There is no alternative to prevention

I’m an internist, a doctor who specializes in the prevention and treatment of adult diseases.  To do this, you have to know what it is that causes us harm, how to prevent it, and how to treat it when prevention either doesn’t work or isn’t possible.  I can’t prevent someone from getting, say, lupus, but I can prevent a lot of people from having heart attacks.

Some prevention is quite simple and effective: if I can get people to quit smoking, lower their blood pressure through the use of diet, exercise, and/or medications, I can prevent a lot of heart attacks and strokes.  If I can get women who are trying to get pregnant to take folic acid I can help prevent birth defects such as spina bifida.

Often, the so-called alternative medicine community tries to claim prevention as their own, as if real doctors either don’t know or don’t care about prevention: we know, and we care very much.  We also realize that human beings are imperfect, that life if full of bad luck, and that not all disease can be prevented.

Often enough, behavior simply can’t be changed.  Many people suffering from serious consequences of obesity may never be able to lose sufficient weight, leading to a cycle of weight gain due to inactivity and inactivity due to weight gain.  Like many illnesses, obesity, tobacco dependence, and other diseases that appear to be amenable to simple behavioral changes are not so simple and are real disorders of physiology that are not under the patient’s conscious control.

But some things are clearly (to me) under someone’s conscious control. Choosing not to wear a motorcycle helmet or a seat  belt is just stupid. So is giving birth to a child in a pool full of urine and feces.

The evolution of human birth practices is pretty damned interesting, something we all have a stake in.  Until quite recently, most babies, even in wealthy countries, were born at home with family in attendance.  This was dangerous and not infrequently led to the deaths of mothers and babies.  It became a fad in later years to give birth in hospitals, a practice which was quite dangerous until the cause and prevention of childbed fever was discovered.

In much of the mid-20th century, hospital births became the norm, but so did a paternalistic approach that often reduced parental involvement to nothing: the father was kept out of the delivery room, and the mother was given little control over the birthing process. (For a more complete and accurate history, browse Dr. Amy’s blog.)

Childbirth is still dangerous for mother and child, especially outside of the industrialized world, but there are ways to make it safer for mother and child.  We have, for example, institutions in this country called “hospitals” which contain surgeons, neonatologists, nurses, and other experts at keeping moms and babies alive through one of the most dangerous events in either’s lifetime.

For many reasons, some people choose to try to go back to the bad old days and deliver babies at home, or even worse, at home under water.  My first experience in labor and delivery was awesome.  The controlled chaos, the smell, the change in shape of anatomy, the smell.  Most moms would pee and poo during labor and the nurses would rush to keep the field clean for the baby.  And the babies were beautiful.  They would be delivered by mom and doctor, someone would cut the cord, a pediatrician would make a quick assessment, and the baby would be given to the mom.  Aside from the smell and the surprising anatomical distortions, it was beautiful.  But picturing all that urine, feces, and amniotic fluid floating around waiting for a baby to slip into it without the benefit of immediate emergency support, that’s just insane.

Prevention is usually better than treatment, especially if the outcome you’re trying to prevent is the death of a mom or a newborn.

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  1. saffronrose

     /  August 28, 2011

    I’m guessing the painting is of a doctor giving a family smallpox vaccines, unless it’s for cowpox instead.

    You write: “If I can get women who are trying to get pregnant to take folic acid I can help prevent birth defects such as spina bifida.”

    I had asked about dentalwork during pregnancy, and my dentist told me to take folic acid if I was trying to get pregnant, and to start pre-natal vites as well. I think I only took 400 mg (or mcg–can’t recall the usual), and I was 192 lbs at the time. A few years after, I read an article about pregnant women, folic acid, neural tube defects (and miscarriages?), and rates of birth defects. Heavier women had more miscarriages/children with birth defects, but the study didn’t consider titration of folic acid dosage to weight, which would have made sense. I would certainly advise any heavy woman facing pregnancy to take 800 (unit) of folic acid, or at least to get plenty of foods laden with it.

    I hadn’t considered the effluent factor in birthing pools, but I’m not sure I ever thought very highly of it in the first place. I would have liked to have had a midwife-assisted birth, but due to age (39), weight (above), and family history of diabetes (I failed the 3 hr test at 8 weeks), I was disqualified for such a birth, even in a hospital. Go to a high-risk OB, do not pass GO…

    I was a good, compliant patient, managing my blood glucose faithfully, and changing the dosage on the insulin once I was on it, as needed per instruction. I certainly heard, throughout the pregnancy, that someone “could never have done that”, and I wondered at that, given that two lives would be at risk, and many more would be affected, in my case. I also heard that gestational diabetes was a hoax that doctors used to get more money. Uh, sure–whatever you say, but I’ll just be going along now. It was, by the way, clear that the host was losing weight on the prescribed diet, but the symbiont was gaining. I gained a whole nine pounds after they made me eat more!

