Midwives and lactation professionals use the term “evidence based medicine” so often, you might think they actually practice it. You would be wrong.
That’s because evidence based medicine is often hijacked by ideologues and industry.
Dr. David Sackett, credited with popularizing the phrase and concept, explained it in an influential 1996 paper, Evidence based medicine: what it is and what it isn’t:
[pullquote align=”right” cite=”” link=”” color=”” class=”” size=””]Evidence based medicine was never meant to be a tyranny. It is NOT supposed to produce one size fits all recommendations.[/pullquote]
Evidence based medicine is the conscientious, explicit, and judicious use of current best evidence in making decisions about the care of individual patients.
John Iaonnidis explains how EBM has been hijacked hijacked:
As EBM became more influential, it was also hijacked to serve agendas different from what it originally aimed for.
Industry immediately recognized the possibilities of hijacking EBM:
Influential randomized trials are largely done by and for the benefit of the industry. Meta-analyses and guidelines have become a factory, mostly also serving vested interests. National and federal research funds are funneled almost exclusively to research with little relevance to health outcomes… Risk factor epidemiology has excelled in salami-sliced data-dredged papers … and has become adept to dictating policy from spurious evidence…
Diabetes care serves as a cautionary example.
In 2009 a large-scale study of tight blood sugar control showed that, contrary to guidelines, tight control actually increased the death rate for adult onset diabetics. How could EBM have been so wrong?
It quickly became apparent that the guideline for tight control was approved over the protests of many diabetes experts. Second, there was a third party that would benefit from a guideline for tighter control: the drug companies that sold insulin, and they promoted such a guideline. Third, the National Committee for Quality Assurance, a supposedly impartial organization that sets the standards used by insurers to determine whether a treatment qualifies for payment, had received money from the drug industry.
When industry stands to benefit from evidence based guidelines, they use their influence to promote guidelines that benefit themselves. They start with the guideline result they want — greater use of their products — and then produce the “evidence” to support it. Then they market it as “evidence based” medicine.
Sadly, ideologues can hijack evidence based medicine in exactly the same way.
Midwives and lactation professionals start with the guideline results that they want — greater use of their services — and proceed to produce the “evidence” to support it. Then they market it as “evidence based” medicine.
How?
Influential midwifery research is done by and for the benefit of the industry of midwives, doulas and childbirth educators and published largely in journals dedicated to promoting them. They start with the results they want — women should be pressured to have unmedicated vaginal births — and proceed to produce the “evidence” to support it. Moreover, they conduct research on low risk women who have few complications and then extrapolate extravagantly — and absurdly — claiming that it was the midwifery care that led to low risk of complications. Then they market their claims as “evidence based” medicine.
Influential breastfeeding research is done by and for the benefit of the breastfeeding industry and published largely in journals dedicated to promoting breastfeeding. They start with the results they want — breastfeeding has major health benefits — and proceed to produce the “evidence” to support it. They conduct small trials riddled with confounding variables and then extrapolate absurdly to make extravagant claims that are never validated and never come to pass. Then they market their claims as “evidence based” medicine.
Midwifery and breastfeeding ideologues have hijacked research to create “evidence” designed to serve their own interests.
They’ve also violated a central tenet of evidence based medicine.
Sackett explained:
Good doctors use both individual clinical expertise and the best available external evidence, and neither alone is enough. Without clinical expertise, practice risks becoming tyrannised by evidence, for even excellent external evidence may be inapplicable to or inappropriate for an individual patient. Without current best evidence, practice risks becoming rapidly out of date, to the detriment of patients.
Evidence based medicine was never meant to be a tyranny. It is NOT supposed to produce one size fits all recommendations since even excellent evidence may be inapplicable to or inappropriate for an individual patient.
Evidence based medicine is not “cookbook” medicine. Because it requires a bottom up approach that integrates the best external evidence with individual clinical expertise and patients’ choice, it cannot result in slavish, cookbook approaches to individual patient care.
Promoting “normal birth” is a slavish, cookbook approach to patient care. Unmedicated vaginal birth is NOT best for every mother. When providers ignore that fact, babies and mothers die.
“Breast is best” is a slavish, cookbook approach to patient care. Breast is NOT best for every baby. When providers ignore that fact, babies die.
In a subsequent paper, Ioannidis likens evidence based medicine to a treasure ship hijacked by pirates.
