Medical anthropology paper tries to rebut my criticism of modern midwifery, but unwittingly bolsters it

454B30BB-C1A0-4744-86E4-2340F7552AAA

Midwives have a problem with scientific evidence.

It wasn’t always that way.

[M]idwives were initially enthusiastic about basing clinical practice on scientific evidence. That’s because they had long told each other that midwifery was “science based” while obstetrics was not… It has been quite a shock to midwives and childbirth educators to learn that most of their own practices have never been scientifically validated. Even worse, from the point of view of ideology, their critique of modern obstetrics flies in the face of the existing scientific evidence… Thus began the attack on scientific evidence.

I wrote those words almost ten years ago. In the intervening years I have detailed how the problem has only gotten worse. Now a new medical anthropology paper tries to rebut my criticism of modern midwifery’s cavalier dismissal of scientific evidence that doesn’t support their pre-determined conclusions. Ironically, the author ends up substantiating my claims. She demonstrates what I have been writing recently: contemporary midwifery is more religion than science.

Personal experience is evidence, just not scientific evidence; it is religious evidence.

Andrea Ford of the University of Chicago has written Advocating for evidence in birth: Proving cause, effecting outcomes, and the case for ‘curers’ a forthcoming paper in Medicine Anthropology Theory.

At least two conceptions of ‘evidence’ circulate in current maternity care: it is used in biomedical ‘evidence based obstetrics’ and also by people seeking to reform conventional obstetric practices. Inspired by recent fieldwork in California, this article uses the history and philosophy of science to tease apart implicit differences in what ‘evidence’ is understood to be, distinguishing biomedical evidence based on controlled experiments used to prove cause, from reformist use of evidence foregrounding patient outcomes…

Ford believes I am an avatar for “traditional” biomedical evidence in contrast to midwives who have a “reformist” view of evidence:

The popular blog The Skeptical OB, written by obstetrician Amy Tuteur, is an exaggerated foil … that exemplifies this confrontation. She was notorious among some reformists for her often-vitriolic rhetoric and insistence on the moral corruption of ‘the natural childbirth industry’. Tuteur directly confronts evidence usage in at least fifteen posts, calling the idea that obstetrics is not evidence based a ‘smear campaign’… She calls reformist [midwifery theorists] usage of evidence a double standard, in which evidence is embraced when it aligns with prior ideological commitments (or profits) but dismissed when it doesn’t.

Kudos to Ford for accurately representing my views rather than caricaturing them. Unfortunately, she’s far less successful when she attempts to rebut them.

Tuteur is attempting to arbitrate which ‘side’ is using evidence correctly, which is quite different from my objective in considering its rhetorical and practical function as a boundary object that can be claimed by people with different aims and assumptions, enabling people to feel like they are speaking the same language even without consensus.

But I’m not trying to arbitrate who is using evidence correctly. I am simply noting that obstetricians use scientific evidence, while midwives are reduced to pretending beliefs are scientific evidence. Of course Ford cannot admit that; she prefers to claim that midwives seek to replace “proving” with “curing.”

In my fieldwork, reformists [midwifery theorists] seemed generally enthusiastic to explain why particular outcomes occurred, but they do not attempt to prove why scientifically — that is, experimentally. I found narrations of causality to be common; for example, that nipple stimulation releases oxytocin and oxytocin causes contractions, therefore nipple stimulation will effect the onset of labor.

Such explanations are not arbitrary personal claims (‘anecdata’, as one disparaging commenter on one of Tuteur’s evidence posts phrased it), but neither are they objectively-randomized quantitative proofs. They are rational, not experimental. Controlled trials, by contrast, are experiments, seeking to prove cause by eliminating all but one potentially-causal factor, and randomization is the closest approximation to researcher objectivity, so RCTs are the ‘gold standard’ for trustworthy experience.

For Ford, it doesn’t matter whether nipple stimulation can be proven to induce labor so long as the midwife and patient believe it can. In this way, midwifery theorists can assert with a straight face that what the patient believes has happened is “scientific evidence” on an equal footing with objective evidence of what has actually happened.

…[R]eformist activism [midwifery theory] has redirected the focus of ‘good research’ onto outcomes prioritizing the patient’s perspective …. seeking empirically good outcomes no matter their rationale …

Ford imagines that I and other obstetricians fear substituting objective evidence with belief. She references philosopher Isabelle Stengers:

She warns that if proof and cure are independently valued and sought, doctors will cry out for some way to identify charlatans so medicine is not just arbitrary — in this case, practicable by lay midwives, citizen scientists, intuitive mothers, a nurse with a website. Tuteur’s blog, The Skeptical OB, falls in line with this prediction.

Medicine should “lose the fiction” that …

the suffering body ‘should’ be able to tell the difference between real medicine and fake — for example, between labor induced by an intravenous drip of pitocin, and that which coincides with nipple stimulation, eating spicy food, and walking up stairs, all of which are non-medical techniques to influence labor’s onset …

Ford misunderstands my objection.

