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Becoming a Critical Reader: The Five Basic Questions

April 18th, 2010 by avatar

Since it has been a while since we’ve had any articles in this series, you may want to refresh your memory by rereading the first and second installments in the “Becoming a Critical Reader” series. I promise it won’t be so long of a gap before the rest of them!

OK, having reviewed and identified your own personal biases, you are ready for the second read-through, where you can more critically read the article. We’ll spend the next few posts in this series going through the various types of articles and the things you’ll want to consider when doing this more critical reading. Some questions will be pretty universal, no matter what type of article you are reading. Others will be more specific to the various types of articles. We’ll cover those specific questions over the next few posts.

The basic questions to ask as you read:

1. What did the authors set out to do? Hopefully you’ve already figured this out in your preliminary run through. If you’re not clear on that, make that the first thing you look for. When you find it, write it down so you don’t lose sight of that aim in the remainder of your reading.

2. Did the article really do what it set out to do? Look for the “conclusions” or “results” sections to see what the authors say about a study. Sometimes what is written here will have nothing to do with their original intent. Not that this makes the conclusions invalid, because sometimes studies do make important and interesting discoveries in tangential information. Ideally, the authors should at least address the original aim of the study, even if it was to say “we did not find what we expected to find.”

NOTE: This question is NOT the same question as “Did the study show what I think it should have shown” or “Did the study look at what I wanted it to study?” Sometimes I hear people disparage a study by saying “They looked at the wrong thing! Instead of studying ‘when is the best time to do an induction?’, they should have studied whether to do them at all!” This is unfair. The study is no less valid because it addresses a different issue than you would have chosen to research. The question is “Did they do what they set out to do?”

3. Did the article use appropriate methodology? Some methods might not be a good way to study a particular question. Other methods might be a better approach. While some are fond of saying that only a double-blinded, randomized controlled trial can give you sufficient answers, it’s not always realistic or ethical to do research in this way. We’ll go more into detail on that in our next series on methodology, so don’t worry if you don’t know enough to make a good judgment on this aspect right now.

4. Did the author show undue bias or influence? Many studies will have a disclosure on the first or last page of a study that tells who paid for the study or if the researcher has any conflicts of interest. While I wouldn’t necessarily dismiss a study because of a potential conflict of interest, I certainly would be using a VERY fine-toothed comb in my perusal of the study!

5. Do the conclusions match the data? Sometimes there is a pretty obvious mismatch between the two. I once read a study where the author concluded that a vaccine for GBS would save lives. However, the aim of the article was to find out if prenatal screening for GBS would reduce the incidence of serious GBS infections. Vaccines were not mentioned anywhere in the article, except in the conclusions area. It seemed an obvious mismatch to me.

Sometimes the mismatch might be more subtle. This is why you’ll want to jot down that answer to the initial question, “What did the authors set out to do?” At this point, go back and see if both their data and conclusions answer that.

These five questions are a good place to start as you review articles. I suggest that you take some time this week to find the full text of a study and read through it, answering these questions as you go.

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The Fifth Healthy Birth Blog Carnival: Push it real good!

April 11th, 2010 by avatar

I kicked off this blog carnival with a post titled, “Six Reasons I *Heart* Qualitative Research.”  I had been wanting to write a post about qualitative research for a while, and the topic of the second stage of labor was the perfect opportunity, since there’s so much great qualitative research on second stage.

After collecting the posts for this carnival, I have discovered why. Women want to tell their stories about pushing their babies out. With only a couple exceptions, everyone who contributed to this blog carnival wrote about their own personal experiences.

Just like good qualitative research, the stories show what spontaneous, upright pushing looks, feels, and sounds like.

