Monthly Archives: September 2009

Reply turned post, heart heavy but not too heavy style

I replied on Los Angelista’s post “How Do We Talk Productively About Racism On Blogs?” (h/t What Tami Said). It seemed relevant, considering what has been happening on this blog lately.

Here it is:

Great post that I really needed to read today.

I have had difficult conversations about race on two of my blog posts this week. One wasn’t even about race! The other ended up spilling onto other posts.

After a lot of really emotionally draining arguments and being called a racist at the end of both conversations (I am a white woman and both commenters are white women, by the way), I was reeling. But, I couldn’t help but think, hey, I can walk away from this. I can pretend racism isn’t my problem and ignore it. I don’t have to write about race on my blog.

I can only imagine how hard this is for someone of color. Someone who can’t choose to ignore racism. Someone who is expected to a patient educator who always takes the high road and watches her “angry” tone.

So, then I signed on Facebook and saw that my little brother, chairman of the local Young Republicans club, thought this chart was oh so funny and accurate. I didn’t comment, yet. The chart was posted on a third party’s page, one that I am not friends with. So, I am in limbo, thinking I have the valid option of “staying out of it.” And, I am feeling sorry for myself for walking around with arguments against it in my head, and my fingers itching to type them, and my heart heavy for the hatred in America and my stomach in knots because some of this hatred is coming from my own family.

But still, I can, to a certain extent, still be separate from the fray by choice. And all of this frustration and unease I am feeling, it is not anything compared to what people of color must be feeling in this culture of racism denialism.

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New, improved KALI questionnaire

Here is the new, improved KALI (Knowledge and Attitudes of Labor Interventions) questionnaire. Thanks for all the input. I think everyone who gave suggestions will see them reflected in the questions.

I included the demographics this time. I struggled a lot with this section, and still have a lot of guilt. I want to say I feel like I am part of the problem currently, since “gender” is a binary in my study. I wanted to include “transsexual” and “intersexed” or even “other” and a blank as an option, but my mentors nixed it. They say this is not the purpose of the study, and isn’t relevant to my study population. I have no idea if there are no ob/gyns in the tri-county area who don’t strictly identify as “male” or “female”, but I guess they are assuming there aren’t any. I caved. I did hold out for allowing people to pick more than one race. Geez.

*************************

The KALI Project Survey

Thank you for agreeing to participate in the Knowledge and Attitudes of Labor Interventions (KALI) survey. This survey is intended to gather information about obstetrical practice patterns. The survey is anonymous, and should take about fifteen minutes. By completing this survey, you are giving consent to be part of this study.

First, we would like to gather some information about you and your practice. Please answer these questions by either circling your answers or writing your answers in blanks provided. This information will be kept confidential.

1. What is your gender?
Male       Female

2. Age:
20 – 29      60 – 69
30 – 39      70 – 79
40 – 49      80 – 89
50 – 59      90 or older

3. Do you have children?
Yes       No

4. Race (choose as many as apply):
White / Caucasian          Native Hawaiian / Pacific Islander
African American / Black         Native American Indian /Alaskan Native
Asian or Asian American           Other:________

5. Ethnicity:
Hispanic or Latino
Haitian
Neither Hispanic nor Haitian

6. How would you describe the location of your ob/gyn residency?
University
University affiliated
Community
Other: ________________

7. Year of residency completion ______

8. Which of the following most accurately describes your practice type?
Public hospital
Community health center
University based practice
Private practice
If private –
Large partnership (four or more partners)
Small partnership (two or three partners)
Solo practice
Military / government
Other:____________________________________________

9. Do you currently practice obstetrics?
Yes
If yes:
Average clinical time spent with prenatal clients:______________(%)
Average number of deliveries per year:________________
No

10. Which of the following most accurately describes your personal practice scope?
General obstetrics and gynecology
General gynecology only
Obstetrics only
Laborist
Maternal Fetal Medicine
Reproductive Endocrinologist
Gynecologic Oncology
Urogynecology
Other: ______________________________

11. Which of the following most accurately describes your current malpractice coverage?
_____None / I “go bare”
_____I pay for individual malpractice insurance
_____My practice pays my malpractice premiums
_____I am an employee of an institution that pays my malpractice premiums
_____I am an employee of an organization or institution that provides legal defense but
not malpractice insurance
Other: ___________________

Please rate the following statements about obstetrics as accurately as possible. All questions will have this scale available for you. Please choose whether you:

1. Strongly agree
2. Agree
3. Neither agree nor disagree
4. Disagree
5. Strongly disagree

1. _____Restricting maternal intake of all nutrition by mouth during labor prevents serious adverse maternal outcomes.

2. _____Elective cesarean section should not be performed on a woman desiring several children.

3. _____Doulas (i.e. private labor coaches, or trained labor companions) improve maternal and newborn outcomes.

4. _____Episiotomy should be avoided if at all possible.

5. _____The use of continuous external fetal monitoring (EFM) increases the risk for cesarean delivery.

