Cesarean section as a narcissistic injury
Narcissistic injury is a term from psychoanalysis. A narcissist in psychoanalytic theory is different from our colloquial use of the word. Rather than being a person who is obsessed with herself, a narcissist is a person who suffers a deep sense of inferiority and masks it by projecting an air of grandiosity and excessive self regard. A narcissistic injury occurs when reality threatens the narcissist's carefully constructed facade of perfection.
In reading the work of homebirth and natural childbirth advocates, I am repeatedly struck by the assumption that a not having an uncomplicated vaginal birth is viewed as an imperfection. Hence the use of words like "failed" and "broken", the insistence on comparing birth to competitive sports, and the use of goofy birth "affirmations" that are all variants of "I can do it."
I suspect that some homebirth and natural childbirth advocates experience a C-section as a narcissistic injury. A narcissistic injury is not simply an imperfection. It is an imperfection that threatens the narcissist's protections against feelings of inferiority.
For example, many people need vision correction, but the overwhelming majority are able to accept that their eyes are not perfect without viewing it as a fundamental deficiency. Similarly, many women have C-sections and view the surgery as nothing more than one of many acceptable ways to have a baby. In contrast, a small proportion of women have such a fragile sense of self, and have constructed such elaborate defenses to protect against these feelings, that a C-section is experienced as a "failure," a sign of being "broken," and an insupportable assault on a very fragile sense of self-regard.
Experiencing C-section as a narcissistic injury can explain many confusing aspects of homebirth and natural childbirth advocacy, particularly among advocates who have already had a C-section. The refusal to see a doctor (with some women even refusing to see a midwife) can be explained as the inevitable result of regarding even the possibility of pregnancy complications as personal criticism, combined with the inability to tolerate criticism of any kind.
It can also explain the seemingly inexplicable reactions to the death of a baby at homebirth. Reacting to a baby's death by being "proud" of oneself for having a vaginal birth is extremely bizarre. However, it makes sense if the mother's overriding preoccupation is to preserve her narcissistic mask of perfection and keep feelings of inferiority at bay.
The real problem, then, for women who view C-section as "failure" is not the C-section, but the outlook of the women themselves. C-section is experienced as a narcissistic injury, not because it really is an injury, but because women with carefully constructed defenses that keep feelings of inferiority at bay feel those defenses threatened by the lack of perfection.
I don't expect homebirth and natural childbirth advocates to acknowledge this. Narcissists are notorious for their lack of introspection and their insistence on blaming everything on everyone else. They could never acknowledge that the source of their distress comes from within; they are compelled to externalize it to others who are supposedly criticizing them or disrespecting them.
Labels: C-section, philosophy
Childbirth Connection publishes its latest attempt to smear modern obstetrics
Childbirth Connection is a lobbying organization for the "natural" childbirth industry. In an ongoing effort to promote the socially constructed values of a small subgroup of women, it publishes papers that purport to show that "natural" childbirth is supported by the weight of scientific evidence, and is desired by the majority of American women. There's just one problem; it's not supported by the weight of scientific evidence and it does not represent the desires and values of American women.
It's Listening to Mothers Survey II is a case in point. The report concludes that obstetric technology is overused, there are too many interventions, there are too many C-sections and women are not appropriately informed of the risks of interventions. Yet their conclusions are completely belied by the evidence in the report.
Mothers generally gave high ratings to the quality of the United States health care system and even higher ratings to the quality of maternity care in the U.S... [M]ost felt that the malpractice environment caused providers to take better care of their patients.
By law ... women are entitled to full informed consent or informed refusal before expriencing any test or treatment. Most mothers stated that they had fully understood that they had a right to full and complete information ... and to accept or refuse any offered care...
A small proportion of mothers reported experiencing pressure froma health professional to have labor induction (11%), epidural anesthesia (7%) and cesarean section (9%)... Despite the very broad array of interventions presented and experienced ... just a small proportion (10%) had refused anything ...
The people at the Childbirth Connection wrote a report about listening to mothers, and then proceeded to ignore that mothers were pleased with American obstetric care. Why did they ignore their own evidence? They ignored it because it did not match the predetermined conclusion that the socially constructed values of the "natural" childbirth industry represent the "ideal" way to give birth.
Today they published their latest effort to substitute their personal values for the scientific evidence and for the values of the majority of women in the US. As usual, they start with the conclusions and work backward. As usual, they present no evidence to support their claims. You can read the entire 128 page report
here. I cannot summarize all 128 pages, but I will offer 4 specific examples of the way in which the Childbirth Connection attempts to pass off personal opinions as scientific evidence.
First, the title of the report is truly Orwellian, Evidence Based Maternity Care: What Is It and What Can It Achieve. The title is Orwellian because virtually none of the conclusions are supported by evidence in the paper or any evidence at all. The fundamental claim, that "natural" childbirth with minimal intervention is better, safer and healthier is not supported by scientific evidence. This is a classic example of using "scientese" to trick people. Obstetrics is evidence based medicine. "Natural" childbirth is values based opinion. Trying to hide that fact does not fool anyone who is familiar with the actual scientific evidence.
Second, the willingness to place personal opinion above scientific evidence is best exemplified by the section of the report on epidurals.
... Labor epidurals alter the physiology of labor and increase risk for numerous adverse effects. Undesirable maternal effects include immobility, voiding difficulty, sedation, fever, hypotension, itching, longer length of the pushing phase of labor, and serious perineal tears.
The authors provide ZERO references to back up these claims. The central claim, that epidurals alter the physiology of labor is flat out false. The scientific evidence shows the opposite.
The authors have simply fabricated several of the so called "undesirable" maternal effects including immobility, and sedation. That begs the larger question: undesirable to whom? The answer is that the side effects (the real ones, not the made up ones) are undesirable to the members of Childbirth Connection. The authors provide no evidence that the patients consider these side effects to outweigh the benefits of effective relief.
Indeed, the authors acknowledge that the majority of women do not share their disdain for epidurals, but in the classic manner of "natural" childbirth advocates, they ascribed it to ignorance without offering any proof.
Many laboring women welcome the pain relief of epidural anesthesia, but they do not appear to be well-informed about the side effects.
Once again the authors present ZERO evidence for their implication that women would forgo pain relief if they were "better" informed.
Third, the report, like virtually all "natural" childbirth and homebirth advocacy is filled with deliberate distortions. The authors compare neonatal mortality rates among countries, and fail to compare the more accurate measurement of perinatal mortality. The authors discuss the "charges" for obstetric procedures instead of the actual reimbursements. The authors claim that systematic reviews "give the most trustworthy knowledge about beneficial and harmful effects of specific health interventions," but that is flat out false. Systematic reviews are completely dependent on the quality of the studies that the authors choose to include and whether those studies are representative of the existing scientific literature. Systematic reviews are a good starting point for evaluating obstetric procedures, but they are hardly the "most trustworthy" sources of scientific information.
Fourth, in case you were unclear on the fact that this report is intended to be smear of modern obstetrics, the authors helpfully mention the history of diethylstilbesterol (DES) to suggest that even though the scientific evidence does not support their claims of harm from various interventions, it does not mean that harms might not be discovered in the future. In other words, they feel free to ignore the existing scientific evidence if it does not support their predetermined conclusions.
This report from the Childbirth Connection is not consistent with the scientific evidence, and is not consistent with the desires and values of the majority of American women. It is nothing more than an extended attempt to promote the personal opinions of a small group of "natural" childbirth advocates.
Labels: philosophy
Patient preferences and mode of delivery
Susanne suggested that I review the article in this month's journal Obstetrics and Gynecology,
Mode of Delivery: Toward Responsible Inclusion of Patient Preferences. The article is written by seven women, two obstetricians and five professors of philosophy, including Rebecca Kukla. I have quoted Kukla's philosophical work on mothering in previous posts.
The paper is interesting, but I found it curiously out of touch with the current realities of obstetric care. I was also confused by the emphasis on "cost effectiveness," and societal consideration which really has no place in a discussion between patient and provider, and can only be addressed on a system wide basis.
It seems to me that the authors started with their conclusions and then worked backward to justify them. Their conclusions were that women should have more choice in determining mode of delivery for VBAC, breech and twins, and essentially no choice in maternal request C-section. Their desired conclusions rest on unexamined assumptions, that vaginal delivery is inherently "better" than C-section delivery, and that the current C-section rate is "too high." The authors offer no discussion or justification of these assumptions, which guide all subsequent reasoning.
