Having babies...with science

July 3, 2014 12:50 PM

Evidence Based Birth is a blog with articles by Rebecca Dekker, a PhD nurse and faculty member at the University of Kentucky, summarizing the best medical evidence for childbirth practices. To start, check out the table summarizing the state of US maternity care to see the differences between current standard childbirth practices and evidence based care. The topics page lists the currently available articles.

Some highlights:

From Friedman’s Curve and Failure to Progress: A Leading Cause of Unplanned C-sections

The definition of a “normal” length of labor that is currently used by most healthcare providers is obsolete. . . . As long as mother and baby are both healthy, and as long as the length of labor does not qualify as an arrested labor, laboring women should be treated as if they are progressing normally. Women who are being medically induced should be given more time to complete the early phase of labor. . . . In the end, if more care providers begin using evidence-based definitions of labor arrest and failed induction, we will begin to see fewer of these diagnoses, and a simultaneous lowering of the Cesarean rate.

From The Evidence for Doulas

When continuous labor support was provided by a doula, women experienced a 31% decrease in the use of Pitocin, a 28% decrease in the risk of C-section, a 12% increase in the likelihood of a spontaneous vaginal birth, a 9% decrease in the use of any medications for pain relief, a 14% decrease in the risk of newborns being admitted to a special care nursery, and a 34% decrease in the risk of being dissatisfied with the birth experience.

From What is the Evidence for Induction or C-section for a Big Baby?

In summary, evidence does not support elective C-sections for all suspected big babies, especially among non-diabetic women. There have been no randomized, controlled trials testing this intervention. It is likely that for most non-diabetic women, the potential harms of an elective C-section for a big baby outweigh the potential benefits.

From The Evidence for Skin-to-Skin Care after a Cesarean

In summary, the research we have so far demonstrates that “very early” skin-to-skin care after a Cesarean is safe and beneficial. More research is needed on “immediate” skin-to-skin care , or care that is initiated in the operating room. The low rates of skin-to-skin after Cesarean and reports from researchers suggest that women and care providers may face multiple barriers to skin-to-skin care after Cesareans.

From What is the Evidence for Pushing Positions?

For women without an epidural, pushing in an upright position is associated with a decrease in the risk of episiotomies, vacuum and forceps-assisted deliveries, and fetal heart rate abnormalities, an increase in the risk of second-degree tears, and a possible increase in the risk of having blood loss more than 500 mL. Women with walking epidurals who push in upright positions may experience a shortened labor and pushing phase. More evidence is needed to evaluate pushing positions in women with traditional (non-walking) epidurals. The take home message is that women should push in any position they find comfortable– it is not necessary to be continuously upright or continuously lying down during the pushing phase.

posted by medusa (37 comments total)

On a personal note, this blog was enormously helpful to me when I was advised to induce for low amniotic fluid: I was able to read the article on induction for low fluid and learn that 91% of physicians believe that low fluid is a risk factor for poor outcomes (in otherwise healthy pregnancies), but the evidence says that induction for low fluid increases the risk of poor outcomes. Having that information was crucial for our decision making.
posted by medusa at 12:59 PM on July 3, 2014 [5 favorites]

It's frustrating to constantly be protecting yourself from your hospital's default decisions to do something that increases risk to either mother or child. We know people who avoid this by choosing premiere hospitals far away from their homes, and by choosing to have birth at home. Neither of these options are available to average people with average insurance who just want to have a healthy birth with emergency services available but truly standing by, rather than trying to put the birth on rails that fit neither the statistics nor the actual mother in the room.

We have a few children and we've learned that confidence and experience is the best way to help the birth go well. If the mother's doing all the work, the staff doesn't have much to do, and that really helps them to stay uncomfortable with intervening unnecessarily. Unfortunately, you can't really teach confidence and experience to new parents.
posted by michaelh at 12:59 PM on July 3, 2014

Except that the second link on the page when I visited claimed that the evidence was in support of moxibustion to address a breech birth. Soooooo... not really feeling the "evidence-based" here, honestly, not without a whole bunch more caveats attached to that kind of recommendation.
posted by Scattercat at 1:04 PM on July 3, 2014 [7 favorites]

9% decrease in the use of any medications for pain relief

If Dekker considers this a positive, she is essentially a natural childbirth partisan rather than a disinterested party concerned only with "evidence". Here's a counterpoint to Dekker's work (although I'll say that while I usually like the Skeptical OB, I found this post a little lacking.)
posted by Ralston McTodd at 1:06 PM on July 3, 2014 [13 favorites]

Except that the second link on the page when I visited claimed that the evidence was in support of moxibustion to address a breech birth. Soooooo... not really feeling the "evidence-based" here, honestly, not without a whole bunch more caveats attached to that kind of recommendation.

