Science & Sensibility

I have felt a little bit like a slacker blogger lately, but it’s not for lack of thinking and writing about birth. I just wrapped up an article called Social Media, Power, and the Future of VBAC with Hilary Gerber from Mom’s Tinfoil Hat and Desirre Andrews from Preparing for Birth which we submitted to the 50th anniversary “Looking Back – Looking Forward” special issue of Lamaze’s Journal of Perinatal Education. I’ve also been working with Kristen Oganowski from Birthing Beautiful Ideas to coordinate the development of an NIH VBAC Statement Primer for consumers. We have a bunch of brilliant contributors on board and will be launching the primer later this month at Lamaze’s new (very cool!) social networking site for women, Giving Birth with Confidence.

Now the big looming work comes in the form of conference season. And I want you (yes YOU) to help me. I have a love-hate relationship with conferences. Mostly love. I love how much sharing, connecting, and learning happens. I love finding out what old friends and colleagues are up to and meeting the people doing the most interesting, innovative, and important work in the field. But attending (and especially speaking at) a conference is a lot of work, and often disrupts progress in my other (equally if not more important) work. Also, I hate that conferences take me away from my family.

So…I want to make the most of the opportunities these conferences offer. I want to maximize the amount of sharing, connecting, and learning we – collectively – do. And I want to leave these conferences not with tons of new projects and commitments for myself, but with tons of new opportunities for the broader maternity care community (that means YOU) to drive meaningful improvements for women, infants, and families.

Here’s some more about the conferences I’m attending, and how YOU can be part of them.

On June 7 I’ll be at Health 2.0 Goes to Washington.

Um, have I mentioned lately that I think social media is going to transform maternity care? Well I developed this delirious optimism by hanging around (online) with the Participatory Medicine crowd.  I get to actually meet most of them next week!

I first caught on to the Participatory Medicine train when I read a Grand Rounds blog carnival on the theme of “Meaningful Use” almost exactly a year ago. “Meaningful Use” is government speak for the goal of implementing electronic health records (with piles and piles of stimulus money) in a manner that actually improves care. The Participatory Medicine folks are front and center in the conversation, pushing for patient-access to be the defining characteristic of meaningful. It’s all about liberating the mounds of data that will exist in electronic health records and letting innovators, policy-makers, scientists, and – most importantly – patients themselves use that data to improve health.

I have 10 minutes to speak but a whole day to connect and learn.  Here are my questions for you to help me make the most of this opportunity:

1. What do you think are the most innovative ways women are using the internet or social media to have healthier, safer, and more satisfying childbearing experiences?
2. What are the types and sources of maternity care data that you would most like to see become available?
3. What kind of data do you think should be documented in electronic health records during pregnancy, birth, and the postpartum and newborn period? Think outside the box.
4. What do you think would be the most important benefits (and for that matter, risks or drawbacks) of having complete, unhindered, timely access to your maternity care records?
5. What ongoing or forthcoming projects in the maternity care world could use the insights or funds of outside (non-birth-enthusiast) social innovators?

The following week (June 12-16), I’ll be at the American College of Nurse-Midwives Annual Meeting.

I’m only attending ACNM for one day, but traveling with my family for my kids’ first-ever trip to the nation’s capitol.  I’m giving two educational sessions that couldn’t be more different from one another. First, I’m presenting a talk called, “How Not to Get Duped by Obstetric Research” about the importance of thinking critically about evidence, and how honing critical analysis skills can can help midwives practice and advocate for safe and effective care. The other talk is a panel discussion with Amie Newman from RH Reality Check and Mary Murry, CNM, from The Mayo Clinic “Pregnancy Week by Week Blog,” moderated by Melissa Garvey from ACNM’s own Midwife Connection Blog. We’ll be talking about why more midwives should be blogging and how they can get started.  We recorded a really lively discussion about these issues on The Feminist Breeder & Friends Radio Show on International Day of the Midwife – a preview of our ACNM panel – which you can listen to here:

My questions for YOU:

1. What do you think is the optimal role of midwives (specifically certified nurse-midwives and certified-midwives) in blogging and other social media?
2. How can we protect the privacy and dignity of the women and families we serve (and for that matter, the people we work with) when midwives share about our work in social media spaces?
3. What obstetric routines or beliefs would you most like to hear me critically analyze?  I promise to make at least a blog post or two out of my How Not to Get Duped talk. (Actually, what I’ll also do is write parts of the talk from my prior blog posts, so if you have any favorite posts from the archives that you think would make good case studies, please suggest them!)
4. What are the best DC outings to do with a 3 and an almost-6 year old?

Lastly but Oh-So-Not-Leastly, I’ll be attending the Normal Labour and Birth 5th International Research Conference in July.

