Current Research and Paradigm Shifts

I will never be free from medical ethics and consumer advocacy.  I am thankful for that.  Not only have I learned so much about my body and the complications of the medical field, but I have also learned that much of this knowledge can be applied in other fields.  I am hopeful that my research will help further an inevitable paradigm shift in my field that has yet to be “named.”  I can’t be more specific about it at this time.

I can be specific about my reading list:

  • Groopman’s How Doctors Think is at the top of the list (but currently MIA from my library, argh!)
  • Gawande’s The Checklist Manifesto and Complications: A Surgeon’s Notes on an Imperfect Science
  • Gadamer’s The Enigma of Health
  • Medical Error, Rosenthal & Sutcliffe (eds.)
  • Medicine Looks at the Humanities, Newel & Gabrielson (eds.)

I suppose this will keep me busy over the long winter break!

Stakeholders for the Homebirth Summit

Stand and Deliver posted more information about the upcoming Homebirth Summit called by the ACNM.  Have a look at Rixa’s post and my previous post if you haven’t already (additional links on my previous post).

Geraldine Simkins, president of MANA, sent out a message with more information regarding this “work team.”  I’d like to further break down the point that addresses “stakeholders.”

The stakeholders are NOT ANY ORGANIZATION but rather are individuals who are defined as belonging in these nine stakeholder groups:

    • Consumers (from a variety of perspectives)
    • Consumer advocates (doulas, childbirth educators, childbirth and women’s healthcare activist)
    • Home Birth midwives (CPM, CNM, LM, Amish, traditional, whatever)
    • Obstetricians and OB family practice
    • Collaborating MCH providers (nursing: L&D, neonatal, pediatrics; CNMs who provide backup)
    • Health insurers and liability insurers
    • Health policy, legislators, legal, ethics
    • Research and education: Public Health, epidemiology
    • Health models, systems, administrators

In this way, the WHOLE SYSTEM is at the table. Otherwise, we will not be able to seriously come to consensus.

Here are my thoughts on each identified group of stakeholders:

  • Consumers from a variety of perspectives – why would they invite consumers who have no understanding of or appreciation for home birth to the table?  How would an anti-homebirth consumer help improve home birth?  How are these people being chosen?
  • Consumer advocates – are these all people who currently (or have a history of) support families who desire or choose home birth?  Doulas, CBEs, and activists are not necessarily supportive of or educated about home birth.  How are these people being chosen?
  • Homebirth midwives – ok good, hopefully they will select some midwives (with solid experience & reputations) who have chosen NOT to be certified.
  • OBs and FPOBs – aside from receiving transfers in a hospital setting, what experience do they have with homebirth?  It is possible that an FPOB would be more supportive of home birth, but puh-leez, how many OBs have actually attended home births???  Additionally, how forceful will a FP be in an arena over-represented by “first class” medical participants or will they be subverted by their more ‘highly esteemed’ colleagues?
  • Collaborating MCH providers – other than practitioners who willingly back up homebirth midwives and their families, what business do these other people have weighing in on homebirth?  I have yet to meet a nurse who thinks home birth is a good idea.  This is now the second category of stakeholders that I place within the larger category of ‘back up.’
  • Health insurers and liability insurers – at this point in time, I think it will be useful to have this group participate in the discussion.  They need to “face the music” and know that women and their families expect home birth to be a viable option.  Insurance is often a barrier for people who desire home birth.  Additionally, liability insurers have stuck their big fat toes into every crevice of maternal-fetal care, so they need to know what a huge obstacle they are providing for families searching for the best options that suit their needs.  (The fact that my OB couldn’t/wouldn’t deliver a breech baby because of his stinkin’ malpractice insurance drives me INSANE to this day!)  This group should listen and learn.
  • Health policy, legislators, legal, ethics – what in the HELL kind of catch all category is this?  I can’t make sense of it.  However, representatives from state-level governing/licensing boards, like Montana’s Alternative Health Care Board, should participate.
  • Research and education: Public Health, epidemiology – please add medical anthropology to this group!
  • Health models, systems, administrators – again, too vague for my comfort.  And it is premature to invite this group to the table.

