"midwives' views" etc have NO place in our literature. Bugger their views!”

The other evening I posted this article to twitter.

“Women who plan to birth at home with midwives are more likely to receive Evidence-based Care http://fb.me/1puDpq2un”

The article described research that found that first-time mothers who chose to give birth at home were not only more likely to give birth with no intervention but were also more likely to receive evidence-based care that women who gave birth in hospital despite care by the same midwives. (BIRTH 39:2 June 2012)

There was an immediate reply tweet from a female obstetrician who has the twitter name @obgynkenobi

Image from Twitter @obgynkenobi

Obygnkenobi  tweeted:  “primips should not then home birth according to recent bmj RCT. This article is level 9 evidence. Sorry.” 

I responded:  er no, that's not what that study showed at all

Obygnkenobi  tweeted: “p0s [nulliparas]: increased risk of adverse outcomes if home birth. Please don't make me get out of bed to get the ref. it's cold.”  

I responded: "the BMJ study showed a miniscule increase risk to the neonate with a primigravid woman birthing at home"

Obygnkenobi  tweeted: “let's not just pick and choose which evidence suits us”.  

I replied:  “birthing at home is still far safer than driving with your child in the car or having a swimming pool in one's back yard”

Obygnkenobi tweeted:  "I'm not debating the safety. I'm debating the article that stated that homebirth midwives were more likely to use EBM [evidence based medicine]” And further “Yes, the absolute risk is low but if EBM is the master we all serve, primips should not home"

I wrote back: “actually, the researchers said that people needed to be aware of the risks, not that they shouldn't”

Obygnkenobi tweeted: “because clearly, "some" midwives choose whichever evidence is more appropriate to their aims”  

I asked "clearly"? why clearly?"

Obygnkenobi replied:  "b/c some mws (and drs) don't practice EBM. Interpreting evidence based on proving a point"

That comment reminded me of the way people responded to a very poor study that changed practice overnight, so I replied “Hmmm, I guess the Term Breech Trial is a good example of your point. So many so quick to jump based on such flawed research” 

Obygnkenobi responded: “probably true to a degree. However I know many skilled docs who won't touch a breech” 

To that I commented: “then they're not skilled with breech; over decades I've seen many breech births & brilliant doctors & midwives; now fear rules”

Obygnkenobi  tweeted: “It's not just the medicolegal aspect but the trial confirmed what they had always thought”. 

I was confused by that statement, so replied: “sorry, you've lost me here” and when I thought more about what she said, I asked: “so you think they stopped doing breeches because the skewed trial confirmed what obstetricians thought all along?”

Obygnkenobi responded: “no but it probably was one of the factors #beforemytime"

I was confused by this comment too, because surely, understanding why we do what we do involves knowing one’s history and ensuring that what we are doing is evidence based. I am also aware of how one’s own cognitive bias leads us to perceive and interpret things from our own viewpoint, which is what happened with the Term Breech Trial. Cognitive bias was also happening in response to the BMJ article, so I tweeted in response “the biggest issue is ensuring the evidence is robust and real - we know how easy it is to find what you are looking for”

Obygnkenobi  tweeted: “So there IS a role for using our brain!! Who'd thought!”

I didn’t recognise this at the time as sarcasm, but I did feel confused so said: “and I'm not sure what this was in relation to either?? erk - I've missed something :( and I was enjoying this conversation”

Obygnkenobi replied:  “EBM raises a difficulty: either use our brains or use evidence. It's ok to use either but don't dress it up as EBM if it's not”

I fully agreed with that statement about evidence based [medicine] care being a difficulty, I was experiencing that in this conversation and replied: “very much so!”

Obygnkenobi  then tweeted: “precisely. And that's why the article with "midwives' views" etc have NO place in our literature. Bugger their views!” (my emphasis)

I was surprised and disheartened by that comment and replied: “I find that comment depressing :( “

Obygnkenobi responded:  “ok. How about: ebm and individuals views should not coexist in the same article. Better?” and then “individuals views are ok, so long as they're not gusseyed up to look like evidence. It's all good really.”

