Proponents of “alternative” medicine often disagree profoundly on treatment methods. Sick? In pain? Try this homeopathic remedy that contains no active ingredients. Stick needles into acupressure points. Wear magnetic foot pads to pull the toxins out of your body.

But on one point all proponents of “alternative” medicine agree. Since the source of all your troubles is a weak immune system, the key to treating and preventing all illness is “strengthening the immune system.” Indeed, this belief is so widespread, it appears that the only people who don’t subscribe to it are people who actually know something about the immune system, doctors, immunologists, microbiologists, etc. The idea that disease can be treated and prevented by “strengthening the immune system” depends on a profoundly flawed, almost cartoon like, view of the immune system itself.

The immune system is tremendously complicated, involving as it does innate cellular immunity and humoral (antibody) immunity. Multiple poorly understood organs make up the immune system. Anyone actually know what the spleen is for? And how about lymph nodes and bone marrow? Those are also quite complex. It is the interactions of these types of immunity, within the various organs of the immune system and throughout the body that determine whether and how we can fight off disease.

The “alternative” medicine view of the immune system, which is the same as the lay view of the immune system, is cartoon like in its simplicity. The individual components of the system, and their specific functions are never discussed or even mentioned. Too complicated. The cascade of events that occurs when the body’s outer defenses of skin or other tissues are penetrated by a foreign substance is completely ignored. Also, too complicated.

Instead, the immune system is conceptualized as a unitary entity that it either weak or strong. If you get sick, your immune system must be weak. In order to prevent illness, or to treat it once it occurs, you must “strengthen” your immune system. And how do you do that? The way you do everything in “alternative” medicine: you eat the right foods, and take vitamins and supplements.

But, of course, as doctors know, illness is not caused by a weak immune system. The specific mechanisms of illness depend on the specific causes. One possible cause is a failure of innate cellular immunity to find and destroy bacteria that penetrate the barrier of the skin. Another possible cause is the inability of the humoral (antibody) system to create antibody fast enough to overwhelm a viral invader. Instead, the invader gets a tremendous head start before the body can fight back and the virus overwhelms the host. Yet another factor is the presence or absence of various immune system organs. For example, it is well known that removal of the spleen leaves people particularly vulnerable to infection by the pneumococcus bacteria.

In every case, the disease results from a complex interaction between the disease causing agent and a specific component of the immune system. Moreover, there is no evidence that nutrition, vitamins or supplements can do anything to change the balance in these interactions, since the fundamental problem is not malnutrition, or vitamin or mineral deficiency.

It’s not as though we don’t know what a truly weakened immune system looks like. Chemotherapy (which preferentially kills fast growing cells) and certain disease like AIDS, knock out one or more components of the immune system, rendering people more susceptible to disease. If enough of the immune system is compromised or destroyed, the individual becomes vulnerable to infections that would otherwise be harmless or never occur in the first place.

In addition to ignoring what a weakened immune system looks like, and imagining that nutrition is the source of “strength” of the immune system, advocates of “alternative” medicine and lay people have another naïve belief about the immune system. They appear to think that the immune system can be overwhelmed by too much information. Ignoring the fact that each individual faces hundreds, thousands or more immune challenges each day, “alternative” medicine advocates argue that vaccines, particularly those designed to immunize against more than one disease at a time, “overwhelm” the immune system, particularly what they imagine to be the “underdeveloped” immune system of small children.

Ironically, the truth is exactly the opposite. Vaccines are one of the few things, if not the only thing, that can strengthen the immune system by giving it a head start against a microscopic invader. Humoral (antibody) immunity takes time to ramp up if the body has never seen the invader before. It’s as if the body can’t start making weapons until it has already been invaded. Vaccines act like a picture of the enemy. Vaccines allow the body to “see” what the invader looks like before the invasion, and to stockpile weapons for the coming fight. When the assault ultimately occurs (when the person is exposed to the disease), the counterattack can begin without delay, and therefore it is much more likely to be successful.

As a general matter, a detailed understanding of system function is not necessary for lay people to understand what the system does. People do not need to know about all the different clotting factors to understand that blood should clot when you are cut and that something is wrong if it doesn’t clot. No one would invoke the idea of a “weak” clotting system to explain why a hemophiliac is bleeding to death, and no one would recommend eating the right foods, or taking vitamins or supplements to treat hemophilia.

Ordinarily, a detailed understanding of immune system function would not be necessary for lay people to understand what the system does. Unfortunately, a detailed understanding of the immune system has been replaced with a cartoon like caricature of the immune system, leading lay people to believe that it is either weak or strong, and that it can be strengthened by eating right. It is this cartoon like view that makes lay people vulnerable to the claims of “alternative” medicine practitioners and it is this cartoon like view that must be changed.

The hallmark of homeopathy is the belief that tiny doses of medicinal substances have big effects. It’s like insisting that the less salt you put in water, the more salty the water will taste. In other words, it defies common sense, is scientifically unfounded, and has been thoroughly debunked.

Even more inane than the concept of homeopathy are its proponents’ attempts to explain how it works. Homeopathy is, perhaps, the paradigmatic pseudoscience, and like most pseudosciences, it invokes science while at the same time ignoring the scientific evidence.

One of the best (and inadvertently funniest) examples can be found on today’s Huffington Post. Dana Ullman has written How Homeopathic Medicines Work: Nanopharmacology At Its Best.

