When Research is Flawed

On the heels of my next-to-last post, I thought this link was apropos. It is a list of critiques of studies that purport to show one thing when serious flaws actually show something else. Henci Goer has also written The Assault on Normal Birth and “Spin Doctoring” the Research.

I wish I could remember where I read this, but it’s been too long ago — and it didn’t deal specifically with obstetrics or birth — but it basically said that a lot of the research that goes on today is extremely biased. One scientist reported that he was asked to participate in research, and found out that the article had been written before the results were even complete! In essence, he was just hired to stamp his name on the study so that other people would accept it. In theory, this wouldn’t happen — not only would doctors and scientists refuse to stoop to such unethical levels, but if they did, then the editors of these well-respected journals would surely catch the mistakes and not let them be published. Yet they often are. Another problem is that much of the researched is “leaked” or pre-released to the media before it is even published in the medical journals. This means that the public hears the spin-doctored version of the study (or merely an editorial) before the professionals and scientific peers have the opportunity to thoroughly read the research and find errors in the design, methodology, etc.

While I read with great interest some recent stories, I try to always keep this fact in mind — simply because some well-educated professionals say some nice-sounding things, it doesn’t mean that the conclusions are founded on good science. For instance, take the recent report of maternal cell-phone usage causing behavioral problems in children. Is there a scientific and/or medical reason for it — for instance, that the radio waves interfere with the growth and development of the fetal brain? or is it simply that mothers who talk on the phone too much ignore their children?

The problem is that many people don’t read more than the headlines, abstracts, or editorials of these studies, and these things may reflect the authors’ bias instead of what the research actually shows. For instance, several years ago there were headlines across many of the nation’s papers that “Home birth has twice the neonatal death rate of hospital birth.” Well, the major flaw of this research was that any out-of-hospital birth was included in the “planned home birth” group — even those that happened in the car on the way to the hospital (obviously, that was a planned hospital birth — it just didn’t happen that way), and even those that happened from 34-37 weeks (which are preterm births, and midwives don’t attend these births which are for obvious reasons riskier). They also didn’t exclude those babies with lethal birth defects who would have died regardless of birth place.

So, when reading research, it’s important to realize these things, because not everything is always as it seems.

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Seth’s birth story

Today is my younger son’s 2nd birthday. I’ve been thinking about posting my birth stories for a while, so here goes…

Even though my state allows non-nurse midwives, the closest one I could find was well over an hour away, so when it seemed like I was heading into labor on Friday of Memorial Day Weekend, I called her to let her know she should come. Apparently, my uterus just didn’t like what I had eaten for supper, because by the time the midwife and her assistant came, my contractions had almost stopped and were not strong. You’d think I’d know real labor from false labor the second time around, wouldn’t you? 🙂

Real labor started on Monday afternoon — Memorial Day. Even though the contractions were strong, they were only about every 7-15 minutes apart. Having had one false alarm, I didn’t want to make the midwife drive that far again for another false alarm, so I decided to wait until the contractions were every 5 minutes or until my water had broken. Contractions continued every 7-15 minutes apart all night long. I had to breathe and vocalize through them. And my husband had to sleep because he had to get up in the morning and drive. (He was driving a big rig at the time, and had a load that needed to be delivered that day. I found out later that it would have been just fine if it had been delivered on Wednesday. He says he told me that; I told him next time don’t listen to me when I’m in labor.) 🙂 What was going through my mind that morning (probably some 15 hours after labor started), is that I still hadn’t settled into a reliable pattern, so I didn’t count that I was in “real” labor, and it was likely that I wouldn’t go into “real” labor until he got back. I was afraid that he’d stay home all day, and nothing would happen, and then he have to go when I was right in the middle of labor, or just after the baby was born, and I didn’t want that. Besides, I had stayed up all night in the living room so he could sleep, and if he didn’t go, then my night of laboring by myself without him even being awake to rub my back was wasted. (Like I said, “don’t listen to me when I’m in labor” — that was the muddled labor hormones talking.) So, off he went.

I was so tired, and just felt completely defeated. Nothing was going as I had planned. We were staying with my mom at the time (not where I wanted to be); my midwife was over an hour’s drive away, and I had already disturbed her once (not what I wanted to do again); and then my husband had to leave. Plus I hadn’t gotten much sleep because of the blasted contractions. I was able to sleep between some of them, but it was quite a restless night. I called the midwife around noon to let her know what was going on, but I didn’t really let her know that I was in labor — I guess I wanted her to read my mind?? What I told her was that I was having some contractions, but they weren’t in a regular pattern, and I’d call her when they settled into a regular pattern or when my water broke.

