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Monday
Aug222011

A Midwife and an OB Walked Into a Blog...

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By Jill Arnold

 

One of my favorite discussions of all time on this blog occured on the post, Defensive Medicine is a Symptom of a Risk Society, in January 2011 as part of the Defending Ourselves against Defensive Medicine series. It veered off in multiple directions and stayed pretty interesting from start to finish. 

I plucked two comments and my response to them in case you’re not up for meandering through nine pages of comments. Obviously, you will find context in the whole discussion in the link above.

 

Ina May Gaskin wrote:

Many interesting exchanges have taken place since I’ve been able to contribute anything more to this interesting discussion/debate. I understand now that one reason that Dr. Tuteur has objected so strenuously to my ideas comes from the helplessness she and other staff members felt during her residency when those three mothers who did need obstetrical intervention refused it, unaware that their babies really could (and did) die for lack of it. I don’t think she made up that incident.

She doesn’t think that I have been truthful in recounting some experiences I had during the early part of my career. That’s unfortunate, because I make it a point not to exaggerate. I didn’t make up the incident (it was the eighth birth I witnessed, by the way), in which repeating the traditional wedding vows made it possible for my friend’s cervix to dilate fully after she had been stuck at 7 cm for more than a day. She gave birth about an hour and a half after that impromptu ceremony. I realize, of course, how hard it can be for anyone who prides herself on being “rational” and skeptical to accept this, but I’m stuck with what did happen. There were witnesses.

Regarding Grantly Dick-Read, I think it’s better to read him before swallowing whole the ways his critics have picked at him. I think it’s unfair to a writer to quote his critics without reading his primary material. I haven’t read his book about his experiences in Africa (though I did order it today), but it will take more than the article abstract that Amy posted to convince me that he was a racist.

I don’t find it at all hard to believe that he encountered tribal people whose experience told them that a labor could be prolonged when a mother had a sexual secret that she was keeping. It doesn’t mean that will happen with everyone, but it does happen sometimes. And no randomized controlled trial will ever demonstrate this. Niles Newton did some interesting research in this area, but like many other rigorous scientists, her work has largely been ignored by technophilic feminists.

Judith Goldsmith (author of Childbirth Wisdom from the World’s Oldest Societies), who did read No Time for Fear wrote: “One thing he [Dick-Read] found was that ‘the more urbanized natives who lived in the town brought their wives into the hospital, and it should be noted that they had more discomfort and made more noise than the village women at home.’”

After noting another writer who observed the same phenomenon among the Pima of Arizona, Goldsmith notes: “It would seem, therefore, that easier natural childbirth is made possible by the attitudes, ways of life, and other intrinsic practices of the material minimal lifestyle, and not by the physical (racial) characteristics of non-Western women.”

Here’s another wise observation she made:

“….nowhere in the tribal world did a woman give birth among strangers. She carried out this intimate act among relatives and friends whom she knew well and trusted.”

“Down on biology” feminist academics can argue all they want about whether certain things happen or not. Hopefully, all will be curious enough to investigate farther than the academics who used to sit in rooms in cities, arguing about how many teeth horses (or women) had, without bothering to count any.

In case no one has ever seen this method for having a baby with an intact perineum, try this:http://www.youtube.com/watch?v=9bF_T3wBE14

G’night for now.

 

Amy Tuteur’s response:

” I understand now that one reason that Dr. Tuteur has objected so strenuously to my ideas comes from the helplessness she and other staff members felt during her residency”

You don’t have to conjure up any secret motivations. I’ve explained why I object strenuously to your ideas: I find your philosophy of biological essentialism and anti-rationalism completely unpersuasive, and I have pointed out ad nauseum that most of your empirical claims are factually false. That’s more than enough reason to explain why I disagree with you.

In recounting those anecdotes, I was not describing my “helplessness” since I did not feel helpless. I recounted those anecdotes specifically to illustrate my claim that homebirth and NCB advocates don’t understand the risks of their choices because the NCB literature is silent or lies about those risks.

Let me make myself very clear, Ms. Gaskin, so you cannot twist or misinterpret what I mean. I disagree with almost everything you say because I think you are wrong. The scientific evidence does not support your claims, and your invocations of non-rational forces and energies is nothing more than quackery.

 

My attempt to sum up the entire thread:

Amy has more or less placed the OB philosophy in the science category and NCB philosophy in the mysticism (or non-rational) category. Scientism holds science as superior and therefore will always trump any non-empirical philosophical explanations for phenomena.

