Home birth advocates often argue that OBs don't use evidence-based care in their practice.
So I have a question... where's the evidence that shows the safety and/or effectiveness of the following common home birth practices:
- herbs used to induce labor
- essential oils to induce or augment labor
- castor oil to induce or augment labor
- breech deliveries attempted outside of a hospital
- twin deliveries attempted outside of a hospital (or higher order multiples)
- treating GBS with garlic
- treating GBS with Hibiclens
- VBACs attempted without use of electronic fetal monitoring
I'm throwing this blog post together quickly so I'm sure I'm missing some.... help me out here.
If there is evidence to support any of these, I would love to read them so please add in the comments!
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The following were added in the comments by "excpmstudent" (thank you for sharing!):
-evidence to support use of homeopathy for anything
-evidence to support use of herbs for postpartum hemorrhage
-evidence to support use of *no medications* to treat postpartum hemorrhage
-evidence to support maternal supplementation with Vitamin K to prevent newborn hemorrhagic disease in the breastfed newborn.
-evidence that midwives have the ability discern variability of fetal heart tones with the exclusive use of auscultation.
-evidence that if no vaginal checks are done, it's safe to keep a woman home and not in labor after her water breaks for days or a week or longer.
-evidence to support prolonged 2nd stage. (I'm talking 6-24 hours OR LONGER. I wish I was joking with this one.)
-evidence to support expectant management of prolonged 3rd stage of labor. (Again, for HOURS. For some midwives, the sky's the limit on waiting for a placenta to come out)
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How about...Pre-e can be cured by eating dozens of eggs every day. Placenta previa can be delivered at home if you pierce the placenta with a drinking straw and pull the baby through. Eating a piece of cinnamon candy and blowing on a woman will stop PPH. Eating placenta will stop a PPH, or simply ordering the woman to stop bleeding. I'm not against homebirth but why in the name of God do they need to use such insanely stupid methods?
ReplyDeleteI thought this was a joke until I saw the comment about the cinnamon, which I've heard about. There are definitely some non-evidence-based care practices when it comes to PPH, will add to my blog, thank you!
DeleteLike you, I am curious what CPMs mean when they lament that women would go to hospitals if OBs only used "evidenced based care." Perhaps they are referring to old Farmers Almanacs that discuss cattle births. Cause you know, cattle are still mammals.
ReplyDeleteLOL :) I "get" where the sentiment comes from - it's something I once argued. But I now have a better understanding of certain standard procedures, how beneficial (and even life-saving) preventative action can be, etc.
DeleteI found this interesting and eye-opening:
http://www.theunnecesarean.com/blog/2011/1/15/defensive-medicine-is-a-symptom-of-a-risk-society.html
But when you argued it (way back when), what exactly did you mean?
DeleteDid you believe that OBs ignored evidence that proved some of the things listed in your post were beneficial? Or did you believe that OBs ignored evidence and practiced defensive medicine "instead"?
That is what I am trying to understand - and I've asked some commenters on SOB the same thing, never getting an answer. Perhaps if you get any evidence for the above, I will finally know.
In short, it was the naive belief that low risk equals no risk.
DeleteIn long....
To piggy back off of the defensive medicine article I linked, ACOG guidelines, for instance, consider post 42 weeks as post date. So I pretty much assumed it was nonsense to think of an induction prior to 42 weeks.
But NOW, I would be very, very hesitant in letting a pregnancy go that long and would certainly never do so without doing obsessive kick counts, NSTs and BPPs. I certainly would not go a day OVER 42 weeks. Just as a baby coming too early can have issues, so can a baby coming too late.
I didn't understand that a doctor, over the course of many years of studying and training and thousands of babies being delivered, probably has seen or dealt with things that I didn't know or understand or even dream about. Their standard of care is going to reflect it. They might have a 41 week rule b/c they have seen first hand the dangers of going too close or over 42 weeks. Just as a home birth midwife might find herself believing that going over 42 weeks is virtually no big deal b/c she has yet to experience a bad outcome in doing so thus far in her career, her standard of care is going to reflect that.
Anecdotes played a large part in my beliefs. You hear too many stories of babies born at home like twins, breech, 43 or 44 weekers, 11+ poounds, etc and you start to believe that nothing is too risky..... b/c you don't hear the other side... the stories of the perfectly healthy little babies that die at home b/c they were breech, the second twin, born 2 days after 42 weeks, etc...
Low risk becomes no risk b/c high risk becomes low risk.
