Thursday, July 31, 2008



So my post on evidence-based medicine is a little long in coming (it's in draft form) but in the meantime I wanted to share. Looking up medical PDA applications for my mom (there are a lot) I came across something I think says a lot about the way you might deliver with a doctor.

As a doula and someone who talks with women about pregnancy and birth, I hear so many women say "I trust my doctor," or "I like my doctor," when contemplating birth choices. They believe that this will be enough to give them the healthy, normal birth experience they want. I know that there are many fabulous doctors out there - I haven't been able to work with many of them, but I know that there are doctors who practice more like our conception of midwives, than some certified nurse-midwives do! (And I have worked with some of those CNMs - never assume that because someone is a "midwife" that they have a certain standard of practice.)

But when women tell me things like "I like my doctor," I get an uncomfortable feeling. That you like your doctor is great, but that should only be the first item on your list. Like this person? Okay, check. Now let's ask: What are their intervention rates? What will they allow you to do and not do in labor? Under what circumstances? What's their c-section rate? What percentage of women in their practice deliver without medication? Would they be willing to deliver a breech baby vaginally?...etcetera.

When women say "I trust my doctor," do they trust them because they've gone through all the above questions with their doctor, or because they assume that all doctors practice identically and their doctor's training will be all they need?

And in the end, if you like them and trust them, is your doctor even in the room for more than a few minutes at the end to catch the baby? Because they could always be tracking you down in the cafeteria, or from the comfort of their own bed, with this:

For serious, people. Your doctor can monitor your contractions and fetal heart tones from their iPhone! Real time! Talk about hands-on medicine!

More information here, if you want it.

All I have to say is, if I'm ever in the position of needing an OB, my first question might well be "Will you be turning me into an iPhone application, or treating me like an actual person?"

Monday, July 7, 2008

Informed Choice: The Gold Standard

After I wrote my last post, where I discussed the rights of women to make decisions about their medical care and have those decisions honored, I got a link to a statement from a Canadian OB/GYN who is responding to statements from the American Medical Association (AMA) and American College of Obstetricians and Gynecologists (ACOG).

A bit of background: Ricki Lake, the TV talk show host, gave birth to her second child at home and decided that she wanted to make a documentary about our country's maternity care system and the alternatives available. The result was The Business of Being Born, which was released theatrically and on DVD in the past year. I have met more than one pregnant woman who decided to switch from hospital care to a home birth after seeing this movie. It's been screened all over the country and in hospitals, and it's gotten a decent amount of media attention.

This, apparently, requires action from our country's medical authorities. Both ACOG and the AMA released statements opposing home birth. ACOG's called for births to take place only in the hospital or birthing centers, and the AMA's supported that resolution. ACOG calls home birth "fashionable" and "trendy" (as someone noted, this is probably a big surprise to the Amish, who aren't generally called "trendy" yet have chosen home birth for generations). Why? It might have something to do with the fact that this movie is actually influencing women's choices, and that means less business for the OB/GYNs (although with home birth at less than 1% of the total births in this country, it's going to take a lot of screenings for that to truly tip the balance).

There are plenty of doctors who are not on board, however. Dr. Andrew Kotaska, noted Canadian researcher and Clinical Director of Obstetrics and Gynecology at Stanton Territorial Hospital, issued the following response. I wanted to repost it not just because it shows that there is opposition within the profession, but because of his statements about patient choice:

I would invite ACOG to join the rest of us in the 21st century. Modern ethics does not equivocate: maternal autonomy takes precedence over medical recommendations based on beneficience, whether such recommendations are founded on sound scienctific evidence or the pre-historic musings of dinosaurs. In the modern age, the locus of control has, appropriately, shifted to the patient/client in all areas of medicine, it seems, except obstetrics. We do not force patients to have life-saving operations, to receive blood transfusions, or to undergo chemotherapy against their will, even to avoid potential risks a hundred fold higher than any associated with home birth. In obstetrics, however, we routinely coerce women into intervention against their will by not "offering" VBAC, vaginal breech birth, or homebirth. Informed choice is the gold standard in decision making, and it trumps even the largest, cleanest, RCT. [my emphasis]

Science supports homebirth as a reasonably safe option. Even if it didn't, it still would be a woman's choice. ACOG and the AMA are, by nature, conservative organizations; and they are entitled to their opinion about the safety of birth at home. As scientific evidence supporting its safety mounts, however, (to which BC's prospective data is a compelling addition) they will be forced to accede or get left behind. The concerning part of this proposed AMA resolution is the "model legislation."

If ACOG and the AMA are passive-aggressively trying to coerce women into having hospital births by trying to legally prevent the option of homebirth, then their actions are a frontal assault on women's autonomy and patient-centered care. Hopefully the public and lawmakers realize the primacy of informed choice enough to justify Deborah Simone's words: "We don't need to be angry or even react to these overtly hostile actions from the medical community. We just need to keep doing what we do best; the proof is always in the pudding." It is sad to see the obstetrical community still trying to earn itself a wooden club as well as the wooden spoon; if the resolution passes, it is sad to see the politico-medical community helping them.

Andrew Kotaska


Next post answers Seth's second question: Why is there a gap between the evidence base and medical practice? Part of the answer lies in a conversation I had with my parents (both doctors) just a couple of days ago. Stay tuned!