…[T]he pirates have hijacked the EBM ship because it is a superb, worthy vessel loaded with goodies that are deemed to have high value. No pirates with some profiteering mind would have ventured to
capture a sinking tub that had no treasure.
Those who care about babies and women must fight back.
…We should do our best to throw overboard the pirates who have captured the ship and then stay the course to more rigorous, more unbiased evidence that matters for patients and healthy people.
It will not be easy:
Finance-based medicine, conflicts of interest (financial and other), just-bring-more-money approaches to research, questionable research practices, … salami slicing, spurious reward systems, methodological illiteracy and innumeracy, “basic science” hype, and overall stark ethical poverty are becoming increasingly common …
But it is a worthy task. Babies and mothers are depending on us to take back evidence based medicine from midwifery and breastfeeding ideologues who have hijacked it.
I’m so glad you explained that evidence based practices should not be applied to every person in every circumstance. Guidelines should be, well – guidelines!
Unfortunately, often these practices are made into rigid rules and standards, treated as universal truths, and used to bully both patients and doctors.
Has anyone seen this? https://evidencebasedbirth.com/groupbstrep/ I just found this garbage online. I cant even begin to describe all the lies and misleading crap in this article all claiming to be based on scientific evidence. Apparently strep B is not that serious and is not as common as we are told and antibiotics can seriously harm an infants “microbiome”. Here is a small part of the article=
Researchers have looked at the risk factors for GBS in young,
non-pregnant women (Feigin, Cherry et al. 2009). People with these
factors may be more likely to carry GBS:
Multiple sexual partners
Male-to-female oral sex
Frequent or recent sex
Tampon use
Infrequent handwashing
Less than 20 years old
All I could think about when I was reading this was the preventable death of baby Wren and how his mother was told to use garlic for strep B
Was she told to douche with Hibiclens or something similar? The thought of that anywhere near my ladybits makes me want to cringe.
Yeah me too I think garlic in the vagina would burn just a bit.
Bizarre. Are doctors supposed to change their GBS screening or treatment based on this? “Well you test positive, but since you haven’t used a tampon in nearly 9 months, it’s fine to skip the antibiotics.” Umm no.
I really should not be surprised anymore at the bullshit these people spread, but somehow I am. They were basically implying that antibiotics for strep B are ineffective and they damage the micro biome -(gasp!) possibly putting breastfeeding at risk. These assholes have no brains and no shame. They will do anything to make mom feel having a home birth is safe so they can get paid. Morally bankrupt monsters.
As a pathologist, GBS scares me. I’ve done too many autopsies on babies dead of it. But the thought of treating every single woman who carries it as a commensal with antibiotics scares me too-at the moment, its treatable by fairly simple antibiotics. If we treat thousands of pregnant women to try and clear their carriage of it, many of whom who would not have developed invasive disease anyway, the likelihood is we will eventually end up with a multidrug resistant GBS that we can’t treat, we don’t know what the impact could be on the developing fetus, and many of those treated will simply re-colonise again anyway.
The RCOG doesn’t recommend routine screening because treating with antibiotics prior to labour doesn’t improve the perinatal mortality rate or reduce the rate of early onset GBS, that’s why they recommend treating women known to carry it during labour only.
They did an large audit recently and found some differences in practice between stand-alone midwife units, along-side midwife units and obstetric led units. Mostly though, if a woman is known to be a GBS carrier, she is risked out of a standalone unit in the UK. GBS is a really controversial area-there’s ongoing discussions and arguments all the time about is the RCOG stance correct and why don’t we do the same as USA and France?
So, I wonder if that evidencebasedbirth site is dismissing GBS as a problem because their interpretation is that in some countries its not actively treated until labour, and some countries don’t even bother screening for it, meaning it must be harmless?
I think they are dismissing it. I think its a way for them to calm concerns about strep b in a homebirth. Cause if mom gets scared about it she will go to hospital and the midwife wont get paid to attend a home birth.
I am in the US and I had strep b with my first and I had IV antibiotics when I was in labor and that was it.
