Damn damn damn

I’ve grown accustomed….no, just kidding.

No, it’s worse than that. I made 200 copies of my survey, my mentor distributed about 30 copies, and one was filled out by an obstetrician already.

Then, I figured out that there was a major error. A stupid, little, major error that invalidates any results from those copies. I have the scale on the first page of the obstetrics questions set as strongly agree = 1 to strongly disagree = 5. On pages 2 and 3, it is set to strongly disagree = 1 to strongly agree = 5.

Damn.

So, the silver lining is: I wanted to do it as an online survey anyway. We discovered this while converting it to an online survey. So, hopefully only one physician wasted his time filling it out. And, may be ineligible because of retest bias issues.

I hope I don’t look like too much of a dork to these physicians now.

Grumble grumble grumble.

Newest, bestest KALI questionnaire, annotated

Here is the annotated survey, with an attempt at dividing the questions into domains and scaling them. So, the domains so far are K=Knowledge, A=Attitude, B= Barrier, P=Practice pattern, and Y=Autonomy of the patient. If a question says “Reversed” after it, then it is phrased in the reverse or negative compared to the evidence cited.

Sorry about the messed up formatting; I swear it looks OK in Word. I will try to edit it later today when I have more time.

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. You are:
[1] Male [2] Female

2. Age:
[1] 20 – 29 [5] 60 – 69
[2] 30 – 39 [6] 70 – 79
[3] 40 – 49 [7] 80 – 89
[4] 50 – 59 [8] 90 or older

3. Do you have children?
[1] Yes [2] No

4. Ethnicity:
[1] Hispanic or Latino
[2] Haitian
[3] Neither Hispanic nor Haitian

5. Race (choose as many as apply):
[1] White / Caucasian [4] Native Hawaiian / Pacific Islander
[2] African American / Black [5] Native American Indian /Alaskan
[3] Asian or Asian American [6] Other:_______________________

6. How would you describe the location of your ob/gyn residency?
[1] University
[2] University affiliated
[3] Community
[4] Other: ____________________________

7. Year of residency completion _____________

8. Which of the following most accurately describes your practice type?
[1] Public hospital
[2] Community health center
[3] University based practice
[4] Private practice
If private –
[a] Large partnership (four or more partners)
[b] Small partnership (two or three partners)
[c] Solo practice
[5] Military / government
[6] Other:____________________________________________

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

10. Which of the following most accurately describes your personal practice scope?
[1] General obstetrics and gynecology
[2] General gynecology only
[3] Obstetrics only
[4] Laborist
[5] Maternal Fetal Medicine
[6] Reproductive Endocrinologist
[7] Gynecologic Oncology
[8] Urogynecology
[9] Other: ______________________________

11. Which of the following most accurately describes your current malpractice coverage?
[1] None / I “go bare”
[2] I pay for individual malpractice insurance
[3] My practice pays my malpractice premiums
[4] I am an employee of an institution that pays my malpractice premiums
[5] I am an employee of an organization or institution that provides legal defense but
not malpractice insurance
[6] 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.(K)1 Reversed

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

3. _____Doulas (i.e. private labor coaches, or trained labor companions) improve maternal and newborn outcomes.(K)3, 4

4. _____Episiotomy should be avoided if at all possible. (K, A, P)1, 5

5. _____The use of continuous external fetal monitoring (EFM) increases the risk for cesarean delivery. (K)6

6. _____In the absence of maternal and fetal medical indications, vaginal deliveries confer more risk than cesarean deliveries. (K)7, 8 Reversed

7. _____Insurance should not reimburse use of doulas for labor and delivery.9 (A,B)Reversed

8. _____I employ episiotomy routinely, because it is easier to repair than lacerations that result when an episiotomy is not used. (K,P,B) 3, 10 Reversed

9. _____Fear of liability claims limit the options I present to my obstetrical patients.(B,Y,P)11, 12 Reversed

10. _____Liability insurance company policies forbid me from performing VBACs. (B,P) Reversed

11. _____Use of upright (non lithotomy) positions during the pushing and birth has no positive impact on perinatal outcomes. (K)1, 13 Reversed