Pseudoscience advocates have learned the benefits of clothing pseudoscience in “scientese,” language that sounds scientific but makes no sense. “Nano” sounds scientific, so Ullman insists that homeopathy is “nanopharmacology.’ As Ullman breathlessly explains:

Although the word “nano” also means one-billionth of a size, that is not its only definition. In fact, “nano” derives from the word “dwarf,” and “nano” is the only word in the English language that is used on common parlance as denoting extremely small AND yet extremely powerful.

Sounds cool and so scientific, doesn’t it? Just a few minor problems, though. First, nano does not mean powerful and has nothing to do with power. Second, there is a scientific discipline of nanopharmacology and it means something very different than what Ullman pretends it means.

According to Nanopharmacology.com:

Nanopharmacology is the use of nanotechnology for — discovery of new pharmacological molecular entities; selection of pharmaceuticals for specific individuals to maximize effectiveness and minimize side effects; and delivery of pharmaceuticals to targeted locations or tissues within the body. Nanotechnology will generally be defined as the science of constructing and assembling objects on a scale littler than one hundred nanometers. The end results of nanotechnology may be miniature particles (in powders, lotions or coatings) or macro-scale objects with nanoscale modules and unique characteristics.

In other words, nanopharmacology refers to the size of the medication delivery system, NOT the dilution of the medication.

How does homeopathy work? Well, it doesn’t work; copious scientific evidence has thoroughly debunked homeopathy. Ullman ignores that point to speculate on various possibilities, each more ridiculous than the last.

Scientists at several universities and hospitals in France and Belgium have discovered that the vigorous shaking of the water in glass bottles causes extremely small amounts of silica fragments or chips to fall into the water. Perhaps these silica chips may help to store the information in the water, with each medicine that is initially placed in the water creating its own pharmacological effect.

Or, perhaps these silica fragments do nothing. Certainly it doesn’t help water “store information” since that is a chemical impossibility.

Or maybe it’s the bubbles:

Further, the micro-bubbles and the nano-bubbles that are caused by the shaking may burst and thereby produce microenvironments of higher temperature and pressure.

If it’s not the silica fragments or the bubbles, maybe it’s the waves:

Normal radio waves simply do not penetrate water, so submarines must use an extremely low-frequency radio wave. The radio waves used by submarines to penetrate water are so low that a single wavelength is typically several miles long!

If one considers that the human body is 70-80 percent water, perhaps the best way to provide pharmacological information to the body and into intercellular fluids is with nanodoses. Like the extremely low-frequency radio waves, it may be necessary to use extremely low (and activated) doses for a person to receive the medicinal effect.

Of course every self-respecting quack must invoke, and profoundly misinterpret, quantum mechanics:

Quantum physics does not disprove Newtonian physics; quantum physics simply extends our understanding of extremely small and extremely large systems. Likewise, homeopathy does not disprove conventional pharmacology; instead, it extends our understanding of extremely small doses of medicinal agents.

But quantum physics is involves sub-atomic particles of very small size, NOT small numbers of particles.

Homeopathy is nothing more than pseudoscience, and a particularly inane pseudoscience at that. It is not involve nanopharmacology. However, we can say that belief in homeopathy is evidence of mega-stupidity, best defined as startling gullibility combined with a profound deficit of scientific knowledge.

“Natural” childbirth advocacy is riddled with fallacious arguments and one of the most common types is known as the “argument from ignorance.” It could more properly be described as the “appeal to ignorance”; ignorance in this setting refers not to a characteristic of the person offering the argument but as a description of the quality of the evidence. Specifically, there is no evidence.

To understand how an argument from ignorance is structured, why it is a fallacy, and who might invoke an argument from ignorance, let’s start with an easily understood example from outside the realm of childbirth.

… there is nothing in the files to disprove his Communist associations.

This line was famously uttered by Senator Joseph McCarthy when accusing individuals of being secret Communist sympathizers and therefore unfit to participate in American public life. What’s wrong with this argument?

1. Arguments from ignorance typically share the same structure:

Person 1: I assert A.
Person 2: Where is your evidence for A?
Person 1: I find no evidence for “not A” so A must be true.

The argument of McCarthy followed the same structure:

McCarthy: “John” is a Communist.
John: I am not a Communist and there is no evidence to show that I am a Communist.
McCarthy: But there’s no evidence to show you are not a Communist, so you must be a Communist.

What’s wrong with this structure? It’s easy to see when the argument is about Communist sympathies. We understand that if a person is falsely accused of being a Communist, there will, of course, be no evidence that he is a Communist. Therefore, the claim that the lack of evidence “proves” he is a Communist is demonstrably false.

2. Arguments from ignorance place the burden of proof on the wrong person.

In logical argument, the burden of proof is on the person making the claim. If McCarthy wants to claim that John is a Communist, McCarthy must provide the proof. It is not up to John to prove that he is not a Communist. Indeed, there is no way to prove that you are not a Communist since there is likely to be no evidence of any kind.

3. Arguments from ignorance are usually invoked when the person making the claim has no evidence for the claim.

It is a tactic of desperation. If the person making the claim had evidence, he would present it. An argument from ignorance is an implicit acknowledgment that there is no evidence for the claim.

4. The person making the claim generally has a specific ideological reason for doing so.

McCarthy wanted to shame the Truman administration and punish those he did not like. He was not interested in following evidence where it led. He had determined the conclusion in advance and created an “argument” that allowed only for that predetermined conclusion.

