How not to compare statistics

Feb 5th, 2015

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I’ve spent the last five years learning how to interpret research, I know it isn’t easy.  I didn’t always know this.  I used to think I could read the conclusions of a paper, check out a few things and either incorporate it or ignore it.  The problem was, just like all humans, my trust in a paper was more related to how closely it resembled what I already believed than anything within the design of the study.

Now when I read a paper I go through a long process of making decisions;

• What exactly is the research question?
• What theory does this study build from?
• What assumptions does the underlying theory make?
• Is this design appropriate for this framework?
• Is this population appropriate for this question?
• Have they designated outcomes a priori?
• Are they using appropriate statistical tests?
• What are the sources of bias?
• Will the biases move the estimate away from the null?
• Do the results answer the research question?
• Do the results indicate a clinically relevant difference?
• Do the conclusions make sense given the framework and underlying theory?
• What does this study add to what is known on this topic?

No, this list is not complete.  No, I can’t teach you to do this…remember this is a process of learning I’ve been working on for over five years.  I’ve learned to read as a clinician, as an epidemiologist, as a policy maker, and as a designer of research.

But there are some simple mistakes you can learn to recognize when you see them on your social media feed or in blogs.  I want to show you one I saw this week. The specific numbers do not matter, we will be looking at the concept of an unequal comparison.

The number of deaths/injuries from a specific vaccine in the # years:  X

The number of deaths/injuries from the illness in the # years: 0

The comments on this post were evidence that people thought the appropriate comparison should be: because X > 0, people should not get the vaccine.

Why is this an unequal comparison?  Because this pretends to be comparing the risks of being vaccinated to the risks of not being vaccinated; but it only shows the total risks to being vaccinated.

What do I mean?

To compare vaccination to no vaccination you need to compare the total number of deaths/injuries in a vaccinated population (which the post in question included); to the total number of deaths/injuries in the same population if they were not vaccinated (which the post in question did not include).

The total number deaths/injuries in a vaccinated population in # years: X

The total number deaths/injuries in a non-vaccinated population in # years: Y

It is only from this comparison that you can determine the risks of vaccination vs. no vaccination. You cannot have both the protection of being vaccinated (0 injuries/death), and avoid the risks of being vaccinated (X) because you can only be vaccinated or not vaccinated.  You either accept the full risk and benefit of vaccination, or you accept the full risk and benefit of not being vaccinated.

Now you are armed with one more technique for decision making, and you can apply it to all types of scientific comparisons.  Next time you read a social media post or a blog that gives a comparison, take a step back and figure out if it is unequal. If it is unequal, find the numbers to make it equal and then decide if you would make the same conclusions about that decision.

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Midwife as Coach

Jan 18th, 2015

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I want to share a wonderful line I heard recently.

“I am going to remind her of the goals she set for herself.  As her coach, that is my job.”

This resonates so well with my philosophy of care.  As a midwife, it is not my job to set the goals.  It is my job to give  information and education, to lay out the options and the most likely outcomes.  It is the woman’s job to decide the goal.

Why?

Because she will never be committed to a goal she doesn’t set.

But if I can get her to share her goal, to tell me what she would like to accomplish, we can work on it together. She does still have to do the ‘work’, I cannot do that for her.  But I can giver her information and encouragement.

When she is discouraged and wants to give up, I can remind her of the goals she set for herself.  As her midwife, that is my job.

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What I learn from hosting a web directory – five things you should change

Jan 10th, 2015

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If you have never looked at the Natural Childbirth Directory, you should.  This portion of the website is truly a labor of love.  While the rest of the pages need little work but annual review, these pages get updated often because the links change and people submit new websites.  It takes a lot of work and is part of the reason I regularly ask myself if all the work I put into the website is worth my time.

Keeping the directory gives me a chance to look at many childbirth professional websites.  I get to see what people are doing that is good, and what people are doing that they should probably change.  I thought I would take a minute to give you my top five things you should change about your website. They are all variations of the same theme — websites that give useful information build trust in the reader.

1. You don’t list your location

Just because you are a doula doesn’t mean I know what you do.  It doesn’t mean I know what I am purchasing if I hire you. If you teach childbirth education classes, can I tell from your website what your classes are like?  Does your website let me know I can participate in your classes without hiring you also as a midwife? This is especially a problem in areas where families have multiple choices for service providers because the other providers probably give me this information.  Providing this information builds trust in your business and prevents potential clients from walking away just because it was easier to get information from another provider.  Websites that can tell the reader what they do build trust in the reader.

3. You don’t list your availability

Your website should in some way let readers know if you are able to provide the services they need when they need them.  Why?  The first question your potential client has is if you are available when they are due. Midwives and doulas may want to add a blanket statement such as “Now Accepting New Families.” Or you may want to provide a more specific information such as, “Openings for families due in January and beyond.” This saves you time responding no to people, but also increases the likelihood someone who fits your time frame will contact you. One caveat, make sure you keep your availability updated or it will work against you (people will think you no longer work in that capacity). Websites that answer the most common question build trust in readers.

4. You don’t list a calendar of events

This is especially important for businesses that provide education.  A reader should be able to tell when your next class or series of classes begins and what will be covered in that class.  If you do drop-in information nights, be sure these are listed. This information needs to be easy for readers to find and understand, so give full date, time and location — remember, only the most invested will call or email to get more information. Websites that provide current information build trust in the reader.