I put my older son down for his nap (he was 19 months old at the time), and continued with the blasted labor. The contractions hurt so bad! When I was in labor with my older son, I thought “epidural” one time, and that was it. This time, I thought “epidural” with every contraction for several hours. I tried every position I could think of, including several positions I thought would be horrible, but nothing else was working. None of it worked. What I really needed was somebody to apply counter-pressure to my back. A nice chiropractic adjustment probably would’ve helped. I had pubic symphysis disorder, which I think may have contributed at least somewhat to the labor pain. Whether it was due to fetal malpositioning, PSD, just my bad luck, or something else, I don’t know. In my first labor, I opted to get a labor pool, but it didn’t seem to help that much, so I opted not to get a labor pool this time — and I was wishing for it something fierce!

Finally, about 3:30 in the afternoon, my water broke. YES!!! FINALLY!!! So I called my husband, the midwife, my mom, and my best friend to let them know that something was finally happening. Remember that my midwife lived over an hour away; plus she had to arrange for child care. My back was hurting terribly during contractions, and it really felt like I need to use the bathroom. Of course, I knew this was a classic sign of birth being imminent, so I resisted the urge. Until the thought popped into my mind that I hadn’t gone to the bathroom all day, and maybe if I emptied my colon, it would relieve some of the pressure!

My mom had come home right before this, bringing my brother’s two kids; my sister also had just arrived with her three kids; and my other sister’s kids popped in from next door. Lovely. My memory is a little muddled at this point, but I must have briefed my mom on what was happening, and I think the midwife called in to see how things were going at that point. Anyway, my mom flipped out — she’s very nervous about birth anyway (was knocked out against her wishes for all four of her births, so has no memory of anything except contractions, going to the hospital, and waking up with a pubic shave and a big episiotomy) — and she starts crying, and hustling the kids off to my sister’s house next door. I go to the bathroom to try to relieve some of the pressure I’m feeling [all you seasoned birthers are probably smiling right now — or am I the only one who can make myself believe that I’m not really pushing, I’m just going to the bathroom?]. My sister comes into the bathroom and tries to make me get into bed, so that I don’t push (per the midwife’s orders). She didn’t realize that I had been in labor so long — thought that when my water broke was when labor had started, and thought it was a premature urge to push and/or a precipitous labor. [Ha! I wish!] By that time, I had pushed one time, and felt the baby’s head move way down. I knew there was no stopping it!

About this time, my husband calls to see how things are going; the midwife is calling in on another line (as she’s racing down the highway trying to get there in time — no way!); and one push has put the baby to crowning. My mom is trying to handle two phones at once, and is crying and flustered; my sister is trying to get me to stop, and I tell her there’s no way. And then my mom hangs up on my husband!!! When I found out later that had happened, I was furious, but what could I do?

I’m not really sure if the first push put the baby at crowning, or if it was the second push, but anyway, the next push birthed his head, and the next push birthed his body. I was in hands-and-knees position, and my sister caught him. She handed him to me, and we started drying him off with towels. About this time, a lady from church (a former nurse) arrived. My mom called her all flustered when it became apparent that I was going to be having the baby without the midwife, and she dropped everything and left her 5 children (the oldest was old enough to babysit!) and flew down. Seth wasn’t breathing yet, but he was looking around and looking at me. Everybody else was kinda freaking out, but I could tell everything was just fine — he was still getting as much oxygen from the placenta as he was before he was born, so I knew he was all right. When they started rubbing him briskly with the towels, he cried in irritation, and everybody else breathed a sigh of relief. He started nursing immediately.

His birth time was around 4:30, about an hour after my water broke, but nobody looked at the clock right then. It could have been much earlier if I hadn’t tried not to push. About 10-15 minutes after that, I pushed the placenta out. We were all still in the bathroom, so clean-up was a breeze! Just wipe up what little blood there was with the towels, and toss ’em into the washing machine. (We kept them until the midwife got there, so she could verify that it wasn’t a hemorrhage — my mom thought it was a lot of blood, but I could tell that it wasn’t very much. It’s just that a little goes a long way. A “hemorrhage” in a vaginal birth is more than approximately 2 cups of blood — visualize 2 cups of red food coloring spilled onto your floor, and it looks like a lot.)

We didn’t have an ultrasound at all, so we didn’t know if he was a boy or girl until birth. When he came out, my sister said, “Oh, he’s beautiful!” and I said, “Oh, he is a boy?” which is what I had thought most of the time. She kinda laughed and said, “I didn’t check!” So I looked and was the first to find out for sure that he was a boy. He seemed so small! I thought he was about the size that my older son was at birth, which was 7 lb. 5 oz. I called him, “My itty-bitty boy.”