6. _____In the absence of maternal and fetal medical indications, vaginal deliveries confer more risk than cesarean deliveries.

7. _____Insurance should not reimburse use of doulas for labor and delivery.

8. _____I employ episiotomy routinely, because it is easier to repair than lacerations that result when an episiotomy is not used.

9. _____Fear of liability claims limit the options I present to my obstetrical patients.

10. _____Liability insurance company policies forbid me from performing VBACs.

11. _____Use of upright (non lithotomy) positions during the pushing and birth has no positive impact on perinatal outcomes.

12. _____The use of continuous EFM does not result in a reduction of cerebral palsy.

13. _____All women in early active labor should have an amniotomy (i.e. artificial rupture of membranes or AROM ) if they present with their membranes intact.

14. _____Few women would choose to have a vaginal birth after cesarean (VBAC) if they knew the consequences of uterine rupture.

15. _____I regularly employ episiotomy to shorten the second stage of labor and delivery.

16. _____Low risk labor patients should be offered the option of intermittent fetal heart rate monitoring in labor.

17. _____Elective cesarean section should only be performed after accurately determining 39 weeks of gestation.

18. _____Mediolateral episiotomies result in less postpartum pain than median episiotomies.

19. _____The hospitals in which I attend births do not have sufficient staff to support intermittent fetal heart rate monitoring during labor.

20. _____Most patients attempting vaginal delivery benefit from oxytocin (Pitocin) augmentation of their labor.

21. _____I regularly employ episiotomy to prevent pelvic floor relaxation.

22. _____Hospital policies forbid me from performing VBACs.

23. _____If my partner or I were pregnant for the first time, I would recommend an elective cesarean delivery in the absence of any medical or obstetrical indication.

24. _____I have made changes to my practice because of the risk or fear of liability claims.

25. _____Childbirth is only normal in retrospect.

26. _____Clinical guidelines are useful tools for me in daily clinical practice.

27. _____I regularly employ episiotomy to prevent perineal trauma.

28. _____The use of continuous EFM reduces perinatal mortality.

29. _____I encourage my patients to try alternative or upright positions during the pushing stage.

30. _____Physicians should initiate discussion of elective cesarean delivery as part of routine prenatal care.

31. _____I refer patients who want to attempt a trial of labor after a prior cesarean delivery to another practitioner.

32. _____Women should have the right to refuse an episiotomy.

33. _____I recommend that most patients use a doula for their labor and delivery.

34. _____I feel that it is a woman’s right to elect to have a caesarean section even if there are no clear maternal or fetal indications.

35. _____There is high interobserver and intraobserver variability in interpretation of fetal heart rate tracing.

36. _____Hospital standards of care or policies sometimes get in the way of optimal management of individual patients.

37. _____I discuss the risks and benefits of episiotomies with my patients prior to delivery.

38. _____Routine artificial rupture of membranes (AROM) increases the risk of cesarean delivery.

39. _____If a patient asks if she could use a doula for her delivery, I would encourage her.

40. _____Most women with one previous cesarean delivery with a low-transverse incision should be counseled about VBAC and offered a trial of labor.

41. _____Episiotomies increase the risk of third and fourth degree tears.

42. _____Clinical guidelines are overly rigid and difficult to adapt to individual patients.

How often do you consult the following sources regarding obstetrical practice?

1= Never 2= Rarely 3 = Sometimes 4 = Often 5 = Always

1. _____ACOG Practice Bulletins
2. _____ACOG Committee Opinions
3. _____Obstetrics and Gynecology Journals (e.g. the Green Journal, the Grey Journal)
4. _____Cochrane Database
5. _____PubMed/MEDLINE
6. _____Electronic evidence-based services (e.g. Epocrates, UptoDate)
7. _____Books and/or textbooks
8. _____Professional conferences
9. _____Physicians in my practice
10. _____Physicians in my local community
11. _____Physicians I trained with in residency
12. _____Physicians I consider experts in the field
Other sources: ____________________________

Have you ever been the subject of a professional liability claim or litigation?
Yes
If yes – Did the liability claim involve an obstetrical claim? Yes No
No

Thank you for your time and participation!

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Reply turned post, reverse racism style

This is a reply turned post of one of my recent posts. When I posted my picture of a racist display mocking President Obama and the letter I wrote to my local paper, a commenter started talking about reverse racism that she experienced living in “the ghetto”. Here is my reply:

IMO, that was ugliness and prejudice. I am sure it felt awful and I am sorry.

We can argue and disagree on this, but most people who study racism in a scholarly way say that the power differential occurs when you as a white person gets to go home, see the heroes and beautiful people in ads portrayed on TV who look like you, all of the pictures in magazines of people who are supposed to be beautiful who look like you, and go put money in the bank who most like has a white CEO who looks like you, and just live in a society in which you know that, regardless of your lower class upbringing, you have a lower maternal mortality rate than a rich black woman, you have a better chance at getting a job, and many, many other privileges.

