In the world of healthcare, and certainly in the world of maternal-child health care, there is a lot of intimidation that many consumers experience. Again, I don't mean to imply that all or even most health care providers intentionally intimidate or that they are intentionally manipulative. However, this phenomenon occurs whether it is perceived by the consumer, or it is in fact true. A familiar tune I hear in casual conversation with women (and some of their mates) was that their provider told them such and such conclusions about "the research." When these couples mentioned said conclusions to others (another provider, educator, friend or what have you), the others told them, "well that's not what the research actually says." Alternately, the couple hears a particular recommendation from a friend/educator/health care worker and mentions it to their health care provider (HCP). This provider then tells the couple that no, that recommendation is based on faulty information, and such and such it what I recommend. When it comes to conflicting statements, who are these consumers more likely to believe? Their friend who has "only read" about these topics, their birth or other educator who may not be a health care professional or the "expert" who has 12 years of schooling and 15 years of experience under his/her belt? There are many conclusions drawn about research studies, many many conclusions. The researchers themselves draw their own conclusions based on their observations. The professionals who are reading the research journals draw their own conclusions, and then impart their interpretation to their patients. Sometimes, it can be reminiscent of a game of telephone. Not to suggest that providers are intentionally twisting the original study conclusions, but sometimes things get lost in translation, particularly when the concepts are oversimplified. Additionally, patients hear things through the filters of their own perspective.
One couple saw the OBGyn on call during a routine prenatal appointment. This OB mentioned the baby was in a breech (buttocks down) position which was revealed in the ultrasound performed just prior to the appointment. The provider then went on to say very causally that "a few years ago a study was done on vaginally born breech babies and found that it was very risky for babies, so now no one does it anymore. If the baby doesn't turn by the time 37 or so weeks come along, we're looking at a c-section (paraphrase)." Firstly, this is a tremendous oversimplification and narrow interpretation of the overall research results. The study, done in 2000 by Hannah et al (= 'and others') [full text of the original article may be found here], which is commonly referenced by those opposing all forms of vaginal breech birth, found that planned cesarean delivery for breech presentation had significantly better outcomes than did planned vaginal birth for breech. However, the study had several key flaws. The population that was selected for evaluation of vaginal breech birth included infants who were in the unfavorable footling breech presentation (which inherently can have a greater risk for umbilical cord compression), infants who had known fetal abnormalities and/or had fetal demise prior to enrollment in the study. These contaminated the inclusion and exclusion criteria (see definition: Clinical Trials.gov: Inclusion/Exclusion Criteria), which therefore skewed the final study results. Another factor that distorted the study findings was that approximately 19 % (10 babies) of the 51 fatal cases in the vaginal breech group were reported to have been attended by providers with "no" experience with vaginal breech deliveries. (For an excellent critique on this study, see
time for the baby to turn on his own (many healthy babies are still
breech around the 30 week period). Incidentally, this expectant mother had recently been reading about the vaginal vs cesarean breech birth research topic and knew that his conclusion was incorrect according to the overarching body of research. Still, being a first time expectant mother and a "good patient,' she wasn't confident enough in her own knowledge and articulation to debate the topic with the "expert." The woman was herself a HCP who was very used to interacting with other HCP's and skilled in her clinical knowledge. But even this did not remove the intimidation that often hovers in a "patient-doctor" relationship. This provider took a single study (which was significantly flawed) and used it as a weapon to tell the woman in this case that "a cesarean was the only option if baby's position was unchanged." The average person going to their HCP wouldn't even know that the stance this OB took was not truly research based. Two concepts were working in this situation: 1) he was a medical expert and 2) he (very loosely) referenced ''research.'' How do you argue with that if you don't know any better?