12. _____The use of continuous EFM does not result in a reduction of cerebral palsy. (K)6

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

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. (A,P,K)1, 14 Reversed
14. _____Few women would choose to have a vaginal birth after cesarean (VBAC) if they knew the consequences of uterine rupture.(Y,A,K)3 Reversed

15. _____I regularly employ episiotomy to shorten the second stage of labor and delivery. (B,P,A)15 Reversed

16. _____Low risk labor patients should be offered the option of intermittent fetal heart rate monitoring in labor.(K,A,Y)6

17. _____Elective cesarean section should only be performed after accurately determining 39 weeks of gestation.(K)2, 8

18. _____Mediolateral episiotomies result in less postpartum pain than median episiotomies. (K)16, 17 Reversed
19. _____Prior to an induction, patients should be counseled about the possible need for reinduction or cesarean delivery.(K,Y)18

20. _____The hospitals in which I attend births do not have sufficient staff to support intermittent fetal heart rate monitoring during labor.(B)6 Reversed

21. _____Most patients attempting vaginal delivery benefit from oxytocin (Pitocin) augmentation of their labor.(K,P)1, 19Reversed

22. _____I regularly employ episiotomy to prevent pelvic floor relaxation.(K,P) 3, 5, 16, 17Reversed
23. _____Hospital policies forbid me from performing VBACs.(B)20-22Reversed

24. _____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.(A)7, 23, 24 Reversed
25. ¬_____I have made changes to my practice because of the risk or fear of liability claims. (B)11, 12 Reversed
26. _____Childbirth is only normal in retrospect.(A)3Reversed

27. _____Clinical guidelines are useful tools for me in daily clinical practice.(A,P)25

28. _____I regularly employ episiotomy to prevent perineal trauma.(K,P)5, 15, 17Reversed

29. _____The use of continuous EFM reduces perinatal mortality.(K)6Reversed
[1] Strongly agree [2] Agree [3] Neither agree nor disagree [4] Disagree [5] Strongly disagree

30. _____ Labor induction for non-medical indications (psychosocial or logistical) should only be attempted after establishing a gestational age of 39 weeks. (K,P)18

31. _____I encourage my patients to try alternative or upright positions during the pushing stage.(A,B,P)1, 13, 26, 27

32. _____Physicians should initiate discussion of elective cesarean delivery as part of routine prenatal care. (A,P)28 Reversed

33. _____I refer patients who want to attempt a trial of labor after a prior cesarean delivery to another practitioner.(B,P,K)29, 30 Reversed

34. _____Women should have the right to refuse an episiotomy.(Y)12, 29, 31, 32

35. _____I recommend that most patients use a doula for their labor and delivery.(A,P,K)1, 9

36. _____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.(A)3, 28 Reversed

37. _____There is high interobserver and intraobserver variability in interpretation of fetal heart rate tracing.(K)6

38. _____Hospital standards of care or policies sometimes get in the way of optimal management of individual patients.(B)33 Reversed

39. _____I discuss the risks and benefits of episiotomies with my patients prior to delivery.(Y)31, 32

40. _____Routine artificial rupture of membranes (AROM) increases the risk of cesarean delivery. (K)1, 14

41. _____If a patient asks if she could use a doula for her delivery, I would encourage her.(Y,A)1, 4
42. _____ Time and scheduling pressures affect the way I manage labor and delivery.(B) Reversed
43. _____Most women with one previous cesarean delivery with a low-transverse incision should be counseled about VBAC and offered a trial of labor.(K)34

44. _____Episiotomies increase the risk of third and fourth degree tears.(K)5, 16, 17

45. _____Clinical guidelines are overly rigid and difficult to adapt to individual patients.(B)25 Reversed

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 sources: ______________________________________________________

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

Thank you for your time and participation!

