Thank you Amy and readers for allowing me the great opportunity of contributing my conference analysis to Science & Sensibility.

At no other conference has choosing between concurrent sessions been so difficult. However, from the moment the schedule was posted some weeks ago I knew there was one I had to attend. Assessing Interactions Between Culture & Choice focused on today’s generation of mothers and what shapes their perceptions, experience and consequently choices about birth.

Generation Y women are today’s young mothers and will make up the bulk of midwives’ clients in the approaching years. What shapes their perspectives on pregnancy and birth? And how will their expectations impact the way they choose to give birth?

Demographics and Influences

Generation Y is loosely made up of adults born between the mid 1980s and the mid 1990s In the conference session, we reflected on what influences this generation of women:

1. This generation is extremely comfortable with technology, having craved the “toys that make the noise” including Nintendo/Sega/Xbox game consoles, mini laptops and iPods. The toys of this generation often involve one-on-one interactions with a computer rather than a friend.

2. The “Audit Society” (Power 1997) is the norm for this generation. The 1980s saw an explosion of auditing activity in UK and American society. Teachers chart performance and activities of students, employees audited their own activities for their employers and health workers began recording up to the minute activities of their patients and one another.

3. To this generation “the most desirable women aren’t women at all – they’re girls.” The womanly shape, once held in esteem by the Greeks all the way up to pre-Twiggy models is seen as overweight to this generation. Smaller frames, straight figures and other pre-pubescent qualities are idealized by Generation Y women (or at least the media they consume). Not ironically, Gen Y has also been referred to as the Peter Pan Generation.

The first two in this hardly exhaustive list of predictors can help to explain how medicalized birth is quickly being assumed as the norm by today’s women. (And as Dr. Eugene Declercq of Boston University pointed out over lunch, the majority of U.S. women are satisfied with their maternity care.) In fact, as UBC doctoral candidate Esther Shoemaker points out from her mixed methods research of young women and new mothers, “Natural” birth to them does not equal “Normal” to us. Natural birth, to most of the women in her study, is synonymous with vaginal birth. Even if labor was induced, an epidural administered or forceps used, the women who gave birth vaginally experienced their birth as natural. I have witnessed this in my own Generation Y peer group of young mothers.

Further, the majority of those Shoemaker interviewed desired a vaginal birth in their antepartum interview, but also voiced an ambivalence about whether or not they actually would give birth that way when the time came. “If something happens I of course will have a c-section.” Oddly enough, perception of safety was not mentioned but the women said they would default to whatever their individual practitioner suggested.

In some cases reported, the practitioner suggested procedures to the Shoemaker participants that increased the degree of medicalized beyond what they expected for their birth. When this occurred, each of the participants changed their plans for their second birth. They either embraced the medical model completely or rejected the medical model in favor of a physiologic birth. So while they were ambivalent or passive first time mothers, they actively created their birth plans for subsequent children. The finding has important implications for today’s mothers as this was true for all Shoemakers’ participant’s whose birth experience was more medicalized than her birth expectation.

Intriguing findings in the studies:

1. Birth, to this generation, is, as UBC scholar Kathrin Stoll points out, a normal physiological process (71%), inherently risky and filled with “unavoidable complications” which necessitate technological interventions.

2. Of the women Stoll interviewed, 70% worried about how they and/or their partners would perceive their bodies during and after pregnancy.

3. According to Shoemaker, who studied what happened in subsequent births among women whose first births were more medicalized than expected, one of two extremes were common. The women would either fully embrace the medical model (e.g., plan a c-section with all the bells and whistles) or she planned to birth at home with no interventions.

The findings of this session’s speakers are all interesting and important for us as midwives, childbirth educators, and activists. When shaping our message about normal birth it is important to meet women where they are, use their language and respect their experience of the world and their bodies. How will we “market” normal birth as we are privileged to know it to the coming mothers?

About Katie Fulmer:

Like many of you, I have birth on the brain and care deeply about the health and wellbeing of our mommas. I am currently a student midwife with Illysa Foster, author of Professional Ethics in Midwifery Practice. My academic focus was Medical Anthropology as an undergrad at the University of Texas in Austin and I look forward to continuing my study of maternity and child care at the PhD level.

I went as an agent of data dissemination. My job: to use social media (blogs, Twitter) to help make sure the conference proceedings didn’t just rattle around the four walls of the conference hotel, but got out to those in the field working to improve maternity care wherever we each are.