What I find particularly instructive about the McCarthy example is that we understand that if the person is truly not a Communist, the fallacious argument will be impossible to disprove. In other words, the more likely it is that he is not guilty, the more difficult it will be to prove that he is not guilty.

Let’s turn to ways in which “natural” childbirth advocates use the argument from ignorance. They almost always deploy it when confronted with evidence that undermines their ideological beliefs. They have a predetermined conclusion in mind, and they are committed to ignoring any evidence that stands in the way of that conclusion.

“Natural” childbirth advocates are sure that modern obstetrics is harmful, not helpful. The evidence is not on their side, however. The neonatal mortality rate has dropped 90% and the maternal mortality rate has dropped 99% since the inception of modern obstetrics. “Natural” childbirth advocates don’t want to accept the evidence and often make the following argument from ignorance to me:

NC Advocate: Improvements in sanitation are the true cause of the decline in neonatal and maternal mortality.
AT: Where is the evidence for that claim?
NC Advocate: Can you show that sanitation didn’t cause the decline in mortality rates? If you can’t then it is perfectly reasonable to assume that sanitation did cause the decline in mortality rates.

Of course, if sanitation didn’t cause the decline, there would be no evidence to show that it didn’t cause the decline. So it is entirely unreasonable to conclude that the lack of evidence about sanitation shows that modern obstetrics cannot take credit for the decline in mortality rates.

Homebirth advocates make a similar argument when confronted with the data that homebirth increases the neonatal mortality rate compared to low risk hospital birth. Their predetermined conclusion is that homebirth is as safe or safer than hospital birth and they must reach that conclusion regardless of the evidence. Hence the following argument:

HB Advocate: Well the data may show that homebirth increases the risk of neonatal death, but hospital birth increases the risk of postneonatal death even more. Lots of babies hurt by obstetrics interventions die from those interventions, but only after 28 days has passed.
AT: Where is the evidence that hospital birth increases the postneonatal mortality rate?
HB Advocate: Where is the proof that hospital birth doesn’t increase postneonatal mortality. If you can’t present proof, then it is perfectly reasonable to assume that hospital birth increases the risk of postneonatal mortality.

In this case, it is actually possible to prove that hospital birth does NOT have a higher ponstneonatal mortality rate than homebirth. Indeed, in the few data sources available, homebirth has a higher postneonatal mortality rate as well as a higher neonatal mortality rate. So homebirth advocates have used ignorance of the existing data to speculate on what that data shows.

The bottom line is straightforward. Any claim requires proof presented by the person who makes the claim. Those who don’t believe the claim are not required to provide evidence that it is not true. Lack of evidence that the claim is not true in not proof that it is true or even a plausible reason to suspect that it might be true.

You can’t make this stuff up.

If you want a good laugh, try reading some of what passes for midwifery “philosophy” these days. I’d particularly recommend Normal Childbirth: Evidence and Debate by Soo Downe. It has certainly provided me with hours of entertainment.

As I detailed in a previous post, midwives are having a serious problem with scientific evidence. It seems that the scientific evidence does not support their beliefs. The obvious response is to modify their beliefs, but that’s not the course they have chosen. Instead, they are challenging the concept of scientific evidence. And like many other purveyors of pseudoscience, they have latched on to the language of quantum mechanics.

Of course, its midwifery advocates, like all its pseudoscience advocates are utterly ignorant of theoretical physics and the concepts of quantum mechanics. It sounds so good, so very scientific, and in pseudoscience, how it sounds is much more important than what it means.

Let’s back up a bit and look at the way that pseudoscience works. Wanda Mohr, writing for an audience of nursing students, explains the difference between science and pseudoscience:

Perhaps the most important characteristic that sets pseudoscientific practices apart from genuine scientific practices is the lack of concern with valid evidence. Practitioners of pseudoscience rely on eyewitness testimonies and personal anecdotes rather than well controlled and publicly verifiable studies…

Pseudoscientists operate from a set of assumptions, or assertions taken for granted or supposed that may be either explicit or hidden…

Professor Downe is quite open about her assumptions. In fact she lets Robbie Davis-Floyd leads with them in the preface, in the very first line of the text:

Let me be very clear. As the chapters in this book illustrate, the Western technocratic approach to birth, which has become the global technocratic approach to birth, is wrong. Simply and fundamentally wrong…

But Professor Downe has a problem. The scientific evidence does not support her pre-existing beliefs, so she sets herself the task of substituting scientific evidence with, in her words, “alternative ways of seeing.”

Downe accurately describes the concept of scientific evidence:

The currently held authoritative scientific and practice paradigm in most Western countries is based on the belief that the best, most certain evidence is gained from research based on the study of specific elements of the system, with enough individuals to be fairly sure that the results can be generalized to whole population. The ideal has been termed ‘large trials with simple protocols’. It is believed that this model increases certainty and that the findings from such trials, if they are carried out well, should be applied wholesale to individuals.

But this is precisely the paradigm that produces the scientific evidence that does not comport with Prof. Downe’s ideological assumptions. Since the assumptions must be right, it follows that the definition of scientific evidence must be wrong. Prof. Downe could make that simple assertion, but she knows that everyone would laugh. So instead she opts for what seems to her a more sophisticated assault on scientific evidence.