When is the last time someone said a president or Supreme court justice who looked like you got their position did it only based on their race, not merit? See how ridiculous that sounds to a white person? Or that the health care plan that you’re proposing is really reparations?

Here is a great essay by a fellow white person, anti-racism activist Tim Wise, who discusses this:

The myth of reverse racism.

Here is an exercise that helps you look at this. I am sure many of these items, especially those in the beginning, you may be able to say …”See, we’re the same.” But wait until you dig a little further.

White privilege exercise.
(I have had trouble with this link. Right now it is set up for Firefox, since I can’t get to directly link to the .doc. If you do a google search on white privilege score, the exercise is the first link)

Once you leave that library or that situation with those black people and think about it, you know they are angry because of a LACK of power. They don’t think you’re lessor and use that to oppress you. They think you’re an oppressor and use that to attack you. They may make that judgment based on your race, but that does not give them racial power over you.

If an Iraqi soldier ends up alone and unarmed in a bunch of angry Iraqi insurgents and gets the crap beat out of him, that doesn’t change their power differential. Yes, the Iraqi soldier was “overpowered” by the Iraqis, but that doesn’t make it reverse racism.

I have lived in the “ghetto”, (that’s Racism Bingo card O2, by the way) and my husband grew up there. I did the white flight thing and moved from a neighborhood that was 90%+ African American in Miami Gardens Florida. If you want a trip in the police blotter, do a google search on “Miami Gardens” + the word “crime”. And, most of the crime is black on black. It’s unsafe to live there for them, too.

I felt afraid for my young, blond, pale white son there when I saw the kids at the playground glare at him and walk away when he asked to play, and was afraid of the gang bangers who tinkered on cars at the edge of the playground and jealously guarded their turf, cursing loudly enough for us to hear, every time we were there. I still feel extreme guilt for having the privilege and ability to move to a NICER neighborhood where more people look like me. I am proud of my multicultural neighborhood now.

But, can a black person do that? How often can a black person go to a safer place where more people look like them?

And, finally, the main problem I have with the term reverse racism is that it is used to deny that racism against people of color, especially African Americans, is a persistent, real problem with significant negative effects on a huge subpopulation of our country, and in the long run, negative effects on all of us. Your examples are a perfect illustration about how cultural and institutional racism against blacks can turn around and hurt white people. My last post linked to an article on how that racism denial, and I would like to add the competitiveness that lower class white people feel when people talk about racism, is what allows racism to thrive.

Edited to add: Kittywampus (with a little help from) Stephen Colbert does a great job discussing this here. Great minds think alike!

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CIMS response to The Today Show

The Coalition for Improving Maternity Services has written a fantastic response (pdf) to the horrid hit job disguised as journalism that was the Today Show’s The Perils of Midwifery (link to video) . I am reposting it here:

Sept. 23, 2009

Dear Producers of The Today Show,

The Coalition for Improving Maternity Services (CIMS) and the undersigned organizations are disappointed with The Today Show’s misrepresentation of midwives and home birth that aired on Sept. 11, in a segment titled “The Perils of Midwifery,” later changed to “The Perils of Home Birth.” This biased and sensational segment inaccurately implied that hospitals are the safest place to give birth even for low-risk women and mischaracterized women who choose a home birth with a midwife as “hedonistic,” going so far as to suggest that these women are putting their birth experiences above the safety of their babies. Neither could be further from the truth.

Unfortunately, The Today Show did not do its homework on the evidence regarding the safety of home birth and midwifery care. The segment featured an obstetrician who presented only the American College of Obstetricians and Gynecologists’ (ACOG) position in opposition to home birth, but it did not make any attempt to present the different viewpoints held by the many organizations that are committed to improving the quality of maternity care in the US. We are deeply saddened that the show did not take the opportunity to note that both CIMS and The National Perinatal Association respect the rights of women to choose home births and midwifery care, and that the respected Cochrane Collaboration recommends midwifery care because it results in excellent outcomes.
There is no evidence to support the ACOG position that hospital birth for low-risk women is safer than giving birth with midwives at home. What the research does show is that the routine use of medical interventions in childbirth without medical necessity can cause more harm than good, while also inflating the cost of childbirth. However, the current health system design offers little incentive for physicians and hospitals to improve access to maternity care practices that have been proven to maximize maternal and infant health.

“Birth is safest when midwives and doctors work together respectfully, communicate well, and when a transfer from home to hospital is needed, it is appropriately handled,” says Ruth Wilf, CNM, PhD, a member of the CIMS Leadership Team.

That is why the national health services of countries such as Britain, Ireland, Canada, and the Netherlands support home birth. In those countries, midwives are respected and integrated into the maternity care system. They work collaboratively with physicians in or out of the hospital, and they are not the target of modern day witch hunts. These countries have better outcomes for mothers and babies than the US.

