Is the Childbirth Connection qualified to give medical advice?

The Childbirth Connection is the leading lobbying group for natural childbirth advocacy. As their website explains:

… [O]ur organization has … carried out media outreach, and developed a broad range of clinical, educational and advocacy programs; dozens of consumer and professional publications; many conferences and symposia; and numerous surveys and program evaluations…

No doubt they are qualified to lobby on behalf of their personal beliefs, but are they really qualified to offer medical advice to pregnant women?

They claim to be deeply concerned about offering accurate summaries and interpretations of the scientific evidence on which modern obstetrics is based. Among their stated goals:

* To exercise their legal right to informed consent and informed refusal, women need access to full and accurate information based on the best available research about all options for care from early in pregnancy through the postpartum period…

* Caregivers and institutions have the responsibility to provide evidence-based care that respects and supports the innate physiology of pregnancy, labor and birth, and the mother/baby connection, and addresses the family’s needs, values and preferences.

I can’t disagree with those goals. But is the Childbirth Connection capable of accurate assessing the obstetric scientific evidence in order to provide accurate information?

Considering that we are discussing the massive scientific literature of obstetrics, you might think that the Childbirth Connection would have obstetricians among its reviewers, but you’d be wrong. There is not a single obstetrician on the Board or staff of the organization.

In fact, there is no one who has an MD and no one who has a PhD in a scientific field. Therefore, the Childbirth Connection has no way of vetting their publications to be sure that they accurately represent the current state of obstetrics and obstetric research. And that failure to appropriate vet their medical and scientific claims is glaringly obvious to anyone who DOES routinely read the scientific literature.

Consider the issue of labor induction. Amy Romano, previously of Lamaze International and now working for the Childbirth Connection, describes information purported to be the “best evidence” on labor induction as “a systematic review of the highest quality research.” It is nothing of the kind.

An obstetrician would start a review of the literature on induction by reading a chapter in an obstetrics text that provides an overview. “Induction in Labor” in Williams Obstetrics is a relatively short chapter (6 pages) and reviews more than 100 scientific papers on the topic. Then an obstetrician would proceed to a literature search to review the scientific papers submitted in the last 1-3 years since the textbook was published. In the last two years alone several hundred papers have been published on labor induction

In contrast, the Childbirth Connection reviewed only 4 scientific papers on the topic! Not only does this fail to meet the criteria of a systematic review, it barely skims the surface. So if the Childbirth Connection failed to review the majority of the literature on labor induction, what did they do? They cherry picked a few papers that reached conclusions that they liked and IGNORED everything else.

And what does the Childbirth Connection’s “evidence” purportedly show?

They acknowledge that induction has definitely been shown to improve outcomes in the three most common medical indications for induction:

* Pregnancy lasting beyond 41 weeks [note: outcomes improve at 41 weeks a week before the traditional cutoff of 42 weeks]

* Prelabor rupture of membranes (PROM) at term (37-42 weeks)

* Increased blood pressure near the end of pregnancy

Then there are medical indications where the medical evidence is not as strong, primarily because there have not been enough studies done yet. The Childbirth Connection mentions them and misrepresents the scientific evidence about them.

Preterm prelabor rupture of the membranes (PPROM)- Here the Childbirth Connection misrepresents current obstetrical practice. In premature rupture of membranes, the benefit to the baby of more time in the uterus outweighs the risk of infection, so the recommendation is NOT to induce unless an infection develops.

Gestational diabetes requiring insulin – Again the Childbirth Connection misrepresents the situation. First they fail to mention Type 1 (insulin dependent diabetes) at all, despite the fact that it is a major medical indication for labor induction. The stillbirth rate in insulin dependent diabetes is more than triple the rare for non-diabetic mothers. Insulin dependent GESTATIONAL diabetes is a much less common phenomenon, and therefore, as the Mozurkewich paper acknowledges, there is little evidence available on induction in that setting. However, it is hardly unreasonable to assume that insulin dependent gestational diabetes poses the same harms to babies and to proceed under that assumption until further data is available.

Intrauterine growth restriction (IUGR) at term – Yet another misrepresentation. The Childbirth Connection claims that “more and better studies” are needed to determine if induction improves outcomes in IUGR. But IUGR is KNOWN to be responsible for a significant proportion of stillbirths. There is no treatment for IUGR, so the best hope for preventing stillbirth is to deliver the baby.

How does the Childbirth Connection summarize the medical indications awaiting more studies?

What common “reasons” for induction are not supported by rigorous research?

For a surprising number of conditions, the effectiveness of induction has not been proven (Mozurkewich and colleagues 2009, a systematic review). Yet many women have induced labor with the understanding that they or their babies will benefit. More or larger studies are needed to confirm the benefits and harms of induction in these situations.

In other words, they imply that these are not “reasons” for induction, that they will produce no benefit, and therefore we should wait for more evidence. But we KNOW that insulin dependent diabetes increases the risk of stillbirth and we KNOW that IUGR increases the risk of stillbirth. No obstetrician is misrepresenting the evidence when he or she recommends induction to prevent stillbirth in this situation. And no one is recommending induction for preterm rupture of membranes so it’s ucclear why this was included among spurious “reasons” for induction.

What might the average woman take away from this Childbirth Connection publication?

It seems to me that they are supposed to take away the following impressions:

Inductions are bad.
Don’t trust your obstetrician.
Obstetricians ignore scientific evidence.
There is no reason to induce for insulin gestational diabetes or IUGR.

And all four are wrong.

They really have nerve to represent this as “best evidence.” It isn’t a complete review of the evidence. It isn’t the best evidence. And even the minimal evidence that has been presented has been misrepresented by the Childbirth Connection.

They have no business giving medical advice to women. They lack the qualifications, and based on this piece and others like it, they lack the ability to review the massive scientific literature of modern obstetrics.

They are certainly entitled to promote their personal agenda, but they are not entitled to give erroneous “medical advice” to do so.