Women get intrapartum IV antibugs here, but only if its known that they are carrying GBS, and the only way you’d know is if you’ve had a UTI or had a previous affected pregnancy. You can have it done privately here but its not screened for routinely. We audited our GBS stillbirths and neonatal deaths a while back (we had a mum who lost her baby and she complained to the chief medical officer, so there was an enquiry). Most of our stillbirths were in cases where the mum had been entirely asymptomatic and only found out when she presented with decreased fetal movements. We didn’t have any intrapartum deaths, and the neonatal deaths we had (can’t remember the figures off hand, we looked at 3 years and I think it was maybe 2-3 in the region) were all premies <30 weeks with mums who presented with spontaneous rupture of membranes and pyrexia.
From my point of view, a standard part of the autopsy is to swab fetal lung, stomach and heart blood. Some pathologists do spleen swabs instead of heart. If you get positive cultures from the lung and stomach, that's proof that the amniotic fluid was infected (because babies swallow and aspirate the amniotic fluid during intrauterine life) but its not proof of fetal sepsis. If you get a positive culture from fetal blood, that's the proof. It always amazes me just how little inflammatory response you can get in a fatal GBS infection. The placentas in these cases are typically very mildly inflamed-there's often only a minimal inflammatory cell population on the chorion and amnion. There is generally considered to be no correlation between the intensity of the inflammatory infiltrate on the membranes and the causative organism, and I've had cases where I've seen thick sloughing exudate, visible pus coating the placenta with an accompanying stench and the baby has been reasonably OK and easily treated. But in GBS there is very little response normally-its like it simply blasts through the defences and gets into the baby and puts it into sepsis before there's even time to mount any sort of response from either mum or baby. Scary, scary bug.
Just as a parent GBS scares me. If it werent for modern medicine/antibiotics my son probably would have died from GBS. Was GBS the leading cause of newborn deaths before antibiotics? I think I remember reading that it was buy im not sure.
I don’t know about the pre-antibiotic era, but certainly in the 1960s and 70s, the mortality rate for early onset GBS infection in neonates was >60%. If you got it, your chance of survival wasn’t good.
“If we treat thousands of pregnant women to try and clear their carriage of it, many of whom who would not have developed invasive disease anyway, the likelihood is we will eventually end up with a multidrug resistant GBS that we can’t treat, we don’t know what the impact could be on the developing fetus, and many of those treated will simply re-colonise again anyway.”
Does any country do it this way? We were taught it is not “clearable” as the gut is so heavily colonized that it will always come back. If it is found in the urine at any point, yes we try to clear it from the urine, and any of these women will also get abx in labor. But for the average woman, when they test positive on recto-vag swab late in pregnancy, we don’t try to clear it, just give abx in labor. The US has been doing it this way (routine screening and treatment in labor) since 2002 I think, and no drug resistant GBS yet.
I don’t know of any official guidelines or recommendations suggest this, and the UK guidance doesn’t support this at all, but certainly I’ve heard it from parents. We had a case in my region that led to the local health authority doing an audit of GBS associated stillbirths and neonatal deaths, and the lay representative on the committee was very determined that we should look at carriage rates and clearance rates. I don’t think she had any real understanding of the problem-all the literature shows there’s no point clearing it because it just comes back, and her answer was permanent antibiotics in those cases. The charity she was associated with refused to sign off on the audit because of our conclusions (which were in line with RCOG guidelines).
Not the most accurate of writing:
“Infection of the uterus (aka “chorioamnionitis”) ”
Nope. Endometritis is infection of the uterus. Chorioamnionitis is infection of the placenta. Intra-amniotic infection would be more accurately infection of the amniotic cavity within the pregnant uterus and placenta.
Doesn’t surprise me though-I’ve spent years trying to teach people how to swab a placenta properly and no-one listens.
OMG Donna just replied to me in the other post. The other day she said water birth was safe and I said water labors are ok but not water birth. She just linked a site about water birth. Its the same site I just linked to about strep b. That is where her department researched its unsafe practices from. evidence based birth.com what a joke does she really think that is a good source for information?
LOL. Sounds like…….basically everybody??
I think I found that site when I got pregnant or just before…and then I saw the article about moxibustion, and concluded the whole site was garbage.
The term ‘evidence’ has been hijacked by all manner of unscientific and pseudoscientific providers – from homeopaths to subluxation-based chiros.
They misuse the term ‘evidence’ to mean anything they want it to mean – happy customers, anecdotes, single case reports, solicited survey results.
It’s very hard now to take back the term because anyone can look up a “study” by Googling, and providing a “link” (not ‘reference’) that they haven’t read, can’t access the full paper, and wouldn’t understand even if they did.