Childbirth is the leading reason for admission to US hospitals, and hospitalization is the most costly health care component. Combined hospital charges for birthing women and newborns ($75,187,000,000 in 2004) far exceed charges for any other condition. In 2004, fully 27% of hospital charges to Medicaid and 16% of charges to private insurance were for birthing women and newborns, the most expensive conditions for both payers. The burden on public budgets, taxpayers and employers is considerable.

As US birth outcomes continue to worsen, it should come as no surprise to The Today Show that childbearing women are seeking alternatives to standard maternity care. After all, American women and babies are paying the highest price of all—their health—for these unnecessary interventions, which include increasing rates of elective inductions of labor and cesarean sections without medical indication.

To the detriment of childbearing families, the segment “The Perils of Midwifery” totally disregarded the evidence. Although the reporters acknowledged that research shows home birth for low-risk women is safe, that message was overshadowed by many negative messages, leaving viewers with a biased perception of midwifery care and home birth. CIMS makes these points not to promote the interests of any particular profession, but rather to raise a strong voice in support of maternity care practices that promote the health and well-being of mothers and babies.

One of the ten Institute of Medicine recommendations for improving health care is to provide consumers with evidence-based information in order to help them make informed decisions. The Institute recommends that decisions be made by consumers, not solely by health care providers. The Institute maintains that transparency and true choice are essential to improving health care. We remain hopeful that the medical community will soon recognize the rights of childbearing women when it comes to their choices in childbirth and will respect and support these choices in the interest of the best possible continuity and coordination of care for all.
We urge The Today Show to provide childbearing women with fair and accurate coverage of this important issue by giving equal time to midwives, public health professionals, researchers of evidence-based maternity care, and especially to parents who have made choices about different models of care and places of birth.

Sincerely,

Coalition for Improving Maternity Services

Academy of Certified Birth Educators
Alaska Birth Network
Alaska Family Health and Birth Center
American Association of Birth Centers
American College of Community Midwives
American College of Nurse-Midwives
Bay Area Birth Information
Birth Network of Santa Cruz County
Birth Works International
Birthing From Within, LLC
BirthNet
BirthNetwork National
BirthNetwork of Idaho Falls
BirthNetwork of NW Arkansas
Choices in Childbirth
Citizens for Midwifery
Doulas Association of Southern California
Evansville BirthNetwork
Harmony Birth & Family
Idaho Midwifery Council
Idahoans for Midwives
InJoy Birth and Parenting Education
International Childbirth Education Association
International MotherBaby Childbirth Organization
Island Families of Micronesia
Lamaze International
Madison Birth Center
Midwives Alliance of North America
Motherbaby International Film Festival
Nashville BirthNetwork
National Association of Certified Professional Midwives
North American Registry of Midwives
Ohana Island Care-Guam
Oklahoma BirthNetwork
Our Bodies Ourselves
Perinatal Education Associates, Inc.
Reading Birth & Women’s Center
Rochester Area Birth Network
Sage Femme
The Big Push for Midwives Campaign
The Tatia Oden French Memorial Foundation
Triangle Birth Network
Truckee Meadows BirthNetwork

About Us

The Coalition for Improving Maternity Services (CIMS) is a coalition of individuals and national organizations with concern for the care and wellbeing of mothers, babies, and families. Our mission is to promote a wellness model of maternity care that will improve birth outcomes and substantially reduce costs. The CIMS Mother-Friendly Childbirth Initiative is an evidence-based mother-, baby-, and family-friendly model of care which focuses on prevention and wellness as the alternatives to high-cost screening, diagnosis, and treatment programs.

References:

1. The Perils of Home Births, http://www.msnbc.msn.com/id/21134540/vp/32795933#32795933
2. Birth Can Safely Take Place at Home and in Birthing Centers, http://www.pubmedcentral.nih.gov/picrender.fcgi?artid=2409129&blobtype=pdf
3. Offers All Birthing Mothers Unrestricted Access to Birth Companions, Labor Support, Professional Midwifery Care, http://www.pubmedcentral.nih.gov/picrender.fcgi?artid=2409134&blobtype=pdf
4. ACOG Place of Birth Policies Limit Women’s Choices Without Justification and Contrary to the Evidence, http://childbirthconnection.com/article.asp?ClickedLink=790&ck=10465&area=27
5. Ratifiers and Endorsers of The Mother-Friendly Childbirth Initiative, http://www.motherfriendly.org/ratifiers.php
6. Choice of Birth Setting, http://www.nationalperinatal.org/advocacy/pdf/Choice-of-Birth-Setting.pdf
7. Position Statement on Midwifery, http://www.nationalperinatal.org/advocacy/pdf/Midwifery.pdf
8. Midwife-led versus other models of care for childbearing women, http://cochrane.org/reviews/en/ab004667.html
9. Evidence-Based Maternity Care: What It Is And What It Can Achieve, http://childbirthconnection.com/pdfs/evidence-based-maternity-care.pdf
10. Lamaze Healthy Birth Practices, http://www.lamaze.org/ChildbirthProfessionals/ResourcesforProfessionals/CarePracticePapers/tabid/90/Default.aspx
11. Millennium Development Goals Indicators, United Nations, http://mdgs.un.org/unsd/mdg/Data.aspx
12. National Vital Statistics System, Birth Data, http://www.cdc.gov/nchs/births.htm
13. Induction By Request, http://www.marchofdimes.com/prematurity/21239_20203.asp
14. Cesarean Birth By Request, http://www.marchofdimes.com/prematurity/21239_19673.asp
15. Crossing the Quality Chasm: A New Health System for the 21st Century, http://www.iom.edu/CMS/8089/5432.aspx
16. The Mother-Friendly Childbirth Initiative, http://www.motherfriendly.org/mfci.php

