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"I would rather have questions that can't be answered than answers that can't be questioned." Richard Feynman, PhD
How much should you use research and evidence based information to inform your birth?
Is research in the realms of pregnancy and birth useful or practical?
If so, how does it inform your pregnancy and birth?
If not, what can you use to inform your birth?
Questions of research and evidence based medicine are what I'm writing about today!
Though in the west we are used to looking at research as part of our medical information and evidence based information has become a popular idea for pregnancy and birth, however the limitations of research and evidence in regard to birth can impact your birth and these are important issues that aren't readily shared by medical professionals.
The concern with research is that, research is often mistaken for truth. When something is published in research, it is considered by those of us outside the realm of research to be a final answer, but research is part of science, the continual search for answers. Really, when you think about life, and all the complexities of the human body and how we interact with our world, it is so complex and full of questions that we may not ever answer.
Even more so, when it comes to birth, the in-utero life of babies, and the transition of life for a newborn, research can never factor in all the variables and all the things we just don't know! And actually, I find that fact to be reassuring, knowing that we don’t have to know everything or understand all the aspects of birth and life, it just finds a way. I feel there is a bit of calm in knowing that some parts of life are still pure and shrouded in the mysterious wonder of life itself.
The more we muddle our understanding with science, the more complicated we make life, and living our life. I don't watch a lot of television, I just don't have any time left in my day for it often, but I did watch a cute show after it came highly recommended by a friend called The Good Place, and one of the episodes talked about how hard it can be to live in our current society with all the complexities we now have in the system. I won't go into exactly how they were using this for the show, but they were talking about how difficult it is to even buy a tomato, because that tomato comes with so many negative consequences - we have the GMO issue, fertilizers and pesticides, water consumption, ethical treatment of growers and harvesters, transportation of the tomato to your store, the effects from transportation for you to go to the store to buy the tomato, so many things to think about in regard to something that should be so simple.
To bring this back to birth, let’s take a simple example of induction of labor because this is so common and so many women are faced with this scenario during their pregnancy.
A draft of a study published in 2019 byAnna Maria Marconito evaluate the research around the topic of induction of labor begins with this abstract:
"The rate of labor induction is steadily increasing and, in industrialized countries, approximately one out of four pregnant women has their labor induced. Induction of labor should be considered when the benefits of prompt vaginal delivery outweigh the maternal and/or fetal risks of waiting for the spontaneous onset of labor. However, this procedure is not free of risks, which include an increase in operative vaginal or caesarean delivery and excessive uterine activity with risk of fetal heart rate abnormalities. A search for “Induction of Labor” retrieves more than 18,000 citations from 1844 to the present day. The aim of this review is to summarize the controversies concerning the indications, the methods, and the tools for evaluating the success of the procedure, with an emphasis on the scientific evidence behind each."
In the article, the researcher covers in some depth a few of the common reasons of induction, including elective induction, or induction in the absence of fetal or maternal indication or an induction that is planned before a need arises, rather than as the need comes up.
Essentially, the researcher has difficulty determining whether aspects of the results are a product of the precursor of the induction of labor. The precursors include things like, post-term pregnancy, diabetes or gestational diabetes, pre-mature rupture of membranes, suspected large baby, called macrosomia, oligohydramnios, which is extra amniotic fluid, and a whole list of others, you can find the article here if you would like to read it.
"In conclusion, for very few of the precursors reported in the guidelines and in the scientific literature, there is clear evidence that IOL [Induction of Labor] actually improves the obstetric and/or perinatal outcome. An example for all is isolated oligohydramnios at term, a popular precursor for IOL: a recent meta-analysis including 2,414 women with oligohydramnios and 33,585 controls but only one randomized trial with about 50 women showed that oligohydramnios represents a risk factor for IOL, caesarean section, and short-term neonatal morbidity. However, it is difficult to define precisely whether the outcomes represent the effect of IOL itself or that of the precursor. The same applies to other clinical situations in the presence of maternal and/or fetal pathology."
So you can see that often the actual research isn't conclusive, and part of it's job is to get deeper into what the real questions are, just as this researcher has done. However, many doctors, the self-proclaimed birth experts who write books, people in your Facebook groups and social circles who believe they are reading facts in these studies, even a fair number of midwives today, they are all turning to research to try to define the boxes that we enclose pregnant women and their babies into, to try to define safe and unsafe and try to predict what will happen in a woman's birth.
The other confounding factor for most of the research is that it generally involves births that have high intervention rates on many levels because these are predominantly hospital births and just the mere fact of being in a hospital means there are automatically interventions involved, at minimum, some level of fetal monitoring, an IV line or hep lock for fluids or just in case medication access, being put on a labor clock, maybe being denied food and water if that's the hospital policy, and even simply the constant watching by medical staff when you may not want anyone in your space.
