When the boat rocks, go with the flow

For those of you who don’t follow my life like a soap opera, let me explain. No, that would take too long. Let me sum up. (A race to see who names that butchered movie quote first).

I just got a predoctoral research fellowship at my medical school. I am taking a year off to do research, both my own research project and helping my mentors with their work. I had anticipated doing a randomized controlled trial (RCT) of doulas (trained labor attendants) in a population of women on Medicaid, which would be largely African American and Hispanic urban women. These women have dramatically worse birth outcomes than the rest of the population. My hope was to, eventually, encourage Medicaid to cover the cost of a doula.

Well, that plan had several obstacles. It would be very difficult to apply for funding, get awarded, conduct, analyze, write and submit an RCT of that magnitude in a year. Based on calculations, to have adequate power to claim any sort of confidence, I would need an intervention group of about 45. Paying for doulas and scheduling that many births would be a stupendous and annoying task.

To top it all off, there is already a great body of research supporting doulas. In fact, there is a 2007 Cochrane Review that concludes “All women should have support throughout labour and birth” based on the available research, and a United States Preventative Services Task Force evidence based review of labor and delivery in 2008 that gives continuous support by a doula a rating of “A”, which means “the USPSTF strongly recommends that clinicians provide [the service] to eligible patients. The USPSTF found good evidence that [the
service] improves important health outcomes and concludes that benefits substantially outweigh harms.” Only one other birth intervention got a rating of A, upright position in the pushing stage. Neither of those practices are standard of care.

However, some practices with weaker support of even recommendations against their use, such as denying food and water to laboring women and episiotomy, respectively, are routine and common during birth in the United States.

So, my wonderful mentors, who I am loving more and more every day, said that it sound to me like I would be working hard to contribute data that was already abundant. What I want to know is why there is a disconnect between evidence based clinical research and practice. Also, it seems that the same practices that are proven in literature but ignored in practice are the woman centered, autonomy encouraging practices, and the practices that disfigure and deprive women are the ones that persevere.

So, now I am going to do a study on attitudes on and barriers to incorporating certain practices into clinical obstetrics. I think I am going to compare those four practices: episiotomy, denial of food and water, continuous labor support by a doula, and upright positions in second stage. I want to examine perceptions of their evidence, confidence in the support of their effect on outcomes, and general attitudes toward each of the practices and evidence based medicine in general. I am going to write a questionnaire andsend it out to ob/gyns, probably ones in Florida, but we’ll see.

Cool? I think so.


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31 responses to “When the boat rocks, go with the flow

  1. This is great news. It did occur to me when you wrote about your research plans that there was already a great body of evidence on doulas. You should check out this paper – one of the interesting findings is that they were more successful at getting providers to adopt a new intervention in the name of quality improvement (prophylactic oxytocin) than abandon a practice that was already widespread (episiotomy)

    A behavioral intervention to improve obstetrical care

    • MomTFH

      Excellent. Thanks for that link. I have started a literature search and hadn’t come across that one yet. Perfect.

  2. Oh wow. This is terrific. While you’re at it, can you add continuous fetal monitoring to the list? That’s another area where the evidence against it is quite overwhelming, yet so many doctors insist on it. I imagine that fear of liability is one big reason. Then again, if you figure out how to get docs to stop doing routine episiotomies, your results might be transferable.

    Very cool project. I hope you’ll post more about it here as you get further into it.

  3. EFM definitely merits a look, I agree. Anyway I think your project sounds quite fun and interesting. A larger question–do you think that your end project will be able to change behavior at all?

  4. MomTFH

    Actually, I was considering doing continuous external fetal monitoring, especially since ACOG had a recent position statement against it, and the AHRQ does not particularly support it. And, I was considering including oxytocin augmentation of labor.

    I need to pick the right amount of interventions to ask about, and selected the original four because they were all in the USPSTF list. I definitely have not finalized the survey.

    • I kind of like your original four because, unlike EFM (which – *please* don’t get me wrong – is criminally overused), doing away with routine NPO and reducing the use of episiotomy do not require system-wide changes such as staffing changes, retraining staff, and getting buy-in from the risk managers, etc. They just require cultural/behavioral shifts (difficult enough). I think you might find that EFM is too special a case to lump in with other practices. My 2 cents, at least.

  5. You make me giddy. That might be more of a telltale sign of what makes me giddy in life than a commentary on your post.

  6. Sounds like a great start for an original research idea. I am currently doing a research study on the effects of infant massage on premature infants from 32-37 weeks gestation. There is already a lot of literature supporting infant massage, but not so much in the late preterm range.

    I would love to do a research project on recovering infants on mom’s chest instead of a radiant warmer for the first two (?) hours of life. I wanted to look at neonatal temperature regulation and breastfeeding success. What do you all think?

    • MomTFH

      Oh, RR, I think that would be a fantastic study. What infants? Full term, normal APGAR?