And I have some research I want to write about – really interesting, important research from every discipline you could imagine. But I left the three-day meeting thinking more about the (broken) link between evidence and practice than about any of the new, emerging evidence. I’ll get to the new research over the coming weeks, but first, a look at two stories that dominated the conference.

#1: Home birth on the defensive?

The plenary session by Dutch physician and epidemiologist, Simone Buitendijk, might have highlighted the unique model of midwife-led primary care geared toward planned home birth for low-risk women – a model that many birth advocates and researchers look to as a beacon of hope and reason. Buitendijk herself was co-author of the definitive study of planned home birth safety, a population-based study of over half a million births that found planned midwife-attended home birth as safe as planned midwife-attended hospital birth. And a Cochrane systematic review that came out around the same time as the Dutch home birth study provided definitive evidence that midwife-led care is superior to physician-led or shared models of care. So the Dutch have gotten it right, right? Time to celebrate and emulate? No, instead of a plenary about Dutch primary maternity care as a model to emulate, Buitendijk’s talk was a sobering call to action.

According to Buitendijk, in spite of this evidence (or perhaps in direct response to this evidence?) a well-coordinated media campaign in the Netherlands over the past year has emphasized the dangers of home birth, pointing to an entirely different body of evidence: comparative data showing that Dutch perinatal mortality rates are higher than those in other European countries. Although only about 30 of the 1700 Dutch perinatal deaths occurred at home, and perinatal mortality at the population level is affected far more by incidence and management of preterm birth and congenital anomalies than by the labor and birth care of low-risk women with term pregnancies, the Dutch mass media have made this a story about midwifery care and home birth. The result: the rate of home birth has dipped below 25% for the first time in Dutch history.

#2 VBAC is Back?

Eugene Declercq, who gives – hands down – the world’s most engaging and fun lectures about perinatal statistics, had the pleasure of making an 11th hour revision to his plenary talk on vaginal birth after cesarean (VBAC) thanks to ACOG, who released their new VBAC practice guidelines at 5pm the day prior. (Hat tip to yours truly for tipping him off about the new guidelines. I even got written into his plenary remarks, as the young woman with whom he had a “stimulating conversation” that led him to “stay up all night.” Har har, Gene!)

Anyway, we see in Declercq’s talk the familiar story of how VBAC rates increased briefly then plummeted in the early 2000’s as a result of new research on uterine rupture and, more precisely, an editorial by the ob-gyn editor for the New England Journal of Medicine saying that planned repeat cesarean is “unequivocally” safer than planned VBAC.

Research driving practice! That is, if the research (or overzealous interpretations of it) supports restricting practice.

Where’s the up-tick in VBAC rates when the Cochrane systematic review was published in 2004 concluding that “Planned elective repeat caesarean section and planned vaginal birth after caesarean section for women with a prior caesarean birth are both associated with benefits and harms?” The up-tick isn’t there because by then research wasn’t driving practice – ACOG guidelines calling for “immediately available” emergency obstetric care in VBAC labors were driving practice. And it wasn’t the NIH Consensus Development Conference on VBAC or the massive AHRQ systematic review underpinning the conference (i.e., evidence) that have been heralded as the beginning of the end of hospital “VBAC bans,” it’s ACOG’s (somewhat noncommittal) move away from the “immediately available” standard.

Evidence is not driving practice. Between evidence and practice there lives some kind of cocktail of power, money, activism, media, influence and serendipity (and preservatives). The relative strength of the ingredients dictates how practices evolve. Keeping with the cocktail metaphor, the VBAC plenary ended with an invitation to consumers and our advocates to shake things up – activism being the best hope for ACOG’s new guidelines to be used to drive meaningful change for the many, many childbearing women in the United States with scarred uteruses.

This all reminds me of a third plenary talk at the Normal Birth Conference – Patti Janssen’s lecture, Transforming Research into Policy: Ingredients of Influence, in which she quotes social scientist, Martin Rein.

It also reminds me of Kay Dickerson of the Cochrane Collaboration who said, “We are only to get evidence-based healthcare in this country through consumer activism.”

More on Janssen’s plenary, and updates on the research, coming soon.

In the meantime, 140-character-sized updates from the conference are constantly streaming on Twitter.

