How to have an evidence-based pregnancy


#1

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#2

The article was so good we get to read it twice!

However, this article doesn't really tell you how to have an evidence based pregnancy so much as tell you how it differs from regular pregnancy advice.

Traditional pregnancy book: An expert[1] weighs the various risks and makes recommendations based on those risks, typically in the form of "don't do X" and "do Y". When presented with a situation where the evidence is sparse, these experts almost uniformly err on the side of caution, with a cumulative effect of over-restricting a mothers activities to avoid the miniscule chance that she encounters a rare complication that someone wrote an article about once in the New England Journal of Medicine.

Evidence based pregnancy book: The book just contains the known risks for various activities, and has you make the decision yourself. Downside: The available evidence can be poor and offer little usable input into your risk calculation.

[1] "Expert" is often just "person who had a baby, or knew someone who had a baby". There are way too many bad pregnancy advice books out there.


#3

What do you mean read it twice? It doesn't look like the text got double posted to me. Is that what you're seeing?


#5

I had my daughter at a birthing center, home birthing at that time not really an option in MD (no nurse midwives had attending doctors to support a home practice). I had read and was presented by the midwifery group a lot of information about how cascading interventions starting with Pitossin and going on to epidurals lead to medically unnecessary c-sections.

Later, when I was teaching prenatal yoga I researched this area more deeply on my own, and what I found was that the statistics were really hard to understand and presented very differently by midwives and doctors. There was no real hard and fast information about epidurals leading to c-sections. I would say that the evidence did seem to lean more toward it being better for people to have some drugs available and mostly toward the one thing that is not widely available, a doula to support the mother's emotional needs while the hospital staff cares for her medical needs.

In the end I decided that I had no business giving medical advice and that I could only teach techniques that a mother could use during labor if she chose not to have an epidural. I think the doctors do have first hand information that the books and articles do not provide, but this difference between how midwives were interpreting data differently from doctors I found quite offensive; it seemed that people were more interested in promoting their agendas than finding out what really made for a safe delivery.


#6

Strange, I just went back to the article and not only is it not duplicated, but it's much longer and has multiple sections now?

It looks like the version I commented on was just the Overview repeated twice.

Oh, and the link at the top of the BBS thread doesn't work, and there's no BBS link at the bottom of the article. Well, there is, but it's to a different discussion.


#7

Prof Alice Roberts has been talking on twitter a lot about home birth and risks recently.I think NICE has been encouraging home births.

http://www.theguardian.com/lifeandstyle/2013/mar/10/alice-roberts-on-science-childbirth-risks

http://www.theguardian.com/lifeandstyle/2014/may/13/pregnant-women-home-births-midwives-baby


#8

Huh. I did not see what you must have seen at all. At any rate: Fixed now!

Oh, and the link at the top of the BBS thread doesn't work, and there's no BBS link at the bottom of the article. Well, there is, but it's to a different discussion.

That's not what I'm seeing. The link at the top of this thread works for me and the "Join the Discussion" link at the bottom of the story comes straight here. Have you considered the possibility that your web browser is possessed? jk/


#11

Your point, "I would say that the evidence did seem to lean more toward it being
better for people to have some drugs available and mostly toward the one
thing that is not widely available, *a doula to support the mother's
emotional needs* while the hospital staff cares for her medical needs." is dead on.

We would like t say that "the science" indicates x is better than y, and sometimes that is indeed the case (choosing for a c-section when the baby is getting suffocated by its umbilical cord, for example). The problem is that each of us are different, and what is tolerable to one may be vastly less for another. I am phobic of needles. The idea of having an IV in me whilst delivering was far far more upsetting than the pain of natural childbirth. For me, the pain was preferable. Would I then say that all women should make my choice because it worked for me? Of course not. I suspect that most women would not mind the IV much, and would find the option of pain killers pretty appealing.

I did not have a birth doula. Although my partner was extremely supportive and was a good advocate for me, the one piece of advise I tell every expectant mom is to seriously consider a doula. Every birth is different, whatever happens the mother will probably not be in the best position to self-advocate, and so long as one has a doula who understands the mother's needs and desires relating to the delivery it can make a world of difference. Even if everything goes perfectly smoothly, knowing that there is someone who is very familiar with the process who is there for you is a tremendous emotional help.