Personal experience is evidence, just not scientific evidence. Personal experience is religious evidence. It is a variation on the argument from religious experience.

The argument from religious experience is the argument from experiences of God to the existence of God. In its strong form, this argument asserts that it is only possible to experience that which exists, and so that the phenomenon of religious experience demonstrates the existence of God. People experience God, therefore there must be a God …

Ford’s midwifery version could be articulated as follows:

It is only possible to experience that which exists so if a patient or midwife “experiences” a labor being induced by nipple stimulation or spicy food, that demonstrates that nipple stimulation and spicy food must be a forms of labor induction.

Viewing “evidence” in this way speaks to the fact that midwifery has become more religion than science.

As I wrote just last week: Consider midwives like Sheena Byrom and Hannah Dahlen. They “believe in” the superiority of unmedicated vaginal birth. Their “belief in” the power and perfection of natural childbirth exists prior to and independent of scientific fact. It is both immutable and non falsifiable.

Ford would have us conclude that the fact that Byrom and Dahlen (and some of their patients) believe unmedicated vaginal birth is superior is proof that it is superior in exactly the same way that religious experience is “proof” that God exists.

This ‘personal care’ reflects an orientation around the birthing person’s perspective, which is the fundamental difference between curing and proving.

But it’s not the difference between curing and proving; it’s the difference between religious belief and scientific evidence.

The ultimate irony is that while Ford thinks she is rebutting my criticism of modern midwifery, she is both corroborating and bolstering it.

  • Sue

    “Spicy food” induces labor? So, the entire Indian subcontinent and central America all have premature labor? “Spicy” is a judgement used by people whise noemal diet is bland. Maybe bland food inhibits labor!

  • MaineJen

    You know you’ve lost the argument when you start having to redefine the word “evidence.”

    • fiftyfifty1

      MaineJen, don’t be so closed minded. You must consider the rhetorical and practical function that “evidence” plays as a boundary object!

      • Juana

        You must consider the rhetorical and practical function that “evidence” plays as a boundary object! philobabble.
        There, fixed that for you (and especially Mrs. Ford).

        • AnnaPDE

          I’m currently trying to get my oldest to do a decent job on his English assignment, which involves analysing a song’s lyrics. He’s managed to write a draft of considerable length with sentences that include all the pretentious buzzwords with exactly zero content related to the actual subject at length. Now this kind of babbling is a classic strategy when you have to write something but have no idea what you’re talking about — not entirely unexpected in an 8th grade essay.
          But in something supposed to be an academic article in an actual journal? By someone who is trying to explore the details of how people understand and draw conclusions from observations? That’s a bit concerning.

          • fiftyfifty1

            Oh enough of the hegemony! Let his essay be a boundary object of the liminal space.

          • AnnaPDE

            So it will be, trapped in the tensor field spanned between the base vectors of hope, reluctance and pseudo-objective expectations, until the subjective grading kernel collapses all of it into certainty on Monday afternoon, with questionable emotional repercussions. But then at least we can stop nagging whether he’s even looked at the damn task.

      • KQ Not Signed In

        Yep, those are all words all right.

      • Allie

        Yeah, I have an honours degree in English literature (plus most of the credits for an MA), a JD and MBA, and I have no idea what this means: “my objective in considering its rhetorical and practical function as a boundary object that can be claimed by people with different aims and assumptions, enabling people to feel like they are speaking the same language even without consensus.”

        • fiftyfifty1

          It’s almost certainly not what she meant, but this is what came to my mind:
          We fake midwives are fighting to gain territory. Now as many as 1.5% of women are duped by our rhetoric! How can we continue to move the boundary toward higher % of women buying into homebirth? Doctors already cite evidence, so let’s claim we have “evidence” too! The aim of doctors is to help people, and since we will speak the same language, women will make the assumption that that’s our aim too (of course our real aim is to dupe the women into funding our birth hobby, LOL!) There couldn’t be a more practical rhetorical device! Women will think the consensus is that homebirth is safe–because “evidence” duh!

          • Juana

            “At least two conceptions of ‘evidence’ circulate in current maternity
            care: it is used in biomedical ‘evidence based obstetrics’ and also by
            people seeking to reform conventional obstetric practices. Inspired by
            recent fieldwork in California, this article uses the history and
            philosophy of science to tease apart implicit differences in what
            ‘evidence’ is understood to be, distinguishing biomedical evidence based
            on controlled experiments used to prove cause, from reformist use of
            evidence foregrounding patient outcomes…”

            In other words, the usual argument “we midwives don’t need this science stuff, we have other ways of knowing”, just with bigger words.

          • fiftyfifty1

            “we midwives have other ways of knowing” just with bigger words.

            In this case she is using bigger words, but sometimes she actually uses “ways of knowing” like in the first chapter of her dissertation. She’s not trying to hide it.

