, there are more complicated reasons for study disparities. First, some basics. The 'best' kind of trial is so-called randomized. That means that researchers select a group of subjects, sign them up for the study, and then, assign them to receive a certain treatment on a "random" basis. For example, they will either get, or not get, an epidural during labor. This is extraordinarily difficult to do, as most women are not ambivalent about their choices for pain relief during labor, and would not accept such random allocation. (Nonetheless, randomized trials of epidural analgesia in labor have been done.) For ethical reasons, the researchers need to allow women to change their mind during the study. For example, if they are randomized to receive an epidural and find that labor is actually not so bad, then they can not be forced to receive the epidural. Likewise, if they are randomized to no epidural, and find that labor is very painful, they must be allowed to receive an epidural if they wish. These so-called "protocol non-compliant" patients make statistical analysis complex, and interpretation of the results difficult. Depending on the outcome being studied, these trials are often expensive and time-consuming. Of course rare events (let's use uterine rupture as an example) need an even larger number of women to study. The importance of randomization can not be stressed too highly. Non-randomized studies suffer because the subjects being compared may differ in meaningful ways that would influence the outcome being investigated, something statisticians call "selection bias". For example, any non-randomized sample of women in labor receiving epidurals will show that women with more complicated labors, longer labors, and more difficult labors will tend to get epidurals more than women having easy, smooth labors. Hence an analysis of any outcome in this type of cohort would be skewed by the nature of the patients. Likewise, if one tries to compare any type of obstetrical or birth outcome in a non-randomized sample of say, women who have midwifery care vs. physician care, or home birth vs. hospital birth, or vaginal vs. cesarean delivery - these studies will always suffer from a preponderance of healthier patients in the midwifery or home or vaginal groups, respectively. On the other hand, randomizing women to one or the other of these types of care is extraordinarily difficult, some may say impossible. The other kind of study is retrospective. For the purposes of childbirth, these studies will look at medical charts or birth certificate data to compare outcomes. The whole story may not be revealed because there is no interaction with the patient, and the charts may not reveal the entire story.

Bottom line: Look at the type of study to determine its weight.

The next issue has to do with where the study is published. Some journals or medical publications may be more or less "friendly" to studies that show a certain type of outcome. One possible approach to this dilemma would be to have editorial review panels of these publications consist of members of both the medical and non-medical community when childbirth-related manuscripts are considered. This would allow for some cross-pollination between the natural and obstetrical camps. That will never happen, of course. Birth is too political. And in the end, women are stuck in the middle, often unsure what is best for them.

Pre-prenatal care

An interesting story that reminded me of how my mother gave me a bottle of folic acid on my wedding day. Obviously, mom knew best.
http://www.nytimes.com/2006/11/28/health/28natal.html

From the New York Times...

A story about ineffective fetal oxygen monitors.
http://www.nytimes.com/2006/11/23/health/23baby.html?_r=1&oref=slogin

Cultural perspective

This is an interesting article, from an expat website called Expatica, about giving birth in Spain.
http://www.expatica.com/actual/article.asp?subchannel_id=81&story_id=31786

...and another story about hypermotherhood in India.
http://www.hindu.com/thehindu/holnus/004200611240312.htm

Back in Boston

At my reading last night at Brookline Booksmith, two members of the audience made excellent points that I would like to share. One mother wondered why there is so much conflicting information when it comes to the scientific study of obstetrics. For example, why do some studies say an epidural is safe for mothers and babies -- that it is even OK to have an epidural early in labor -- while other studies caution about the relationship between epidurals and higher cesarean rates, difficulty pushing, problems with breastfeeding, prolonged labor, etc. ? Another member of the audience, a woman who works in labor and delivery at one of Boston's large teaching hospitals, responded by saying how difficult it is to study birthing women because of ethical and legal constraints. The result is that advocates for different birthing methods or points of view can trash each others' studies by saying they were not large enough or thorough enough. The politics of birth get in the way. And expectant mothers are left scratching their heads. It's a gross disservice to women. One resource that might be helpful for women is the Cochrane Database of Systematic Reviews (www.cochrane.org). The British-based library collects scientific studies, sorts through them, and attempts to cut to the bottom line. The database is easily searched using keywords such as breastfeeding, epidurals, cord cutting.