  • Kristin at Birthing Beautiful Ideas posted three remarkable videos that show how a pushing urge develops, grows into strong bearing down efforts, and culminates in the baby’s birth.
  • Sheridan at the Enjoy Birth Blog prepared educational videos showing several women instinctively birthing at home and others using mother-directed pushing in the hospital.
  • Well-rounded Mama, who blogs about the maternity care needs and experiences of women of size, shares photos of women of all sizes pushing in upright positions.
  • The nurse blogging at At Your Cervix posted her thoughts on upright positions and shares a diagram of images of nearly every position imaginable.
  • Macondo Mama describes in detail how her care providers supported her in second stage (proving that care during a spontaneous birth need not mean the care provider or labor companions sit there doing nothing.) They helped her work with her voice, breath, and movements to birth her baby, provided feedback about the baby’s descent, and gave support to her partner.
  • Tiffany at Birth In Joy shares some of the encouraging words from her labor support team: “Way to go, you’re moving the baby down!” “I’m not in a hurry, rest if you want.” and so many other phrases of support and caring.
  • boheime at Living Peacefully with Children shares the words she herself said while birthing her baby. When her water broke just as she transitioned to second stage, she coped with the intensity by talking tenderly to her baby “Okay baby, let’s go slow. We will do a little bit and then take a little break. Mommy needs to take a break, and then we will go a little more. It won’t be long and then I can hold you. Just a little bit and then Mommy needs a break.”
  • The midwife blogger at Birth Sense recalls attending a birth of a mother who wanted a more calm and unrushed experience the second time around. “The room was quiet, except for the soothing music she had chosen, and the soft sound of her breaths. Carolina was bearing down gently with her contractions for several minutes, then made eye contact with me and said, ‘The baby’s coming.’ I couldn’t see anything, as she had her hand covering her perineum, but moments later, the baby’s head was out. One more push, and the rest of the baby was born into Carolina’s waiting hands. She smiled at me, ‘That was so much better than being yelled at to push!’”
  • Desirre at Preparing for Birth collected the comments of two dozen women sharing what it felt like to push and give birth.
  • Three bloggers offered analogies. Lori at Choices in Childbirth compares the shifting and wiggling that gets a baby born with the best way to get a stuck wedding ring off. “I’ll grab hold of my wedding band and pull forcefully toward the tip of my finger,” she writes. “Invariably, it moves a fraction and then gets stuck. The flesh between the band and my knuckle gets all bunched up, my finger starts to turn frighteningly red, and I begin to wonder if the ring will ever come off. On my second try, I tug on the ring while gently jiggling it back and forth. This time it moves right along without any trauma to my finger at all.” Doula, Annie Reeder suggests that the winning combination of upright posture and relaxed pelvic floor that helps get the baby out is something some women may already be familiar with – that is, if they have ever hovered over a public restroom toilet while urinating. The aspiring Lamaze educator at the Birthing Goddess Blog presents a common sense analogy many of us are already familiar with: “Who would ever think of having a bowel movement while lying down? No one, right? Same goes with a baby being born.”

Contrast these with the stories that document the opposite: our cultural norm of rushed and managed birth, and the emotional and physical toll this approach can take.

  • Dionna at Code Name: Mama recently helped her sister have a natural birth and describes her as calm and coping well until the hospital staff forced her into bed to give birth. She writes, “She was uncomfortable on the bed, and when the nurses forced her to lie down, she began to cry from the pain and pressure – not from the fact that the baby’s head was crowning – but because she had felt more comfortable and in control in the position she chose for herself previously.”
  • Mamapoekie at Authentic Parenting had an urge to push that stopped her in her tracks as she walked across her room. “When the contraction subsided,” she writes “they led me to the birthing bed, positioned me on my back and had my legs in the stirrups before I knew what happened.Everything was kind of a blur, but I remember wondering where everybody came from, because all of a sudden, there were three midwifes, two OB’s and my husband miraculously reappeared. I had not the strength to fight the position I was in and my husband was shaking like a leaf in a thunderstorm.”
  • Rebecca at Public Health Doula laments the many great labors she has attended that take a turn for the paternalistic, medicalized worse once the woman is 10 centimeters dilated. She writes, “The second a woman is judged to be ‘complete’, everyone in the room suddenly gets license to, quite frankly, be a total jerk to her. Before she has pushed even once, there is the presumption that she is going to push ‘wrong.’ She is never even given a chance to try pushing in different positions or for a few contractions to get the hang of it. Instead, the nurse spells out the position she should assume (chin to chest, pulling back on her thighs, on her back? but of course!), support people are given her legs to hold, and she gets the 3-pushes-per-contraction speech. Then from the first push she is loudly coached, counted off, and urged on MORE MORE MORE KEEP GOING PUSH HARDER HARDER HARDER and that’s about when I start grinding my teeth.”