If we’re talking about the philosophy of OB vs. NCB, as Amy has framed it, we’re not speaking about how it is practiced. Courtroom Mama had an interesting point about many women opting for “not obstetrics”, which I suspect in most cases is not a knee-jerk act of defiance but simple psychology— aversion as a result of an unpleasant, distressing or extremely difficult experience within the health care system. I would also guess that most women choosing “not obstetrics” never really knew there was anything besides the OB philosophy, so the insistence of framing this as OB vs. NCB seems short-sighted and borders on a false dilemma.

One thing that has been fascinating has been watching the discussion between Amy and Susan, a proud, religious biological essentialist and supporter of the NCB philosophy. It feels like something that could have taken place half a century ago. Thanks again for your time in constructing your comments.

I agree wholeheartedly that NCB philosophy, at its purest and as I understand it, is biological essentialism. It ranks unmedicated, vaginal birth as superior to all other ways to become a mother.

The “feminist non-rationalist” framework is not quite as clearly argued here because the examples given seem to connect the mystical explanation of phenomena (anti-scientism) to a social group which endorses choice. The mysticism connection to NCB philosophy is well cited, however.

The source of contention seems to be whether or not there is a psychosomatic aspect to pregnancy and labor, and really, whether there is a psychosomatic aspect to anything. This is the classic debate between the Cartesian view of the patient (edit: the patient’s body) and what psychosomatic medicine refers to as the “body-mind.” It bleeds through into discussions about alternative medicine, which I guess is why Amy has named her blog the Skeptical OB. And if there’s anything on science blog (Amy, yours is sort of a sociological/science/activist/politics blog, no?) that will drive scientists and doctors up the wall, it’s claiming that a treatment works based solely on a personal experience.

Research on birth in the fields of psychology, psychiatry and neuropsych appears to be scant at best, so anything beyond birth being a just a parasympathetic event that requires oxytocin to cause uterine contractions, etc., (Unless, of course, this process is preempted with surgery and the construct of birth is changed.) will always lose the research battle. It doesn’t mean that in 30 years we’ll all be looking at this from a completely different perspective, but as of now the connection is unproven and therefore unscientific (says this lay person).

For further reading, this 2009 paper about psychosomatic medicine (found on the Columbia University site at http://www.columbia.edu/cu/psychology/tor/Papers/Lane_2009_Neuroscience_Psychosomatic%20Medicine_Part2.pdf) explains a bit about neuroscience in psychosomatic medicine. Here are a few excerpts:

One of the primary goals of research in psychosomatic medicine is to delineate the biological mechanisms whereby psychological, behavioral, and social factors influence disease outcomes, and to use this information in the service of optimizing medical care

[A]pplying current methods in human neuroscientific investigation in psychosomatic research would greatly enhance our ability to identify causal mechanisms that underlie mind-body linkages to disease pathogenesis

This work constitutes an outstanding foundation for “brain-body” research because we are now able to study how different mental processes are instantiated in the brain.


Within the framework that Amy is working, I’d have to say (as a layperson, so who cares, right?) that most non-biological (i.e. psychological) claims about birth are unscientific, as they are yet unproven. Neuroscience appears like it might someday bridge that gap, but as of yet, it hasn’t.

As far as correctness and being right is concerned, a cultural relativist (like me) will hold that separate philosophies are equal and can both lay moral claim to rightness, with none being superior to the other. The moral of that story is that moral/cultural relativists are a pain in the ass.

Thanks for the discussion.

 

 

 

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Reader Comments (61)

you...you...LAYPERSON!

I love your last paragraph from the bottom of my dead, uneducated heart.

August 22, 2011 | Unregistered CommenterFoxyKate

I know, right? I am a supergross layperson.

August 22, 2011 | Registered CommenterJill

"A Midwife and an OB Walked Into a Blog..."

and guess who got sixteen stitches and guess where.

August 22, 2011 | Unregistered CommenterSaanen Mother

Anyone who has ever been constipated can tell you that the biological processes of the body respond to psychosomatic stimulus. If changing your daily routine can stop up your intestinal tract, when the process of defecation is commonplace and something with which we are very familiar, why would we expect birth to be immune? Birth is intensely emotional and after years of being told that it is the most dangerous thing a woman can do, of course some of us are going to have physical manifestations of those ingrained cultural fears.

Maybe a doctor who practices such intensely personal medicine should be taking refresher courses in basic psychology. I can't imagine letting anyone who doesn't understand this sort of thing anywhere near my own vagina.

