Dr. Biter speaks about suspension and reinstatement at Scripps

I saw over at Navelgazing Midwife that Dr. Biter recently spoke about his suspension, reinstatement, and resignation at Scripps Encinitas. (Also take the time to read NGM's previous post, Why doctors don't care.)



He mentioned his plans to open a freestanding maternity center towards the end of the interview. Speaking of which, you'll find Alan Huber's series on birth centers quite fascinating. Read them in this order:

Hospital, Birth Center, Home,…. Which Is Safest?
Birth Centers versus Homebirth
Birth Centers, Past, Present, and Homebirth
Comparing the Hybrid Birth Facility and Homebirth

14 months old!

Two days late due to packing up, cleaning our apartment, and traveling cross-country on a high-speed train...now we're in Paris for a week before we head back home.

I hear people talking about the "Terrible Twos," but my children operate on their own timetables. Zari didn't really start tantruming until she was closer to three. Dio seems to have started a year early! He is so determined to do things himself, and when he cannot, he DOES NOT LIKE IT ONE BIT. He has an instant on/off switch whenever he gets frustrated or interrupted. He emits an ear-piercing shriek and/or throws himself onto the floor crying and screaming. So we're always on our toes trying to distract him or calm him down.

He wants to walk everywhere by himself. He wants to push the stroller rather than ride in it. He wants to eat all by himself with a spoon or a fork. He wants to do what he wants, when he wants--which is impossible when there are 3 other people in the family. He hates riding in the bus. Even yesterday's train ride was a big challenge; he wanted to be walking and climbing the entire time. I'm especially worried about the cross-Atlantic ride home, but at least I will have help on the way back.

But Dio is so much fun, too. I love watching him walking around and flapping his arms with excitement, running away from me with an impish grin, giggling with Zari over a silly game they've made up. He loves balls, birds, dogs, and airplanes. He is our dog-spotter, shouting "dog! dog!" whever we pass one. He likes to play with sticks and dirt and rocks and leaves and pine needles. His vocabulary and comprehension are expanding all the time.

A brief list of his words, ones I can think of while I'm typing:

• Words he can say: dog, bird, cat, Zari ("yaya" or "zaza"), mama, more, poop, banana
• Plus words he can sign: potty, airplane, nurse,
• Plus words he understands: no, all done/all gone, Mister Monkey (his sock monkey that he snuggles with at night), food/eat, go get _____, turn around (for going down the stairs), give it to me, papa, I'm going to get you!

Sleeping has been a bit of a challenge this past month, but it's mostly due to Zari and Dio having to share a room and thus waking each other up. I just keep telling myself it's just a few more weeks and it will get better once the kids are back in their own rooms...

Kingsdale Gynecologic Associates: Doula Ban and Birth Plan

Remember back when  the Aspen Women's Center banned "doulahs"? There's another obstetrical practice that has not only banned doulas, but also written up a one-size-fits-all birth plan.

Yes, despite the very strong evidence that doulas have significant positive effects on the course of labor, on intervention rates, and on women's experiences, Kingsdale Gynecologic Associates has banned doulas "because of concerns for increased risk to you or your baby." Their "thoughtful, unanimous decision" to ban doulas comes down to this: "It has been our experience that they may serve to create a state of confusion and tension in the delivery room, which may compromise our ability to provide the safest delivery situation possible for you and your baby."

Not only does the pregnant woman no longer have access to a companion of her choice during labor, she has to sign the physicians' birth plan. Among other things, this birth plan notes that IVs are necessary for a safe labor, that you will only be allowed ice chips and popsicles, that you'll probably want drugs, that they will cut episiotomies to avoid bad tears, and that continuous fetal monitoring provides the "safest possible delivery."
Evidence-based medicine has been tossed out the window.

But this one takes the cake:

The labor and delivery nurses and doctors together act as “doulas” in a sense that we will be your advocate to provide positioning options, pain control and pushing techniques to make the process as easy as possible.

Yes, the physician who arrives when the baby is crowning and the nurses who are tending to several laboring women and spending almost no time doing direct labor support are somehow the equivalent of a doula--a person who knows the woman well, whose entire task is to provide continuous support and information and encouragement, and who never leaves the woman's side.

I'm sure a lot of us could come up with snarky/sarcastic/witty remarks to the doula ban and the birth plan (hey, it rhymes!). But better yet, I'd love to see someone edit the documents purely from an evidence-based medicine point of view, complete with up-to-date references. Perhaps we could create a wiki and work on this together? I'd be more than happy to send the completed documents back to Kingsdate Gynecologic Practice.

You're also free to write directly to the physician group and voice your thoughts:

Kingsdale Gynecologic Associates
1315 West Lane Avenue
Columbus, Ohio 43221
Click here for Directions

Phone: (614) 457-4827
Fax: (614) 326-0250

Still, the best reaction is if pregnant women leave Kingsdale Gynecologic Associates in favor of a provider who respects women's wishes and supports evidence-based care. For example, CNM Emily Neiman wrote that her midwife/physician practice, Women's Contemporary Health Care, would be "happy, thrilled, ecstatic to have these women transfer to our practice. We have no issues with doulas, 'allow' you to write your OWN birth plan, and provide continuous labor support."