      • I think studying this in full term infants is another case (like continuous support) where evidence is ample, and the real question is why evidence is not being put into practice. If you focused on late preterm infants and were careful to look at previous studies and design your study in a way that fills in gaps in the evidence, it would be a real contribution.

        I’m really eager to see your infant massage research.

        • Thanks Amy,
          I will probably start out with a small QI project, but focusing on nurses attitudes toward recovering babies on mom’s chest is intriguing.
          The infant massage research is going a long, very slowly. As all research does. We hope to be done collecting data in two years.

  7. MM

    Princess Bride, of course!

  8. “Let me explain. No, that would take too long. Let me sum up.”

    Dang it, MM beat me to it!! But yeah, Inigo Montoya in Princess Bride.

  9. I am going to have to join your folowers. Any one who can quote the princess bride is worth reading!

  10. I like your research question. I have to say, my Docs rarely do epis and they only do NPO for women we think are going to the big room. We give clear liquids to women who have a epidural.

    Also you can push up right with an epidural in place. Have the woman put her hands on the top of the bed and her knees in the middle. Looks like yoga table top position. Then raise the head of the bed. Many folks find this comfortable to push in. I ask the Father to guard her leg so it wont fall off and I watch the other leg. I do have to let the epidural wear down a bit sometimes in order to do this. But I have had good luck with it.

    • In my hospital, women with epidurals are “prohibited” from getting into hands and knees as you describe because “it’s a patient safety issue.” It’s so arbitrary, and of course the woman doesn’t know if her hospital is one that encourages upright movement with epidurals or if she’ll be told to stay on her back once the epidural is in… Same with restricting food (“patient safety”).

      Do you know your doctors’ episiotomy rate? Even in hospitals where the rates have come down considerably in recent years, there is usually still room for improvement. The national rate in 2005 was 25% (primips and multips combined), according to Listening to Mothers. At the University of New Mexico Medical Center, where there is a multidisciplinary team of researchers studying best practice for reducing genital tract trauma, they have brought the episiotomy rate down to 1% across all providers (midwives, OBs, and FP docs).

    • MomTFH

      Pinky, I am pleased that your hospital and its docs seem to be incorporating evidence based practices in labor and delivery. I am not convinced that is the case around here. I saw a two inch midline episiotomy cut for a 36 weeker with no distress and only 20 minutes of pushing. My professor, the head of our ob gyn department at my medical school, told me he didn’t think a primip could deliver vaginally without tearing! (And even then, an episiotomy is not preferred.)

      I am going to ask about practices, not just attitudes. But, this will be self reported by the physicians (I am pretty sure I am only going to ask physicians, but may ask other involved personnel, we’ll see) and I am not sure how accurate the reporting will be. I may use something like Listening to Mothers to estimate prevalence of certain practices. I haven’t really examined their data, but from what I know, it isn’t exactly a scientific survey and probably isn’t divided by state.

  11. Amy’s argument against including EFM makes sense to me. Isolating the cultural/behavioral variables from the institutional barriers to change will make the project more feasible. And you definitely want to make sure you don’t end up with an unwieldy behemoth that you won’t be able to finish properly in the time allotted.

  12. love love love the new angle! thank you for doing this work!

  13. This is amazing! What a valuable study this will be. Thank you for this!

  14. Megan

    I love this idea and think you’ve honed in on a key issue – why isn’t evidence followed by change? Amy is right, sometimes like with EFM its because that change requires a lot of other changes (like staffing levels) that feel expensive or too much work. But deciding not to use the scalpel, or letting someone have a granola bar, or welcoming a doula into the room? CHEAP AND EASY!!

    I wonder if you want to do your survey in a state where the data on hospital intervention rates is collected in detail? I know they collect and publish this data in NY State for example but not in a lot of places, so don’t know if Florida is one. Anyway, then you could compare the survey responses you got from the OBs who practice at a hospital with high episiotomy rates and/or high c/s rates with the ones who practice at a hospital with low rates. And you don’t have to rely so much on self-reported data for the interventions.

  15. Love it!!!! I interviewed (but ultimately didn’t get) an internship with a non-profit that does a lot of international work and has its own research-to-practice department. It sounded so interesting – why doesn’t research get translated? (Why aren’t doulas part of the standard of care? I once heard someone say “if you could put doulas in an IV every woman would get one”).

    One thing I’d say for the upright positions is that I suspect the nurse piece of the equation a lot to do with it. In many hospitals I’ve worked in, pushing starts long before the doc or midwife comes in. The nurses get her started and coach her through the beginning stages; sometimes the provider comes in to check on how things are going and leaves again. Then when the woman is “close” the call goes out and the provider shows up to catch. The provider may be OK with other positions, but if they show up and she’s on her back, well then, she’s on her back and she must have wanted to be there. Active encouragement for everyone including nurses to use different labor positions could help. (Along with being creative even with epidurals, as others have noted).

