Others write letters, EBM style

Go read this excellent letter of support on behalf of a physician who is being harassed by his hospital for supporting midwives, VBAC attempts and vaginal breech deliveries.

Here is an excerpt:

When medicine is practiced primarily for profit, convenience and out of fear of litigation it is not good medical practice nor is it evidence-based medicine. The c/section rate in this country is nearing 1/3 of all births. While the current hospital model will profit from this trend you must ask at what cost? Evidence is clear that repeated c/sections put women at greater risk and the evidence mounts that babies born this way have higher rates of breathing difficulties, breastfeeding difficulties and learning disabilities. Doctors and midwives who stand up for patients rights are often the target of ridicule and harassment by the very hospitals and organizations that their hard work supports. Does this sound like what is happening at your facility??

Another part I like is this line:

“If a hospital is not safe to have VBAC, it is not safe to give birth.”

It is so stunningly simple. I may have even heard it before, but forgotten, but right now it sounds incisively brilliant.

Reply turned post, othering style

I love the posts on Stork Stories. The blog author is an experienced, conscientious OB nurse and CLC. This week I was a little dismayed by the victim blaming tone of her post about having a run of racially and ethnically diverse, difficult patients. This part in particular bothered me:

“Is it too much to ask for a little bit of responsibility to understand at least a little something about what is involved in childbirth, postpartum, newborn care and the legal recording of birth in the facility, state and country in which they have chosen to give birth! Is it too much to ask that an individual try to learn what may be asked of them???” Not everything in the post was as clearly victim blaming, and I included a more reasonable statement of hers in my comment.

However, discussing problems with experiences with people of other races and ethnicities is really difficult, even with the most conscientious and progressive people. I hope I did OK:

I think this is the key:

“There are times when these situations unfortunately occur. Many times the individuals involved are Americans who are 2nd or 3rd generation of mixed ethnic background or are of no discernable ethnic or cultural background, have lived in this country all of their lives and still exhibit the same type difficult personality traits.”

Here is a good example of what happens in obstetrics when it is harder to relate to people who are “other” than us for some reason.

I know it is frustrating when there are language and cultural barriers, but I am not sure any of the people you described were necessarily fully choosing to be in the situation they were in. I don’t think many women want to be in a hospital in which their culture and language are not well understood or well received, and would prefer to be white, insured, from the United States, and would prefer not to be drug addicted or have aggressive men fighting outside of their room. But, since becoming privileged and safe is not in their control, let’s try to show a little empathy to people who need it more, not less.

I understand these situations are more trying since there are language and culture barriers, but think how much worse it is for the patients, too, and try to step back from making sweeping generalizations about anyone.

End of comment.

I wanted to add here that I had a very interesting discussion just yesterday with a black female ob/gyn at my medical school. She is a mother and is of Jamaican heritage, and wears her hair in dreadlocks. I am not fond of describing people as “black” or “dreadlocked” or other such adjectives if it is not relative to the conversation, but it is in this case. She was telling me about how you can pretend how it doesn’t matter what you do, but when one is from a less privileged position (a mother in medicine, black, female, and osteopath in an allopathic residency, etc.) you are representing whether you like it or not.

She had a cesarean delivery last year, and her child was born with a cleft lip and palate and had to undergo multiple surgeries in the past year. She is being pressured to finish up her MPH project, while still practicing as an ob/gyn full time and performing in her duties as a professor. When she brought up her surgery, delivery, and child’s health problems, the department head told her that if women are meant to be taken seriously in this day and age, they shouldn’t use those kinds of excuses.

WTF? If any man here had to undergo major abdominal surgery, a major life transition (new baby) and his child ALSO had to undergo multiple surgeries within an 8 month period, I think people would cut him a little slack. There is nothing wrong with acknowledging the realities of parenting, regardless of gender, or acknowledging the realities of health care issues. We are people. We are not just blacks, whites, moms, women, foreigners, whatever. We are real people with real needs. What’s wrong with a little nuance and empathy?

I write letters, health care style

I decided to contact the White House today. Here is my letter:

I am a mother whose pregnancy was turned down by Blue Cross Blue Shield as a preexisting condition. I am a medical student who doesn’t want to turn away any mothers when I am an ob/gyn because they don’t have insurance coverage.

Please, please do not abandon the public option. The Republican party has not responded to any attempts at bipartisanship yet this term. Compromise doesn’t work if the other side only says “no”.