French breastfeeding blog

I came across a lovely French breastfeeding blog the other day, via my Stat Counter. It's called MamaNANA Blog: Pour allaiter en beauté. I came to the blog via the post Je sèvre ou pas ("Should I wean or not?"), in which the author and commenters discuss whether/how/when to wean and ideas for weaning celebrations. For all you French speakers, take a minute to look through the blog--I think you'll love it!

New York midwives and written practice agreements

A few days ago, The New York Times published this article about the current status of NY midwives: Doctors’ Group Fights a Bill That Would Ease Restrictions on Midwives. Since the closure of St. Vincent's, half of NYC's home birth midwives have been unable to obtain practice agreements. All midwives, hospital or home-based, currently need a signed practice agreement with either a hospital or physician. So New York state's midwives sought a legal solution to this impasse. Here's what happened:

A week ago, a bill that would repeal that requirement breezed through Assembly and Senate committees, and its champions expected it to pass the full Legislature within days. Then it hit heavy opposition from the American Congress of Obstetricians and Gynecologists.

In a memorandum, backed by a press conference in Albany on Thursday, the congress challenged the safety of midwife-attended births and suggested that the bill was a ploy to allow midwives to expand their turf and directly compete with doctors. “While this legislation does not intend to extend a midwife’s scope of practice, it has the ability to pave the way for midwives to open their own independent birthing centers,” it said.

Heaven forbid that midwives compete directly with physicians.

But wait--it gets even better. ACOG's reason for requiring written practice agreements is that without a practice agreement, giving birth with a midwife, including hospital-based midwives, will become terribly unsafe. The only thing standing between the laboring woman and disaster is this piece of paper. Here's how:

The obstetricians’ group has argued that written agreements are needed to keep women safe. Suppose a woman is giving birth in a hospital, attended by a midwife without a practice agreement, and the woman starts to hemorrhage, Donna Montalto, executive director of the New York division of the congress of obstetricians, said Thursday.

“What obstetrician who has never seen the patient, doesn’t know the midwife, and happens to be at home at their son’s baseball game is going to say, ‘Sure, I’ll come in and take care of your patient,’ ” Ms. Montalto said.

Yes, in the absence of a signed agreement, physicians will be asked to come in from their children's sport games and attend to an unknown woman. Gasp. As if unknown women never go into labor when a physician is on call. As if attending physicians know all of the women they deliver personally--except for those pesky midwife patients.

Not only is this totally ridiculous--on-call physicians attend to whoever goes into labor, known or unknown--it distorts what would actually happen if a woman giving birth in a hospital with a midwife began to hemorrhage. The midwife would administer the same anti-hemorrhagic medications that a physician would! She wouldn't be calling a physician in from his son's baseball game to give her patient a shot of Pitocin or methergine.

I'm calling this one...

Code Mec!

Articles now online

I put both of my recent articles online ("Staying Home to Give Birth" and "Attitudes Towards Home Birth in the USA.") You can now access them directly, as well as my dissertation, via the sidebar. Happy reading!

Pregnancy, birth and breastfeeding resources needed in French

I'm looking for French-language resources on the topics of pregnancy, labor & birth, adjusting to the postpartum period, and breastfeeding. Can be blogs, articles, research studies, websites, books, videos, etc. Especially things that would be helpful for a woman pregnant with her first baby and due to give birth in about 6 weeks.

Thanks!

When diet and exercise fail

This is a response to Fat Obstetrics at Navelgazing Midwife, which was a response to a post about separate maternity facilities for obese pregnant women at The Unnecesarean and Exaggerating the Risks Again at The Well-Rounded Mama, which discussed an article in The New York Times arguing that Growing Obesity Increases Perils of Childbearing.

Diet & Exercise--the most common phrase whenever the topics of obesity and weight loss arise. At the end of the day, achieving or maintaining a healthy weight is simple: eat healthier and exercise more.

Or is it that simple?

The millions of people who have tried this approach, and failed, can testify that there's something going on besides calories in through food and calories expended through exercise.

Mayo Clinic endocrinologist James A. Levine has discovered a third major player--more important, even, than diet and exercise combined--in regulating weight levels. It's called NEAT, short for non-exercise activity thermogenesis. NEAT is the energy we expend in everyday activities such as fidgeting, cleaning, gardening, or cooking. When you're not sleeping or sitting, and when you're not actively exercising, you're producing NEAT. This short interview with All Things Considered explains the basics of NEAT:



Through a rigorous research study involving precisely calibrated meals, high-tech underwear, and $1,000 drinks to ensure study participants weren't "cheating" with outside foods, James Levine discovered that NEAT explains why some people weigh more and others less, despite similar levels of food intake and exercise. From his primer on NEAT:

For the vast majority of dwellers in the U.S., exercise activity thermogenesis is negligible. NEAT, even in avid exercisers, is the predominant constituent of activity thermogenesis and is the EE [energy expenditure] associated with all the activities we undertake as vibrant, independent beings....

