Sunday, November 27, 2011

A lesson in being wary of health articles in the news

I recently read a news article about a new study on the safety of home birth. Later, I wanted to find the article again. All I remembered was that it was from the Huffington Post, so I navigated back to that site, and what did I see in the pregnancy section? I saw this unintentionally hilarious juxtaposition of articles:

They really are right next to each other like that. See for yourself here (at least until new stories push it off the front page).

One of these articles is about how home birth is basically safe. The other is about how it's really risky for first-time mothers.

The best part? Both articles are based on the exact same study - this one that was recently published in the British Journal of Medicine.

And it's not just that each article is highlighting a different aspect of the study. They each pull out different figures to talk about the risk to first-time mothers to make it sound more or less safe, according to the article's mission.

The pro-home birth article says: "... researchers found a higher risk for first-time mothers planning a home birth. Among those women, there were 9.3 adverse events per 1,000 births, including babies with brain damage due to labor problems and stillbirth. That compared to 5.3 adverse events per 1,000 births for those planning a hospital birth."

The second article, the one highlighting risk, says: "Serious adverse outcomes for the baby are rare - occurring just 3.5 times for every 1,000 babies whose birth was planned in an obstetric unit. But the research, carried out at Oxford University, shows this figure rises to 9.5 per 1,000 babies if the mother chooses a home birth."

These articles are actually using two different figures for the risk of adverse outcomes for babies born in a hospital! So what's the truth? Is a home birth, according to this study, less than twice as dangerous to the baby, or almost three times as dangerous? Because one article says one thing, and the other article says another.

Fortunately, the BMJ study is available online, so we can find out. First of all, a summary website for the study uses the 5.3 vs. 9.5 per 1000 figure. Doing a quick skim and a text search of the article itself, I couldn't even find that 3.5 adverse outcomes per 1000 births figure, but I did find a statement that the study overall had 4.3 adverse outcomes per 1000 births. That number includes both first-time mothers and mothers who have had children before. Knowing that, I'm guessing that the 3.5 per 1000 figure must be multiparas (women who have had at least one child before).

Thus, it seems clear that the second article cherry-picked its numbers, and compares multiparas giving birth in the hospital to nulliparas giving birth at home in order to make the risk sound greater than it is. On the other hand, the first article definitely downplays the risk and glosses over it.

This highlights the importance of always being wary when we read health news in popular media. Authors often misinterpret, misrepresent, and misconstrue the data, and almost everyone has some bias toward one side or the other. This may be deliberate, unconscious, or accidental, but it's still very common.

Sorry for the funky formatting in this post. I messed it up and can't figure out how to fix it.

Friday, October 7, 2011

First birth

Well, I went to my very first birth recently. Up until a few days ago, I'd never so much as been around a woman in labor (except for when I was inside one, as the baby).

I'm still processing it, but I'll say one thing: I wish it had occurred to me to look up some YouTube videos of transition, and not just "Jason's peaceful waterbirth!" Because, whoa, I was not prepared for that. (I know that women often freak out during transition, but I clearly did not realize what level of panic was possible. I also didn't have enough experience to be confident that it was transition, and if it wasn't even transition yet, yikes...)

P.S. I was an apprentice doula, mostly just being an assistant to a very experienced doula and observing.

Thursday, August 11, 2011

Quickie book reviews

The Birth Partner by Penny Simkin:

  • Lots of very practical information for helping a woman in labor. For example, I'd heard of doulas doing "take charge routines," but I didn't completely understand what it was until I read the description in this book. Lots of great tips on positioning and many ways to support a woman in labor.
  • I felt like this book was aimed mainly at birth partners like dads, co-parents, friends who would be at the birth, etc. It's not just for doulas. It's very accessible to someone who just wants to help their wife/friend/partner give birth.
  • Talks about pregnancy discomforts and how labor and birth go so you can be informed as a birth partner. It's quite comprehensive and really covers all you need to know if you're the dad supporting your wife, for example.
  • Very helpful for doulas, too.
HypnoBirthing by Marie Mongan:
  • Gotta be honest, I had to return this one to the library before I could finish it. 
  • Enjoyed reading the history of HypnoBirthing - what a cool lady she was to fight for her right to be awake at her birth and have her husband present! Contains some lovely, positive birth stories.
  • Good overview of what self-hypnosis is; nice focus on positive language; etc. Has some nice relaxation and visualization exercises.
  • The book is clearly designed to be used with a course; sometimes there are notes about exercises that "you'll learn during your course." Because of that, I certainly wouldn't say that I "know" HypnoBabies just from reading this book. If I'd listened to the CD I'd probably know it a little better. As it is I'd say I'm at least more familiar with it now, especially with the positive language and how the relaxations work. 
  • I'd say that you can probably learn a lot and get pretty good at it just from reading the book, doing the CD, and practice your relaxation a lot. Not having access to a course shouldn't be a barrier to doing HypnoBabies, but the author clearly thinks that you should be doing a HypnoBabies course if at all possible. 
Born in the USA by Marsden Wagner.
  • A book about the flaws in the modern American maternity care system, sort of in the same vein as Pushed. The big difference is that this one was written by an OB, not by a journalist. It has a lot of great "insider" information coming from an OB, but is, I think, less balanced; he's not a journalist and he doesn't work quite as hard to include the "other side's" view. Pros and cons. I appreciate having a book like this from an "insider," though, and I think that value helps to balance out the flaws.
  • The main point of the book is that our current system really puts doctors first. I'm paraphrasing here, but he notes that  ACOG is a trade organization, like a labor union. They have two main priorities: protecting the interests of their members, and producing a better product (in this case, health babies primarily, also healthy mothers). However, if there’s any conflict between those two goals, the interests of the members always come first. (ca. p. 32)
  • His argument (it's the subtitle of the book, in fact) is that our maternity care system must be changed to put women and babies first, not doctors and hospitals.
  • Makes some good points about how loyalty to the ACOG party line is strictly enforced, as OBs who try to do things differently from their colleagues are often ostracized: fired, hospital privileges revoked, unable to work and forced out of town, etc. This makes it very difficult for reform to come from within that community.
  • He actually seems to be a fan of lawsuits because it's a way for non-doctors to force change. He also makes a good point about capping damages: if you cap damages at $250,000, but medical negligence disables your child to the tune of a million dollars in lifetime care and medical bills, is that right? Should that family go bankrupt for the sake of a doctor's malpractice premiums?
  • He talks a lot about Cervidil, and rare but disastrous consequences from other interventions.
  • Makes some very good points about how universally accessible prenatal care would prevent many, many premature births and neonatal deaths, and also save a lot of money on NICU care.
  • I did find the book to be quite biased in some cases exaggerated to the point that it does hurt the message a little.
  • Overall, though, I found it to be quite thought-provoking and mainly pretty reasonable. I think it's valuable to have an OB speaking about the problems he sees in obstetrics and arguing for more midwives and the evidence is good. The book is very well-cited with an extensive list of sources at the back.

Friday, August 5, 2011

Book review: Birth as an American Rite of Passage

Today's book review: Birth as an American Rite of Passage by Robbie Davis-Floyd.

I read this book at least two months ago, honestly. I think I had a hard time writing about it because it was so amazing. It was hard to think of just writing a few paragraphs about it when I just want to basically reproduce the book, I had so much to say about it.

This book looks at birth in the USA from an anthropologist's point of view. Specifically, it uses anthropology's observations about the construction and function of ritual in society to analyze birth as a set of rituals. The main argument is that (1) rituals perform a function in communicating the values of society to the person/people taking part in the ritual, and (2) birth as it as set up today functions as a ritual. The concepts come from academia, but Davis-Floyd takes care to explain the academic concepts in everyday terms. The book does have a bit of an academic tone but it's set up to be accessible to any reader. I've never taken any sort of anthropology or sociology class and I didn't have a hard time with it.

I found the analysis very powerful and very illuminating. It's not hard to see how modern hospital birth has many elements of ritual to it. These days, many women have the experience where they come in, they put on the hospital gown, they get their IV, they get their fetal monitor, the bag of waters is broken, etc. These things, when does as part of the routine of arriving at the hospital, are not done because they are necessary, but they feel like things that must be done. There's this whole ritual to getting set up for birth, a whole ritual to labor.

Additionally, modern hospital birth has many elements in common with rite-of-passage ceremonies throughout the ages: the "initiate" (being initiated into motherhood, in this case) is put in unfamiliar circumstances, put in strange clothes, often made to do things that she doesn't fully understand - "made strange to herself," and put into circumstances where she is vulnerable and unsure, making her very receptive to the messages that the ritual is sending.

