Archive for February, 2010

Mother-Friendly in Texas

February 25th, 2010 by avatar

Tomorrow marks the beginning of the Coalition for Improving Maternity Services Mother-Friendly Forum and I’m happy to report that I made it to Austin ahead of the big North East storm. I have been to all but one CIMS Forum in the past 5 years, slinging infants to a couple of them. They just keep getting better, in my opinion.  The CIMS Forum is where The Birth Survey, a grassroots project to improve transparency in maternity care, was born several years ago. Last year we got phenomenal presentations about the Northern New England Perinatal Quality Improvement Network and Dr. Michael Lu’s research on racial and ethnic disparities in birth (pdf), among others.

This year we’ll hear about the results of a 3-year multi-stakeholder national project to create a blueprint for maternity care reform, get an update from documentary producer and book author Ricki Lake, and hear from experts including Judy Norsigian, Nancy Lowe, and Penny Simkin.

Could I be more excited to present (twice!) among these amazing leaders?

Henci Goer and I will be giving a round-up of “ah ha” moments from our 3+ years (ouch) analyzing the obstetric literature in preparation of the forthcoming second edition of Obstetric Myths versus Research Realities.  I’ll also be presenting with About.com‘s Robin Elise Weiss and blogger Jenn Johnson from BabyMakinMachine.com about the potential for blogs and other social media to promote consumer engagement and mother-friendly birth.  Speaking of blogs, blogger and perinatologist Chukwuma Onyeije got me (and Hilary from MomsTinfoilHat) hooked on the Prezi presentation platform. Here’s the Prezi I put together for my portion of the blogging talk.

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Becoming a Critical Reader: Bias, Bias Everywhere!

February 17th, 2010 by avatar

Pretty much everyone would agree that there is bias in research. Most people would say that bias is inherently bad. While it absolutely can be a bad thing, it can’t be completely eliminated. So what can be done about bias in research?

There are many kinds of bias:

  • Researcher bias: researcher sets out wanting to the study to prove something, and intentionally or unintentionally manipulates the study to make sure that happens
  • Sponsor bias: The organization that sponsors the study either encourages researcher bias or manipulates the publication of the data. Some studies might be completely suppressed, some might have overly inflated press releases touting minimal results.
  • Publication bias: Journals must be selective in what they publish due to space limitations, but I think it is fair to say that some journals may choose not to publish a study that might anger its audience.

But today I want to focus on READER bias:

Your first job in the critical reading of an article is to check your bias. We are all human, and so we all have bias. Sometimes it is hard to see your own biases. Take a look at the pictures below. In the first picture, we can tell that there is something there, but it is difficult to see. In this case, the letters are lined up with our angle of vision.


In this second picture, the letters are running the opposite way as our line of vision, and as you can see, suddenly that bias is crystal clear!


The same is true with our reading of the research. The biases that we have act as a filter that alters our reactions to the research. If we already have our minds made up that induction of labor = bad, then any research on labor induction is going to be seen through that filter. Any research that seems to place induction in a favorable light will be seen has highly suspicious. Any minor flaws will be exaggerated. Any research showing bad outcomes from inductions will likely get a “free pass” and flaws may be overlooked.

Murray Enkin, author of “A Guide to Effective Care in Pregnancy and Childbirth”, said this:

Perhaps the most important bias of all resides in the (potential) reader, who determines how (or if) the results will be read and interpreted.

I would agree with him. I have, over the years, seen the best and worst of research used to back up various points, ignoring the quality (of lack of it!) as long as it agrees with them. This is a normal human tendency, and one that is at the heart of many discussions about the available research.

But the good news is that reader bias isn’t impossible to overcome.

The solutions? Awareness of bias and a change of perspective! As you read, consider how this research might be read and understood by someone with a completely different perspective. When you read a study that really resonates as a great study with you, play “devil’s advocate” and pick it apart. Be merciless in looking for flaws, weaknesses and the other types of bias listed above. The same is true of seeing an article you disagree with. Look for strengths and solid evidence. Have an open mind to other possibilities. Sometimes when doing this, you’ll be able to see some aspects you would never have noticed otherwise.