NEAT is likely to contribute substantially to the inter- and intra-personal variability in EE. Argue thus; if three-quarters of the variance of BMR [basal metabolic rate] is accounted for by variance in lean body mass and, TEF [thermic effect of food ] represents 10-15 percent of total EE, then the majority of the variance in total EE that occurs independent of body weight must be accounted for by NEAT. Evidence supports this. NEAT is highly variable and ranges from ~ 15 percent of total daily EE in very sedentary individuals to >50 percent in highly active persons. Even minor changes in physical activity throughout the day can increase daily EE by 20 percent. NEAT is impacted by environment, but is also under biological control.

In other words, a person's level of exercise (running, swimming, biking, etc.) has only a small effect on her total energy expenditure and thus her body weight. Levine's research study found that overweight people expend far less NEAT than people at a normal body weight--even after they have lost weight. The reverse is true for lean people who gain weight artificially (i.e., on purpose for a research study such as Levine's). From a Mayo Clinic report of Levine's research:

NEAT — more powerful than formal exercise — determines who is lean, and who is obese. Obese persons sit, on average, 150 minutes more each day than their naturally lean counterparts. This means obese people burn 350 fewer calories a day than do lean people....

[Levine] adds that the NEAT defect in obese patients doesn't reflect a lack of motivation. "It most likely reflects a brain chemical difference because our study shows that even when obese people lose weight they remain seated the same number of minutes per day," says Dr. Levine. "They don't stand or walk more. And conversely, when lean people artificially gain weight, they don't sit more. So the NEAT appears to be fixed. But as physicians, we can use this data to help our obese patients overcome low NEAT by guiding the treatment of obesity toward a focus on energy as well as food. We can encourage NEAT-seeking behaviors."

Levine is actively involved in developing real-life, affordable solutions for increasing people's NEAT. Levine has built a working "treadmill office," complete with a 2-lane walking track that serves as the meeting room and desks equipped with treadmills rather than chairs. By walking at 0.7 mph instead of sitting at a desk, a person expends 800 additional calories per day just by going to work.

Lynne Rossetto Kasper of The Splendid Table visited Levine's treadmill office and has this fascinating report (approx. 10 minutes).

If you want to learn more about NEAT and how to incorporate it into your everyday routines, you can read Move a Little, Lose a Lot: New N.E.A.T. Science Reveals How to Be Thinner, Happier, and Smarter. And if you can, walk rather than drive to the library!

Hike to Peillon

I woke up this morning thinking it was Friday. But it wasn't. So we started looking at where we could go for a day trip on the regional bus system (anywhere for 1 Euro and children ride free). After lunch, we decided to visit Peillon, a perched village in the mountains behind Nice. The only "problem," which turned out to be our reason for visiting, was that the bus stop was at the bottom of the valley. A hike straight up the mountain sounded fantastic. Here's the view from the bus stop. You can see Peillon perched at the top of the closest peak.

Here's a better picture (not my own)

Dio napped in a hiking backpack on the way up. At the entrance to the village was a fountain, where Dio took a nursing break.

Zari hiked all the way up and almost all the way down. I was very impressed. She was really proud of herself for making it up "all by herself."

Our next stop was a water spigot. We refilled our water bottle and the kids played in the water for a good half-hour until we dragged them away to see the rest of the town.

The entire village was up and down and under charming little archways. Not the place for a stroller or a bike.

The only flat surface in the entire village was the square in front of the church. A bored-looking teenager kicked a soccer ball against the church wall. Not much else to do in Peillon.

It's so out of the way that there are no shops. Just a restaurant, a church, and lots of charming little houses.

I love the pots of flowers going up this staircase.

Dio found another water spigot and got even wetter.

A cat caught a mouse and played with it before eating it.

Sometimes I look at Zari and amazed that she is part of our family. She's so beautiful--in the full sense of the word, not just on the surface. She's her own person and is very much aware of what's going on around her.

Time to head back down. The view of the valley.

After we made our way back down (with Zari riding in the Ergo on the final stretch), we had an hour and a half to kill before the bus came. Since we were at the bottom of a valley, we figured a mountain stream wouldn't be far away. We were right. We played in the cool, clear water, the perfect thing after a long, hot hike. And then we waited...and waited...and waited for the bus. It was the last one of the day and we hoped that it was going to come. Since I'm back home blogging, you have probably figured out the bus finally made it!

It was a lovely day.

Baby bird

Dio looks like a baby bird when he eats.

News roundup, C/S and VBAC style

I came across several notable stories and blog posts this week relating to cesarean sections and VBAC.

First, I want to share a lovely birth story of an obstetrician's unexpected VBA2C. Dr. Poppy Daniels' first four births were all induced. She had a cesarean section, two vaginal births, and then another cesarean section. She had scheduled another cesarean section for this fifth birth, but Mother Nature had other plans. Dr. Daniels went into labor the day of her surgery--her first spontaneous labor ever! She was 9 cm dilated when she arrived at the hospital, and it was an easy choice for her to give birth vaginally. In addition to telling the stories of her five births, Dr. Daniels also explains the obstetrical culture in which she trained:

I trained in downtown Philadelphia where an addicted mom with no prenatal care could deliver on one end of the hall, while a high risk IVFer from the Main Line might be delivering on the other end. Although we worked side by side with midwives, we only became involved if their patients developed complications or needed a C-section. Needless to say, like most OB residents, my experience with normal, low-risk physiological birth was minimal.

