BIAS IN OBSTETRICS
BTCanada would like your help. We want to hear from mothers, regardless of how or when you had your child(ren), about bias in obstetrics and how it impacted your decisions and your life after childbirth. What things were you told were true only to find out that they weren’t for you? Please drop us a letter or an email. Please specifically state that your comments are about bias in obstetrics. We will not reply to your comments unless you specifically request that.
The medical definition of bias is ‘any trend in the collection, analysis, interpretation, publication or review of data that can lead to conclusions that are systemically different from the truth.’
Bias is also defined as ‘an attitude that inhibits impartial judgment or an unfair policy stemming from prejudice. It is an error caused by systemically favouring some outcomes over others.’
There are no shortages of bias in obstetrics, both now and in the past. When we’ve had a chance to hear your voices we will publish an article highlighting them on this page.
BIAS IN OBSTETRICSPenny Christensen, Chair, Birth Trauma Canada
Bias induced myopia and naiveté is used as an excuse to disregard women’s
rights. “But we didn’t know” becomes
their mantra when they are caught in their lies. And for some this is true. There really are people so stupid they can’t
figure out they are stupid and there is no cure for ignorance in this
case. They are hapless victims of their
conditioning and training. Most bias
can’t trace this as its only source.
Most ‘stupidity’ is inexcusable.
Claiming ignorance is hollow and indefensible. Most people guilty of perpetuating
obstetrical myths and bias aren’t naïve and they have the intellectual capacity
for reasoned thought. They just don’t use it. They have the ability to see cause and
effect. They have first hand knowledge
of it and they have had for decades, even centuries. Some recognize this and are too afraid to
speak up lest they be ridiculed or ostracized for speaking the truth. When those brave few do speak they are
treated like lone voices in the wilderness but change doesn’t happen without
them.
The most disheartening reason for perpetuating bias and myth in any form of
systemic discrimination is also the most common. They simply choose not to change their ways
because their station in life is threatened if they do. They hold tight to their attitudes. When chinks start to appear in their armour
they just beat their drums louder and with more viciousness. It is why bias is so hard to overcome. They
refuse to ask questions they don’t want to hear the answers to. They conduct studies that ignore variables
that discredit their hypotheses. They
pontificate endlessly without considering or caring about their victims’
experience. It doesn’t occur to them to
even ask. In the face of credible
evidence they shut their eyes tight, cover their ears and hum. They blather on about supporting evidence-based
science and empowering women but many of them do neither. It is childish and unprofessional behaviour
and it strips them of their credibility.
Humans can always be counted on to preserve their own groundless sense of
superiority over others. People will
elevate their own status by sacrificing the rights of others. And this doesn’t take very long. Put a group of equals in a room, assign one
group to be the ‘controllers’ and the other group to be the ‘controlled’ and
watch the degradation start to happen within hours. Overall, we aren’t a very altruistic or
superior species. That doesn’t stop me
from being optimistic about our evolution as a species. I’ve just learned to temper my optimism with
a heavy dose of realism.
Bias, and the discrimination it spawns, makes chumps out of educated
people. This is why education is only a
partial remedy. People need to know how
to recognize bias, refuse to believe it and then resolve to banish it. Bias exists without any credible evidence and
often without a shred of common sense.
This isn’t the same as a lack of information supporting it. There is usually no shortage of supporting
blah, blah, blah, but, of course, not all information is valuable. Bias hurts people, often badly and
permanently. Sometimes it kills
them. It robs people of their
credibility and it blocks progress and advancement. It is the reason our descendents will wonder
of us “How could they be so moronic. The
truth was so obvious. Why couldn’t they
see it?” It is the reason we ask the
same of our ancestors.
What is true for some isn’t necessarily true for others. A world without bias recognizes that. Universal human rights give people the right
to make their own decisions. They do not
give other people the right to make decisions for them. Give women access to unbiased, intelligent
information and let them make their own decisions. Don’t assume they are not capable of that
because they, most assuredly, are.
Consider these statements:
1)
Cancer patients do not have the right to safe and effective pain control
because pain is a natural consequence of cancer and cancer is a naturally
occurring human condition.
2)
Those in burn units who are directly responsible for their injuries have
no right to effective pain relief or compassion. If they don’t like that choice they shouldn’t
have burned themselves.