Mohr, writing about pseudoscience in nursing, anticipates this approach:

Most recently, several quacks have defended themselves using concepts from postmodernism… Postmodernists have applied such ideas and concepts as Gödel’s theorems, relativity, quantum mechanics (particularly the uncertainty principle), chaos theory, and catastrophe theory to literature and psychoanalysis.

The postmodern movement has infiltrated health care and nursing. This approach encourages people to believe that healthcare advice based on scientific research is of no more value than any other healthcare advice… Some authors borrow terms from theoretical physics without regard for what those terms actually mean… Many readers have little understanding of the scientific theory being invoked or the philosophical implications of what is being said. They may assume that if an author has a PhD, he or she should be believed without question.

Soo Downe, PhD faithfully follows this pseudoscientific approach:

Maxwell’s laws of thermodynamics represented an important shift in concepts of nature from those that pertained previously. While his first law described the principle of conservation of energy, the second described its dissipation (such as by movement producing heat). This implied a shift from order to disorder and led to the concept of entropy (that matter breaks down over time). Einstein’s relativity and quantum theories built on this work…

Never mind that Einstein was not the originator of quantum mechanics, Heisenberg and Schrodinger were. Never mind that Einstein was a vociferous critic of quantum mechanics. Never mind that Einstein famously retorted “God does not play dice” in response to the implications of quantum mechanics. (And those who are familiar with physics know that Maxwell’s equations are about electromagnetism, not thermodynamics.) Einstein was smart and he had something to do with quantum theory so that must make it true and relevant to midwifery.

The implication of the new subatomic physics was that certainty was replaced by probability, or the notion of tendencies rather than absolutes: ‘we can never predict an atomic event with certainty; we can only predict the likelihood of its happening’… This directly contradicts the mechanistic model we explored above, and it implies that a subject such as normal birth needs to be looked at as a whole rather than its parts…”

Wait one moment while I picked myself up off the floor from laughing so hard. Prof. Downe seems to have missed the most basic, most important fact about quantum mechanics, which is not surprising since she doesn’t have a clue as to what it means. Quantum mechanics is an explanation of events at the atomic level, not on at the level of objects in the world. So unless Downe would like to discuss the individual atoms that make up the molecules that make up the cells of the fetus, quantum mechanics has no applicability.

Never mind. It sounds so cool and so scientific.

When we turn to the implications of this paradigm shift for our understanding of health, it becomes clear that the benefit or harm of an intervention for an individual can only be established with reasonable certainty by identifying and taking into account all the relevant “noise”. This includes environment, carer, attitudes, skills and beliefs, and the expectation of the woman and her family. Similarly, the appraisal of research and evidence needs to consider the concept of attitudes and roles of researchers and how these may have framed or influenced the process of generating evidence…

Prof. Downe has managed a stupidity trifecta: she used the wrong theory, from the wrong field, wrongly interpreted to reach the ideologically predetermined result.

It’s not as though Downe wasn’t warned about this approach, as she acknowledges:

… [A] number of authors have cautioned against oversimplistic generalization of the seductive post-modernists aspects of multipliticy and connectivity that are expressed in these theories. Carol Haigh, writing from a nursing perspective, sees the misuse of chaos theory as being particularly prevalent within nursing and research and philosophy. She cautioned that application of the chaos contruct is not relevant without a thorough understanding and use of the mathematical underpinnings of the theories…

The same warning applies equally to the misuse of the quantum mechanics. But Downe airily dismisses this criticism. She doesn’t quibble with the idea that she lacks a thorough understanding of the mathematical underpinnings of the theories, but:

While we accept her thesis to some extend, we depart from her apparent rejection of the potential for the insights of complexity and chaos to provide new ways of seeing at the macro level…

Of course, this is that view that is the problem. Quantum theory has no applicability to midwifery or to the concept of scientific evidence. If Downe understood quantum mechanics, and the mathematics that underpins it, she wouldn’t dare apply it to midwifery. It is precisely because she hasn’t a clue as to what it means, that she thinks it is “relevant.”

You might expect that such appalling news would be front and center in the latest newsletter of the Colorado Midwives Association, the organization of Colorado homebirth midwives, but you’d be wrong. It doesn’t appear until the second page in the President’s Letter by Karen Robinson, CPM.

You might expect that the extraordinary news would lead her letter, but no, the beginning of the letter is devoted to the higher registration fees. Instead the news is relegated to the 7th paragraph:

In looking back over the past couple years of statistics, I see that there were 5 perinatal deaths reported each year for 2006 and 2007. This represents a perinatal death rate of 8 per 1000 for those two years, and that is too high for the low-risk population we serve. The state perinatal mortality rate for all births from 2003 to 2007 was 6.4 per 1000.

In other words, the perinatal death rate of LICENSED homebirth midwives in Colorado, caring for low risk patients, exceeded the perinatal death rate of 6.4/1000 for the entire state (all races, all gestational ages, all birth weights, 2003-2007)! Homebirth was the most dangerous form of planned birth by far.

Ms. Robinson continues:

I don’t believe we have a poor perinatal mortality rate, but if solid data shows we do, then I will be at the forefront of the effort to improve our practices and lower the perinatal mortality rate for homebirth in Colorado.

If she’s going to be at the forefront, then she had better get out there. The just published statistics for the year 2008 are even worse. Last year, licensed Colorado midwives had a perinatal mortality rate at homebirth of 8.6/1000. These numbers are nothing short of horrifying.

