Midwives have a large and ever growing problem with scientific research. The stark reality is that scientific research demonstrates that most of what is exclusive to midwifery is unsupported by scientific evidence and much of it (including all of homebirth midwifery) is irrational.
Hence, there is a large and ever growing divided between midwifery research and scientific research. Scientific research seeks to learn, specifically to learn how the human body works and how to maximize healthy outcomes. Midwifery research, in contrast seeks to justify, specifically to justify a primary role for midwives in the delivery of obstetric care.
Midwives make no bones about it. Consider the chapter, RCTs and everyday practices … a troubled relationship, in the leading textbook on midwifery “evidence,” Promoting Normal Birth – Research, Reflections and Guidelines, edited by Sylvie Donna.
RCTs are randomized controlled clinical trials, generally considered the gold standard of scientific research. Why is the relationship between RCTs and everyday midwifery practices troubled? Because RCTs (like most methods of clinical research) don’t support the practices exclusive to midwifery. Therefore, scientific research, which seeks to learn. must be discarded in favor of midwifery research, that exists only to justify midwifery.
The author of the chapter, Jette Aaroe Clausen, makes it clear that midwives have nothing against scientific evidence per se. If it supports midwifery practice, it’s fine, but she rails against the “hegemony” of science when it does not support practices exclusive to midwifery.
… It is now take for granted that evidence always improve midwifery care. Evidence has gained a hegemonic status in midwifery and obstetrics …
Clausen approvingly quotes Murray Enkin, a supporter of midwifery and evidence based medicine, who apparently has recommended that there must be a parting of the ways:
… The power of randomised trials, particularly as they feed into official health care guidelines, is enormous. They are a form of advice unlike ordinary advice; because of pressure to conform, there may be no option to refusal. The ‘scientific evidence’ has achieved a mythical status; it is excessively powerful rhetoric, a tool that has so easily become a weapon.
No one can accuse midwifery advocates of hiding their motivation. Truth isn’t even mentioned, because midwifery advocates are uninterested in what is true. The reference to scientific evidence as a weapon is particularly revealing. Midwives used to promote scientific evidence as a tool that could be used to undermine obstetrics. But it turns out that scientific evidence undermines midwifery instead and therefore it is nothing more than a weapon against aims of midwifery advocates.
Clausen goes on to illustrate this “problem” with an excruciatingly stupid attempt to justify monitoring the fetal heart rate with the Pinard stethoscope over the far more accurate Doppler. I won’t bore you with a complete recounting of a justification that can only be charitably described as idiotic, but I will offer a few choice quotes for your entertainment. Interestingly, both the Pinard vs. the Doppler have absolutely nothing to do with the role of RCTs in midwifery and obstetrics, but I guess if you are writing a thoroughly nonsensical chapter arguing for ignoring scientific evidence, using an example that has nothing to do with the subject at hand has a certain “logic.”
And no, the following quotes are not satire:
‘Listening to the stomach’ and ‘listening to the fetal heart’ are often understood as synonymous acts.
How can we describe the relationship between the midwife and the Pinard? Verbeek describes the relationship between the experienced midwife and the Pinard as an embodiment relationship, i.e. she becomes a ‘Pinardmidwife.’
[M]any midwives use ‘listening to the stomach’ as a way of bringing the mother child relationship to the foreground.
In fact, the Pinard can be used as more than a medical device or a connecting tool. Some midwives use the silence of the Pinard to keep the unborn baby inside the woman’s body …
The Pinard invokes a private and intimate connection to the unborn baby because only one person can hear the fetal heart sound … whereas the [Doppler] invites multiple listeners to share the sound.
What does this have to do with RCTs? Nothing. What does this have to do with scientific evidence? Nothing. What is the purpose of this bizarre exposition within a chapter purporting to discuss the deficiencies of the RCT? Beats me, but Clausen thinks she has accomplished something:
I have now illustrated the relationship between everyday midwifery practices and randomized trials. Randomised trials are not innocent experiments… Since some randomized trials come to carry tremendous authority they carry the potential to destroy local productive practices… As one standard prevails, other standards cease to exist.
Ahh. We have come to the heart of the matter. Scientific evidence in general, and randomized clinical trials in particular have the potential to destroy the authority of the midwife. As her “standards” of practice are revealed to be based on what enhances her role rather than what promotes safety, she is being displaced.
In case that wasn’t clear enough for you:
… [T]he use of randomised trials trials and the promotion of evidence based midwifery come at a price. Evidenced-based medicine is strongly connected to positivist science, and within this framework, everyday midwifery practices can easily be framed as irrational and unfounded …
What’s the problem with scientific evidence in general and RCTs in particular? Simply put, they make midwives look like fools.
