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Thursday, August 12, 2010

The Double Standard of Statistics, Scientific Literature and Anecdotal Evidence

Wow, that sounds like more of a dissertation than a blog post. Which this could easily turn into, because I must be on a tear or something.

Yesterday I was surfing My OB Said What?!? and was equally amused and horrified to see that Dr. Amy had joined the fray of commenters. (She even brought one negative Nellie with her, unfortunately, although her post thankfully didn't make a damn bit of sense.) Somehow I welcomed it, though, because it makes for interesting debate and dialogue, all while exposing her typical urgency and unprofessionalism. It's hard not to while in that forum because of the negative, condescending comments of the readers - and who can blame them? As I told Dr. Amy, how can we not be condescending when we're used to, over the course of one or several pregnancies, having lies poured in both ears, over and over again, which have only served to either make us paranoid of our own normal bodily function or cause us to despise and demonize doctors and medical staff?

It's the same condescension offered up every day to pregnant patients, but now that the shoe is on the other foot, it's a totally different ball game!

I think Dr. Amy was getting a little paranoid, because she was definitely not in her own territory. Her pleas of "read the scientific literature! Ignore all the home birth studies because they are lies!" kind of made me laugh - a desperate grasping at straws to get us to turn from our 'ignorance' and come rushing in droves to the hospital. Remember my friend's home birth story I posted a while back? Especially how she was approached by an acquaintance who works in labor and delivery, who literally bribed her with a fancy vacation in order to prevent her from having the birth she desired and deserved? My friend R knows perfectly well, as do many, many homebirthing mamas, that if a true need for medical care should arise, they will be en route to the nearest hospital. Once there, they should not be treated cruelly or with disdain, and neither should Dr. Amy assume that all home birth advocates are out for the 'experience' only, ready and willing to put their baby's life in danger. Honestly, who in their right mind does that?

Dr. Amy told us to 'read the scientific literature.' Okay, I will. But after many of us have read that 'literature,' we're criticized. We're told (especially by Dr. Amy) that we cannot possibly understand risk, interpret statistics, or be able to decipher complicated medicalese. So which is it, doc?

We're also criticized for where we choose to obtain that knowledge: often, the Internet. Sure, you can't always believe everything you read on the computer - Billie Jo's Guide to Pregnancy might not be as reliable a source as any number of good birthing sites or blogs out there. But most blogs and sites I frequent do one thing: post links to studies and cite sources. Is that 'researchy' enough for you?

Many of the same medical journals our doctors read can be accessed by us, the average pregnant lady. Sure, they might be a bit difficult to understand if you haven't recently completed a college course in Medical Jargon 101, but some people do have the mental capacity to look up those terms to get a basic grasp of what they're reading. *gasp!* I know, this sounds crazy, doesn't it?!

The interesting thing about studies and statistics is that they can and often are flawed. When it comes to the safety of VBAC (a relative term, I know) I remember reading one doctor on a message board presenting the highest possible rate of rupture to readers, which scared more than one away from even attempting a VBAC. I cited another study that presented the actual rate of rupture as much lower, but again, because I'm just a woman with personal experience and no lab coat, it didn't mean much to them.

As far as studies and statistics go, you also have to be able to read between the lines. A lot. Some figures estimate that 85 percent of women who attempt a VBAC are successful. That does not mean that in 15 percent of women they experienced a catastrophic uterine rupture, hysterectomy or loss of baby. Some people tend to see that 15 percent as a failure and nothing more, which to them totally overshadows the 85 percent.

Another thing doctors have a problem with is anecdotal "evidence." "They're just stories!" many of them say. Who cares if your grandmother's neighbor's sister's aunt had a VBAC. That's only one person!

To me, birth stories are important. They must be - we tend to get into the nitty gritty personal details of our parts and their functions with perfect strangers when it comes to talking about birth, yet otherwise would clam up tighter than a drum. Somehow when it comes to the state of our cervixes, we are all too willing to share. And that's okay!