Food for thought

Nina Planck, an expert on organic food, recently gave birth in the New York area. If you check out her website she has some interesting thoughts on the connection between what she calls traditional vs. industrial food and traditional vs. industrial birth. Check it out: http://www.ninaplanck.com/index.php?page=who_is_nina

Beyond kegels

I am posting this email I received from a physical therapist:

The comment I wanted to make, which you have touched upon in your blog, was that as a physical therapist who specializes in treating women with pelvic floor dysfunctions, both incontinence and pelvic pain, I am dismayed by the discussion that comes up in the uro-gyn conferences I attend, concerning the pelvic floor and childbirth. Yes, some women actually have muscle tearing, nerve damage, weakened connective tissue BUT what never comes up, especially from the gyn's, is the practice of sending patients for a post-partum physical therapy evaluation and starting treatment if necessary. Unfortunately, many female ob's are opting for Csections as way to "preserve" the pelvic floor and that attitude influences the profession.
Unlke Australia and other countries where physical therapists are more involved in obstetric and post-partum care, there is less awareness among physicians that women can benefit from PT.
thanks for listening,
Debra Goldman, PT
Montclair, NJ

New York state of mind

I am finally home after spending two busy days in Manhattan talking about my book. The first talk, on Monday, was at Realbirth, a childbirth education center downtown founded by the formidable, warm, and brainy Erica Lyon, who has a book of her own coming out in the spring called "The Big Book of Birth." Lyon, who is obviously passionate about birth, relayed a surprising bit of information during the event. Earlier this year, the National Institutes of Health convened to discuss whether mothers should be allowed to request a cesarean simply out of want, not medical need. The panel ultimately decided that women should have that right and health insurers should pay for it. However, while Lyon was attending the panel, one of the experts testifying about the idea said that women did open themselves to the risk of having placenta abnormalities in later pregnancies after a cesarean because the scar can interfere with how the placenta implants itself onto the uterus. 'But surely you only see that happen once in a great while?' the expert was asked. Not so. 'How often does it happen?' More than a dozen times a month. That is alarming.

Yesterday, I spent about 30 minutes batting at questions from Brian Leher, who hosts a call-in talk show on New York's NPR station. One of my favorite calls -- actually it was an email sent to Brian during the program -- was from someone complaining that women seem to be more concerned about their birth experiences than the safety of their babies. Which is the biggest pile of hogwash I've ever heard. What mother would ever knowingly put her unborn baby at risk? Who ever said that having a pleasing birth experience was mutually exclusive with safety? And whoever said that making a mother miserable with unwanted procedures and interference during birth necessarily made delivery safer? In fact, many studies have shown that the more comfortable and supported a woman feels during labor, the better the outcome will be for her and the child. Anyway, here is a link to the show if you missed it.
http://www.wnyc.org/go.py?r=http%3A//www.wnyc.org/shows/bl/episodes/2006/11/13%23segment68925.

The final talk last night was at Half King, a Chelsea restaurant/bar owned by author Sebastian Junger. It was the first time I've had to deal with having people eat while I've read a detailed account of what goes on during a c-section. But the audience didn't seem to mind and many even advanced to dessert.

Miami Advice

Last night, members of the Junior League of Miami turned out for my reading at Books and Books in posh Coral Gables. Before the event began, the group sipped chardonnay and sparkling water in the lovely store's open-air courtyard. It was there that I met a local dermatologist, who promptly recommended preventive Botox for women my age, to take care of wrinkles "before the horse is out of the barn." So it was not surprising to me that, an hour later, during the question-and-answer session after my reading, that the same woman was the very first on my tour who publicly admitted to me that, if pregnant, she would schedule an elective cesarean "for cosmetic purposes." Who needs to risk pelvic floor morbidity when you can get a tummy tuck (a la Britney Spears?) while delivering. It's an interesting point. Of course, there are studies that show the mere weight of the pregnant uterus can cause incontinence (usually temporary) among some women. But more and more, we seem to be focused on the concept of the "honeymoon vagina." And how to keep it in tact. Instead of lecturing about how recent studies looking at nearly 6 MILLION births found elective cesareans to be much more deadly for mothers and babies than vaginal births, I turned to another woman in the front row, who had already disclosed that she had had three vaginal births. "How is your pelvic floor?" I asked with a chuckle. "Fine!" she gushed. Enough said.