3)
Encourage surgical patients to forego pain relief both during and post
surgery. Instead, have a staff member providing
one-on-one encouragement not to have effective pain relief. Patients should be encouraged to think of
their suffering as ‘a good pain’, to ‘work with the pain’ and to embrace ‘an
altered sense of consciousness’. Infer
that anyone who wants pain relief is a weak minded failure. Encourage competitive suffering with post
surgery get-togethers.
4)
Hospital policy should ensure that all palliative care patients ask at
least twice before their request for pain relief is considered. If death is imminent consider denying the
request.
5)
Trauma sustained during torture results in damaged bodies and damaged
psyches. Depositing a large sum of money
in their bank account will make them forget all about it.
6)
Psychiatric studies show that pre-rape courses reduce the terror women
feel during and after rape.
In a civilized society these statements
would beggar belief, and with good cause.
They are offensive, insensitive and cruel.
Now
consider the same statements when they are made about pregnant women:
1)
Maternity patients do not have the right to safe and effective pain
control because pain is a natural consequence of childbirth and childbirth is a
naturally occurring womanly condition.
2)
Those women who get pregnant should not expect choice in delivery
options, nor should they expect pain relief or compassion. If they don’t like that they shouldn’t get
themselves pregnant.
3)
Encourage obstetrical patients to forego pain relief during and after
childbirth. Instead, have a staff member
providing one-on-one encouragement not to have effective pain relief. Patients should be encouraged to think of
their suffering as ‘a good pain’, ‘to work with the pain’ and ‘to embrace an
altered state of consciousness’. Infer
that anyone who expects effective pain relief is a weak-minded failure. Encourage
competitive suffering with post birth get-togethers.
4)
Hospital policy should ensure that all obstetrical patients ask at least
twice before their request for pain relief is considered. If birth is imminent consider denying the
request.
5)
Trauma sustained during childbirth results in damaged bodies and damaged
psyches. As soon as you put her baby in
her arms she will forget all about it.
6)
Psychiatric studies show that pre-natal courses reduce the terror women
feel during and after childbirth.
These statements should beggar belief but
they actually reflect obstetrical attitudes for the past several decades and,
in many obstetrical circles (this country included), they are still widely accepted. Such attitudes maintain a deplorable status
quo. They prevent advancement. Systemic discrimination always involves the
attitude that a certain sub-group of the population is not deserving of humane
treatment. They are considered
inferior. What is considered
unacceptable for other humans is considered acceptable for the group
discriminated against. This is true for
any form of systemic discrimination, whether it is based on race, ethnicity
and, in this case, gender. Underlying
all obstetrical bias is misogyny.
Only recently have some obstetrical
associations around the world back-tracked from their long held views that
childbirth is the only situation where patients can be denied pain relief,
under the care of a physician, when safe and effective methods of pain control
are available.
A) Childbirth is healthy Childbirth is NOT healthy. It isn’t now and it never has been. I’m not sure if people who say this are being
wilfully deceptive or just plain stupid.
The end result is the same. Women
are not well served by this bias. Women
told this preposterous statement by people who know better, or should know
better, have unrealistically high expectations about motherhood and the
childbirth experience. B) Childbirth is natural (and therefore good)
When fertility rates go up so does the rate
of women’s health problems. Parity is
directly related to urinary incontinence, anal incontinence,
uterine/vaginal/rectal/urinary prolapse, sexual pain and/or lack of sensation
during intercourse, chronic pelvic pain and neurological problems throughout
the body. Parity is also associated with
heart disease, diabetes, gallstones, thyroid disorders, Alzheimer’s disease and
a number of different cancers (breast cancer, renal cancer, etc.) Having children for women is also associated
with obesity – and all that entails.
Women who have children have much higher unemployment rates and this
puts them at higher risk for living in poverty.
And don’t even get me started on the effects of stress. None of this stuff is healthy.
Ignoring or dismissing the obvious
maintains the status quo and affords no hope for positive change that will
improve women’s short term and long term health.
Nature isn’t just about fuzzy puppies and rainbows. Nature is also cruel, unfair and tragic. None of the people who espouse this obstetrical bias that I have met, to date, are willing to live in caves and forego the technological advancements that enhance their lives. Humankind exists solely because we can use our brains and ingenuity to counteract nature and none of us would last very long in nature. We can’t run very fast, we can’t see or hear very well, we have no body covering to protect us from heat, cold, insects and the sun’s radiation. We are susceptible to all kinds of infectious and non-infectious disease. The human body is not a superior design. We need our brains, ingenuity and technology to survive.