I’m not speaking at this conference. I’m going for the sole purpose of blogging it! I wrote a proposal to the conference organizers suggesting that they let me attend and help disseminate the proceedings. They agreed!  I think this is a huge opportunity to learn from the people doing the research about how to optimize the health and safety of healthy women and their babies around the time of birth. We’ll also hear from leaders who are creating and maintaining integrated, midwife-led primary maternity care systems, the gold standard for achieving “woman-centered, safe, effective, timely, efficient, and equitable” care.

What happened when bloggers and other connected consumers attended the NIH Consensus Development Conference on VBAC was astounding and continues to deliver. Since that experience, I’m addicted to putting scientific findings in the hands of engaged, connected consumers, because, as Kay Dickerson from the Cochrane Collaboration says, “We’ll only get evidence-based healthcare in this country through consumer activism.” Today activists have more access than ever before to information and are getting increasingly social media savvy. There’s no telling what we can do if we put our innovative, passionate minds to it and work collaboratively.

So here’s what I want to know from YOU:

1. Whose research are you most interested in hearing about? (Look over the Normal Labour and Birth agenda to see who will be presenting about what.)
2. Would you rather have a little bit of information/analysis about more of the presentations or more in-depth analysis of fewer presentations?
3. Are there any researchers you would like me to conduct a “Consider the Source” Interview with?

Finally, any readers who are planning to attend any of these conferences – I invite you to submit a guest post. I’d love to share multiple perspectives (not to mention the tremendous work of blogging all of these meetings!) Just email me at amyromano [at] Lamaze [dot] org.

Amy Romano Uncategorized ACNM, announcements, cesarean, childbirth education, Healthy Birth Practices, hospitals, interventions, maternity care systems, media, midwives, NIH Consensus Conference, Normal Labour & Birth Conference, Participatory Medicine, Personal Health Records, safety

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.

Amy Romano Uncategorized cesarean, hospitals, maternity care systems, media, practice variation, transparency

Many of you will have read the story of the woman laboring on Christmas Eve who suddenly went into respiratory and cardiac arrest in front of her horrified husband. She recovered shortly after her son was delivered by emergency cesarean, and the baby, too, was successfully revived. As the MSNBC article tells the tale:

After their miraculous recovery, both mother and the baby, named Coltyn, appear healthy with no signs of problems, Martin [the obstetrician who responded to the Code Blue and performed the emergency cesarean] said. She said she cannot explain the mother’s cardiac arrest or the recovery. “We did a thorough evaluation and can’t find anything that explains why this happened,” she said. Mike Hermanstorfer credits “the hand of God.”

However, an ABC video interview with Tracy and Mike Hermanstorfer and Dr. Martin provides details that call into question the hospital’s failure to find an explanation. I have transcribed the relevant section.

Tracy: [Tracy was being induced for her third child because membranes ruptured.]The pains [with Pitocin] were a lot harder than I remembered. We decided to go ahead and do the epidural for the very first time. . . .

ABC: Mike, you were holding her hand as Tracy got the epidural. . . . When did you start to notice that there was a problem occurring?

Mike: Well, we had her sitting up when they were doing the epidural and afterwards she lay down and said that she was tired and that’s when the whole nightmare started.

ABC: What happened?

Mike: She started going numb and everything in her legs . . . and she laid down to close her eyes and take a little nap . . . and she wasn’t waking up.

ABC: When did you notice that her breathing was shallow or her color was blue?

Mike: Well, I felt her hand—I was holding her hand—and it started getting cold and I looked down at her fingertips and her fingertips were blue and one of the nurses noticed that the color in her face was completely gone. She was as gray as a ghost.

ABC: Code Blue was declared, a scary thing in any hospital. [Dr. Martin arrives in response.]

Dr. Martin: . . . When I ran into the room, the anesthesiologist had already started breathing for Tracy. There were preparations already being made to start a resuscitation should her heart stop. About 35 to 40 seconds after I got in the room, her heart did stop and we started making preparations to do an emergency cesarean delivery right there in the room in the event that we were not successful in bringing Tracy back. Unfortunately, in most of these situations, despite the best efforts of the team, Mom is often not able to be revived, so we anticipated that possibility and when it became clear that Tracy was not responding to all the work that the team was doing on her, we had to make that difficult decision to do the cesarean section, primarily in an effort to give Coltyn the best chance at a normal survival and also hoping that it would allow us to do a more effective resuscitation on Tracy, and fortunately, she cooperated and we got a heartbeat back immediately after delivering Coltyn.