Let's first look at what the authors said:
We believe that responsible guidelines around mode of delivery are a function of four considerations, which interact in complex ways. First and foremost are clinical considerations of safety and efficacy, which include the extent to which the provider is comfortable with managing the specific approach. Second are considerations of cost effectiveness, which are especially important for options whose use would be prevalent. Third are the broader clinical and social consequences of expanding choice. Considerations here include the potential for diversion of resources, unintended shifts in institutional practices and provider expertise, as well as potentially subtle shifts in the pressures or untoward cultural presumptions subsequent patients will face. These three factors circumscribe boundary conditions on what providers can responsibly provide to individual patients. They also provide comparative information key to informing choices within the range of broadly safe
and cost-effective options.
Fourth are considerations of patient values and preferences, including the extent to which patients would trade one set of possible outcomes for another, how important differences in potential outcomes are to them, and how robustly variable preferences are across the population. In general, the stronger the preferences, and the greater the divergence among them, the stronger the case for patient-flexible guidelines. For one thing, the standard for acceptable medical risk and cost is in part a function of what patients value — as elsewhere in medicine, an option that brings a slightly higher risk or cost can be acceptable if it has a benefit that some patients value highly. Further, where outcomes are broadly equivalent in aggregate risk of adverse outcomes or cost, patient preferences are of obvious importance.
These four considerations are critical to defining what constitutes responsible care. The higher the probability of significant harm, the more restricted the range of reasonable options, even in the context of divergent patient preferences; the stronger and more variable the patient preferences, the more they should be given directive weight; the higher the externalities, and the less cost-effective an option, the more justification for prescriptive guidelines.
Simply put, the authors believe that the four considerations for decision making should be:
1. safety
2. cost effectiveness
3. social consequences of expanding choice
4. patient preferences
In my judgment, the authors are pretty far off the mark in their conclusions. They include two considerations that have no place in patient-provider discussions, and they ignore two considerations that have tremendous impact on the current situation in obstetrics today.
Neither cost effectiveness, nor social consequences have any place in patient-provider discussions of treatment choices. I'm surprised that the authors included them. Change the specialty from obstetrics to oncology, and the problem becomes glaringly obvious. When cancer patients face the failure of first line treatment for their disease, and are considering the next step to prevent inevitable death, neither cost effectiveness, nor social consequences have any place is a discussion of options.
Should an oncologist suggest to a patient that it would be cheaper or better for society if the patient would just go home and die? Of course not. Undoubtedly, once a patient has failed first line treatment, it WOULD be cheaper and generate far few problems for "society" if the patient just gave up. That's not how we make medical decisions. A core principle of medical ethics is "beneficence," determining what is good for the patient. The interests of society (or the insurance company) have no place in the patient-provider relationship.
As far as I can tell, cost and societal considerations mask the handwaving necessary to reach the authors' predetermined conclusions. Allowing greater choice in mode of delivery, but prohibiting maternal request C-sections can only be intellectually justified by including the interests of society (or so the authors believe). Otherwise, it would make no sense to assert that women who value vaginal birth as an interest in and of itself should be allowed to incorporate that value, but women who value C-section birth should not be allowed to act on their personal values.
Secondly, and inexplicably, the authors fail to consider two interrelated factors that are driving the currently high C-section rate, malpractice claims and the inability of patients to understand risks. The authors acknowledge that C-section IS the safer mode of delivery in the situations under consideration:
VBAC: "After a number of well-publicized reports of complications of trials of labor after previous cesarean, and motivated by the small but real risk of uterine rupture"
twins: "the small but statistically significant risk of complications in delivery of the second twin."
breech: "In 2000, a large, randomized trial of cesarean compared with vaginal delivery for breech, the Term Breech Trial, found that combined perinatal and neonatal mortality and serious neonatal morbidity were significantly lower in the planned cesarean delivery group compared with the planned vaginal delivery group (1.6% compared with 5%)."
Therefore, since C-section is known to be the safer mode of delivery, there is essentially no defense in a malpractice case when complications occur during vaginal delivery in the three settings under discussion: VBAC, twins and breech. I find it inexplicable that the authors fail to address this critical point: C-section IS safer, and doctors have no defense for failing to perform a C-section in these settings.
So when it comes to the authors' first consideration in these situations, safety, C-section is almost always the safer option.
The authors, appropriately, devote a great deal of attention to the issue of patient preferences:
For example, as with women who have not had a prior cesarean, many women facing birth after cesarean strongly value the opportunity to deliver vaginally... For these women, decreased access to VBAC can be experienced as a significant loss...
And:
... Women who place high value on vaginal birth may also wish to avoid the significant discomfort and small risk of emergent cesarean associated with external cephalic version and articulate a reasoned preference for vaginal breech delivery.
Those preferences are real, but the authors fail to address the basic issue that the standard for determining treatment is informed consent, not preferences. Simply preferring a vaginal delivery does not constitute informed consent for refusing a medically indicated C-section. This is not a trivial distinction, and the authors' failure to address it calls into question their conclusions about the role of preferences.
I find the paper very disappointing. It does not offer any practical advice for a systematic way of incorporating patient preferences into decisions about mode of delivery. In its failure to acknowledge the central role of malpractice litigation when C-section is known to be the safer option, and its failure to address the critical issue of informed consent, it mischaracterizes the problem and offers merely a weak justification for predetermined conclusions.
Labels: philosophy
Medicine values judgment; homebirth advocacy insists on certainty
Homebirth advocates include a spectrum of opinion, but on one point everyone seems to agree: complications are rare. There's just one problem. Complications are not rare, they're common.
Why the disconnect? Partly it is because of the underlying, and erroneous, belief that if it is "natural", it must be good. Therefore, the way childbirth occurs in nature can't have many complications if it is to be "good". Yet there is another, more profound reason that speaks to the deepest longings of homebirth advocates, the desire for certainty. Homebirth advocacy is made up of a few simple rules: "nature" is always right, everything must be allowed to happen naturally, interfering is what causes complications, etc. All of them can be summed up conveniently in the aphorism: Trust Birth.
Homebirth midwifery requires very little in the way of training (compared to other forms of midwifery) because very little knowledge is supposedly needed. Keep your hands off and call 911 in the rare case that a disaster occurs. In the meantime, you are free to let labor to drag out endlessly, and, to encourage the mother not to give in to the basic human desire for pain relief.
Obstetrics, on the other hand, presupposes that childbirth is complicated, complications are fairly common and judgment is key to ensuring good outcomes. In other words, you can't simply sit back and assume that everything is going to turn out fine. Since the chances are relatively high that complications will develop, observation is critical; detecting early signs of complications is desirable; and judgment is needed to interpret the early signs and determine a course of action.
Why do obstetricians spend four years beyond medical school delivering hundreds or thousands of babies before they're allowed to practice on their own? If you believe that judgment is a critical element in providing safe care, you are committed to a long period of training. The only way to acquire good judgment is by experience with a large and varied array of situations.
Homebirth midwifery assumes that one size fits all. Just stand back and everything will be fine. Obstetrics, in contrast, assumes that reasoning and judgment will often be required, and makes every effort to hone those skills. Homebirth midwifery laughs when a woman has an "unnecessary" Cesarean for a baby who turns out to be healthy; if only the doctor had "trusted" birth, everything would have been fine. Homebirth midwifery is shocked when a baby who is assumed to be fine emerges dead. Yet that kind of outcome can only occur when the practitioner is not paying attention, is not reasoning, is not using judgment to distinguish between the theory of "trusting" childbirth and the reality of the woman in front of her.
"Trust birth" is a one size fits all strategy. It provides comforting certainty. Obstetrics is individualized and uncertain. That makes it far more difficult, but it also makes it safer.
Labels: philosophy
"Normal birth", does it exist or is it just a value judgment?
If you search for scientific papers about "normal birth", you will find very few prior to 2007 when the expression was popularized by midwifery organizations. The Royal College of Midwives started their "Campaign for Normal Birth", and papers began to appear with titles like "Preserving Normal Birth" and "Normal Birth: Women's Stories". What does it really mean to call a birth "normal"? Does it reflect actual statistics on what birth is like or is it merely a value judgment? Is birth "normal" when it follows a particular course, or is it "normal" by virtue of fulfilling the function of producing a healthy baby for a healthy mother?