I didn’t respond to those two statements as it was 1230am and I was not wanting to say anything that could be misconstrued or appear rude.

The next day I tweeted:  @obgynkenobi I'm curious to know if you read the actual paper?

I haven’t received any response to my query. 

This morning I tweeted: @obgynkenobi “did you see this? Term Breech Trial 10 years on” 

That article is worth reading as it revisits the criticisms of the Term Breech Trial and highlights the fact that there has been an increase in maternal deaths with the rise of caesarean section surgery for breech presentations following that study. 

The abstract states:

Abstract:  In 2000, the Term Breech Trial was published, and its authors recommended cesarean section as the safest mode of delivery for breech-presenting babies. Criticisms of the trial were raised at the time, which the authors dismissed. Since then, maternal deaths have been recorded among women undergoing cesarean sections for breech presentations. Accordingly, those initial criticisms deserve to be revisited. (BIRTH 39:1 March 2012)

Not only did the BMJ article that Obgynkenobi had referred to earlier in our twitter conversation Perinatal and MaternalOutcomes Perinatal and maternal outcomes by planned place of birth for healthywomen with low risk pregnancies: the Birthplace in England national prospectivecohort study   not say women having their first baby should not give birth at home, they concluded: 

“Our results support a policy of offering healthy nulliparous and multiparous women with low risk pregnancies a choice of birth setting. Adverse perinatal outcomes are uncommon in all settings, while interventions during labour and birth are much less common for births planned in non-obstetric unit settings. For nulliparous women, there is some evidence that planning birth at home is associated with a higher risk of an adverse perinatal outcome. A substantial proportion of women having their first baby who plan to give birth in a non-obstetric unit setting are transferred to an obstetric unit.

These results will enable women and their partners to have informed discussions with health professionals in relation to clinical outcomes and planned place of birth. For policy makers, the results are important to inform decisions about service provision and commissioning. The relative cost effectiveness of the different birth settings will also be of interest to policy makers and is being compared in another component of the Birthplace Research Programme.

Further research is needed into the avoidability of adverse perinatal outcomes, the effect of staffing and service configuration on outcomes, and more detailed analyses of transfers from non-obstetric unit settings. It is unfortunate that routine maternity information systems are not currently of a sufficiently high quality to enable the analyses presented here to be repeated without carrying out another large prospective cohort study.”

I also retweeted the article that sparked the twitter conversation:

I tweeted: @obgynkenobi in terms of evidence based practice, did you actually read the article about midwives use of evidence and place of birth? 

There is still no response, but it is Sunday!   

I would like to think that we can have good, intelligent conversations about evidence and practice without denigration and dismissive behaviour.  

Interprofessional collaboration in Delivery Suite was the subject of a research project I did in 2008. Attitudes like those displayed here by this obstetrician fit the model of Negative Interprofessional Interactions and stereotypical behaviour. This model is linked to low social and emotional intelligence of the midwives and obstetricians together with adverse outcomes for women and their babies.  Obstetricians and midwives don't feel good about these negative interactions either. I certainly feel very disconcerted with the attitude of this doctor towards midwives and our practice and the misinterpretation of these three studies.  

Right Livelihood Award: Ina May Gaskin

The world's premier award for personal courage and social transformation, The Right Livelihood Award honours and supports those "offering practical and exemplary answers to the most urgent challenges facing us today".

The wonderful Ina May Gaskin, affectionately referred to as 'the mother of midwifery', was awarded the Right Livelihood Award this year for:

“… for her whole-life’s work teaching and advocating safe, woman-centred childbirth methods that best promote the physical and mental health of mother and child.“

Ina May's acceptance speech is sobering as she carefully catalogues the abuses that have been and continue to be perpetrated against women and their babies in the name of industrialised birth; inspirational as she talks about the brave and loving doctors who have acted in the face of repression and vilification from their less than women centred peers and seek to scare women into submission to the medical juggernaut...