Over 500,000 women die directly of childbirth every year.
Most are in the developing world because they do not have access to life
saving medical technology and qualified obstetrical care. Many, many more suffer life altering
morbidity problems. In the developed
world we have less maternal mortality and far more ‘near misses’. My point is that just because something is
natural doesn’t mean it is safe.
For those who feel that if it is natural it
must be good, consider all the things that are natural and definitely not good
for you:
Tornadoes, earthquakes, tsunamis,
mudslides, floods, hungry polar bears, any other predatory animal, spiders the
size of dinner plates (Really. In Australia. Ewww), poisonous
spiders, poison ivy, poison oak, any other poisonous plant, those big snakes
than can crush you, HIV, tuberculosis, those ticks that carry Lime Disease,
mice that carry Hantavirus, any other infectious disease, marauding elephants,
cyanide, arsenic, radon, hurricanes, death, botulism toxin. You get my point.
C) A healthy woman’s body knows how to give birth
Does a healthy man’s body ‘know’ not to
have prostate problems? Does a healthy
child’s body ‘know’ not to get cancer? To
suggest they do is both ludicrous and cruel.
Bad things happen to people everyday precisely because their bodies
don’t ‘know’. As addressed above, the
human body isn’t an anatomical wonder.
Men have urethras that pass through the prostate gland – a gland that
gets bigger as they age, restricts urine flow and has a strong tendency to
become malignant. Some children are born
with a pre-disposition to cancer and other sad genetic afflictions. It is not their fault. It is not a woman’s fault either when things
turn bad during childbirth. We are the
only species where birth involves pushing an infant that is too large through a
space that is too small. There is no
better way to make someone feel like a failure than to pump up unrealistic
expectations about what their bodies are capable of. The role of medicine and technology is to
address these inadequacies and to make us healthy and keep us healthy despite
anatomical deficiencies.
Cemeteries prior to modern medicine are
full of healthy young women and their babies whose bodies didn’t ‘know’ and who
didn’t make it. These tragedies still
happen today but no where near the same numbers. Today they are ‘near misses’. None of these women are failures. Those who don’t make it are tragic
victims. Those who had near misses are
survivors.
D) Childbirth is only painful if a woman thinks it will be painful.
Good grief.
Childbirth is painful for the same reason kidney stones are painful or
surgery without anesthesia is painful. Pain stimuli activates neurotransmitters
responsible for pain. They transmit that
information to the brain and the brain responds. Fear is an adaptive response to pain. Without this association we would never learn
who or what to trust and what dangerous things we should avoid. Telling someone to relax while they are
suffering immensely is maladaptive and counter-intuitive. It is another way to make women feel like
failures. Why this bias developed with
respect to women and childbirth speaks more about disregard for women than
rational thought.
E) Non-pharmaceutical methods are effective pain relief
There are two effective ways to relieve
pain. Both are pharmaceutical. The first is to prevent pain messages from
reaching the brain (like a spinal and/or epidural) and the second is to mess
with how the brain receives pain messages (like opium derivatives). The second way has serious drawbacks. Doses large enough to provide complete pain
relief for the mother would kill the baby, and likely kill the mother. Any dose alters the mother’s perception of
reality.
Breathing techniques, water baths,
massages, having someone in your face with ‘encouragement’ and going to your
happy place do not relieve pain. They
layer other sensations on top of pain or give you something else to think about
while you are suffering. If these
techniques actually relieved pain anaesthesiologists would be all over them in
other areas of the hospital. You would
read headlines like:
“Man
passes kidney stones painlessly over three days, without morphine, relying
solely on his Kidney Stone Passing support person and breathing techniques.”
“Anesthesiologists
are shocked by pain-free open heart surgery performed without anesthesia in the
Jacuzzi. Patient sipped herbal tea and
chatted with the surgical team during surgery.”
“Anesthesiologists
outraged that aroma therapists are replacing them.”
Not going to happen.
F) Childbirth is painful because women need to be punished for being women.
This is un-adulterated misogyny and still
widely accepted.
G) Women need to suffer to be good mothers
Same comment as above. If this were true we wouldn’t hear from good mothers who didn’t suffer and from good mothers who did suffer whose babies serve as a trigger for traumatic stress symptoms and who struggle with the tremendous guilt that brings.
