Control Matters.

I am reading a book called The Decision Tree and on page 12, after several pages discussing the evolution of studying heart disease, the author comes to one defining point:

Control matters.

All of the do this, dont do that we have going on in health care leaves us with feeling like we are supposed to be told what to do and how to do it, rather like errant children who have been busted for stealing cookies.

In the world of pregnancy and birth, being weighed highlights just how bad this can get for a mom-to-be. A nurse prompts you to take off your shoes and step on to the scale. She then plays with the scale and comes up with a number and writes it down. A completely passive process that leaves one feeling like she has no control over such a simple function. It is training for handing over all the functions of pregnancy, even the simplest, yo someone else.

So how would moms feel if they took back this role? “thanks, I can weigh myself.” or ” what was my weight”? Or even more interestingly, I don’t feel like being weighed today?”

One mom was so pleased to see the weight gain, her pregnancy with triplets was an example of control over her long journey of trying to have a baby

Another mom was weekly tsk tsk’d over her weight gain because she was obviously fat and obviously judged for it. She felt she had no way to control the unprofessional attitudes of her providers or their increasingly weight-based interventions that had no basis in what was actually occurring in her pregnancy or with her baby.

Who is in control of your pregnancy? What decisions are you making? The answer could affect your overall health picture for life.

Dealing with deaths at birth.

I’m putting this out here because there are and have always been deaths at birth.
If you are a mama who isn’t wanting to discuss this because you are expecting, skip it, please! You deserve peace.

So, how do we process these things? How do we tell others?

I wrote a blog post a while back:

http://birthaction.org/2011/08/28/capitalizing-on-loss-and-risk/

about how anti-homebirth people used death at birth to put forward an agenda
and how sometimes, natural birth advocates do it as well.

So how do we talk about these losses reasonably? Explain them? Explain that it’s not a competition between hospital or homebirth but instead, a journey of independence and the right to take on risks for ourselves??

Where’s the Data? Proof ACOG can’t get its act together over cesareans.

There is no data registry for uterine rupture in the United States or for any other adverse obstetrical event such as cesarean. We treat each cesarean as if it’s the first one since the scalpel was invented. What if there was a randomized data pool that each cesarean HAD to register in if you were a member of ACOG. Let’s see..the obvious questions:

• Provider (you could assign providers numbers and make it anonymous, there is a way to provide accountability and still track those providers who are doing shoddy work)
• Hospital
• Scar Type
• Scar Length
• Scar Location
• Closure Materials
• Infection Present, Infection within 24 hours, Type of Infection (cultured),
• Patient demographics
• Number of Prior cesarean(s)

This would offer so much information:

• If some obs have every single patient over 200 lbs getting a cesarean for “big babies” and others have a true bell curve, there is evidence of fat bias.
• If a certain closure material is used, repeatedly, with bad outcomes, there will be trends.

Most importantly:

There would be data to work with to start talking about uterine rupture outside of the realm of “we’re terrified because it can happen to anyone” because after thirty years of cesarean “research” it’s time to stop pretending that studies don’t change outcomes, it’s time to stop pretending that physicians determine more of why a cesarean happens than mothers do, it’s time to start tracking information so that if a mother has a uterine rupture, we can look back and ask these questions about what happened in her previous pregnancies and draw the lines to providers, materials, procedures, interventions that are drawing lines to a future where every woman has a cesarean, is at more risk to lose more babies and have more complications.

Fundamental Assumptions About Home Birth

It’s coming. The invitation-only summit about homebirths. So we’re going to start talking about some fundamental assumptions that may or may not be correct when we think about home birth.

Myth: Homebirth is only protected when midwives are licensed.

Yes, that’s a myth. Homebirth isn’t about which provider is doing it or how their state handles that provider.

The Truth: Home birth is the natural result of pregnancy. Whether or not a woman chooses to go to a hospital should be her choice. When we talk about home birth, we should begin with the fundamental truth that we should first protect a woman’s right to bodily integrity, including location of birth.

Once we have established this right, including the possibility of legislation, then we can talk about how to legislate providers.

Myth: Women are independent adults competent to made medical decisions.

Yes, it’s a myth because it’s a trick statement. In many states, pregnant women are not treated as competent individuals either by actual legislation regarding legal competency or by default laws dictating what a pregnant woman must do, cannot do or what must be done to her newborn. These laws in effect negate her right to bodily integrity again and MUST have clauses added allowing her to refuse such intrusive acts upon her body.

In addition to these laws, in every state, we must begin to recognize and enforce assault and battery statutes against providers who do procedures on women without express written consent. The abuse of blanket consents must stop and a woman’s right to say no to a procedure should not be overriden by threats of CPS or refusal to treat while in labor. Women presenting in hospitals after a planned homebirth changes to a transfer should not be abused by their providers, either verbally or physically, and they should still retain the right to refuse specific care.

