"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.  

Health Care Hashtags Resource on Twitter

I've been learning more and more about Twitter. 

Twitter is a great resource for information about anything you may find interesting.  The river of tweets provides ongoing and rapidly changing news headlines. Tweets are text-based posts of up to 140 characters displayed on the user's profile page. At any moment, you can see what people are experiencing, what is important to them and what they are thinking. If the topic of the 'tweet' is your subject area, then you can choose to interact or not. The stream of information lets you know something of interest about what is important to you. Of course, it's sensible to only 'follow' people who's work/life and/or philosophy is of interest to you.

Last week, in response to something I tweeted, I was invited to join a scheduled twitter chat about the use of social media and healthcare on Sunday night.  Here's the link to the conversation. As the benefits of social media in health care, in particular, maternity services and information sharing, is of great interest to me, I joined in.  I found the process confusing at first. The conversation is like being at a big party where everyone is talking at once.  If you read the transcript of the session you will see what I mean.

How amazing that a transcript of the event can be produced and stored in a virtual file to be accessed at any time! That resource is so useful to me.  I was able to return to the information and read it at my leisure. What's the purpose you may ask?  That conversation has much to offer. I was looking for links to any useful information; I wanted to check out how others are thinking about the use of social media, the benefits and pitfalls of doing so. I was also interested in how practitioners are talking about ways to keep professionally safe using the medium; all of which and there was much more in that conversation to explore,  provides food for thought.

For those of you who are interested in health care, Twitter offers a real opportunity to engage in real time with people from anywhere in the world about your topic of interest, from the comfort of your own home/computer.  No need to travel and lose time in getting to different parts of the world to learn from people who know what you want to know; the only expense is your computer and internet server/connection.  A really important and liberating aspect of Twitter is that there is no 'status' to get in the way of discussion or communication on Twitter.  People who are technology nerds, CEO's, journalists, mothers, fathers, PhD's, scientists of all kinds, anyone who is interested, communicate and collaborate in an open, respectful way about their chosen topic.  If anyone is not respectful, they are 'unfollowed' - no one is interested in 'fighting' or engaging with those who 'troll' and disrupt.

This morning, when I was checking the twitterstream # tags for twitterchats on health care and the use of social media (#hcsm and #hcsmanz), I found a tweet about a site that compiled all the twitter conversations about different aspects of  health care.  That site is found here.   I noted that midwifery didn't have a hashtag, so have filled out the form to create a midwifery presence on that site.  I've just been exploring the site that hosts the hashtag directory  and that web page is interesting too, well worth having a look at and considering what an online presence is all about.

If you are interested in exploring the conversation about health care and social media tonight (Sunday) on twitter, join us using the hashtag #hcsmanz in your twitter posts. If you are not yet on Twitter, go here  to learn about Twitter and to open up an account (it's free) and start tweeting!  You can 'follow' me - which means you follow my conversation. You can tweet back anytime you like in response to any tweet. If you do follow me, then put the hashtag #hcsmanz in the tweet. After you post, you can click on the hashtag and that will take you to the list of tweets about that subject. Then you can save that search as a list which can be accessed, with updates, at any time.

I look forward to our conversations on Twitter.

What do you think, will I see you there?  Comments and questions welcome.