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

May 5 is International Day of the Midwife.  Many communities have events planned to coincide with this celebration. If your community does not, there are still plenty of opportunities to learn about, celebrate, and advocate for midwives and the midwifery model of care.  For the second year in a row, midwives and their advocates from all over the globe will participate in Virtual International Day of the Midwife.

Lectures, facilitated discussions, art exhibits, and other events have been scheduled and everything is available online.

Here are just a few of the offerings:

• Keeping women safe: a psychophysiological approach to the third stage of labour
• How do we engage young mums in a culturally safe way to improve antenatal education
• Implementing the CenteringPregnancy model of group based antenatal care at St George Hospital, Sydney: Lessons learned
• Shortage of midwives; situations, solutions and concerns
• Looking at informed consent
• Update on Haiti
• Nutrition for Two

As my contribution to the event, I will join Amie Newman from RH Reality Check and Mary Murry from the Mayo Clinic to discuss the role of blogs for promoting midwives and the midwifery model of care on The Feminist Breeder and Friends Radio Show. Amie, Mary, and I will be on a panel at the American College of Nurse-Midwives Annual Meeting discussing the same topic.

Happy International Day of the Midwife!

Amy Romano Uncategorized announcements, midwives

Note: If this post looks familiar, then thank you for being one of my dedicated readers who has followed me from the very beginning. Yes, this is a repost of my very first blog post and this week marks the first anniversary of Science & Sensibility! Happy blog-aversary to us!  Later this week, I’ll share a few of my favorite posts and other milestones over the past year. And if you missed this one a year ago, here’s an “understanding research” lesson all wrapped up in a package of very good news (ok, not-so-new news) about midwives!

Often, the closer I look at a study, the less confident I become about the results. I’ve learned that you can’t always trust a paper’s title or abstract, and media coverage of new studies can be woefully misleading, even when it is not carefully orchestrated by those with a vested interest (which it often is). Being advocates for “evidence-based care” means not just knowing that a study has been published, but knowing whether that study is any good, and in what circumstances (if any) the results are relevant and reliable. It also means having our guard up against deeply flawed studies that shape policy and practice despite their limitations. (Henci Goer has done a fantastic job deconstructing some of these influential studies in her series, When Research is Flawed.)

A systematic review synthesizes all of the literature on a given topic, using rigorous criteria for which studies will be included. For instance, Cochrane systematic reviews are typically confined to randomized, controlled trials in which there is no evidence that the randomization process has been intentionally subverted. For this reason, Cochrane reviews are considered the “gold standard” of evidence.

But what happens when the trials that make up a systematic review themselves have flaws or limitations? We end up with Cochrane reviews that can mask problems in the literature, and we can inadvertently put the evidence-based “stamp of approval” on a practice that still needs to be studied further. This is referred to as the “garbage in, garbage out” phenomenon, and we see plenty of it in the obstetric literature.

One kind of garbage that Cochrane reviews rarely address is crossover. This is when some of the participants randomized to the “control group” (e.g., no intervention) end up getting the intervention that is being tested. This problem is rampant in trials of induction, pain relief, and episiotomy, among others. Some women randomized to “expectant management” end up getting induced; some women randomized to “non-epidural pain management” end up getting epidurals; some women randomized to “conservative use of episiotomy” end up getting episiotomies, and so on.  This makes it much more difficult to use our statistical toolbox to discover differences between the two groups, and as a result we see smaller differences, or even no difference. The “evidence-based” conclusion then becomes “there’s no difference is unwanted outcomes, so the intervention is harmless.” But “no difference” can also mean “this study wasn’t big enough to find a difference” or, in this case, “there was too much crossover to detect a true difference.”

The crossover problem usually drives me crazy because it often serves to perpetuate medical-model bias and medical-model practices. But I had an “ah ha” moment when I discovered a crossover-of-sorts problem in the 2008 Cochrane systematic review of midwife-led care. This review was released to fanfare within the birth community. Finally, the enormous body of literature on midwifery had been synthesized by Cochrane reviewers and the conclusions were firmly in favor of midwife-led care! The results were, indeed, unusually impressive. While the conclusions of many Cochrane reviews are couched in tentative language and call for more research, the reviewers here concluded decisively, “Midwife-led care confers benefits and shows no adverse outcomes. It should be the norm for women classified at low and high risk of complications” (p. 17). Still, when I looked a little closer, I was perplexed that some of the differences the Cochrane reviewers found were small or even non-existent. What? No difference in c-sections? Only a small difference in episiotomy? What’s going on here?

A kind of crossover is the culprit, and this time it means that the good news just gets better! It turns out, of the 11 trials comprising over 12,000 women, in all but 1 of these trials (with only 318 participants), some or all of the women in the control groups were actually cared for by midwives. The difference was that that these midwives were supervised by physicians, or they shared their client caseload with physicians. The Cochrane reviewers were not interested in comparing midwives versus doctors. They took it for granted that midwifery care itself is safe, effective, and satisfying. This is, after all, a global consensus, to which the United States remains in stubborn and lonely opposition. Working from the assumption that midwives are an important part of the maternity care system, the question becomes how should we organize that system? Who should coordinate the care of childbearing women – midwives or doctors? Midwife-led care means that women receive their primary maternity care with the midwife, and the midwife engages an obstetrician or other consultant when some aspect of the woman’s or baby’s care falls outside of the scope of independent midwifery practice. This stands in stark contrast to the typical arrangement in the United States, when midwives are supervised by obstetricians or employed by hospitals, and obstetric protocols and productivity standards drive midwifery practice.

Women often believe that going to an obstetrician practice that employs midwives is getting “the best of both worlds.” The Cochrane review of midwife-led care in fact tells us that such arrangements are ineffective, inefficient, and may be hazardous to the health of women and babies.

Citation: Hatem M, Sandall J, Devane D, Soltani H, Gates S. Midwife-led versus other models of care for childbearing women. Cochrane Database of Systematic Reviews 2008, Issue 4. Art. No.: CD004667. DOI: 10.1002/14651858.CD004667.pub2.

Amy Romano Uncategorized crossover, maternity care systems, midwives, systematic review

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

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 analysis – please 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.

Amy Romano Uncategorized maternity care systems, midwives, safety

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 Charge, planned 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.

Amy Romano Uncategorized Healthy Birth Blog Carnivals, Healthy Birth Practices, home birth, hospitals, interventions, midwives