Rixa has an excellent post up at her blog Stand and Deliver. She wrote about yet another obstetrics practice that is refusing to allow their clients to bring a doula, but is forcing them to sign a birth plan that says episiotomies may be used to prevent tears, among other evidence free ridiculousness.
What is even worse, two commenters defend this position, with unsubstantiated statements that assume that doulas are somehow dangerous, and these interventions are what ensure a healthy baby and healthy mom. One of these commenters claims to be a physician!
I wrote a reply:
Argh, this is so frustrating. Rixa, excellent post. I have some points in response to the actions of the Kingsdale Gynecologic Group, their birth plan, and the replies from “B” and the anonymous physician.
First, I’d like to point out that using a doula as they currently exist, with their current level of training and lack of licensure, has been rated as one of the most effective labor interventions for improving birth outcomes, based on excellent evidence. Here is the article by Berghella et al on Evidence Based Labor and Delivery Management that covers this intervention (along with many of the other interventions mentioned in the original post and the comment thread.) It states that having a doula is one of the most effective interventions available. How a physician could criticize this practice, which has an evidence rating of A, but defends analgesia, which has no positive effect on birth outcomes, is beyond me.
Doulas are not immune from liability. They can be sued just like any other individual. They do not provide medical treatment, so do not need to carry malpractice insurance. I think that is a bizarre idea. Nurses, including labor nurses, do not carry malpractice insurance. Why should doulas, who simply provide emotional support and information?
Also, how does it make medico-legal sense to deny women the choice of an evidence based intervention that improves outcomes (doulas), but support interventions that are shown by copious evidence to be harmful (episiotomy) or are non-evidence based and have even been questioned in recent editorials in ACOG’s Green Journal (depriving oral nutrition during labor)? Who needs to “get their priorities straight”? If “[t]he important thing is a safe and healthy delivery for both the infant and mother”, why not support the evidence based interventions like doulas, especially if it is what the woman wants, instead of insisting on harmful or questionable interventions? (Sources: JAMA’s Outcomes of routine episiotomy: a systematic review, which says episiotomy is more harmful than helpful, and should be “avoided at all costs”, and the Cochrane Review on Restricting oral fluid and food intake during labour, which concludes that “women should be free to eat and drink in labour, or not, as they wish.”)
And, how are ALL birth plans nonsense? With obstetricians refusing access to doulas, encouraging episiotomies, and restricting food and fluids, what are we classifying as nonsense? How about when obstetricians induce women who are 39 weeks gestational age (if they wait that long!), with no medical indication for induction, and have a low Bishop’s score? Then, they are put in the hospital, told they cannot ingest anything but ice chips, and their induction takes several days (due to the unfavorable cervix). Let’s say they have only lactated ringer’s solution in their IV, so they are not receiving any glucose for 48 hours. If the woman has no glucose, her blood sugar will plummet and she may get an altered mental state. That, plus pitocin augmentation, may lead to the frequent request for analgesia in patients that originally intend to try to avoid unnecessary medication. I wish this was uncommon. Are you really suggesting that a birth plan is nonsense here? Or the current standard of care? The Listening to Mothers survey indicates that these interventions are all too common.
I find it really disheartening that people, including a physician and a gynecologic group, will defend harmful and baseless interventions, simply to bolster a paternalistic model of care, instead of an evidence based practice such as hiring a doula.