Revenge of the bacteria

It's not often that you find scary stories in scientific journals, but a new paper in the journal Microbiology offers a scary story indeed. Effect of subinhibitory concentrations of chloride on the competitiveness of Pseudomonas aeruginosa grown in continuous culture does not sound particularly menacing, but this paper raises the spectre that the antibacterial cleansers used every day to clean our homes and ourselves may lead to bacteria that are resistant not only to the cleansers but to powerful antibiotics as well.

Americans have become obsessed with "germs." While there are certainly harmful bacteria and viruses that we would do well to avoid, the environment is full of bacteria and viruses that are harmless to humans. Antibacterial cleansers target all bacteria, regardless of whether or not they are harmful. That might be appropriate in the setting of the operating room, but it is excessive in non-medical settings. Yet manufacturers of anti-bacterial cleansers suggest otherwise:

Some days it seems like the kitchen is more than the center of your house—it's the entire house. It's the room where you and your family gather and where your "stuff" tends to end up too. No matter how much it becomes the hub of your home, the kitchen is still where you prepare and eat your meals—and where you are probably most concerned about bacteria and other germs spreading from surface to surface. That's why we've invented a simple solution that will help you easily keep your kitchen clean and disinfected.

Clorox® Disinfecting Kitchen Cleaner kills 99.9% of common household the bacteria and other germs that can make your family sick. Plus, its bleach-free formula also cleans countertops, tabletops, and tough surfaces like stainless steel to a streak-free shine. It's an effective formula you can use on almost any surface.*

Well, maybe antibacterial cleansers aren't really necessary in the home, but there's no harm, right? Actually, it seems like the widespread use of these cleansers has the potential to cause serious harm.

The active ingredient in Chlorox Disinfecting Kitchen Cleaner, and many other antibacterial cleansers, is benzalkonium chloride. The authors of the new paper suspected that Pseudomonas aeruginosa bacteria can become resistant to benzalkonium chloride if they are exposed to low concentrations of the chemical. In addition, they postulated that if bacteria became resistant to benzalkomium chloride,they would also become resistant against antibiotics that kill bacteria in similar ways.

If Pseudomonas is exposed to high concentrations of benzalkonium chloride, all the bacteria will die. However, if the bacteria are exposed to lower concentrations of benzalkonium chloride, some bacteria will die, but others will become resistant to the antibacterial cleanser. That, in itself, is worrying. If we continually wipe down our kitchen counters with benzalkonium chloride, Pseudomonas will eventually become resistant, making the antibacterial cleanser useless.

Even more concerning is the fact that the bacteria that became resistant to benzalkonium chloride also became resistant to the antibiotic ciprofloxin, even though the bacteria had not been exposed to ciprofloxin. It seems that the adaptation that allowed the bacteria to resist the effects of benzalkonium chloride also allows the bacteria to resist the action of ciprofloxin.

In other words, the use of the antibacterial cleanser eventually rendered the cleanser ineffective. That's disturbing, but not surprising. What is surprising is that the bacteria that were resistant to the cleanser could no longer be killed by the antibiotic ciprofloxin. In attempting to make our environment safer, we may actually be making it far more dangerous.

The problem of antibiotic resistance has been known for decades and we have learned that antibiotics should only be used when absolutely necessary in order to limit the possibility of bacteria becoming resistant. This paper suggests that the same warning should apply to antibacterial cleansers as well. They should only be used when absolutely necessary, and not used indiscriminately to "keep your kitchen clean and disinfected." The use of antibacterial cleansers is not merely unnecessary; it has the potential to be very harmful.

Oooh, Ricki Lake is talking about me!

Ricki Lake tweeted her followers this morning:

152 comments on our site
@mybestbirth.com taking on Dr.
Amy,AKA 'The Skeptical OB'Check
out the amazing dialogue taking place. add your 2¢

Ms. Lake is referring to the post, Amy Tuteur, aka "The Skeptical OB," Has a Blatant Issue With Home Birth, and the comment thread that extended for several weeks and 152 entries thusfar. I'm a bit surprised that Ms. Lake is proudly pointing to the discussion since I presented the scientific evidence on a number of aspects of homebirth and no one had an effective response. Here's the latest comment I left on her site:

"I'm so glad that Ricki Lake tweeted her followers to check out this post. It gives me an opportunity to summarize what I have said and to point out the many inaccurate claims that Ms. Lake has made about homebirth.