August 22, 2011 | Unregistered CommenterMamaPsalmist

For SaanenMother: Rimshot

August 22, 2011 | Registered CommenterJill

"Within the framework that Amy is working, I’d have to say (as a layperson, so who cares, right?) that most non-biological (i.e. psychological) claims about birth are unscientific, as they are yet unproven."

Let me see if understand what you are saying:

1. The obstetricians are correct that modern obstetrics is supported by scientific evidence.

2.Homebirth and natural childbirth on the other hand are not supported by scientific evidence.

3. Maybe, although is no evidence, there are other forces at work that we will find out about later.

If that's what you mean, I would agree with that.

I would point out, thought that psychosomatic aspects of medicine and anti-rationalism are NOT the same thing and cannot be treated interchangeably.

If by psychosomatic you mean the idea that the mind impacts the body, that is a concept firmly embedded in science. Non-rationalism is the idea that there are OTHER forces, like spiritual forces, that come from outside the body to impact the body. It also invokes the idea of special powers such as intuition that give certain people secret knowledge.

The bottom line, though, is that as long as NCB and homebirth acknowledge that their personal beliefs about birth and women are just that, personal beliefs, and stop claiming that NCB and homebirth are based on science, they'll have no quarrel from me.

August 22, 2011 | Unregistered CommenterAmy Tuteur, MD

Thank you for posting this again. I can honestly say that my issue with Amy Tutuer is that she automatically disregards anyone who isn't in her realm. I am amazed at how quickly she devolves into name calling (as in my case labeling me as willfully blind), and that makes me wonder about the strength of her "science" to back up her arguments.

August 22, 2011 | Unregistered CommenterNichol-doula

Amy, I think this post sums up much of my personal skepticism toward obstetrics:

http://www.theunnecesarean.com/blog/2011/8/11/guidelines-are-only-as-good-as-the-evidence-that-underlies-t.html

I had an excellent first birth with an obstetrician in a small town with an evidence based practice, but we moved before I had my other children. I could not find an OB in our new, large city who had an evidence based practice. For instance, one OB told me she often cut episiotomies "because usually I just can't wait." Another told me she would not have allowed me to go into labor naturally when I dilated 6 cm before birthing labor began (she said, "I would have gotten out my amniotic hook"), this even though my baby was born 3 days before her official "due date" (the OB I had for that birth waited for me to go into labor on my own). One of my best friends, a physician with an MPH who has a research based career used a midwife for her births because of similar concerns. If obstetricians practiced based on the evidence of their profession, I probably wouldn't have considered other care, especially because it made for big insurance hassles . While some midwives may practice with elements of mysticism, this is not why I birthed with a midwife. I birthed with her because she actually followed scientific standards of care. If someone wants to use a mystical philosophy that does not conflict with scientific evidence, what's the problem? There's nothing remotely harmful about reciting wedding vows while in labor. There's a lot more harm that comes with unnecessary episiotomies, cesareans, and inductions done because "everyone is doing them" (standard C).

August 22, 2011 | Unregistered Commenterpraminthehall

Dr Amy- Have you ever been to a homebirth? Or, since you approve slightly more of birth centers (which are honestly mostly the same as homebirths!), would you attend or observe a birth center birth? If not, why not? Many of us who advocate for the option of home birth have observed hospital births and home births, and because of that experience, can see the benefit in moms staying at home as long as there is no indication of an emergency situation. If you have never witnessed that perspective, how can you really advocate for one over the other? Sometimes no study can really replace actually witnessing something for yourself.

August 22, 2011 | Unregistered Commentersara

"http://www.theunnecesarean.com/blog/2011/8/11/guidelines-are-only-as-good-as-the-evidence-that-underlies-t.html"

That's both unfortunate and revealing. Unfortunate because The Big Push deliberately misrepresented the study AND conveniently ignored the fact that 0% of homebirth midwifery meets Level A guidelines. Unfortunate, because you never read the original paper, have no idea what it actually said and were willing to believe the deliberate misrepresentations of the author of the post.

Moreover, you seem to have misunderstood the point of this post. Jill is acknowledging that when it comes to scientific accuracy, I am right and Ina May just ignores science altogether.

Jill is saying that it is her personal belief that vaginal birth is best even though that's not what the scientific evidence shows. She has every right to that personal opinion as do you, but you need to realize what Jill has acknowledged: the scientific evidence does NOT support NCB or homebirth advocacy.

August 22, 2011 | Unregistered CommenterAmy Tuteur, MD
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