Although I am not a birth professional, except in so much as I focus a certain percentage of my practice on prenatal health, I feel compelled by recent events in my personal life to write a short entry on the hotly contested phenomenon of home birth.  No topic I ever discuss inflames stronger sentiments in two deeply polarized camps.  After all, what could excite your passions more than the safety of your newborn? It’s no small topic so, naturally, choosing the manner of birth for your own family requires a great deal of consideration and research.  Unfortunately, looking online may lead unsuspecting couples into a labyrinth of blogs and chat rooms with endless blistering dialogues by angry opponents and proponents maligning one another from their corners. It’s distressing, polarizing and, above all, unhelpful.

Without claiming to end the age-old debate, I will suggest that some resolution could be found in a simple definition of terms.   Appealing to the BC College of Midwives Handbook on Planned Home Birth, I have found this simple definition.

Home birth involves careful screening of clients by their midwives for suitability and

Coordination between midwives and other health care providers.  Home birth is not simply

an interaction between a midwife and client, but is provided within a broader support

system that includes hospitals, physicians and emergency services.

The key point is the co-ordination of several services working in concert to ensure the best possible outcome for baby and mother.  “Home birth” describes the decision to birth at home, under the care of appropriate healthcare providers (in BC that would be 2 midwives or one midwife and a college approved second attendant) with a back-up plan, emergency services, and appropriate transportation. In BC, the maternity care system facilitates this choice through the availability of well-trained midwives and through a good transportation and referral system.
Many opponents interpret home birth as an inherently antagonistic approach where women “rebel” against the patriarchal medical system and strike out on their own to do it “their way”.  Thus birth is mangled into a political statement where it becomes a form of protest.  In this view, home birth pays primary consideration to the woman and her birth experience while the baby and his survival are secondary.  As we can see from the above definition, this is categorically false.  Home birth exists very much inside of the current medical standard of care.  B.C. College-registered midwives are some of the best trained birth professionals in the world who attend births in both home and hospital settings.  They carry emergency equipment such as oxygen, resuscitation equipment and anti-hemorrhage drugs; they have hospital and prescribing privileges.  These are not fringe para-medical professionals; they are one very important link in a chain of services to ensure safe care.

So hopefully this definition helps to clarify the grave misunderstanding of homebirth as an irresponsible choice of woman who risk their baby’s lives to satisfy their own need to define themselves.  In addition, I’d like to leave you with a link to a massive study done recently here in BC.  It’s well done and notes no significant difference between planned home birth (as defined by the College of midwives) in terms of perinatal mortality and morbidity.  I worked with the primary researcher Dr. Patricia Janssen Ph.D. several years ago on an acupuncture study at BC Woman’s hospital and know her to be a tireless advocate for healthy birth.  As it happens, Lee Saxell, who also worked on this study, was the second attending midwife at my daughter’s birth.  Here’s a link to the full text article.

http://www.cmaj.ca/cgi/rapidpdf/cmaj.081869v1

Osteoarthritis is a degenerative joint disease which slowly wears away the cartilage (soft cushion between the bones) within the joint.  It is characterized by pain, stiffness and a reduced range of motion.  It can occur in one or both knees.

WHAT CAUSES OSTEOARTHRITIS?

While it is not fully understood why the cartilage wears away, we do know that it is a “wear and tear” disease which is aggravated by several factors.  For example, a past injury can increase your chances of developing osteoarthritis.  It typically affects you with aging and is more common in people who are obese.  It is also twice as common in woman as men.

HOW IS OSTEOARTHRITIS TREATED?

Your doctor will probably recommend therapies that help you manage the pain.  Here are some of the most common:

Rest your knee and avoid activities that aggravate the pain

Ice the affected joint for 20-30 minutes twice a day to reduce swelling/inflammation and reduce pain

Use painkillers such as acetaminophen (such as Tylenol) and ibuprophen (such as Motrin)

Injections into the joint of steroids or Hyaluronic acid

Surgery

HOW CAN ACUPUNCTURE HELP?

Acupuncture is an effective, clinically proven method for reducing the symptoms of Osteoarthritis and is an excellent alternative to injection therapy.  It leads to lowered levels of pain and immobility associated with the disease.  In addition, there are no side effects or adverse reactions to acupuncture. People who receive the treatment report less pain, greater mobility, and higher quality of life. Many scientific studies have confirmed that acupuncture works as an excellent addition to conventional treatment of this very common disease.

A randomized controlled trial (RCT) must conform to very specific criteria.  Firstly, statistical significance will be reflected in an appropriate sample size.  So, for example, a multi-centered study involving 100’s or 1000s of participants is generally preferred over a small sample of 48 people.  Secondly, randomization requires that participants are allocated into groups by some form of chance method thus eliminating the confound of “self selection”.   Ideally, there will be three groups: a treatment group, a control group (receiving either no treatment or “standard treatment” from their medical doctor) and a “placebo” group which undergoes an “acupuncture-like” treatment to compare with the actual acupuncture treatment.  These groups ideally need to be double-blind.

These controls are required for the purposes of comparison.  The World Health Organization (WHO) in its 1995 publication entitled Guidelines for Clinical Research on Acupuncture specifies six potential controls:

• Mock TENS
• Sham acupuncture
• Non-treatment
• Standard therapy
• Real acupuncture
• Minimal acupuncture

Each control possesses its own unique qualities.  Mock TENS involves taping an inert electrode over an acupuncture point on the subject’s skin which he believes is stimulating the point with mild current electricity.  In sham acupuncture, needles are inserted at non-acupuncture points, and minimal acupuncture refers to inserting the needles superficially such that the skin is broken, but the needle never goes to muscle depth.  Here a question emerges: do these controls differ significantly enough from real acupuncture? Can we be assured that we are eliminating the variables we hope to eliminate, namely the placebo effect?  Many acupuncture studies find that the acupuncture-like treatment is only marginally less effective than real acupuncture in the treatment of pain perception.  In fact, according to Irene Lund and Thomas Lundeberg, these placebo controls are anything but inert.