Now here's where the book really blew my mind. Often, when I read about interventions in labor and birth that are proven to be unhelpful or harmful except for rare cases (episiotomy, augmentation with Pitocin, confinement to bed, etc.), I ask myself, "How on Earth can so many doctors do this when we know that this performs no useful function?"

This book, at last, answers that question. The answer: they do these things because they do perform a function. They help communicate the message of the ritual. The messages of the ritual include:

  • that a woman's body is defective and can't be expected to work properly without help.
  • that technology is always good, and adding in technology always makes things better. 
  • that nature is subordinate to humankind and its technology. (This is communicated by the relentless speeding of labor, the near-compulsory Pitocin augmentation, etc. The natural rhythm of the mother's body and labor must be made to fit into the rhythm of the hospital schedule.)
  • that society has a certain ownership of and interest in the baby. (Hence, taking the baby away from the mother for a time, asserting that the hospital's right to the baby trumps the mother's. Also, court-ordered C-sections and such things symbolically show that society has the right to override the mother's wishes because the baby belongs to society, not just to the mother.)
What an eye-opener for me. Why does a doctor perform an episiotomy? It shows that the doctor (and society and technology) is the savior, saving the woman both from tearing and from the inadequacy of her body to stretch properly and let the baby out. And it shows the woman that her body cannot birth without the help of the doctor, society, and technology. 

To readers who are unfamiliar with this kind of analysis, I want to emphasize that, no, this doesn't necessarily happen consciously. Doctors don't sit down together and say, We want women to really get the impression that their bodies are bad, and we really want to communicate how technology is paramount and way better than nature. How are we going to do this? Let's strategize! That's not how it happens. 

Rather, the doctors started out already with the belief that women's bodies were defective - that belief goes back a very long way, to the Greeks and Romans and beyond - and that technology was better than nature. That certainly came about in the Enlightenment, but the Christian belief in man's superiority to nature goes back farther than that, too. So we have doctors, we have men and women at the turn of the century, totally steeped in these beliefs. These beliefs then shape their actions: Women's bodies are weird and defective, so we need to intervene in birth. Technology is better than nature, so if we use technology, things will happen better. From that line of thinking, these practices emerge. And they become entrenched, they become part of the ritual. 

Once a ritual is established, you feel like it must be performed that way in order to make things turn out well. And when you perform that ritual right and things turn out well, you get the feeling that everything turned out well because you performed the ritual well.

Imagine a wedding where they didn't exchange rings, or where the bride just showed up without walking down the aisle to great ceremony, or where they just exchanged rings without saying any vows. You'd get a bad feeling about it, wouldn't you? You might think that the marriage probably isn't going to turn out very well, because if they didn't even care enough to go through the whole marriage ritual, well, what does that say about how seriously they're taking this? 

Now that doesn't even have the weight of scientific studies, or the word of thousands of doctors; that's pure ritual. Imagine how much harder it is to shake off the childbirth ritual that is supported by these doctors who we respect so much! And so you get the situation of, well, I've done thousands of births with Pitocin and episiotomies, and I've got lots of healthy moms and babies. What's going to happen if I stop?!

So these beliefs shape what doctors do, which becomes ritual. And the ritual shapes what women believe, because those original beliefs are encoded in the ritual, and they send those messages to laboring women. 

Of course, how successful the ritual is at communicating those beliefs varies. There's a whole chapter on it in Davis-Floyd's book where she analyzes the messages that women got from their births and whether they internalized or resisted those messages. It's quite fascinating.

I really can't recommend this book enough. The analysis is so powerful, and the understanding that it provides about the function of the modern birthing apparatus above and beyond producing healthy babies is terrific and invaluable.

For what it's worth, although it's kind of an expensive book, I found it at my local library.

Friday, July 29, 2011

Doula training

Oh my goodness. Doula training was amazing. Just amazing. 50 women, every one so passionate about birth, together for four intensive, wonderful days of education and training. There was just so much energy and joy in the room.

I'm going to compromise my anonymity here, because I think it could be valuable to others for me to say what class I took. So, it was at the Simkin Center at Bastyr University near Seattle, and one of the instructors was the legendary Penny Simkin. I know, how lucky am I, to live in this area and have that opportunity?