She comments that modern maternity care exists in a climate of fear and wonders how many of the obstetrical "problems" are caused by the very actions and interventions thought to make birth safer.

Reflecting back over my journey, I see how much the field of obstetrics has managed to contribute and sometimes outright cause complications, all the while assuming they are just keeping everyone safer. And I see how much fear has overtaken the natural birthing process. I’ve said before that shows like Deliver Me, A Baby Story, and Birth Day should be renamed “Fear Factor” because they play on a woman’s often natural concerns about the birth by portraying the whole process as highly dramatic, with a woman strapped down and hooked up, by a doctor gowned and gloved like an alien visitor and often highlighting very anxious family members. Sure a woman has fear, fear that something is going to happen to her or the baby, fear of pain, fear of failure, that she just won’t be able to “do it.” Add in snarky, cynical nurses and doctors who ridicule anyone who seems to want to be in charge of her birth (after all we’re the experts)…limited labor support or assistance in the form of doulas or labor coaches except in certain areas…restricted mobility, food and drink…and almost endless interventions and you have potential for trouble. We have cultivated an environment that this is normal, and somehow now some women even find value in being “risky.”

Dr. Daniels' mentor was Dr. Lauren Plante, author of the fantastic essay "Mommy, what did you do in the industrial revolution?" (cited in my article Attitudes Towards Home Birth in the USA). I recently found out that Dr. Plante, a maternal-fetal medicine specialist, had two midwife-attended home births.

Next, Kristen at Beautiful Birthing Ideas provided a summary of three articles addressing VBAC--all quite favorably--in the June 2010 issue of Obstetrics & Gynecology, aka "The Green Journal."

Next, The Well-Rounded Mama expresses her frustration with the overblown risks of obesity in childbearing women. In Exaggerating the Risks Again, she discusses and critiques a New York Times article titled "Growing Obesity Increases Perils of Childbearing." Her analysis is excellent and covers many points not relating directly to cesarean section or VBAC. An excerpt from her discussion of cesarean section rates in obese women:

The implication here (and alas, many doctors share this perception) is that cesarean sections in women of size are safer than vaginal birth. Barring major complications, nothing could be further from the truth.

The truth is that cesarean sections are FAR more risky than vaginal birth for all women, and especially so for "obese" women. There is the risk of anesthesia complications, hemorrhage, blood clots, and a very serious risk for infection. Doing surgery on a very fat woman is complicated, and the relative lack of vascularity in adipose tissue means that oxygenation and therefore healing is more difficult.

Yet despite the documented increased risk from cesareans to "obese" women, more and more doctors are doing them pre-emptorily. They have such an exaggerated sense of risk around vaginal birth in women of size that they no longer are willing to let fat women even try.....or will only "let" them try if they induce labor early. And therein lies the answer to much of the high cesarean rate in women of size.

And finally, the topic of obesity and pregnant women surfaced at The Unnecesarean in Do overweight pregnant women need separate high risk hospitals?--something proposed as a "solution" to the "obesity problem" by a physician in the New York Times article. Like The Well-Rounded Mama, the author of this post doubts that separate hospitals for obese pregnant women would do anything but push the cesarean rate higher. Great discussions going on in the comments...be sure to join in!

"Breast is Best" instructional video

Dou-la-la alerted me to a fantastic instructional breastfeeding video called Breast is Best. This is only a 7-minute sneak preview, but it has a lot of great material. I am going to contact the filmmakers to see about a review copy.



More about the video:

A teaching video about breastfeeding, mother's milk, and early contact with the newborn. We see women at ease with their bodies and mothers and babies treated with respect for their skills in nourishing and seeking nourishment. Topics covered in the 45 minute video include: attachment, positioning, sore nipples, blocked ducts, engorgement, mastitis, sleepy babies, increasing milk supply, night feedings, breastfeeding premature infants, pumping and hand expression, breastfeeding twins and toddlers, and the role of support people and prenatal caregivers. Breast is Best was written and directed by obstetrician Gro Nylander, National Coordinator for the Baby-Friendly Hospital Initiative in Norway, and produced by the Norwegian Film Institute.

This mainly new version of Breast is Best is revised and extended to also demonstrate e.g the importance of skin-to-skin contact, even in caesarean section, easy feeding at night, step by step feeding cues and latching on, toung-tie, carrying etc. etc.

You may here watch a 7 min. short version. The full version of Breast is Best may be ordered from:
HEALTH-INFO, Video Vital AS, P.O. Box 5058 Majorstua, 0301 Oslo, NORWAY.
HEALTH-INFO@videovital.no

Children in public spaces

One of the comments about our museum day yesterday got me thinking about how children are expected to, and realistically act, in public spaces. The commenter wrote:

why do you think children running through museums is acceptable, let alone laudable, behaviour? Museums are not parks for children to run in, nor for them to tantrum in.