Another example I heard about just yesterday was a breastfeeding mother who was discussing immunity with her baby's pediatrician. The mother made a statement about her baby receiving passive immunity from her breast milk, thus helping to provide protection from illnesses (Passive immunity is obtained naturally as a result of the transfer of antibodies, in this case from mother to infant, and is relatively short acting, weeks to months. It differs from active immunity which an individual's body produces for himself.) The pediatrician informed her that passive immunity via breast milk was "a myth." Strong statement. In fact, in addition to many similar antibodies, sIgA, a bactericidal (bacteria-killing) antibody has been identified as one of the most abundant in breast milk. There are also dozens of other compounds that contribute to the immune enhancing properties present in breast milk (please see this article for further definitions: Human Milk and Lactation, Carol Wagner, MD). One would hope that an experienced pediatrician who is worth his title is not ignorant of very extensively researched topic surrounding the passive immune properties of breast milk. Another explanation for this kind of statement about the "myth" of passive immunity was that this provider perhaps was attempting to get this mother to agree to the intervention he was pushing (immunizations). Rather than providing accurate research to present his case and allowing the mother to make a decision based on that research, this provider took a fairly defensive approach. By using the term "myth" this pediatrician came across to the mother as quite demeaning. Simply speaking, the provider was either ill-informed or manipulative (not in a sinister, but rather desperate sense). Neither one gives a parent much confidence in his/her HCP. These two examples demonstrate a general attitude that is common with some providers: my opinion=the facts/"science"/research. In other words, they see their personal perspective (which is highly influenced by mentors, clinical experience during school, colleagues' experience and their own professional experience) as indistinguishable from research-based findings and facts.
At times, providers place their patients' decisions on their own shoulders (this is understandable given how litigation-obsessed health care consumers tend to be, particularly in obstetrics). Providers can get very personally or emotionally or perhaps fearfully involved in the decisions their clients make, forgetting whose decision it really is. Some fear that if the patient does not make the decision that they (the providers) are recommending (which they usually make in good faith), the patient and/or perhaps child will suffer damages. These damages would not only be on the conscience of the provider (whether rationally or not thinking he could have prevented the damage), but also leave him vulnerable to being sued by dissatisfied clients who are looking for somewhere to hang the blame. Certainly, if there is neglect or malfeasance, a provider should be held accountable. But no one should chastise a well-intentioned provider for not wanting to be sued (more on this in a future entry). This along with many other factors sometimes leads providers to use "the research" or their "expert" opinion as a weapon, rather than the service it is supposed to be. Meanwhile, the people who suffer most from this kind of paternalism are the families. And on the thread of fear, why are we so afraid to just let the facts speak for themselves? Why do we feel the need to pressure others, throw our credentials and experience around or embellish the facts just to get someone to make the choice we want them to make? A consumer may make a poor choice even after hearing the truly research-based facts, but it is still their choice. It is always their choice. Let's let the research speak for itself.
Families need to be educated, encouraged and supported to formulate their own opinion, their own philosophy and to make their own decisions. This is not paternalism. I am not speaking of indoctrination, rather empowering families by teaching them how to teach themselves. I believe if families want the best possible outcomes, they must take responsibility for their education and learn to decipher research themselves. This is not advocating that families distrust their providers. Rather, it is encouraging us to get away from blind dependency on the "experts" and shift to a confident, collaborative relationships between clients-providers. The more that families take responsibility for their health and health education and the less that providers promise the world and stifle their patient's self learning, the less fear, manipulation, distrust, paternalism and litigation we will see. Correspondingly, more collaboration, confidence, responsibility and better patient outcomes will follow. But it MUST begin with the consumer--i.e. the patients. If consumers are lazy and unwilling to educate themselves and check the facts and instead dump their woes and needs on providers, the results will be at best suboptimal and at worst, devastating. Providers will be unfairly responsible for other people's poor choices and families will suffer loss. Support and nurture young families. Teach others to teach themselves.
Thanks for your thoughts on this subject, Deb. There is probably part of the story that is not represented, but I am just surprised that an OB would feel the need to make a comment on the position of the baby at 29 weeks when in his own words there are still 8 weeks for things to turn around. What is the need in worrying a mother with that information so early? Is it to prepare her for the idea of a c-section?ReplyDelete
Another thought - I remember when A. was just a newborn relaying to my pediatrician something I had read in a book about the need to allow your baby to nurse on one breast for atleast 15 minutes because the hind milk comes in after the baby has exhaused the fore milk, and the hind milk is the very calorie-rich milk that will be more sustaining to the baby. My ped laughed at this idea, and asked me where people were getting this information. Now, it could be that that theory is complete bologna (I would love to know if you or others have more information on this subject), and in that case I am thankful for having been straightened out. However, the manner in which he responded to me did two things - 1) it made me less comfortable to express concerns and questions to him in the future, and 2) I felt discouraged from reading and learning on my own. I think it would have been helpful for him to first encourage me for my desire to educate myself, but then respectfully explain why he disagreed with what I had read.