Anyway, we wrapped the placenta in a chux pad and put it in a plastic bag to keep from making a mess with it, and I went to bed with my newborn son. Somebody brought my other son back over, and he wasn’t too sure immediately about the baby, but liked him pretty quickly. At some point, somebody called my husband or he called back — anyway, he heard that the baby was born, and everything was okay. About an hour after birth, the midwife and her assistant got there and checked everything out, and did all of the post-birth stuff (weighing, measuring, etc.) My husband was delayed by a car wreck or construction or something, so didn’t get home until about 3 hours after the baby was born.

When the midwife and her assistant saw the baby, they said, “Oh, he’s big!” But then, they’re used to seeing newborns, whereas it had been almost a year since I had seen a newborn baby. He was 9 lb. 2 oz. Born without a tear, only “skid marks.”

The birth was quite a bit different from what I had expected — so much for visualizing how birth will go, huh? Even though my water didn’t break until the end (and it had broken at the beginning of my first labor), the contractions were just as painful, if not more so. I was alone. Sometimes I see women writing that their “perfect” birth involves them laboring alone, outside under the moon or whatever. No, thanks — been there, done that (well, not the “outside” part), and don’t want to do it again.

Let’s just say that I completely understand why women seek the care and comfort of other women during labor. But my main regret is that my husband wasn’t there. In thinking about giving birth the second time (even prior to Seth’s conception), I always envisioned my husband receiving the baby as I pushed him out. Instead, he was the last person in the family to see him — my siblings and all their children saw him before my husband was even home. I’ll have to make sure my husband knows this next time around (if there is a next time) — don’t require me to think very much during labor! When I’m in labor, it feels like my brain is underwater — sights and sounds are muffled, and I’m pretty much “submerged” into labor. Listen to me when I say things like “rub my back,” but anything that requires more thought than that is subject to tremendous error! You learn something new every labor.

Welcome Dr. Amy Readers!

I just noticed that Dr. Amy linked to my blog recently. Pull up a chair and make yourself at home! Thanks for your interest!

Too much or not enough?

I’ve got a small garden and a black thumb. Since last year I killed most of my plants by not watering them enough, I was determined this year not to neglect them. So I’ve been watering them frequently. The plants didn’t seem to be making the transition very well, so I thought I wasn’t watering them enough — it didn’t rain very much, about a month ago (but I now think the dew was abundant). So I was watering them more… but it seemed to help them less. So, I contemplated that maybe I was watering them too much, so determined to cut back on watering. And then we went into a rainy spell. Which drowned my plants. Sigh…

But that got me to thinking about birth — when there are interventions that can be used, is it too much, or not enough? I’m a natural birth advocate, so when I read some studies about when interventions are used, I read them with a jaundiced eye. My first thought typically is, “Ok, so what this study is saying is that this intervention is better than that intervention — but what about no interventions at all?” For instance, Henci Goer writes a critique of a study that concluded that early epidural doesn’t increase the C-section rate compared to late epidural. You can read the full critique because there are several points of interest; however, the most important point is that this study doesn’t really compare early epidurals to late epidurals, plus there is no true control group of women who did not get an epidural at all. Our current national C-section rate is about 30%. About 10% of women who planned to birth at home end up transferring to the hospital for all reasons (inducing or augmenting labor, pain relief, nonreassuring fetal heart-rate, etc.); not all of these women get C-sections. Home-birthing women are a self-selected group, and they are by definition low-risk, so this would account for some of the difference; but two out-of-hospital studies had a 4% C-section rate. Most women who participate in studies such as the above epidural study are low-risk (the typical study will be limited to full-term first-time moms pregnant with only one baby), although many women who choose to give birth at home have had previous vaginal births.

So, what I would like to see are well-designed studies that compare an intervention to no intervention — a truly natural birth compared to a medically-managed birth. The only problem is, most hospital births can’t be called “natural” in just about any way. Women do not “naturally” lie in bed on their backs with EFM belts across their bellies in labor. “Natural” is movement. Many women in hospitals are not allowed to eat or drink anything, but are forced to rely on IV fluids for hydration and sustenance. Although not all women want to eat or drink in labor (I didn’t in my first labor, but did in my second labor), it is not “natural” to deny them food or water if they want it. Have there been any studies that compared C-section rates of women who were allowed freedom of movement in the hospital versus those who were required to stay in bed? Or studies comparing women allowed to eat freely versus those who were restricted?

