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Thursday
Nov122009

Denialism

Denialism is a new word to me. I didn’t have to Google it to figure out what it meant; that was easy. I deduced the word was defined as the act of denial, probably in the face of facts. When I did Google it, sure enough, many options to explore denialism popped up, including a Wiki entry. (You know you’ve made it when you have a Wikipedia entry.) 

Mark Hoofnagle is one of three authors who write the “Denialism Blog.” (Chris Hoofnagle and PalMD are the other two.) Hoofnagle’s bio says, “Mark Hoofnagle has a(n) MD and PhD in physiology from the University of Virginia, and is now a general surgery resident. His interest in denialism concerns the use of denialist tactics to confuse public understanding of scientific knowledge.” I like the subtitle of the blog: “Don’t mistake denialism for debate.”

Hoofnagle has outlined six tactics that might be used to maintain the appearance of legitimate controversy;

  1. Conspiracy - Suggesting opponents have some ulterior motive for their position or they are part of some conspiracy.
  2. Cherry picking – Picking apart a critical paper supporting their idea, or famously discredited or flawed papers meant to make the opponents look like they are based on weak research.
  3. Contextomy - Using a statement out of context to further their position.
  4. False Experts - Paying an expert in the field, or another field, to lend supporting evidence or credibility.
  5. Moving the goalpost - The use of the absence of complete and absolute knowledge to prevent implementation of sound policies, or acceptance of an idea or a theory.
  6. Other logical fallacies - Usually one or more of false analogy, appeal to consequences, straw man or red herring.

Denialism is spreading in our country. From the “birthers” who don’t believe Obama is an American citizen to the continued denial of the Holocaust, standing on the moon and that HIV doesn’t cause AIDS. Depending on where you stand, the other side looks foolish, if not downright stupid, to believe in such absurd ideas. Denialism isn’t just not believing something, but not believing in the face of scientific, hands-on, well-studied and multi-checked facts.

This begs the question, whose facts are to be believed?

In the birth world, denialism meets evidenced-based medicine.

Evidence-based practice is a common request from those in the natural birth arena. We want an end to continuous fetal heart monitoring and keeping women from eating or drinking in labor because numerous studies show they do not improve outcomes. What if the research counters what the natural birth community believes and wants to continue doing? Many different studies have proven that the Active Management of Third Stage is safer for women, yet midwives and their clients insist on the Physiological approach. Natural birth advocates get all up-in-arms about allopathy continuing routines that have been disproven over and over, yet we do the exact same thing. Who’s in the wrong then?

There is no scientific evidence that homeopathy works. Yet midwives embrace it wholeheartedly. There is no scientific evidence that says keeping a woman in bed improves outcomes, yet hospitals continue with this practice… even when there is contrary evidence saying it might be detrimental. Why do we expect them to accept our quirks if we aren’t able to accept theirs?

Shifting sideways some, denialism takes a different form when discussed in the natural birth context. To me, one of the greatest forms of denialism comes from the Unassisted Childbirth (UC) faction. While no studies show the dangers of a UC (reporting would be self-disclosing and therefore difficult to measure), anecdotally, one simply needs to look at the UC boards at MotheringDotCom (MDC) to see the extremely high rate of affected babies to come to the logical conclusion that perhaps UCing isn’t such a good idea after all. In my own life, I have known of two babies that died during a UC. I have never known of a baby that died from the lack of a medical team’s care (meaning from a baby being left to perish without a team working to keep the baby alive). When babies die in the hospital, it is almost always because of congenital or prematurity issues. Rarely, full-term, pregnancy-healthy babies die. There are stillborns in each category, but monitoring absolutely can alert a care provider to act to help a baby birth alive. (And not just continuous monitoring.) When tragic things happen on MDC, the women  soothe each other, finding ethereal reasons for the tragedy; she didn’t think positively enough, it would have happened in the hospital anyway or it was the baby’s time. It’s heretical to say, “Maybe you should have gone to the hospital sooner” or even, “I wonder what would have happened if you’d had a midwife there.” Women go out of their way to help a mother not feel guilty for her choice, believing she already feels guilty enough, but in their comforting, they are leading the acolytes to believe it would have happened no matter where the woman was.