I would argue that the biggest difference between the medical model and the "normal birth" paradigm is that the medical model derives from statistical analysis and focuses on the functional outcome of birth, whereas the "normal birth" paradigm makes explicit value judgments ("normal" is superior) and is obsessed by process, rather than outcome.
Doctors describe "normal" with reference to large populations. How do we know what a normal blood sugar is? We look at the distribution of blood sugar levels through the population and the functional results. Normal is the statistical range of blood sugars compatible with healthy bodily function. This has two important corollaries. 1 There is no particular value assigned to normal blood sugar, beyond the value of avoiding illness. 2 A blood sugar level is normal regardless of how the level was attained. A blood sugar of 100 is normal regardless of whether it occurs spontaneously in a non-diabetic individual or whether it occurs after a dose of insulin in a diabetic.
When it comes to childbirth, also, doctors describe "normal" with reference to large populations. How do we know what the normal length of labor is? Doctors look at the distibution of labor lengths throughout the population. "Normal" is the statistical range of labor length compatible with minimal complications. The same two corollaries that applied to blood sugar also apply to length of labor. There is no particular value assigned to a labor of normal length, and, more importantly, a normal length of labor does not depend on whether it occurs spontaneously or whether it occurs because of pitocin augmentation.
The "normal birth" paradigm is very different. Because of the value judgment that "normal" is superior, every effort is made to pretend that all spontaneous variations are "normal". In fact, for all intents and purposes, spontaneous IS "normal". Hence, getting stuck at 8 cm for 5 hours is "normal" and should simply be observed. The "normal birth" paradigm is obsessed with process. A pitocin induced labor that follows the curve is not "normal" (even though it falls well within the statistical guidelines for length of labor) because it did not happen spontaneously.
Obstetricians are focused on functional outcome. A "normal birth" is one that gives a healthy baby to a healthy mother. In contrast, believers in the "normal birth" paradigm actually spend time debating whether a women who has a C-section has had ANY "birth" let alone a "normal birth". The "normal birth" paradigm uses the word "normal" in the same way as homophobes refer to heterosexual relationships as "normal"; it claims or implies that C-section birth is "abnormal" in the same way that some people refer to disabled people as "abnormal". The "normal birth" paradigm uses the word "normal" in the worst possible sense; as a value judgment where "normal" is superior and everything else is "abnormal".
Labels: feeling superior, philosophy
What is "normal"?
Homebirth advocates like to pretend that almost anything that happens is "normal" simply by virtue of the fact that it happened. Are you still pregnant 3 weeks after your due date? Must be normal, since it happened. Are you in labor and stuck at 8 cm for the past 6 hours? Must be normal, since it has happened to some women in the past, and a few have even gone on to deliver live babies.
The corollary of the homebirth fantasy that almost everything is "normal" is the conviction 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 very unlikely 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 ALREADY accounts for most of human variation. Anything that lies outside the range of normal is very unlikely to be normal.
Labels: philosophy
Birth is not trustworthy
If you wanted to know if birth were trustworthy, one of the best places to find out is MDC. As homebirth and "natural" childbirth advocates prattle on and on about "trusting" birth, one complication after another occurs. Within the past 48 hours, the following complications were reported within birth stories:
1. Another homebirth death. This one happened to a woman who had had multiple previous successful homebirths. The pattern is depressingly familiar; a cord prolapse, emergency hospital transfer, emergency C-section, baby died.
2. A face presentation. This was discovered and managed appropriately by the homebirth midwives. The midwife did a vaginal exam and the baby sucked on her finger. Transfer to the hospital and C-section followed. Mother acknowledges within the birth story that the C-section saved both the baby's life and her life.
3. A stillbirth just barely averted. Mother reports grudgingly agreeing to a biophysical profile on the insistence of her obstetrician/midwife practice. She did not think it was necessary. At the biophysical profile, the baby scored 0/8. She was immediately transferred to the hospital and while being prepped for a C-section, the baby had a severe bradycardia. The C-section was done immediately. Baby appeared to be suffering from growth retardation and had two true knots in the cord. Mother acknowledges that doctors prevented a stillbirth in progress.
Once again we learn some basic facts. Birth is not trustworthy. Babies die because some women do not understand that birth is not trustworthy. Trusting birth does not prevent or change the incidence of cord prolapse, malpresentation or fetal distress. In fact, the severity of the outcomes seem directly related to the degree of trust the mother insisted upon. The mother who was most trusting ended up with a baby who died. The mother who transferred on her midwife's recommendation ended up with only a C-section. The mother who grudgingly agreed to a biophysical profile enabled her doctor to avert a stillbirth in progress.
Labels: philosophy
No support for some central tenets of homebirth advocacy
This month's issue of the journal Birth has not one, not two, but three separate studies that cast substantial doubt on certain important tenets of homebirth advocacy.
1. Homebirth advocates like to claim or imply that obstetricians are hiding the fact that C-sections are dangerous for both babies and mothers. Obstetricians aren't hiding anything. They know that the "dangers" of C-section are grossly overstated by homebirth advocates. Obstetricians and other doctors have higher rates of C-section than the general population and a substantial proportion would choose C-section in the absence of a medical indication.
Cesarean Section: Norwegian Women Do as Obstetricians Do Not as Obstetricians Say:
Background: The worrying trend of an ever-increasing incidence of delivery by cesarean section has been commented on repeatedly. Studies from the United Kingdom and the United States have found that many obstetricians would choose cesarean section for themselves without strict medical indication, whereas similar studies from Denmark and Norway have indicated that almost none would choose cesarean section for themselves. The purpose of this study was to report the proportion of Norwegian obstetricians who have children born by cesarean section and to compare the rate with that among other physicians and that with the general population. Methods: Questionnaires were sent to 1,500 random members of the Norwegian general public, 1,500 randomly selected physicians, and 423 random surgeons asking whether they had children born by cesarean section. All were between the ages of 40 and 65 years. Results: The response rate was 78 percent. In the general public with children, 12 percent reported that one or more of them were born by cesarean section. The average was 8 percent among those with only basic schooling compared with 16 percent (p < 0.02) among those who had been to university for more than 4 years. This figure was 19 percent among physicians in general (p < 0.001 compared with the general population), 26 percent among surgeons, and 27 percent among the 189 specialists in obstetrics and gynecology (p < 0.02 compared with the physicians in general). Conclusion: The rate of cesarean section in the general population is unlikely to fall as long as so many obstetricians have their own children delivered by cesarean section.
2. Homebirth advocates like to claim that women find vaginal birth inherently preferable to C-section, but that is not what investigators discovered. In this study, a substantial proportion of women changed from preferring a vaginal delivery after they had had the experience of labor or of vaginal birth.
Impact of First Childbirth on Changes in Women's Preference for Mode of Delivery:
Background: A woman’s childbirth experience has an influence on her future preferred mode of delivery. This study aimed to identify determinants for women who changed from preferring a planned vaginal birth to an elective cesarean section after their first childbirth. Methods: This prospective longitudinal observational study involved two units that provide obstetric care in Hong Kong. A mail survey was sent to 259 women 6 months after their first childbirth. These women had participated in a longitudinal cohort study that examined their preference for elective cesarean section in the antenatal period of their first pregnancies. Univariate and multivariate analyses were performed to identify determinants for women who changed from preferring vaginal birth to elective cesarean section. Results: Twenty-four percent (23.8%, 95% CI 18.4–29.3) of women changed from preferring vaginal birth to elective cesarean section after their first childbirth. Determinants found to be positively associated with this change included actual delivery by elective cesarean section (OR 106.3, 95% CI 14.7–767.4) intrauterine growth restriction (OR 19.5, 95% CI 1.1–353.6), actual delivery by emergency cesarean section (OR 8.4, 95% CI 3.4–20.6), higher family income (OR 3.2, 95% CI 1.1–8.8), use of epidural analgesia (OR 2.6, 95% CI 1.0–6.8), and higher trait anxiety score (OR 1.1, 95% CI 1.0–1.3). The most important reason for women who changed from preferring vaginal birth to elective cesarean section was fear of vaginal birth (24.4%). Conclusions: A significant proportion of women changed their preferred mode of delivery after their first childbirth...