Have you, I dunno, read the actual post?
posted by Behemoth at 1:15 PM on July 3, 2014

For VBAC the table (irritatingly only presented in picture form) says US care is 7-9% while the evidence supports "Every eligible woman should be offered a VBAC; 74% will be successful."

The problem is that neither the table nor the footnotes define "eligible." If, say, 11% of women who have had a caesarean are eligible for VBAC, then at a 74% success rate that's pretty much smack in the middle of 7-9%. I suspect that the percentage of eligible women is considerably higher than that (or else why include it in the table), but without it the only number is 74%, which is a highly misleading comparison.
posted by jedicus at 1:17 PM on July 3, 2014 [1 favorite]

Have you, I dunno, read the actual post?

Yes. It said that one in eight women benefited from moxibustion and that this was therefore a potentially useful treatment. It did not suggest a plausible mechanism for why burning herbs next to your toes would cause your baby to magically rotate, and it didn't address the fact that this was probably more about the placebo effect (or perhaps whatever "posture control" is) than about the mystic Chinese herbs.

I won't argue that the placebo effect of acupuncture and moxibustion and so on can be very potent for those who believe in them, but if I'm looking for evidence-based medicine, I don't want to see that sort of thing conflated with actual treatment for serious conditions, even things like breech birth that don't have a lot of effective options available for them.
posted by Scattercat at 1:19 PM on July 3, 2014 [5 favorites]

I suspect that the percentage of eligible women is considerably higher than that (or else why include it in the table) . . .

Because you are deliberately publishing incomplete or misleading information in table form to grind your particular axe. Why else? The use of the term "evidence-based" as a proxy for "highly partisan" is particularly galling here.
posted by The Bellman at 1:22 PM on July 3, 2014 [3 favorites]

If Dekker considers [reduction in pain relief medications] a positive, she is essentially a natural childbirth partisan rather than a disinterested party concerned only with "evidence".

If the reduction is because doulas are telling women not to get pain medication, spreading unfounded scare stories about pain medication, or physically standing in front of the pain medication preventing anyone from giving it to the women in labour - sure.

If the reduction is because women with doulas feel that they are handling the pain better, I fail to see how that's not a good thing?

I am not at all opposed to pain relief in labour and had a fair amount of it myself, but if Random Woman A wants to try without it, I am all in favour of her having the kind of labour where she's getting that.
posted by Catseye at 1:31 PM on July 3, 2014 [1 favorite]

Yes. It said that one in eight women benefited from moxibustion and that this was therefore a potentially useful treatment. It did not suggest a plausible mechanism for why burning herbs next to your toes would cause your baby to magically rotate, and it didn't address the fact that this was probably more about the placebo effect (or perhaps whatever "posture control" is) than about the mystic Chinese herbs.

Oh, so the problem is that you are unclear on the distinction between "evidence" and "understanding." Got it.
posted by Behemoth at 1:34 PM on July 3, 2014

Evidence for efficacy usually means evidence that it works beyond the placebo effect not that it works because of the placebo effect! Otherwise you'd find evidence that almost anything is effective so long as the patient believes it might be.
posted by Justinian at 1:42 PM on July 3, 2014 [10 favorites]

A study was specifically cited in the full article that attempted to control for the placebo effect by using "fake" moxibustion: If you look at the exact numbers, 58% of the women who used moxibustion had a baby who was head-down at birth, compared to 43% of the fake moxibustion group and 45% of the usual care group.

Generally, support for "evidence-based" methods implies an open mind towards scientific evidence, even if you believe the actual techniques to be tainted with woo, or whatever else might have caused a summary dismissal of the entire blog because the word moxibustion appeared in it.
posted by Behemoth at 1:49 PM on July 3, 2014 [1 favorite]

just skimming this site and the Skeptical OB seems like everyone involved needs a little less axe grinding and a little more time spent on understanding statistical analysis.
posted by JPD at 1:50 PM on July 3, 2014 [1 favorite]

Dekker is a natural childbirth partisan. She's deeply cozy with the Lamaze people (the Science & Sensibility blog is them), ICAN (they claim to give info about cesarians; their conclusions are always that cesarians are evil), and the homebirth/midwifery community (aka, civilians who will come to your house and hope that there's no medical emergency while you give birth, because they can't manage one).