Thanks for the additional thoughts.
DeleteIn the UK we very rarely induce earlier than about 41+5 unless there are other complications, because there are risks involved with induction - we certainly wouldn't be worried about a woman going to the full 42 weeks, although midwives do get a bit twitched after that and offer daily CTGs etc. Different system I suppose!!
DeleteThere are risks with induction... but there are risks in a pregnancy lasting longer than a placenta can properly function. I think it ideally should come down to individual circumstance. I don't think a "41 week rule" should be the norm but I also don't think going past 41 weeks should be done so without monitoring.
DeleteI would add:
ReplyDelete-evidence to support use of homeopathy for anything
-evidence to support use of herbs for postpartum hemorrhage
-evidence to support use of *no medications* to treat postpartum hemorrhage
-evidence to support maternal supplementation with Vitamin K to prevent newborn hemorrhagic disease in the breastfed newborn.
-evidence that midwives have the ability discern variability of fetal heart tones with the exclusive use of auscultation.
-evidence that if no vaginal checks are done, it's safe to keep a woman home and not in labor after her water breaks for days or a week or longer.
-evidence to support prolonged 2nd stage. (I'm talking 6-24 hours OR LONGER. I wish I was joking with this one.)
-evidence to support expectant management of prolonged 3rd stage of labor. (Again, for HOURS. For some midwives, the sky's the limit on waiting for a placenta to come out)
Just a few off the top of my head. Good post.
Can I quote you and add this list? Thank you for sharing!
DeleteFeel free. Happy to contribute to this discussion.
DeleteThank you. I added and linked to you.
DeleteHi Dani: I've loved your comments on the SOB. I noticed you live in So Cal. I'm new to your blog, but am curious if you do doula work in the LA area? I love to refer moms I know (I know lots of newly married young women at church) to a good doula who is well-educated and well rounded in childbirth issues. Also, sending women to a quality childbirth teacher is great, too. The most popular Bradley one in our area is NOT someone I would recommend. Anyway, I'd love to be able to contact you or find out how I can refer you to others. Perhaps you can find a way to contact me through my blog?http://childbirthcheerleader.blogspot.com/ Thanks!
ReplyDeleteHi Laura, thank you for the comment. I will check out your blog to see if I can find your email. Otherwise, you can email me at danielle at douladani dot com
Deleteepidurals "drug" babies
ReplyDeleteepidurals lead to c-sections
epidurals interfere with bonding
epidurals interfere with breastfeeding
labour pain is good for you.
Epidurals cause autism. Correlation = causation, don't ya know.
DeleteHi, I found you via the Skeptical OB. Over there I'm SarahSD.
ReplyDeleteFor many of these, I would say that the reason there is no evidence is that there is no research on the question, and there is no research on the question because the scientific/medical community doesn't think it is a question worth asking (I'm thinking of questions like - do certain herbs/oils/scents induce labor, use of garlic for GBS, ingesting your placenta, etc). Now, I'm not saying that we should automatically take these questions seriously. But when you ask "where is the evidence of X?", it assumes a level playing field for the questions that does not exist.
In cases where the study would be less likely to cause harm (I think ingesting placenta might fall into this category), the research isn't being done because the idea is simply dismissed. In other cases (like using garlic for GBS), a controlled study would never happen because the consequences of the garlic NOT working is too risky. There are lots of reasons why these questions would be dismissed, and some are probably more valid than others.
I'm not saying that we should then automatically believe the anecdotal accounts as evidence, just that the "where is the evidence?" question glosses over the unevenness of the playing field when it comes to what questions are deemed researchable by medical science.
Hi Sarah, thanks for the comment. I do see what you are saying, but....
DeleteIt seems like a double standard to me. Interventions are interventions. It seems they are only perceived as "evil" when done inside a hospital. If birth is so normal and natural, then there should be no induction herbs or etc etc.
It also seems like a gamble or an experiment to see what can work without actually becoming "medical." For example, GBS can be serious and life threatening - why ignore that evidence and treat it with garlic, based on a theory that garlic could work? A care giver saying "garlic is a safe alternative to IV antibiotics and just as effective" is a lie b/c there is no proof. To mislead someone by eluding to that (or anything of that nature) is wrong.
And also, what about the situations of twins, breech and VBACs.... those have been researched. They are ignoring the evidence if they lead mothers to believe it is safe to attempt such deliveries anywhere other than inside a hospital with immediate OR access and/or continuous EFM.
