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


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.

[pullquote align=”right” cite=”” link=”” color=”” class=”” size=””]Personal experience is evidence, just not scientific evidence; it is religious evidence.[/pullquote]

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.