It's gross that she pretends to be unbiased.
posted by purpleclover at 2:09 PM on July 3, 2014 [11 favorites]

The problem is that since either of these thing might be true, it's not good evidence that avoiding pain relief = a positive outcome. If a woman feels pressured into avoiding pain medication she desperately wants, that is bad. If a woman feels supported and cared for and that lessens her subjective experience of pain, that is good.

The "Evidence for Doulas" post claims that it's the latter. It cites this article as evidence. (Interestingly, that article also presents evidence that having emotional support during labor doesn't just reduce pain and anxiety during labor; it can also improve womens' experiences during the first weeks of parenting, because having a better labor experience boosts their self-esteem.)
posted by fermion at 2:12 PM on July 3, 2014

Behemoth: I know how to look at studies, I just don't think the evidence supports what she says it supports. Or at least that she is being somewhat misleading. For example, from the meta-analyses she herself cites "Cephalic version by moxibustion for breech presentation":

Moxibustion was not found to reduce the number of non-cephalic presentations at birth compared with no treatment (P = 0.45)

So from the very studies she is using to support her position the biggest takeaway should be that you get the same number of breech births with moxibustion as with NO TREATMENT AT ALL. But she presents it as something else by looking at results compared to acupuncture or when moxibustion is combined with postural techniques which themselves are useful in reducing breech.
posted by Justinian at 2:15 PM on July 3, 2014 [6 favorites]

The problem is that since either of these thing might be true

Seriously? There's an epidemic of doulas physically preventing women from accessing pain relief? I admit a slight bias here in coming from a different system where doulas are pretty rare, but I was kind of taking it for granted that the presence of a doula wasn't affecting women's access to, or information about, pain relief at all.

Like I said, I had serious pain relief during labour myself and am certainly not ideologically opposed to it. But my ideal situation would have been to feel like I didn't need it at all.

(On reflection, this may actually have quite a bit to do with the differences in UK/US systems? We don't have a big natural-birth-vs.-hospital-birth divide here - our hospital births seem, by US standards, to be fairly out there in the natural birth direction in the first place.)
posted by Catseye at 2:21 PM on July 3, 2014 [1 favorite]

Also see Alice Dreger:

http://www.theatlantic.com/health/archive/2012/03/the-most-scientific-birth-is-often-the-least-technological-birth/254420/

And Chris Kresser:

http://chriskresser.com/naturalchildbirth
posted by zeek321 at 2:26 PM on July 3, 2014

As a health sciences researcher, I have to say that the more I read the site, the more perturbed I'm getting. The author's inferences are frequently as telling about the author as they are about the research cited. For example regarding prolonged labor she writes:

Women who had longer labors were more likely to have an infection of the uterus (23.5% vs. 12.5%)... The authors did not describe the number of vaginal exams women received, which was important, because a larger number of vaginal exams could have contributed to higher infection rates among the women with long labors.

Much as I agree that lots of "routine" obstetric practices are dubious, this sort of writing is far from a dispassionate reading of the evidence, subtle as it may be to a lay reader.
posted by drpynchon at 2:26 PM on July 3, 2014 [11 favorites]

Again, doulas aren't very common here so I may have misunderstood, but it is my impression that their role is to provide emotional support and not to provide/instruct/interfere with the actual medical care the woman's receiving, yes? They aren't actually medical professionals? Are they actually giving women medical advice?

At any rate, though, what Dekker actually says about doulas and pain relief is:

The third reason that doulas are effective is because doulas are a form of pain relief (Hofmeyr, 1991). With continuous support, women are less likely to request epidurals or pain medication (Hodnett, 2011). Why are women with doulas less likely to request pain medications? Well, women are less likely to request pain medications when they have a doula because they just don’t need an epidural as much! Women who have a doula are statistically more likely to feel less pain when a doula is present. Furthermore, by avoiding epidural anesthesia, women may avoid many medical interventions that often go along with an epidural, including Pitocin augmentation and continuous electronic fetal monitoring (Caton, Corry et al. 2002).

...which seems a long way from "anything that reduces the use of pain relief medication is fine, whatever the mechanism by which it's doing it."
posted by Catseye at 2:56 PM on July 3, 2014

it is my impression that their role is to provide emotional support and not to provide/instruct/interfere with the actual medical care the woman's receiving, yes? They aren't actually medical professionals? Are they actually giving women medical advice?

In theory, yes. In reality ... it's pretty blurry. If you'll forgive an anecdote: My friend's doula instructed her to stay home after her water broke, even though my friend tested positive for group B strep. (My friend followed her doctor's instructions to go to the hospital and get started on antibiotics to prevent illness in her newborn.) Doulas also tend to be affiliated with birth centers and homebirth midwives, and places where you can take Bradley classes and otherwise prepare for a childbirth without pain medication. (At least the ones I found when I was pregnant were. I live in crunchy Northern California.)
posted by purpleclover at 3:30 PM on July 3, 2014 [1 favorite]

She could not ask for pain medication because people who hire doulas tend to want to avoid pain medication.