Of course the medical folks use these same arguments with homebirthers, saying that it’s a risk to deliver at home without continuous monitoring and the capability of an operating room to facilitate a cesarean in the case of the rare emergency. They surely believe Natural Birth Advocates (NBAs) are denialists, too. They point to studies that demonstrate that homebirth is absolutely more dangerous for babies. The major study, sometimes referred to as The Pang Study, has been de-bunked by several professional NBAs, yet is still quoted by med folks. When studies support homebirth as a viable option, factions of researchers and physicians attack methodology. NBAs do the exact same thing; it’s a war of the statistics. What’s amusing to me is when the study benefits either side and is hailed as the latest proof that they are right. No consideration is made regarding methodology then; it’s obvious the study is perfect when the beneficiary needs it to.

Denialism takes many forms… depending on your viewpoint. Pick any hot button issue and you find divisiveness that accuses its counterpoint of denialism: Homebirth/Hospital birth (including UC), ultrasounds, vaccinations, circumcision, naturopathic remedies/medications, television, cell phones, microwave ovens, shampoo, global warming… and on and on. (Interestingly, I hardly hear about a computer’s possible negative effects.) As mentioned above, a plethora of studies demonstrate the scientists’ point of view regarding controversial topics; a few studies do the same for the natural community. Each believes they are right and the other is wrong. Who is right? How do we separate the wheat from the chaff? Do we tend to be on one side or the other depending on how we were raised (similar to choosing religion or political parties)? Did homes that fostered individual thinking produce open minds that can embrace alternatives even when they have no scientific proof? Are there personalities that lean one way or the other? Are left-brained thinkers more apt to live a scientific life? (Of course there is a range from far left-brained to far right-brained folks.) I would love to see a study about this.

Does denialism equal lying to oneself? Or might it be simply looking at a topic, squinting and turning your head sideways to justify your thoughts.

I tend to be somewhat balanced between the two poles. (At least I like to think I am.) Looking at me from the natural vantage point, I am sometimes considered a medwife. I do not struggle with “interventions” when they are called for. I don’t hesitate to send a woman in for medications if she can heal quickly from them. Yet, I also advise natural methods of healing –from supplements to acupuncture- things that are often poo poo’d by the medical community. To them, since I am a homebirth midwife, I am seen as a kook. It’s definitely a balance walking between the two. I often joke about being the tie-dye and Birkenstock-wearing midwife who wears make-up tested on animals and who’s been known to eat too much McDonald’s. I love that I have a wide range of friends… from Christy Funk who owns the natural mom and baby store Belly Sprout to the most medicalized CNMs and family members. I believe walking on both sides of the line helps keep me balanced, looking at both sides of most issues and forcing me to keep an open mind.

Yes, as we all know, it’s the open mind that can pull our pendulum hard towards one direction or the other. A conundrum we all struggle with… and rarely perfect.

 

Reader Comments (16)

Very well said. I have often considered becoming a homebirth midwife, but I'm sure I'd drive off a fraction of possible clients because I prefer evidence-based practice (i.e. I would not be comfortable recommending or working with homeopaths and other such). I also think that local statistics are more meaningful that national ones when it comes to giving birth. If my local hospital has a 45% C-section rate and my midwife of choice has a 1% transfer rate and no maternal/fetal mortality, then I'm feeling pretty good about choosing a homebirth with her :) If the only local midwife I can find has had several losses or the hospital is progressive, then I would feel more comfortable in the hospital. That's not how the stats get used, unfortunately

November 12, 2009 | Unregistered CommenterJan Andrea

I just never understand WHY a women wouldn't want a guardian at her birth. I always felt like I was freed up to labor and just do my part of birthing by having a professional there. I am so out of it after a birth, I don't even think I'd have the skill to know if something was wrong-and I'm a birth doula! It just seems like there's so many things that are not a big deal when a midwife/doctor is present that are really dangerous in their absence. Cord issues and shoulder dystocia are the most blatant, but what about the baby that just can't tolerate labor? Or seriously prolonged labors that do need chemical intervention? I believe our bodies are designed, but nothing is this world is perfect-no body process runs smooth 100% of the time.

