Saturday, July 28, 2007

A little example of faith versus science - in an unexpected place

This is not a post about religion at all. It is about warring approaches within the field of medicine. Specifically, how we in the U.S. deal with birth.

There are two layers of faith involved. First, and more obviously, is the faith people have in doctors. Sure, one should "have faith" in one's doctor in the sense of feeling trust and believing that the doctor knows what they're doing - the sense of "having faith" that refers to trust or dependability based on prior observation and evidence. However, (and yes, it was the homeopathy discussion that prompted this) many people seem to "have faith" in a more religious sense, i.e., they believe doctors are infallible authority figures, and promptly turn their critical thinking and confidence off when in one's presence.

The second layer is even more disturbing, especially combined with the first. In the field of obstetrics at least, doctors practice medicine by faith. And I mean "faith" in the full-on "believing things contrary to evidence, and stopping your ears and singing 'lalalaIcan'thearyou' when presented with such evidence" way. It all starts out very reasonably - giving birth is an uncomfortable, sometimes painful experience. It would be nice to alleviate the discomfort. Also, sometimes moms and/or babies are injured or even die during the process. It would be terrific if we could prevent that.

To this situation, add new technology. For instance, electronic fetal monitoring. It makes perfect, rational sense that EFM, which allows doctors to constantly monitor fetal heart rate during labor, would improve outcomes for babies. Babies that might have suffered hypoxia and brain damage or even death during labor could be identified and quickly rescued via c-section. All of this is perfectly reasonable, and I agree with the reasons EFM came into use. Of course at that time, there was no research available on actual outcomes with EFM - doctors went on logical deduction that it would be helpful.

Except, once research was done, it became clear that EFM is associated with poorer outcomes for mother and baby. The main reasons seem to be twofold - first, having constant information on heart rate means a very high "false positive" incidence for fetal distress. Scientific study indicates that intermittent readings with a hand-held doppler device actually result in more healthy moms and babies, perhaps because troubling trends that can be identified with this method are much more likely to be indicative of real trouble, versus isolated decelerations that are picked up by the always-vigilant EFM.

The other big factor is that EFM requires the mother to be lying in bed, stationary, so she can be strapped to the machine. As far as I know, every single study of labor and delivery has found better outcomes when mothers can stand, squat, walk, and otherwise remain upright and move around. Looking at the mechanics of birth, this makes perfect sense.

The story is similar for many other technological interventions - from epidurals to inductions to ultrasound estimates of size, it would seem that the innovation would improve birth outcomes, but they actually result in lots of pain, fear, and unnecessary surgery, injury and side effects to mothers and babies, and often disruption of breastfeeding, which has ill effects for both as well.

So it makes me cringe when I hear mothers blithely say, "Oh, my doctor said this is a big baby, so I have to be induced next week," or "Why wouldn't I get an epidural - the doctor says it's perfectly safe!" These people are handing over their intellect to a person who is a product of a system that rejects evidence-based practice in favor of authoritarian received wisdom and perceived infallibility.

Gee, that reminds me of something.


Sheila said...

You're so right about the medical approach to childbirth being stuck in a wrong mindset. Most people go to the doc with a problem that needs to be diagnosed and solved. So docs approach childbirth the same way. "Uh...this is the diagnosis: there's a baby in there, but don't worry, I'll help you get it out." However, normal childbirth is not a problem to solve-yay- and normal labor is not something that needs a doc to intervene. I also am thankful for the interventions available for abnormal labor, meaning problems that arise.
On the other hand, I am totally happy to hand the credit for that whole amazing process to a Creator God, as there is so much evidence of intelligence needed from start to finish. I personally think it is hilarious to believe that by simply wishing it so, some ancient creature developed a penis or vagina or a perfectly safe uterus. I mean, come on, an umbilical cord? On demand?

Christy said...

Hey Sheila, thanks for commenting!

I totally agree with you about birth. And I am so grateful for the amazing interventions we can use in dangerous births - we just need to learn to use them more judiciously.

As for evolution, I'm not sure if you're using hyperbole or are genuinely misunderstanding natural selection. No wishes involved, just random changes either favored or disfavored by circumstance, over mind-bogglingly long time periods.

It's funny because for me, human birth is a great demonstration of the jerry-rig nature of evolution. Giant heads and small pelvises mean our kids are born "premature" compared to other mammals. It makes a lot more sense to me that that happened through natural selection, than it being the result of a woman taking advice from a talking snake.