So, according to Dr. Martin, Tracy is an example of how things can go suddenly and horribly wrong for no discernable reason in a healthy woman having a normal labor. All I can say is that Dr. Martin must have slept through the class on epidural complications. Tracy’s story is the classic sequence that follows what anesthesiologists term an “unexpectedly high blockade,” meaning the anesthesiologist injected the epidural anesthetic into the wrong space and it migrated upward, paralyzing breathing muscles and in some cases, stopping the heart. High blockade happens rarely, and even more rarely does it result in full respiratory and cardiac arrest—one database analysis of 11,000 obstetric epidural blocks reported a rate of 1 in 1400 women experiencing a high block and 1 in 5500 requiring intubation, and no woman experienced cardiac arrest. It does happen, though, and I am willing to bet that high blockade and its sequelae happened to Tracy.

The moral of the print version would be: have your baby in a hospital where you can be saved should this happen to you. The video interview, however, reveals a different picture. The real moral of the tale is that the safest and healthiest births will be achieved by avoiding medical intervention whenever possible. Induction of labor is by no means always necessary when membranes rupture and certainly not immediately. If Tracy had been allowed to start labor on her own, which, considering that this was not her first baby, she would likely have done within a few hours, she probably wouldn’t have wanted the epidural any more than she did for her first two children. Tracy almost certainly would have gone home the day after Christmas after another uneventful, unmedicated vaginal birth. Instead, she is recovering from surgery, and she and her husband have the emotional trauma of her and her son’s near miss experience to deal with. Along with the Hermanstorfers, we can thank God for the prompt actions of the hospital team, but the safe money says they were rescuing her from a disaster they themselves had caused.

Henci Goer Uncategorized complications, epidurals, induction, media, PROM

If anyone is wondering whether good quality childbirth education is necessary in our “information age”, the past month offers three compelling reasons to think that women remain profoundly in need of a trustworthy, reliable resource for learning how to have safe and healthy birth experiences.

1. The December issue of Obstetrics & Gynecology reports results of a survey by UnitedHealthcare of 650 insured women who had given birth to their first child within the previous 18 months. Researchers asked the mothers, “At what gestational age do you believe the baby is considered full term?” Nearly one in four (24%) chose 34–36 weeks, half chose 37–38 weeks, and the remaining quarter chose 39–40. Researchers also asked, “What is the earliest point in the pregnancy that it is safe to deliver the baby, should there be no other medical complications requiring early delivery?” More than half (52%) of the new mothers chose 34 to 36 weeks, while fewer than 10% chose 39–40 weeks. For neither question did women’s responses vary significantly by age, ethnicity, marital status, education, region of the country, or income.

The researchers did not report which women took childbirth education classes and whether responses were more accurate among women who did. But another research team has reported that childbirth classes that include specific content focusing on risks of elective induction are effective at reducing demand for such inductions. Now that hospitals face Joint Commission core quality measures for perinatal care that include refraining from elective deliveries prior to 39 weeks, the results of UnitedHealthcare’s survey strongly suggest that educating women about the risks of cutting a healthy pregnancy short will play an important role in helping hospitals comply.

2. In the current issue of Birth, a team of midwifery researchers report findings from a qualitative study of 10 top selling childbirth advice books. The researchers used discourse analysis to gauge such factors as how the woman’s role was portrayed, whether language emphasized risk, how birth settings and providers were described, how pain and coping strategies were discussed, and whether the books provided full disclosure of best scientific evidence. While a few books provided evidence-based information, normalized the process of birth, and situated the mother at the center of decision-making, others painted birth as scary, risky, foul, and debilitating, or reinforced messages that women should cede their power to doctors and modern medicine. The researchers conclude,

The U.S. medical and obstetrical community presents itself as practicing according to best scientific evidence. However, many of the books examined, 70 percent of which were endorsed, reviewed, and/or written by physicians, did not systematically present data to support or refute common maternity practices. Why? Does evidence counter or conflict with common obstetrical practice? Will women become ‘too’ demanding or make decisions for which they are deemed unqualified?

3. RH Reality Check just posted an interview with childbirth educator, Vicki Elson, whose documentary film, Laboring Under an Illusion, explores another way people in our culture learn about birth: on television. She presents 100 clips from sit-coms, “reality” birth TV shows, movies, and childbirth education videos to juxtapose real births with fake births and “let people make up their own minds.”

Vicki describes her impetus for making the movie:

I was doing a workshop for nurse-midwives at a local hospital when a particularly ghastly and unrealistic (and Emmy-winning) episode of “E.R.” came out. The midwives said their phones were ringing off the hooks because moms were scared that they could die like the lady on TV. Meanwhile, Murphy Brown was America’s liberated TV mom who could anchor the news and stand up to Dan Quayle. But in labor, she was wilted and powerless, except when she was strangling men by their neckties. I wanted my kids and their friends to grow up with realistic, nourishing imagery about the power of their bodies to do normal things like have babies. I was working with midwives Rahima Baldwin Dancy and Catherine Stone on a workshop called “Empowering Women in the Childbearing Year,” and we started collecting clips to show childbirth educators what they were up against from the culture. It’s still a struggle to compete with compelling but unrealistic imagery that sticks in people’s minds. I expanded on that project to write my master’s thesis 10 years ago, and when the kids grew up I finally got around to updating the project and putting it on DVD so it’s more useful and accessible.”

