Conversations after the survey

I have been doing a recruitment push for obstetricians to take my survey. I originally planned on doing qualitative interviews with some of the physicians, and using them in the discussion. Although I eventually decided to only do quantitative research, I still get to have some really thought provoking conversations with the physicians once they complete the survey.

I have gotten great responses from the obstetricians. Of course, I wait until they have completed it to discuss it, and let them lead the conversation. I don’t want them to think I have enormously strong opinions in any direction. I discuss methodology, survey validation, and sometimes share anecdotes, but don’t make any soap box speeches.

One physician took the survey today, and said he thought it showed a slant toward midwifery. I found this interesting, since there is no mention of midwifery in any of the questions. I asked him what he meant, and he said that the questions about upright positioning and doulas were the sorts of things that midwives would do.

Now don’t get me wrong, I loved talking to this physician. He showed a genuine concern for autonomy of the patient, was not at all interested in forcing procedures on anyone, and thought “we should be humans first and physicians second” when dealing with patients, especially during pregnancy. I told him “In the same vein, we should treat our pregnant patients like mothers first and patients second.” He said he thought the ideal model for maternity care was the cooperative midwifery based model of care in the United Kingdom.

He also said the most important thing to consider is: the mother is leaving and taking her baby home, regardless of the mode of delivery. She lives with the the birth the rest of her life, not the obstetrician. He said yes, you can get sued for 18 years, but he knows, as do most obstetricians, that most cases don’t end up winning if you didn’t screw up. He thinks the litigation issue is an exaggerated scare story, and he has been sued. He said it’s about doing a job well, not an investigation of the essence of your soul, which is how he sees many obstetricians react.

But, as I complained in this post, those exact practices, upright positioning and using a doula, are more evidence based, according to the non-midwifery based United States Preventative Services Task Force, than the other interventions I ask about (continuous external fetal monitoring, routine artificial rupture of membranes in active labor, episiotomy, etc). But, somehow, simply including them in this survey, with no mention of the word midwife once, makes my survey somehow biased toward midwifery.

He didn’t mention the word “bias”, but another physician did mention the word “bias” after taking the study. (The responses have been overwhelmingly positive. Neither of these two physicians found the amount of alleged bias very problematic). I just think it’s strange. The USPSTF, Cochrane reviews, etc. examined the body of literature and then concluded there are evidence based benefits of doulas and upright positioning, but even asking about that seems questionable to some practitioners.

Well, I was setting out to examine the disconnect between evidence and knowledge and attitudes of practitioners. I guess I have found it.


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29 responses to “Conversations after the survey

  1. It’s incredibly biased, because it has very little to do with real scientific evidence and is all about the faux “evidence” created by midwifery advocates. For example, there’s little evidence that gravity (upright positioning) has any impact on labor.

    It’s also biased in that it assumes the mother is Western, white, reasonably well off and wants a particular “birth experience.” Moreover, it assumes that the health of mother and baby can be taken for granted, and that no measures to prevent complications are needed.

    You should think carefully about the responses you have gotten. You don’t realize how truly biased you are. It comes through loud and clear in a simple survey.

  2. “The rest of my survey is taken from ACOG position statements and validated surveys.”

    The bias is that the survey is all about atmospherics and has virtually nothing to do with discipline of obstetrics. It’s like sending out a survey about the wallpaper, chairs and magazines in an obstetrician’s office, neglecting the major principles of obstetrics and then wondering why obstetricians consider it biased.

    “Please tell me how the USPSTF evidence review that I link to above, that rates upright positioning with a grade of “A” and evidence support quality “good”, is faux evidence.”

    If you are a medical student, I really shouldn’t have to explain this to you.

    1. Always read what you are citing. The following comes from your reference:

    “The review was limited to the healthy woman, carrying a singleton healthy gestation in vertex presentation, entering spontaneous labor at term (37-41 6/7 weeks)… We excluded specific aspects,
    such as induction, intrapartum fetal monitoring (and related interventions) other than admission tests, group B streptococcus prophylaxis, meconium, anesthesia, operative delivery, multiple
    gestations, early neonatal care, and management
    of the third stage of labor because each of these topics would require an extensive review beyond the previously described scope of this article. We
    also excluded management aspects related to cesarean delivery, because the technical aspects have been covered before.”

    So the review is limited to a very small slice of the obstetric population and does not apply to all populations.

    2. The grading of the evidence refers, not to the quality of the evidence, but to whether a particular policy or procedure should be “offered.” Moreover, this recommendation involves only the second stage. There is no evidence offered about upright positioning in the first stage. From the study:

    “The upright position in the second stage is associated in women without epidural anesthesia with a 4-minute shorter interval to delivery”

    In other words, it makes virtually no difference. That’s hardly a ringing endorsement of upright position in labor.

    3. Cherry picking. According to the USPSTF, there is insufficient evidence to recommend homebirth and the USPSTF believes that birth center birth should not be offered because it increases the risk of perinatal mortality. Do you agree with those positions?