Before I get started on the main topic, I want to first say that I used "running around" as a figure of speech equvialent to exploring, rather than running at breakneck pace and being totally wild and crazy. Dio can't even run yet. He's still figuring out the walking part!
 
Another aside: I wonder what it is about the internet that lets people write things they would never say face-to-face...
 
Anyway, back on topic...children in public spaces. If children are ever going to be in public spaces--grocery stores, parks, museums, churches, theaters--they will need practice and regular exposure to the norms of public behavior and interaction. In other words, they learn by being and doing and observing others. Not by being kept in the house for the first several years of their life.
 
I'm not saying, of course, that we should let kids do whatever they want in any and all settings. For example, at church, we teach our children that we sit quietly. We bring activites and books and snacks to keep them occupied. And we take them out into the lobby if they're being exceptionally noisy. (Which happens at least once every week!) When I brought Zari to the ballet last week, I explained that we don't talk when the dancers are on the stage and that we clap after they're done dancing.
 
But having children of my own has given me a lot more patience and tolerance for normal kid behavior. Giggles, shrieks of laughter, bumps and falls, cries of fatigue/hunger/boredom, and even temper tantrums are inevitable when you are in public with your children.
 
Over at Womanist Musings, Renee wrote this in My child takes up space:

What really needs to be recognized about children is that they don’t have the capacity to act in the same way that adults do. This does not make them lesser beings and we need to find a way to accommodate them, even when they make drinking a latte a less then comfortable thing.

Renee's post was a response to the Feministe post by Jill called On hating kids. While I don't necessarily agree with Renee's characterization of the Feministe discussion as a "child hate fest," I did find Jill's original post and many of the comments disturbing at heart. The assumption that you can make your children behave a certain way, that you can anticipate temper tantrums and plan your day around accordingly...laughable and totally, entirely not at all realistic. For example, Jill wrote:

And while I don’t think that kids should be categorically barred from restaurants (and even small children from certain types of bars at reasonable hours), I do think that parents have a responsibility to evaluate their own child’s behavior and mood that day and decide whether it makes sense to go to a particular place at a particular time; and parents, ultimately — not everyone else out in public — should bear the burden of making sure that children behave according to the behavioral standard of a particular place, whatever that may be.

Even if I carefully "evaluate my child's behavior and mood," it's prone to change radically about two seconds later. My 13-month-old son, for example, has a super-sensitive trigger. He can be completely calm and happy, then a millisecond later he'll be screaming and shrieking, thrashing around on the floor, totally out of control. Then with a little creative distraction, the tantrum will disappear almost as quickly as it came. I can attempt to assuage the worst of the tantrum, to help him calm down--which is what you see happening in the pictures of our museum day. But "making sure" that he behaves? Nothing short of sedation or anesthetization could "make sure" he never has a meltdown.
 
I found this comment at My child takes up space particularly compelling:

Adding them to the author's original premise, a number of respondents seem to premise their rejection of children, children in public space, and "uncontrolled children" on an unstated assumption of violence or the threat of violence.

A child cannot be “made to behave,” on the spot and in public without violence or the threat of violence. It is force - actual physical force - which undermines the assumption that a parent must publicly control her children.

The immediacy of the child’s moment (especially a young child) is not translatable into an easy solution, especially just so upper middle class complainants don’t have their Sunday brunches interrupted by the intrusion of lesser beings....

The expectation, expressed at Feministe (and I'm sure, elsewhere) that children conform to adult expectations of behavior, or be excluded, really cannot be understood without understanding this as the threat of violence. The belief that parents can control an immediate moment of upset assumes that the parent must intervene to suppress the behavior, to shut the child up, in that very moment - or lose some sort of implied social sanction. It's the expectation that a parent - more often than not, a woman - punish her children so that others don't have to experience inconvenience, making the mother an agent of social repression, inculcating in her own children a fear of women as the proximate agents of suffering.

How we treat children--our own as well as other people's--speaks volumes about our core values as a society. Children are our most vulnerable group, dependent on the adults around them. They deserve to be nurtured, loved, guided, and most of all, accepted as a normal part of what it means to be human. Even if that means they make some noise at museums, at church, or at restaurants.

Museum day

Almost all of the museums in Nice are now free. We took advantage of this today and explored the Palais Lascaris and the Musée Masséna.

The Palais Lascaris is in the middle of vieux Nice. We never even knew it was there. From the outside, it looks like any other old Niçois building. It has a collection of old musical instruments: pianos, harps, violins, guitars. Some of them are still used for concerts held in the Palais.

The main floor had this old apocethary. Pretty cool.

The kids had a hoot running around. We tried, unsucessfully, to keep them quiet.

Inspecting old war medals.

"Plus fait douceur que violence" (Gentleness accomplishes more than violence)

Dio had a temper tantrum

Calming down

All better

Looking cute in her Heidi braids

While Dio was taking his afternoon nap, Zari and I went to the Musée Masséna, which is right next to the opulent Hotel Negresco. The museum is situated in an ornate villa with beautiful gardens. The scale of the place was more palatial than villa-like.

We smelled the roses on the way out.

From opera-goer to trash-collector

Last Sunday Zari and I went to see a ballet at the Opéra de Nice, which is about 200 feet away from us. This was Zari's first big cultural event.