Women who prepared carefully for birth were not necessarily immune to repression and coercion in second stage.

  • Simone Snyder, blogging at ICEA.org, had prepared a birth plan that clearly laid out her wishes for a spontaneous, upright second stage. Instead, she got “doctor’s high pitched, screeching voice-’Push Push Push’-the nurse counting in my face-the confusion and fear as I lay there on my back in the hospital bed”. In her post, she writes, “There is a point [in my birth video] where you can hear me say ‘I don’t understand what to do-do I push-what do I do?’ All the direction, all the shouting and commotion-I was not encouraged to listen to my own body and therefore I was lost.”
  • Karen Angstadt at Intentional Birth went on the hospital tour, heard all the right answers and even saw the squatting bar she hoped to use, only to find out when it was time to push that none of the doctors would agree to use one. In her birth story she recalls that with persistence she was “allowed” to try a few squats, “before being told, ‘This isn’t working’, and put on my back for the remainder of the birth.”
  • Hilary at Moms Tinfoil Hat had been careful to do her homework, and thought hiring a nurse-midwife would ensure that she could have a natural birth. “I ended up flat on my back…pushing against a cervical lip for three hours, while being barked at and blamed by my CNM,” she writes. “I remember begging her to stop, and feeling defeated while I was forced to push, and push, and push, as my mother, husband, and even the labor nurse looked on with dread. I was unprepared for pushing the first time around, and terrified of it the second.”
  • Melodie at Breastfeeding Moms Unite planned a home birth and wrote a birth plan and still got told what to do. In her birth story, she recalls, “I remember when transition was finally over. A sudden peace washed over me. A calm in the storm. I was 10 cms. They told me I was ready to push. Except I wasn’t. My body wasn’t. I didn’t feel the urge. My midwife decided that this would then be the perfect time to instruct me ‘how’ to push.”

On the other hand, several bloggers’ stories show that it is possible, healthy, and feels amazing to push a baby out with one’s own immense power in all sorts of unexpected circumstances.

  • even with an epidural. Paige at The Baby Dust Diaries had complications that necessitated an epidural and confinement to bed. When the nurse began counting and coaching, she simply told her to stop. In her post, Paige shares the breathing technique she used to birth her baby gently.
  • even lying flat. Kiki at The Birth Junkie shows that it is the freedom to experiment with positions in second stage – not a certain position per se – that makes the difference. In her first birth, she knew instinctively to stay off her back, a knowledge that was confirmed when she tried it briefly. In her second birth, something deep down told her to try pushing on her back again, and this time it was just the thing to get her baby to come under the pubic bone . He was born with the next contraction.
  • even in the midst of grief. Molly Remer at Talk Birth, recalling her own three births, shares the story of birthing her third son too early for him to survive. (She was experiencing a second trimester miscarriage.) She writes, “I found myself kneeling on the floor in child’s pose. This position felt safe and protective to me, but I finally coached myself into awareness that the baby wasn’t going to come out with me crouched on the floor in that manner. I told myself that just like with any other birth, gravity would help. So, I pushed myself up into a kneeling position and my water broke right away.” Her baby was born moments later.
  • even when birthing twins. With the deck stacked against her (twins, one baby breech, an epidural, and stuck on her back) the mother of four blogging at Cream of Mommy Soup gave into the urge. She writes: “For a million reasons, I was impressed with my body. But pushing was the most surprising part of the whole adventure. I could not believe that my body had done that for me — had given birth to two children, in fairly rapid succession — without any assistance from my brain. It was awesomely primal, that experience.”
  • even when the baby is 11+ pounds.  Three (count’em – THREE) of our bloggers shared stories of pushing out 11+ lb. babies. In “How My Wife Had an 11+ lb. Baby At Home and Didn’t Die,” the nurse blogging at Man Nurse Diaries invites a guest post from said superhero wife, who uses gravity to birth her baby quickly when the umbilical cord begins to get squeezed during pushing. Born not breathing, their daughter resuscitates herself via an intact umbilical cord after birth, never needing the oxygen the midwives had handy. Things were a little less dramatic for our other two 11 pounders. Lauren at Hobo Mama reports having a really good time pushing out her baby, despite it being the culmination of a 42 hour home birth turned hospital transfer. As she pushed, Lauren overheard her midwife and nurse praising her pushing efforts. She writes, “Even in the distraction of pushing out an 11-pound, 13-ounce, baby, that exchange brought a smile to my face!” Finally, Jill at The Unnecesarean tried a bunch of positions until she found the sweet spot. In a post that started the “Captain Morgan maneuver” meme, Jill writes, “I put one leg on the edge of the tub and felt the baby spin out. It was freaking glorious feeling. I wouldn’t trade those twenty or thirty ridonkulous transition contractions for anything in the world if it meant that I would have had been unable to feel that.”

