Did you see this? - Page 3

[IwannaBanRN]

Originally Posted by Magdalen1978 

I did, in fact, realize that the post on attachment parenting and autism was satirical -- which does not make it any less absurd and obnoxious.  Thanks, Jeminijad, for your snarky suggestion that I did not grasp this woman's intent.  Oh, by the way, that was sarcasm I just used.

I agree with other posters that this woman's tone is thoroughly inappropriate.  It's one thing to suggest that homebirth should take place under particular conditions and with the appropriate safety measures in place, and that homebirth is in fact not a good idea for some moms and babies.  It is another thing entirely to mock an entire way of thinking and deride a very diverse group of women because they make choices that contradict her particular understanding of science and data analysis. 

Of course an OB is going to flame homebirth! A midwife is paid $5000 a patient for ALL care! Prenatals, labor, delivery, postnatal care and newborn care. But an OB, well, that's another story and it all depends on what interventions you get, even if you DON'T want them. It can easily rack up to $20,000 and if your OB decides you should have a c-section when you fail to progress past 4 cm in the last 4 hours, even though it's obvious you won't get anywhere when you're strapped to a bed by uncomfortable monitors, blood pressure cuff, and IV that'll most likely double the cost of the hospital bill. Where's this money going? Oh THAT'S right! The OB! Because they DESERVE $20,000 for stepping into the room and catching your baby and cutting a cord. Why pay an OB $30,000 with needless intervention, not to mention what was paid for OB appts, when you can cover everything with a midwife in the comfort of your own home for $5000? The decision seems simple, at least with low-risk women that educate themselves on childbirth and take responsibility for their own births. OB's get mad when women homebirth with a midwife because that's tens of thousands of dollars not going into the OB's pocket.

Now, don't get me wrong. OB's are GREAT when they are needed but do you NEED an OB to catch your baby? No. You need them when you or baby is in immediate distress and they cut you open to get baby out. OB's are good at surgery. They are surgeons and that's what they should be doing, not catching babies. And I HATE it when people say that a doctor "delivered" the baby. No, YOU delivered it, but the baby was caught by someone else.

[jenniferlynne]

Originally Posted by IwannaBanRN 

Yeah, but most of those people are book smart, not common sense smart. Smart enough to get through med school and have high reading comprehension scores? Yes! Determine common sense and basic knowledge of the people that they are treating's needs? NO!
 

That's a pretty sweeping generalization there and, IMO, completely unfair.  Sure there are doctors whose bedside manners need improvement, but the same could be said about certain midwives too.  And there certainly are doctors who have excellent common sense and understanding of their patients' needs!

[IwannaBanRN]

And you don't think this OB's view isn't sweeping and painfully over-generalized? There are PLENTY of competent OB's out there, and my very first OB was so great to me. But it's doctors like Dr. Amy that make people rethink OB's and her attitude would turn a patient off to ALL OB's, most likely.

[SympatheticDad]

Originally Posted by IwannaBanRN 
OB's are GREAT when they are needed but do you NEED an OB to catch your baby? No. You need them when you or baby is in immediate distress and they cut you open to get baby out. OB's are good at surgery. They are surgeons and that's what they should be doing, not catching babies. 

And this is where we can see the fundamental misunderstanding in action.

Mothers do not need intervention ... except when they do.

Babies can be born without problems ... except when they can't.

An OB's primary job is not to respond to emergencies, although they do that too.  An OB's primary job is to prevent the emergency from developing in the first place.  That's worth saying again:  Obstrectic medicine is primarily preventive in nature.  The reason OB's engage in so many (so-called) "unnecessary" interventions is because, ideally, they're intervening before an emergency develops.  So instead of waiting until your baby has been suffocating for an extended period of time, they respond to changes in fetal monitoring that indicate that a problem may be developing.  After the fact, it's easy to look back and say "Well, that was unnecessary, because nothing bad happened," but that's not how one properly uses statistical analysis.  You don't claim that wearing your seat belt was unnecessary just because on a given car trip you didn't crash.

In many cases, intervening after an emergency develops is too late for the baby, and too late for the mother.  One of the things that chills me to the bone here is when I see mothers being advised to skip important testing or monitoring "because it might lead to interventions".  That's like telling someone who wants to cross  a usually quiet street that should be clamping their hands over their eyes and shouting "LA LA LA I CAN'T HEAR THE CARS."  As the patient of a doctor or midwife you can always decline medical care.  You can fire your doctor or midwife.  But you can't make good decisions if you deliberately avoid collecting the necessary information.