We sat in the front row. I imagined what it would have been like to attend an opera a century or two ago.

The next day, all of Nice was closed down. There were police everywhere. They came a few days before the event and searched our apartment (and all the others nearby). A huge line of police cars was on the Promenade des Anglais.

President Sarkozy hosted 50 heads of state from Africa for the 25th sommet Afrique-France. He dedicated a new monument right next to our apartment building. It is really ugly--9 huge beams of rusted iron leaning together. When we were chatting with the police inspectors about the monument, they exclaimed, "quelle horreur!" After the ceremony, Sarkozy and the other African presidents dined on our street, about 2-3 blocks down.

Eric got about 3 feet away from the president.

We walked around the new monument after the ceremony. The kids rolled around on the astroturf and climbed on the platforms. Zari saw all the discarded water bottles and had to remedy the situation.

So she lined them all up, according to the volume of water remaining.

We pretended to be imporant persons.

What explains physicians' beliefs about home birth?

I've been corresponding with Lara Freidenfelds, author of The Modern Period: Menstruation in Twentieth-Century America. She posed me the following question about the dissonance between obstetricians' perceptions of the safety of home birth, versus the research evidence. She wrote:

As I've been teaching about the controversies over maternity care, students have asked me some crucial questions I have not, so far, been able to answer. I'm wondering if you might be able to help, since you know the literature so well. Basically, my students (and I) want to know why the doctors' concerns about sudden extreme complications do not seem to show up in the morbidity and mortality numbers for home births. Are they simply mistaken about what can go wrong, and how much of an emergency it constitutes (i.e., do home birth midwives get these patients to the hospital anyway)? Are physicians/hospitals not actually very good at addressing emergencies either (i.e., all the monitoring in the world doesn't actually catch the impending stillbirths; hemorrhages are not noticed and addressed quickly enough)? Are the causes of maternal and infant mortality and severe morbidity in home and hospital births the same, or different (i.e., is home birth maternal mortality/morbidity the result of hemorrhage, while in the hospital it's the result of c-section complications)?

I tell my students that my guess is that a well-staffed and equipped birthing center would likely be the safest option, since women could have low-intervention, midwife-supported care with emergency backup immediately available. But the one study you cite which included birthing centers did not seem to support this theory. Would it be reasonable to argue that the various kinds of support offered by home birth actually reduce risks for drastic emergencies by a big enough margin to offset the dire results when a drastic emergency actually does happen out-of-hospital?

Basically, I want to understand why physicians' intuitions seem to be so far wrong. While I think the physicians' organizations are quite self-serving, the individual doctors I've talked to seem quite earnest, not at all cynical, in their concerns about home birth, and they always call up examples of times when they believe they were able to save a mother's or baby's life only because they had a physician's skills and hospital equipment at the ready. Are they wrong because many of these emergencies were iatrogenic? Or because they are wrong to write off other cases of mortality and severe morbidity that they do not realize were iatrogenic (or at least avoidable in a home setting)? What, besides self-interest, might explain the divergence between physician's experience-based intuitions and the large-scale studies?

I'm guessing these aren't easy questions, or I'd have seen them answered somewhere. If you'd be willing to hazard a guess, or outline the limits of the data so far available, I'd appreciate it tremendously.

I'm particularly interested in hearing from my blog readers, especially those who work in a hospital environment: OBs and family physicians in particular, as well as CNMs and nurses. Could you please chime in too? Correct me if I'm wrong, add to what I have to say, offer new perspectives I haven't thought of, etc. I know I have OBs and family practice physicians reading this blog. If you're one of those, please take a minute to answer Lara's questions from an insiders' perspective!

Here's my reply--or rather, a preliminary attempt at tackling this large, complex question.

Let me first mention the research or published material that already addresses this. The first resource that comes to mind is chapter 7 ("Obstetric Training as a Rite of Passage") in Robbie Davis-Floyd's book Birth as an American Rite of Passage. I'm in France, so I don't have my book to refer to directly. But I remember that she discusses how obstetricians' first-hand experience, especially in scary/dangerous/traumatic situations, often supersedes their numerous encounters with "normal" birth. In other words, one bad hemorrhage impresses itself far more vividly upon their minds than the hundreds of births with no excessive bleeding. This translates into a tendency to act (react?) with the worst possible situation in mind, even when the current situation does not warrant that specific reaction. For example, imagine a physician who, after experiencing a uterine rupture, will no longer attend VBACs at all. Never mind that most VBACs occur without serious complications and that there is the possibility of something going wrong in a cesarean--that one bad experience governs thoughts and actions far more than the hundreds/thousands of good outcomes. Not too surprising, really. This kind of thinking is part of human nature.

Probably the only research specifically examining obstetricians' perceptions of home birth (midwives) is by Melissa Cheyney. I referenced her work in my recent article "Attitudes Towards Home Birth in the USA," so I won't repeat it here, except to say that it's a great resource.