But we know that these stories are not the norm, at least in U.S. hospitals, where more than half of women with vaginal births give birth on their backs and 4 out of 5 are told how and when to push, according to the 2006 Listening to Mothers II Survey. Not surprisingly, many of the stories women shared were of births that took place at home, where women can more easily follow their own instincts to birth their babies, and are usually attended by midwives and labor companions who encourage and support those instincts.

  • Amy at 263-and-dna felt the urge to push before her midwife even arrived, then settled into the urge once she got there. She writes, “I started to push almost immediately – b/c we were READY. I didn’t need coaching or encouragment. I knew what to do and when to do it.”
  • Carol at Aliisa’s Letter has attended many births at home, learning something new from each one. She writes, “I saw the benefits of a variety of pushing positions: sitting (curled around the uterus), kneeling, hands/knees, squatting and side-lying. Each labor pattern and birth was unique and unfolded with its own revelation.”

The stories bloggers shared for this carnival are phenomenal and important. They call into question our cultural norms of what is safe, healthy, and appropriate care. Just as Robin at The Birth Activist learned in her childbirth class to reject the dominant cultural image of  laboring woman as stranded beetle and Michelle at The Parent Vortex likewise began to question cultural ideals of men telling women how to give birth after reading Janet Balaskas’ book, Active Birth, perhaps the posts in this carnival will be the spark the next woman needs to question unhealthy, unsafe obstetric routines.

To me, the posts in this collection suggest that what happens during the second stage of labor and how well the women is cared for may be the most important factor in how she sees herself and interprets her experience after giving birth. Not surprisingly, the care and support that helped women feel triumphant and strong are also supported by evidence of optimal safety. But reading through these posts, I’m also struck at how difficult it is to foresee the roadblocks to safe and healthy second stage care, and give women the tools to navigate around them. Having made her choice to have a hospital birth with a group of doctors she likes, pregnant blogger Jenn from Baby Makin’ Machine is sick of people telling her how to have her baby. Jenn has discovered what almost every mom has discovered before her: everyone wants to tell you what to do and how to do it, whether or not you ask for their advice, and it doesn’t stop once the baby is born. The best way to find a path through it all and parent with confidence? Follow your instincts, be patient with yourself, be assertive when something seems unsafe or uncomfortable (even if everyone else seems to be going along with it), and fall back on common sense. It’s good advice for second stage and for parenting.

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Are upright birthing positions harmful?

April 8th, 2010 by avatar

Just a few weeks before her death last year, Karen Kilson, a beloved local doula and childbirth educator, sent me this email:

Screen shot 2010-04-08 at 12.52.51 PM

She didn’t hear back from me, because it was one of too many emails I let sit in my inbox until I had the time to write a coherent response. And in the meantime she passed away.

Karen was a life-long learner and was in fact studying to sit for her Lamaze Certification Exam when she died. She shared information as voraciously as she collected it. So in her memory, I thought I would respond to her email here on the blog as part of the Fifth Healthy Birth Blog Carnival.