    My amnio index was never great (no matter how much water I drank), and after primary induction drugs did nothing to advance my labor, I was going to be sent home after *one last* AFI ultrasound. After 3-5 hours, and several unreturned calls from my OB to the radiology dept., she came to track a radiologist, or at least the ultrasound, down until she got an answer. Mucus plug was still there, but there was only about a cup of amnio inside, so it was emergency C-section for me. Having promised the Mother that I would do whatever I had to in order to get a healthy baby if/once I was ready to carry to term, She called me on that but good! However, instead of the 10 lb baby I was told I’d have, he was only 7 lb 10 oz, with an APGAR of 9.

  2. MissKittysPlayhouse

     /  August 28, 2011

    In paragraph 6 you refer to “childhood fever”. I believe the term you meant to use was “childbed fever” a.k.a. puerpural fever. The term originates from the fact that the fever originated in the days immediatedly following the delivery, as women lay in the “childbed.” Thanks.

  3. In spite of both of us having some degree of interest in alt medicine, ex and I were both rather intent on evidence based birthing. Indeed our biggest frustration with Caleb’s birth was that her doctor (something of a hippie) was hell bent on vaginal birthing, in spite of what eventually turned out to be 36hours of brutal labor that ended in C-sec anyways (and significant vaginal tearing). Given all the complications involved – even rather early on, trying to do home birthing would have either ended up with us going to the hospital anyways, or no Caleb and lifethreatening complications for ex.

    And with David, an attempt at home birthing would almost certainly mean he wouldn’t be sitting here watching Dora the Explorer right now. Of course he ended up coming into the world through C-sec anyways (though that was not ex’s desire). But he needed to be taken out as soon as he was and he wasn’t breathing when he was born. Even attempting a vaginal birth would have resulted in his being stillborn and again, would have been lifethreatening for ex.

    I can totally understand and sympathize with the desire for a home birth. My dad actually has the headboard of the bed he was born in. But I am pretty damned adamant about hospitals for birthing. There are too many things that can go wrong, many of which just don’t offer the luxury of time in which to get to the hospital. There is something very comforting about having a trauma team close at hand and ready to jump in if needed – not to mention residents prepared for the possible necessity of a c-sec. And of course it is absolutely wonderful to have doctors and nursing staff who are trained to deal with minor complications and who can quickly make decisions about whether or not they should call in others.

  4. Emily

     /  August 28, 2011

    I would like to make a few points (not entirely related) in relation to your post. Your post seems very emotionally reactionary (not in itself a bad thing), but I’m not sure that you are really treating the decisions of women to try and avoid a hyper medicalized birth seriously.

    I notice that you leave midwives out of your equation. I just gave birth six weeks ago in a hospital, but with a doula and a midwife. This hospital has a holistic birthing center with tubs. I had intended to use them, particularly for laboring, but was unable to give birth there because my risk factors changed (I was induced because my blood pressure had started to climb, but was not yet preclampsic).

    I was able to labor in many different positions–standing up, on hands and knees using the upright hospital bed as support (I sent most of my labor this way). My baby was partly OP (she was facing the side, not the back), and my doula got her turned (not any of the medical professionals). I had a very good experience and was very happy not to have a doctor involved (given the ridiculous c-section rates). I was in a hospital with physician backups if needed. I have found (including during my pregnancy) that often times doctors do not listen to me. I can assure you that I wanted the person delivering my baby to take the time to listen to me and my concerns, and I was much happier with a midwife for that reason (and others).

    I have heard many stories of women giving birth in hospitals who are not allowed to labor on their sides, much less in many different positions because that’s not how doctors are trained to do childbirths. You talk about the mother and the doctor delivering the baby, but women still often do not have much control over the process. This lack of control and spiraling interventions in births (which are often also risky for the mother and baby) is what leads many people to try and reject the medical model for childbirth. Yes, it is risky, but it pregnancy and birth are not illnesses.

    Also, I think you have some of your history wrong. Many more European and
    American women died in childbirth during the 19th century in hospitals than did giving birth at home (the rates of death at home were lower in the 18th and 19th centuries) because people did not understand things like germs, so doctors/nurses were not even washing hands before engaging in medical procedures. Of course this all changed as germ theory made inroads into the medical profession. Babies were (and in non-industiralized countries) always at high risk in infancy and childhood.

    Isn’t urine sterile? And the baby has been sitting in the amniotic fluid for months–those don’t seem like serious concerns. Fecal material could obviously be problematic, but I’m not sure that someone wiping it up in the hospital completely mitigates the risk there. Seems like there are many more risks of infection given that the baby passes through its mother’s vagina–strep, yeast, and other infections can be transferred during a vaginal delivery, and these seem like a much more serious risk. Do you have evidence of women giving birth in tubs experiencing higher risks because of fecal material?

    • While I respect your concerns, anecdotes don’t really measure up to data. Home births and water births are much more dangerous than hospital births.
      Of course, it entirely depends on what you value: if you wish to have the best chance of the mother and baby living, a hospital is the best choice. if you wish to have the most autonomy, staying at home is probably best, as long as you realize that mom and baby are at much higher risk of death.
      Yes, urine is sterile, poop is not. Amniotic fluid is only sterile if there has been no staining by meconium.

