Reply turned post, I reject your reality! style

OK for Mythbusters, not for health advocacy

I have been participating in the Facebook group VBAC Facts Community for a little while now, ever since meeting the wonderful community founder Jen Kamel at the VBAC Summit last year. It is a supportive group, and Jen runs the site well with the help of moderators and a good foundation of evidence.

This group, at times, can be a good example at how distorted internet microcosms can make uncommon opinions seem much more accepted. In this community, using midwives and having a home birth comes up in almost every thread, it seems. I have seen using a midwife treated like a hipster fashion choice recently on Jezebel and other sites. However, midwife attended births still make up less than 10% of births in the United States. Hardly a huge trend. Midwives are underutilized here compared to many other countries with better maternity and neonatal outcomes than we have. But, depending on your source, midwife attended and/or out of hospital births may seem to be common or even a glorified standard. However, in the circles I travel in my daily grind as a physician, choosing out of hospital birth is fringe, reckless behavior.

So, it’s like entering a portal in another world when I participate on a thread in the VBAC group, and the commenters have a heated argument about epidurals, and many participants did not get one. On our labor and delivery floor, it is a rare to never occurrence that someone wouldn’t get one. Because out of hospital birth, choosing not to have an epidural even if you deliver in a hospital, and VBAC are such rarely available, rarely supported choices, I am usually on the side of defending people who advocate for such choices as underdogs, not the holier than thou bullies that many paint them to be.

It’s also a really strange place for me to be in when I gently try to correct medical inaccuracies, and I sometimes get painted as a brainwashed surgico-technocrat physician. I correct fellow physicians when they say all VBAC is dangerous. For real, even my attending physicians. I also have corrected fellow physicians who state episiotomies are preferable to tearing. But, I also correct women in the VBAC group who state things that are medically inaccurate, like that worsening hypertension in pregnancy is not serious and does not warrant an induction or cesarean unless the fetus is in distress, or that leaving the hospital midlabor is a reasonable course of action if one is faced with unwanted interventions (in one particular thread in which I was painted as a typical brainwashed South Florida cesarean happy physician, the intervention that warranted attempting to leave midlabor was continuous external monitoring).

These are not the majority opinions even in this microcosm. But, they are often aggressively defended positions. One that has come up repeatedly, recently, is an insistence that tubal ligation is linked to “post tubal ligation syndrome”, which leads, according to some posters, to the majority of women needing hormonal interventions to control heavy menstrual bleeding, and / or hysterectomy to control intractable post procedure pain.

I think these communities are incredibly valuable, not just because of the sharing of strictly evidence based facts. I think a lot, even the majority of the benefit is the support and stories from other women who have experienced similar choices and situations, or share similar priorities and stories. I think in the VBAC community, and in pregnancy and mothering as a whole, there is so much value to support, empathy and stories. However, there is a big difference between asnwering an original poster who says “what was your experience with tubal ligation?” and someone answering “geez, I had pain and menstrual irregularity after” and an original poster saying “I am planning on a tubal ligation” and a slew of commenters saying “NO! This is PROVEN to cause a, b and c horrible side effects to the majority of women who get it!” and usually a touch of “Have you considered Natural Family Planning?”

Sigh.

I have reluctantly been the heavy in many of these conversations, but it is triggering a bunch of pet peeves of mine. 1. Medical inaccuracies masquerading as facts. 2. Ignoring the expressed informed choice and priorities of the woman posting and substituting the commenters’ own priorities and (often faulty or anecdotal at best) information

So, this coalesced into a recent thread, and here is the reply I posted:

“This is the best article I have found on post tubal ligation syndrome:

http://www.nejm.org/doi/full/10.1056/nejm200012073432303#t=articleResults

It is a good article because it compares women who have had tubals with women whose partners have had vasectomies. It is also a good study because it has an N number of over 9,000 subjects who had the tubal ligation. It is also authored by a group from the Centers of Disease Control (the CDC). There is no economic conflict, and the New England Journal of Medicine is about as high quality a publication as it gets. Here are the results:

“The original concern about sterilization involved the risk of heavy bleeding and intermenstrual bleeding, but we found no evidence of either problem. Furthermore, we found that women who underwent sterilization were likely to have decreases in the amount of bleeding, the number of days of bleeding, and the amount of menstrual pain and an increase in cycle irregularity. We know of no biologic explanation for these changes, most of which were beneficial, in women after tubal ligation.”