    • MomTFH

      Please define “atmospherics” and tell me how the most common routine interventions of labor and delivery are not the practice of obstetrics. What IS the practice of obstetrics if it is not the most common procedures and interventions ordered or performed by obstetricians?

      You are not making any sense. Why would JAMA print a metaanalysis of all of the research on episiotomy if it wasn’t important to the practice of obstetrics? Why would the Cochrane Database and ACOG and the USPSTF do these reviews? We’re not talking about wearing your own pajamas in the hospital.

      You would probably have called twilight sleep and routine episioproctotomy and high forcep delivery “atmospherics”. You can’t invent categories for research to suit your point of view. Notice the response you got from CMAJ.

      I notice no links supporting your claims. No equivalent meta-analysis with different conclusions. Typical.

      I have also read what I have cited.

      They grade the evidence to say whether the practice or procedure should be offered (e.g. the rating of “A” for doulas and upright positions during pushing, which means they should be recommended to ALL eligible patients) and they ALSO give a quality of evidence rating, and both of those got the highest evidence rating of “good”.

      BOTH ratings are in every USPSTF evidence review. They were all over the chart about the included interventions AND on the key explaining the rating system.

      Not only did you not read the study I have linked to in every one of these useless arguments I have had with you about my study, but you have apparently not read any other USPSTF evidence review.

      You, again, look like a fool. And you are the one slinging the amateur “you didn’t read the evidence!” nonsense, again, to someone who you know has read it, and obviously knows it much better than you do.

      Dr. Amy, I have lost my patience. I don’t like answering every mudslinging bit of nonsense you can come up with to insult me. I am sorry, I can’t think of a more appropriate analogy but: you constantly take every bit of monkey poop you can pull out of your butt and throw it to see what sticks. I am not the zookeeper, Dr. Amy. My blog is not your monkey cage.

      As Dr. Fogelson has said on his blog, “these types of comments not in the best interest in dialogue.”

      I will delete any further comments that stink with disrespect and random, unfounded accusations that are clearly more true of you than me. I am not a willing accomplice in your desperate attempts to stay relevant in the online obstetrics community. As usual, I still have not banned you, since I believe people should be given the chance to rise up to intelligent commenting. Sounds like what you were asking for on SBM, no?

      • >> As Dr. Fogelson has said on his blog, “these types of comments not in the best interest in dialogue.”

        I believe the comment I was responding to was “Dr Nick FAIL”, which isn’t quite the same.

        • MomTFH

          I was assuming when you said “these types”, you meant rude insults that were not related to constructive debate. I am sorry if you don’t agree that Dr. Amy’s behavior on this thread and others on my blog fall under that category.

          I try to maintain a respectful dialogue on here and elsewhere on the internet. I find this very difficult when subjected to the kind of off base hostile non-arguments that Dr. Amy has presented on this thread and in the past.

  3. “I don’t like answering every mudslinging bit of nonsense you can come up with to insult me. ”

    Hilary, this is nothing compared to what is awaiting you in clinical rotations and residency. Do you want to be an obstetrician or don’t you? If you want to be an obstetrician, others will hold you to a far higher standard than what passes for “evidence” among homebirth advocates and midwives.

    Don’t believe me? Ask other obstetricians. I realize that you think you know much more than we do, but that’s a very dangerous attitude to have. You have zero clinical experience, minimal understanding of scientific evidence, and a very clear bias. You should be trying to learn from others who have much more experience, instead of desperately searching for reasons to ignore them and claiming that you are being “insulted.”

    Didn’t you just write an entire post complaining that other doctors pointed out your bias and you don’t understand why? I explained it to you. You can choose to ignore it and you can blame the messenger, but you’d be better served by giving it some serious thought.

    • MomTFH

      I have extensive clinical experience. Again, insulting me with nonsense.

      My mentors, the IRB, and the physicians who took my survey do NOT think I have excessive bias. One doctor said questions on the only interventions that the UPSPTF rated with an A made him think of midwives. That shows a disconnect in obstetrics. I am sorry if I am biased toward evidence.

      If anything, I am biased toward exactly what the scientific evidence says, and many obstetricians are biased toward the typical standard of care.

      I am learning from others. Lots. I have long, thought provoking, RESPECTFUL conversations with many practitioners who are practicing today, unlike you. All of them have told me it is an interesting and wonderful study, even the ones who took the time to go through it question by question with me. All want copies of the published results. All think I have a good shot at getting published.

      I can’t believe I am leaving up this last comment.

      This is not your litter box. I do not write this blog to be insulted by you. You explained nothing.

      You ignored all of my valid points about your inaccurate claims. You are pretending like you didn’t “explain” USPSTF grading and rating to me, when I was completely right and you were completely wrong.

      Have you no shame? Do you think everyone else is ignoring your ridiculousness?

      I am the one who as a “minimal understanding” of scientific evidence?? Have you read this comment section?

      • You are right; looking over my comments, the tone is not respectful. Therefore, I owe you an apology and I do apologize.

        I stand by the content, however. The survey exhibits a bias by emphasizing process over outcome.