Consider:

Curiously, these statistics are not mentioned on the website of the Colorado Midwifery Association. The state is aware that perinatal data rate for homebirth is extraordinarily high. The midwives themselves are aware that the perinatal mortality rate for homebirth is extraordinarily high. The only people who haven’t been informed, it seems, are the patients.

How can a woman in Colorado make an informed decision about homebirth with a licensed midwife if she has no idea that the homebirth death rate exceeds not only that for low risk births, but exceeds the rate that includes high risk births as well?

Raw statistics can be found here for 2006, 2007, and 2008.

Pregnancy is often heralded as a time of hope and happiness. But when issues of risk enter—as they always do—pregnancy also challenges our ability to reason well. There is a tendency to think of safety in ways unmoored from evidence.

The above quote comes from a fascinating new paper in this month’s issue of a leading bioethics journal, The Hastings Center Report. Risk and the Pregnant Body by Lyerly, Mitchell , Armstrong , Harris, Kukla , Kupperman , and Little. The paper explores what the authors describe as “historical cultural themes around pregnancy and birth.”

These include themes about purity in pregnancy and control in birth—both of which can lead to reasoning about risk that is oriented more by magical thinking than evidence—as well as themes about the roles and responsibilities of motherhood. As many have noted, pregnancy can refract and intensify the already demanding moral standards of sacrifice we apply to mothers. In the present context, this can lead to a tendency to unreflectively judge any risk to the fetus, however small or theoretical, to trump considerations that may be of substantial importance to the woman herself.

The authors consider the impact of these themes on pregnant women and on medical professionals. In this post, I’d like to focus on pregnant women and other lay people.

I have argued in the past that thinking about risk in general, and pregnancy in particular, is plagued by the habit of ignoring the magnitude of risk. In pregnancy; women will express horror of trivial or merely theoretical risks and ignore real risks. This defect is enhanced by the tendency of lay people to vastly overestimate trivial risks and vastly underestimate real risks, which is more pronounced among advocates of “natural” childbirth and homebirth. Hence the avoidance of the theoretical and unsubstantiated risk of caffeine during pregnancy while simultaneously embracing the very real risk of homebirth.

The authors offer an intriguing explanation for the obsession with the trivial, theoretical and often unsubstantiated risks attending the behavior of pregnant women: the emphasis on purity in pregnancy.

… [C]oncerns about purity reflect a form of magical thinking rather than evidence-based reasoning about actual harms and dangers. As psychologists point out, magical thinking is the tendency to see causality in coincidence and to substitute rituals and taboo for empirical evidence. In the context of pregnancy, magical thinking can turn an innocuous exposure into a dangerous one—a sip of beer to poison, a bite of sushi to contamination. Such thinking is considered a familiar and natural response to uncertainty and the unimaginable… The temptation is to tell ourselves that if we can only find and follow the right set of “musts” and “mustn’ts,” all will be well …

The perception of risk has also been profoundly influenced by the contemporary view of mothering:

The dominant idea of a “good mother” in North America requires that women abjure personal gain, comfort, leisure, time, income, and even fulfillment; paradoxically, during pregnancy, when the woman is not yet a mother, this expectation of self sacrifice can be even more stringently applied. The idea of imposing any risk on the fetus, however small or theoretical, for the benefit of a pregnant woman’s interest has become anathema. A second cup of coffee, the occasional beer, the medication that treats a woman’s severe allergies but brings a slight increase in the risk of cleft palate, the particular SSRI that best treats a woman’s severe recalcitrant anxiety disorder but brings a small chance of heart defects—all are off limits, or nearly so, to a “good mother.”

Yet this professed belief is belied by the ways that we actually behave and the fact that we sanction many potentially “risky” behaviors when it is convenient for us to do so:

We accept small risks to our children for our own sakes every day. We believe it reasonable to impose the small risk of fatality introduced every time we put our children in the car (safely restrained in a car seat), even if our errand is mundane and optional… To be sure, balancing such risks can be among the most challenging tasks of parenthood. But we recognize that reasoning about risk is inevitable, that thoughtful, responsible trade-offs are a fact of life …

Lyerly and colleagues have given us a cultural framework within which we can situate current view of risk in pregnancy. Consider the issue of epidurals for pain control in labor. According to “natural” childbirth advocates, the “good mother” will forgo and epidural, an “achievement” considered remarkable because so many women “give in” to the pain.

But this view of epidurals is at odds with the scientific evidence of their safety. Rather it reflects the cultural obsession with purity of the pregnant body. Everything introduced into the pregnant body in any way must be tightly controlled. Moreover, the “good mother” must endure agonizing labor pain since she is not entitled “personal gain, comfort, leisure, time, income, and even fulfillment” let alone pain relief.

In other words, “natural” childbirth reflects cultural preoccupations, not scientific evidence. The “natural” childbirth advocate’s understanding of risk in pregnancy and the range of “acceptable” responses to risk has almost nothing to do with the actual magnitude of the risks under consideration, and everything to do with how she wishes to view herself and other mothers.

Homebirth advocates often argue that homebirth costs less than hospital birth, but a new study from The Netherlands reveals that homebirth does not save money. Even the authors were surprised by the results.