So, here’s an exercise for you. Take a few minutes, and write down what your biases are when it comes to research. Which kinds of research, which methods, which topics do you particularly feel drawn to? Which ones seem silly or useless? For inspiration, you may want to read a personal commentary article written by Murray Enkin (2008) where he goes through his own personal biases. The things he feels a bias for or against may not be the same for you. I know I have a disagreement with one of his stated preferences. But taking the time to carefully think through your own personal biases, to clearly acknowledge the filters through which you view the research, can only help you as you try to step back and make a critical analysis of the research.

Reference: Enkin, M. W. (2008) Biases in evaluating research: Are they all bad? Birth: Issues in Perinatal Care. 35(1). 31-32.

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Becoming a Critical Reader: An introduction

February 16th, 2010 by avatar

We’ve finished our series on finding research articles, the next series will focus on how to critically read articles in order to evaluate them. I think we all know there is good research and bad research, so now we’ll explore how to tell the difference.

You’ve found an article that looks promising. Now what?

First, you’ll want to give it a quick read-through. You’ll be going back later to do the real critical analysis, so don’t get bogged down in the details at this point.

Start with the abstract, a short summary of what the article contains. The abstract will give you a brief overview of the article and its contents. Keep in mind that abstracts are not comprehensive, and are written by the study authors. They are in a sense similar to theatrical trailers. You can often get the basic gist of what the article is about from the abstract, but just like a well-done movie trailer can make a bad movie look good, you can’t gauge the quality of an article by the abstract alone. Read the whole thing!

You’ll often hear references to “studies”, “the research” or “the literature” – but not all articles published in professional journals are the same. In this initial read-through, you’ll want to determine what kind of article this is and if it fits your needs.

Among the kinds of articles you may find in professional journals are:

Literature Reviews – These articles attempt to do a search of all available research on a particular topic and summarize the research for the reader.

Case Reports – Generally these articles focus on more rare events or novel experiments. They may help the author find others who have experienced similar rare events, or “show off” the author’s creative solutions to such rare events.

Opinion piece – In these articles, the author shares a personal opinion on any topic or thoughts on a piece of research. It is not uncommon for the editor of a journal to publish a comment piece on a new study being published in that same issue.

Original research – This is generally what people are referring to when they talk about “studies”. In original research, the authors have done something from scratch. This may be an experiment that was conducted, a new analysis of information previously gathered (like data extracted from chart reviews), interviews, surveys, etc. We will go into much more detail on original research in future articles.

Systemic review/Meta-analysis – We will get into the details of these in a later article, but for now, just know that these kind of articles take the data from previously published studies and analyze that data to come up with a conclusion. The most well-known of these types of articles are the Cochrane Reviews.

Next you’ll want to make sure you’re clear on one thing: What did the authors set out to do? When you do the critical reading, you’ll be keeping that purpose in mind as a measuring stick of sorts to see how well the authors or researchers accomplished that goal.

And that’s it for the initial read through! Now that you have an overall sense of what the article you’ve found is all about, we’ll get ready to do the real critical analysis.

Tomorrow: how to detect bias in research!

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Healthy Birth Blog Carnival #4: Avoid interventions that are not medically necessary

February 8th, 2010 by avatar

We’ve been featuring each of the Six Lamaze Healthy Birth Practices in our series of blog carnivals, and this time we’re talking about interventions. Interventions in labor and birth can be helpful – even life-saving. But there’s no denying the fact that too often they are used when a safer, more supportive approach would have worked just as well or better.

Ya Say You Want an Intervention? Well, You Know…

Women need the information about what interventions might take place in labor, when they are beneficial, what the risks are, and how to minimize those risks. Rachel Leavitt at The Beginnings of Motherhood offers a very balanced discussion of the pros and cons of two very common interventions: epidurals and pitocin. Desirre Andrews at Preparing for Birth shares a list of “hidden in plain sight” interventions that may affect a woman’s emotional state, slow her labor progress, or even cause physical harm. Lauren Wayne at HoboMama writes about her experience with an intervention that can sometimes seem invisible – vaginal exams. Well Rounded Mama discusses the disproportionate use of various interventions in women of size and argues for a supportive, proactive approach to preventing labor dystocia.