I'd be happy to discuss with Ms. Lake any of the following facts that I presented (Ms. Epstein promptly disappeared from the comment thread when I offered to debate her):

1. Childbirth is INHERENTLY dangerous. It is and has always been one of the leading causes of death of both young women and babies.

2. The best study of American homebirth midwifery (Johnson and Daviss, BMJ 2005) actually shows that homebirth with a CPM has triple the neonatal death rate of hospital birth for comparable risk women. The authors hid this by failing to compare homebirth in 2000 with low risk hospital birth in 2000.

3. The CDC statistics for linked birth infant death show that homebirth with an American homebirth midwife is the MOST DANGEROUS form of planned birth in the US. Planned homebirth with a homebirth midwife has triple the neonatal death rate of low risk hospital birth.

4. The recent publication of the Dutch and Canadian studies is bad news for American homebirth. The studies shows that homebirth with an American direct entry midwife has more than triple the death rate of homebirth with a Canadian midwife or a Dutch midwife. The central lesson of both studies is that homebirth can only be safe when practiced by highly educated, highly trained midwives under rigorously controlled conditions, a position in direct opposition to the philosophy of American homebirth.

5. The Colorado Midwives Association reported its own mortality statistics. Colorado LICENSED midwives have an appalling rate of perinatal mortality of approximately 8/1000 (and rising), far exceeding the perinatal mortality rate for low risk births in Colorado.

6. Homebirth advocates like to quote US infant mortality statistics, but infant mortality is a measure of pediatric care. According to the World Health Organization, the correct measure of obstetric care is PERINATAL mortality and according to the World Health Organization, the US has one of the LOWEST perinatal mortality rates in the world, LOWER than Denmark, the UK and The Netherlands.

That's just a few of the facts that I have presented. I would be happy to discuss them publicly with you any time Ms. Lake. A public discussion, in print or in person, would give all women the opportunity to evaluate your claims and my claims for themselves. If you are sure that you have made accurate claims you have nothing to fear.

I'd be happy to debate you in any neutral forum of your choice, Ms. Lake. How about it?"

Fallacy of the lonely fact

Imagine an argument that goes like this.

Jane: Australians are thieves.
John: Can you prove that?
Jane: Are you saying that no Australians have ever stolen anything?

Jane has committed the fallacy of the lonely fact. Knowing that at least one Australian has stolen something, she has concluded that all Australians are thieves. The example of the Australians shows that it is an absurd “argument” but it is a favorite of “natural” childbirth advocates and lactivists.

For example:

NCB Advocate: Obstetrics is not evidence based.
Me: Can you prove that?
NCB Advocate: Are you saying that no principle of obstetrics has ever been proven wrong? Look at what happened with episiotomies.

Or:

NCB Advocate: C-sections are usually unnecessary.
Me: Can you prove that?
NCB Advocate: Are you saying all C-sections are necessary? I know for a fact that my cousin’s C-section was unnecessary.

Or a slightly different formulation:

Me: The benefits of breastfeeding have been overstated.
Lactivist: So you’re saying that breastfeeding is no better than bottle feeding?

In every case, the reasoning is based on the assumption that a specific example tells us something about the whole. The fact that episiotomies were used even though scientific evidence later showed them to have no benefit is used to justify the assumption that everything in obstetrics is used even though there is no scientific evidence to support it. A single (or a few) unnecessary C-sections are used to justify the assumption that all (or most) C-sections are unnecessary. In the third example, a single criticism of the benefits of breastfeeding is used to justify the assumption that I believe that breast feeding has no benefit at all.

