Midwives and lactation professionals use the term “evidence based medicine” so often, you might think they actually practice it. You would be wrong.
That’s because evidence based medicine is often hijacked by ideologues and industry.
Dr. David Sackett, credited with popularizing the phrase and concept, explained it in an influential 1996 paper, Evidence based medicine: what it is and what it isn’t:
[pullquote align=”right” cite=”” link=”” color=”” class=”” size=””]Evidence based medicine was never meant to be a tyranny. It is NOT supposed to produce one size fits all recommendations.[/pullquote]
Evidence based medicine is the conscientious, explicit, and judicious use of current best evidence in making decisions about the care of individual patients.
John Iaonnidis explains how EBM has been hijacked hijacked:
As EBM became more influential, it was also hijacked to serve agendas different from what it originally aimed for.
Industry immediately recognized the possibilities of hijacking EBM:
Influential randomized trials are largely done by and for the benefit of the industry. Meta-analyses and guidelines have become a factory, mostly also serving vested interests. National and federal research funds are funneled almost exclusively to research with little relevance to health outcomes… Risk factor epidemiology has excelled in salami-sliced data-dredged papers … and has become adept to dictating policy from spurious evidence…
Diabetes care serves as a cautionary example.
In 2009 a large-scale study of tight blood sugar control showed that, contrary to guidelines, tight control actually increased the death rate for adult onset diabetics. How could EBM have been so wrong?
It quickly became apparent that the guideline for tight control was approved over the protests of many diabetes experts. Second, there was a third party that would benefit from a guideline for tighter control: the drug companies that sold insulin, and they promoted such a guideline. Third, the National Committee for Quality Assurance, a supposedly impartial organization that sets the standards used by insurers to determine whether a treatment qualifies for payment, had received money from the drug industry.
When industry stands to benefit from evidence based guidelines, they use their influence to promote guidelines that benefit themselves. They start with the guideline result they want — greater use of their products — and then produce the “evidence” to support it. Then they market it as “evidence based” medicine.
Sadly, ideologues can hijack evidence based medicine in exactly the same way.
Midwives and lactation professionals start with the guideline results that they want — greater use of their services — and proceed to produce the “evidence” to support it. Then they market it as “evidence based” medicine.
How?
Influential midwifery research is done by and for the benefit of the industry of midwives, doulas and childbirth educators and published largely in journals dedicated to promoting them. They start with the results they want — women should be pressured to have unmedicated vaginal births — and proceed to produce the “evidence” to support it. Moreover, they conduct research on low risk women who have few complications and then extrapolate extravagantly — and absurdly — claiming that it was the midwifery care that led to low risk of complications. Then they market their claims as “evidence based” medicine.
Influential breastfeeding research is done by and for the benefit of the breastfeeding industry and published largely in journals dedicated to promoting breastfeeding. They start with the results they want — breastfeeding has major health benefits — and proceed to produce the “evidence” to support it. They conduct small trials riddled with confounding variables and then extrapolate absurdly to make extravagant claims that are never validated and never come to pass. Then they market their claims as “evidence based” medicine.
Midwifery and breastfeeding ideologues have hijacked research to create “evidence” designed to serve their own interests.
They’ve also violated a central tenet of evidence based medicine.
Sackett explained:
Good doctors use both individual clinical expertise and the best available external evidence, and neither alone is enough. Without clinical expertise, practice risks becoming tyrannised by evidence, for even excellent external evidence may be inapplicable to or inappropriate for an individual patient. Without current best evidence, practice risks becoming rapidly out of date, to the detriment of patients.
Evidence based medicine was never meant to be a tyranny. It is NOT supposed to produce one size fits all recommendations since even excellent evidence may be inapplicable to or inappropriate for an individual patient.
Evidence based medicine is not “cookbook” medicine. Because it requires a bottom up approach that integrates the best external evidence with individual clinical expertise and patients’ choice, it cannot result in slavish, cookbook approaches to individual patient care.
Promoting “normal birth” is a slavish, cookbook approach to patient care. Unmedicated vaginal birth is NOT best for every mother. When providers ignore that fact, babies and mothers die.
“Breast is best” is a slavish, cookbook approach to patient care. Breast is NOT best for every baby. When providers ignore that fact, babies die.
In a subsequent paper, Ioannidis likens evidence based medicine to a treasure ship hijacked by pirates.
…[T]he pirates have hijacked the EBM ship because it is a superb, worthy vessel loaded with goodies that are deemed to have high value. No pirates with some profiteering mind would have ventured to
capture a sinking tub that had no treasure.
Those who care about babies and women must fight back.
…We should do our best to throw overboard the pirates who have captured the ship and then stay the course to more rigorous, more unbiased evidence that matters for patients and healthy people.
It will not be easy:
Finance-based medicine, conflicts of interest (financial and other), just-bring-more-money approaches to research, questionable research practices, … salami slicing, spurious reward systems, methodological illiteracy and innumeracy, “basic science” hype, and overall stark ethical poverty are becoming increasingly common …
But it is a worthy task. Babies and mothers are depending on us to take back evidence based medicine from midwifery and breastfeeding ideologues who have hijacked it.