"Cascade of Normal" from Vicki Van Wagner's talk on midwifery in an Inuit region of Arctic northern Canada

Remember, there's an Open Thread for conference attendees and enthusiasts to post messages. You can follow all of the updates from the conference on Twitter by following the #birthconf hashtag and find more analysis here on the blog - AMR]

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For the past 50 years Lamaze International has been promoting normal birth practices in North America and more recently worldwide. Despite these educational efforts women are being over-treated more now than they have been in over 30 years. For example, 31% of women in the United States give birth by cesarean surgery. The overuse of interventions with harmful side effects when there is little or no expected benefit for mother or baby has led to worsening maternity care outcomes in the United States and many other countries. In addition, women do not get adequate information so they are aware of the excess, unnecessary risks they and their infants are being exposed to.

One of the reasons these educational efforts may not have been as effective as desired is that our conversations may not be persuasive enough or clear enough. For example, it is not universally understood or agreed upon how to define a normal birth, the differences between normal and natural birth, and which behaviors constitute a normal birth. Conversations and language affect how persuaded others are to make changes. In fact, 50 years of diffusion of innovation research tell us that for women to demand safe, high quality maternity care, we must engage in clear conversations that outline specific desirable behavior changes and show that women and babies can expect better health outcomes if these changes are made.

Lamaze International hired a public relations market research firm to conduct research and identify which messages are the most effective for persuading women to adopt normal birth practices. Online surveys were conducted among 811 women aged 16-44  and 408 Lamaze Certified Childbirth Educators.

Indeed, the research showed that the meaning of the words “normal” and “natural” was not interpreted by the women and educators the same way. For example, 36% of women felt that ALL vaginal births are “normal birth”, while 63% of Lamaze Certified Childbirth Educators defined “normal birth” to be a birth without medical intervention. Women and Lamaze childbirth educators are likewise divided when deciding if the terms “natural birth” and “normal birth” are generally similar or generally different in meaning.

Lamaze International found that the words safe and healthy are the most effective words for communicating and promoting the birth practices Lamaze has endorsed for years. Everyone wants a safe and healthy birth. Mothers are particularly motivated to keep their baby and themselves safe and healthy. Most importantly, the practices are safe and healthy.

As a result of these and other findings, Lamaze International updated our six evidence-based key practice papers in Fall 2009 to ensure women realize that these practices simplify the birth process with a natural approach that helps alleviate fears and manage pain, with the ultimate goal of keeping labor and birth as safe and healthy as possible for each individual woman. Every woman needs clinicians who promote, support, and protect these six practices:

1. Let labor begin on its own

2. Walk, move around and change positions throughout labor

3. Bring a loved one, friend or doula for continuous support

4. Avoid interventions that are not medically necessary

5. Avoid giving birth on your back and follow your body’s urges to push

6. Keep mother and baby together – It’s best for mother, baby and breastfeeding

Conflict of Interest Disclosure: The research was funded by Lamaze International.

It’s 40 bucks well spent. I don’t know another author who can make research methods and statistics this engaging and clear to read.

Don’t forget our Understanding Research series, too!

But I want to take a step back and ask a larger question - is meta-analysis even appropriate for the study of home birth?

Meta-analysis is a statistical process that pools data from multiple studies. It is intended to achieve two related goals:

• have adequate statistical power to detect differences in rare but clinically important outcomes (such as perinatal mortality among babies of healthy women)
• establish a definitive answer to an important clinical question, so that policies and practices can adapt to conform to the new “truth” and other researchers don’t have to study the issue anymore.

Let’s look at these two issues separately in the context of the Wax meta-analysis.

Statistical Power

Lack of statistical power could not possibly be the rationale for conducting a meta-analysis on the safety of home birth. That’s because there already is a study large enough to detect differences in intrapartum and neonatal death. In fact, it contributed 94% of the data on planned home birth in the meta-analysis (321,307 of 342,056 planned home births). That study found virtually identical rates of neonatal death in both the planned home and planned hospital births*, with relatively narrow confidence intervals. Neonatal deaths on day 0-7 occurred in 3.4 per 10,000 of each group and when combined with intrapartum mortality and adjusted for confounding factors, the relative risk was 1.00 (95% CI 0.78 to 1.27). That means that there was a 95% likelihood that planned home birth results in somewhere between a 22% reduction and a 27% increase in intrapartum or neonatal mortality.)