The study is Cost Analysis of the Dutch Obstetric System: low-risk nulliparous women preferring home or short-stay hospital birth – a prospective non-randomised controlled study. It is worth reading merely for the update on the Dutch system of homebirth. It differs in important ways from the perceptions of American homebirth advocates regarding the Dutch system. The homebirth rate is less than 30% and falling and transfer rates are extraordinarily high:

… [T]he organisation of the Dutch obstetric system is unique, with a high percentage of home births (about 29% of all pregnant women) and a low rate of medical interventions (the rate of Caesarean sections is about 15%)… Overall, the home birth rate has decreased during the last ten years (from 35% of all births in 1997-2000 to 29% in 2005-2008). For nulliparae, the home birth rate is much lower, namely 18% in 2006. There is a high referral rate during pregnancy (45% of all nulliparae in primary care) and delivery (43% of all nulliparae who started delivery in primary care)…

Rather than being a paradise of perfect obstetric outcomes, the system has been plagued with poorer than expected results:

The Dutch obstetric system has received a great deal of attention in the literature. However, the system has increasingly come under pressure since the national perinatal mortality rate (between 22 weeks of pregnancy and 7 days postpartum) was shown to be one of the highest in Europe (10‰ in 2004)…

The study is notable for the comprehensive view of obstetric costs. As the authors explain:

Several studies have examined the economic implications of home births or short-stay hospital births in comparison with a hospital birth. However, these studies were performed outside the Netherlands… Furthermore, some of these studies had a very limited time frame, not looking at the costs from an early stage of pregnancy until a fixed period after delivery. These studies also did not calculate the societal costs of giving birth, meaning that … [the] primary focus [was] on health care costs… [In this study] not only the health care costs (i.e. costs of care givers, medication and hospitalisation) are included, but also the costs of patients (i.e. out-of-pocket costs, travel expenses), their family (i.e. informal care) and other non health care costs (i.e. productivity losses).

The results were surprising:

… The total … costs over the whole period followed (from 16 weeks of pregnancy until six weeks after delivery) amounted to €3,695 for women who intended to give birth at home and €3,950 for women who intended to give birth in a short stay hospital setting… The costs of pregnancy and delivery are (slightly) higher in the home birth group, while the costs associated with postpartum period are higher in the short-stay hospital birth group.

When looking at the different cost categories, the costs for contacts with healthcare professionals are statistically significantly higher in the home birth group (€138.38 vs. €87.94). There are also statistically significant differences between both groups regarding ‘costs of maternity care assistance at home’ (€1,551.69 vs. €1,240.69, and ‘costs of hospitalisation mother'(€707.77 vs. 959.06).

According to the authors:

… We expected that the costs of home births would be much lower than those of short-stay hospital deliveries. From the results however, it can be concluded that there is no difference in the total costs between the home birth group and the short-stay hospital group. In the home birth group, more costs were spent on maternity care assistance in the postpartum period. This conclusion is in line with the result that the costs of hospitalisation of the mother and child in the postpartum period are higher for the short-stay hospital birth group. In the Dutch obstetric system, women who remain hospitalised after delivery receive fewer days of maternity care assistance at home …. This leads to lower costs for maternity care assistance at home than for the home birth group.

The results of the cost analysis for the actual place of birth showed a large difference in antenatal costs in “week 29-42” between women who gave birth in secondary [physicia] care and women who gave birth in primary [midwife] care. This means that most of the complications during pregnancy arise in the last period of the pregnancy. All respondents were at low risk at the beginning of their pregnancy. When complications occur during pregnancy, their midwife (primary care) has to refer them to much more expensive secondary care…

This study has several major strengths:

1. It involves only women who were considered low risk at the start of pregnancy.

2. The women differ only in their preference for place of delivery. All women would have qualified for a homebirth had they desired one.

3. Since the study considered pregnancy in its entirety, it took into account the additional costs incurred by women who were low risk at the start of pregnancy but became higher risk.

4. The study considered additional costs such as ambulance costs for transport during labor and costs for home care.

5. The study looked at the actual costs of providing services. In the US studies often look at the billing rates which are merely theoretical since hospitals providers are reimbursed for a fraction of the billing rate.

6. The study took place within a system that provides comprehensive care so all costs (including ambulances, home health aides, etc) were readily accessible and could be included.

The authors conclude:

The objective of this study was to give a view of the Dutch obstetric system from an economical perspective. This study provides insight into the societal costs of the two groups of women giving birth for the first time in the Netherlands with different intentions regarding place of giving birth. Because of the high rate of home births in the Netherlands, the obstetric system is currently a topic of debate. In summary, from the results of this cost analysis, it may be concluded that there is no difference in the total costs between low-risk nulliparae who prefer to give birth at home and low-risk nulliparae who prefer to give birth in a short-stay hospital setting.

Several months ago, I discussed a bizarre paper in the midwifery literature. In Homebirth midwives wonder why no one takes them seriously:

Including the nonrational is sensible midwifery, by Jenny A. Parratt, and Kathleen M. Fahy, was recently published in the Australian midwifery journal Women and Birth. This piece has a very simple premise and conclusion: Many principles of midwifery are not supported by science. Rather than modify midwifery to reflect scientific knowledge, it is personally more satisfying to midwives to justify and celebrate their ignorance. Hence, we celebrate!