          • rational thinker

            “we midwives have other ways of knowing”

            TRANSLATION: we consult our box of magic crystals they will turn different colors for different problems.

          • fiftyfifty1

            ETA: Reading her dissertation is fascinating. I kept thinking “she doesn’t know what she doesn’t know.” She studies NCB in the Bay Area as an anthropologist. But also as a practicing doula. She says she works at “refusing the temptation to partisan fervor” and I believe she sincerely means to do so, but the problem is that she is well versed in NCB thought (and anthro thought), but has major Dunning Kruger when it comes to medicine science. An example is her description of one of her doula cases–a woman who pushed 4 hours despite OB advice for C-section 2 hours earlier, then ends up having a shoulder dystocia the CNM can’t resolve, so the baby is delivered emergently covered in mec by the in-house OB, who saves the baby using protocol moves of episiotomy and McRoberts. Ford then claims shoulder dystocia is “unpredicatable and has no accepted protocol for prevention or treatment.” Oh yeah? Hello, prolonged second stage is one of the well known predictive factors. Thus the established preventive rec of CS after 2 hours of fruitless pushing. And if a SD does occur there is indeed a accepted treatment protocol–one that doctors and nurses drill on in their downtime–the HELPER protocol. But instead of knowing this, she and the other doula debrief at a restaurant, complete with Monday morning quarterbacking that the Gaskin Maneuver would have saved the day and a debate about whether the fact that the woman needed a OR repair under general anesthesia for her 4th deg tear was a worse injury than a CS or not. Sheesh.

          • Mel

            *blinks a lot*

            I had 4 badly organized contractions with Spawn over 30 hours before he was born by CS, so I am spitballing this one – but I’m assuming that 4 hours of pushing is fucking exhausting, right? Like glazed-eyed exhaustion with rubberized limbs was passed a few hours ago and we’re into a whole new territory? And that having a full-term infant’s head and torso deep in your pelvis doesn’t magically improve mobility, right?

            So….how many maneuvers can an OB crash team complete in the amount of time it takes for an exhausted woman to move into the Gaskin position? All of them? All of them twice?

            Never had a 4th degree tear, either – but NICU parents could pick those moms out from a mile a way. The sheer amount of padding on their wheelchair plus the fact that the poor woman was still visibly in pain made me feel lucky to have walked away with just-short-of-a-transfusion anemia and a neatly healing CS incision since I was comfortable as long as I didn’t need to move my torso (and even that was manageable within 10 days)

          • fiftyfifty1

            Yeah, there is a lot of criticism of the OB with the pretext of asking anthro questions. Why did the OB react to the SD as an emergency? Why didn’t she take a few minutes and calmly ease the baby out? Was that episiotomy really needed? Why didn’t she try the Gaskin? A glaring lack of questions in the other direction: Why didn’t I even see this coming? (she was blindsided, didn’t even realize what was going on until it was over.) How close to dying was this baby? Why was this woman so determined to have a vaginal birth? What could the CNM have done different in counseling this woman? What else might the OB be trained to recognize and treat that’s not even on my radar? Am I participating in a type of cult?

            And then just a glaring lack of understanding of the science. She gives a synopsis of the birth process and it’s one error after another, some little some big (she actually confuses shoulder presentation with shoulder dystocia at one point.) I mean find a proof reader. Does she not have even a single OB friend she could have asked? If not, screw up your courage and approach somebody from the OB department of your university. I thought that was what universities were for- professionalism, sharing knowledge etc.

          • Mel

            Even her critical questions show a profound lack of interest in medical science.

            Why did the OB react to a shoulder dystocia as an emergency? Because the doctor had 7 minutes or less to prevent brain damage in the infant which is a pretty good definition for an emergency.

            Why didn’t the OB use up a few minutes and ease the baby out? Well, time is brain function for starters. Second – and this is a pretty easy idea – the baby is entrapped with a shoulder pressed against the pubic bone. Until that shoulder is reduced in size, that kid is not going anywhere.

            Was the episiotomy needed? Unless the woman could fit two adult hands in her vagina without one, yes.

            WHy no Gaskin? Because the McRoberts worked without wasting time and baby brain….

          • fiftyfifty1

            I agree. She displays a profound lack of interest in medical science. One of her quotes that jumped out at me, chilled me really, was this:

            “Formal ‘evidence based research’ was far more a fascinating object to stand outside of and think about than it was kin to my own thought process.”

            Yeah, that’s clear. She neither understands science, nor is interested in understanding. You know, it’s one thing to be ignorant of the science. That I can forgive- we all start from ignorance. But lack of intellectual curiosity is something else. That, yes, I have a hard time forgiving. She literally does not care what science says. Is not interested. Finds it “fascinating” only the way anthropologists find it fascinating that the Yanomami feed menstruating girls with a stick. Has already made up her mind that there is nothing deeper to learn there.

    • sara

      Or had to call on “existence of God” as your backup point.