"We must wake up to the fact that it is easy to scare women about their bodies, especially in countries in which midwives have little or no power in policy-making, relative to physicians and the influence of large corporate entities. This takes no real talent. Given such imbalance, fear, ignorance, and greed begin to reinforce each other, and rates of unnecessary intervention soar, with women and the babies suffering the consequences"

Ina May's speech is heart warming as she asks the Hungarian Goverment to release Agnes Gereb, a Hungarian doctor who supported women to birth at home and encouraging as she offers a vision of a better world through optimising midwifery care and supporting women's choices ...

Another site came across my computer screen this morning, and given the content is highly relevant to the content of Ina May's speech, I thought it was entirely appropriate to link it here.

I'm not sure why the midwife broke the sac on this breech baby as she was born, I would have thought it was better left alone to provide that lovely buffer that intact membranes offer.  Even so, I'm grateful to the woman and her family and to the midwives for sharing this delightful photo journey. The explanatory notes are very useful.

Ina May's book Spiritual Midwifery, together with Frederick Leboyer's Birth Without Violence, changed my world when they were released in 1976.  I first heard Ina May speak at a preconfernce workshop at the 1992 Homebirth Conference in Sydney.   I was so emotional on being in the presence of Ina May, that I spent most of the workshop in tears - her passion and 'right thinking' about women and birth still has that effect on me as I watch and listen to her speech accepting her Right Livelihood award.  Thank you Ina May for all you have done and are doing for Women and Birth and Midwifery.  Congratulations on receiving this prestigious award. You certainly deserve it.

Birth Genius

Birth is amazing.

Women's embodied wisdom about birth is brilliant and babies ability to be born is stunning. Both geniuses come together when they are supported wisely in an optimal environment to express their innate ability and intelligence. 

Trust, both of self and the others in the birth environment by the woman is a powerful mediator for birth to go well.

The others have to be trustworthy though.

This video gives an excellent example of genius in action.



I would have loved to see the woman hold the baby, the cord to have been left intact and the film to have shown the placenta being born.  I do love seeing this video of the birth of this footling breech baby with the cord around it's neck three times. I've watched it quite a few times!

There is something exquisitely satisfying about an example of everything being right with something that others say is wrong or dangerous. An example of natural intelligence in action.

The gentle way the practitioner held and touched that baby was delightful and reverent, as it is meant to be.

I couldn't help but compare that behaviour of the doctor in the video to the behaviour I saw recently at a birth.

The doctor kept poking and pushing at the baby's head as it was being born.  The doctor then pulled the head around, twisting the neck the wrong way ( I said where the back was on palpation; that information was ignored).  Then, obviously worried about the possibility of shoulder dystocia, the doctor proceeded to tug the baby out.

The woman tore and needed sutures (not as bad as last time apparently!).

I felt strongly that the meddling caused the tearing. She had been labouring in a quiet, self managed way and if she had been supported to push that baby out with her urges, with patience and direction to push gently between contractions, she could have avoided the tear.

I guess surgeons don't have a problem with suturing, after all, it's their bread and butter.

For the woman, however, it's her body and good to keep intact.

I also recognise that the recumbent position leaves women open to being 'manhandled' during birth. An upright position makes touching so much more difficult. I suspect that the vulnerabilty inherent in the recumbent position makes touching and manipulation 'ok' whereas when a woman is upright, she is more in her power. I wonder if her size in an upright position appears bigger and therefore less vulnerable?  Lying down was her choice and of course, should not be an invitation to unnecessary interference.  I wonder if lying down on our back triggers the primitive brain region to assume dominance in those that are upright?

When Tracy Donegan read this post, she sent me an article about positions of power posing and neuroendocrine effects.  Thanks for this information Tracy!

Another beautiful example of breech birth is given by Lisa Barrett on her blog. One of my favourite photos of birth is in the photo essay.

Lots to think about here.