I’ve managed to miss Vicki’s presentation at two conferences I’ve attended and have not yet seen the film, but the trailer is delightful and Amie Newman’s interview at RH Reality Check is enlightening. I suggest you click on over.

Amy Romano Uncategorized childbirth education, induction, media

Reports of new research studies can be found almost everywhere on a daily basis: On the nightly news, in mainstream magazines, in forwarded e-mails, on Facebook and Twitter feeds. But can these reports be taken at face value?

Let’s look at a few examples:

First a small blurb published in Reader’s Digest in February 2007:

Fresh flowers can cheer up any drab room — not to mention score points with your sweetie. But make us kinder as well? So says Harvard psychologist Nancy Etcoff, PhD.

She sent 54 people either a mixed bouquet or a candle in a hurricane glass. Flower recipients said they felt more compassion toward others than those who got the candles, and reported more enthusiasm at work too. Place blooms in the kitchen or bedroom so you’ll see them first thing in the morning. That’s when moods tend to be lower and blossoms can provide their biggest boost.

This sounds like a very official, authoritative study. It comes from a “Harvard psychologist” and even details a little about the methodology. However, I searched pretty extensively and was not able to find that it had been published in any academic journal. The researcher, who is an instructor teaching one class at Harvard, does not even list it as part of her published research on her Harvard web page. The study is, however, extensively touted on the web page of the Flower Promotion Organization and the Society of American Florists, which includes as part of the study “documentation” an article by an interior designer on where to best place flowers in your home. To me, this brings the study into some question. Who paid for the study? Was it commissioned by one of the organizations that exist to convince people to buy flowers? If so, there is a possibility of a bias in the methodology or conclusions. It’s difficult to evaluate a study that has not been published. Why was it not published? I am left with more questions than answers, and I’d hesitate to place too much faith in this study.

As I suspect in this case, all too often media reports of studies are based on a press release alone, and the reporters never see the real study. Press releases are written in a way to make headlines, not necessarily for complete accuracy, and reporters under a deadline don’t always do much more than use the facts in the press release.

Another example, taken from my local newspaper:

Wow, pretty interesting findings, aren’t they? Well, tracking down the actual study turned out to be difficult (you can read about it here) but when I did, it turned out to be a study on rats. Yes, rats. The newspaper article, with its references to “you” and “mom”, implied that the research was done with humans, but in fact it was animal research. Results from animal research may or may not be applicable to humans.

In another article from Reader’s Digest, the author lists a bunch of research findings about the potential harms of vitamins, among them this claim:

Researchers at the National Cancer Institute (NCI) found that men who took more than one multivitamin daily had a higher risk of prostate cancer.

However, the author oversimplified the NCI report in a way that can be easily misunderstood. To quote from the NCI report:

We found that multivitamin use was unrelated to overall risk of total and organ-confined prostate cancer. (p. 761)

The possibility that men taking high levels of multivitamins along with other supplements have increased risk of advanced and fatal prostate cancers is of concern and merits further evaluation. (p. 754)

A subtle difference, true, but also an important one. Multivitamins did not affect the overall rate of prostate cancer, or of the subgroup of cancers that have not spread. High levels of vitamin use (more than 7 multivitamins in a week, combined with other supplements) may have had an effect on the more rare, advanced forms of cancer.

That word “possibility” is very important. It signals that there is a gray area here where something has not been proven or disproven, but could go either way. It may be the vitamins and supplements contribute to the aggressiveness of cancers, but it also may very well be that they don’t. That’s why the authors recommended further research. When you read the word “possibility” think of it as a hypothesis – a guess – something that should be researched further.

In this study, researchers had a fairly small number of people with advanced cancer – only about 1/10 the numbers they had for localized cancer. This makes it hard to draw strong conclusions about the advanced cancers. Yet those conclusions are the very thing that the popular media article focused on!

These kinds of issues are fairly common in the popular media. Remember the writers and reporters at the various magazines, newspapers or web sites aimed at the general public are likely NOT trained in reading and understanding research. With this lack of knowledge, they are likely to make easy mistakes, like broadly generalizing and not picking up on subtleties like the prostate cancer article.

With a little education and a careful reading of research, you can skip the mainstream media, learn to read the actual studies yourself, and avoid pitfalls like these. Next time, I’ll discuss how you can find the studies to read them for yourself.

Andrea Lythgoe Uncategorized bias, media, Understanding Research