As an example of the inanity promoted by the authors, I quote this:

For example, when a woman and midwife have agreed to use expectant management of third stage, but bleeding begins unexpectedly, the expert midwife will respond with either or both rational and nonrational ways of thinking. Depending upon all the particularities of the situation the midwife may focus on supporting love between the woman and her baby; she may call the woman back to her body; and/or she may change to active management of third stage. It is sensible practice to respond to in-the-moment clinical situations in this way… Imposing a pre-agreed standard care protocol is irrational because protocols do not allow for optimal clinical decision-making which requires that we consider all relevant variables prior to making a decision. In our view all relevant variables include nonrational matters of soul and spirit.

I referred to the paper in a post earlier today, Midwives have a problem with scientific evidence. It came to the attention of one of the authors who has written in defense. This appears to be a genuine comment from Kathleen Fahy:

I find your rudeness and arrogance breathtaking. You seem to have a very clear view that body and mind (let alone soul) are separate. You are not up to date with the research in neurobiology and psychophysiology which demonstrates clearly the effect of thinking and feeling on human physiology. You might think it is ridiculous that skin to skin contact between a woman and her baby is seen as important in midwifery: it IS important for the woman’s natural oxytocin to be released which does at least two important physiological things; one contract the uterus and two assists with breastfeeding. Is it really your view that without the drug pitocin then women would all be having postpartum haemorrhages? Amy, you sound like a fundamentalist; you need to open you mind to knowledge and critically appraise new research rather than resort to selective reporting and ridicule. Kathleen

The defense is as illogical and unconvincing as the original paper.

1) There is no scientific research in neurobiology or any other field that supports the use of nonrational treatments.

2) There is no evidence that postpartum hemorrhage can be prevented or treated by skin to skin contact between a woman and her baby.

3) Rather than address the scientific evidence on postpartum hemorrhage, Fahy prefers to put words in my mouth. I did not say that all women will have postpartum hemorrhages without pitocin. I said that recommending “supporting love between the woman and her baby” is a flourish of outright stupidity, and Fahy has offered no reason to change that claim.

Caroline Hastie, another Australian midwife and co-author with Fahy and Maralyn Foreur of the new book Birth Territory and Midwifery Guardianship submitted this comment:

In regards to ideas about rationality and the non-rational, you may like to read this book on your journey to start understanding these concepts and why they are so important to supporting birthing women and midwives. Body and soul: a social history of the self

Ms. Hastie’s own book includes such gems as:

During women’s experience of childbirth, midwives also have the capacity to become aware of nonrational power and knowing… Being open to the nonrational can teach midwives about trust, courage and their own intuitive abilities.

And (I’m not making this up):

Nonrational power is inexpressibly unique, diverse and whole at the experiential level…

Spirit is power… Spirit is nonrational, ever moving, and acts in sometime idiosyncratic ways as it is free of what we rationalize as possible and impossible. The direction, force and flow of spirit extend beyond rational boundaries of time, space and matter…

The power of the spirit is the energy underlying all that in the world and the cosmos; it has been given other names, for example Universal Energy and the subtle yet vital energy called qi…

The effort to promote and defend the use of the nonrational in midwifery is astounding. Including the nonrational is not sensible midwifery; it is immature, self-absorbed, dangerous behavior. It reflects the unfortunate obsession among many midwives with their own feelings and need for validation.

Australian midwives are currently protesting the governments plan to bring them under the supervision of physicians. Frankly I regard any attempt to promote the nonrational in midwifery as evidence that midwives cannot be trusted to care for women without direct and continuous supervision by physicians.

The new mantra of midwives and their advocates is “evidence based practice.” Lamaze, the childbirth education organization has changed the name of their blog to “Science and Sensibility” emphasizing the importance of science and promising:

Lamaze education and practices are based on the best, most current medical evidence available, and can help reduce the overuse of unnecessary interventions while improving overall outcomes for mothers and babies.

But midwives and childbirth educators like Lamaze have a problem. The scientific evidence often conflicts with their ideology. They could address this problem in several ways. Midwives could modify their specific ideological beliefs on the basis of scientific evidence. Childbirth educators could question whether ideology has had an inappropriate impact on the promulgation and validation of their recommendations. Both those approaches would involve a threat to cherished beliefs. They, therefore, have taken a different approach. They’ve tried to justify ignoring scientific evidence.

As midwives Jane Munro and Helen Spilby have documented in The Nature and Use of Evidence in Midwifery, midwives 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:

At the beginning of the evidence based practice movement, much of the midwifery profession responded enthusiastically to the potential for change. Critical to this was the publication of resources of a quality not previously available to midwives … Evidence based practice was seen to be offering a powerful tool to question and examine obstetric-led models of care that had dominated the previous decades. The results of such examination could have meant ‘starting stopping’ the unhelpful interventions that had embedded themselves in common practice even suggested that it offered to ‘take us out of the dark ages and into the age of enlightenment’ by demanding that women were only offered care and treatments that had been evaluated.

But (surprise!) it turned out that obstetrics had been based on scientific evidence all along and it was midwifery that ignored the scientific evidence in favor of ideology. As I have pointed out many times, almost all practices exclusive to midwifery (as opposed to copied from obstetrics) have never been tested. They might be valuable; they might be useless; they might even be harmful. No one bothered to check before implementing them because they were based on an approved ideology.

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. As Munro and Spilby explain:

… [S]ome midwives have not been so enthusiastic [about evidence based practice], viewing the drive to create and implement evidence as a threat to their clinical freedom.