I’m constantly seeing cut-paste lists of “links” (never proper references) without discussion of the actual studies. People talk of them as “PubMed links” as if that meant “systematic review of RCTs published in the Lancet”. Frustrating.
Of course, if I point this out, I am ‘arrogant’.
Exactly. Brings to mind the Golden Age of young earth creationism “debates.” Dumbass #1 writes a paper about how humans and dinosaurs frolicked together when Jesus created the universe 6,000 years ago and uploads it his website. Dumbass #2 writes a paper stating the same conclusion and links to Dumbass #1 as authority. Dumbass #3 now has two “authorities” to link in his paper. Next thing you know, there’s a self-proliferating circle of ever-expanding bullshit “evidence” supporting a patently false conclusion.
Same thing with anti-vaxxers, except the “authorities” are Mike Adams, Barbara Loe Fisher, Suzanne Humphries, Joe Mercola, Kelly Brogan, Andy Wakefield, etc. Celebrities making major bank on the Dunning-Kruger effect are a poor substitute for old-school evidence, but try telling that to the average garden variety internet dipshit.
In the UK, we have NICE (the national institute for health and care excellence) which is supposed to provide evidence based guidelines and pathways for all health care in the NHS, and also advises on quality standards. These are supposed to be independent, written by an independent committee and every one of them is supposed to go out for consultation with stake holders, the medical, nursing and paramedical services, the public and other groups like charities. Unfortunately, the guidance is dependent on, and only as good as, the committee drafting it, and there is evidence that their guidelines have been subject to pressure from various stakeholders. In my own area, NICE issued guidance stating that women who had had a stillbirth should not be encouraged to see the baby after delivery because it increased her risk of post-natal depression and post-traumatic stress disorder. The ‘evidence’ for this was a small study which was riddled with confounders-it was a postal survey reliant on self-reporting of any mental disorder, and didn’t consider the pre-existing mental state of the woman or look at her past history. But for some reason, NICE ignored all the experience of the various baby loss charities. There was an outcry about it and eventually it was re-drafted.
But it shows that the NICE guidance isn’t always an accurate reflection of the evidence. The NICE quality standards on post-natal care show significant bias:
The quality statement for formula feeding states: “Babies who are fully or partially formula fed can develop infections and illnesses if their formula milk is not prepared safely. In a small number of babies these cause serious harm and are life threatening, and require the baby to be admitted to hospital”
The statement for breast feeding states: “Breastfeeding contributes to the health of both the mother and child in the short and longer term. Women should be made aware of these benefits and those who choose to breastfeed should be supported by a service that is evidence‑based and delivers an externally audited, structured programme”
There isn’t a single mention about the complications that may be associated with breast feeding, or a single mention about the benefits of formula feeding. When they talk about outcomes, they say that hospitals should monitor “Rates of hospital admissions for formula feeding‑related conditions”. It says nothing about recording the rates of hospital admissions due to exclusive breast feeding. All they record is that each hospital should record the rates of breast feeding initiation and record how many are breast feeding at various weeks and months down the line. I suspect that NICE has very deliberately chosen to ignore certain factors because they’ve had so much pressure from breast feeding ‘experts’.
You are right – much has been written about the possible ideological and even financial bias of consensus guidelines.
Properly conducted systematic review are preferable.
The issue with NICE is that they claim to base their guidelines on systematic reviews-the guidelines are written clearly referencing reviews and the hierarchical strengths of other evidence they’ve considered, but it’s still not wholly independent because it depends on the biases of the committee members. You have to have people with expertise in that field writing the guidance, and their personal preferences can slant how the committee interprets papers, or uses the reviews. Unless they are absolutely ruthlessly self-critical, it’s a normal human response to want to think that what you believe is the truth. I think that’s why we’ve got the breast feeding guidance we’ve ended up with-the people on the committee started out with a belief that breast feeding is better, and allowed that belief to colour their recommendations, despite the actual scientific evidence not backing them up in the way they’ve claimed it does. But the NHS treats NICE guidance as immutable, fixed and gold standard-I’ve heard it cited in court in inquests (as in the staff didn’t follow it), and it’s been cited as evidence in professional malpractice cases involving medical and nursing staff, even though in law, failure to follow guidelines is not recognised as primae facie evidence of substandard practice.