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Race, race, race

I have had some frustrating encounters regarding race lately. First of all, there was racist display at a store at the touristy beach near my house. No word back from the newspaper about my letter to the editor. I may just have to write to the Ramada chain, since it is right outside their lobby and many people may associate it with the hotel.

Then, I got into it on a post on Alas, a Blog. It was a great post on many aspects of medical research, birth and race. Two commenters decided to take a whack at criticizing the research by taking random guesses about it without actually, you know, reading it.

A similar thing happened on Our Bodies, Our Blog. A link to an essay lamenting the shameful disparities between women of color and white, non Latino women in our country when it comes to perinatal outcomes prompted a commenter to say “But what about the white women?!” in the form of a weakly attempted criticism of a lack of inclusion of Caucasian women. It was an unfounded criticism of selection bias, and the essay wasn’t a study, it just referred to some epidemiological data. (Although I must say the comment was confusing in general. But, the “what about the white women?” part was crystal clear.)

These are two different types of issues. The first is the kind of situation that Jay Smooth so eloquently talks about here:

Someone, an individual, is doing something racist like putting up that display. This is what most people think of as classic racism. It’s also what many people would think may cause an ugly scene if someone wanted to talk about it. I took a quick photo and scampered out of that store.

However, the second and third example bug me on a different level. OK, maybe RonF on Alas has a history of making similar racism apologist arguments, as a commenter on here suggested. But why did the other commenter claim they were reluctantly jumping in to point out something they just had to correct me on, when they obviously didn’t have any actually knowledge about research or statistical analysis, and the point was just a random guess? Why did the commenter on Our Bodies, Our Blog feel the need to cry wolf about selection bias when the original post was talking about institutional racism and its effect on maternal and neonatal outcomes, not calling her a racist?

I am a pre-doctoral research fellow who researches birth. I am taking a Masters of Public Health class that involves analysis of the flaws of public health research studies with an M.D./Ph.D. who has been a reviewer for the CDC and worked for the government for decades conducting research and making public health decisions based on research. I am not trying to pull rank here. I am just saying it makes me really twitchy when people use baseless random hypothetical criticisms of research to justify denying the effects of racism. One of the most compelling issues for me when it comes to racism is the scary, overwhelming evidence of the pervasive negative health effects of institutional racism. (I could link to endless research here, so let’s just link to this and this. Their bibliographies offer a nice starting point if you’re hungry for more.)

There is a difference between the two situations. Obviously, I believe in calling out the former: blatant slurs or images or props that are symbols of racism.

But, the other is just as bad. Denying the very real effects of sometimes very subtle institutional and societal racism is just as bad, if not worse. The first study I link to above has this to say about denying institutional racism (emphasis mine):

Institutional racism occurs when seemingly innocuous policies and practices result in the disproportionate harm to particular race/ethnic groups. Institutional racism doesn’t require intent but is inherent in its outcome.13 Personal or individualized racism refers to personal prejudice resulting from negative attitudes and/or beliefs about a particular racial group’s motivations, abilities and intentions.14 It too does not require intent and as Jones states12 can be an act of either commission or omission. Internalized racism occurs when members of the stigmatized group accept or internalize the negative messages and stereotypes regarding their race/ethnic group that are perpetuated in society.12 This form of racism affects how one perceives himself/herself, including his or her self-worth and influences acceptance/tolerance of racially biased treatment or maltreatment by others.

Racism persists in American society because beliefs and attitudes that are not blatantly racist but result in racist behavior or outcomes are often not perceived to be racist. As Parks states, “racism thrives on denial“.15

People identify with these institutions. I am going to be a white obstetrician. Trust me, I am identifying with the people delivering the health care that is failing these women. It’s OK to have high standards. It’s OK to acknowledge where we are failing. It’s OK to admit that there are groups of people that many of us don’t belong to that have it worse than us in some ways. It is hard to discuss for some people, because they cannot admit that they have privilege. So they will make up imaginary flaws in statistical research to desperately deny there is institutional racism.