November 12, 2009 | Unregistered Commentersara

Great post Barb! I very much enjoyed reading this and feel like I am in a similar position. I try to walk a fine line but sometimes very difficult. There are things that I do that are not EBP (third stage management for example) but then there are many things that do follow researched practices. I like to think that midwifery is an art and not just a science. Some of what we do is intuition and based on personal experience. And that's not always a bad thing! But I just can't get right with UC.

November 12, 2009 | Unregistered CommenterCiarin

Another fab post Barb! I love it!

I know that I am a bit of a medwife. I love high-risk. I love it. I find it interesting, exciting, challenging... I am good in that environment, trying to get the birth as 'normal as possible, guarding the space for the family...

But I am not a fan of homeopathy, I like active management of the 3rd stage simply because it saves lives & I use EFM when attending a high-risk birth - simply so I know what that fetus is doing - not necessarily to improve an outcome (though this is often a knock-on effect).

I strongly believe that we need many genres of midwife & that we can all contribute to the birth community. I am a greater asset to a woman in a hospital than I am at a homebirth right now. I feel that women choosing homebirth don't 'need' me, whereas in a hospital, I am a powerful advocate.

I'm so glad that we are all so very different.

November 13, 2009 | Unregistered CommenterLizzie

Most Americans don't even believe in evolution. When you are taught to distrust science to that extant then you aren't exactly going to trust it for anything else. Americans are more likely to be biblical literalists, and biblical literalist find science threatening to their spiritual beliefs and therefore convince themselves it is flawed. It's a world where fairy's and leprechauns can be just as true as scientific theory (and where people don't even understand the meaning of the word 'theory' as it relates to a body of scientific evidence). Some public schools are not even allowed to teach evolution, and when they do, they do a really crappy job of it and tell all the students it is "just one *theory*". Some schools want to teach creationism, the epitome of denialism, right alongside evolution in science class. What can we really expect when people are taught from childhood to deny science and to shun critical thinking? They are actually taught to convince themselves of things that do not have any proof, and believe that this idea is "scientific" fact. Critical thinking is a skill that Americans are just not taught.

November 13, 2009 | Unregistered CommenterJennifer Z.

Sara, I think a lot of women decide to UC because they feel unsafe with the care providers available to them. Either midwifery is unavailable or illegal where they live, or they have had a bad experience previously and felt violated by their care provider to the point that they don't trust anyone with their body and/or baby. There are some who UC for a personal spiritual experience and others because they think it gives them some kind of birth cred. Some also who have birthed a lot of babies and feel they know more than their care providers.

That being said, I don't agree with any of those reasons. If I could not trust care providers in my area, I would travel somewhere else to birth. If it was my own body issue (for example, previous abuse or rape) I would seek counselling before or during pregnancy. I would talk at length with my care provider about how much involvement they would have if my birth progressed normally. Et cetera.

While I think home birth is the safest for most mothers and babies, I don't think unattended birth is safe. For the record, my midwife was very hands off, the birth progressed normally, the baby and I were very healthy and would have been fine in a UC situation...but I am still grateful for my midwife's wise and calm presence should we have required her expertise. I was seriously not equipped in the midst of labor to identify potential issues, even though I had read more on the topic of normal birth than anyone I knew.

November 13, 2009 | Unregistered Commenterhillary

Thank you for this post, which helped to clarify for me something I was struggling with in the childbirth class I took. I took one focused on natural childbirth, because that is what I want, but I found the readings that came with the class problematic. For example, one week we read an article about the use of medications in childbirth which focused on one theme - no medication has been proven absolutely to be safe in childbirth. This rang a warning bell with me because there is no scientific research that can prove anything absolutely, it can just suggest likelihoods. The next article for that week was on the use of herbs in labor. Hey, wait a minute, these herbs haven't been proven absolutely safe either - they haven't even been systematically studied! There seemed to be a weird double standard going on.

November 13, 2009 | Unregistered Commenternishkanu

Love Love Love this Barb! You bring words and validation to my muddled internal journey as a midwife. Thank you!