This is it, right here. If a woman is even considering a doula, chances are she has already decided that she'd like to go without pain medication (or minimally, or only after careful consideration and attempts at non-drug pain relief options / attempts at other techniques to manage pain, etc). For some women, it's a reaction against the (what seems automatic) pressure to get an epidural.

I went without, but I was very hardcore about wanting things that way. In my mind at the time, I viewed getting an epidural as a kind of failure (for me, according to my own personal values for my own childbirthing experience).

It's important to look at what the mother's goals are, going in.
posted by marble at 4:54 PM on July 3, 2014

That's not necessarily true (re: people choosing doulas because they don't want pain medication). I agree, though, that you have to look at your goals. Example: it's helpful to look at resources such as Penny Simkin's Pain Medication Preference Scale. My local doula collective is big on this Evidence-Based Birth stuff, but just like the Skeptical OB and her appallingly biased stance against homebirths, it's a pick-and-choose situation.

I've been very pleased so far with my doula, who has added experience as a CNA in a local hospital and has been very clear that she supports my desire to Not Be A Martyr. And she has to be: I already know I've got to get hooked up to an IV for GBS purposes.

It's not easy to make sense of a lot of these things (my crunchy breastfeeding class REALLY glossed over any possibility of formula feeding after I have minor surgery), but you just have to do the research. How will you know if this stuff is even out there?
posted by Madamina at 7:33 PM on July 3, 2014

Of possible interest, from Ina May Gaskin's website: Maternal death in the United States - a problem solved or a problem ignored shows evidence of a pretty shocking gap in the data for maternal mortality in the US, which already ranks 40th in maternal safety.
posted by BinGregory at 8:36 PM on July 3, 2014

Having spent my time in the trenches of debates about "natural" childbirth, epidurals, other pain relief, freedom to move, waterbirth etc. etc., I have concluded that the root of much of the bitterest debate is that, at some point, a lot of people seem to feel that they have an inherent right to decide what is best for a pregnant/laboring woman, regardless of what she is experiencing or how she feels about it.

The reason there the Lamaze folks, blogs like this one, ICAN and other organizations exist is the appalling lack of respect and consideration women receive in a typical gestation/birth. Stats are brought forth on both sides about the "best" way to birth, but honestly, the issue is really a political one. Women should be able to choose from a range of options and approaches and not only not be judged, but be fully supported. But as a society, we are not comfortable with allowing the pregnant/birthing woman to make those choices. We don't think she is capable, or that she deserves, to birth whatever way she wants to. It gives her too much power and that makes a lot of people uncomfortable. Pregnant women are often infantilized and treated with condescension and occasional brutality.
posted by emjaybee at 10:01 PM on July 3, 2014 [6 favorites]

I don't much mind people doing whatever floats their personal boats 'an it harm none' etc., but yeah, if you call your site "evidence-based" and then say that evidence supports long-discredited non-scientific techniques, then I feel safe in regarding any other medical advice you might give as highly suspect. It might or might not be good advice in its own right, but you've proven that either you don't have a good filter for bad evidence or you're deliberately lying for reasons of your own, and whichever it is, I don't want to have to parse everything you say through additional veracity checks before I feel safe applying it.
posted by Scattercat at 1:07 AM on July 4, 2014 [3 favorites]

Catseye, you're missing my point. The reason(s) why women asked for less pain medication are very important, and so is their subjective experience of pain.

Eh? Okay, I'm not sure which one of us is missing the other's point here, but clearly there has been some serious breakdown in communication if you feel it necessary to tell me that women's reasons are important. That's the point I was making in the first place!

So, to attempt once again to clear this up: Of course women's reasons for not asking for pain relief, and women's experiences of pain, matter hugely in any discussion on this subject. I have never disagreed with this; it doesn't seem that Dekker has disagreed with this; and while I'm sure that there exist people who think that 'no pain relief' is the only goal and screw what we're putting women through to get there, I don't (thankfully) see any of them in this discussion.

On a related note, it's a shame there's nothing on Dekker's site on non-epidural pain relief drugs (due, I'm guessing, to them being relatively uncommon in the US), because it would have been interesting to read a little more about that. The hospital where I gave birth offered gas and air (Entonox), diamorphine, Remifentanil and epidurals. The diamorphine did nothing for me except make me even more exhausted, and the epidural was excellent in some ways and awful in others, but the gas and air was amazing.
posted by Catseye at 3:08 AM on July 4, 2014

Scattercat, you can't just dump acupuncture and moxibustion under the group of "long-discredited non-scientific techniques" when so many Cochrane meta-studies say "insufficient evidence, requires more research" before they can make a clear "this does work" versus a "this doesn't work" conclusion.