Interventions carry risks of other interventions, which introduce risks of their own. Carol van der Woude cared for a woman whose labor turned complicated and high tech when the simple act of breaking a woman’s water set into motion a cascade of intervention. It’s an all-too-common story she she tells in her post, One Thing Leads to Another. Code Name Mama also describes a typical cascade-of-interventions birth story, contrasts that story with her real birth story (made safely possible by the supportive care of a midwife and a few interventions used judiciously), and provides a treasure trove of information about all of the interventions she could have ended up with but didn’t. Kiki at The Birth Junkie describes her birth planning process as “a domino effect in reverse” – in learning how to avoid a much-unwanted episiotomy she was forced to explore alternatives to lying flat on her back and discover that many routine labor interventions restricted mobility. Learning long before labor begins about interventions and knowing which you’re okay with and under which circumstances is essential for informed decision making, she argues.

Having Interventions: An Experience in the Eye of the Beholder

When we talk about interventions that are “medically necessary” it implies that sometimes the use of interventions (and their downstream effects) are unnecessary. In reality, there are few if any interventions in labor for which you can draw a perfect line between “necessary use” and “unnecessary use”, and different women are willing to accept different risks and value different benefits, so an objective assessment of necessity may in fact be meaningless. Rixa Freeze of Stand and Deliver explores this issue in her post, Necessary/Unnecessary, a round-up of four birth stories, and suggests an alternative view:

The prominent theme in these four sets of birth stories is that the women who felt the interventions were necessary and welcome … rather than unnecessary and traumatizing…, freely chose the interventions on their own–on their own request, on their own timetable, and on their own initiative. They knew it was time for assistance. They were the primary actors in their births, rather than recipients of others’ agendas. They held the locus of control, even when that meant asking others to do things for or to them at some point (IV, epidural, Pitocin, or c-section).

One of the birth stories Rixa reflected upon was that of my sister, Katherine. Katherine, who shared her story at her midwife’s blog, Women in Chargeplanned a home birth and ended up with a c-section after over three days of labor. Her birth story offers an important example of midwife-led physiologic care with timely access to needed interventions, given in a humane, and respectful manner.  Over the phone just a half a day after her cesarean, Katherine told me her birth was “fun” and audibly beamed with pride and amazement, which was about the most inspiring thing I’ve experienced in a very long time.

At the other end of the spectrum are the women whose “care” in labor is emotionally or even physically traumatic and who experience lack or loss of autonomy. Jenne Alderks at Descent Into Motherhood advocates for women who experience their births as trauma (as many as 9% of women, according to the Listening to Mothers II Survey) and coordinates a support group at Solace for Mothers. Jenne writes about these issues in the context of  her own traumatic birth story in which her efforts to exercise her right to informed refusal led her midwife to kick her out of the hospital.

Changing the Culture of Birth

Women can protect themselves from unnecessary interventions by choosing a care provider and birth setting with low intervention rates. Unfortunately, most women currently lack access to the information they need to assess intervention rates in their communities. I spoke about this issue last month with Danielle from Momotics in her radio show on the importance of Transparency in Maternity Care.

We don’t have adequate transparency now, and until we do, women will have to find out about routine practices at community hospitals by asking hospital staff or local birth advocates. Sheridan Ripley at the Enjoy Birth Blog brings us through a four part story of a woman who learned about routine hospital practices during a tour of the labor and birth unit and made a courageous choice to change hospitals and care providers just days before her estimated due date. The result was worth it!

Greater transparency is only one aspect of a larger political and cultural shift needed to reduce unnecessary interventions. Maureen Finneran Hetrick writes about some of the health care reform efforts currently underway, including payment reform and midwifery legislation, that might help rein in intervention rates in her guest post at the ICAN blog, Can healthcare reform decrease unnecessary interventions? Mom’s Tinfoil Hat gives readers an update on her fellowship research examining obstetrical culture by assessing obstetricians’ knowledge of the evidence basis for various common interventions and their attitudes toward routine use.

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Reply Turned Post, “Lights, Camera, Unnecesarean*!” Style

February 4th, 2010 by avatar

The Today Show, not known for their excellence in birth journalism, showed a live cesarean on air earlier this week. The birth advocacy community has weighed in on the shoddy reporting and the circumstances of the cesarean, pointing out that the stated indications (“big babies run in the family” and “she was past her due date”) do not in fact justify elective primary cesarean surgery.