3. Homebirth advocates claim that homebirth and birth centers cost less, but research fails to confirm that claim. I have written about this in the past and cited similar papers. Both homebirth and birth centers are resource intensive (personnel and equipment) and are not offset by corresponding decreases in the need for resources elsewhere in the system.
Economic Implications of Home Births and Birth Centers:
Background: It is widely perceived that home births and birth centers may help decrease the costs of maternity care for women with uncomplicated pregnancies and deliveries. This structured review examines the literature relating to the economic implications of home births and birth center care compared with hospital maternity care... Results: Eleven studies were included from the United Kingdom, United States, Australia, and Canada. Two studies focused on home births versus other forms and locations of care, whereas nine focused on birth centers versus other forms and locations of care. Resource use was generally lower for women cared for at home and in birth centers due to lower rates of intervention, shorter lengths of stay, or both. However, this fact did not always translate into lower costs because, in the U.K. ... more midwives of a higher grade were employed to manage the birth centers than are usually employed in maternity units, and because of costs of converting existing facilities into delivery rooms... Conclusions: This review highlights the paucity of economic literature relating to home births and birth centers... Further economic research that involves detailed bottom-up costing of alternative options for place of birth and measures multiple outcomes, including women’s preferences, would help address the question of whether out-of-hospital birth is beneficial in economic terms.
Labels: philosophy
More thoughts about midwives discouraging pain relief
From
Navelgazing Midwife, commenting on the article
Natural childbirth: whose birth plan is it anyway?:
I think that many of us say we support women’s choices, but when it comes down to it, do we really?
When we’re at a baby shower, do we listen to another woman’s birth story, picking it apart in our heads (hopefully, only there!), tsk tsk tsking her choices and wishing for her the “empowering” birth we had?
When someone tells us they are having a scheduled cesarean, are we careful in how we want to make sure they know about the VBAC option without judging her choice as it stands today?..
When women have cesareans, no matter how they walked there, to me, it is such an enormous gesture of love towards the child… it is the demonstration of just how far a mother will go to save her child, that she will be cut open to allow him or her to come to life. I wish the women themselves could somehow set aside the horrible emotional pain, just for a moment, and see how amazing they were/are...
I now know, though, that not everyone wants the same experiences as I do. For some, medicating is their choice for working through those painful times, for not feeling as if they embarrassed themselves. I feel that as long as they aren’t medicating their entire lives, maybe it isn’t so bad to allow others to get through isolated incidents numbed… in the psyche or in the body. If it brings them through to a place of joy in the end, who am I to say one way is better than another?
I’m not ready yet for the next tattoo session – and if (through some miracle) I were to have another baby, I know I would have to dig deep again to birth in awareness and completely sober. It will be the same with the next tattoo.
But, I can do it. It’s what I choose to do. Not better, nor worse… just my own way.
Labels: philosophy
Midwives, in thrall to ideology, discourage pain relief
Natural childbirth: whose birth plan is it anyway? in the Sunday Telegraph is a fascinating exposition of the rise and tyranny of the philosophy and fabricated claims of Grantly Dick-Read":
As any woman with children knows, the politics of childbirth are so highly charged they make infighting between Labour and the Tories look like a teddy bears' picnic...
Maureen Treadwell of the Birth Trauma Association ... says that far too often ideology takes precedence over individuals' needs. 'The consequences can be unbelievably cruel...'
At the heart of much of the argument are the philosophies of Grantly Dick-Read, a British obstetrician who was convinced that much of labour pain came from society conditioning women to expect it. His 1942 classic Childbirth Without Fear expounded his belief that women educated to be free of fear and tension would experience birth as a 'normal and natural defecation'...
Dick-Read became the first president of the Natural Childbirth Trust ... [which] later became the National Childbirth Trust ... Yet Treadwell believes they may also encourage an unnecessarily stoic attitude. '... I have noticed that several midwives who have gone down its route believe pain relief leads to a cascade of interventions, when with modern techniques there is little evidence to back this.'
Belinda Phipps not only acknowledges the stance of the these midwives, but supports it:
... Belinda Phipps, the NCT's chief executive, defends such a stance. 'A lot of women who feel they are denied an epidural are on the verge of starting to push the baby out and don't actually need one any more... [A]n experienced midwife will know she's actually getting ready to push and persuade her to wait a few more minutes... Afterwards most women are very pleased they were coaxed into holding out.'
Not suprisingly, many women are outraged that their wishes are being ignored in favor of the midwives' ideology:
... 'I talk to women who have been left screaming in agony because they were either not offered or were refused pain relief,' Treadwell says. 'Afterwards, they've needed psychological help, their relationships have been scarred, they've been afraid of getting pregnant again, they don't bond with their babies.' Figures compiled recently by The Sunday Telegraph showed epidural rates vary hugely between hospitals; medical experts said the low use of epidurals at dozens of hospitals was 'extremely disturbing'.
The government, in a transparent attempt to save money, is encouraging homebirths and discouraging pain relief:
In Britain the number of home births has risen from a low of one per cent in the 1980s to nearly three per cent today, a trend that the government seems eager to assist. Last year it announced a target of ten per cent home births by 2009. Yet Treadwell is dubious that such initiatives correspond with actual demand: 'In Wales they've had a ten per cent target for home births for a while, but the figure sticks at less than four per cent, which probably reflects the number of women who actually want them...'
The result, Treadwell says, is that the government is discouraging pain relief when more and more women need it... I talked recently to an American obstetrician who was appalled at how our hospitals are praised for their low rates of pain relief. What about the suffering women? This is the 21st century, for heaven's sake.'
The ultimate irony, as I've pointed out many times, is that Grantly Dick-Read was
a racist and a sexist who made up his claim of painless childbirth in order to encourage women of the "better" classes to have more children. Dick-Read, deeply influenced by the eugenicists of the early 20th century, was concerned about "race suicide" if the "inferior" races had more children than middle and upper middle class white people. Dick-Read's claims about primitive women and childbirth have their origin in sexist philosophies of
labor pain as punishment for women who didn't know their place, and
racist theories that "primitive" women were hypersexualized, understood their "place" in relation to men, and therefore had painless childbirth.
Labels: philosophy
Homebirth in a post-fact society
Most homebirth advocates cannot independently evaluate the claims and scientific evidence used to promote homebirth because they lack basic knowledge about science, statistics and childbirth. Much of what they think they "know" isn't factually correct. You might expect, therefore, that if homebirth advocates learned more about those topics, particularly science and statistics, that they would stop making false claims. That wouldn't necessarily happen, because many of these people simply make up their own "facts" and feel justified in doing so. They are not alone. As Farhad Manjoo details in his new book,
True Enough: Learning to Live in a Post-Fact Society we live in a society that not only promotes belief over fact, but justifies belief in utterly discredited claims by promoting belief AS fact.
Manjoo writes: In the book, I spend much time on Leon Festinger's theory of "selective exposure" — the idea that in order to avoid cognitive dissonance, we all seek out information that jibes with our beliefs and avoid information that conflicts with them. While the theory is controversial, there's ample evidence that selective exposure plays a role in how people parse the news today. Survey data show that folks on the right and folks on the left now swim in very different news pools. Right-wing blogs link to righty sites, while left-wing blogs link to lefty sites. This phenomenon is definitely at work in the world of homebirth advocacy. While it is not suprising that lay people will create websites filled with misinformation to promote a point of view, the web is currently filled with websites created by supposed experts, direct entry midwives, that are filled with fabricated claims that bear no relationship to reality. The midwives in question have absolutely no idea what the facts are, and they don't appear to care. If they believe it, they simply present it as a fact. | |
Websites such as
Midwife: Sagefemme ...,
Homebirth: A Midwife Mutiny,
Woman to Woman Childbirth Education and many more operate as "post-fact" zones, where simply believing something makes it true. It appears that direct entry midwives write off the top of their heads, check nothing, and copy citations without ever actually reading them; then they link to each other as "proof" in one vast echo chamber of misinformation.
In a post-fact world, it does not matter if a claim is objectively demonstrated as untrue. The claimants just go on making the claim as if it were true. The "Swift Boat Veterans for Truth" (a truly Orwellian name) fabricated a story of John Kerrey's service in Vietnam that had absolutely no basis in reality. It was discredited thoroughly and repeatedly in the mainstream media, yet the "Swift Boat Veterans" continue to receive sympathetic treatment in the right wing media.