Does this lead to false positives, to situations where, had the OB not acted, everything would have been fine?  Yes, certainly.  But you can't tell which cases are which in advance.  The expertise the OB is providing is that of advising you as to what situations statistically warrant intervention versus which ones don't.  

People misunderstand all of medicine, not just obstetrics.  People have a vision of doctors figuring out new techniques on the fly to magically fix problems.  That's not how it works.  I would say that one of the primary things we pay doctors for is their understanding of statistics and to help us to make decisions about when to act and when not to act.

Ignoring the realities of childbirth will result in everything being fine for you - except when it's not.

[sosurreal09]

PP your post is great, right I get that...but statistically c section rates are higher at certain times (change of shift, when it's getting late especially...OB just wants to go home already?) and certain days of the week (Friday, heck the weekend is starting perfect time to cut you open so I can go enjoy it!) I would not call that preventative and/or life saving...

Another factor is that OB's and other healthcare workers are scared of malpractice and sueing. Can you blame them? Maybe if this country wasn't so sue happy... So they need to make sure they "did everything they could" so no one turns around and says they messed up. So I think a lot of c-sections come out of fear...

[SympatheticDad]

I'm not gonna stand here and defend bad medicine -- you've had bad doctors, I've had bad doctors, we've all had bad doctors.  I just feel like someone has to say that "some OBs are bad" isn't the same thing as "OBs are bad."

[IwannaBanRN]

Originally Posted by SympatheticDad 

And this is where we can see the fundamental misunderstanding in action.

Mothers do not need intervention ... except when they do.

Babies can be born without problems ... except when they can't.

An OB's primary job is not to respond to emergencies, although they do that too.  An OB's primary job is to prevent the emergency from developing in the first place.  That's worth saying again:  Obstrectic medicine is primarily preventive in nature.  The reason OB's engage in so many (so-called) "unnecessary" interventions is because, ideally, they're intervening before an emergency develops.  So instead of waiting until your baby has been suffocating for an extended period of time, they respond to changes in fetal monitoring that indicate that a problem may be developing.  After the fact, it's easy to look back and say "Well, that was unnecessary, because nothing bad happened," but that's not how one properly uses statistical analysis.  You don't claim that wearing your seat belt was unnecessary just because on a given car trip you didn't crash.

In many cases, intervening after an emergency develops is too late for the baby, and too late for the mother.  One of the things that chills me to the bone here is when I see mothers being advised to skip important testing or monitoring "because it might lead to interventions".  That's like telling someone who wants to cross  a usually quiet street that should be clamping their hands over their eyes and shouting "LA LA LA I CAN'T HEAR THE CARS."  As the patient of a doctor or midwife you can always decline medical care.  You can fire your doctor or midwife.  But you can't make good decisions if you deliberately avoid collecting the necessary information.

Does this lead to false positives, to situations where, had the OB not acted, everything would have been fine?  Yes, certainly.  But you can't tell which cases are which in advance.  The expertise the OB is providing is that of advising you as to what situations statistically warrant intervention versus which ones don't.  

People misunderstand all of medicine, not just obstetrics.  People have a vision of doctors figuring out new techniques on the fly to magically fix problems.  That's not how it works.  I would say that one of the primary things we pay doctors for is their understanding of statistics and to help us to make decisions about when to act and when not to act.

Ignoring the realities of childbirth will result in everything being fine for you - except when it's not.

Ummm.....if you read my post at all, and actually referenced ALL of it, you would see that I said "The decision seems simple, at least with low-risk women that educate themselves on childbirth and take responsibility for their own births ". It's utterly irresponsible to take care into your own hands if you have not taken precautions and take responsibility for your body and your child by educating yourself about risks and reasons you should be seeing an OB. But definitely NOT an OB like Dr. Amy. Like I said earlier, her attitude would turn many patients off to OB's alltogether. I know that not all Dr's or OB's in general are like her or her "followers" because my very first OB was amazing with me. She doesn't condone homebirth, but wouldn't be so inappropriate as most OB's about homebirth.

[IwannaBanRN]

Originally Posted by sosurreal09 

PP your post is great, right I get that...but statistically c section rates are higher at certain times (change of shift, when it's getting late especially...OB just wants to go home already?) and certain days of the week (Friday, heck the weekend is starting perfect time to cut you open so I can go enjoy it!) I would not call that preventative and/or life saving...

Another factor is that OB's and other healthcare workers are scared of malpractice and sueing. Can you blame them? Maybe if this country wasn't so sue happy... So they need to make sure they "did everything they could" so no one turns around and says they messed up. So I think a lot of c-sections come out of fear...