I also did some original research of my own into what physicianss think about home birth (quoted from my article):

To discover additional physician perspectives on home birth, we read through five years (Jan 2005-Oct 2009) of discussions about home birth in the OB-GYN-L archives, a list serve for OB/GYNs and maternal-fetal-medicine specialists and the occasional family physician or midwife. Although this discussion group is not a representative sample of obstetricians, the themes serve as a starting point for future research about physicians’ attitudes towards home birth.

First, legal and political constraints played a significant role on limiting physician involvement with home birth, either direct (attending home births) or indirect (providing collaboration, consultation, or backup to home birth families and midwives). Several physicians wanted to provide backup and/or collaboration with home birth midwives, but their hospitals or malpractice carriers specifically forbade these actions. In addition, many physicians on this list could not move beyond an adversarial view of all patients as potential litigants. Besides having to protect themselves against (real or potential) lawsuits, physicians dealing with home birth transfers often faced the brunt of the families’ anger, disappointment, and hostility. They did not enjoy being seen as the “bad guy” in situations they sometimes described as “train wrecks.” And, since home birth midwives often do not carry malpractice insurance, physicians are more likely to be sued for a negative outcome in a home birth transfer. In sum, physicians often characterized themselves as victims of out-of-control legal and bureaucratic systems, forced to adhere to regulations that benefit hospital administrators and trial lawyers at the expense of patients’ wellbeing. In addition, some OBs on this discussion list suggested that the ACOG’s and AMA’s disavowal of home birth was motivated less by safety concerns and more by licensure and professional recognition issues.

Second, physicians held a wide range of opinions about the safety of home birth. Some physicians adhered strongly to the ACOG position that birth outside of a hospital setting can never be as safe, because of the unpredictable nature of birth complications and the access to monitoring and emergency treatments that a hospital can offer. Some characterized home birth as an inherently risky and selfish behavior, on par with smoking, drug abuse, or other dangerous lifestyle choices. Other physicians questioned these definitions of safety, turning instead to research on home birth and discussing the strengths and weaknesses of various studies. Other list members suggested that physicians could benefit from interacting with home birth midwives, who consistently achieve high rates of spontaneous, unmedicated vaginal births. They also noted that improved communication between physicians and home birth midwives would make home birth safer. Others proposed revising certain hospital practices that currently drive some women towards out-of-hospital births.

Another place to discover, indirectly, why physicians feel the way they do about home birth is to look at legislative testimony about direct-entry midwifery. One thing to keep in mind, though, is that physicians' public testimony might not accurately reflect their real concerns about home birth. For example, in the mid-1990s, Dr. Marsden Wagner gave a speech in Des Moines about scientific literature on the safety of midwife-attended out-of-hospital births. He wrote this in a letter to the Iowa Scope of Practice Review Committee on June 6, 1999:

After my speech two Des Moines obstetricians took me aside and chatted with me in the extraordinarily frank manner often found when physicians talk privately with each other. They told me that while they were aware of the research I had quoted proving out of hospital birth to be a safe alternative, they nevertheless frequently use lack of safety as an issue in order to frighten politicians and the public in order to maintain their monopoly over perinatal services. They then explained that the real issue for them is not safety but economic. They do not like the economic threat that midwives and out of hospital birth represent. As they put it to me: “We will not have these midwives taking money out of our pockets!”

I'm sure that many physicians are sincere in their beliefs and perceptions about home birth--however accurate or misguided--but we cannot forget the factors that influence how physicians portray home birth in a public setting.

Now that I've mentioned what little research exists explaining the dissonance between physicians' beliefs and research evidence on home birth, let me leave the safety of citations and delve a little further.

Robbie Davis-Floyd's research already touched on the power of anecdote and personal experience. I want to reiterate how tremendously important this is in framing how we perceive the world around us. Think, for example, of the multiple factors that influence how pregnant women make decisions about their care. I don't think any pregnant women makes her decisions entirely--or even mostly--upon the statistics from randomized controlled trials. Her family and friends' birth experiences, her personal beliefs and values, her birth culture, and her relationship with her care provider are all powerful forces shaping which choices she will or will not make. The same is true with physicians. Evidence-based medicine play only a small role in clinical decision-making. Experience, personal judgment, anecdote, fears of litigation or failure or of a bad outcome...all of these influence how a physician perceives home birth.

Most physicians form their beliefs about home birth without ever having attended one. On the other hand, almost all midwives, doulas, birth advocates, childbirth educators, etc have witnessed both home and hospital births, either first-hand when they were giving birth, or in the role of doulas, friends, etc attending other women. This gives "home birth advocates"--how I hate that term, since it's a gross generalization and easily turns into caricature--much more ground to stand upon than physicians when discussing the relative merits or disadvantages of home and hospital birth.