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IRB ups and downs

So, my research project got approved by expedited review yesterday by a representative of our Institutional Review Board (IRB). I am fond of this particular reviewer. He is an M.D./J.D., which is impressive in itself. He has a bronze star. He fought in Vietnam. He was a sheriff. He was a state legislator. He was a head and neck surgeon. He ran the correctional medical system in Florida for a while. Now he’s a professor at our school on many surgical topics, on Medical Ethics (he wasn’t the one who I had issues with) and on Medical Jurisprudence. I like to joke around that he’s training to be an astronaut next.

Well, he read through my IRB application. Since my project is a simple survey with no compromising or legally sensitive questions of physicians, who are not a vulnerable population, it qualified for an expedited review. But, the reviewer warned me that even though the IRB committee should not override his approval, it was still a possibility. I got hints of political undercurrents in his explanation.

Well, apparently they were warranted. I got an email telling me to not perform my study on any human subjects yet! I need to go talk to the chairman of the IRB, since my mentor is on the IRB and is one of my coinvestigators. Even though she isn’t the one who performed the expedited review. Even though the same situation is true for the other research fellow (my fellow fellow), who was approved last week by the same reviewer performing a similar expedited review. So, I am going to keep my head low, and forward the information on to the reviewer and my mentor and see what happens.

I don’t anticipate there will be any major problems in getting my study approved, since it really is a low risk study with a focus well within the normal boundaries of medical academic research. I think this is the typical kind of static one encounters when dealing with anything with the term “institutional” right in the name.

So, I’m treading water. I did take all of the suggestions on my questionnaire that were offered, and I want to thank everyone for their time and good ideas. I think my questionnaire was unquestionably improved. I will post an updated version soon.

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I write letters, racism style

obama displayI wrote a letter to the editor of my local newspaper. (Click to embiggen the picture)

It went a little something like this:

Jimmy Carter was right; there is confident, overt racism in much of the
opposition to Obama. It’s not just in isolated enclaves or in the Deep
South. I was using an ATM at a shop called “Sticks and Stones” in the
Oceanwalk Mall at the Ramada Inn in Hollywood Beach. The proprietor has a
display in a small enclave right inside the doorway, across from the ATM. I
attached a picture that I took with my iPhone. It has a cardboard cutout of
Obama, a stuffed baboon, and a book on Wild Chimapanzees.

I was disgusted, not only because this shop owner felt so confident in his
racism that he would put up a display like that, but also because there are
so many people who apologize for and deny similar situations and incidents.

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Reply rurned post, pet peeve style

I get really annoyed when someone posts about some research, like this great post on Alas, a Blog on race and low birth weight, among other things, and someone who has no clue about research says “oh, but what about (insert obvious confounder that was obviously controlled for by the researchers here). Therefore, this study I didn’t even read must be total BS!”.

Some racism apologist commenter (RonF) decided to say that a study on the influence on racism on low birth weight is based on perceived racism, not real racism, and besides, he’d really like to see some research on poverty and low birth weight because that’s totally the real and only association with low birth weight.

Here is my reply:

Thanks for a great post.

Ron, you know, researchers who get published in major publications actually have to analyze their data for obvious confounders. (That’s a fancy statistics term for other variables that may be responsible for the outcome, like poverty instead of race being associated with low birth weight). I am sorry if I sound sarcastic, but this is a pet peeve of mine.

In fact, these same researchers wrote another entire study about poverty, race and low birth weight. You said you’d really like to see research on that topic. Do you actually believe you are the first person to consider this connection, and that you wouldn’t be able to find it? Or do you mean you’d like someone else to look it up for you, and in the meantime you’d just like to muse about the harms of racism being faked in published research by whiny black mothers who are mistakenly perceiving nonexistent racism and researchers with guilt and poor analysis skills?

It’s really frustrating when someone hasn’t bothered to read any of the abundant research that shows that race is an independent risk factor (independent from income and social economic status) for all sorts of health care outcomes, including low birth weight, but feels qualified to say the outcomes are incorrect and they have a much better theory, based on seeing no data and no research.

A simple search on the authors if you were trying to read the study before criticizing it, or on the topic of race, poverty and low birth weight before hypothesizing about it would find this:

Women’s Lifelong Exposure to Neighborhood Poverty and Low Birth Weight: A Population-Based Study

Here is the abstract:

Objective To determine whether women’s lifelong residential environment is associated with infant low birth weight. Methods We performed race-specific stratified and multivariate binomial regression analyses on an Illinois vital record dataset of non-Latino White and African-American infants (1989–1991) and their mothers (1956–1975) with appended United States census income information. Results Non-Latino White women (N = 267) with a lifelong residence in low-income neighborhoods had a low birth weight (< 2,500 g) incidence of 10.1% vs. 5.1% for White women (N = 10,647) with a lifelong residence in high-income neighborhoods; RR = 2.0 (1.4–2.9). African-American women (N = 18,297) with a lifelong residence in low-income neighborhoods had a low birth weight incidence of 17% vs. 11.7% for African-American women (N = 546) with a lifelong residence in high-income areas; RR = 1.5 (1.2–1.8). The adjusted population attributable risk (PAR) percent of LBW for lifelong residence in low-income neighborhoods was 1.6% for non-Latino White and 23.6% for African-American women. Conclusions Non-Latino White and African-American women’s lifelong residence in low-income neighborhoods is a risk factor for LBW; however, African-Americans experience a greater public health burden from this phenomenon.

