Monday, 25 January 2010

Ethics, AMA and that South Australian Homebirth 'study'

Barbara Katz Rothman, Ph.D,  Professor Department of Sociology,  City University of New York, is the author of fabulous books such as The Tentative Pregnancy and In Labour: Women and Power in the Birthplace. W.W. Norton and Company, 1982, now updated as Laboring On: Birth in Transition in the United States, With Wendy Simonds and Bari Meltzer Norman. Routledge, 2007.

Professor Katz Rothman famously said "Birth is not only about making babies. Birth is about making mothers - strong, competent, capable mothers who trust themselves and know their inner strength".

Barbara Katz Rothman made another great comment about how whenever there is a move to return power to women, patriarchal interests rise up in protest to reclaim their position. I haven't got the exact quote, but something along that line.

What is particularly interesting right now is that the negative voice of reproductive medicine headed by their president, is growing louder and louder, warning everyone that birth is dangerous!  The voice is getting louder, telling women and the community that birth at  home is dangerous, just as the Federal Government begins to move to increase women's birth choices and position midwifery as the health care profession most suitable and appropriate to provide primary health care for childbearing women.

Coincidentally, a report on homebirth in South Australia was published recently in the AMA medical journal.

Medical Journal of Australia article on SA homebirth

The president of the AMA Dr Andrew Pesce, wrote the editorial of the issue of the AMJ which published the 'study'. He listed his competing interests this way

"I am President of the Australian Medical Association, which is opposed to home birth in Australia".

The title of Dr Pesce's editorial is "Planned home birth in Australia: politics or science?"

Dr Andrew Pesce (Dr 3am)'s Editorial in the MJA

Good question, Dr Pesche, all looks good and transparent on the surface so far!

Dr Pesche discussed the controversy surrounding homebirth and midwifery practice and quoted the following 'facts' from the 'study' of SA homebirth statistics:

"planned home birth was associated with a sevenfold increase in risk of intrapartum perinatal mortality compared with planned hospital birth, and a 27-fold higher risk of death due to intrapartum asphyxia.6 These differences were significant despite a sample size of only 1141 home births. Overall perinatal mortality standardised for gestation and birthweight was more than double that of planned hospital births, but because of low numbers these differences were not statistically significant. Of course, not all severe adverse perinatal outcomes in labour can be avoided, but they are better avoided, statistically speaking, when birth is planned to take place in a hospital birth unit".

Deeper analysis of the 'data' reveals the statistics are somewhat skewed. I have written else where about the results of this 'study'.  As the old truism goes there are 'lies, damned lies and statistics' - it requires enormous rigor and willingness to look at one's blind spots when interpreting statisics.  One of the ways to assist with blind spot removal is to have independant reviewers go over the results of data interpretation. Everyone would presume the AMJ would do that to maintain credibility and transparency. A reasonable assumption given that the Journal’s website links to the World Association of Medical Editors Position Statement on “Conflict of Interest in Peer-Reviewed Medical Journals”:

However, following various online articles debunking the analysis of the statistics, including an article by Melissa Sweet at  Don't believe the homebirth horror headlines galvanised Dr Pesche and the AMA to seek a right of reply.

In his reply to the criticism of both the article and his editorial, Dr Pesce said

"My editorial was primarily about the politics of home birth.  Most neutral commentators have commended me on the balance of the editorial".

As Croakey comments "Dr Andrew Pesce, for those who haven’t been following the story thus far, is the president of the AMA (which opposes homebirth), an obestetrician and gynaecologist, one of the reviewers of the new study, and also the author of the MJA editorial on the study".

Now wait a minute! Dr Pesce was one of the reviewers of the new study? Hmmmm  and wasn't Dr Mark Keirse, an obstetrician,  one of the authors of the discredited Bastion study also cited by Pesce as evidence of the dangerous nature of birth at home?

Uh oh.  Excuse me,  the bias is showing.

I'd love to know who the 'neutral commentators' were!

Using 'science' to back up biased opinions is hardly new or unique to this particular study and the rhetoric which surrounds it.  However, frightening childbearing women and the community about the safety of birth in any context is unethical, given what we know about the way that the hormones of fear impact upon both the fetus and the woman.

Dr Pesce also asks the reader

" be fair, my editorial did mention the lower intervention rates, the similar rate of post partum haemorrhage and other favourable outcomes of home births found in the study".

Dr Pesce needs to listen to the despairing voices of midwives and student midwives who struggle daily with the way that medicine interferes, disrupts and pushes the birthing process into places that women are not ready to go with disabling consequences.

for example

"So, after watching BOBB (The Business of Being Born) and doing my current reading about the history of midwifery/hospitals/medicine, my eyes have been opened, yet again (still!) as to how harmful the hospital environment can be towards childbirth and women.

Yes, hospitals, medicine and nursing care can save lives. However, ever notice the trickle down effect of us *causing* some of the problems in the first place?"
Some self loathing, some guilt, and a whole lot of venting

It's time Dr Pesce to stand back and look at who's interests are being served in this 'debate' and controversy?  This 'shroud waving' and 'spin doctoring' of facts is an 'emperor has no clothes' kind of situation. What do we make of it in light of the fact that over $2.11 million dollars of tax payer's 'safety net' money has been siphoned off into the pockets of some doctors?

Changes to obstetric safety net are fair, despite foul cries – Croakey

The big question is how do we get to work together so that the woman is in control of her body and reproductive process and we as health care professionals are there to support and encourage every woman to feel safe in her own body and respected for her evidence informed choices?  There are some great doctors who really respect women and believe that the natural brilliance of the birth process works well when women are informed and supported to labour and birth undisturbed in the place of her choosing. These doctors are there, respectfully supportive for the rare occasion when some kind of intervention is warranted.

Birth is as safe as life gets Dr Pesce.  The therapeutic use of self as a health care practitioner is what makes both life and birth safer. As Barbara Katz Rothman says "birth is about making strong and capable mothers". Time to stop pulling the rug from under women's sense of self with all this 'turf war' rhetoric!


InfoMidwife said...

I really enjoyed reading this post.. how true is your quote
"whenever there is a move to return power to women, patriarchal interests rise up in protest to reclaim their position"

Joy Johnston said...

I have come back to this post, and appreciate its wisdom in a complex and important matter.
Now, in September 2011, midwives face a position statement on homebirth that has been endorsed by the regulatory authority before the midwifery profession has been given an opportunity to review and comment on it. In this position statement reference is made to both the Kennare et al (2010) paper on planned homebirth in South Australia, and similarly discredited Bastian et al (1998), which included data collection by unreliable and unacceptable methods.