Reference List

(1) Berghella V, Baxter JK, Chauhan SP. Evidence-based labor and delivery management. Am J Obstet Gynecol 2008 November;199(5):445-54.
(2) ACOG Committee Opinion No. 394, December 2007. Cesarean delivery on maternal request. Obstet Gynecol 2007 December;110(6):1501.
(3) Reime B, Klein MC, Kelly A et al. Do maternity care provider groups have different attitudes towards birth? BJOG 2004 December;111(12):1388-93.
(4) Hodnett ED, Gates S, Hofmeyr GJ, Sakala C. Continuous support for women during childbirth. Cochrane Database Syst Rev 2007;(3):CD003766.
(5) Hartmann K, Viswanathan M, Palmieri R, Gartlehner G, Thorp J, Jr., Lohr KN. Outcomes of routine episiotomy: a systematic review. JAMA 2005 May 4;293(17):2141-8.
(6) ACOG Practice Bulletin. Intrapartum Fetal Heart Rate Monitoring: Nomenclature, Interpretation, and General Management Principles. Obstet Gynecol 9 A.D. July.
(7) Gunnervik C, Sydsjo G, Sydsjo A, Selling KE, Josefsson A. Attitudes towards cesarean section in a nationwide sample of obstetricians and gynecologists. Acta Obstet Gynecol Scand 2008;87(4):438-44.
(8) NIH State-of-the-Science Conference Statement on cesarean delivery on maternal request. NIH Consens State Sci Statements 2006 March 27;23(1):1-29.
(9) Green J, Amis D, Hotelling BA. Care practice #3: continuous labor support. J Perinat Educ 2007;16(3):25-8.
(10) Klein MC, Kaczorowski J, Robbins JM, Gauthier RJ, Jorgensen SH, Joshi AK. Physicians’ beliefs and behaviour during a randomized controlled trial of episiotomy: consequences for women in their care. CMAJ 1995 September 15;153(6):769-79.
(11) Hyer R. ACOG 2009: Liability Fears May Be Linked to Rise in Cesarean Rates. MedScape Medical News 2009 May 9.
(12) Florida Liability Lowdown. American College of Obstetricians and Gynecologists; 2009 Aug.
(13) Gupta JK, Hofmeyr GJ. Position for women during second stage of labour. Cochrane Database Syst Rev 2004;(1):CD002006.
(14) Smyth RM, Alldred SK, Markham C. Amniotomy for shortening spontaneous labour. Cochrane Database Syst Rev 2007;(4):CD006167.
(15) Low LK, Seng JS, Murtland TL, Oakley D. Clinician-specific episiotomy rates: impact on perineal outcomes. J Midwifery Womens Health 2000 March;45(2):87-93.
(16) ACOG Practice Bulletin. Episiotomy. Clinical Management Guidelines for Obstetrician-Gynecologists. Number 71, April 2006. Obstet Gynecol 2006 April;107(4):957-62.
(17) Carroli G, Mignini L. Episiotomy for vaginal birth. Cochrane Database Syst Rev 2009;(1):CD000081.
(18) ACOG Practice Bulletin No. 107: Induction of Labor. Obstet Gynecol 2009 August;114(2 Pt 1):386-97.
(19) Wei SQ, Luo ZC, Xu H, Fraser WD. The effect of early oxytocin augmentation in labor: a meta-analysis. Obstet Gynecol 2009 September;114(3):641-9.
(20) Lyerly AD, Mitchell LM, Armstrong EM et al. Risks, values, and decision making surrounding pregnancy. Obstet Gynecol 2007 April;109(4):979-84.
(21) Roberts RG, Deutchman M, King VJ, Fryer GE, Miyoshi TJ. Changing policies on vaginal birth after cesarean: impact on access. Birth 2007 December;34(4):316-22.
(22) Coleman VH, Erickson K, Schulkin J, Zinberg S, Sachs BP. Vaginal birth after cesarean delivery: practice patterns of obstetrician-gynecologists. J Reprod Med 2005 April;50(4):261-6.
(23) Bettes BA, Coleman VH, Zinberg S et al. Cesarean delivery on maternal request: obstetrician-gynecologists’ knowledge, perception, and practice patterns. Obstet Gynecol 2007 January;109(1):57-66.
(24) Wu JM, Hundley AF, Visco AG. Elective primary cesarean delivery: attitudes of urogynecology and maternal-fetal medicine specialists. Obstet Gynecol 2005 February;105(2):301-6.
(25) Vinker S, Nakar S, Rosenberg E, Bero-Aloni T, Kitai E. Attitudes of Israeli family physicians toward clinical guidelines. Arch Fam Med 2000 September;9(9):835-40.
(26) Difranco JT, Romano AM, Keen R. Care Practice #5: Spontaneous Pushing in Upright or Gravity-Neutral Positions. J Perinat Educ 2007;16(3):35-8.
(27) Gilder K, Mayberry LJ, Gennaro S, Clemmens D. Maternal positioning in labor with epidural analgesia. Results from a multi-site survey. AWHONN Lifelines 2002 February;6(1):40-5.
(28) ACOG Committee Opinion No. 395. Surgery and patient choice. Obstet Gynecol 2008 January;111(1):243-7.
(29) Fenwick J, Gamble J, Hauck Y. Reframing birth: a consequence of cesarean section. J Adv Nurs 2006 October;56(2):121-30.
(30) Goodall KE, McVittie C, Magill M. Birth choice following primary Caesarean section: mothers’ perceptions of the influence of health professionals on decision-making. Journal of Reproductive and Infant Psychology 2009 February;27(1):4-14.
(31) Simpson KR, Thorman KE. Obstetric “conveniences”: elective induction of labor, cesarean birth on demand, and other potentially unnecessary interventions. J Perinat Neonatal Nurs 2005 April;19(2):134-44.
(32) Helewa ME. Episiotomy and severe perineal trauma. Of science and fiction. CMAJ 1997 March 15;156(6):811-3.
(33) Block J. Pushed: The Painful Truth About Childbirth and Modern Maternity Care. New York: Da Capo Press; 2007.
(34) ACOG Practice Bulletin #54: vaginal birth after previous cesarean. Obstet Gynecol 2004 July;104(1):203-12.