Translation: African-American women who have lived in high-income neighborhoods had worse birth weight outcomes than white women who lived in low income neighborhoods.

There has been plenty of research that simply being a minority in this country is enough to affect you in many significant ways. It doesn’t matter if someone on a website hypothetically believes minorities have ever experienced “real” racism to make the measurable effects of racism true.

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Edited with an update. The fool continues to defend institutional racism by grasping at straws in his effort to criticize the study, which he STILL HASN’T READ. Laughingly, he thinks there is a problem with the N (the number of subjects in the study.) I was forwarded research by a classmate yesterday of a gyn medical device that one of our professors is a fan of yesterday. The largest study had an N smaller than 30. The study I link to above? TENS OF THOUSANDS. Apparently this dipshit thinks researchers are supposed to misrepresent what happens in real life (like, more African American women live in persistent poverty in this sample, and lots more of them have low birth weight (LBW) infants) to make the numbers match exactly between groups (and therefore…prove nothing?) Then, Mr. Concern Troll says it is all well and good to talk about the lofty goals of eliminating racism, which he is not denying (except that he is) but realistically, what are we supposed to do about this?

Here is my reply:

RonF, you need to read more than an abstract to know what was controlled for. Also, in a multivariate analysis in which the researchers look for many risk factors, as this was, researchers may not even choose to publish risk factors that did not have clinical significance.

And, a disparity in the N numbers is not a problem with research, especially if one of the groups is a minority and is naturally present in lower numbers. In fact, the N numbers are NOT that disparate in this study, and just guessing that is true does not make it true. In fact, they clearly prove a higher prevalence of LBW in African Americans.

It’s amusing in a sick way, because the N is one of the strongest parts of this study. I am having a hard time having this discussion with you and not totally calling you out as a rabble rouser grasping at straws to apologize for and diminish racism.

If you want to discuss the fine points of statistical analysis, um, read a whole study first, and then take a biostats class.

What is important is the power of your N number. And, the power of this study is impressive. If you knew anything about research, or even read the full text of any of these studies, you would know that.

What else must be done? Well, first of all, we have to get ignorant white men to stop denying facts about the extent of the problem on websites so we can have a productive conversation about this.
*******

Edited again to add:

Someone came on to defend RonF, albeit she claims it is a reluctant defense. She also didn’t bother to read the original research or the other study by the authors I linked to, but thinks she is qualified to comment on their flaws. She criticizes the N and the “statistical analysis” of the original qualitative study. Here is my answer:

The statistical rigor I was referring to was of the quantitative research done by the same authors, which I link to in my very first post and from which I pasted the abstract. There is only one “N” in the qualitative interview, since there is only one group of subjects, so I assume RonF was also referring to the quantitative study when he claimed that there was a “disparity” between numbers in multiple groups.

You don’t control for confounders or variables in a qualitative study with interviews. It is not appropriate, for obvious reasons, other than in your subject selection. The qualitative research was done with a typical number of subjects for qualitative research, a small group, and is not set to the same “rigor” standards as quantitative research.

In other words, there is absolutely no statistic analysis in a qualitative study, so criticizing a qualitative study for its statistical analysis when there isn’t any, is, well, a sign you have no idea what you’re talking about. In fact, a qualitative study that tries to assign quantitative values to open ended interview answers is seriously flawed and should be criticized for even attempting statistical analysis, since the study method is not suited for statistical analysis.

Qualitative research is usually open ended interviews with a small group of subjects to get more nuanced information about complicated, multi factorial topics. Like racism, which is obviously sadly lacking in nuance in much of the discussions of the topic. It is a common technique in health issues that also involve power balance questions, such as pregnancy and birth.

As for “racial discrimination”, I am really missing the finer point here. If you show me flaws in so called statistical analysis of all of their background literature review, including the excellent quantitative study with the huge N, that point to simply being African American as being a risk factor, one that is greater than genetics or poverty or whatever other risk factors are examined, then we can talk.

It seems to me, yet again, as you are linking to the layperson’s news article that discusses the scientific article, that you, like RonF, have not bothered to read any of the original research. I would really think twice about discussing “rigor” when that is your method of looking into a study’s quality.

I know I am coming across as really pissy, and I apologize, but I would never go on a website and pretend to criticize something as technical as statistical analysis of medical research if I didn’t have a pretty good idea that I had an accurate criticism. It would be like me going on a website on engineering and start telling people their blueprints are messed up because I read some other person’s paragraph about their blueprints. It’s more complicated than all of that, and this armchair amateur hypothetical musing is one of my pet peeves.