In other words, cherished ideological beliefs conflict with scientific evidence. Thus began the attack on scientific evidence.

As a first approach, midwives and childbirth educators have rejected the definition of evidence. As defined by Sackett, the founder of evidence based practice, it is “the conscientious, explicit and judicious use of current best evidence in making decisions about the care of individual patients.” That sounds objective, and evidently, objectivity is a problem. They have attempted to solve that problem by insisting that evidence can only be defined in context. “Context” in this case really means “ideology.”

Scientists see the ideology free nature of scientific evidence as one of its strengths and therefore privilege it as the ideal form of evidence. But Lomas, writing on evidence in midwifery, rejects this privileged status:

[I]t is important that context evidence should not be viewed as any less ‘scientific’. They advocate moving forward from the epistemological argument about what is ‘best evidence’ towards a ‘balanced consensus’ …

The use of the word “consensus” is illuminating. Evidence can only be evidence if it includes the opinions of midwives and childbirth educators, whether those opinions are based on science or not. Indeed, the scientific facts are merely one aspect of evidence. “Social science oriented research” and “the views of stakeholders” are supposed to have equivalent weight.

Such is the genesis of goofy midwifery papers like Wickham’s Evidence Informed Midwifery, and, my personal favorite, Parrat and Fahy’s Including the nonrational is sensible midwifery. When the evidence does not support your claims, the use of adjuncts, including nonrational ones, will justify any beliefs.

The bottom line is this: many midwives and childbirth educators use the term “scientific evidence” merely as a rhetorical device, in the same way that creationism and other form of pseudoscience use the term “scientific evidence.” As Coker details in his article Distinguishing Science and Pseudoscience:

Pseudoscience appeals to the truth-criteria of scientific methodology while simultaneously denying their validity.

Similarly, midwives and childbirth educators invoke the criteria of scientific methodology while simultaneously insisting that their opinions matter more.

It’s official. America hates fat people.

Human beings are constantly searching for socially sanctioned reasons to feel superior to others and in 2009, those who are thin feel mighty superior to those who are not. How else could a college dare to make body mass index (BMI) a graduation requirement?

According to James DeBoy, the chair of Lincoln’s Department of Health, Physical Education, and Recreation, the point of the new policy is to keep students healthy:

“There’s an obesity epidemic,” DeBoy says. “The data are clear that many young people are on this very, very dangerous collision course with heart disease, diabetes, and stroke—health problems that are particularly bothersome for the African-American community.”

The move by Lincoln University in Pennsylvania is ironic to say the least. Proudly billing itself as “The Nation’s First Black University,” Lincoln seems to have forgotten why it exists in the first place. For two hundred years, irrelevant criteria, like race, have been deemed important requirements for entrance to and graduation from college. Not only has Lincoln University introduced an irrelevant requirement for graduation, but the administration has managed to choose an irrelevant requirement that is more likely to affect black students than those of other races.

Henceforth, all students will be required to endure a physical examination to determine BMI. If the BMI exceeds the arbitrary limit of 30, the student must enroll in “gym” class to qualify for graduation. Lincoln University justifies it discrimination against the overweight by invoking the purest of motives; they’re moved by the humanitarian impulse to preserve health and prevent illness. Oh, really? So why is it bad to overeat but okay to sleep around?

Arguably, promiscuous sexual behavior is responsible for more illness, emergencies, and anguish during the college years than promiscuous consumption of food. Promiscuous sexual behavior is associated with dramatic increases in sexually transmitted diseases, leading to serious infections, hospitalizations, and long term health problems like infertility and potentially fatal diseases like AIDS. Unintended pregnancy causes health problems and psychological distress. If Lincoln University is really concerned about student health, wouldn’t it make more sense to include a pelvic or penile examination as a graduation requirement? Those with sexually transmitted diseases could be forced to attend “health” class to learn about responsible sexual behavior.

And as long as we are talking about regulating student behavior, why is it bad to overeat but okay to drink yourself to death? Alcohol abuse is arguably the most serious health problem at colleges. Perhaps Lincoln University should consider locating sobriety check points throughout the college campus. Random breathalyzer testing could identify students who drink to excess, and then they can be required to take a class on responsible drinking before qualifying for graduation.

Indeed, there are colleges that have instituted specific lifestyle guidelines on drinking and premarital sexual activity, but they do so for religious reasons. They explicitly favor certain lifestyle choices over others and are not afraid to say so. They do not camouflage their views with pious claims of preserving the health of their students.

Regardless of what the administration of Lincoln University tells the world, or even each other, about their motivations for instituting a BMI requirement, the de facto discrimination against overweight students has very little if anything to do with health. If the university were truly worried about student health, they would be addressing the most important threats to student health first, instead of ignoring those altogether. Lincoln University has decided to discriminate against the overweight for the oldest reason in the book: because they can.

Prejudice against the overweight is one of the last remaining social sanctioned prejudices. Never mind that Lincoln University is in the business of education and should be granting degrees based on educational criteria. The opportunity to single out, embarrass and penalize those who overeat was just too hard to resist. Perhaps the administration might consider taking an easier and less expensive route and simply force overweight students wear apparel emblazoned with a scarlet “O.”

When we are raised to believe that prejudice against those who look different is wrong, it is a relief to find a prejudice against those who look different that is right. Overt racism, sexism, ageism and even homophobia are out. Fortunately, discrimination against the overweight has never been more in.