Demographics-wise, I was expecting the class to be fairly small - say, 20ish people; and I was expecting to be perhaps the only woman without children. I had the impression that many women get interested in birthwork after having a birth experience, so I expected it to be a crowd of mothers.

Instead, the class was a full 50 women! An unusually large group, I've since heard. The vast majority of the class was under the age of 35; there was even at least one high schooler, which I thought was neat. Slightly over half of the women did not have children. There were actually quite a lot of the early-to-mid-20s, childless women, like myself. I found that very reassuring. In a way, I'm glad that we had such a big class, because there was such a diversity of experiences. We had college students, we had a few ladies in their 50s, mothers and non-mothers; women who wanted to be doulas, women who were already doulas, women who wanted to be midwives; nurses, lactation consultants... oh, and quite a few pregnant ladies, too!

As far as the course material, it was quite comprehensive. There were some basic overviews of pregnancy, the stages of labor, complications, etc. - stuff that we were expected to know, but it was reviewed. Probably the most useful thing was our discussions and practice on how to be active listeners. That made me realize that I very rarely practice active listening. My main goal in a conversation is just to keep it going; I often want to hear information from the other person, but I want to give information from them, too. Sometimes I just want to hear or tell an entertaining story. The give and take is important. But in doula work, the doula's role as a conversation partner is much more as a listener, and much less as a teller, than in an everyday conversation.

Overall, I found the training to be incredibly inspiring and encouraging, as well as very informative and educational. It was a very supportive environment that gave me a lot of confidence that this is work that I can do. I am very lucky to be starting out in a region where doulas are very supportive and collaborative, not isolated and competitive as they can be in some other places.

Friday, July 8, 2011

Pre-Modern Death in Childbirth

More than once, I've seen homebirth advocates remark that homebirth is good and safe because it's natural: before there were hospitals, every woman gave birth at home, and most of them came through it just fine!

And just as many times, I've seen homebirth opponents reply: Yeah, umm, a lot of those women died. Giving birth at home is like giving birth in the middle ages, when mothers were dying left and right! (The Middle Ages gets mentioned a lot in this sort of argument. I guess we're to picture homebirth as if it were taking place in the most exceptionally ignorant, disease-ridden situation we can imagine.)

Of course, both arguments are wrong. The evidence of the past doesn't support or preclude homebirth. Things were very different then. Looking at the past, those of us in developed countries should be very glad that birth is so much safer now (for us, in our countries). In wealthy countries, our comparative good health and ease of access to information and skilled birth attendants makes birth remarkably safe, regardless of where we do it.

What, I ask myself, were the biggest killers of women back in the day? My suspicion is (1) infection, the deadly "childbed fever," and (2) postpartum hemorrhage. If I'm right that those were the major killers, well, that really speaks for the safety of homebirth today! Modern understanding of hygiene helps to prevent infections; antibiotics can (for now) take care of any infection that does occur. As for hemorrhage, it's scary, but any good midwife should see it happening and get the woman to the hospital in time, where the mother will most likely be saved. The literature for the LifeWrap notes that a woman can bleed to death in less than two hours. That's very bad news if you're hours away from a hospital, but it's kind of encouraging for women giving birth in developed countries who can get to a hospital in just a few minutes.

Anyway, I'm trying to do some research to see if my ideas here are correct. Here's what I have so far.

This website has a graph midway down the page of leading causes of modern maternal mortality. This is worldwide, not just U.S. Ignoring the many deaths from unsafe abortion, pregnant and birthing women are most likely to die of:
  1. Hemorrhage.
  2. Sepsis (infection).
  3. Obstructed labor.
  4. Eclampsia.
This WHO page gives different percentages, and it puts eclampsia down as a more frequent killer than obstructed labor, but the top four killers remain the same. That particular page cites a much lower percentage of death from unsafe abortion, though still 13%.

Maternal mortality is going to be dominated by places where we could characterize medical care as "pre-modern": places where women have poor pre-natal care, little or no access to trained and skilled birth attendants, and long distances or no access to hospitals. According to the WHO, "99% of all maternal deaths occur in developing countries, where 85% of the population lives." Thus, we can take worldwide causes of death in childbirth as representative of "pre-medical" birth.