The fallacy of the lonely fact is often used by “natural” childbirth advocates, lactivists, and many proponents of alternative health. It is meant to substitute for a lack of actual evidence. “Natural” childbirth advocates don’t know whether specific obstetric recommendations lack evidence, and they don’t want to bother finding out. They use one example and generalize to everything else. C-section activists don’t know what proportion of C-sections are unnecessary. The fact that some may be unnecessary is enough for them to assume that all (or most) are unnecessary. Lactivists routinely overstate the benefits of breastfeeding, and when question, don’t bother to find out the magnitude of the benefits. They prefer to claim that anyone who questions any benefits questions all benefits and therefore can be dismissed.

The fallacy of the lonely fact is a fallacy because it is based on the assumption that a specific example (episiotomies, for instance) can be generalized to the every possible example (all of obstetrics). Just as the fact that one or even more than one Australian stole something doesn’t make all Australians thieves, a single example can never be assumed to apply universally.

Cesarean, mortality, and the law of diminishing returns

At first glance, the graph above appears to represent an indictment of contemporary obstetric practice. From 1970-1980, the C-section rate rose precipitously, and the neonatal mortality rate also dropped precipitously. Since then, the C-section rate has continued to rise ever faster, but neonatal mortality, although continuing, has declined at ever slower rates. Yet this is exactly what we would predict if the C-section rate were following the law of diminishing returns.

According to Wikipedia, the law of diminishing returns (also known as the law of marginal utility) means:

... in a production system with fixed and variable inputs (say factory size and labor), there will be a point beyond which each additional unit of the variable input (i.e., man-hours) yields smaller and smaller increases in outputs, also reducing each worker's mean productivity. Conversely, producing one more unit of output will cost increasingly more (owing to the major amount of variable inputs being used, to little effect).

In the case of Cesarean sections, the law of diminishing returns would predict that there will be a point beyond which each addition increase in C-section rate yields smaller and smaller decreases in neonatal mortality rate.

Imagine a hypothetical first world country that has 1 million births per year. In this hypothetical country, we are able to analyze the number of lives saved by C-sections and we are able to analyze it in hindsight so that we know which C-sections were necessary. As the C-section rate rises, the numbers of lives saved drops off (diminishing returns). In our hypothetical country, we can chart how many lives are saved for each percentage point of the C-section rate. Each percentage point of the C-section rate represents 10,000 C-sections. Our chart might look something like this:

C-section rate	lives saved/10,000 C-sections
0-5%%	20,000 (every mother and baby)
6-10%	10,000 (every baby)
11-15%	5,000
16-20%	500
21-25%	50
26-30%	5
31-35%	0.5
36-40%	0.05

We can see the law of diminishing returns in action here. At a C-section rate from 0-5%, every C-section is necessary, and every C-section saves the life of both mother and baby. From 6-10% every C-section is necessary and saves the life of the baby. From 11-15% half the C-sections are necessary, resulting in a savings of 5000 lives. At rates higher than 15%, retrospective analysis reveals that far fewer C-sections are life saving. By the time a C-section rate of 35-40% is reached, only one additional baby will be saved every other year.

The results can be expressed another way. We can determine retrospectively how many C-sections were unnecessary. Here's that chart:

C-section rate	unnecessary C-sections/10,000
0-5%	0
6-10%	0
11-15%	5,000
16-20%	9,500
21-25%	9,950
26-30%	9,995
31-35%	9.999.5
36-40%	9,999.05

So the law of diminishing returns tells us that, beyond a certain point, we will have to do more C-sections to save one neonatal life. In other words, beyond a certain point, we will have to do more unnecessary (in retrospect) C-sections for each life we save.

Of course, that tells us about C-sections in the aggregate, but the decision to perform a C-section is made on a case by case basis. Moreover, in court, the decision to find an obstetrician guilty of malpractice for not performing a C-section is also made on a case by case basis. The parents and the court really don't care how many unnecessary C-sections you have to do to save one baby, if that baby is their baby.

Yet the C-section rate can be too high. When you get to the point that you are saving 1 baby every 10 years, the C-section rate is clearly too high. However, a tremendous premium is placed on the life of each and every baby. That societal value is reflected in the fact that our judicial system operates as if we believe that if a C-section had even a remote chance of preventing the death or disability, that C-section should have been done, and because it wasn't done, the parents should be compensated.