Physicians who have been fortunate enough to attend home births usually come away transformed from the experience. This happened to Dr. Marsden Wagner (who, to be fair, is dismissed as a kook/raving lunatic/etc by his detractors). Upon the invitation of a Danish midwife who worked primarily in a hospital setting but who also attended births at home, Dr. Wagner began attending home birth. He wrote:

It would be impossible for me to exaggerate the influence of my experience with homebirth on my opinion of obstetrical authoritative knowledge and practice. Home birth is as different from hospital birth as night is from day. Trying to describe home birth is like trying to describe sexual intercourse - you can give the outlines, but you can never adequately describe the personal dynamics, feelings, ambience. (Childbirth and Authoritative Knowledge, p. 370)

In Carol Leonard's memoir Lady's Hands, Lion's Heart, this same transformative experience happened to her OB husband, Dr. Ken McKinney when he attended a home birth for the first time. (At this point, she and Ken were not yet in a relationship.) Here is Carol's account:

Jessie's labor goes without a hitch. She paces up and down her crate [Jessie lives in a converted shipping crate] like a caged tigress, stopping only to pick dead leaves off her houseplants. During the hard time of transition, she lies on her side, panting heavily like a great cat. I sit beside her, rubbing her back and giving her sincere words of praise and encouragement. Out of the corner of my eye, I watch Ken as he sits in a chair, nervously flipping through magazines, pretending to be nonchalant about the whole thing.

A slight smile creeps across my face. I really am fond of this man. I know he is worried that all hell is going to break loose, and he will have to bail me out. As Chief of Obstetrical Services at MVH, what would be the consequences of his being caught attending a crate-birth with a maverick, lunatic-fringe midwife? His credibility within the medical community would be shot. This really is a huge risk for him. I admire his courage. I look at him, studiously engrossed in Woman's Day, and I feel a rush of tenderness...

When it comes time for Jessie to push her baby out, she spontaneously gets up into a huge, old, overstuffed armchair and drapes her legs over each arm. She says this feels the best to her. It is great for me; I can see clearly without doing the usual gymnastics. This position seems to bring the head down quickly. Soon, I am oblivious to Ken and anything else in the room. I ask Jessie to slow her efforts down, to blow out through her mouth instead of blocking her breath.

I say, "Beautiful. Gentle, Easy now. Nice!" over and over as the babe's head slowly stretches Jessie's skin taut. As always happens at this point, my focus becomes so complete on the crowning head, that when Jessie's baby girl slides into my hands, there is a stillness behind all motion. I hold my breath until she takes her first, as if my very will can coax the living spirit into her glistening body. Her color changes rapidly, going through a rainbow of hues until it is a healthy rose. I quietly hand her up to her skunk-haired mother.

It is only now that I become aware of Ken's watching intently over my shoulder. I turn to grin at him. He gives me a triumphant thumb-up....Ken is excited and energized by the experience. He talks the entire way back.

He says that this has really been an eye-opener for him. He has been on the verge of quitting obstetrics because it is so impersonal and dehumanizing; the routine of women, drugged and unconscious and unable to push, often requiring forceps. He calls it the "knock 'em out, haul 'em out" school of obstetrics. He's been getting bored and disgusted; he knows there is more to it than that. This is the way it is meant to be, with women in their power, in control of their experience.

We sit on a rock, warming ourselves in the spring sunshine. He allows as how he still wouldn't feel comfortable attending births at home. His training makes him feel most secure with an operating room, fully equipped for an emergency cesarean, just down the hall. But why couldn't women have a similar experience, even if they have to be in the hospital? Why couldn't changes be made in standard hospital procedures that would allow women to dictate how they want their births to be? His all fired up now. He turns to me and asks if I would help him identify the routines that are archaic and unnecessary, changes that will make hospital births more human. I agree, knowing that I can come up with that list in about two seconds flat.

This lack of first-hand exposure to home birth, in combination with only seeing "failed" home births (i.e., home birth transfers for reasons ranging from exhaustion to needing pharmaceutical pain relief to fetal distress or hemorrhage), lead to a very skewed perception of home birth. Many physicians probably cannot imagine any of the benefits of a home birth because it is so far beyond their realm of experience. So in their minds, home birth is simply hospital birth minus all of the technology--a scary thought indeed. What physicians likely do not understand is that home birth is not simply the subtraction of medical technology from birth, but the addition of an entirely new process that has subtantial benefits for mother and baby. Home birth really is a world away from industrialized, institutionalized birth. As such, I understand how impossible it would be for a hospital-based practitioner to grasp what home birth is like if they have never actually witnessed one in person.

What else might explain physicians' perceptions of home birth safety? Well, there are some who firmly believe that the research evidence on home birth is wrong, plain and simple. Some have argued that every study claiming to find similar safety outcomes between home and hospital birth is either deeply flawed, or that the conclusions are totally wrong, or both. This outright rejection of the evidence is not too common--usually the evidence is simply ignored.

And I've already referred to the role of litigation, both above and in an earlier post Litigation and the Obstetric Mindet.

This post is already far too long, so I will end without tackling Lara's question about birth centers and leave that to my readers. I am really curious to learn the reasons for ACOG's dramatic about-face in its position on freestanding birth centers. As recently a 2006, ACOG disapproved of home birth and freestanding birth centers for the exact same reasons. Then, in 2008, the ACOG and AMA both approved accredited freestanding birth centers--the first ever endorsement of out-of-hospital birth. Why this sudden change? Why for birth centers and not home birth (it's not as though the outcomes of birth centers are significantly better than home birth, at least that I'm aware of)? Is there anyone who knows more about the motivations for this change in policy?

Please take the time to respond to Lara's questions. I'd love to hear from you!

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