    • As a fairly educated patient who is thinking hard about this very issue right now… I think you are right. It is really the nurse who determines what happens unless there is a doula or a very assertive coach in the room. We did not have a doula, and my husband isn’t the assertive type, so really the nurse made most of the decisions in our first delivery. I pushed for 4 hours and almost got sent for a c-section, when probably all that I needed was for someone to tell me to try a different position. Once they threatened a c-section, I summoned up the energy for a few big pushes- I suspect I would have been done already if I’d been in a better position. I was in the bed, with the back raised so that I was partially upright. I had an epidural, but had carefully not pushed the button to get more doses so that I could feel the urge to push (which I did). I also still had feeling in my legs. I could have used the SQUAT BAR that I just recently learned my hospital has and allows use of, even in cases where an epidural has been administered.

      I will say that the fact that the bed back was relatively upright was due to the nurse. She sat me right up when it was time to push.

      I am trying to coach my husband to be more assertive this time, because even though I’m a fairly assertive and educated patient… it is hard to do this when you’re busy dealing with contractions and pushing and all that.

      I can afford a doula. I just think it is silly that I have to find one just to make sure that someone suggests simple things like changing position.

      Thanks for the post- I stumbled on this while looking into options for delivery #2. Good luck with your research and here’s hoping that things actually start to change.

      (BTW, at my hospital, I was not given an episiotomy and I was allowed clear liquids, including broth. I was hooked up to the fetal monitor, but I fuzzily remember that this was because I was induced. They were happy to remove the monitor if I wanted to move around, which I did once or twice.)

  16. Megan

    Agree with Rebecca – it was my L&D nurse, not my OB, who pressured me to stay on my back during pushing when I specifically requested a more upright position. I tried to ask again, but was told “the baby can’t get past the public bone if you are too upright”, an apallingly ignorant statement that I was too busy pushing to try and argue with any more at the time. It is so hard to get out of laborland and engage. So, she believed she knew about what worked in pushing. And it was definitely HER beliefs that prevented an upright position from being used in my case. Can you include labor RNs in the survey? 🙂

    • MomTFH

      I am only going to research physicians. I think research into nurses and midwives is also very valid and necessary. However, I think making this a comparative study among different levels of health care practitioner would complicate and dilute this particular study.

      I have seen nurses and midwives arguing against upright positioning, insisting on coached pushing and valsalva pushing with counting, and other non evidence based and non woman centered practices. It is definitely a problem among health care practitioners of all levels.

  17. Roxanne Bamond

    How incredibly interesting and informative. I believe if doulas were provided post-birth there would be a rapid decline in post-partum depression also. I have worked clinically with women who have sufferred everything from a mild depression (baby blues) to a psychotic break post-birth triggerred by severe fatigue, confusion, and lonliness.

    • MomTFH

      I am interested in the long term benefits of doulas, and I completely agree with you that there is most probably a relationship with decreased PPD. I also would guess that in some populations, it may even enhance attachment and parenting skills in general.

  18. You are probably already aware of this study, but thought I’d mention it just in case you haven’t seen it yet. It might prove useful in your work.

    Acta Obstet Gynecol Scand. 2009;88(7):793-800. Audit and feedback: effects on professional obstetrical practice and healthcare outcomes in a university hospital.

    Costa ML, Cecatti JG, Milanez HM, Souza JP, Gülmezoglu M.
    Department of Obstetrics and Gynecology, University of Campinas, Brazil.

    OBJECTIVE: To assess the effects of audit and feedback on the practice of professionals in obstetrics. DESIGN: Before-after intervention study. SETTING: Obstetric unit of a university hospital in Brazil. METHODS: Before the intervention the prevalence rates of six evidence-based interventions were assessed. Seminars and workshops were administered, with the baseline results and also the main contents from systematic reviews on the topics studied, followed by detailed discussion of each topic, based on the Reproductive Health Library. After four months, the same practices were measured again and compared with the pre-intervention period. MAIN OUTCOME MEASURES: Selective episiotomy; continuous electronic fetal monitoring (EFM) during labor of low-risk pregnant women; antibiotic prophylaxis in cesarean section; active management of third stage of labor; routine induction of labor at 41 weeks for uncomplicated pregnancies; and continuous support for women during childbirth. RESULTS: Both periods showed a similar number and mode of deliveries. There was a significant reduction in episiotomies (RR = 0.84; 0.73-0.97) and an increase in continuous support for women during childbirth by a companion (RR = 1.42; 1.24-1.63). Although there was not a significant change in the use of oxytocin during the third stage of labor, there was a shift to the internationally recommended dosage of 10 IU (p<0.0001). There was no significant change in the use of antibiotic prophylaxis for cesarean section, continuous EFM, or routine induction of labor at 41 weeks for uncomplicated pregnancies. CONCLUSION: Audit and feedback can be used as a tool to improve obstetrical practice, at least for some interventions and when the medical staff is open and receptive to change.

    PMID: 19452325

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