H) Women need to reach an ‘altered state of consciousness’ to properly give birth.
This ‘altered state of consciousness’ is dissociation and dissociative amnesia. It is a human response to severe psychological and physical stress and it should be avoided, not encouraged.
I) It is a woman’s fault if she has a miscarriage or her baby has a birth defect. She must have done something wrong.
15% of pregnancies end in miscarriage. 2-3% of babies born will have a birth defect. They are not caused by eating pineapple, having a glass of wine with supper, watching acrobats, bathing, full moons or any of the other preposterous and blaming theories out there. Heaping this kind of guilt on women who are struggling with pregnancy loss or struggling with the burden of coping with congenital defects in their children is indefensible.
Developmental biology is a complex science. There are numerous chances for errors during fetal development. A woman cannot control her genetics or those of her fetus.
J) A healthy baby is enough to make up for the trauma of childbirth
A prize, no matter how wonderful, does not
cure physical or psychological trauma in any situation. Offensive statements like this isolate and
further traumatize all trauma victims.
Monetary compensation does not end PTSD for torture survivors. You don’t tell someone who has lost his legs
that he should be happy he didn’t lose his arms. It is no different for women after
childbirth. The experience of childbirth
and the baby are two separate things. The attitude that a healthy baby makes women forget the trauma of their childbirth experience is patently untrue. Women carry that experience with them for life. Fatalism and stoicism are not the same as getting over it.
K) “ Cesarean surgery on demand will
have disastrous social and financial consequences for health internationally”
Blaming women who choose cesarean section for destroying the social and financial fabric is vicious. Heck, let’s blame them for conflict in the Middle East and pine beetle deforestation as well. It would make as much sense. Those with specific biases often use words like ‘empowerment of women’ and rail against ‘views not supported by evidence’, when they, as in this case, are guilty of the same transgressions. Scare mongering and manipulation are not empowering to anyone other than those wielding power. Denigrating those who don’t agree with your point of view is not respectful, to women or anyone else.
When I was first made aware of the source of this statement I was speechless. It is a direct quote from the Canadian Midwives Association found in their rant against maternal request cesarean section. I was not expecting such a visceral, inflammatory attack on a woman’s reproductive choice and autonomy from an association of women who fight so hard for a woman’s right to choose a less managed childbirth experience. We can’t blame patriarchal misogyny for this. This is blatant woman on woman abuse.
I want to make it clear that not all midwives think this way. I’ve talked to some who find this stance as repugnant as I do.
I strongly support a woman’s right to choose. Midwives have been maligned and controlled for centuries and I can’t blame them for feeling a bit scrappy. They provide a professional service strongly desired by some women who have every right to make that choice and that choice should be fully funded but a midwife-attended vaginal birth is not the only acceptable choice women can make. The choice any woman makes is the right one for her and should be respected, not denigrated.
L) Episiotomies are necessary to protect the pelvic floor.
This bias was once widely held. Millions of women around the world were
subjected to routine episiotomies for decades in the belief that cutting the
perineum would have a better outcome for the pelvic floor than spontaneous lacerations. Studies supporting this bias appeared in
medical journals and doctors and nurses everywhere believed this. There was lots of information to support this
stance but not a shred of credible evidence.
That is the nature of bias.
Deliberately damaging the pelvic floor to save the pelvic floor is as
inexcusably stupid in hindsight as it should have been during the decades women
were subjected to routine episiotomies.
M) If it is in a medical journal, it must be true. (Or how to recognize a spin doctor)
This simply isn’t true. Many medical journals (particularly with respect to childbirth) are propaganda vehicles for a particular bias. One estimate states that only 0.1% of all medical studies published every year can claim to be both scientifically sound and potentially relevant to doctors and patients. There are many days when I think that estimate is overly generous. Dr. Richard Smith’s The Trouble with Medical Journals [RSM Press, 2006] provides insight about this serious problem. Integrity in medicine remains as elusive (and worth fighting for) as integrity in any other business. There are people working hard to support genuine evidence-based obstetrical information, more humane treatment of pregnant women and factual accountability and transparency. More power to them. It has been, and continues to be, an uphill struggle.