Maybe if more women were ACTUALLY educated about the birthing process and took responsibility of what is going on, there wouldn't need to be precautions taken to prevent suing. There would be a waiver saying that they knew what was going on with their body and knew about the real risks of interventions or not using available interventions.
 

[jenniferlynne]

Originally Posted by IwannaBanRN 

And you don't think this OB's view isn't sweeping and painfully over-generalized? There are PLENTY of competent OB's out there, and my very first OB was so great to me. But it's doctors like Dr. Amy that make people rethink OB's and her attitude would turn a patient off to ALL OB's, most likely.

That's highly debatable, and it really isn't the point.  I wasn't taking issue with your comments about Dr. Amy but rather with your generalization that the scientifically minded commenters posting on her blog (and doctors in general, it seems) lack common sense and the ability to understand the people they treat. That is a completely unfair generalization. You may be right that Dr. Amy isn't going to win over someone who's stubbornly determined that NCB is best at ALL costs (and there are people like that here, the ones SympatheticDad compared to someone crossing the street and shouting 'LA LA LA, I CAN'T HEAR ANY CARS") but she may very well win over people who are on the fence or those who can look beyond the tone to some of the more disturbing facts that she presents.  As I've said before, I completely understand people being put off by her tone but what I don't understand is the immediate dismissal of the information she presents because of the way she says it.  Like it or not, some of what she says is true and should be considered -- not instantly dismissed -- by people who want to make a fully informed choice about the kind of birth they want to have.  

[IwannaBanRN]

The "disturbing facts" are about people who either aren't educated about the risks or ignore warning signs all together, not people who are aware and taking responsibility for their actions. I know that if I were "risked out" of a homebirth, I wouldn't go against the facts that I couldn't homebirth without killing me or my baby. I would go to the hospital, but also research what interventions are avoidable within the hospital. That's called an informed decision. I could "want" a homebirth so bad, but wanting my baby alive would totally outweigh that. The responsibility of my body and baby would not go into the doctor's hands if I were hospitalized. I still have a responsibility to be informed as much as possible.

[sosurreal09]

Well yeah of course the woman SHOULD BE INFORMED. The reality is not all women are or even want to be, so that means we should just cut their baby out b/c they didn't care enough to research? Many many people blindly trust Drs with many, many things....

[jenniferlynne]

Originally Posted by IwannaBanRN 

The "disturbing facts" are about people who either aren't educated about the risks or ignore warning signs all together, not people who are aware and taking responsibility for their actions. I know that if I were "risked out" of a homebirth, I wouldn't go against the facts that I couldn't homebirth without killing me or my baby. I would go to the hospital, but also research what interventions are avoidable within the hospital. That's called an informed decision. I could "want" a homebirth so bad, but wanting my baby alive would totally outweigh that. The responsibility of my body and baby would not go into the doctor's hands if I were hospitalized. I still have a responsibility to be informed as much as possible.

I don't think you and I are actually too far apart on this.  I don't have an issue with people making an informed choice to have a home birth, as you described, but there are people who do not, who immediately dismiss the risks of birth and barrel on with their plans despite all evidence pointing to the fact that they are not a good candidate for home birth.  How many times have we seen threads here asking for encouragement in having an HB or an UC despite signs warning that there could be increased risk?  It worries me to death to see threads like that, and while sometimes people do speak up and say that the poster may want to see an OB or consider a different birthing plan, sometimes others dismiss or play down the concerns.  It worries me.  Those are the kind of people that Dr. Amy is criticizing, them and the poorly trained birth attendants who are often to blame for poor outcomes.  She may be totally, 100% against HB in all cases, and I am not, but I am trying to acknowledge the validity of some of her points despite her tone and approach. That seems necessary to me in order to consider all the evidence and make a fully informed decision.

(FWIW, both my births were in the hospital but were lovely, mostly intervention-free with midwives [CNMs, obviously].  While I always felt a home birth wasn't for me, I fully understand and support the choice to birth at home.  I'm not PG yet but we are considering a third and I had been toying with the idea of a HB; for better or worse, reading Dr. Amy convinced me otherwise)

[jenniferlynne]

Originally Posted by sosurreal09 

Well yeah of course the woman SHOULD BE INFORMED. The reality is not all women are or even want to be, so that means we should just cut their baby out b/c they didn't care enough to research? Many many people blindly trust Drs with many, many things....