One of the most effective ways of reducing health care costs is to increase quality of care by reducing unnecessary interventions. Childbirth is the most common reason for admission into the hospital, and cesarean section is the most common hospital surgical procedure. Please support patient centered quality of care panels, evidence based medicine incentives and a departure from procedure based reimbursement.

Looking into the midwifery based model of care practiced in most countries with better maternal and neonatal outcomes wouldn’t hurt, either. Midlevel practitioners are less expensive, can spend more time with patients, and are less likely to use expensive interventions. Many physicians would be happy to work with midwives, and practices and hospitals in the United States already successfully incorporate midwifery into their obstetric and gynecologic health care delivery.

Anyway, good luck, and don’t sell out your base. Medicare faced a similar fight, and the Democrats feasted on that well fought success for a long time. Let’s do it again.

Health care reform question

Barack Obama is having a live conference on health care reform today. I RSVP’d with this question.

(From a medical student studying to be an ob/gyn who is also a mother):

Unnecessary, expensive interventions in labor and delivery not only increase health care costs but lead to poor outcomes for mothers and babies. How serious is your health care team about improving quality of health care, including reducing the cesarean section rate? This has been a goal of the HHS since Healthy People 2000 was written, and the rate has continued to skyrocket. Childbirth is the most common reason for hospital admission in the United States, and cesarean section is the most common surgical procedure performed in United States hospitals. Small changes can save millions of dollars AND improve quality of care.

http://articles.latimes.com/2009/may/17/business/fi-cover-birth17

Two things I found out yesterday

Rixa, the intrepid blogger at Stand and Deliver, won Lamaze International’s 2009 Media Award! If you haven’t read Rixa’s blog, (or Lamaze’s Science and Sensibility, for that matter), please check them out through the links above.

Her interview with Amy Romano is fantastic, chock full of analysis and information about modern maternity care. I was so tickled to see Rixa say she likes my blog! Like a cherry on the top of a sundae of a post. It is a wonderful, comprehensive look at both the quantitative, outcome based aspects of pregnancy and birth care, and the emotional, woman centered view of being pregnant and birthing.

I also found out that the Kali project shares a name with an escort service and live web cam of women sex workers in British Columbia. I was slightly amused and slightly dismayed. I consider myself to be “sex positive” and don’t mean to shame sex work. I am not a fan of exploitative sex work that exclusively involves women fulfilling what the mass media says is the male heteronormative ideal. Anyway, I hope they don’t mind sharing the name.

The KALI project

Apparently research has shown that studies with acronyms (ALLHAT, NHANES, etc.) are more likely to get published. Well, I have a tentative title / acronym for my study: The KALI (Knowledge and Attitudes of Labor Interventions) Project.

Kali is a Hindu goddess with a complex history. According to Exotic India:

“Kali’s nudity has a similar meaning. In many instances she is described as garbed in space or sky clad. In her absolute, primordial nakedness she is free from all covering of illusion. She is Nature (Prakriti in Sanskrit), stripped of ‘clothes’. It symbolizes that she is completely beyond name and form, completely beyond the illusory effects of maya (false consciousness). Her nudity is said to represent totally illumined consciousness, unaffected by maya. Kali is the bright fire of truth, which cannot be hidden by the clothes of ignorance. Such truth simply burns them away. “

Sounds perfect to me!

Good discussions

There is some great stuff going on in the comments section in my recent “Reply turned post, birth power struggle style”. I could have done a few more reply on a reply turned post turned posts (huh?) but that made my head dizzy, so I figured I would just link there.

Reply turned post, birth power struggle style

This is a long reply to a post on Wandering Scientist’s blog called Thoughts on Labor, in which she tells her birth story:

I was fascinated by your birth story. You know, I have read so many of them online, but reading yours while I am learning about qualitative research through my fellowship gave me an idea.

You know, I have read so many of them online, but reading yours while I am learning about qualitative research through my fellowship gave me an idea.

One of the reasons I am interested in these birthing issues is I want to examine the power relationships between health care practitioners and women. I am going to use a survey (quantitative) and some in depth interviews (qualitative) with obstetricians in my area. Maybe I could follow up with some qualitative and quantitative research with women regarding birth interventions. Listening to Women has already approached this, but I think it’s mostly quantitative. Maybe I could do some qualitative research on birth stories on the internet to examine women’s perspectives on their interactions (and those of their personal support system, such as your husband in your case) with health care practitioners during the birth process. You did some thoughtful processing of this in your post.