The world of vaccine rejectionism is also a post-fact world. Andrew Wakefield, the originator of the claim that the MMR vaccine "causes" autism, has ADMITTED that he faked the claim for financial gain. Vaccine rejectionists continue to cite his thoroughly discredited work as "proof" even after he admitted that he made it up.
Similarly, it appears not to matter how many times homebirth advocates are told that neonatal mortality is the wrong statistic to measure obstetric care; perinatal mortality is the correct statistic; and the US has one of the lowest perinatal mortality rates in the world. Virtually every homebirth advocacy website continues to repeat the claim because they "believe" that modern obstetrics is unsuccessful and they "believe" that the neonatal mortality rate is an indication of this "fact".
Anyone seeking objective information about homebirth would do well to keep this in mind. The chance of finding out the facts about homebirth on a homebirth advocacy website are the same as finding out the facts about Bush's incompetence on Fox News. Reading the homebirth literature and homebirth websites does not make a person "educated" about birth options. The only way to become educated on the topic is to read the scientific literature itself, and to read competing interpretations of that literature. In a "post-fact" world of homebirth advocacy, beliefs are presented as "facts"; people pick the "facts" that appeal to them; and advocates make sure that they never have to read or hear anything that has not been vetted in advance by people who share their beliefs.
Labels: philosophy, pseudoscience
And they wonder why no one takes them seriously
You can't make this stuff up.
This piece of psychobabble is what passes for research in the world of midwifery,
Including the nonrational is sensible midwifery, by Jenny A. Parratt, and Kathleen M. Fahy, was recently published in the Australian midwifery journal Women and Birth. This piece has a very simple premise and conclusion: Many principles of midwifery are not supported by science. Rather than modify midwifery to reflect scientific knowledge, it is personally more satisfying to midwives to justify and celebrate their ignorance. Hence, we celebrate!
In many ways, the article resembles religious rationales for maintaining belief in creationism in the face of the overwhelming scientific evidence that creationism is nothing more than wishful thinking. It is striking how the language of the article resembles that used in justifications of religious belief:
Much of life cannot be apprehended or comprehended on a purely rational basis... Consider, for example, the sensations that may arise when watching a sunset, hugging a loved one, hearing a bird's song or delighting in a sense of bodily capability... Similarly a midwife's ordinary practice of being with the woman can be experienced by the midwife in quite extraordinary — nonrational — ways...
The centrality of emotion is similar; the nonrational beliefs must be good because they help people feel better about themselves; interestingly, the "people" in question are not laboring women, they are midwives. This article is a justification of irrational midwifery beliefs on the basis that they make midwives feel good about themselves.
Experiencing the nonrational may include sensations of inner power and/or inner knowing... These experientially grounded, nonrational aspects of life have been described variously as mysterious, sacred, spiritual and intuitive... Experiences that are nonrational are experiences of unity and wholeness; ...
And, of course, no discussion of religious justification is complete with reference to the "soul".
Our soul is our own particular organic expression of the spiritual milieu of nonrational power. The soul moves in parallel with spirit: thus soul is nonrational, ethically neutral and idiosyncratic... Through our soul we may interpret and experience the power of spirit in diverse and contrasting ways: e.g. liberating, oppressive, joyous, peaceful or challenging...
The central claim of the paper is that the inclusion of the non-rational is midwifery "enhances safety", although the authors' explanation seems to show nothing of the kind.
When the concept of 'safety' is considered in childbearing it can illustrate how insensible rationality can be and how negative consequences can occur. Safety is an abstract concept because it is difficult to define and can only be considered in general terms. Rational dichotomous thought, however, provides 'safety' with the following defining boundaries:
- 'safe' has a precise opposite called 'unsafe',
- every situation/person/thing must be either be safe or unsafe,
- a situation/person/thing cannot be both safe and unsafe,and
- it is not possible for a situation/person/thing to be anything
other than safe or unsafe.
The authors have created a straw man. Perhaps they understand safety to be an either or dichotomy, but real medical professional recognize safety as existing on a continuum. Some techniques, treatments and situations are safer than others, but there is no single technique, treatment or situation that is "safe", rendering everything else "unsafe". The authors complain:
... What is deemed as safe is aligned with what is rational and what is unsafe is aligned with what is irrational. As irrationality is not acceptable this essentially forces the definition of safety to be thought of as 'true' even though it may not fit with personal experience and all situations... As the standard birth environment is the medicotechnical environment of the hospital this is presumed to be the safest. Its 'opposite', the home environment, is therefore rationalised to be unsafe. To argue otherwise would define the rational person as irrational... In the purely rationalist way of thinking there is no other option except to consider that honouring the nonrational variabilities of individual bodily experience is irrational and unsafe.
The authors end with a flourish of outright stupidity:
For example, when a woman and midwife have agreed to use expectant management of third stage, but bleeding begins unexpectedly, the expert midwife will respond with either or both rational and nonrational ways of thinking. Depending upon all the particularities of the situation the midwife may focus on supporting love between the woman and her baby; she may call the woman back to her body; and/or she may change to active management of third stage. It is sensible practice to respond to in-the-moment clinical situations in this way... Imposing a pre-agreed standard care protocol is irrational because protocols do not allow for optimal clinical decision-making which requires that we consider all relevant variables prior to making a decision. In our view all relevant variables include nonrational matters of soul and spirit.
Evidently, even if the woman bleeds to death for lack of pitocin, the decision to "support love between the woman and her baby" is still the correct one because her "soul" is "safe".
And, of course, the central focus: how does this make the midwife
feel:
Being open to the nonrational in midwifery practice makes room for midwives to self-reflexively acknowledge aspects of themselves, such as their fears, in a way that does not interfere with their practice. During birth, making room for the nonrational broadens both midwives' and women's knowledge about trust, courage and their own intuitive abilities including the changing capabilities of bodies. And by including the nonrational midwives can then most honestly be with the woman's own fears as she opens her embodied self to her own unique process of childbearing.
At least these people are honest, even if completely inane. A fundamental (perhaps, the fundamental) goal of midwifery is to make midwives feel good about themselves. Coming face to face with their own ignorance makes midwives feel bad about themselves. Fortunately, there is a way to pretend that there is no such thing as ignorance. If a midwife thinks it or "feels" it, it automatically becomes knowledge. If the ultimate goal of midwifery is to make midwives feel good about themselves, then the inclusion of the nonrational is indeed "sensible".
Labels: philosophy
The perpetuation of biased beliefs
I have written repeatedly about the fact that while homebirth advocates claim to be educated, most of what they "know" about childbirth is factually false. They are easily duped because they lack the most basic knowledge about science, statistics and childbirth itself. However, even when they come into contact with accurate information, they tend not to change their beliefs. That's because people routinely act in ways that perpetuate their own biased beliefs.
An article in the Economic Journal,
The Self-Perpetuation of Biased Beliefs, by Wing Suen, lays out the problem:
A basic tenet of science is that the accumulation of evidence will eradicate false beliefs... Alas, this is too optimistic a view for the progress of economics and other social sciences... Why is it that mistaken beliefs seem to have a life of their own, refusing to disappear in the face of accumulated data?
The failure of data to resolve differences in prior beliefs is not confined to the realm of science. Indeed the failure is so much more severe in other areas of life that many conflicting beliefs seem to be incapable of ever having an empirical resolution. The focus of this paper is not on why people have different beliefs... The real puzzle is why these conflicting beliefs can persist [in the face of new evidence].
It is well known that people with biased beliefs are more likely to choose sources of information that are biased. That is certainly the case for homebirth advocates. According to the author, if groups of people with differing beliefs are exposed to the same data, both groups will revise their previous views by incorporating the new data. However, when the price of access to the original data is "too high" (if, for example, it requires a level of expertise that is simply not available to the average person), the average person must rely upon an expert to present the information. Moreover, that expert must present the information in such a way that the average person could understand it. Of necessity, that will mean simplifying the information in such a way that much of its original meaning may be lost. Different experts may simplify the same information in different ways, depending on what outcome they wish to ensure.