I don’t think there’s any evidence of widespread issues post tubal. In fact, this high quality study seems to indicate the opposite. I am not saying a tubal ligation is right for everybody, but I do think it is inappropriate for every thread on here in which tubal ligation is mentioned to devolve into a pronouncement that tubals are PROVEN to cause these problems, often with alarming figures like half of all women who get tubals end up with hysterectomies, etc.

As I have also said, it is inappropriate at best and borderline bullying at worst for women on here to disregard a woman’s stated informed choice and substitute their own priorities, especially if they are coming from a place of anecdote and questionable information. It is also inappropriate to ignore a woman’s expressed desire for a highly effective form of birth control (like a tubal or IUD) and to tell them to try NFP* instead, when it has a typical failure rate much higher. I hold a woman’s right to make informed decisions about her reproduction to include highly effective birth control if desired as well as safe options for trial of labor after cesarean.

I am not a surgery lovin’ medicoindustrial defending brainwashed doctor. I trained as a midwife, had both of my kids unmedicated** with midwives, and have never used hormonal birth control myself due to my own priorities and reasons. I support low intervention birth and VBAC for two main reasons which may seem contradictory, but are wonderfully not. 1. It’s a woman-centered approach and 2. It is an evidence based approach. Bullying women into avoiding their choice of safe contraception is neither.”

*I love this site for comparison of contraceptive methods: http://www.birth-control-comparison.info/
**The first labor was augmented with pitocin without my informed consent, but was otherwise unmedicated

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8 Comments

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8 responses to “Reply turned post, I reject your reality! style

  1. cileag

    It is always interesting to hear other health care providers experiences. I work as a labor nurse in a busy urban Midwest labor and delivery unit with a large midwife practice, and of course, a large OB practice. Our epidural rate is approx. 60%. I chose to have my first child at home but my second was an induction for cholestasis that was followed by a seizure, which ultimately was diagnosed as primary adult onset seizure disorder (although treated as eclampsia in the hospital). In general, I think we have a very mother and baby friendly hospital— with water birth available and staff comfortable with intermittent auscultation and wireless telemetry units available. And yet, it is still frustrating when patients or family members or doulas come armed for dispute or fearful of any intervention at all. It is sometimes so exhausting walking the line between offering low intervention care and also being evidence based on both side, I.e. giving accurate info on appropriate inductions and vbac statistics.

  2. MomTFH, keep on keeping on! Your pet peeves are my pet peeves! You can’t cherry pick the science and only use it when it proves your point. I strongly dislike when anyone does that! Women have a right to all the information and to make a decision that feels good to them. And that decision might just be different then what feels good to someone else. More power to them! Keep standing up for the science, to the masses both trained as doctors and to those who are not! We ALL appreciate you!

  3. YES!!! Among certain group (or perhaps certain subsets of certain groups), there seems to be this assumption that any sort of medical procedure/intervention/training/etc. = BAD, and then anything that’s “natural” (which is already a problematic term) = GOOD. What’s striking is that these very same groups often criticize physicians for using sweeping generalizations and mis-reading or mis-interpreting what current evidence says about best birth practices.

    That’s a long-winded way of saying “thank you” for adding your voice to the mix.

  4. And this is why we appreciate the presence of Hilary’s experience and knowledge in the VBAC Facts Community as well as other like-minded care providers.

  5. OMDG

    Have you thought about getting a master’s in clinical epi when you’re done with residency?

    I also hate when people cherry pick science, recite bad science as gospel (and oh boy there is a lot of that out there), and use personal experience as evidence.

    Personally, I don’t think I would have a VBAC by choice, but that’s because the reason for my first c-section was arrest of descent (baby’s head >95th percentile, my pelvis… is not), and the success rate is lower for women like me. Also, I have no interest.

    • MomTFH

      I love epi! Love it. I am still musing over what to do when I’m done.

      VBAC success rates are based on several factors. Having a non-repeating indication certainly helps.

      But, the main issue with VBAC is for it be an option for good candidates who do want to attempt.

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