By adding a bunch of smaller, older, and flawed studies, excluding the intrapartum deaths (which may be affected by intrapartum events and therefore are potentially modifiable by the birth setting) and adding deaths that occurred between 8-28 days (which are less likely to be related to intrapartum events and therefore are less modifiable by birth setting), we suddenly have nearly three times the neonatal mortality rate with planned home birth and a confidence interval you could drive a truck through?  (a 95% chance that home birth increases the risk of neonatal death by somewhere between 32% and 625%)  Hmmm…

Definitive “truth”

The other reason to undertake meta-analysis is to definitively settle a clinical question. Meta-analysis, after all, holds a privileged place atop the evidence pyramid, where it is considered the “best evidence.”  But is a deeply flawed meta-analysis really better than an adequately powered, methodologically sound study? The answer, of course, is no. All the meta-analysis does in such cases is separate the reader from the primary source of the data so that they can’t assess it for themselves, while putting the evidence-based stamp of approval on whatever statistics the meta-analysis software spits out. But people with a political motivation to authoritatively declare a certain definitive truth may realize that most people don’t bother to check to see if a meta-analysis is done appropriately or critically assess the quality of the included studies. They just go, “Oh look, there’s a meta-analysis of home birth and it said it’s 3 times riskier than hospital birth. That settles that! It’s a meta-analysis, after all!”

So if not a meta-analysis, then what?

OK, so if meta-analysis was not the right tool, what is?  And can we stop studying the safety of home birth now that we have that large study that contributed 94% of the home birth data to the meta-analysis?

The way I see it, the large study that showed equivalent perinatal outcomes between home and hospital birth tells us definitively that home birth can be safe. But it doesn’t tell us that home birth is intrinsically safe. We need to continue to study home birth using all of the tools in the research toolbox, qualitative and quantitative, to determine under what circumstances home birth is safe and how to optimize care and outcomes in all birth settings. And we need to stop pushing home birth underground in the United States where it remains a fringe alternative, poorly integrated with the maternity care system, with no standard safety net in place for women who begin labor with the intention to birth at home but turn out to need hospitalization in order to birth safely. Shame on the American Journal of Obstetrics and Gynecology for making this task even more difficult than it already was, by publishing and publicizing a junk meta-analysis.

*edited 7/12/2010 to correct a (serious) error. Sentence previously read “virtually identical rates of neonatal death in both the planned and unplanned home births.”

Dr. Williams

The principle of primum non nocere came into widespread use at the turn of the twentieth century, in large part due to Dr. J. Whitridge Williams, a prominent obstetrician at Johns Hopkins and original author of that Bible of the field, Williams Obstetrics. In 1911, Dr. Williams was invited to speak before the Committee on Midwifery:

The generally accepted motto for the guidance of the physician is ‘primum non nocere’ and yet… incompetent doctors kill more women each year by improperly performed operations than the ignorant midwife does by neglect of aseptic precautions.

His pejorative attack on midwives aside (and Dr. Williams was thought to be more magnanimous towards midwives than most obstetricians in his day!), it’s clear from his statement that this maxim of nonmalfeasance had become standard medical approach. If Dr. Williams were alive today, what do you think he might say of our practice of elective inductions and the high rate of Cesarean sections. Primum non nocere underlies many of the guidelines physicians use today for medical decision making—it’s why powerful antibiotics are not routinely prescribed for viral infections, why operative ear tube placement is not a first-line treatment for ear infections, and why EMS responders first stabilize the head and neck of a car accident victim even before beginning CPR. Although there are limitations to its applicability resulting in endless debates within medical ethics circles, primum non nocere has nevertheless undoubtedly saved many lives and averted unnecessary suffering.

It seems that the good Dr. Williams was on to a curious paradox regarding healing and harm, however, and was perhaps an unwitting early patient safety pioneer. Nearly 100 years after his speech above, the Institute of Medicine released a landmark report titled To Err is Human. In this year 2000 report, the authors estimated that anywhere from 44,000-98,000 people die each year in hospitals due to medical error. This report also confirmed a finding published nearly ten years earlier by the Harvard Medical Practice Study in the New England Journal of Medicine: More than two-thirds of medical errors are preventable, and a 28 percent are due to negligence of a health care professional.

What do these numbers mean? It means that, every day and a half, a fully loaded Boeing 747 would have to drop out of the sky before passenger loss of life surpassed patient loss of life. It means that at least three fatal plane crashes every week would be the result of problems like faulty instruments, poor aircraft design and construction, control tower miscommunications, and pilot fatigue. Would we tolerate such odds each time we board a plane? Why then do we tolerate them each time we enter a hospital?

Coming soon: A closer look at causes of medical errors

1. Was the topic well identified? Each literature review should contain a clearly defined statement of what the author is trying to learn more about.

2. Was search thorough? The article should detail exactly how they conducted a search for relevant articles, and how articles were included or excluded. For example, it is very common for authors to limit their review to studies published in English or in the last 5 years, etc.