Karen hit on an important conundrum. Unlike practices that have benefits and no documented harms, such as movement and upright positions in the first stage of labor, continuous labor support, and skin-to-skin contact after birth, the Cochrane Systematic Review shows that upright positions are associated with a statistically significant increase in the likelihood of blood loss exceeding 500 milliliters, the clinical definition of postpartum hemorrhage. I have in fact personally heard care providers citing this finding as a rationale for keeping women in the traditional stranded beetle position.

So, are women trading an increased risk of postpartum hemorrhage for the benefits of being off their backs?

A critical look at the evidence in context suggests that the answer is “almost certainly not.”  Here’s why:

1. Some of the trials included in the Cochrane review used unreliable methods of estimating blood loss, such as simple visual estimation. This would probably bias against upright positions, since in addition to seeing blood loss, when the woman is upright you can hear it, too.  However, the result was statistically significant even after the Cochrane reviewers excluded the studies that used clearly unreliable estimation methods.

2. Blood loss greater than 500 milliliters may be the clinical definition of postpartum hemorrhage, but very few women losing that amount of blood would exhibit symptoms or need treatment. After all, a healthy non-pregnant person donates that much blood at a blood drive, and pregnant women have 50% more blood than non-pregnant people, which their bodies are designed to get rid of after birth. A much more meaningful definition for postpartum hemorrhage might be 1000ml or even 1500ml, significant postpartum anemia, or need for blood transfusion. The only one of these outcomes that the Cochrane review reports is blood transfusion, for which there was no significant difference between upright and supine positions.

3. One study with particularly rigorous methodology found increased blood loss in the sitting or semi-sitting positions compared with recumbent positions, however the difference was observed only when perineal trauma occurred. This suggests that it is not the position the woman assumes in second stage but the position she assumes after birth and before necessary perineal repairs that contributes to excess blood loss.

Restricting women to give birth on their backs poses significant risks, including an increased likelihood of perineal trauma, a small increase in the likelihood of an instrumental vaginal birth, more fetal heart rate decelerations, and more severe pain. Then there are the intangible benefits, which come out loud and clear in many of the phenomenal contributions to the second stage Blog Carnival (which I will post at the end of the weekend). The statistically significant excess in an arbitrary amount of blood loss does not outweigh those benefits, whether or not the excess is an artifact of measurement errors. The excess blood loss seen with the combination of upright positions and perineal trauma underscores the need to minimize perineal trauma during birth. Effective strategies for reducing trauma include avoiding episiotomy, instrumental vaginal birth, or the combination of the two, supporting spontaneous pushing, and birthing the baby’s head between contractions.

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Patient safety, disciplinary action, and the marginalization of midwives

April 4th, 2010 by avatar

It sounded like an April Fools joke, except the story broke two days early. Doctors in North Carolina induced and ultimately performed a cesarean on a woman who wasn’t pregnant.

The case happened in 2008 but we all learned about it this week because the North Carolina Medical Board finished their investigation and issued “letters of concern” to the doctors involved. Public letters of concern appear to be the least punitive disciplinary action performed by the state Medical Board, according to their list of published board orders (PDF).

To which I respond: Letters of concern? Seriously???

The consensus on Facebook and around the web was that if midwives had been involved in an incident of this magnitude, they would have had their licenses revoked post-haste. Why? Because all kinds of disciplinary actions are made against midwives, whether they are practicing safely or not. Very often, the complaint is issued by a physician rather than a patient. It’s all part of what Marsden Wagner, perinatal epidemiologist and former director of Women’s and Children’s Health in the World Health Organization, in an editorial in the Lancet, called:

a global witch-hunt…the investigation of health professionals in many countries to accuse them of dangerous maternity practices. This witch-hunt is part of a global struggle for control of maternity services, the key underlying issues being money, power, sex, and choice.