And on the other end of the spectrum, many women blindly trust their midwives -- some of whom are woefully undertrained -- and downplay the very real risks of birth.  I think we all agree that every pregnant woman should be as informed as possible about birth.  To me, that means considering all the facts, even those delivered in an unpleasant manner.

[Imakcerka]

Yes, and some people refuse to trust anyone but themselves and their intuition.  However, how many times have we been wrong?  What needs to be brought up here is how we can make our way to a happy medium.  How can we educate each other about the benefits of both as well as the negatives without putting our blinders on and creating a larger divide? 

I don't believe in statistics and all numbers can be falsified.  Just throwing that out there.
 

Originally Posted by sosurreal09 

Well yeah of course the woman SHOULD BE INFORMED. The reality is not all women are or even want to be, so that means we should just cut their baby out b/c they didn't care enough to research? Many many people blindly trust Drs with many, many things....

[IwannaBanRN]

Ignoring problems doesn't make them any less real than what they are(and frankly, the high risk people's posts scare me as well), and I appreciate doctors when those things do arise, but low-risk or not, be informed. Birth isn't an exact science and I believe that many doctors treat it like it IS science, rather than two human-beings trying to make a transition into a new chapter in their lives.

Imakcerka, are you posting from a phone? There's a load of gibberish within your post. Just letting you know.

[Turquesa]

Erigeron,

Despite her acerbic style, I continue to read Dr. Amy because she knows how to do science.

I couldn't disagree more.  I don't believe that we're allowed to link to anti-homebirth sites (who knows The Rules anymore? ) but please bear with me.  The references that I make will be easy to find on a search engine or her blog.

Here is just one example.  In a recent blog post, she sang praises to the recent Chen study on electronic fetal monitoring.

Yet the Chen study compares EFM not to intermittent auscultation but to no monitoring at all.  Well, duh.  Monitoring is important.  So I suppose that routinely strapping women down to a piece of machinery that yields a high false positive rate could arguably be better than nothing. 

Through sin of omission, however, Tuteur neglects to mention that the Chen study does not take into account intermittent auscultation, which the the U.S. Preventive Services Task Force, Royal College of Obstetricians and Gynaecologists, and Royal Australian and New Zealand College of Obstetricians and Gynecologists continue to uphold as highest evidence-based standard for low-risk pregnancies.  (The American College of Obstetricians and Gynecologists, ever the maverick when it comes to following the evidence, won't come in favor or against EFM's routine use, implicitly giving OB's their blessing to practice against the evidence).  "Requiring" that all laboring women submit to EFM belts continues to go against the evidence.

I know that Tuteur also embrace the Wax meta-analysis as the big I-told-you-so to buttress her beliefs, but a critical perusal will show you that the home birth deaths that it considered included extremely limited birth certificate data and did not control for planned v. unplanned births.

That's not somebody who knows how to do science.  That's somebody who knows how to twist it to conform to her biases.

Most people are not educated in medicine. That's fine, obviously--that's why we have doctors. But it's hard for a layperson to do research and make an informed decision on their own, because they don't have the background.

Well, conducting and interpreting research doesn't require a background in medicine.  It requires training in statistics and methodology.  Out of curiosity, how much coursework in research methodologies do nursing and medical programs require?  I was looking at Dr. Tuteur's alma mater but don't see any set-in-stone numbers of how much is actually required for graduation.

 These courses present students with an introduction to the social factors that influence health and disease both domestically and globally, the principles of clinical epidemiology and biostatistics required for the evidence-based practice of medicine and critical appraisal of medical literature, an overview of health care policy issues and options, and the ethical dimensions of medical decision-making.

Perhaps the topic is integrated into the required coursework, so it's only fair that I ask.  I have a Master's degree in one of the "soft sciences" and had to complete six credits in research methodology. 

There's a big difference between being an informed layperson and being a medical professional--there is a large body of knowledge to apprehend.

I agree about that large body of knowledge.  I recently did an online course (from an extremely reputable school, not Google U. ) on medical research.  I no longer have the citation (may dig it up if I get curious and motivated enough), but did you know that for just an internist, there are 17 new studies studies PER DAY that they need to review in order to stay on top of the research?  That's a tall order for somebody working doctor's hours!  Can you imagine what this figure might look like for a surgical specialist?  An obstetrician, for example?  I'm therefore not sure where you are getting this notion that being a doctor automatically means that one is staying of abreast of the research, let alone practicing by it.     

