The evidence suggests

I find myself asking this more and more.

Are you a logical, numbers-focused person?  Do p values excite you? How about multiple regression graphs with obviously sloping lines? Multiple regression analysis with orthogonal contrast coding?

I was never a great math person, but statistics in grad school made sense to me.  It was like I could visualize numbers in a way that I couldn’t with multiplication and division.   The patterns of data and whether or not the patterns were more than just random coincidence just made sense in my mind.  I took several statistics classes, and used MRA to publish my Master’s work.

Granted, it has been 18 years since I did hard-core stats work and defended the methods of that study.  I don’t remember everything, but I feel like I have the ability to look at any scientific publication and understand the basics.  I know the difference between practical and statistical significance.

So, it should be a given that I can delve into the studies on PubMed and read for myself about the associations of birth interventions and birth outcomes, right?  But here’s the thing, I do.  Almost every  day.  And yet, I can’t leave the computer feeling confident in whatever has been concluded, no matter which way the conclusion leans.

Depending on who is doing the work, how the study is designed, what questions were asked, and what variables were measured, a different answer will emerge.  Just because something is published does not make it a fact. We can’t simply read the abstract and accept it if it matches our beliefs. In the science of medicine and birth, just as in the science of measuring public attitudes about hunting, there are so many variables that cannot be measured, never mind the treatments that can’t be tested against a control. Additionally, there are so many outcomes that are never considered. So I find myself relying more and more on common sense and physiology.  That’s not cool for someone who relies on numbers, who is always looking for clear-cut answers.

What is Evidence Based Medicine?  It is a relatively new term coined in the early 90’s when doctors decided it was unethical to treat patients based solely on anecdotal practice history and bias. Up until that point, practice guidelines were typically determined by one or two leaders in the field.  One study, with a pitiful sample size (think Friedman’s Curve), was the basis for all of modern obstetrical care and still is, despite evidence that it is simply inaccurate and misleading.  Prior to that, if a doctor believed something to be better (such as, the second stage of labor is the most dangerous to the baby, so let’s knock women out, cut open their vaginas and wrangle the baby out with forceps), that is what the doctor did.  Thank heavens we have doctors and midwives who now ask for research questions to be answered and who apply that knowledge in their work.  But, guess what? It takes an average of 17 years for research conclusions to be incorporated into everyday practice.  And what if the research conclusions are misleading, inaccurate, outdated, based upon small sample sizes, or apply only to medicated birth, as they have been since Friedman’s work was published?

Is there really such a thing as evidence-based medicine?  Is there a right or a wrong way to do things when it comes to childbirth?  Honestly, I don’t think so.  We can only act upon what we know, and what we know is dependent on whether we are asking the right questions and measuring the responses in the right ways, whether we are considering the various factors that influence where the research was done, and whether iatrogenic interference is influencing the results.

Did you know that most studies that evaluate the affects of birth interventions on birth outcomes don’t even consider breastfeeding as an outcome? Certainly, very few consider long-term breastfeeding as an outcome.  If breastfeeding as an outcome is measured, many times women who breastfed one week are lumped into the same outcome group as women who exclusively breastfed for 11 months.  How can we find a difference in breastfeeding as an outcome if we lump such different groups of women together?

So here’s what it boils down to: medicine is not a science, it is an art. And ultimately, there is no right or wrong decision to be made.  There is only an informed decision or an uninformed decision.

I attended a birth where the client had several complications. She was advised to get an epidural to help lower her blood pressure.  Up to that point, it was being managed with an ace inhibitor and was under control but widely-variable.  We were working hard to use deep relaxation techniques, and she was handling the sensations of birth well. When she asked what the risks of the epidural were, she was told there was a tiny chance of a headache following the epidural and a likely drop in maternal blood pressure (which is what was needed). There was no other explanation of potential side effects. After the epidural meds were administered, she began to shake, she felt woozy, and her blood pressure tanked.  Her baby’s heart rate dropped, and the nurses pushed syringe after syringe of ephedrine. She continued the rest of her labor with an oxygen mask, nausea, light-headedness, shaking, and ultimately needed a Cesarean when her baby’s heart rate did not recover.

Did she make an informed decision? No, because she wasn’t told about the risk of too low blood pressure.

Talk to your doctor about all aspects of your care. How does it affect bonding, breastfeeding, risk for cesarean, discomfort during recovery? Get your information from all kinds of sources. Be sure your doctor is giving you a full picture of the benefits and risks of all the choices you are making.  Understand that the phrase “the research shows….” may or may not mean anything in your individual situation.

Don’t make the right decision. Make an informed decision.

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