Midwives practicing in states that refuse to license direct-entry midwives are the most vulnerable. Consider the case of Ohio Mennonite midwife, Freida Miller, who was jailed for appropriately administering a life-saving medication, pitocin, to a woman experiencing a postpartum hemorrhage. For cultural and religious reasons, the women in the community Miller served would be unlikely to accept routine hospitalization for childbirth unless the benefits clearly outweighed the risks, which for many women they don’t. Rather than equip the midwife with a drug (pitocin) that is considered so essential for women’s safety that it is given routinely to all women birthing in hospitals, the government removed the community’s midwife altogether. In the name of public safety.

Even when midwives are licensed, they are not immune from predatory disciplinary action. A licensed midwife in California was issued a cease and desist order at gunpoint and ultimately had to surrender not just her  midwifery license but her licenses to practice as a registered nurse and a nurse practitioner. The complaint was made by a physician in the community, not a patient. Among the board’s findings: she performed a vaginal exam before labor (routine practice in most obstetric offices), failed to obtain informed consent before performing an episiotomy (true of approximately 25% of all episiotomies performed in hospitals, according to the Listening to Mothers II survey), and failed to clearly chart the course of treatment for a patient (Didya ever hear the one about the doctor with bad handwriting?). To be fair, the investigation revealed evidence of other, more serious transgressions, but the scale of the disciplinary action seems out of proportion with the evidence, especially when we consider what obstetricians have to do to have their licenses revoked. (Seriously, googling “obstetrician license revoked” yields surprisingly few cases and most include drinking on the job, having sex with patients, or having a pattern of many preventable bad outcomes.)

Midwives who have avoided disciplinary action by state boards may be arbitrarily deemed unsafe by hospital administrators. By publicly citing safety concerns but keeping the details sufficiently vague, hospitals succeed in forcing midwives out. Cases that have been analyzed in the research literature reveal economic motives, however. A hospital in California recently suspended the privileges of a group of nurse-midwives, stating that the absence of a neonatal intensive care unit at the hospital rendered its patients safe only in the hands of obstetricians. Never mind that the only randomized, controlled trial reporting admission to a special or intensive care nursery showed higher rates in the physician group than the midwife group (9.4% vs. 7.9%).

Photo courtesy of Birth Action Coalition

Photo courtesy of Birth Action Coalition

Is Disciplinary Action the Best Way to Protect Patient Safety?

We need to stop the predatory use of state and hospital disciplinary action against midwives, and equalize the process for all categories of care providers. But whether disciplinary action is against midwives or physicians, is punishment the best way to deal with breaches in patient safety? After several high-profile cases in which health care professionals went to jail for making medical mistakes, the patient safety community is rallying around alternatives to punishment, and producing evidence that these alternatives are in fact more effective.

As nurse and patient safety expert, Barbara Olson, argues in one the posts that made me fall in love with her blog (the other post being her birth story), punitive actions, especially when they are the only actions taken, do not address the root causes of unsafe care, nor do they make care safer.

We can and will argue about what constitutes the safest kind of care. But perhaps we should instead be asking what kind of maternity care system can most reliably deliver safe care. Achieving such a system will take a collaborative effort among all types of health care professionals and the women they care for. Fortunately, some brilliant minds have been hard at work determining what such a collaborative effort might look like. The Institute for Healthcare Improvement is sponsoring a webinar on April 8 titled, “Momentum for Maternity of the Safest Kind.” The speakers, who include Maureen Corry and Rima Jolivet from Childbirth Connection, will discuss the recent work of the Transforming Maternity Care Project. If you have been eager to hear more about this work, this is a great opportunity.

So, should the doctors who performed the ultimate in unnecesareans have gotten more than letters of concern? Probably. Maybe. It’s hard to know without knowing what the root cause analysisplease tell me they did one - revealed. But there must have been other opportunities for such a breach of safety to have been avoided. A system that can so completely lose sight of patient safety desperately needs to have its assumptions, routines, and safeguards examined.

When preventing avoidable harm is a fundamental aim of a maternity care system, the logical strategy is to address the root causes of injury, and to arrange care and resources to keep women and babies safe.  That’s exactly what midwives do, yet instead of embracing them, our system marginalizes them.

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