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Obstetric Myths Versus Research Realities

Chapter 1: Introduction

As a childbirth educator and a childbirth assistant, I have read or heard obstetric myths--old doctors' tales, if you like--many times. Here are some examples, along with the disinformation they convey:

"My doctor says trying to turn the baby from breech to head down would be like driving on the wrong side of the road at 90 miles per hour." Myth: External cephalic version is unacceptably risky.

"They said if I didn't want the electronic fetal monitor, I would have to sign a paper saying they could not be held responsible if anything went wrong with my baby." Myth: Electronic fetal monitoring prevents fetal death and brain damage.

And, of course, the perennial favorite,
"When I asked about episiotomy, he said, `Which would you rather have: a nice, clean cut or a jagged tear?'" Myth: Episiotomies prevent perineal injury.

Anyone working to improve the childbearing experience and help women avoid unnecessary intervention can fill in the blank on a long, frustrating list that begins, "But the doctor said . . . ," where the doctor was wrong. And while the evidence in the medical literature is solidly, often unequivocally, against whatever "the doctor said," without access to that evidence the pregnant woman is quite reasonably going to believe her doctor, whom she presumes is the expert.

This book is my attempt to make the medical literature on a variety of obstetric issues accessible to people who do not have the time, expertise, access, or proximity to a medical library to research it on their own. This includes those who teach pregnant women, those who care for them, those who plan maternity care, and the women themselves. My goal is a compact reference, scholarly yet understandable to people without medical training, and organized so that readers can readily find the information they want. Secondarily, I want to explain the huge gap that yawns between common obstetrical practice, which claims to be research based, and what that research actually says. This paradox puzzled me greatly, as I think it must trouble all those trying to reform maternity care.

Accordingly, an introductory chapter gives basic information about the different types of medical studies, how to evaluate them, and some basic statistical concepts. (Don't worry, you don't need to know a lot about statistics. A little knowledge will take you a long way.) Mostly you need to know some commonsense questions to ask and what to look for while reading through an article. Because a major stumbling block in reading the medical literature is the specialized vocabulary, I provide a glossary at the end of the book and define terms in the text as well.

The Glossary and Chapter 2, on evaluating studies, will provide enough background to read the abstracts (summaries) I have written of medical papers or to tackle the studies directly. (Most medical school libraries are open to the general public. Many hospitals also maintain libraries.) One of the better-kept secrets of medicine is that it is not an arcane body of knowledge comprehensible only to doctors.

The main body of the book is divided into three parts. Part I is entitled "The Cesarean Epidemic" because our outrageous cesarean rate--nearly one out of four women gives birth by major surgery--is the hottest of the birth issues. It begins with a general overview followed by a closer look at the four most common indications for cesarean section in order of frequency. Part II, "Pregnancy and Labor Management," takes pregnancy and labor chronologically, dealing with some myths of mainstream medical practice. (I have by no means covered them all.) Part III, "The Case for an Alternative System," argues for midwives, their noninterventive approach, and out-of-hospital birth.

Each chapter follows a pattern:

  1. A stated myth followed by a quotation from the literature stating the reality.
  2. An essay that analyzes mainstream belief, pointing out its fallacies.
  3. A list of significant points gleaned from the studies and keyed to my abstracts.
  4. The outline by which the abstracts will be grouped.
  5. The numbered abstracts themselves.

I have had to be selective but have included enough to make my case. Surprisingly few issues were controversial. In most cases the evidence was overwhelmingly on one side. I have also liberally sprinkled my abstracts with quotations because I think it is important to have what the researchers say in their own words without filtering through me.

Each abstract begins with its citation structured in this way:
Author's last name and initials, next author or et al. if there are more than three. Title of the article, with only the first word capitalized. Journal Title Abbreviated year;volume(issue):page numbers.

For example:
4. Thorp JM and Bowes WA. Episiotomy: Can its routine use be defended? Am J Obstet Gynecol 1989;160(5):1027-1030.

Sometimes I have inserted my own comments or definitions, which appear in brackets, in the body of the abstract itself. Occasionally I have added explanatory notes to an outline heading.