How can you distinguish the bad from the good? It is a problem even those with an understanding of the scientific process struggle with. One of the first ways to educate oneself about the prevalence of obstetrical bias is to read archived obstetrical journals. With the benefit of hindsight the bias (and related misogyny) presented in many of these published studies practically jumps off the page. How do you recognize bias without the benefit of hindsight? I’ll take one study and dissect it to show what tools of deception are used. You can look for the same in other studies.
I’ve chosen ‘Maternal mortality and severe morbidity associated with low-risk
planned cesarean delivery versus planned vaginal delivery at term’. It is authored and championed by the
Public Health Agency of Canada; the Department of Obstetrics and Gynaecology,
University of British Columbia, Vancouver; Perinatal Epidemiology Research
Unit; Department of Obstetrics and Gynaecology and of Pediatrics, Dalhousie
University; the Faculty of Nursing and Department of Obstetrics, Gynecology and
Reproductive Sciences, University of Manitoba; Departments of Pediatrics and of
Community Health Sciences, University of Calgary; and the Departments of
Pediatrics and of Epidemiology and Biostatistics, McGill University,
Montreal. The lead author is Shiliang
Liu. It was published in the Canadian
Medical Association Journal (CMAJ) Febraury 13, 2007.
Supposedly illustrious connections, to be
sure.
Their conclusions were that planned cesarean
deliveries (PCD) had higher morbidity rates than those associated with planned
vaginal deliveries (PVD) when comparing healthy pregnant women at term.
This was a surprising conclusion to
me. I have read many medical studies
comparing PCD with PVD that arrive at the opposite conclusion – both in North America and around the world. The National Institute of Health (United States),
in a statement about maternal request cesarean section, concluded that the
quality of evidence available wasn’t good enough to say which was safer for the
mother – an uncomplicated PVD or an uncomplicated PCD. How then, can different research scientists
arrive at such diverse conclusions? Rule #1 in recognizing bias in medical studies
is: Are there other better designed studies
around the world that dispute the study in questions’ conclusions? Could there be? Is there controversy about the conclusions or
results?
Rule #2 : Look for study design flaws.
The U.K. instituted thromboprophylactic guidelines for cesarean deliveries in 1995. Cesarean deaths (and morbidity) associated with thrombosis and thromboembolism declined sharply thereafter. (The Society of Obstetricians and Gynaecologists of Canada – SOGC – wouldn’t follow suit for another 5 years.) Other guidelines for better care of cesarean mothers were accepted and more widespread around the same time. [spontaneous vs. manual extraction of placenta, non-closure vs. closure of peritoneal layers, more reliance on regional vs. general anesthesia, etc.] Any study seriously comparing mortality and morbidity rates associated with PVD and PCD would ensure advancements were accounted for in your study period. This study purposely looked at 14 years of Canadian (except Quebec and Manitoba) restrospective data – from 1991 to 2005 - with the majority of planned cesareans prior to 2000. This is a perfect example of how study design can be used to mask bias and skew results.
Rule #3: Look for what they aren’t telling you as much as you look at what they are.
There is no better way to ‘prove’ your point of view than to ignore variables that don’t support your position. Let’s look at the stuff they aren’t telling us.
Maternal Mortality: This study concluded that ‘the difference we observed in in-hospital maternal deaths between women undergoing planned cesarean vs. planned vaginal delivery was not significant.’ (The emphasis is mine) In reality no women died in the planned cesarean group whereas 41 (0.02%) died in the planned vaginal delivery group. Are these deaths insignificant? I wonder if they would have considered these numbers insignificant if a similar percentage of deaths occurred in the PCD group and not in the PVD group?
How was maternal morbidity defined?
*Hemorrhage requiring hysterectomy (0.03% PCD; 0.1% PVD)
Hemorrhage requiring transfusion (0.7% PVD; 0.2% PCD)
Any hysterectomy (PCD 0.6%; PVD 0.2%) (not sure if this includes those women who had finished childbearing and required a hysterectomy for other medical reasons. It is certainly easier to do this at the same time as a cesarean. Requiring a hysterectomy after a vaginal delivery for the same reasons wouldn’t be captured in this data set as it would require a separate operation. None of this is mentioned.)