Take a group of five women who meet weekly for play date. Say three of the women have all been attended by the same physician and were all induced, all ending in a cesarean for either "failure to progress" or fetal distress. Mom #4 saw a different doctor, and mom #5 is newly pregnant, new to the ballgame and wanting to know as much as possible in order to have a normal, low-intervention birth. If that were me, the anecdotes of these women would tell me that the doctor who attended moms 1, 2 and 3 might be a little intervention-happy and it's time to move on.

Don't the stories of these women account for anything? They should, because the number one thing most pregnancy websites recommend you do when searching for a new OB is to seek the advice and recommendations of friends.

It doesn't take a rocket scientist to realize that when hearing the stories of moms, that the c-section rate is through the roof, that inductions are heavily used and often completely unnecessary. Even though you aren't reading their chart or conducting a formal investigation, these stories definitely say something, loud and clear.

The thing that gets me about 'anecdotes' is that they're only bad when they're coming from you. You can tell your doctor about the dozen or so moms who have safely VBACed and have healthy babies, and yet you're told to completely disregard the stories of these moms. Yet, when I was weighing my options with my doctors (two separate physicians, two different pregnancies) both physicians felt obligated to tell me about previous patients who had experienced ruptures. Were either of these women induced with Pitocin? I asked, only to get a muffled response of "I don't remember" both times. Either you're making it out to be something it wasn't, doctor, or they weren't even your patients - because if they were really catastrophic ruptures resulting in hysterectomy, loss of baby or mother, that's something you're unlikely to never forget. So what makes my anecdotes dismissed, and yet suddenly my OB is more credible? Isn't he, in fact, doing the very same thing I'm doing - telling a story?

The problem with all of this, especially "scientific literature," is that it seems like you can always find a study that tells you what you want to hear. There are no shortage of studies that say VBAC is safe, and yet there are those studies that say it's dangerous. It's all in how you interpret it, or how it's interpreted to you. If you're cornered in the doctor's office with a fear-mongering OB who only wants to sway you away from making the Big Decision to VBAC, it's going to come off as a lot more dangerous because of his/her influence.

Lots of studies have come out now to completely blow most of the outdated practices of modern obstetrics out of the water: the often unnecessary use of episiotomies, using a c-section as a way of  avoiding pelvic floor damage , inductions leading to a higher rate of cesareans , and the importance of both maintaining an upright position as well as taking in light food and fluids in labor. Actually, to some this is old news, and has been practiced by old-school midwives for centuries. Any woman can access this information from countless books, reliable internet sources, and other places, and yet this continues to be status quo in many hospitals around the world, despite the studies and literature that proves otherwise. So it looks like the only person who isn't "reading the scientific literature" is the doctor.

Ultimately, though, especially with doctors like Dr. Amy, the research you do will never be reliable enough, never be good enough, never be the right study. The rules constantly change as the game is played, and it seems like the pregnant patient is rarely the winner, no matter what.


Anonymous said...

Engaging her is pointless, she has steadfastly refused to learn ANYTHING from our side, after more than four years of debating all over the internet.

K said...

My OB hit the nail on the head, "Most OB's practice fear-based medicine, not evidence based medicine."
Dr. Amy is the poster child for fear-based medicine.

The Deranged Housewife said...

Sadly, when you do a google search of "fear-based obstetrics" very little comes up. I did a post a long time ago about this and it doesn't even show up on the first page. Ironically, an OB named "Dr. Robert Fear" does show up, though. Wonder what he's like? LOL

Holly Goodman said...

Great post! Surely there's some middle ground between Dr. Amy and the whole "nothing bad could ever happen to me, I'm having an unassisted birth!" sort of thing. I find that doctors use anecdotes too!

LK said...

I was amused by Dr. Amy's comment on understanding statistics. I'm a graduate student in applied quantitative methods; basically, I design studies and interpret statistics. While my research has been within education, not medicine, the principles are the same.

My amusement came from the fact that most doctors know frack-all about statistics. Many of them farm the analysis work out to statistical consultants or biostatisticians, who do the analysis and then tell the researcher what the results mean. I'll agree with her in that the statistics reported in research articles can be difficult for a layperson to understand - but it doesn't mean that your average doctor is much better at it either.

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