5. You don’t give good contact information

OK, now go make any necessary changes to your website.

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End of the Year and Waterbirth

Dec 30th, 2014

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When I wrapped up the last series I thought I could make weekly posts…I was ambitious.  I was correct in my suspicion that my workload would increase near the end of the semester. I am now in the midst of a working break between semesters and I don’t see an end to the heavy workload for a few months.  The trick is figuring out how to balance the blog with my “real” job.

I do have some things to show for my hard work. Continue reading

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Wrap up for Fear of Childbirth

Oct 30th, 2014

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Thank you for exploring the concept of fear of childbirth with me.  My personal understanding of childbirth fear has changed in the 15 years I have been working with expectant women.  Fear of childbirth is a more complex experience than natural childbirth theories I learned so long ago seem to accept.Even so, I have been challenged by the research readings this past month, and I hope you have too.  Here are the top three lessons I learned this month:

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Fear of childbirth and Guilt

Oct 28th, 2014

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As I researched for this series, I was struck by Fisher’s (2006) paper on the social context of fear.  The thesis of this study was the social context of childbirth influences how women understand childbirth, and this impacts how they experience it on an individual level. In the discussion of prospective fear, Fisher discusses prior research on first time mothers and their fear of the unknown.  Without prior experience, these mothers do not know what to ask.

But at the same time they are told their bodies were designed to give birth, that they ‘should’ be able to do this.  While this provides courage for some mothers, others are left feeling that they somehow missed something important — that they are different because they fear. This leaves them feeling inadequate and actually increases the fear. Continue reading

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“Ignoring” fear of childbirth

Oct 24th, 2014

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This week we’ve been looking at ways childbirth educators think about managing women’s fear of childbirth.  We talked about education and relaxation, but today I want to talk about ignoring the fear. If you can’t think of any natural childbirth theories that support the use of ignoring fear, it is because there are not any.  But that doesn’t prevent this method from being used.  Continue reading

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“Relaxing” the fear of childbirth away

Oct 22nd, 2014

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Earlier this week we looked at research that both supported and refuted the idea that you could teach away the fear of childbirth. Today I want to focus on another tactic for managing fear of childbirth, relaxation.  This discussion is a little more theoretical, a little more about defining what things mean than the last few posts which focused on research.

Just like education, the first place I learned of the value of relaxation for childbirth was in Dick-Read’s Fear-Tension-Pain cycle.  The basic concept was that fear caused tension, and the tension caused pain.  So if I learned to relax during labor, I could stop the effects of the fear. Dick-Read is not alone in this assertion, Penny Simkin wrote a fabulous piece on the physiological effects of stress on labor. This is often used to support the importance of physical relaxation to promote comfort during labor. So the question is, what does relaxing do to the fear? Continue reading

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“Teaching” away fear of childbirth

Oct 20th, 2014

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We’ve been talking about fear of childbirth, and last week we spent some time in the research looking at sources of fear.  Today I’d like to change gears and begin looking at ways childbirth professionals think about dealing with women’s fears. First method to review — education.

The concept that you can teach away childbirth fear first appeared in the philosophies of Grantley Dick-Read.  His philosophy, dubbed the Fear-Tension-Pain Cycle, claims that through education about birth the fear of birth is removed and therefore the tension and pain are reduced.  Is he correct?

References

• Fisher C1, Hauck Y, Fenwick J. How social context impacts on women’s fears of childbirth: a Western Australian example. Soc Sci Med. 2006 Jul;63(1):64-75. PMID: 16476516.

• Fenwick J1, Staff L, Gamble J, Creedy DK, Bayes S. Why do women request caesarean section in a normal, healthy first pregnancy? Midwifery. 2010 Aug;26(4):394-400. PMID: 19117644.

• Stoll K1, Hall W2, Janssen P3, Carty E4. Why are young Canadians afraid of birth? A survey study of childbirth fear and birth preferences among Canadian University students. Midwifery. 2014 Feb;30(2):220-6. PMID: 23968778.

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Fear, Pain, and Childbirth

Oct 17th, 2014

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Last week I introduced you to the idea of the value of perfect health.  If you remember, a physician places a higher value on perfect health than the general public; the general public puts a higher value on avoiding a condition than the people who live with that condition.  This comes from economic research into what is generally termed as “utility.”  These studies measure how much people are willing to do to avoid certain conditions, or for the chance for complete recovery of a condition.

The fact that the value of not having the condition is reduced when reported by someone who has the condition is an interesting phenomenon. I suppose once you have a condition, like diabetes or hypertension, you learn how to live with it.  It becomes your new normal.  I began to wonder how this might be reflected in childbirth. Continue reading

References

• Stoll K1, Hall W2, Janssen P3, Carty E4. Why are young Canadians afraid of birth? A survey study of childbirth fear and birth preferences among Canadian University students. Midwifery. 2014 Feb;30(2):220-6. PMID: 23968778.

• Elvander C1, Cnattingius S, Kjerulff KH. Birth experience in women with low, intermediate or high levels of fear: findings from the first baby study. Birth. 2013 Dec;40(4):289-96. PMID: 24344710.

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