When I heard that the cesarean had taken place at Beth Isreal Deaconess Medical Center in Boston, I had an “a-ha” moment: That’s the place where Paul Levy is President and CEO. And he has a blog. And his blog has been a sounding board for ideas about health care reform in general and transparency and practice variation in particular. I decided to leave a comment.

Here’s what I wrote about what I really think about the Red Sox the responsibility of hospital leadership to address problems in maternity care including the excess use of cesarean surgery.

I’m sure that the Today Show piece was just a convenient PR opportunity, but when I heard the birth occurred at BIDMC I came here to see what, if any, analysis you offered. Given your recent coverage of practice variation in endoscopies and hypertension treatment, it would seem this is a good opportunity to address practice variation in the use of cesarean surgery. Especially since just last week, a multi-stakeholder group released major recommendations for maternity care reform, which included many recommendations for reining in unwarranted practice variation.

Your hospital currently has the fourth highest cesarean rate in the state of Massachusetts (42%), 12 percentage points higher than the “normal range” (“25-30%”) reported by one of your OR staff during the Today Show piece, and nearly three times the rate recommended by the World Health Organization. True, your hospital cares for many women with high risk pregnancies, but studies that have looked at risk adjustments in cesarean rates have found that these adjustments make little to no difference in the rank order of hospital cesarean rates, and in fact many academic tertiary hospitals are able to safely maintain rates lower than those of community hospitals. The National Quality Foundation, Healthy People 2010, and, beginning in April when new perinatal measures are rolled out, the Joint Commission, all consider the rate of cesarean surgery in nulliparous women with singleton, head down babies (NTSV cesarean rate) to be a measure of hospital quality. You may have “Red Sox Nation plus 1” but you now also have “NTSV cesarean rate plus one” – the woman who gave birth on the Today Show did not have an indication for cesarean delivery that is accepted by ACOG or any other standard-setting bodies. (Her indication was “big baby”.)

I urge you to use this opportunity to ask yourself and your staff what you could be doing better to safely lower your cesarean rate.

(BTW, Paul Batalden’s [whom Levy mentioned in a recent blog post about practice variation] daughter is a nurse-midwife (and a great one at that) so he might have some insights to share with you.)

After another commenter suggested that perhaps the circumstances of the cesarean were a private matter, I had more to say:

I agree that this isn’t an appropriate venue to share commentary about whether or not the televised c-section was appropriate. But as someone who cares deeply about maternity care safety and effectiveness, I often feel that people doing the heavy thinking about health care reform are completely oblivious to maternity care as a major area for improvement. So infrequently in health care debates do we hear about childbearing women or newborns, despite that 4.5 million women give birth each year, outcomes are poor, and hospital charges for maternity care far exceed those of other specialties. I have seen some coverage of maternity care issues on this blog, but the coverage seems to be out of proportion with how much “business” the maternity unit accounts for. That the current post about a televised birth was a lighthearted plug for the Red Sox, I have to admit, was extremely disappointing from my perspective. If we’re going to have a major surgery on live television with zillions of people watching, it seems a fine time to start talking about the procedure, under what circumstances it is safe, evidence-based indications for its use, and how to make sure every hospital is performing it to the highest standard of safety.

Just in the past week, there’s been a Joint Commission Sentinel Event Alert on maternal mortality, the major national reform recommendations I mentioned earlier, and today a front page article at the San Francisco Chronicle on the contribution of cesareans to California’s maternal mortality rate. Seems like there’s plenty of “blog fodder” other than the Red Sox angle.

Levy’s commitment to openness and transparency is unique in the hospital administration world and I support it wholeheartedly. I have to admit it felt like quite a thrill to leave a cogent comment on a blog of a hospital CEO. Even when I’ve worked for hospitals I never had that kind of access.  Of course listening doesn’t necessarily translate into doing. I hope that Levy recognizes that his hospital could be doing much better in their provision of maternity care to the community, begins documenting quality improvement efforts on his blog, and welcomes the input he receives from those of us who have thought quite a bit about what high-quality, high-value maternity care looks like and how to get there.

*Jill from The Unnecessarean coined this term.

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