      • Emily

         /  August 28, 2011

        Do you have references for studies showing home births are so dangerous? As you say, anecdotes are not useful for understanding broad risks, but you are not providing anything other than your own anecdotal experiences of attending deliveries in your post. Also, most physicians are not around much during labor, so you probably haven’t seen much of that.

        Unfortunately, I cannot find the references right now (and I’m typing and searching one handed because I’m nursing), but my understanding is that there is a difference between the stats on home births attended by certified nurse midwives versus other folks who deliver babies at home without formal medical training. And those attended by CNM’s have outcomes much like hospital births, and CNM’s won’t deliver at home if it is not a low risk pregnancy. However, I realize that I need to find some references before you might accept that. I will try to find them.

        CNM’s who attend home births also always have physician and hospital back up. Not everyone who chooses a home birth or a water birth is doing so out of ignorance. When I was hoping to have access to the tubs for my birth (and that doesn’t necessarily mean everyone will/wants to deliver in the tub), I was supplied with many articles detailing studies that supported and found difficulties with water births before I was asked to sign multiple waivers detailing the dangers. I was very well educated about Also, some hospitals (like the one where I delivered) offer tubs for laboring and for deliveries–not all waterbirths are at home. You are painting with a very large and unflattering brush in your depictions of people who choose these options. I think your derision is not helpful to promoting your cause.

        Lastly, many women do indeed urinate and defecate during labor and delivery, but if you are not attached to an epidural, women can get up and urinate and sometimes defecate (depending on whether or not they think you are close to delivering) in a toilet if they are not actually to the point of pushing. The fairly usual intervention of using an epidural changes a great deal of what happens during a medical delivery. I think you should really also consider this in your calculus.

        • There are several articles that show that homebirth triples the perinatal mortality rate even without adjusting for the fact that homebirth women are already “lower risk” than women giving birth in a hospital. Transfers take time and time lost can increase the morbidity and mortality around difficult births. Check out the skeptical OB blog for direct references to studies showing increased mortality among home birth.

          • I’ve been reading her blogs for years, and it’s not that simple. Amy Tuteur is the only one giving out that triple statistic. It’s based on her analysis of one study (the Johnson and Daviss CPM2000 study) and she’s then buttressed it by using raw stats from the CDC.

            In any case, studies in other countries (notably Canada) have had much better results. (the Netherlands also did, but their overall birth statistics aren’t spectacular.) So all we’ve proved is that home birth in the US is unsafe, not that home birth is per se unsafe. I had my first in the UK, and I have to say that I think it is much safer to have a home birth there than it is here. (Disclosure: I have no personal stake in the matter. Thanks to chronic hypertension and a history of severe preeclampsia, I am considered high risk everywhere. Caesarean #2 shall be forthcoming in the next few weeks. Modern obstetrics and I are well acquainted, and I’m grateful, but I do have to say that I’d be quite happy to do things differently were I in a position to do so.)

      • Rachael

         /  January 23, 2012

        I’m a L & D nurse in a major medical center down town. We have a birthing tub. It has the approval of all the powers that be in the department. We have natural nursing practices- birth ball, squat bar, you name it- in the very same hospital that houses a Perinatology Research Branch of the NIH. I’m sure you know which I mean. There is actual research that supports these things- not quack research. Many of these studies are in nursing journals, as nurses and midwives focus on the process of giving birth as something important too. These are not anecdotes. I won’t debate home births with you, as I’m not sure how I feel about it either. However, there is no need to bash something because it is not familiar to you.

  5. I have, over the years, become rather adept at reading the facial expressions of doctors. 🙂 My OBGYN was SO AWESOME and with the best bedside manner EVER, and when I asked about water birthing, she gave just the faintest, tiniest little hesitation, which of course I read as good-bedside-manner for “OMGNOOOOOOOOOOOOOOO!!!” Now I better understand why. 😀

  6. People arguing about acceptable levels of fecal matter? #282 I never gave birth.

  7. I wrote about homebirth awhile ago, and one of my commenters claimed that in the event of a cord accident, you have seven minutes to get the baby the heck out. If that’s true, or even close to true, I can’t imagine being anywhere but very near an OR for childbirth.

    It is possible to give birth in the hospital and still urinate and defecate into a toilet. Unfortunately, epidurals are not universally available to all women who want them. Nor does epidural require one to be immobile. This is anecdotal, but I was “tied to an epidural,” and the nurse brought me a little bedside toilet. She got me settled and waited right outside the room. She came back when I was ready, helped me back into bed (which was exactly where I wanted to be…), and a few minutes later, I pushed out my son.

    That said, the reality is that a surprising number of women take serious risks to avoid hospitals in favor of childbirth into sewer water. Which is interesting. And icky.

  8. Wow, women choosing stinky unsafe homebirth just to have “autonomy”. That is totally surprising. I mean, healthcare providers with bedside manners like the one Melissa Gay described are totally universal, right?

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