Which of these stakeholder groups are rooted in public health and/or naturopathic (including midwifery) perspectives?

  • Consumers (??!!) – maybe, but again, it depends on the “variety of perspectives” invited . . .
  • Consumer advocates (??!!) – see above
  • Homebirth midwives

Which of these stakeholder groups are rooted in allopathic tradition?

  • OBs and FPOBs
  • Collaborating MCH providers
  • Health insurers, liability providers
  • Health policy, etc. (??!!)
  • Research and education – some of these folks might have training in non-allopathic perspectives
  • Health models, systems, etc.

So SIX groups (already with institutionalized POWER) interacting with THREE groups (with hardly any power when it comes to institutional change) with two-thirds of its representation from somewhat questionable backgrounds . . .

And people involved wonder why women (like me) are so concerned?

Hispanic Female Pelvises are Better?

My OB said the most bizarre thing today.  At first it didn’t really strike me as bizarre, but the more I’ve thought about it, the more I’ve realized it’s a crock of shit. PLEASE, where is the evidence?!

I’m not exactly sure how we got onto this topic this morning, but he stated that the Hispanic female pelvis is bigger than the average white woman’s pelvis.  The best birthers are short hispanic women according to the doc.  And then said something about a study in Southern California that I didn’t really pay any attention to.

Let’s just break this down a bit.  According to this post over at The Unnecessarean (July 2010), the cesarean rate in Mexico’s private hospitals is 70% and 40% in public hospitals.  If Mexican women are so much more physically capable of using their pelvises, then why does their cesarean rate exceed ours?  Perhaps pelvimetry is not as much a factor as OBs would like us to think?

The Unnecessarean post, an article written by Cinthya Sanchez that appeared in El Universal on July 18, 2010, further points out:

A 2002 study based on public health data from 126 countries found that the estimated rate of cesarean sections in the world was 15%, while in Latin America and the Caribbean, the average rate was 29.2%: Mexico (39.1%), Brazil (36.7%), Dominican Republic (31.3%) and Chile (30.7%).

None of these cesarean rates support my doctor’s assertion that a woman’s genetic structure has anything to do with achieving a vaginal birth.  According to Jesús Lujan, an obstetrician-gynecologist specializing in human reproductive medicine and the director of Clínica Pronatal, other factors are at work here.

“Women are marked in advance by previous cesarean section, any uterine scar in general, and cephalopelvic disproportion, which is almost always an imprecise measure because not all professionals use the same parameters for diagnosis. Mothers are told that are too short and that we are sure your pelvis is smaller than the baby’s head, that they are too old and will be unable to handle birth, that the cord is tangled, that sex will never be the same, and many other lies,” says Lujan.

Aha!  I knew it.  I wonder if some jackass OB in Mexico is currently telling his patient that you need to be tall with a Nordic bone structure (my genes) to have a baby fit through the pelvis?  What do you think?

For more information on CPD (cephalo-pelvic disproportion) diagnoses (and what it probably doesn’t mean for you) and pelvises, I recommend:

Contributing to the Modern Cesarean Epidemic: an example of insufficient evidence in my field

Today I was in class trying to follow along in a fast-paced discussion of voice pathologies.  One such pathology discussed was the Human Papilloma Virus which can attack the vocal folds.  Colds and other viral infections can manifest as papillomas (small harmless epithelial tumors) on or near the vocal folds (membranes of the voice box).  This is called Recurrent Respiratory Paillomatosis (RRP).

RRP shows up in children, and the suspected cause is a HPV-infected mother.  When a baby descends through his/her mother’s birth canal, the baby can contract HPV if the mother carries the virus.  Adult onset RRP evidently is becoming more prevalent, possibly due to changing sexual practices.

In the course of teaching us about HPV and the respiratory equivalent, RRP, the instructor stated that pregnant women with HPV should have their babies “delivered” via cesarean section.  The instructor was given this information by . . . you guessed it . . . a DOCTOR!  I couldn’t hold my tongue.  I wanted my colleagues to be sure to know that although a doctor may suggest that a pregnant woman with HPV should have a cesarean, that it’s not a mandate.