Should a woman need to be so educated on interventions and when they are appropriate that she or someone she brings or hires can run interference to protect her from her paid health care practitioners?
Your husband takes the frequent claim that cesarean is the malpractice preventing option and jumps to the conclusion that it is somehow a safer option and prevents catastrophic problems. However, research usually shows that outcomes are generally worse for the mother, the baby, and future pregnancies with cesarean delivery. There are so many aspects to this I can’t just cite one study. There will be an extensive bibliography on this in my final paper, and you can search my blog history or The Unnecesarean for references .
Or, just search the recent contents of the so called Gray Journal (follow the search link and enter this: “Am J Obstet Gynecol”[TA] AND “cesarean”[TIAB] ) and Green Journal (enter: “Obstet Gynecol” [TA] AND “cesarean”[TIAB]). These journals are the bully pulpits of mainstream professional American obstetrics.
Coming to the realization that physicians, nurses, midwives, and even patients with full informed consent and insurance and/or means may make decisions during birth that do not favor the health of the mother or the fetus / neonate is a difficult one for people realize and discuss. My theory is that the interventions chosen by health care practitioners favor the practitioner’s role and make it easier, and that certain risks to the birthing unit are acceptable if it favors the correct direction in the power relationship. Women respond to pregnancy, birth, and subsequent pregnancies and births in a wide variety of ways, and may choose anything from elective cesarean to unassisted homebirth, depending on a variety of factors. There is less of an expectation for women to follow evidence based practices, but I hope there is an expectation for health care practitioners to do so.
Malpractice is a commonly quoted boogeyman as a reason to intervene, but research also indicates that using evidence based algorithms for interventions can lower cesarean rates and malpractice rates simultaneously. Many studies show an association between high malpractice payouts and premiums and high cesarean rates, but the casuality is missing in that association. What if it is the other way around? Interventions chosen despite evidence against their usage in many situations may arguably cause more malpractice suits and higher premiums. Causality is hard to prove in complex situations like this, but it can easily be argued that this association may not only be influenced in one direction.

Umm, yowza

My reading list for this “vacation” also includes some journal articles. Sometimes when I search for an article by author, I find that the author has written many interesting articles. That happened today when I was juggling multiple portals to find a link for a long reply turned post in progress. I entered the author SL Clark in the search for the American Journal of Obstetrics and Gynecology, and got a list of gems.

One on the use of oxytocin made me sigh as I saved a copy. We are visiting with my in laws right now. My sister in law was given oxytocin for what ended up being a three hour active labor and delivery. I try not to second guess treatments of my family and friends once they have occurred, but this surprised me so much that I stammered “Why??!!”

She, like her mother, has incredibly quick labors, and we were all concerned whether she would make it to the hospital in time. Unfortunately for her, her epidural didn’t “take”. She thought the augmented contractions were unbearable. I had augmented contractions without an epidural my first labor, and they aren’t any fun, even if it is your plan to tough it out pain-wise. I wish I had known to refuse it or at least challenge its use. Like her, I was in active labor with intact membranes, I was low risk, and the fetus wasn’t in any distress. We were both given oxytocin upon admission. She told me she wasn’t going to take any childbirthing classes before her first delivery because her physician told her she “didn’t deserve to feel any pain.” I found that statement infuriating and misleading, but I kept my mouth shut. Unfortunately, by his logic, she was less deserving this time around.

Another article of his is what led to the title of this post. The results of his group’s review of maternal mortality since 2000 concludes that mortality during cesarean section is eleven times that of a vaginal delivery.

RESULTS: Ninety-five maternal deaths occurred in 1,461,270 pregnancies
(6.5 per 100,000 pregnancies.) Leading causes of death were
complications of preeclampsia, pulmonary thromboembolism, amniotic
fluid embolism, obstetric hemorrhage, and cardiac disease. Only 1
death was seen from placenta accreta. Twenty-seven deaths (28%)
were deemed preventable (17 by actions of health care personnel and
10 by actions of non-health care personnel). The rate of maternal death
causally related to mode of delivery was 0.2 per 100,000 for vaginal
birth and 2.2 per 100,0000 for cesarean delivery, suggesting that the
number of annual deaths resulting causally from cesarean delivery in
the United States is about 20.

Vacation Reading List

I am spending a week in the mountains of western North Carolina. It is gorgeous here. I am so lucky that my fellowship is flexible enough that I can bring some books and my laptop up here with my family and spend some time at the creek and some time working.

My reading list:

The Handmaid’s Tale – Margaret Atwood
Mass Hysteria: Medicine, Culture, and Mothers’ Bodies – Rebecca Kukla
A Guide to Effective Care in Pregnancy and Childbirth – Murray Enkin et al
The Political Geographies of Pregnancy – Laura R. Woliver