Uterine rupture (0.3% PVD; 0.2% PCD)
*Anaesthetic complications (PCD 5.3%; PVD 2.1%)
Obstetric shock (0.2% PVD; 0.1% PCD)
*Acute renal failure (0.04% PCD; 0.02% PCD)
*Assisted ventilation or intubation (0.1% PCD; 0.05% PVD)
*Puerperal venous thromboembolism (0.6% PCD; 0.3% PVD)
*major puerperal infection (PCD 6.0%; PVD 2.1%) You can’t blame an uncomplicated, planned cesarean for puerperal infection. This is the result of poor infection control, lack of asceptic technique and substandard staff and hospital cleanliness and hygiene. Many hospitals have zero infection rates for planned cesareans. A rate of 6.0% is shameful.
*in-hospital wound disruption (PCD 0.09%; PVD 0.5%) This rate will go up if they aren’t done properly.
*Obstetrical wound hematoma (PCD 13%; 2.7% PVD) ditto
* Consider how these variables could change if the study period included only data after 2001 with the changes in obstetrical practice I’ve previously mentioned. This study also looked at planned cesarean deliveries for breech deliveries as representative of all planned elective cesareans but breech cesareans are more difficult than cesareans for cephalic presentations and would reasonably be expected to carry higher maternal risks.
What about the other variables they aren’t mentioning?
Short term and long term health problems
urinary incontinence, anal incontinence, pelvic prolapses, sexual problems, post traumatic stress, genital tract trauma, subsequent gynaecological surgeries and infections that occur after hospital discharge are examples. All of these serious morbidity issues are associated far more (or exclusively) with PVD than PCD but they aren’t even mentioned. No legitimate study ignores important variables. Study conclusions depend on how you define your study terms.
Maternal experience
How did each individual mother feel about
their experiences? What about the
benefits of avoiding anxiety and pain of labour and delivery? Sedation, tranquilizers, anti-depressants and
anti-anxiety pharmaceutical use is part of pregnancy and especially labour and
delivery. How about a reduction in
concern about the baby’s health?
It is also worth mentioning that this study
ignored the very real problem of doctor and hospital variations. Including statistics from rogue doctors and
substandard hospitals misrepresents the ideal.
The way morbidity was defined in this study would favour higher adverse
effects for surgical deliveries than for vaginal deliveries given this reality.
Rule #4 Was the study independent?
Often medical studies are designed or paid for
by pharmaceutical companies, medical device companies or people who would like
to keep their jobs. There are a number
of dirty tricks used to hide negative results in such cases. I don’t think that factored into this study
but it is something you should be aware of when you look for bias in other
studies.
Many reputable medical journals insist on
independent statistical analysis of raw data as a means of reducing bias and
maintaining integrity. This study did
not have independent statistical analysis.
Censorship by publishers and editorial
staff is another area that limits the integrity of some journals. Unless these controversies are exposed by
someone with integrity and inside information or are picked up by a responsible
member of the media these issues never see the light of day, yet they have a
profound impact on what appears in medical journals.
As an example, consider the Canadian Medical Association Journal (CMAJ) and its recent struggle with editorial independence.
On February 20, 2006, Dr. John Hoey and Dr.
Anne Marie Todkill, long-standing senior editors of CMAJ, were fired by the
publishers – the Canadian Medical Association (CMA). The CMA had recently decided that their long
standing policy of making women come to them for post-coital contraception
[levonorgestral or Plan B] violated a woman’s right to reproductive choice
because of the barriers they had placed in a woman’s way. They made Plan B available without
prescription. The CMAJ sent 13 women to
buy the emergency contraceptive over-the-counter in pharmacies across Canada, and
report their experiences. The
pharmacists asked them for personal data, including the woman’s name, address,
date of last menstrual period, when she had unprotected sex, customary method
of birth control, and the reason for dispensing the medication. This was done at the recommendation of the
Canadian Pharmacists Association (CPA), which also advised members to store the
information permanently on their computers.
Clearly the CPA had their anti-choice barriers in place. The Canadian Women’s Health Network (bless
their hearts) said the obvious by stating that collecting this information was
unnecessary and a violation of privacy.
The CPA complained to the CMA, demanding that the names of the
pharmacists be removed from the CMAJ article (bullies never like being exposed)
and the CMA ordered the CMAJ to comply.
The CMA then fired Hoey and Todkill, stating they wanted to ‘freshen up’
the journal. The rest of the full time
editorial staff resigned on February 28, 2006.
The former editorial staff at the CMAJ
launched a new open-access journal [Open Medicine] in April, 2007.