It is likely that control procedures used in many

acupuncture studies aimed at being inert are in

fact activating [certain structures] and consequently

alleviating unpleasantness and re-establishing the

patient’s sense of self-esteem and wellbeing.

(Acupuncture in Medicine 2006;24(1):13)

Unfortunately, the control methods themselves have not been adequately tested to eliminate this problem.  If no pilot studies confirm the inertness of sham techniques then we cannot be sure what they are capable of and thus what untold variables are potentially released like a wildcard into a “controlled” study.  Lund and Lundeberg thus go on to assert that “neither minimal, superficial, [nor] sham acupuncture… may be regarded as placebo as they are not inert” (ibid).   Also of note is the “blinding” issue:  it is impossible to have a double-blind study in acupuncture.  Ideally neither the practitioner nor the participant should know who is receiving the real and the placebo treatment.  However, the practitioner must be trained and qualified and thus will clearly knows who is receiving the sham and who is not.

These confounds illustrate the difficulties which plague contemporary study of acupuncture.  However, the problem runs deeper than the issue of control groups.  In the attempt to fit the phenomenon of acupuncture into our current methods of scientific validation, we unwittingly misrepresent its finer qualities.  As a whole system, the human organism possesses properties not seen in its constituent parts.    All living systems, from the individual cell, to the organism and even the earth itself, possess emergent properties, features which emerge at a certain level of complexity.  For example, the flavor of salt is present in neither the sodium nor the chloride, yet taken together, saltiness emerges.  Knowing that the whole is greater than the sum of its parts should alter the way we approach any phenomenon, yet we still attempt to explain acupuncture by pulling it apart and artificially reconstructing it when it is clearly not amenable to reductionist science.

So how does this apply to me and my everyday practice?  Opponents of acupuncture often appeal to the placebo effect, claiming that suggestibility accounts for the healing when no “actual proof” exists.  I have no satisfying answer to this assertion, except to ask myself and others to apply a little scientific scrutiny to the whole concept of “placebo”.  Interestingly, I witness events on a weekly basis for which there is no proof.  If a patient claims his condition has improved, I have no choice but to believe him.  I take in the evidence of my senses; I perform my skills; I anticipate outcomes; I note and record these outcomes in a chart, along with the information from the client; I assess and draw conclusions.  What I have just described is in essence a deeply scientific process.  And I am not unique.   We all do this; we look around our world, asses, judge and behave according to our observations.   So either A) the client and I are engaged in a psycho-emotional drama where I am the “healer” and he is “being healed”, or B) the treatment is working.  It would be very unscientific of me to doubt or deny that which I repeatedly observe.

 So here is my embellished cocktail party response.  James Reston, a journalist for the New York Times, returned from China in 1973 after having undergone an emergency appendectomy while working there.  Although standard analgesia was administered for the actual surgery, his post-operative pain relief came wholly from acupuncture, a virtually unknown procedure in western popular consciousness.   He considered his care to be so impressive that he wrote about Acupuncture in the New York Times.  Since then, much study has attempted to explain the mechanism of action and while no single, comprehensive explanation exists, several theories have emerged. 

 Neurotransmitter Theory is perhaps the most widely accepted explanation for acupuncture’s efficacy.  Here, the procedure stimulates the release of certain endorphins and enkephalins in the central nervous system thereby blocking the effect of “substance P”, a neurotransmitter which enhances perception of pain.  However, this theory only explains acupuncture’s treatment of pain, but does not address why it works for many other symptoms such as allergies or eczema.  Similarly, the Gate Control theory of pain offers another common explanation.  As you receive sensory information such as an injury, a nerve impulse carries this message to the dorsal horn in your spinal cord and with a critical mass of stimulus, pain begins.  Acupuncture triggers the inhibitory cells in the dorsal horn thus “gating out” pain perception.  The pain is never experienced because your brain doesn’t get the message. 

 Much research has attempted to explain acupuncture’s ability to treat various syndromes beyond pain relief.  For example, acupuncture is also known to regulate the autonomic nervous system.  Periods of high stress leave our bodies susceptible to various forms of illness.  This results from over stimulation of the sympathetic nervous system, the aspect of our bodies which mediates the “fight or flight” response.  When you are running for your life, all available resources are directed to the structures of survival.  For example blood supply to your muscles increases to aid in running from or fighting a predator, while vessels irrigating non-survival organs are constricted. Some examples are the digestive and reproductive organs.  It is well known that a labouring mammal exposed to danger will respond by slowing and eventually halting her birthing process until a safer environment for giving birth can be found.  This response is a survival mechanism, working outside the mother’s conscious control, ensuring the survival of her offspring.  Now imagine any number of near-misses in traffic, roaring airplanes, or running for the bus.  While we don’t have sabre tooth tigers keeping us up at night, these stresses constitute our modern day triggers on the nervous system.  Acupuncture stimulates the release of norepinephrine, acetylcholine and several opioids thus normalizing the parasympathetic aspect of the autonomic nervous system.

 So while I’m not usually this long-winded at cocktail parties, at least not early in the evening, I hope I’ve covered the basics for everyone.  I haven’t talked about the electromagnetic theories of acupuncture because I feel it requires a separate entry.  I also want to address our current methods for testing  acupuncture, a question which also begs for an article of its own.