November 19, 2009 | Unregistered CommenterLaura

I have had both a homebirth and a hospital birth -- a fabulous homebirth 3 years ago in a state with a legal CPM in attendance, and a recent hospital birth in my current state where unlicensed midwives have to practice way underground, which seems unsafe to me. I really appreciate your words of advice for those of us who try to walk this line, as well. Your counsel on how to have a rational natural hospital childbirth was EXTREMELY helpful. My homebirth was perfect, my hospital birth was just "fine," but I feel I made the right choice. IThe homebirth proponents in the area felt I betrayed them, but I'm just trying to do what's right for me and my child.

In regards to this post, one question. I understand that managed third stage is statistically safer. But when it comes to my own births... I have a hard time going for managed when my two unmanaged births have been so smooth and uncomplicated. Both times I gave birth, less than ten minutes later pushed the placenta out on my own, bada bing bada boom. Easy as pie, no bleeding, clamped down nicely. I don't think my doctor at my last hospital birth had ever even had an unamanaged third stage and he seemed almost shocked at how simple it was.

So my question is, if it is statistically safer, should I have instead said ok to a $187 shot of pitocin and had him tug on my cord? That just doesn't seem any better to me. I opted for watch and wait -- if I start to bleed, by all means give me the shot but if everything is going fine, is it necessarily better to always manage because that's what the statistical evidence suggests?

Does it have to be one or the other? Are there any studies that look at a hybrid between the two? What exactly IS the definition of managed third stage? Does it always have to include the pitocin, traction, etc. or is it just having those things available as tools? Many of the lists I see online suggest that immediate cord clamping is part of 3rd stage management, but haven't there been lots of reliable studies lately showing that isn't necessarily the best way? I don't really know. But saying "wait a minute until I do it myself' seemed so obvious and responsible, even despite the evidential proof.

I'd be interested in your thoughts.

November 21, 2009 | Unregistered CommenterNess

I've thought the same thing, Nishkanu. I went to a natural baby store and was looking for some toy that wasn't made in China for my baby to chew on while teething and the saleslady took me straight to the homeopathic remedies. I told her I didn't want to give my baby drugs and she told me that they weren't drugs. It doesn't make any sense to me.

My baby did just fine with the teething without the drugs, by the way.

December 6, 2009 | Unregistered CommenterCurdie

Amazing. I read the linked article to the Active Management of Third Stage. The studies and statistics surprise me, there, but it's wonderful to get such solid information, thank you for it.

So, did I get this right? Delayed cord clamping still gets thumbs up. Immediate cord traction gets a thumbs down, but if done right, and only after being given oxytocin (ergot is for the lose, says my dogmatic 'EW!' at anything ergot),AND with counterpressure to keep the uterus from inverting, it's a thumbs up.
That's a surprise. From the huge amount of NCB lit I've been reading, it seemed like cord traction would be a complete no-no, always.

It brings up a question, if you can throw it in a later post - what would you do or want in third stage, knowing what you do, with those options available to you as a birthing mom? (While it would be cool to put whole paragraphs of ideas in a birth plan, I'm not that dumb, lol! Just hoping to get an idea, get as well educated as I can, and then discuss with my midwife without being a doofus on the subject.)

May 9, 2010 | Unregistered CommenterAmanda K.

My own experience is counter to this research.

I bled way too much after both hospital births. During third stage of my first hospital VBAC, the doctor was actually teaching his intern about "controlled cord traction." My records say the placenta was delivered 4 minutes after the baby. They estimated blood loss as 500 cc. After my second hospital VBAC with the same doctor, placenta was out 5 minutes after the baby, and I supposedly lost 600 cc. They kept me on methergine for the whole time I was in the hospital. (This kept my milk from coming in and they kept giving my baby soy formula after I nursed him to keep his blood sugar up.) I went home with a hemoglobin of 9, looking really pasty and pale. I felt weak and tired. They told me the reason I lost so much blood was that I had such a big baby.

When I was at home, and no one pulled on my cord, or gave me any pitocin, it took between 10 minutes and half an hour for the placenta to arrive. I never bled too much at the time of the birth and I never felt that tired and weak afterwards again, even after I had a bigger baby than the biggest one in the hospital.