The CMAJ went on to admit the episode
raised serious concerns about the integrity of the journal and its
reputation. Duh. I give them credit for
laying the cards on the table and admitting mistakes. Positive change doesn’t happen without an
initial admission of guilt. A warning posted on the CMAJ website by the
editorial committee states “In our view, any attempt by the CMA to impose its
influence on the editors would be catastrophic for the CMAJ’s reputation as
well as damaging to the reputation of the CMA.”
Too little, too late?
Such bad behaviour by the CMA and CPA isn’t
restricted to Canada. Censorship and medical integrity issues are
serious problems being addressed (hopefully) around the world.
This cautionary tale highlights the problem
of medical solidarity at all costs and it influences what you will see, and
just as importantly, what you won’t see in medical journals.
N) “A labouring woman needs first to be
protected against any stimulation of the thinking part of her brain - the
neocortex. This part of the brain needs to take a back seat and allow the
primal ‘unthinking' part of the brain connected to basic vital functions to
take over. A woman needs to be in a world where she doesn't need to think or
talk.
This chauvinistic endorsement of trauma induced dissociation is widely
quoted by several (but not all) who champion ‘natural’ childbirth. Statements like this are from that past era
where women were encouraged ‘not to worry their pretty heads’. Being in a world where you are actively
encouraged not to think or talk sounds like a setting for some B grade horror
movie. Not thinking is a bizarre strategy
to champion for thinking, feeling humans.
I haven’t met a woman yet who wasn’t an intelligent, thinking, feeling
type. My advice to any woman
contemplating pregnancy is to put that thinking neocortex into overdrive, not
shelve it. You NEED to think and gather
as much information as you can to make an informed decision that is right for
you. It is vital that you think. Thinking is not a bothersome affliction. It is not something you should turn off, or
accept having turned off, through pain and humiliation induced dissociation or
mind altering drugs. o) "Epidurals will hurt your baby"
There is no more creepy or insidious (and highly effective) way to
manipulate women than to use their maternal love and concern for their child as
a weapon against them. You can force
women to accept all manner of horrors if they feel they are doing it for their
baby. That is exactly what this bias
is. Mother love should be respected as
the beautiful thing it is and not used as an excuse to hurt mothers. There is no credible evidence to support this
bias. There has never been any credible
evidence to support this bias. There
will never be any credible evidence to support this bias because it is not
true. P) “No pain, No gain” Unless you view labour and delivery as an
extreme sport – and some do – there is nothing about this bias that serves
women well. Denying effective pain
relief to woman during labour, delivery and the post partum without a
scientifically valid reason – and there really isn’t any - is misogyny. Despite this it is still a widely held bias. Q)
“Vaginal births are safer than planned cesareans”
“Planned cesareans take longer to recover from than spontaneous
vaginal deliveries”
If either of these were
true we wouldn’t hear so many stories where the opposite was true. If either of these were true many
obstetricians, anesthesiologists, nurses and others with access to inside
information wouldn’t choose a planned cesarean for their own deliveries or
those of their loved ones. If this were
true the vast majority of horror stories we hear about wouldn’t be about
planned vaginal deliveries. And if this
was true most of the medical malpractice suits filed against obstetricians,
midwives and hospitals wouldn’t be about planned vaginal deliveries.
R) “Evolution/Nature wouldn’t make
childbirth dangerous.”
People with this bias have a poor understanding of evolution. They assume that the end product of evolution
is better than the starting point and that maladaptive traits are eliminated as
generations go on. I’m not saying that
natural selection isn’t a powerful and effective force. It certainly is and it isn’t a very pretty
process. Human technology shields us
from the full effects of natural selection.
Left to the unchecked processes of natural selection (like getting rid
of modern shelter/medicine/optometry/dentistry, etc. ) most of the human
population, regardless of gender or age, on earth right now would die, including
those with a poor understanding of evolution.
I wouldn’t last very long myself.
Letting natural selection run amok is the last thing a civilized human society
would, or should, allow. But even if we
did evolution would not eliminate all maladaptive traits. It wouldn’t even eliminate all the stuff that
doesn’t contribute anything. Our own
human genome is ample evidence of that.
Most of the DNA in each of us is evolutionary baggage. It doesn’t code for anything yet we replicate
the whole shebang every time a cell divides.
Mutation is a spontaneous process that can occur during cell division/DNA
replication. This can happen during egg
or sperm division (meiosis) or during human growth and maintenance that occurs
constantly in people of all ages (mitosis).