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!

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.

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.

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 ____________________________

Research progress

I have been hard at work coming up with my questionnaire for my survey of local obstetricians and gynecologists about birth interventions. I am planning on posting the completed survey when I am finished, unless there are some concerns with that. I don’t think any of my subjects read my blog, so I doubt it will add any bias to the results. Besides, it’s not like these issues are new to these practitioners. It’s not like a blog post with questions about these interventions will suddenly make them relevant to their practice.

The wording of some of the questions is based on the survey in this study by Reime et al, and many others are taken directly from ACOG position statements, USPSTF evidence based conclusions, and the like.

So far the interventions I will definitely be asking about are:

Doulas (Continuous Labor Support)
Episiotomy
Vaginal Birth After Cesarean (VBAC) and Trial of Labor (TOL) after Cesarean Section
Cesearean Section Without Medical Indication (CWMI) and Cesarean Delivery on Maternal Request (CDMR)
Upright Pushing Stage
Continuous External Fetal Monitoring (EFM) vs Intermittent
Restricting Oral Nutrition During Labor (Solid and/or Liquid)

Interventions that may be included in the survey include:

Estimation of Fetal Weight (EFW) (based on 3rd trimester ultrasound)
Routine Early Amniotomy (Artificial Rupture of Membranes (AROM) )
Oxytocin (Pitocin) Augmentation of Labor

I would like to ask about all of them. We need to make sure the survey is brief enough for the subjects to want to take the time to finish, and I plan on asking multiple questions on each intervention. I think the first list is more directly a balance of evidence based medicine and patient autonomy (which is a much more difficult concept to define than I thought, but that’s a whole ‘nother post). The second list is more practices that lead to the cascade of interventions. For example, oxytocin augmentation usually necessitates continuous EFM.

I didn’t include out of hospital births, even though I think they are an important and relevant point. I wanted to only cover practices under direct control of the obstetrician. That is also why I didn’t include skin to skin contact after delivery. I think that may more depend on the hospital policies and nursing / pediatrics team.

I just need to come up with a few questions about how they keep up with the current standards of care, and then it’s time to whittle it down.

Then, I need to work on my justification. I need to talk about patient empowerment and autonomy without sounding like too much of a militant feminist. Heh, wish me luck with that.

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!

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.

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