Birth Professionals

Midwifery Evidence

I’ve been trying to be diligent at getting the website updates completed.  They must be completed before I begin classes again in the fall, or their importance will drop to the “don’t have time” category.  Ugh.

It’s been an interesting journey to update the website.

Some days I surprise myself with how thorough I had been.  I’ll make a list of things to “add” to the website, only to find in the midst of updating a section that I already added that five years ago!

Some days I’m surprised with how messy the navigation had gotten.  The website “grew” organically from questions being received and interactions with mothers.  Without an easy way to change the overall navigation scheme, pages were wrapped in an interestingly hard to navigate web. This time, I’m starting over with navigation because I’m updating the whole website.  I hope this makes it easier for new readers to find what they are looking for.

Some days I struggle with how to balance evidence and information. My biggest example is the pregnancy concerns section – where I share things women sometimes try to get rid of backaches, stretch marks or nausea. It is in this section I have the most difficult time finding “evidence” that things work or don’t work. This is partly due to the difficulty in randomizing women to study the effects of an intervention.  Do you randomize before they complain about something – before they get nausea? Because there may be differences in their diet that lead to nausea.  If it is overall diet problems, then depending on the problem in their diet they may have different solutions to the problem.  This gets really complicated really fast.  Most studies tend to be observational, which might point in good directions but might also hide what is really working.

This is a struggle for me because I believe women have the right to the best information possible. I believe that information includes whether or not an intervention works – even if the intervention is eating fresh papaya.  Why?  Because if this is not something the woman ordinarily does, she has to take extra time and money to obtain and prepare the papaya – and she may not like the flavor.  I have no right to decide for her if the extra time, money and eating something she doesn’t care for are worth the “relief” she gets, especially if I don’t know the papaya actually gives relief.

In preparing a talk on menopause, I came across an interesting study that looked at the effects of different types of treatments on hot flashes.  Most women used hormone replacement or soy supplements, a few women used other things and some women used nothing.  This was interesting because it didn’t matter what the woman used, if they followed her for  about two years she reported improvement in the hot flashes – did you get that, they get better on their own.  The only treatment that had any difference in the swiftness of improvement was the hormone replacement.  But here is where I really paid attention – like a good research team they went back and shared what they had learned with their volunteer subjects.  And they asked one more question – now that you know this, what will you do.  Overwhelmingly the women who used soy said they would continue because even though most women didn’t have any benefit, it worked for them.  But remember, the soy didn’t work any better than not doing anything – hot flashes improve on their own when given time.

There are many reasons the women in this study didn’t have improvement from soy, and other studies have found improvements – that isn’t the point.  The point is the women in the study attributed the success of their relief to the soy when there was no added benefit of the soy to just waiting for menopause to progress. The soy cost the women money, took extra time I’m sure.  But it wasn’t doing anything real for these women.  Yet they couldn’t let go of the idea it was the soy, not the normal progression of menopause, that was making the difference for them.  As an author on the internet and a midwife, I need to remember that what I say affects decisions women make.  I don’t want to be the cause of someone believing they have to spend extra time and money on a solution that doesn’t really do anything.

This is one of the reasons the hair on the back of my neck starts to stand when women make comments about how there are many types of evidence, or that some trick always works for them even if evidence doesn’t support it.  You cannot judge the value of a “trick” or treatment or intervention on it’s own.  Just because I ate papaya and my nausea seemed to improve does not mean it was the papaya.  It could have been something else I was doing — maybe getting more sleep or that I stopped eating something else. Or it could have been that I didn’t try the papaya until the time the nausea was going to be relieved on its own.

Considering a small sample without a control to be “evidence” is dangerous.  It is what kept doctors believing some unnecessary things like episiotomy where helpful rather than harmful. And even if the biggest harm that comes to a woman is that she feels she must eat a food she doesn’t like, it still is not worth it to me.

So here I struggle with wondering how to let women know about the things most likely to help their symptoms, and about the things they are going to read that may waste their time and money because we just don’t know if they are helpful at all. And as I struggle through this, I am intensely aware that my natural birth friends may see this concern for quality information not as growth in me, not as a healthy concern for the women and families I serve, not even as responsible midwifery, but instead it may be seen as evidence that I am not really a midwife or not really interested in natural birth anymore.




Jennifer Vanderlaan (Author)