For example, homebirth advocates claim that the most recent statistics on US maternal mortality indicate that maternal mortality is rising. Many physicians and scientists (myself included) believe that the most recent data does NOT indicate that maternal mortality is rising. Both groups take the actual data as their starting point, and, indeed, the total maternal mortality rate did rise from one year to the next. However, homebirth advocates, simplifying the data for the layperson, have left out several critical facts. First, birth certificates have been revised to pick up additional causes of maternal death remote from the actual birth. Second, the risk profile of pregnant women has been changing, with more pregnancies to older women and more multiple births. Anyone who has access to the actual data (both because you actually read the data, and because you are able to interpret it without an intermediary), you will draw one conclusion. If the data is simplified and important factors are left out, the layperson may draw the opposite conclusion.
Suen argues that the desire for experts who will simplify the data to support the preferred bias has a rational (as well as a self-justifying) basis. Of course, people prefer information that reinforces existing beliefs. However, if they are going to receive information that does not confirm existing beliefs, it is more effective to get it from experts that they trust. People reason that if their chosen expert advocates accepting information that subverts existing beliefs, that information must certainly be true.
Suen offers an example:
Consider a person who is predisposed to voting for the Conservative Party. He is not interested in consulting a very left-wing newspaper even if he knows that the newspaper editors possess private information about the candidates. The voter figures that this newspaper will endorse a Labour candidate based on very weak evidence ... Thus the leftist newspaper’s recommendation is of no value to this voter. However this Conservative voter can gain by reading a rightist newspaper. In the (unlikely) event that the rightist newspaper endorses Labour, the voter infers that the newspaper must have received a very strong signal that the Labour candidate is indeed superior. Such information is useful because it will change his vote. The leftist and rightist newspapers may have access to the same information but, because they process the information differently, the Conservative voter prefers learning from the rightist newspaper. Such a rational demand for information from like-minded sources is the key to the theory of self-perpetuating bias.
Similarly, when I point out the blindingly obvious fact that direct entry midwives are undereducated and undertrained, homebirth advocates will dispute it. However, when a direct entry midwife, like Kneelingwoman or Navelgazing Midwife, makes the same blindingly obvious observation, homebirth advocates pay attention, and often agree.
The bottom line is that biased experts can transmit bad news to believers with more efficiency than experts who are perceived to be unbiased or biased in the wrong direction. Unfortunately, such occurances are rare. What does this mean for the average homebirth advocate? It means that when a preferred expert simplifies new information in a way that challenges your existing beliefs, you can assume that the information is correct. However, if the preferred expert simplifies new information in a way that confirms your existing biases, you have no way of knowing if the interpretation is actually correct. In other words, choosing a biased expert may be more efficient in the short run, but is generally inaccurate in the long run.
Labels: philosophy
Responsibility: what does it mean?
One of the more attractive aspects of homebirth advocacy, like other "alternative" health movements, is the notion of "taking responsibility" for one's health. According to the article I quoted yesterday, The holistic heresy: Strategies of ideological challenge in the medical profession:
A controversial aspect of the holistic heresy is its emphasis on a person's 'responsibility' for health ...
Shared responsibility for health erodes the traditional prerogative of the physician, but also serves to shift the liability of therapeutic failure at least partially to the patient.
That's the theory, anyway. However, it doesn't represent what happens in real life. What does it mean to "take responsibility" for one's health?
Imagine this scenario: A woman, after reviewing the evidence from both sides, after carefully considering the increased risks, and after deciding that she is willing to accept the responsibility for the outcome, decides to ... smoke cigarettes.
This situation happens all the time. Indeed, a substantial portion of the population smokes cigarettes. In 2008, everyone knows that cigarette smoking increases the risk of lung cancer, emphysema and other diseases. However, most smokers will accurately point out that not everyone who smokes gets a smoking related illness, that smoking provides both pleasure and concrete benefits such as relaxation and increased concentration, and that adults are entitled to make their own healthcare choices. In addition, there are scientists who assert, and who have testified under oath, that the harms from smoking have been dramatically exaggerated.
So if a woman claims to have made a knowledgeable decision to smoke cigarettes, and is aware of the potential consequences, does that mean that she is "taking responsibility" for her health?
In one very real sense, it does, since she is the one who will suffer if any harmful effects ultimately occur. She is the one who will gasp for breath with emphysema, she is the one who will endure treatment for cancer and who may die a painful death from it. However, it most other ways, she has no intention of "taking responsibility" for her health.
First, most women who elect to smoke cigarettes have some measure of denial about what is can happen. They tend to grossly underestimate the risks of getting a serious illness; they tend to be unaware of a variety of less common illnesses caused by smoking (bladder cancer, peripheral vascular disease); and they tend to grossly underestimate the impact that emphysema, lung cancer and other diseases will have on their life as a whole. So while they may be technically "educated" about the risks, they are not acting with a clear eyed assessment of those risks.
Second, smokers have no intention of managing any complications alone. If they get emphysema or cancer, they will expect and demand state of the art treatment for those diseases. They caused their own disease, but they will expect and demand that others do everything possible to cure or at least ameliorate it. Moreover, they have absolutely no intention of paying for their decision. They bought insurance for just this eventuality. As far as they are concerned, other, healthier people can pay for their illness with higher premiums overall.
In a very real sense, they don't plan on taking ANY responsibility for their health. They plan on other people doing all the work, and paying most of the money to rescue them if their choices were wrong. The bottom line is that women who "take responsibility" for smoking are generally in denial, grossly underestimate the risks of serious harm, have no intention of fixing their own medical problems, and have no intention of paying the bulk of the cost from those problems.
So it is possible to make a terrible healthcare decision while simultaneously claiming to "take responsibility" for one's health. Homebirth is very similar. Most homebirth advocates have no clue as to the real risks of homebirth. Indeed, most homebirth advocates actually believe the opposite of the truth about risks. Second, most homebirth advocates are in denial about the fact that serious complications can occur in low risk women. Third, homebirth advocates expect, demand (and sue) for state of the art medical care to rescue their babies and themselves from their own choices. Fourth, homebirth advocates have absolutely no intention to pay the bulk of the costs that may result for their poor choices, ranging from a long term stay in the NICU to life long special needs assistance for an impaired child.
In other words, all the talk about homebirth advocates "taking responsibility" for their health is just talk. In the ways that count, homebirth advocates expect everyone else to do all the work, take all the responsibility and shoulder the bulk of the expense for their choices. Homebirth advocates intend to take precisely the same responsibility for their health that smokers intend to take, in other words, no responsibility at all.
Labels: philosophy
Reverberations
Kneelingwoman's post about midwifery education continues to reverberate around the web. Comments to her post and to Navelgazing Midwife's similar post range from supportive to "disappointed" to spluttering indignation. Kneelingwoman
continues the conversation by asking some very important questions:
Why don't we want to know what women want? Why do we keep going to conferences and paying out a ridiculous amount of money to stand in a circle, sing and hold hands with the "ya ya sisterhood" and then flatly reject the idea that we should create a midwifery that actually serves women according to their needs in birth instead of what need to provide? Why are we so afraid to grow and change? Why does the very idea that the reason midwifery isn't reaching more women that there is something about it and us that doesn't resonate with the majority not addressed more seriously?
Why? I'll offer a very simple answer. Homebirth midwifery is about the midwives, not the patients. Not every single DEM feels this way, but the structure of the profession makes it obvious that it is the needs of the midwife that comes first.
When you think about it, it explains a lot.
"Why don't we want to know what women want?"
They don't want to know because they are not interested. The overwhelming majority of women are looking for something very different than what most DEMs are interested in giving. They want healthcare providers who are up to date with the latest medical information and who can provide the safest possible care. DEMs want a friendship and bonding over shared philosophical views.
"Why do we keep going to conferences and paying out a ridiculous amount of money to stand in a circle, sing and hold hands with the "ya ya sisterhood" and then flatly reject the idea that we should create a midwifery that actually serves women according to their needs in birth instead of what need to provide?"
Why? Because the conferences are designed around the needs of DEMs and they want to attended conferences that are nothing more than echo chambers for the views they already hold.
"Why are we so afraid to grow and change?"
Growing and changing means confronting the very serious deficiencies of homebirth midwifery education and training. The concept of growing and changing implies that there is actually something more to know than "trusting" birth. Growing and changing means responding to the needs of others, rather than determining who you will care for by whether they meet your needs. Growing and changing implies standards and standards are anathema to those who are undertrained.