You could argue whether these are invasive to you and your birth preferences, but we cannot argue as to whether they are interventions, they are only happening because someone is deciding these aspects for you. Today's post is not about whether or not these are beneficial or necessary, that's an individual choice, all I am focusing on today is to point out that these aspects of hospital birth will impact the unfolding of birth and therefore the results of studies. Therefore, it makes it extremely difficult to use research to apply to a homebirth or even birth center setting where the environment may not be medically focused.
So you can see why using research to make your decisions about birth can make things messy and confusing.
And then we have Evidence Based Medicine.
The history of evidence based medicine is extremely important to this conversation because what is often left out is what exactly is Evidence Based Medicine. It started out of the study of disease progression and public health, from the field known as epidemiology. It was a way to look at real time data from a population, along with research and apply reasoning into a medical practice for an individual patient.
There are three components to evidence based practice - current research, an individual practitioner's clinical experience, and the patient's desires about the care they choose to receive.
Here's where this focus on Evidence Based Medicine becomes problematic for pregnancy and birth. We already addressed the problems with using research in this article, so I will skip to the second aspect, your practitioner's clinical experience.
Your practitioner's clinical experience is a direct expression of their beliefs about birth and their own fears about birth, which themselves are based upon their education, their exposures throughout their life, from as far back as their upbringing and exposures through media, to their school environment and their work environment, and the limitations of the environment within which they practice. And most doctors and midwives who attend traditional schools in the US will tell you that the education is predominately focused on handling emergencies and complications of birth, not on how to recognize normal and variations of normal in pregnancy and birth. This means that your birth provider's understanding of birth is shaped by this exposure to all the "what if's" and that affects what they believe to be safe and normal.
And that brings us to the third aspect, your desires for your care. Today, those of us working in traditional birth see how much a woman's understanding and beliefs about her own birth can be limited by a lack of knowledge about the care you need. Most women giving birth are not birth professionals, not OB's, not midwives, not doulas, so the level of knowledge is limited to what is available in books, online, or what you learn from other people, whether that's in a childbirth course, from your friends and family, and of course from your care provider, all of these sources are also influenced by parts one and two of the Evidence Based Medicine model.
So if the information you get about birth is influenced by misappropriated research, experiences of providers that have been shaped by that same misappropriated research, how do you get clear about your desires for birth?
You can see how this idea of creating a more informed model has actually added it's own variety of muddling to the world of birth, and may contribute to some of the confusion that's out there about birth today.
But you can clarify much of the muddling of the picture we've created, underneath you can see that birth is actually so simple, every time I meet with my cohort of birth practitioners who choose to understand pregnancy and birth from the principles of pregnancy and birth itself, who tap into the mysterious aspects that nature reveals if you step out of the hectic, technology driven world and look around every now and again, I am reminded of just how simple and safe birth can be. The stories I hear from these birth attendants are so different from what's out there in the mainstream, even from your common midwifery practices. These births are full of trust, of intuition, and rational guidance from technology only if it is deemed truly needed with fully informed consent from the parents. It's technology used only after "what if" fears have been addressed and set aside, so their choices are from a calm and rational place, not a fear driven place. This makes so much more room to interpret the scene instead of assume everything is an emergency waiting to happen, until proven wrong.
I know this sounds more complicated than using clear and concise research, something with statistics, facts and data, numbers to base decisions upon, and that's because these decision cannot be made ahead of time, they can only be made in the moment, we are only able to be fully informed when we are in the present moment, we can't predict the future for anyone, we can only pretend that we can do so when we interpret our lives by numbers and statistics.
Instead, to be informed about how birth works, you would be better served with observing natural cycles and seeing the rhythms of nature, rather than getting lost in research, statistics and even what we call Evidence Based Medicine. In the 25 years since the introduction of this method into obstetrical care, we haven't actually improved overall outcomes for mothers or babies, but we have increased a lot of birth trauma.
And if you want to take your knowledge deeper, you can learn some of the basic physiology that we do know to inform you about why birth works over 90%, actually probably about 97% of the time when we get out of the way, when birth professionals get out of the way, when you can just sink into birth and let go, instinctually and intuitively. That’s when birth becomes magical and transformational.
So take some time to watch a sunset, follow the moon through it's phases, plant a seed and watch it grow and transform, watch a fire burn into coals, feel the flavors of your food on your tongue, all of these are lessons from nature, and they all reflect the process of a birth unfolding. Then learn how your blood volume expands to meet the needs of your baby and how this results in a normal lowering of hemoglobin, then you know if you need to supplement iron or not, and learn how your baby's blood flow shifts in the moments after birth and why that cord blood is so important to support that transition - then you don't need someone to define the amount of time to wait to clamp your baby's cord, you intuitively know when it's the right time.
Research is a long way from defining safe and unsafe, perhaps it never will, but nature always knows, you just have to tap into that knowledge. I hope this gives you some peace and new ways to look at how to understand your pregnancy and birth. Thank you for allowing me into this part of your pregnancy journey, I look forward to meeting you here again next time on your wonderful Journey to Birth!
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