[Editor's note: In this post, Lamaze Certified Chidbirth Educator, Doula and Lactation Consultant Jackie Levine answers the question: "How do you incorporate Best Evidence into your childbirth education program?]
A Perspective on Birth
The quick version of the trip that got us to where we are now is that birth moved from home to hospital. Ann Oakley, sociologist, nails both the rationale for that move and its results: “…the significance of the hospital lay in the service it could do for the emergent profession of obstetrics. It facilitated the restriction of competition from female midwives, established the principle of doctor control over client preferences, enabled clinical expertise to be taught to others, and set the stage for the depiction of childbirth as potentially pathological”1.
And Diana Scully, writer on women’s health, makes this breath-taking observation: “Of all professions, medicine has been among the most successful in achieving autonomy and establishing the freedom to work without regulation from outside its own community”2. It’s not hard to understand that the intense socialization process caused by living inside that “community” for years of medical training shapes the ethics, the values, the very behavior of OBs. The autonomy of this community allows the continuing use of practices and protocols that by now just about everyone knows are not based on best evidence. In her recent post on Healthy Birth Practice #5 Joni Nichols asks why best-evidence birthing positions are ignored. That’s a powerful word…ignored!
Pinning our hopes for sane and humane birth on it, we expect that, at any moment, best evidence care must surely begin to prevail, and we examine ways to foster and promote it. But will best-evidence practices really ever begin to outweigh entrenched “opinion-based” care and become the norm? The Six Healthy Birth Practices are based on best-evidence. The very latest Lamaze Webinar asks the question, ”Does evidence-based research guide your childbirth education?” We breathe the concept of best-evidence care as our oxygen.
And there is some slow improvement in intent, one recent and hopeful bit being the ACOG call “for evidenced-based practice and greater cooperation between obstetrician-gynecologists and certified nurse-midwives/certified midwives”, “recognizing the importance of options and preferences of women in their healthcare”.3 Another positive sign is the recommendation by ACOG that OBs actively include patients in the “planning of health services to reduce risk and improve outcomes” with “shared medical decision-making”.4
But we really can’t wait for the slow grind of the universe of medical planets to align properly, and for textbooks and training and institutions to change. How many hospitals still won’t allow anything but ice chips? Why should the health and well-being of the individual come second to the entrenched needs of the institution?
Implementing Best Evidence into Childbirth Education
How could I counter the real-life, day-to-day “doctor control over client preferences” in healthy and natural birth? Credibility is the coin of the realm when women demand best–evidence care, and becomes a really perfect tool when paired with a thorough knowledge of one’s legal rights. Since birth is under the jurisdiction of this self-regulated medical community, birthing women must seem to be knowledgeable in “their” way to be recognized as credible. For the time being, then, perhaps we need to give women a different kind of “evidence,” by giving them a look into the medical community. If women can know more of what goes on inside the profession, if they know a bit of what the docs know, they feel a different level of empowerment. They feel a gravitas in the unfamiliar and sometimes hostile world of the hospital. In Amy Romano’s interview on this blog with J.D. Kleinke, he says: “… providers still do what they always did – because that’s how they always did it. The best ways to realize the vision you’re asking about is to stop treating maternity care–all medical care actually–like a folk art, arm all providers with better information… the single best way to make all that happen is to arm pregnant women with the same information… no more excuses for paternalistic decision-making on behalf of passive patients.”
About two years ago, I had a realization about teaching best-evidence care so that it satisfied the needs of the women in my classes in a more powerful way. I teach Lamaze classes to the maternity clients at a Planned Parenthood Center, and they are, in the main, an under-served population. Since I can follow many of them though their births as their doula, I’m aware that they are often treated with less politeness, shall we say, than are private patients. For them, as for many women, the Healthy Birth Practices could be warnings, for example: “Labor begins on its own” becomes “don’t let them induce you!” I couldn’t help but feel that I must somehow keep them from harm.
As we cover each Healthy Birth Practice, I gather every recent study I can find to demonstrate the huge divide between what best science shows, what they can expect in the way of “real-life” care, and in many cases, how practitioners reacted to the science and scientific news. Once I began to give actual studies, piling up the papers, they said that it felt like they were eavesdropping on conversations within the medical community. It doesn’t matter whether they understand the medical language…very often the titles of studies in themselves are illuminating, and I just highlight the “good parts.” It’s pretty eye-opening to read a chatty bit of a study about estimating late gestational age that says “Predictions of gestational age that are based on ultrasonography in the third trimester can be off by three weeks or more in each direction”5. Of course, no one ever tells that to the women being sent for sonograms at due date to assess for induction. And how about the blog post sent out to the profession by an OB recommending that delayed cord clamping should be the standard of care, citing dozens of studies, and wondering why “we have not heeded the literature,” but understanding that one reason OBs just “ignore” the evidence is that the practice was “championed” by midwives.6 Reading this communication has saddened many a class of mine. It made them want to own their births. It made them aware of how much harm can be done to mothers and babies when the culture fosters a prejudice based on ego and insularity and a continuing but profitless battle for turf in the world of birth.
Having access to what the docs themselves see (and ignore) seems to give real ammunition to the mothers I teach. They have found it super-empowering to know for example, that fetal blood sampling in early labor raises the risk of cesareans, as does continuous monitoring, and that episiotomy for shoulder dystocia is not helpful and should be discontinued, despite its longtime use. They have a solid way to challenge hospital policies. A little role-play and rehearsal rounds out their skills. Not only do they know that the evidence exists somewhere out there…they see it; they own copies of the studies. They feel trusted with special information that they would never otherwise have access to. In addition to learning to trust their bodies, in addition to knowing how birth works, in addition to practicing comfort measures, they learn about what goes on behind the scenes. It expands their sense of control and choice.
These women have little in the way of status when it comes to their stay in the hospital, and I have seen them treated in uncaring ways by imperious staff, but I have also seen them able to counter bullying or threats, implied or otherwise, even as they are vulnerable in labor. They feel confidence in the principle of informed refusal and have amazing natural births. They ask for and they get what is their right; they ask with tact and finesse from a position of knowledge, and most importantly, with confidence. They engage with the reality of what birth is now. They are tigers.
Posted by: Jackie Levine, LCCE, FACCE, CD(DONA), CLC
1-The Captured Womb, Basil Blackwell Inc., NY, 1986 p.29.
2- Diana Scully Men Who Control women’s Health Houghton Mifflin 1980, p.13
3-Joint Statement of Practice Relations between Obstetrician-Gynecologists and Certified Nurse-Midwives/Certified Midwives,” released April 1.
4-ACOG Recommends Partnering With Patients to Improve Safety, Obstet Gynecol. 2011;117:1247-1249 Extract
5-Amniotic Fluid Spectroscopy Assesses Late Gestational Age http://www.ajog.org/article/S0002-9378(10)000076-1/abstract
7- Episiotomy for Shoulder Dystocia Does Not Reduce Nerve Injury Rates, Am J Obstet Gynecol 2011. : http://bit.ly/kE3Gvq