#12

My wife and my first baby was delivered at home just last week. We had an exceptionally experienced and well regarded Midwife who had delivered more than 1,500 babies at home. We met several dozen people who had their babies with our Midwife, including many repeat clients. For us, the direct evidence available to us about our specific Midwife, and from people in situations similar to ours, weighed much more heavily than arguments about national averages.

I couldn't say definitively going into the birth whether homebirth was safer or less safe. But the statistics I saw were close enough, and the risks low enough, that safety wasn't our primary decision factor. We made our choice based on quality of care. The depth of the preparation, the quality of the attention, the feeling of teamwork and shared responsibility, the respect, endemic to the midwifery model of care–in our situation–made it a clear winner.

I get your point about demographic self-selection skewing statistics. But to be honest, this statement reads to me like: "there are some big issues with the fact that people who choose to use Ibuprofen are generally in demographic groups that are less likely to have brain tumors to begin with". Why is it a "big issue" that people make choices appropriate to their circumstances? Or do you mean that it's merely an issue for the data?

I generally agree with this sentiment. Though I would like to comment that well-trained Midwifes are quite capable of handling emergencies. Our daughter was born with an extremely short cord. The delivery went smoothly without any intervention. But about a minute after our Baby was born, the cord detached from the placenta–a very serious emergency. The placenta needed to come out immediately. The Baby had already latched on–which wouldn't have been the case in a Hospital–and the Oxytocin helps the Uterus contract to deliver the placenta. Within 30 seconds of the cord breaking, the Midwife gave my wife a shot of Pitocin, and was ready to "go in and get it" (the placenta), if needed. Thankfully, the placenta shot out about 10 seconds later, and the bleeding quickly subsided.

In a hospital, an OBGYN may have still gone in and "explored" the Uterus to look for tears after the placenta was delivered, causing much more trauma. And I would have supported the OBGYN in doing so too, because I wouldn't have had as long and as trusting a relationship with a Dr. I barely knew as I did with our Midwife, who we had spent 40 hours with over the course of the previous 9 months.

Home birth is not for everybody. You take on a lot of responsibility giving birth to a baby at home. You have to be prepared. But it's truly a wonderful thing to spend the first seconds, minutes, and hours with your new baby in the comfort of your own home. To have privacy, and peace. To deal with the pain by retreating into oneself, as my Wife did, rather than through the brute force of drugs. My Wife doesn't even describe the experience as painful, just laborious.

In my opinion, for better or worse, pregnancy is more akin to weather than climate. If you make decisions based on the "climate" of home vs. hospital birth, you're liable to end up wearing a wetsuit in the desert. You need to understand the climate as broad framing for your decision. But climate is a terrible predictor for your local conditions, so don't forget to look out your window and reason about your own circumstances.


#13

Medical professionals in my area (Northern Delaware, East Coast USA) are not real accommodating of evidence-based medical practices. If you have any pregnancy complications whatsoever (or, rather, if they can convince a tired, emotionally overwrought pregnant woman that they might have any) you will be doing what the high priests of medicine want to do, and be damned to your opinions and evidence.

In the USA physicians are trained to believe that their opinions matter more than yours. They truly do believe this (perhaps it is necessary to their trade) and thus they will feel no real guilt over whatever emotional or psychological manipulation they might use on a pregnant woman to override the evidence-based concerns of a spouse. They see themselves as knights on white horses, the bold champions of humanity.


#14

I would like to point out that this is a pretty broad over-generalization. In my experience, this isn't at all what doctors believe. I think it's reasonable to talk about there being a problem with the way doctors are trained in many places, and there being a problem with an older, but still-present model of medicine that encourages you to just do what the doctor says. But I don't think it's particularly useful to anybody to vilify doctors.


#15

I did not intend to vilify them. I don't believe it is automatically vile, or necessarily evil, to do your best for the human race according to your own best judgement! I'll apologize if my phrasing was a little bitter, but nonetheless I'll leave it stand so our conversational record makes sense.