These two factors may seem insignificant, but they are not. Hunger is your body’s natural signal that you need nourishment, not just sugar-water. When I’m hungry, I get irritable and can’t think as well and don’t deal with things as well — many negatives are augmented. When I was in labor with my first baby, the midwife had me lie on my back once or twice in order to check my cervical dilation. Those contractions were the worst. At that point, “epidural” crossed my mind, but I blocked it out and replaced that thought with, “Now I know why women in hospitals get epidurals.” I could deal with the contractions when I was upright or on my side, but they were just that much worse when I was on my back. If I had to have contraction after contraction while lying on my back, I would have requested an epidural, too, and I was not yet to 4 cm dilated when she checked me. Yet the thought of requesting an epidural or any other pain relief (except counter-pressure on my back during a contraction) never went through my mind again. It’s a completely different experience.

So while a hospital may find that the majority of women require or benefit from this intervention or that intervention, I always wonder if they would have truly been helpful or necessary had they been at home. Just as I over-watered my plants when I should have decreased the water, I wonder if some doctors over-intervene when they would have better results had they used fewer interventions.

Gestational Diabetes Guidelines — Revised

I declined the glucose tolerance test both times I was pregnant. This was my reasoning — if I were to develop true diabetes, there are signs and symptoms of that happening, and I figured my risk of getting diabetes was low. The likelihood of my needing insulin or medication was even lower, so likely all that would be done is that it would be recommended that I follow a diabetic diet and/or watch my intake of sugars. I was doing that anyway.

Even at that time, I had a distinct dislike of presuming there to be a problem when the likelihood was that there would be none. Also, it just didn’t make sense to me to shock the body with that much sugar after fasting for so long — the solution for the test has the equivalent of a can of Coke or a candy bar (more or less, depending on the actual solution and the particular candy bar). First, it didn’t make sense to me to fast during pregnancy — that just sounds like a dumb idea. Second, it makes even less sense to go from fasting to downing a Coke in 5 minutes, and then continuing to fast. Some women experience quite a bad reaction to the test — nausea and lightheadedness are not uncommon.

Also, the first test is not a test — it’s a screening, which means that it will have a high number of false positives. This means that a lot of women will think they have diabetes when they don’t; and a lot of women will be unnecessarily subjected to the more rigorous 3-hour glucose testing. Then, not all practitioners have the same cut-off levels for gestational diabetes — some doctors will diagnose GD when other doctors will not.

So, I was glad to read that the U.S. Preventive Services Task Force “concludes that the current evidence is insufficient to assess the balance of benefits and harms of screening for gestational diabetes mellitus (GDM), either before or after 24 weeks gestation.” You can read more here. It is possible for sub-clinical diabetes to become full-blown diabetes during pregnancy, so it would be wise for some women to be tested (although I wonder why they can’t just have the women monitor their blood sugar several times a day for several days, instead of guzzling the glucose solution while in the middle of a several-hours-long fast); but what this is saying is that there isn’t enough benefit to recommend the screening universally (which is what doctors typically do). You know what this means? Henci Goer was right all along.

What you eat may determine your baby’s sex

Here’s the link to the original story I read. Basically, women who consumed a higher-calorie and/or more nutritious diet around the time of conception increased their chances of having a boy; women who skipped breakfast or cut calories increased their chances of having a girl. Interesting.

Then I read a blog that completely blasted the study’s findings, calling them sexist, and calling into question researcher bias. I have a different spin.

Biologically speaking, women are more important than men — simply because we are the life-bearers, and it takes so long to produce a healthy child. When times are tough and food is scarce, it’s more important to ensure that more females are born than males. (The following is a statement of fact, not of what should be. I am not advocating harems or polygamy or anything like that.) One man can father as many children in a year as he can find willing females. Since it takes almost a year to grow a baby, a woman can only have one complete pregnancy in a year (but may have twins or more). Exaggerating to prove a point, if the population of the world were suddenly reduced to 1 person of 1 sex and 50 persons of the other sex, which would you rather see — one man and fifty women, or fifty men and one woman? Remember, the survival of our species is dependent on the ability of the female to reproduce. So a lone man could conceivably and easily father 25 children every year, under those circumstances, while a lone woman would be hard-pressed to have one child every year.

See? That’s a much better way of looking at things! When the going gets tough, more females are produced! You go, girl! 🙂

Teaching Normal Birth Interactively

This is such a cool resource! In an article appearing in the Journal of Perinatal Education, the authors show several ways that childbirth educators can teach their clients some of the hows and whys of normal birth.

My thanks to At Your Cervix for posting the link on her blog!