Also, since the mechanism by which acupuncture is supposed to work hasn't been determined yet by science, one can't effectively control for this variable between treatment and control groups.

So no, it's not long-discredited. People are still trying to figure it out.

However, I do agree with you that posting the moxibustion article as evidence fails to meet the standard most people expect of "evidence-based care."
posted by kuroikenshi at 2:49 PM on July 4, 2014

You're assuming that there is a mechanism. The most rational explanation is that science hasn't determined the mechanism because there isn't one beyond placebo effect.
posted by Justinian at 4:38 PM on July 4, 2014 [2 favorites]

the homebirth/midwifery community (aka, civilians who will come to your house and hope that there's no medical emergency while you give birth, because they can't manage one).

A midwife is not a "civilian" in the way you seem to be disparaging them. A midwife is a trained medical professional with extensive clinical training. The national health services in the UK, Ireland, Canada, and several Scandinavian countries will dispatch midwives to deliver care in planned home births. Studies show that midwife-attended births, including home births, are safe. Here are the results of a 2009 Canadian study:

Planned home birth attended by a registered midwife was associated with very low and comparable rates of perinatal death... compared with planned hospital birth attended by a midwife or physician.

Here is a 2011 study from the BMJ covering 64,000 births in the UK:

There was no difference overall between birth settings in the incidence of the primary outcome (composite of perinatal mortality and intrapartum related neonatal morbidities)...

Maternal death rates, obstetric interventions, stillbirth, and newborn resuscitation for each birth setting are all provided in the study extracts if you would like to review them.
posted by DarlingBri at 5:43 AM on July 5, 2014 [2 favorites]

If we've had as many studies on acupuncture as we have (and lordy have there been a lot) and haven't been able to see a clear indication if it works or not, I'm comfortable putting it in the "probably doesn't work" bin. Either it doesn't do diddly or else its effect is so tiny that if there IS something it's tapping into, it's clearly doing it wrong.

Anyone who has a plausible explanation for why needles in my feet can cure my headache, have at it.
posted by Scattercat at 9:33 PM on July 5, 2014

A midwife is not a "civilian" in the way you seem to be disparaging them. A midwife is a trained medical professional with extensive clinical training.

May be true elsewhere, but that is absolutely not true in the United States.
posted by purpleclover at 10:53 PM on July 5, 2014

Every time I hear this debate, I want to scream to women to know enough to know what you want and need and then demand it. I agree with those who say that too many people want to tell a birthing woman what she should or should not want. A birthing woman should educate herself and then go with what she wants.

Just a little story, I had one doctor who told me that I should be try harder to deliver a transverse breech child before I opted for a C section, I told him when he could poop a watermelon then he could tell me how hard I should work. He called the surgery team right away.
posted by OhSusannah at 10:58 PM on July 5, 2014

A midwife is not a "civilian" in the way you seem to be disparaging them. A midwife is a trained medical professional with extensive clinical training.

May be true elsewhere, but that is absolutely not true in the United States.
posted by purpleclover 8 hours ago [+]

Indeed.

the United States is unique in the developed world in its history of criminalizing the practice of midwifery rather than fostering collaboration between midwives and physicians, and successfully integrating midwifery into the prevailing maternity care model. [1]

Yes, US midwives will continue to be poorly regulated until the US medical establishment starts regulating them. The US is in a positively shameful position in maternal safety (40th worldwide and dropping) and newborn mortality (40th-ish too, higher than Malaysia and Cuba): one would hope for a glimmer of humility.
posted by BinGregory at 8:01 AM on July 6, 2014 [2 favorites]

May be true elsewhere, but that is absolutely not true in the United States.

May be true in your experience, but that is absolutely not absolutely not true in the United States.
posted by MrMoonPie at 11:25 AM on July 7, 2014

Certified nurse midwives are different than midwives. Because they are nurses. That is why "nurse" is in their title.
posted by purpleclover at 1:46 PM on July 7, 2014

Yes, we're conflating terms here, there are two sets of people in the US that call themselves midwives, one set are fully qualified medical professionals, who work with and are respected by, other fully qualified medical professionals; the other set are unqualified (in any conventional medical sense) civilians.
posted by ob at 8:54 AM on July 8, 2014 [1 favorite]