Earlier in the day I gave a talk at the main branch of the Broward County Library. One woman in the audience told me that many OBs in Florida are not carrying malpractice insurance because it is so expensive. Potential patients must sign a legal waiver acknowledging that they know their doctor has no coverage when they sign up for care. I asked about this during the evening event and almost all of the women in the crowd nodded in agreement, including two attorneys whose OBs had no coverage.

There were two other tidbits I learned yesterday. First, a mother told me that South Miami Hospital has a 63 percent c-section rate (a fact that I have not checked). And another said that a major hospital in the area had banned doulas. Perhaps if there were more doulas present there would be fewer c-sections. Next stop: New York City

Posting from Miami

I am posting an interesting note I received from a British woman this morning. The email made me realize that as we become more of a global village every day, it becomes so much more important to understand how women around the world give birth in order to have the proper context for our own experiences. Here is what she said:

Dear Tina
I have just listened to your National Public Radio interview (24th October) after reading about it on the "normal childbirth" myspace page. On the strength of this I've ordered a copy of your book, Birth: A surprising history, from Amazon, as I can't wait until the UK release date in March 2007!
I wanted to write to tell you about my own just-completed birth stories project, Speaking of Birth, in which a dozen first-time mothers living in my home-town of Brighton UK, talk about their diverse experiences of giving birth.
Speaking of Birth is an oral history of personal experiences of childbirth recounted with frankness, humour and passion. Realised as a one-hour radio programme, first broadcast on www.resonancefm.com, and also available as an audio CD, it documents the mothers' stories and provides a vivid snapshot of the realities of childbirth today. Five hundred copies of the cd were distributed free to new mothers in Brighton in October 2006.
I was motivated to produce Speaking of Birth following my own difficult experience with the birth of my daughter in December 2004 (five day labour ending in emergency caesarean, after failed forceps attempt), and am very interested to read your book - especially to compare women's experiences of childbirth historically and globally with experiences of the women I know.
[Here are the links she provided]
http://www.speakingofbirth.com
http://www.myspace.com/speakingofbirth
http://www.audiocraft.org.uk

Outpouring in Seattle

The large group that turned out for my reading at Third Place Books in Seattle last night was an inquisitive and insightful one and I learned a few things from them that I will pass along here. First, I was told, hospitals are required to provide one-on-one continuous support throughout labor. Although that model is difficult to staff because you never know how many women will give birth on any given day, more states should consider doing the same.
A midwife in training told me that she had worked in Russian maternity wards one summer a few years ago and there, families have to pay extra to allow the father of the baby to witness the birth. But most women, she said, don't really want him there anyway because birth remains the realm of women -- as has always been the case throughout most cultures until the natural child birth movement changed that in the West in the 1970s. After the baby is born in Russia, she said, the new mothers spend time together in a postpartum area, where they can support each other, share stories and see how they each go through the same adjustment period. (I think that is a great idea.) Women in America are far too isolated in the early days and weeks after they give birth.
There was also a lengthy discussion last night of doulas, who offer labor support but don't do any of the technical aspects of birth such as cutting the cord. One woman suggested that perhaps it's time to pair doctors with doulas, having them work as a team, so that they are not on either side of a great divide, with the doula working as the mother's support and advocate and the obstetrician making decisions about care separately. It's an interesting concept, especially as physicians' assistants become more popular. Many studies have shown that having a doula can shorten and ease labor and make birth less complicated. A man, whose children were born 20 years ago, listened intently to the doula dialogue and said that while many men say they don't want a doula because they feel like another woman in the birth room would invade their territitory, guys could use the support too. Birth, afterall, is an emotional event for fathers and they don't always know what to say or do to help. He urged me to encourage men to be open to the idea of doulas.
Another male attendee, a massage therapist, asked whether anyone knew about the spot on a pregnant woman's ankle that, when rubbed, can stimulate labor. If you do, feel free to post here.