"Why does the very idea that the reason midwifery isn't reaching more women that there is something about it and us that doesn't resonate with the majority not addressed more seriously?"
Most DEMs are not interested in reaching more women. They are not interested in providing healthcare. They do not want to try to meet diverse needs of women with different ethnic, cultural, economic and educational backgrounds. They want relationships with women who will echo back DEMs' flattering views of themselves, not patients who question, who disagree and who are non-compliant.
I suspect that both Kneelingwoman and Navelgazing Midwife are correct that direct entry midwifery is on its way out because legislators and consumers will discover just how uneducated and untrained DEMs are. Yet the lack of education and training is not just the problem, it is a symptom of the larger problem. It is virtually impossible to create a profession around the notion that you don't have to do anything more than "trust" that everything will work out fine. In an age when teachers are required to have masters degrees, it is simply not possible to maintain that attending births requires little more than a high school education. Finally, and perhaps most important, the fundamental reality is that most women view midwives as healthcare providers, not new friends. They are not looking for the relationship that DEMs want to give; they are not looking for friends at all; they are looking for professional health care.
Labels: midwifery, philosophy
Can't care for you
What does it mean when a provider of healthcare can't work with anyone who disagrees?
Can you imagine a doctor or nurse saying:
I choose to work only with women who believe in Jesus, because that’s where my passion and training lies. I’m a firm believer in Christianity and in my idealism as a provider, I see spreading the Word through birth care as my contribution to helping change the world.
or
I choose to work only with with white women because that’s where my passion and training lies. I’m a firm believer in the superiority of the white race, and I see this as my contribution to helping change the world by improving the racial stock.
That would be unethical, obnoxious, racist, and illegal.
Evidently these rules of ethical medical care have not reached doulas. According to an article in the NYTimes,
And the Doula Makes Four:
"I choose to work with women who are striving for a natural birth because that’s where my passion and training lies," said Ms. Harris, whose training was as a Bradley-method childbirth instructor, which emphasizes natural birth with intensive support from the husband.
"I’m a firm believer in the natural process," she said, "and in my idealism as a birth worker, I see this as my contribution to helping change the world." In both cases, Ms. Harris referred the women to another doula.
What does it mean when a doula or direct entry midwife refuses to care for women who don't share the same philosophy on pain management or breastfeeding? I think we can draw several conclusions, besides the obvious one that it is completely obnoxious:
1. The doula or midwife is not a provider of health care, but a friend.
Providing healthcare ethically mandates putting aside your own thoughts and feelings. You can't refuse to care for people simply because you don't agree with them. The classic medical example is caring for the injured drunk driver after he has killed an innocent victim. You cannot refuse to care for him, even though you despise what he did, and have just viewed the remains of the person he just killed.
2. It is culturally and ethnically insensitive.
"Natural" childbirth and homebirth reflects the views and beliefs of a small subgroup of white, Western, relatively well educated and relatively well off women. It is not your job as a provider, to proclaim the superiority of your worldview. You must respect, and adjust to the worldview of the patient.
3. It reflects minimal knowledge.
To a certain extent, it reflects the minimal training and minimal knowledge of doulas and direct entry midwives. They don't plan to do much because they don't know much. A patient who doesn't share their birth philosophy might ask for something that they literally know nothing about.
4. It is unethical.
If you represent yourself as a provider of healthcare, you cannot decide whom you will treat based on a philosophic litmus test. You are entitled to point out that the fit between you and the patient might not be the best, but you are not entitled to refuse to care for someone.
5. It's all about YOU, not about women.
In essence, it is determining whom you will treat based on whether they meet YOUR needs, not based on whether you meet their needs. While you may choose to become a healthcare provider because you think, in general, it will fulfill personal needs, you can not extend or refuse care based on whether an individual patient is likely to meet those needs.
Of course, a healthcare provider is never required to provide care that she believes to be medically unsafe, or illegal, or prohibited by medical standards. The actual care provided should be determined by the scientific evidence. However, a healthcare provider cannot refuse to care for someone because she disagrees with a patient on philosophical (or any other) issues.
Labels: philosophy
Midwifery licensing: is it a consumer issue?
Two weeks ago I wrote about
midwifery licensing and rhetorical tricks. Reduced to its basic elements, the arguments for licensing a second, inferior class of midwife with less education and training than any midwives anywhere else in the industrialized world is not particularly compelling. Therefore, American DEMs and their supporters have been forced to resort to rhetorical tricks to mislead the public and legislators about direct entry midwifery. These tricks include obscuring the fact that DEMs have deficient training by claiming they are "experts" in normal birth, muddling the distinctions between certified nurse midwives and DEMs, and using the wrong statistics (infant mortality rate) to make the false claim that the US lags behind other industrialized countries in indicators of obstetric care.
These tactics have been reasonably successful in confusing the issue, but there are other rhetorical tricks that have been met with greater skepticism. This second group of rhetorical tricks represents efforts to portray the issue of DEM licensure as an issue of "choice" or an issue of "consumer rights".
Katherine Beckett and Bruce Hoffman have written in
Challenging Medicine: Law, Resistance, and the Cultural Politics of Childbirth:
Midwives and their supporters consistently frame this debate as one centrally about individual choice, arguing vigorously that women have the right to choose where and with whom they will give birth. As the legislative sponsor in California stated, "At the core of this issue are two simple beliefs: first, that childbirth is a natural process of the human body and not a disease. And second, that a parent has the responsibility and the right to give birth where and with whom the parent chooses ..."
... Notably, birth activists avoided linking this choice to the right to choose abortion by avoiding more general terms such as reproductive choice or the right to choose.
Homebirth advocates are trying frame the "choice" of homebirth as similar to the choice of abortion and therefore guaranteed. Ironically, they want to trade on the widespread and widely acknowledged support for abortion rights despite the fact that many homebirth advocates (and many legislators) do not support the right to choose abortion.
The connection between homebirth and "consumer rights" is even more tenuous. As Christa Craven, a professor of sociology and a homebirth advocates, writes in an article entitled
Is Reproductive Healthcare Access a "Consumer Rights" Issue? in a publication of the American Anthropological Society:
... [M]any homebirthers have begun to adopt the rhetoric of "consumer rights" to defend their right to midwifery care... Through challenging the authority of biomedicalized childbirth, all homebirthers are engaging in dissident political acts, which has forced many ... to justify their actions as an issue of ideological choice (that is "every woman should have the right to use a homebirth midwife"). However, as midwifery advocates have been forced to "legitimize" their choices ... their arguments have become more centered upon "consumer choice" to enhance childbirth options (such as "every woman should have the right to hire a homebirth midwife").
Craven is concerned that the rhetoric of consumer rights speaks only to the concerns of middle class and affluent women:
Although this consumer model offers some midwifery advocates a useful metaphor to describe themselves as political actors, it does not always speak to the experiences of women who have restricted financial options for birthcare. In fact, most middle-class, affluent participants in my study felt strongly that it was their right to have choices in their childbirth experience, while most low-income participants indicated an interest in choices for their birthcare, but also a dependence upon midwives as a low-cost childbirth option...
In other words, when homebirth advocates talk about consumer rights, they mean that women with money have a "right" to spend it how they see fit, not that all women have a right to DEM care.
Homebirth advocates cannot make a compelling argument for licensing a second, poorly trained class of midwife, so they attempt to confuse the issue. Typically they do so by obscuring the poor training of DEMs, by implying that DEMs are the same as CNMs and by falsely accusing American obstetrics of providing substandard care. However, they also attempt to do so by trading on support for "choice" when many do not actually support true reproductive choice, and by asserting a non-existent "consumer right" to buy whatever they can pay for.
Labels: philosophy
Homebirth advocates are not honest with themselves
Kneelingwoman has written another thought provoking post,
What Have We Got To Lose?. The part that I found most compelling is this:
There is an effort being promoted; "The Big Push for Midwives" and ... for me, all of this is very akin to the issue of "risk assessment" -- in increasing numbers, neither parents' nor midwives want to explore the real risks of a course of action, or inaction, and then have to scramble to fix the resulting diseaster ... Midwifery, for many years, has simply not wanted to deal with the reality on the ground because we have listened only to ourselves; not to the women we say we want to stand in solidarity with. We have then been forced into accepting a limited role in the health care system out of stubborn adherence to an educational path that has rapidly outlived it's ability either to reproduce practioners or ensure a viable working life for it's current proponents.