With few exceptions, I have confined myself to articles published from 1980 on. For example, some of the randomized controlled trials of electronic fetal monitoring took place in the 1970s. Articles grouped under each subheading are listed in ascending chronological order of publication to enable you to follow how subsequent studies built on previous findings or filled in holes. Sometimes I make exceptions if the studies are connected, as when a group of researchers studied a population and then later presented follow-up data on the same population.

I have tried to make this book responsive to many different needs. Some people will stop with the overview essay and significant points. Others may use the numbers keyed to those points to look up the abstracts that contain evidence for that particular statement. Yet others will use the broader groupings of my outline similarly. Still others may use the abstracts to decide if they want to see the whole article. Naturally, additional studies will have been published since I completed this book. Nonetheless, once there is a body of well-done studies that reach the same conclusion, future studies rarely invalidate that conclusion.

The closing chapter synthesizes the work of medical anthropologists and others to explain why Western obstetrics operates (in both senses of the word) contrary to its own research findings and what forces shape its beliefs and practices. This chapter amplifies a running theme in the essays that begin each chapter in the main body of the book. It also explains why normally assertive women have docilely accepted a system that manifestly serves them poorly.

Because I have biases (although I hope I am not prejudiced), I think you should know more specifically what those biases are. I believe we have a maternity care system whose unconscious principles and resultant conscious practices fail those who should be its primary beneficiaries.

I am not antitechnology, but I am opposed to the routine use of intervention. I have attended labors in which the judicious use of technology probably saved the baby and even in a case or two, possibly the mother, but the key word is judicious. I believe the injudicious use of technology is doing considerable physical and psychological harm to mothers and babies.

I am not antiobstetrician, and I personally know and know by reputation some very fine obstetricians. Here is what I think defines good care. Good doctors (and midwives):

* Believe childbearing to be a fundamentally healthy and normal part of a woman's psychosexual life.

* Treat women holistically, taking into consideration their thoughts, feelings, concerns, and priorities.

* Respect the right of women to make informed decisions for themselves and their babies.

* Respect labor as an experience with its own lessons and rewards.

* Offer supportive rather than interventive care.

* Evaluate individually and do not treat by rule.

* Start small when intervention becomes necessary.

* Keep abreast of the medical literature.

I believe most doctors want to do well by their patients, although I have seen, experienced, and read about enough instances of arrogance, indifference, ignorance, and even cruelty to have no illusions. This book itself contains numerous examples of all of the above. Still, the main problem is differing definitions of "doing well." Korte and Scaer (A Good Birth, A Safe Birth) explain:

If all childbirth is seen to be dangerous, the overriding concern of the obstetrician becomes, naturally, "a safe birth." . . . [From the obstetrician's viewpoint] there are six key elements; a "safe birth"

* Is actively managed

* Is predictable

* Is controlled by the obstetrician

* Takes place in the hospital

* Is attended by an obstetrician

* Is solely measured by a live baby and a live mother

I understand where this viewpoint comes from. One way of gaining an illusion of control over an essentially unpredictable process is to set up rigid rules. The doctor feels less helpless if he or she is orchestrating events especially if he or she also believes that less aggressiveness will lead to a dead or damaged baby, a malpractice suit, or the disapprobation of peers (more about this later). However, Korte and Scaer point out that a "good experience" and a "healthy baby" are not either-or propositions. This is the point of my book too. I see the doctor's role as lifeguard at the beach, watching out for sharks and intervening should one appear, but believing in women's innate competency as swimmers.

You may be wondering about my credentials to write this book since I am not a doctor--either M.D. or Ph.D. I respond with a story. Penny Simkin, well-known educator, writer, speaker, and editor, was called on the carpet by an anesthesiologist, irate that she had written a handout listing the potential trade-offs of epidural anesthesia when she was not a doctor (although he did not dispute her accuracy). "What are your credentials?" he demanded. "I can read," was her reply. So can I. For that matter, you can too.

I would like to hear from you if you find any errors so that they can be corrected in future editions. I have been as careful as I could, but no doubt some have crept in despite my efforts. I hope you find my book useful. I'd be interested to know if you did.

REFERENCE

Korte D and Scaer R. A good birth, a safe birth. 3d rev. ed. Boston: Harvard Common Press, 1992.


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Last updated Tue, Oct 5, 1999 by
Donna Dolezal Zelzer
, djz@efn.org

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