The above graph represents what we appear to believe about the value of the life of each baby. Personally, I think the standard should be different. The number of unnecessary C-sections done to save one baby every decade should not be unlimited. The standard for determining fault in an obstetric malpractice case should not be to show that a C-section "might" have prevented a baby's death or disability; the standard should be that the doctor could have reasonably foreseen (based on the evidence available) that a C-section was necessary to prevent the baby's death or disability.

C-sections come with costs. We have not even talked about the financial costs, because, in my judgment, these are secondary. However, very large numbers of unnecessary C-sections will result in unnecessary complications and unnecessary deaths. If the C-section rate continues to rise, these unnecessary complications and unnecessary deaths will increase from relatively uncommon occurrences, to occurrences that far outweight the number of babies' lives saved.

We, as a society, need to think about where we draw the line, because we, as a society, through our punishments and incentives, determine how high the C-section rate should be. The graph above is not an indictment of obstetrics. It is a warning to us to consider what we truly value. Do we really believe that it is worth any number of C-sections to save one baby's life? We certainly act as though we do.

A history of hospital birth

On its website, Midwifery Today features a timeline entitle The History of Midwifery and Childbirth In America. The timeline extends from 1660 to the late 1990's. It contains interesting tidbits of information about childbirth practices, interspersed with general historical events. It seems quite comprehensive with the exception of one curious omission. It barely mentions mortality statistcs.

To my mind, the history of childbirth is a continuing effort to master its inherent dangers. Childbirth is and has always been, in every time, place and culture, one of the leading causes of death of young women and the leading cause of death of newborns. Indeed, the primary purpose of a childbirth attendant is to increase the chance that the mother will live, at least, and hopefully the baby will live too.

The secondary purpose of a childbirth attendant is to comfort the mother as she endures the excruciating pain of labor. The history of childbirth has also been a continuing effort to master the pain of childbirth. That's another curious omission from the Midwifery Timeline. It makes no mention of chloroform, general anesthesia or epidurals, arguably among the most important advances in the history of childbirth.

I suspect that the reason for these glaring omissions reflects the direct entry midwifery obsession with process. The outcome, whether or not the mother or baby lived, is virtually irrelevant.

Perhaps another reason why the timeline is silent on the issue of mortality statistics is that they illustrate the spectacular success of modern American obstetrics. For hundreds of years midwives presided over childbirth and had almost no impact on the appalling rates of maternal and neonatal mortality. It was only with the advent of modern obstetrics that the mortality rates began to fall.

I thought it might be interesting to look at the statistics that the Midwifery Today timeline left out. I took as the starting point the timeline itself. It faithfully chronicles the movement of birth from the home to the hospital starting in 1900. In every decade, it reports the ever increasing percentage of hospital births. Yet it is silent on massive declines in maternal and infant mortality that occurred simultaneously. For each point in the timeline where the percentage of hospital deliveries is mentioned, I looked up the corresponding maternal and neonatal mortality rates. The above graph is the result.

As the percentage of births in the hospital rose, the maternal and neonatal mortality plunged. The graph is a powerful way of demonstrating that the association is dramatic. During the 1900's, for the first time in history, using the tools of modern obstetrics, the terrible inherent dangers of childbirth were mastered. Could we do even better? No doubt, and the search continues to make birth even safer than it is today. As Dr. Atul Gawande wrote in his New Yorker article (The Score, How childbirth went industrial), "Nothing else in medicine has saved lives on the scale that obstetrics has." The graph makes that very clear indeed.


Infant and maternal mortality rates abstracted from CDC on Infant and Maternal Mortality in the United States: 1900-1999. Although neonatal mortality is a much better measure of obstetric practice, neonatal mortality figures were not collected in the earlier part of the century. Therefore, infant mortality statistics are used as a proxy, albeit imperfect.

Strengthening the immune system

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.

Homeopathy: nano-doses or mega-stupidity?

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 and the argument from ignorance

"Natural" childbirth advocacy is riddled with fallacious arguments and one of the most common types is known as the "argument form 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.

More goofy midwifery theory

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."

The horrifying death toll of homebirth in Colorado

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 and risk

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 does not save money

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.

Midwifery professors respond

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.

Midwives have a problem with scientific evidence

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.