The most deadly countries for mothers have maternal mortality rates of 1,000 maternal deaths for every 100,000 live births. That's about a 1% chance of dying each birth. (Well, probably greater, when you consider that some women are going to die after a stillbirth, or from an obstructed labor with no live birth.) In the countries with the worst maternal mortality, 1 in 6 childbearing women die from pregnancy-related complications in that country. That's in Afghanistan and Sierra Leone. It's 1 in 7 in Niger. (For comparison, in Europe, it's 1 out of 30,000 women. The worldwide average is 1 in 74 women. Source - Lancet article.)

That Lancet article, "Maternal mortality: who, when, where, and why," backs up the above-cited article and says that postpartum hemorrhage is the leading cause of maternal mortality worldwide.

That same article also notes the disparities in maternal deaths between rural and urban areas. On average, worldwide, a woman giving birth in a rural area is half again as likely to die during birth as an urban woman. (About 640 deaths per 100,000 in rural areas, 447 per 100,000 in urban areas.)


Okay, so, that's modern statistics that may be somewhat representative of past conditions for women. How about actual past conditions? That's not so easy because people weren't exactly doing big medical studies in the 1500s, but there is some evidence, of course!

Here's a cool article available as a PDF online that anyone can access. Published in 1982, it's called "An Attempt to Estimate the True Rate of Maternal Mortality, Sixteenth to Eighteenth Centuries." (Found via this article, which contains a fascinating account of childbirth in ancient Rome!) I will spend the rest of this section discussing that paper.

The article notes first that, of course, the evidence is flawed and incomplete; any estimate of maternal mortality from the 16th to 18th centuries cannot be any better than a very rough, error-riddled estimate. That said, here's what they found. In one parish in England, church registers counted 23.5 maternal deaths per thousand baptisms (so, per thousand births, assuming each birth results in a baptism). The London Bills of Mortality count an average of 15.9 maternal deaths per thousand baptisms from 1666 to 1758, not counting plague years. That's a maternal mortality rate comparable to that in modern Afghanistan. The paper notes that these are "certainly underestimates." For example, deaths from ectopic pregnancies or early miscarriage complications might not have been counted if they couldn't be recognized.

Continuing on, death rates in the mid-1800s were apparently lower, on the order of 5 maternal deaths per 1000 live births. That's a bit higher than Bangladesh's rates today. Odds of the mother dying were much higher when the baby was stillborn, ranging from 57 to 137 maternal deaths per 1000 stillbirths. That's as many as 13% of women dying while giving birth to a still baby. Sort of an intuitive result: unknown pregnancy complications, on which we can only speculate, mean a much higher chance of both maternal and fetal death.

Overall, the paper estimates about 25 deaths per 1000 live births from the 16th to 18th centuries. That's a 2.5% chance of death per birth, or 2500 in 100,000 live births. That's quite a bit higher than the rate in Afghanistan today, which is 1800 maternal days per 100,000 births.

As far as causes of death: a male midwife who lived 1596-1768 described postpartum hemorrhage as one of the leading causes of death in his patients. He also noted that women who delivered on their own had infections less often. Infection was nonetheless a great danger. The paper notes that "even in normal cases, the vagina was repeatedly smeared with materials such as butter, goose grease, capon's or hen's fat, or whole egg. Operative procedures almost inevitably meant infection." Not so hygienic, back in the day.

Now, this was just one paper, so take it with a grain of salt. However, from it, we can glean that pre-modern childbirth was more dangerous than it is in the most dangerous-to-birth-in countries today. Some evidence from New England suggests an average maternal mortality rate of 2.5%. That is, for every 1000 births, there would be 25 women who died. In countries with the maternal mortality closest to that, 1 in 6 childbearing woman will die from complications of childbearing; we can expect that the rate was similar in pre-modern times.


What's my take home message here?
  • Birth in the past was very dangerous. 
  • In developed countries, birth is very safe: we're generally healthy and well-nourished, making complications less likely. When complications arise, we can generally treat them quickly, effectively, and safely.
  • In many countries of the world, birth today is nearly as dangerous as it was hundreds of years ago. In far more countries, maternal mortality rates are 10 to 15 times as high as the rate that appalls us here in the States. We are right to care about having a rising mortality rate in the U.S., but it is also right to care about the staggering maternal mortality in the countries we don't think about very often.

Thursday, June 16, 2011

Big steps

I signed up for a doula training course.

On one hand, it's not much. Just training. I'm not quittin' my day job and I'm not committed to anything more.

On the other hand, it feels huge.