        • MomTFH

          Thank you for the apology.

          My survey isn’t on outcomes. It’s on attitudes and barriers toward implementing evidence based medicine. It is based on research on outcomes. And, that’s not the definition of bias in a study. Not every study focuses on outcomes. And, studies on outcomes can be biased.

          • MomTFH

            And, to be honest, considering the obvious errors and mischaracterizations earlier in the comment thread, even ignoring your tone, it is hard to take advice from you on research seriously.

  4. Stephen Thomas

    I like reading Hilary’s blogs a lot more when she doesn’t have to spend time making that Dr. Amy person look stupid. Dr. Amy is a complete and total waste of your time Hilary. Please delete all of her rants from now on. Every time I read her stuff I feel like I’ve been hit with the stupid stick. Sorry for the angst but I am tired of her and her desire to be taken seriously.

    • MomTFH

      I like writing and interacting in the blogosphere, especially on my blog, when she doesn’t rear her ugliness, also.

      She has ruined many a good comment thread.

  5. mommymichael

    I’ve kept in touch with my high risk ob’s (Yale) via e-mail, and I’d love to share this with them.

    Is there information I can give them about the survey when I e-mail them?

    Don’t feel like you have to engage trolls in conversation. Do what SBM did and kick her out. Her arguments are (most times) nothing but ignorant tripe.

    • MomTFH


      This is the link to the most current survey. I have an online link, but they couldn’t fill it out, since they don’t fit the inclusion criteria for this particular data collection. (Local obstetricians only). I can also email you a word version, if you’d like.

  6. Agree with previous commenters. Don’t feed the troll. She’s a neglected child who lashes out with bad behaviour in a desperate plea for any kind of attention. Even though you are in the right, trying to shut her up with anything other than silence is a fool’s battle, because she will cling to every word you offer her so she can keep running her mouth. Delete, delete, delete. It’s the only way to go.

  7. mommymichael

    did you mean to send me to Jill’s Unnecesarean page with that link? lol

    • mommymichael

      damn broken links!

      • MomTFH

        LOL! Whoops. Was it the Kanye picture? Because that’s too Freudian. I sent that to someone else.

        THIS should be the word version of my survey, cut and pasted into my blog.

        • mommymichael

          Yup, the Kanye picture. ::snicker::

          Also, where would you like them to send the answers?

          • MomTFH

            Why don’t I email you? And then I can give you the word copy, and they can email me or you back if they want.

            Ahh, well, I was tempted to link to that picture, anyway. I guess I did by accident.

  8. mommymichael

    excellent. mrsrobertson at comfortbirth dot com

  9. Hilary –

    I read through the survey and I didn’t really feel that it was particularly biased. It did address a number of ideas that are not part of mainstream obstetrical thought, and I can see why some OBs may think of midwifery from those questions.

    If there is bias to he had, I think it would come from the inconsistency in the way the questions are asked. For example, some questions are positive statements and some are negative statements. These differences will create some bias towards one side or another.

    As for the IRB and whether or not they think it is biased, this is not really what IRBs do, or at least not what they are supposed to do. IRBs are there to protect patients from unethical or inappropriate research. They are not there to police your study design, and in fact they should not do so. It is up to the investigator to write a good study.

    • MomTFH

      Thanks for taking the time to write. I originally had them all phrased as positive statements, and was told to reverse some of them by my mentors. I think it makes them more awkward. I tried to distribute the reversals of statements among the practices evenly.

      It is a list of interventions that varies in certain ways. All of the interventions were evaluated by the USPSTF evidence based review of labor and delivery. They were selected from a longer list. One varying characteristic is how routine or typical the practice is. Another is how well rated the practice is by scientific consensus, which was primarily taken from ACOG practice bulletins and the USPSTF review. Another is how much the practice increases the autonomy of the physician, and another is how much it increases the autonomy of the patient (these last two concerns are not necessarily in conflict).

      I can see how my selection of interventions may look unusual to someone, if they are basing their reaction on current obstetric standards of care in most major hospitals. If one is based it on evidence based practice, one might wonder why I included episiotomy, except that it has a good body of evidence against it, not for it.

      It is obvious to anyone in the community that practice patterns are not based solely on evidence. This study is examining what attitudes and barriers underlie which interventions are preferred.

      • A great way of addressing the reversal of statements issue is to create many different surveys with different patterns of statement reversal. If the statements are not biased by their direction you should see similar numbers no matter which way they were asked.

        Another way is to have two different surveys, that are reversed from each other from each statement – each statement that is positive in one version is negative in the other. Then average the values you get from the two different studies.

        Either of these techniques is arguably better than asking just one direction, but pollster experts could be more definitive about it than me.

        • That is a brilliant idea. I would love to see how similar the results are if you decide to try it, Hilary.

          • MomTFH

            That makes a lot of sense. Great suggestions. I am doing some of the surveys online on surveygizmo. I think you may be able to shuffle questions, but that may just be the order. But, I could have more than one version.

            All thoughts for next time. I may try to validate this survey in different groups.

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