It was strange for this OB to start talking about a c-section so early in the pregnancy. I suppose he might have been giving them a heads up that it was a possibility. At any rate, it was poorly handled.ReplyDelete
K- I remember you telling me about this conversation with the pedi. It reminds me to consider that although physicians are very skilled in their knowledge of disease and treatments, they are not experts in everything, particularly in what is normal and disease-free. Physcians (even OB’s or pedi’s) do not specialize in breastfeeding and from what I understand even the lactation course during an OB or Ped clinicals and residency is optional (if anyone has other information, please let me know.) All that to say, sometimes pediatricians feel they are an authority in all aspects of health and nutrition, when in fact (just like any other professional) they are skilled in certain subjects (again, disease and treatment) and not others. I think this is a tendency that is more prevalent among pediatricians and obstetricians since some of them take on a more paternalistic role with their patients/patient’s parents. The way in which a provider responds to questions or comments says a lot about their approach to practice. Do they value a parent’s education, background and opinion or are they only interested in endorsing their own? Is this endorsement done at the expense of a parent’s confidence in their provider and desire for parents to take responsibility for their health and education? Or does it serve to belittle and disrespect parents and sever a collaborative relationship?ReplyDelete
In terms of the foremilk hindmilk concepts, these are very real. The Breastfeeding Answers Book, which is the lactation consultant’s “bible” and is put out by La Leche League International, has this to say about foremilk and hindmilk:
“The milk the baby receives when he begins breastfeeding is called the ‘foremilk,’ which is high in volume but low in fat. As the feeding progresses, the fat content of the milk rises steadily as the volume decreases. The milk near the end of the feeding is low in volume but high in fat and is called the ‘hindmilk.’ By allowing the baby to decide when he is finished with the first breast, the mother can be sure he has received the proper balance of fluid and fat. Switching breasts too soon might mean the baby will receive only foremilk from each breast, filling him up with low-calorie milk. A baby who receives too much foremilk and not enough hindmilk may gain weight slowly, be fussy at the breast and between feedings, and may have a greenish liquid stool (Woolridge 1988)” as quoted in The Breastfeeding Answer Book, Rev 3rd ed, pg 37
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Many breastfeeding books and consultants give a “15-20 minute” minimum time on a breast to ensure the fore- and hindmilk have both been consumed. This is not because there is anything magical about 15-20 minutes, but rather because it is an approximation of the time it might roughly take for a baby to access both types of milk. A more practical and accurate way of ensuring baby has taken both fore- and hindmilk would be to tell moms to let the baby finish the first breast, (for example the right breast) however long that may take. We know when a healthy full term baby has “finished” a breast when he comes off the breast, either asleep or appearing satiated or still hungry. Moms can choose at this time to offer the second breast, in this case the left breast, if baby still appears hungry, but not to worry if the baby does not seem interested. If baby does take some of the second (e.g. left) breast, he has started to take the foremilk of that second breast. This is why the recommendation for the next feeding is to start on the same breast you left off during the last feeding (the left) so that the baby can “finish” that breast. During this next feeding, the baby may only stay on this left side for a few minutes as he finishes whatever he did not take in during the previous feeding. He would then come off of this left breast when he finishes and could be put on the right breast and the feedings continue. Some babies only take one breast per feeding, while others take one full breast and part or all of the next breast. It just depends on the baby. Although there are no defined numbers and times for a mom to put into her pocket by using this “comes off the breast” principle, it helps moms watch the baby rather than the clock. I specify a healthy term baby because preemies, jaundiced, sleepy or otherwise compromised babies may come off the breast before they have actually had their fill. In such as case, a mom could then burp her baby, arouse him again and put him back onto the same breast to finish. The Breastfeeding Answer’s Book also goes on to discuss that as the baby ages, the time it takes to finish each breast may change. For instance, an older baby, say an 8 month old may be able to finish a breast in 5 minutes. Each mom’s milk content is also different, some being more or less rich in fore- and hindmilk. These differences also influence the time a baby spends at each breast.
Here also are some links to articles that discuss fore- and hindmilk.
Hope that’s helpful!
Thanks for all of this information! It is extremely helpful right now as I've started the whole thing over again.ReplyDelete