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The KALI questionnaire

This is the survey on labor interventions that will be my research project for my fellowship. Many of these are taken from other studies, position statements, practice bulletins, and meta-analysis conclusions. There is also a demographics and practice description portion of the questionnaire, which I did not include in this post. The target population will be practicing ob/gyns in a certain geographical area. Please let me know what you think.

Keep in mind that the question are supposed to be mixed to prevent bias based on how they ordered are in conjunction with other questions on the same topic, and they are mixed in positive and negative phrasing, and mixed in whether they are talking about practice, knowledge, attitudes or future intentions.

Here it is:

Please rate the following statements about obstetrics as accurately as possible. All questions will have this scale available for you to choose to most appropriate response:

1. Strongly agree
2. Agree
3. Neither agree nor disagree
4. Disagree
5. Strongly disagree

1. Restricting maternal intake of all nutrition by mouth during labor prevents serious adverse maternal outcomes.

2. Elective cesarean section should not be performed on a woman desiring several children.

3. Doulas (i.e. private labor coaches, or trained labor companions) improve maternal and newborn outcomes.

4. Episiotomy should be avoided if at all possible.

5. The use of continuous external fetal monitoring (EFM) increases the risk for cesarean delivery.

6. In the absence of maternal and fetal medical indications, vaginal deliveries confer more risk than cesarean deliveries.

7. Insurance should not reimburse use of doulas for labor and delivery.

8. I employ episiotomy routinely, because it is easier to repair than lacerations that result when an episiotomy is not used.

9. Fear of liability claims limit the options I present to my obstetrical patients.

10. Use of upright (non lithotomy) positions during the pushing and birth has no positive impact on perinatal outcomes.

11. The use of continuous EFM does not result in a reduction of cerebral palsy.

12. All women in labor should have an amniotomy (i.e. artificial rupture of membranes or AROM ) if they present with their membranes intact.

13. Few women would choose to have a vaginal birth after cesarean (VBAC) if they knew the consequences of uterine rupture.

14. I regularly employ episiotomy to shorten the second stage of labor and delivery.

15. Low risk labor patients should be offered the option of intermittent fetal heart rate monitoring in labor.

16. Elective cesarean section should only be performed after accurately determining 39 weeks of gestation.

17. The hospitals in which I attend births do not have sufficient staff to support intermittent fetal heart rate monitoring during labor.

18. Most patients attempting vaginal delivery benefit from oxytocin (Pitocin) augmentation of their labor.

19. I regularly employ episiotomy to prevent pelvic floor relaxation.

20. If you or your partner were pregnant for the first time, would you choose / recommend an elective cesarean delivery for yourself or your partner in the absence of any medical or obstetrical indication?

21. I have made changes to my practice because of the risk or fear of liability claims.

22. Childbirth is only normal in retrospect.

23. I regularly employ episiotomy to prevent perineal trauma.

24. The use of continuous EFM reduces perinatal mortality.

25. I encourage my patients to try alternative or upright positions during the pushing stage.

26. Physicians should initiate discussion of elective cesarean delivery as part of routine prenatal care.

27. I refer patients who want to attempt a trial of labor after a prior cesarean delivery to another practitioner.

28. Women should have the right to refuse an episiotomy.

29. I encourage patients to use a doula for their labor and delivery.

30. I feel that it is a woman’s right to elect to have a caesarean section even if there are no clear maternal or fetal indications.

31. There is high interobserver and intraobserver variability in interpretation of fetal heart rate tracing.

32. Hospital standards of care or policies sometimes get in the way of optimal management of individual patients.

33. I discuss the risks and benefits of episiotomies with my patients prior to delivery.

34. Routine artificial rupture of membranes (AROM) increases the risk of cesarean delivery.

35. Most women with one previous cesarean delivery with a low-transverse incision should be counseled about VBAC and offered a trial of labor.

36. Episiotomies increase the risk of third and fourth degree tears.

37. Clinical guidelines are useful tools for me in daily clinical practice.

38. Clinical guidelines are overly rigid and difficult to adapt to individual patients.

How often do you consult the following sources regarding obstetrical practice?

1= Never 2= Rarely 3 = Sometimes 4 = Often 5 = Always

1. ACOG Practice Bulletins
2. ACOG Committee Opinions
3. Obstetrics and Gynecology Journals (e.g. the Green Journal, the Grey Journal)
4. Cochrane Database
5. Electronic evidence-based services (e.g. Epocrates, UptoDate)
6. Books and/or textbooks
7. Professional conferences
8. Physicians in my practice
9. Physicians in my local community
10. Physicians I trained with in residency
11. Physicians I consider experts in the field
12. Other ____________________________

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Personhood bill in Florida

The radical anti-choice lobby has brought a so-called “Personhood” Bill to Florida. This would try to extend human rights to conceptus “at the beginning of biological development”.

If the physiology of pregnancy (like, there is no biological test for conception, and the vast majority of fertilized eggs do not implant, and no major medical organization defines that as the beginning of life) and the major ethical concerns with this don’t already sway you to sign this petition against the Personhood amendment in Florida, maybe this will:

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