Midwifery has a serious problem. A lot of its central claims simply aren’t supported by science.
There are two ways that midwifery theorists could address this problem. They could modify the central claims of midwifery theory (unmedicated vaginal childbirth is best, midwives provides evidence based care, obstetricians ignore scientific evidence) or they could dismiss science. They have taken the second approach with truly laughably results. Their pathetic attempts at dismissing scientific evidence extend from improperly invoking scientific theories of quantum mechanics and chaos theory, which they clearly don’t understand and which have zero applicability to midwifery, to attacks on the notion of randomized controlled trials, to rejecting rationality altogether and insisting that Including the Non-Rational Is Sensible Midwifery.
Simply put, while scientific research seeks to learn, specifically to learn how the human body works and how to maximize healthy outcomes, midwifery research seeks to justify, specifically to justify a primary role for midwives in the delivery of obstetric care and to justify the use of methods and claims not supported by scientific evidence.
Now comes the latest bit of midwifery buffoonery produced by Denis Walsh. You may remember Walsh, a professor of midwifery, as yet another in a line of old white men mansplaining the “benefits” of labor pain to women. Walsh has mangled yet another mainstream theory in a desperate effort to justify ignoring scientific evidence. His new paper, Critical realism: An important theoretical perspective for midwifery research, published in this month’s issue of the journal Midwifery, will no doubt impress other midwives (such big, fancy words!), but real scientists and philosophers would just howl.
According to Walsh:
Midwifery research has grown exponentially over the past 20 years and has been widely disseminated in a range of midwifery and obstetric journals. Research methods that are utilised are increasingly eclectic and reflect the variety of research questions addressing different aspects of childbirth. However conspicuously absent in midwifery journals has been in-depth discussion and debate about the philosophical underpinning of different research methods, though these have taken place in midwifery research texts and other health professions’ journals. The debate asks important questions about the nature of reality (ontology) and how we gain knowledge of it (epistemology). Such a focus is fundamental to research endeavour because unless the right questions are asked about the reality we are attempting to describe, explore or explain, then our knowledge of that reality will remain superficial and impoverished and is less likely to make a difference to childbirth practices and women’s experience. In addition, it can result in research that is inadequately justified, lacks internal coherence and therefore lacks wider credibility.
English translation: Midwifery research is, in large part, nothing more than crap and therefore no one takes us seriously. But even though our research looks crappy, it’s only because no one has explored the deeper philosophical underpinnings.
That’s where critical realism comes in.
What is critical realism?
Critical realism is a philosophy of the SOCIAL SCIENCES (not the natural sciences) combines a general philosophy of science (transcendental realism) with a philosophy of social science (critical naturalism) to describe an interface between the natural and social worlds.
It was promulgated by philosopher Roy Bhaskar:
… [W]hen we study the human world we are studying something fundamentally different from the physical world and must therefore adapt our strategy to studying it. Critical naturalism therefore prescribes social scientific method which seeks to identify the mechanisms producing social events, but with a recognition that these are in a much greater state of flux than those of the physical world (as human structures change much more readily than those of, say, a leaf). In particular, we must understand that human agency is made possible by social structures that themselves require the reproduction of certain actions/pre-conditions. Further, the individuals that inhabit these social structures are capable of consciously reflecting upon, and changing, the actions that produce them—a practice that is in part facilitated by social scientific research.
This may make sense in the world of social science research (although there are many other philosophers who would disagree), but midwifery claims are generally natural science claims, so critical realism doesn’t apply.
Walsh doesn’t really care about the validity of invoking critical realism in assessing the validity of midwifery research, he merely intends to use it as an excuse to ignore scientific evidence in favor of midwifery beliefs and intuitions.
Walsh does not like the scientific evidence about dystocia (stalled labor):
An example of this is the current research into dystocia, a complication of labour that is the principal contributor to caesarean section in nulliparous women. Most of the research has explored interventions to speed up labour … The methods utilised in these studies have been randomised controlled trials … [which] promises certainty in addressing the condition, based as they are on a positivist epistemology (knowledge that is always true and generalisable) … However, the incidence of dystocia and its negative consequences for women continues to rise. If researchers had grasped the limitations of their research methods by critiquing their ontological and epistemological underpinning, they might have asked different questions about the aetiology of dystocia, researched different interventions to manage it and ultimately had a greater impact on women’s outcomes and experience.
English to English translations: The large body of scientific literature on dystocia does not support midwives’ intuitions and claims about dystocia.
Never fear! Critical realism supposedly comes to the rescue:
Nine years ago, Anderson began asking different questions about the aetiology of dystocia, suggesting some new categories – organisational dystocia (lack of continuity of care on labour wards), environmental dystocia (clinical, non-homely décor) and interpersonal dystocia (disagreements between labour ward midwives and obstetricians). Of course what she was hinting at were environmental, social and psychological effects that could impinge upon a woman’s ability to labour normally. Later, Downe and McCourt articulated the limitations of studying labour predominantly by using randomised controlled trials (RCT’s) because the theoretical foundations of trials reside in a positivist epistemology based on simplicity, linearity and certainty. However, labour does not unfold with a singular cause and effect physiology (oxytocin secretion therefore cervical dilatation) which then proceeds with regularity (cervix dilates in a constant trajectory) to end with birth at a relatively predictable point (average of 10 hours). It is a much more complex phenomenon which might more accurately be referred to as ‘orderly chaos’. Clearly, experiences like labour are impacted on by multiple factors in the physiological, psychological and social domains. Simply applying quantitative research methods suited to the controlled confines of a laboratory are not going to capture the intricacies of the uncontrolled milieu of a labour ward.
In other words, midwives don’t like what the scientific evidence shows so it’s okay if we ignore it.
Let’s leave aside for the moment that critical realism has been dismissed on its own terms by philosophers and let’s focus on the relevant facts:
1. The central claims of midwifery theory are not supported by scientific evidence.
2. Midwives have no intention of modifying cherished beliefs just because science shows they are false.
3. There is a desperate, ongoing search among midwifery theorist to justify ignoring scientific evidence.
4. A variety of theories from other disciplines, poorly understood or misunderstood by midwives, are invoke by midwifery theorists to baffle their followers with bullshit.
What should the average pregnant women take away from these bizarre, goofy theoretical justifications? It’s startlingly simple:
If you want science based care in childbirth, stick with obstetricians.