Evaluating Research

Advocates for healthy birth can have a challenging job when it comes to collaborating with all of the different entities that are involved in transforming the maternity care system. One particular difficulty that we are faced with is analyzing medical research. This is particularly important because of the need to understand such research and be able to constructively (and critically) discuss it with the medical community and legislators who create laws surrounding the maternal health system. While taking the Understanding Evidence Based Healthcare: a Foundation for Action course which is offered online (and free!) by The Cochrane Collaboration and the Johns Hopkins School of Public Health I realized it might be beneficial to discuss how to analyze a research article and get a conversation going about how to understand research. I wanted to focus on the aspect of evaluating research because I think many times we get caught up in the results and what they mean but it is also important to be able to understand other aspects of the research to judge whether it is useful.

Below I have created a list of important questions to ask while reading a research report. There are explanations of why each question is important and I have used an article published in 1998 in the Journal of Epidemological Community Health by MacDorman and Singh titled “Midwifery Care, Social and Medical Risk Factors, and Birth Outcomes in the U.S.” to evaluate in this post as an example.

1.      What is the researcher trying to find out or what question are they asking?

2.      Has the researcher demonstrated that they have a thorough understanding of the topic?

3.      Does the data they have collected/utilized match the question they are trying to answer?

4.      How did they define the terms in their study?

5.      Is the researcher humble or do they admit to the limitations of their study?

It is important that the researcher presents a clear question so that the goals of their research are clear. The research question can usually be found at the end of the Introduction or Literature Review of the article. The research question does not always appear in question format but can still be obvious because it may start with “The purpose of this study”, “We are doing this research to understand”, or other statements which can be easily formulated into questions. We can find the research question in the MacDorman and Singh article at the bottom of the beginning section of the article.

“The purpose of this study is to examine whether there are significant differences in birth outcomes for infants delivered by certified nurse midwives compared with those delivered by physicians, and whether these differences, if they exist, remain even after controlling for sociodemographic and medical risk factors.” (you can click on the screenshot to see it details and all!)

An important detail about medical/scientific research is that it uses deductive logic. This means that the researcher should have read an extensive amount of literature in order to determine what is already known or not known about the subject and they should detail that literature in their research. Once they have read the literature they can develop an idea of what they think they will see occur in their research. From here they will design their study to test their idea. If the researcher has not demonstrated their knowledge about the subject area their research will not be useful or conducted correctly. This information is usually presented in a section titled Literature Review. In the MacDorman and Singh article there is no section titled Literature Review but it is apparent the researchers have done their homework as they reference several titles throughout the beginning section of their article. Different journals will use different styles of citation; this one uses a foot note style, others will have the authors’ last name and date in parenthesis.

The data collected by the researcher should be appropriate for answering the question. If the research is looking at how doulas benefit women during birth it would be necessary for the data to contain information about women who labored with and without doulas. Information on the data used by the researcher is usually located in the Methods section of the article. Here is the example from the MacDorman and Singh. They need to obtain data that will tell them about the birth attendant and the various birth outcomes.

“This study uses data from the national linked birth/infant death data set for the 1991 birth cohort. In this data set, the death certificate is linked with the corresponding birth certificate for each infant who dies in the United States.” MacDorman and Singh use a data set from the National Vital Statistics office of the CDC. This data is appropriate for their study because it contains all of the information they are looking for, such as the birth location, attendant, and birth outcomes.

How did the researcher define the terms they are specifically looking at in their question? This is important because the definition can determine the kinds of conclusions likely to be reached by the study. For example: If transfer is defined as births which end up in the hospital after a problem occurs during a birthing center birth then nothing will be said about those transfers that occur during home births. The researcher needs to be clear about these definitions so the reader is clear on what the results actually mean. This information can usually be found in the methods section of the article. We can determine what terms need to be defined by looking at the research question. In the MacDorman and Singh article we need to know how the researcher is defining “physician”, “midwives”, and “birth outcomes”.

Based on this screenshot we can see that physicians are defined as MDs and DOs and midwives are defined as certified nurse midwives. Based on these definitions we know that the results are unique to MDs, DOs, and CNMs.

In the above screenshot we see the definitions for “birth outcomes” are infant, neonatal, and postneonatal mortality, low birthweight, and mean birthweight. These definitions were a little more difficult to locate; it seems as though these authors have forgotten that their audience can be more than the academic and medical community. A hint to help find these definitions is to check out the Methods section. Scientific research often has a subsection called variables. You can usually find the definitions of terms by checking out this section and seeing what the “dependent variables” are.

Lastly, we want to double check whether the author mentions the limitations of their research. No research is ever perfect but great research admits its potential shortcomings. Does the author use their own findings to make suggestions for future research? This will usually occur in the Discussion section of an article and sometimes there is a subsection titled Limitations or Suggestions for Future Research.

“Limitations include the cross sectional nature of the data set, which provides information on the attendant who actually delivered the baby, but not a complete history of prenatal care and labour and delivery care providers”.

While it sometimes seems daunting or boring understanding how to analyze medical research is important because it gives us the tools to debate the validity of studies and information which is known about pregnancy and birth. For example, if we don’t know that medical research should have a detailed review of existing literature and studies, then we cannot argue that a particular study which does not contain a review of existing studies is faulty or should not be considered while creating legislature. Another example might be that advocates could put studies on the table which we know to be strong and useful which have been largely ignored by the medical community and which lawmakers are unaware of.

I have chose to write this as a blog post because I’d like to have a conversation about the importance of understanding research and give people an opportunity add things or ask questions if needed! So please feel free to chime in.

– Cheryl