3. Were the included studies reviewed well? The author of the literature review should point out any important strengths or weaknesses found in the studies reviewed.

4. Was any important study (that should have been included) left out? At first, this will be a hard question to answer, unless you do your own searching. But as you read, read, read and become more familiar with the research on a topic, you may know of studies or authors who commonly write on your topic of interest and you’ll be able to spot things left out.

5. Were conclusions consistent with the information presented? You want to watch out for authors making big leaps or ignoring problems. Try to be fair and balanced as you determine if the author was fair and balanced.

6. And finally, what does this mean for me? That will vary widely based on your personal situation. As a reader, you may be a nurse, midwife, childbirth educator, doula, doctor, or parent. You may have more than one role. Carefully think about how this may – or may not – apply to you in your various roles. (Notice this is always the last question on my lists? There’s a reason!)

Literature reviews are close cousins to the next type of summarizing papers we will look at: meta-analyses and systemic reviews. Watch for those articles coming soon!

Over on Giving Birth With Confidence, I wrote a post called, From the Bedroom to the Board Room: How I learned to nurse in public. It’s about the fact that early in my mothering, I actually breastfed at the board room table while presenting a report to Lamaze’s Board of Directors. And it totally shaped my perception on breastfeeding, my body, and family-friendly policies:

I look back on this time now and I realize how fortunate I was. My earliest experiences of opening my baby’s and my universe to others reinforced that nursing is normal, joyful, and important. In a way, it was totally unremarkable to nurse my baby while addressing my supervisor and her Board of Directors. But at the same time, it was something to be celebrated. The people at the table weren’t weirded out that I was breastfeeding. They loved it – reveled in it. We even talked about how it is important to have babies at our conferences. Our work affects them!

That post is part of the Nursing in Public Blog Carnival. The carnival coordinators got so many great posts, they started a new (amazing!) web site, Nursing Freedom. Go spread the word!

I also have a new post up at RH Reality Check about disparities in infant mortality. I challenge birth advocates to get behind prenatal care models that are effective and proven to reduce preterm birth and close the gap between blacks and whites. I discuss my own experiences with incredible prenatal care from my home birth midwives, and come to the chilling conclusion:

THIS is how prenatal care should be. Right? Well, not necessarily. Unless and until there is a major upheaval in healthcare financing and staffing patterns, having this kind of prenatal care is a privilege. And I don’t mean privilege like “I’m so lucky.” I mean privilege in the sense that I can’t have that kind of care unless others are deprived of it.

If everyone woke up tomorrow and realized that they deserved to have every question answered, every fear and concern explored, every test/procedure/diagnosis explained, we would quickly run out of midwives to provide that care. That is, if our solution was to provide one-to-one care on the traditional prenatal schedule. In short, that kind of prenatal care, however great it is, is not scalable to levels that could benefit all women and babies.

I also discuss CenteringPregnancy, an evidence-based, relationship-centered model of group prenatal care that has shown to reduce preterm birth rates, especially among African American mothers.

I wrote that post as part of Courtroom Mama’s blog carnival at The Unnecesarean. Check out the link to read through the other important posts.

And for those of you who are interested in learning more about infant mortality and disparities in perinatal care, here are a couple of great resources.

This widget from Kids Count, a project of the Annie E. Casey Foundation, let’s you see data for any U.S. state or territory on different indicators including the infant mortality rate, child poverty rate, and teen pregnancy rate.

And here’s a fantastic recent documentary on disparities in infant mortality in Tennessee, one of the states with the highest infant mortality rates, and where funding to address the problem was recently on the chopping block. (Mercifully, the programs seem to have been spared in budget cuts.)

I hope to get to a more thorough deconstruction in the coming days, but in the meantime here are my preliminary notes.

1. The meta-analysis is compromised by the inclusion of a deeply flawed study that relies on birth certificates and includes preterm births, unplanned home births, and home births attended by unqualified providers. In the only analysis in which the researchers excluded this study, the significant excess of neonatal mortality disappeared.

2. The meta-analysis also includes studies that report on births that took place as early as 1976.

3. Home birth research has come a long way in the past several years. Lack of appropriate data collection and other major methodological problems have plagued this area of research. In contrast, a few new studies have really changed the game. And all of these high-quality studies, conducted in low-risk women in integrated maternity care systems, find no excess risk for babies and significant benefits for mothers. Here are some previous posts in which I reported on these studies:

• Why the largest study of planned home births won’t sway ACOG
• A new era of home birth research
• Home birth: the rest of the story

More soon!