I wish I had told my colleagues that uniformly recommending cesarean delivery due to HPV is not an evidence-based practice.  Why is this important?  What if a pregnant woman enters this practitioner’s speech & hearing clinic complaining that her voice is hoarse and weak, and upon further investigation, it is discovered that she has RRP.  This practitioner may tell her that she’ll have to have a cesarean because she has RRP.  That may be one more woman who, heeding the advice of her care providers, would be cut.

Let’s look at some of the literature on the net about both HPV and RRP. (See sources at the bottom of this post.)
Frequency:  According to the RRP Foundation, there are maybe 20,000 active cases of RRP in the U.S., and the CDC estimates that less than 2,000 children contract RRP in a year.  HPV is quite prevalent – approximately 20 million Americans are infected.
Transmission.  Active condyloma during pregnancy or HPV can cause a baby to become infected, but occurrence is deemed RARE.  As stated previously, RRP is becoming more prevalent in the adult population possibly due to changing sexual practices, and HPV has a strong connection to sexual practice.
Childbirth recommendations:  Cesarean delivery is not completely protective from RRP though recommended for consideration when visible condyloma is present in a primaparous pregnant patient.  Cesarean delivery is not protective against RRP in mothers with genital warts.

Well-meaning practitioners from other unrelated fields can and do contribute to the cesarean problem.  However uncomplicated a cesarean may seem when presented antiseptically from a medical provider or behavioral clinician, important questions are not being asked:

  1. How likely is transfer of the presumed pathogen
  2. How is cesarean delivery protective against the transfer of specific STDs and other viral infections
  3. What physical complications can arise for the mother with a cesarean
  4. What physical complications can arise for the baby due to a cesarean
  5. How does cesarean delivery affect the mother-baby dyad
  6. What psychophysical or emotional complications can arise after cesarean delivery (or after traumatic birth experiences); how and when do they manifest
  7. What complications may arise (at birth, in childhood, during puberty, in adulthood) from possible RRP transfer
  8. How should the patient/client prioritize the risks/benefits of vaginal or cesarean birth
  9. What does the mother (and her support team – partner, family members, close friends, etc.) desire
  10. Who is more important – the mother or the baby

This last question is the most perplexing, it seems, for the medical community.  Babies are born innocent and vulnerable.  They are unable to advocate for themselves.  In protecting the rights of the unborn or barely-born (not that I oppose that ultimately, I might add), care providers knowingly and unknowingly subvert the rights of the mother.  The mother is here right now.  She is hopefully a positive contributor to her community.  She may already care for other children.  She may have a life partner.  When her health and happiness is compromised for the well-being of her innocent child, is our society really any better for it?  Which is more important – kinetic energy, a life in process, a current contribution . . . or potential energy, a life about to begin, a possible contribution.

I hope readers will take to heart the broadest implications of this post.  First, medical doctors and insurance companies are not the only ones adding to the increasing cesarean rate.  We find well-meaning contributors in some of the most unlikely places.  Second, questions beyond “how easy is it to fix” must be asked when the life and well-being of the mother-baby dyad is at risk.

For more information on cesarean delivery, please visit the International Cesarean Awareness Network (ICAN) and Childbirth Connection.

Sources Consulted:
CDC information on HPV – http://www.cdc.gov/STD/HPV/STDFact-HPV.htm
Condyloma in Pregnancy Is Strongly Predictive of Juvenile-Onset RRP – http://www.greenjournal.org/cgi/content/full/101/4/645
Course notes
eMedicine – http://www.emedicine.com/med/topic2535.htm
Genital HPV Infection Learning Module – http://depts.washington.edu/nnptc/core_training/clinical/PDF/HPV2008.pdf
RRP Foundation – http://www.rrpf.org/
Women’s Health, HPV and Genital Warts – http://www.womenshealth.gov/faq/stdhpv.htm

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