I don't think we disagree. There is totally a double standard, especially when it comes to interventions and the 'trust birth' mentality. Let your baby choose its due date, until you want to "help it along" with "natural" induction methods; "Trust birth" until something goes majorly wrong.
DeleteI totally agree that "interventions are interventions" and that it is misleading for the NCB folks to pretend that by painting theirs as "natural", they don't count as such (though I think blowing cinnamon candies in a hemorrhaging woman's face should be counted as doing nothing.)
I was just pointing out that the lack of evidence for some of these claims (when there is a lack - like you say, there is some very strong evidence against the safety of homebirthing twins, breech, VBAC and other high risk situations) is not totally neutral. In other words, it's not like you can expect the NCB advocates to have a study to point to that supports OR disputes some of these claims.
Having said that, I do sometimes wonder what definition of "evidence" the NCB crowd are using when they ask for "evidence based care". If they are pushing back against a conventional model of science and medicine, would they welcome a RCT of the use of garlic to treat GBS (a terrible idea, we both agree). I think not. What does "evidence-based" mean for them? Anecdotal? Feel-good?
"though I think blowing cinnamon candies in a hemorrhaging woman's face should be counted as doing nothing"
DeleteHa! Agreed!
I see what you are saying and yes, we are in agreeance. I do think anecdote plays a large part in the beliefs. I have heard so many times things like "I had a 10 pound baby born healthy at 43 week, so see? Baby will come when ready and your body won't make a baby that is too big." I have heard and continue to hear things like that ALL the time.
Overall, when they refer to evidence-based care, I believe a large part is that they believe doctors don't follow things like ACOG recommendations down to a T (or other such studies and bulletins). Inductions prior to 42 weeks, use of Cytotec to induce, use of continuous fetal monitoring, etc... anything that has literature or a study to back it up, and basically no exceptions made - otherwise, the doc is not practicing evidence-based care. "Low fluid is basically an excuse to induce" - a home birth midwife told me this.
NCB/Homebirth practices which I see as not evidence-based:
ReplyDelete- Pretty much all at-home methods of trying to induce labor: sex, eating spicy foods, eating pineapple, and castor oil. The exceptions are acupuncture and acupressure, which might have some evidence behind them. Sex to induce labor was recommended by my doctor just before I delivered my son in September, so I guess that one isn't entirely on the NCB-movement. Not sure about nipple stimulation.
- The Brewer diet to prevent pre-eclampsia (recommended by my doula when I expressed fear of developing pre-eclampsia again)
- Hypnosis to reduce or eliminate pain in labor
- The idea that homebirth for low-risk women is as safe if not safer than hospital birth
- The philosophy that our bodies were "made to give birth" and that, when left to progress on their own, the vast majority of births will end with a healthy baby and healthy mother. The Rh- factor alone makes this patently untrue.
- Advising women to just keep on waiting for labor to start even past 41 weeks. There are risks to going past 41 weeks, and there is evidence that a woman may wind up with fewer interventions if she induces at this point, so it's probably time for NCBers to be putting this on the table more.
Obstetric practices that are not evidence-based:
- Mandatory NPO for all laboring women. IMO, women should be informed of the very-tiny risk of Mendelson's syndrome should general anesthetic become necessary and permitted to make their own decision on whether they want to eat in labor.
- Routine continuous EFM.
- Routine weekly cervical checks in the last month of pregnancy. Unless Leopold's maneuvers have been insufficient to determine fetal presentation, I see no need for checking the cervix.
- Induction due to isolated oligohydramnios.
- Use of Friedman's curve in calling for a failure-to-progress c-section. Hopefully this will begin to change following ACOG's new recommendations, but midwives have been criticizing the curve as outdated for years.
- VBAC bans; refusal to offer TOLAC to eligible women who meet the criteria
- Routine twin c-section even when baby A is vertex or both babies are vertex
- Not as much of a problem anymore, but come on, doctors spent decades giving out episiotomies like candy and telling patients lots of stupid crap like "it strengthens the perineal muscle." ACOG changed its recommendations in 2006, but it's still something to watch out for.
- Remind me again, why is it that American hospitals don't offer gas and air?
- Having women push in lithotomy or semi-sitting
Just my take on it. A pox on both those crappy houses, and I welcome feedback and correction.
- Correction: I mean induction due to isolated late-term oligohydramnios. Of course isolated mid-pregnancy oligohydramnios is a problem.
Delete