Monday, August 17, 2009

Following the Evidence

Last week, I read Birth Day, by Mark Sloan. This is a fascinating tour of the history of childbirth and discussion of the modern practice of obstetrics, through the eyes of a pediatrician.

I should probably go back and read the book again, because it is the least combative and most informative thing I've found so far on childbirth options. Those of you who have never given birth may be unaware of the fierce battles that are waged around many things related to labor, delivery, and the care of newborns. Do epidurals represent the chance to minimize childbirth pain that all emancipated women should demand? Or are they an unnecessary intervention foisted on us by a medical establishment that has "medicalized" a natural process and is trying to scare us into submission? Is the increase in the number of C-sections an indication that we're taking appropriate measures to minimize the risk to mother and baby? Or an indication of how our health care system is out of control? And of course, there is the newly stirred up controversry about breastfeeding. The opposing sides allow no middle ground and distortions of the research are common. It is difficult to find an impartial guide through the research.

All of this hits you at a time when you're not really functioning at your peak levels of critical thought. First, you've waded through the murky risk analysis of choices during your pregnancy- should you avoid fresh strawberries for fear of Listeria? Is that handful of peanuts going to increase the chances that your baby has a peanut allergy? Will well-meaning strangers ever stop giving you advice on your baby's health? (Note to women pregnant with their first child: the answer to the last question, as far as I can tell, is NO.)

Then you go into labor. Even before it is intensely painful it is not exactly comfortable. Your hormones are doing something you've never experienced before. You and your partner are excited and more than a little bit freaked out. Then the real pain hits, and you either decide to have an epidural or work through the pain. Neither is a perfect option, and neither option is without risks. Despite the research you've done ahead of time, you really can't know what you'll do until you feel that pain. And even if you choose to have an epidural, labor isn't really an easy time in which you can sit back and weigh the pluses and minuses of the interventions on offer, Nor, as my experience with my first labor shows, will you necessarily remember the research you've done ahead of time.

Once the baby is born, you go on another brand new hormonal ride, this time with the added spice of extreme sleep deprivation.

There is no area in my life in which I feel less capable of being able to wade through the evidence and make good, sound decisions about what to do than this one. And yet, it is the area where it seems I most need to do it. Practices that the evidence clearly show will increase the chances of an uncomplicated birth (like, for instance, pushing in a more upright position) are not only not routinely used, sometimes they aren't even offered. I actually think my doctor and his nurse practicioner are fairly up to date on the latest research and give me good advice- but neither of them is likely to be there when I give birth.

In Birth Day, Mark Sloan cites some convincing research about how having a continuously present birth attendant (who is not the laboring woman's partner) greatly increases the chances of an uncomplicated birth. However, our current standard practice does not include this- the labor and delivery nurse is responsible for multiple laboring women, and so cannot be a continuous presence for any of them. It seems that doulas, which I had earlier dismissed as an unnecessary expense, may be well worth the money. Unfortunately, I may be coming to this conclusion a bit too late- I don't have the energy to research and interview doulas right now, and the first few I have come across are too "alternative medicine-y" to be a good fit for me. We will probably just rely on a "cheat sheet" to help Hubby and me remember what we've learned and the fact that second labors are usually a lot faster than the first.

What I really want, though, is a medical system that bases its care of me on the evidence. I want to rely on the medical staff attending my labor and delivery to guide me to know what that evidence says and to follow it- they are supposed to be the experts, afterall.


  1. You don't have to have a doula. I've only been reading your blog a very short time, so I don't really know much about your situation, but do you have a physically and emotionally nearby relative you can rely on? How about a good girlfriend?

    If you don't mind giving them a little education about what you want, they do not even have to be aware of the controversy and battle. You can say, "When I'm dilated to 8 and no longer verbal and I'm offered a trip to the bar, we are not going, no matter what I do, just stand firm, and we don't go." Okay, a trip to the bar not likely something you'll be offered and clearly a bad destination at that time anyway, but something benign I could think of off the top of my head.

    Obviously, you and your partner have to be comfortable enough with this person to have them there at such a time, so it can be very difficult to find a non-doula, non-partner, cheerleader/defensive back.

    Good luck!

  2. I just finished reading Better: A Surgeon's Notes on Performance by Atul Gawande. There's a chapter about the alarming increase in c-sections and some causes.

    It also deals with many of the other things that we had been blogging about, including futile end of life care, hospital-borne infections, how poorer countries can care for a greater % of their populace with less $ (the Indian gov't spends $4/yr per capita and still manages to provide breast cancer treatment for all, regardless of ability to pay).

    After reading this book, I can see why he is a Macarthur fellow. Why aren't we discussing these substantive issues?


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