Kneelingwoman describes this as an issue of "risk assessment", but I think the problem is more general. Homebirth advocates are simply not honest with themselves and each other about the inherent risks of childbirth, the serious safety limitations of homebirth, and the woefully indequate education and training of homebirth midwives.
A brief tour around the internet on any given day will illustrate what I mean:
Newsweek is currently running an article on
The Delivery Debate. As part of the article, Katie Prown, campaign manager of The Big Push for Midwives, is quoted:
Prown rejects ACOG's claims that CPMs are less qualified than CNMs. "If those accusations were true, then we would see a different trend than what we are looking at right now," she says. "In the last five years Utah, Wisconsin, Virginia and Minnesota have licensed certified professional midwives … These states are seeing good results. If they were seeing bad results, states would be outlawing CPMs."
I posted a comment that pointed out that her claim is false.
Wisconsin's birth statistics demonstrate that neonatal mortality for homebirth attended by a DEM is consistently TRIPLE the rate of neonatal mortality for CNM attended births. Prown responded:
The Wisconsin statistics that Dr. Amy cites are irrelevant. One, they were compiled before Certified Professional Midwives in the state attained legal status (which happened in May, 2007) and two, they make no distinctions among babies who were delivered by CPMs, family members, taxi drivers or anyone else who may or may not have been adequately trained for the task at hand.
Prown is not even honest with herself about the statistics, so she can't possibly be honest with anyone else: She encouraged people to look at Wisconsin for evidence of homebirth safety without knowing that the statistics show that homebirth is not safe. Now she is furiously backpedaling by claiming that the statistics are "irrelevant" and by falsely claiming that they include non-midwives.
Homebirth advocates are not honest with themselves because they attempt to reason backwards from false conclusions. They are sure that homebirth is as safe as hospital birth, so they insist that it is without even bothering to check. They are completely unaware that the low rates of perinatal and maternal mortality in first world countries are the result of modern obstetrics, so they falsely claim that homebirth is as "safe as life gets". They are so isolated from the reality of obstetrics and even the reality of midwifery (CNMs and the US, and European midwives) that they don't know how poorly the grossly inadequate education and training of American DEMs compares to real midwifery training.
I think that Kneelingwoman is entirely correct on this point. Although it may appear that state licensing of DEMs represents a victory, it is the beginning of the end of American direct entry midwifery. When states get involved and start collecting statistics, it will be impossible to sustain the falsehood that homebirth is as safe as hospital birth. It will also be impossible to defend the grossly inadequate education and training of American DEMs. They, like Canadian DEMs and European midwives, will be forced to adhere to higher standards of education, training and practice.
Labels: philosophy
Midwifery licensing and rhetorical tricks
Homebirth advocates face an uphill task in seeking the legalization of direct entry midwifery. When reduced to its basic elements, the argument for direct entry midwives is not particularly compelling: states should create a second, inferior class of midwife with less education and training than any midwives anywhere else in the industrialized world because .... Well, because there is a tiny group of women who don't have the educational background to qualify for standard midwifery programs, don't wish to spend the time to become qualified, and want to make money attending childbearing women anyway. That's not going to convince many people, so the essence of advocating for the licensing of direct entry midwives is to trick the people being lobbied.
First, it is important to hide the fact that direct entry midwives are grossly undereducated and grossly undertrained. There are specific rhetorical claims designed to obfuscate the substandard training of DEMs. DEMs are portrayed as "experts" in normal birth and "specialists" in out of hospital birth. That's quite a rhetorical trick; the fact that DEMs receive minimal education and no training in managing birth complications is turned on its head to a claim that they are "experts" in uncomplicated birth. The fact that DEMs are barred from hospitals and other healthcare facilities because they are not competent has been turned on its head to a claim that they are "experts" in homebirth. It's not even clear what that means. Are we supposed to consider them "experts" in dialing 911 to bring the real medical professionals in order to fix the life threatening blunders they make at home?
The second rhetorical trick is to blur distinctions between different types of midwives. DEM advocates insinuate, imply and even claim that licensing of DEMs is necessary to provide women with access to midwifery care, although women in all 50 states already have access to midwifery care. DEM advocates falsely claim that American direct entry midwives are similar to other direct entry midwives in the industrialized world. Neither are have nursing degrees, but the similarity ends there. The differences, which are never acknowledged, are far more important. European midwives receive a far more rigorous education, have extensive training in identifying and managing childbirth complications, and are qualified to work in hospitals. American DEMs waste time on pseudoscience "courses", have NO training in managing complications and are unqualified to work anywhere, so by default they are restricted to private homes.
The third rhetorical trick is to misuse statistics. The claim is made that the US trails many other industrialized countries in infant mortality, though infant mortality is the WRONG statistic to use in evaluating obstetrical care. The claim is made that countries with higher homebirth rates have lower rates of infant mortality, although homebirth rates have nothing to do with mortality rates (most perinatal deaths occur in high risk groups), infant mortality is the wrong statistic, and the correct statistic, perinatal mortality, reveals that the US actually has lower rates of perinatal mortality than coutnries that encourage homebirth.
These tactics are meant to hide the lack of training of DEMs, to blur the important distinctions between DEMs and other midwives and to imply that American obstetrics is substandard and lack of midwives is the cause. As rhetorical tricks, they are quite successful. Even homebirth advocates often don't realize that what they are claiming is not true. This is just the tip of the iceberg. In a future post, I'll review the rhetorical trickery of the appeal to "choice" and "rights".
Labels: philosophy
Barking dogs
Navelgazing Midwife has posted a thought provoking piece,
The Gray, Grey Messenger. It starts off as a response to Gloria Lemay's inane comments about hemorrhage (which I addressed in
Idiocy from Gloria Lemay) and ends up considering the appropriate response to risk. NGM has this to say about doctors and nurses:
... [W]ouldn’t most of us do something if we knew someone was going to get hurt? The thought of a baby suffering certainly makes most/all of us ache to our core.
Doctors and nurses share that same inner turmoil we all do when thinking about a baby about to be hurt or damaged. They just look at things from a different vantage point.
I think about my dogs that bark at anyone that comes near the house. It drives me crazy when they both get to yapping, but I also know they are trying to protect me from danger. That there isn’t any danger doesn’t faze them because all they know is, "Someone’s coming close that doesn’t belong here. DANGER!" and they bark. I would never consider teaching/punishing/training them to not bark because the one in a million times they do bark, it will be to warn me of someone who doesn’t belong here.
Doctors, too, are barking dogs, warning, warning and warning of dangers. Most of the time, they are heralding nothing but potential dangers, especially if nothing changes to shift the concerns. But, because of their instinct/experience/training, they do recognize and are ready to defend the baby and mother against severe trouble and turmoil.
Do we really want doctors to stop barking altogether? (I try and keep my dogs from barking inside, instead sending them outside to bark.) Perhaps we can encourage them to use their indoor voices when the mom/energy needs to change positions instead of screeching so loudly we cover our ears.
And then, the question becomes: Who is the translator? Who really knows if there is danger or not? I know many believe a mom will intuit something amiss, but I have been around enough births where the woman was the least aware of what was going on. Do we take a vote from everyone present? Do we ask for a second or third opinion? (I am reminded of people with severe illnesses who traverse from doctor to doctor, looking for the response they desire, it not mattering that they really are sick; they just want to hear that they aren’t.) Do we ask for more time? Who is holding the hourglass? (The baby?)
At one level, this is not a very flattering comparison. Doctors are like dogs who lack the ability to tell the difference between the unknown and true danger. I don't think that was what Navelgazing Midwife was trying to convey, though. What came through for me was this:
There is real danger in childbirth.
Doctors are trying to protect babies and women from real danger.
Doctors do this because they don't want babies and women to get hurt.
Navelgazing Midwife, in describing her frustrations, captures the frustrations of doctors and nurses as well. It is very disppointing to do everything in your power to protect a baby and a mother from harm and then find out that not only does the mother not appreciate your hard work and heartfelt effort, she actually resents it and considers it unnecessary.
Labels: philosophy