I'll have to look at these studies. But I do approach them with scepticism. Is there some confounding factor involved? Were these mothers induced? Did they have their babies at the breast during the third stage? Did they feel so much less comfortable where they were that even though they put the baby to the breast, they didn't release much oxytocin?

Susan Peterson

August 23, 2010 | Unregistered CommenterSusan Peterson

I went to the linked article, and while I understand the text portion, the table is beyond me.

I think the numbers next to the complications show some kind of ratio?
Of patients with physiologic management who had this complication to patients with active management? Or vice versa? The first number, for PPH<500ml was .38. Can you explain what this means? A woman has a 38% lower liklihood of PPH <500ml with active management than physiological, according to this study? Or...???

What is "number needed to treat?"

The number of patients with this condition who needed treatment for it, and who therefore wound up in the study for that complication?

For PPH over 1000ml there were only 12. I think that means that for this variable "n" for the study is 12 women.

But how many women did they start with? How were they randomized into the two groups? Before or after delivery? It would have to be before, I would think. But that leaves the two groups as possibly not random after delivery with respect to length of labor, size of baby, amount and types of medication, and so on.

If you are going to change your practice based on studies, you will want to look at everything which went into how the studies were done.
Suppose a hospital did lab tests on women who had IV's in labor and those who didn't, and on their babies also, and showed that women who had 1/2 normal saline with 5% dextrose (What do they hang in labor?) were better off on several parameters. Would that make you decide routine IV's in labor were a good idea? Or would you ask whether these women were allowed to eat and drink? Maybe if you can't eat and drink for 24 hours an IV isn't a bad idea.

So is there some factor like this which isn't evident in the study report itself, which produced these results?

(Which I would still like to understand the results table for.)

Susan Peterson

August 23, 2010 | Unregistered CommenterSusan Peterson

I don't do math. I don't speak math. I can't translate math. So, asking me statistics questions is futile, sorry.

The whole post was about *thinking*, not just taking one study and changing one's practice because of it. There are tons (dozens?) of studies about AMTS and the overwhelming evidence supports it. Do I pick apart studies? No, because that isn't a skill of mine. However, I *do* depend on trustworthy folks to translate them for me. Also, blessedly, there *are* math geeks in the birthing world and they *do* pick apart the studies (as mentioned in the post), each "side" knowing for sure that they are right. (This debate is going on right now re: a homebirth study that 1) said there is a 3x greater chance of having a baby die in a homebirth 2) had terrible methodology and most of the study had to be thrown out, leaving the results saying there was NO difference in neonatal mortality rates when the baby is born at home.

Is there *ever* a right answer?

And Susan, it would be helpful if you didn't keep offering "what-if" circumstances because we can what-if ourselves to death. Using real instances and real tools/knowledge is much better/easier than conjuring hypothetical situations that may, or may not, ever come to fruition.

August 23, 2010 | Registered CommenterNavelgazing Midwife

My 'what if' was just an illustration of a possible 'confounding factor' in a study.

To me the issue is that if one can't pick apart studies ones self, one is dependent on someone else to do it for you, and which someone else do you trust?

Without analysis of how the study was done, any study, I wouldn't trust the conclusions drawn by the authors.
And in this particular subject I would be especially skeptical.
I think there ought to be a bias to start with in favor of the physiological, an overcomable bias of course.

Just the fact that all these studies are in a hospital environment might lead you to wonder if there isn't something about that environment which affects third stage which is different from the situation at home and which makes these studies not applicable to your practice.

It isn't denialism to ask such questions, I don't think.

Susan

August 25, 2010 | Unregistered CommenterSusan Peterson

No, all the studies were *not* done in the hospital and AMTS is the recommendation from the World Health Organization.

http://www.who.int/making_pregnancy_safer/documents/postpartum/en/index.html

http://www.pphprevention.org/files/Guatemalafinalreport.pdf

http://www.guttmacher.org/pubs/journals/3510509.html

Who do I trust? These three organizations for a start.

August 25, 2010 | Registered CommenterNavelgazing Midwife

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