Of all the hundreds of US physicians I have met, I have never met even one who didn't think he was doing a great service to humanity. And they may well all be right - personally, I haven't resolved my conflicting feelings about modern medicine, and I'm surely not qualified to judge the objective worthiness of all physicians as a group anyway. Yet I have never met one who was clearly doing it only for the money, or only for the social status. They always see themselves as doing a great and noble thing, by being healers, even if they are humble about their own personal worth outside the value of their profession. I do not believe this is insulting, overgeneralising, or misrepresenting the beliefs of physicians as a group - in fact I believe the heroic self-image of physicians is obvious from the evidence of both their deeds and words.

That being the case, obviously many, perhaps even most, will do whatever they have to do in order to achieve their ends. Humans are like that; we have sincere beliefs, that we consider worth killing/lying/sinning/misrepresenting/working for. If a doctor thinks that by telling you something (that might not be real science) he can persuade you to do something he believes will save your child, he's likely going to do it. Seriously, can you offer me any reason to think anything else? They are humans like you and me, and they have beliefs that influence their behavior like you and me.

I don't see any of the above as being dismissive or insulting to doctors. I see it as acknowledging human realities.


#16

I agree with you on the vast majority of doctors being in the profession to help humanity. And I agree that that goal can absolutely go awry.

What I'd object to was more this part:

they will feel no real guilt over whatever emotional or psychological manipulation they might use on a pregnant woman to override the evidence-based concerns of a spouse.

That's simply not true. And I don't think it's a natural outcome of believing your job is about helping humanity. I'm assuming, based on this conversation, that you and I had VERY different experiences with the doctors who were involved in the births of our children. And, given that, I think it's probably reasonable that you feel the way you do. But what you're describing here:

If a doctor thinks that by telling you something (that might not be real science) he can persuade you to do something he believes will save your child, he's likely going to do it.

is not how my doctor works. And, no, I don't think it's a fair description of what people can expect from doctors, in general. Different people approach the goal of "I am the person here to help you" in very different ways. One person might take it to misrepresenting so they can change your mind and get you do what they think you need to do. Another might, instead, do their best to give you all the information they can and explain to you why they are recommending what they're recommending, rather than just saying "you need to do this or BAD THINGS WILL HAPPEN".


#17

Also, you have to consider the case where someone has an actual bad idea and it's up to the doctor to convince them it is not in their best interest.

"I'm only eating raw organic Kale and drinking rain water for this pregnancy, because I read on the internet that it is how cavemen had children and their children were strong and healthy and I don't want to impart the toxins from our modern food into my child."

And then they get all butthurt when the doctor tries to explain that its not a good idea.


#18

Well, I think I've mentioned before that for us it was more like "I am a DOCTOR and I am telling you that if you listen to your husband with his 'evidence' and 'science' then YOUR BABY WILL BE BORN DAMAGED FOR LIFE AND IT WILL BE YOUR OWN FAULT. Now, what decision would you like to make? Ah, you'll let me do whatever I want, very good choice."

Then there were promises made, 30 straight hours of screaming, pain and blood, promises broken, a C-section that should not have been necessary, and a baby with an APGAR of zero. Luckily everyone survived, mostly thanks to the wonders of narcan®. Now you know why I dodged questions about my son's birth during your own pregnancy.

I think I need to note here that the physicians I was dealing with are respected members of their profession (both then and now) with a great deal of experience, and also extremely competent obstetric surgeons, who were completely convinced at every step of the way that they were doing the right thing, and who were completely satisfied with the final outcome - two live patients with scars that would heal. They were practicing their art to the best of their ability and they were not going to take any risks based on scientific evidence when they knew their arts would suffice. Were they wrong? I don't think they were morally wrong. Certainly they are not "bad doctors" by the standards of the profession or of our society.

But me? Well, now that I understand how human psychology intersects the physician's heroic mindset, I am much better able to direct events the way I want them to proceed. The parable of the scorpion and the frog comes to mind; even a frog can shape the future if he sees things clearly enough.

Edit: Probably should not have compared doctors to scorpions. Sorry, couldn't think of a more respectful way to make my point.

Edit2: Gotta go, back tomorrow.


#20

Dominoes really are expanding their range!


#21

Yes. /not jk


#22

Don't all pregnancies start with evidence of same?


#23

There are so many wonderful parts to your post that I want to quote it all!


#24

So you think someone with more than a decade of intensive training has no more basis for an accurate medical opinion than somebody who ordered a couple of books on Amazon?