Cell division is a fascinating, elegant and complex process that is
prone to errors, as all complex processes are.
Most mutations are bad or neutral.
Very few give an individual an advantage. All the positive attitudes about evolution
and nature in the world will not stop this.
Chance – blind, dumb luck or the lack thereof – also influences
evolution. It doesn’t matter if you are
the strongest, healthiest person around - if you are covered in a mudslide,
drowned in a flash flood, swept up in a tornado, killed in a car accident,
whatever, and you haven’t reproduced you obviously aren’t going to be
evolutionarily successful. Consider how many maladaptive traits are carried through from one generation
to the next, even though those with the disease generally don’t reproduce. Cystic fibrosis, hemophilia, muscular
dystrophy, colour blindness are but four examples. There are plenty more. Consider our evolutionary vestiges. We have a tail bone but humans don’t have
tails. They would look darned stupid and
they would make finding a pair of jeans that fit right even more difficult and
we don’t need them. Our early
evolutionary ancestors did and it gave them a survival advantage. Evolution hasn’t rid us of this or any other
trait we no longer use. A trait will
continue in any species as long as enough people have that trait AND it doesn’t
kill more individuals than can survive with it.
Put another way, evolution allows certain traits to continue because
they don’t reduce fitness enough. As well,
many maladaptive traits aren’t even seen until after reproduction occurs. Evolution is measured in the number of reproducing offspring – not lifespan
or quality of life. Evolution doesn’t
give a whit about whether the individual likes it. Consider the lives of two women. The first was a happy camper who was very
rarely sick. She died at 100, not
because she had anything terribly wrong with her. She was sharp as a whip and still
active. She was hit by a bus because her
recent limited mobility didn’t allow her to move out of the way in time. She never had children. Another woman dies at 62 of complications
from diabetes. She also had moderate
dementia. Life had been hard for her, as
one would expect. She had two children
who both had children. It is this woman
who was evolutionarily successful, not the first. It is her genes passed to the next
generation. Evolution will not eliminate any
trait that is required for survival in another capacity. Evolution will never act to reduce the size
of the human head because without our increased capacity for intelligence we
couldn’t survive. Evolution will never
act to increase the size of the human pelvis because to do so would negate, or
seriously limit, our bipedal mobility which would clearly not be advantageous
to survival. Bipedalism requires the
legs to be close enough together so the person can walk and this limits the
size of the pelvic opening. This would be a good time to also consider
cultural pressures on evolution. Two
women walk into a bar. The first is
stunningly beautiful. She is tall and
slim with large breasts and a beautiful face.
The other is tall, with moderate sized breasts, a little plump, a
beautiful face but her hips are huge.
She has a tough time getting on the bar stool. Both are wearing the same outfit. Which one do all the men in the bar want to
go home with? For those interested in learning more about human birth and evolution there
is a book called Human Birth: An
Evolutionary Perspective [Wendy R. Trevathan, Aldine Publishers, 1987] that
can give more insight. S) “Millions of women have given birth
vaginally, so you can too.”
Those with this bias never complete that thought process and see the bigger
picture. Certainly millions of women
have given birth vaginally and survived.
And millions of them haven’t and many, many more have survived but with
negative consequences. T) “I had a vaginal birth without drugs/
planned cesarean/ vaginal birth with drugs/ suffered terribly/ etc. and you
should too.”
People with this bias have what I like to call Centre of the Universe
Syndrome (CUS). The afflicted suffer
from the delusion that, as the centre of the universe, everyone must do and
think exactly as they do and think. Of
course, this affliction isn’t concentrated in obstetrics and it certainly
doesn’t affect only women. Recently, at
an office, I witnessed two men fighting over the best way to put a cutting
board into the dishwasher. Both insisted
their way was the best way and the fists were ready to fly. A wise and diplomatic co-worker suggested
that, at each of their houses, they could put the cutting board in their
dishwashers the way they wanted but maybe it would be best today to wash it in
the sink. Three perfectly acceptable
ways to get the job done. Everyone has their own opinions and beliefs.
They are the product of their own experiences. A person’s fears are a valid part of who they
are. What works for someone doesn’t make
it suitable for someone else. We are the
centre of our own universe but we are not the centre of anyone else’s. U) “A baby is worth the terrible
suffering”
I wonder if people who have this bias think that babies that didn’t result
in terrible suffering and maternal injuries aren’t worth it?