It would help to remain humbly aware that doctors and nurses are not scientists.  They are practitioners with an ethical duty to practice based on science.  But in most cases, they are not the individuals conducting the research through experimentation and observation.  And in most if not all cases, a doctor wouldn't dare approach a patient using an experimentation-observation model, particularly in life-or-death cases where immediate intervention is crucial.   

But if you insist, Erigeron, that we lowly laypeople defer to physicians on these topics, I will happily do so....beginning with Drs. Marsden Wagner, Stuart Fischbein, Henry Dorn, William Sears,

Simone Buitendijk, Elizabeth Allemann.....

[kathrineg]

I go to a practice with two doctors, one is actually very nice and has amazing bedside manner. The other is nice enough but a very poor listener. 

Addtionally, I don't think that doctors necessarily make more if you have a c-section vs a vaginal birth...I think they get paid the same amount, which is usually one lump sum for the entire prenatal period and the delivery. In that sense, their billing is like that of a midwife who charges 4k (or whatever) for the entire prenatal care and birth.

The motivation for OBs to do c-sections seems to be partly to avoid deaths and other complications, partly to avoid frightening and unpredictable situations like shoulder dystocia, partly to avoid litigation, and partly for convenience. I really don't think that money is a huge motivator for them compared to these things.

How much each factor weighs into each OB's decision depends on the OB. I'm sure there are sociopathic OBs who section women just to get to a golf game, but I think they are in the minority compared to OBs who genuinely feel like a c-section is the least risky decision.

As for c-sections before shift changes--it sounds bad, but in the sense that a doctor thinks that a c-section is inevitable they might want to do it themselves instead of turning a mother over to another care provider, which has its own risks and drawbacks. So again, I think there is room for nuance.

[erigeron]

Quote:

Originally Posted by Turquesa 

Well, conducting and interpreting research doesn't require a background in medicine.  It requires training in statistics and methodology. 

Fair enough. Interpreting research in the context of practice is what would take a knowledge of practice that couldn't be conferred solely through statistics and methodology, but if I were putting together a study I'd certainly want a statistician on my team. My program (pharmacy) did not have a specific course devoted solely to this; it was integrated across the curriculum. I would imagine a medical school program would be similar.

I'm therefore not sure where you are getting this notion that being a doctor automatically means that one is staying of abreast of the research, let alone practicing by it.      

I never said that being a doctor automatically means one is staying abreast of the research (though staying current in the profession, if not reading every single study, is pretty much part and parcel of being a medical professional, and continuing education is expected). It does mean that one has the background necessary to interpret the new findings and apply them to practice. Doctors aren't the only people who have this background. But I think it's safe to say that a lot of laypeople who say they "did research" do not have the necessary background, and thus their interpretations are suspect... which was basically the point of my post.

But if you insist, Erigeron, that we lowly laypeople defer to physicians on these topics, I will happily do so....beginning with Drs. Marsden Wagner, Stuart Fischbein, Henry Dorn, William Sears,

Simone Buitendijk, Elizabeth Allemann.....

I didn't insist on any such thing. You're putting words in my mouth. I simply think that it's easy to think that you (generic you) know a whole lot about a subject, when really you don't. Medical professionals have a grounding of knowledge on the human body combined with a grounding in what to look for in research studies that a lay person would be hard-pressed to get.

I do, however, think that Dr. Amy cherry-picks her articles to some degree. I wasn't a fan of, for instance, her conclusion on EFM either. She certainly has her blind spots and I don't take her opinion, or that of any doctor, as gospel. But sometimes it's nice to read something written by somebody who actually *understands* that quoting the abstract as if it proves anything, saying "X hasn't been proven safe", calling obstetricians "surgeons", and other such behaviors that drive me batty, are Bad Science.

[starrlamia]

good post turquesa.

I really dont think the majority of Dr. Amy's followers are physicians, Im sure some are, but considering how easy it is to find her site and how easy it is to lie on the internet, it seems like most of the people on there are not that knowledgable.

My biggest complaint with OBs is the fact that they are trained to view birth as an inherently pathological event, which it is not. Unfortunately the way they are trained is to conduct those interventions without a second though and pass it off as "saving" the mother or baby when there are other evidenced based practices that could be used that avoid such things. However I dont blame the OB's for it, it isnt their fault their training is focused this way. Ive met many wonderful OBs and I have met many craptastic OBs. I think people need to keep perspective and remember that most OBs and Midwives are doing what they believe to be right and they arent neccessarily out to oppress women's autonomy. I really wish in the USA the 2 could embrace and work with each other but that is a whole other political debate I dont feel like getting into.

[coocoocachoo]

Where are you getting that info from?