On Witch hunts and how to read research

We’re going on a witch hunt….. we’re gonna catch a big one….. I’m not scared……. what a beautiful day……

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This song has played over and over in my mind for the last 24 hours.  I tried to drown it out with some other music, but then I looked at a newspaper.   I thought I’d distract myself by making cake…. cake

But then I opened facebook. Guys. I read the comments.Hermione

I know, Hermione, I know.  I avoided stuff, though. Good lord, that headline.

I went to work for eight hours (with 42 fancy cupcakes in a variety of flavours with varying fillings and frostings for my hard working colleagues) and toted up over 10000 steps according to my handy step counter on my phone…..

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But then I saw the opinion piece heralded as news coverage on TV.

Another day in the life of a New Zealand direct entry midwife, another accusation of baby killing.

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I am of course talking about the latest in a slew of attacks against my profession, a group of hard working, life saving individuals, who despite their 24/7 commitment to providing free and internationally renowned care for women continue to be consistently and conveniently labeled as at best inept and at worst dangerously careless by our local media.  It started with this study written by a group of researchers from Otago university.  It hit the media here in this article published by the NZ Herald. The New Zealand College of MIdwives responded in this media statement which, whilst a robust and fantastic response is going largely unreported.

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So.  We midwives aren’t supposed to speak out.  We are supposed to be good, be nice and let the grown ups manage this stuff.  But, this time, the attack was on our newly qualified midwives.  And I will not be complicit in silence as my colleagues are misrepresented.  Not this time.

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I am just gonna pull it apart a little tiny bit. Not all research findings are accurate, relevant or even honest. Not all research is meaningful or up to date.  When research is done, it has to be analysed, critically.  Medical journals do this by having research peer reviewed.  The average non medical, non science geek reader of this blog may not have had much dealing with this.  So they rely on their media to report accurately the analysis that we can Believe.  And here is where we get technical.  (Only I am not great at big words, so I am gonna try to keep it in regular people speak.)

A peer review is only as good as the peers doing the review.  That’s why it was possible for that ridiculous myth about autism and vaccines to get published.  Peers are people who do the same job as you.  People are human.  Humans carry bias and share it willy nilly.  If you get enough people with the same bias, they will agree with each other.   This means that even when an article is peer reviewed, it still needs to be analysed by the people reading it to ensure that there is not a personal bias inherent in the research.

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This particular article is RIFE with bias.

The objective of the research was :”To determine whether experience of midwife-only and nurse-midwife lead maternity carers (LMCs) is related to perinatal mortality.”

As the NZCOM media statement points out:  The data is old.  They have studied a period of time directly before a huge review into midwifery education, and the implementation of much more rigorous support in the first year of practice.  The degree was lengthened by a year, practical hours increased hugely, and a new mandatory first year of practice program was introduced…. directly after the time frame from which they collected data. This pretty much renders the findings of the research out of date prior to publication.

dateThe context of the research matters, too.  Who wrote it?  Why?  What were they hoping to achieve? Who paid for it?

The methodology was flawed.

Methodology basically means ‘how you are going to get your information’.  In this case,  the authors studied outcomes of births in relation to the experience of the registered LMC and then basically said ‘the caregiver is why this happened’.  They didn’t look at other factors related to the outcomes (baby deaths, in this instance), even though that data is available .  They didn’t investigate when or how the baby deaths occurred, or what risk factors existed.  They didn’t even exclude termination of pregnancy occurring after 20 weeks of pregnancy (Yes, it happens, usually in the case of serious fetal abnormalities, and midwives support women through these losses with compassion and care every day all up and down the country. These births occurring after 20 weeks of completed pregnancy in NZ are classified as stillbirths.  Do not even get me started by questioning the fact that these lost babies are loved and grieved for).  They took no care to adjust their analysis of the data to make it more robust.

They looked at who the LMC  (Lead Maternity Carer) was but not who was providing the care at the time.  Which means they failed to recognise one of the great cornerstones of our maternity system.

“These LMC midwives work with midwife partners (mostly in small group practices) and alongside midwives who are employed to work in maternity units to ensure you receive the care that meets your needs. Midwives also work collaboratively with other health professionals such as obstetricians to meet any additional medical or health needs.” (https://www.midwife.org.nz/women-in-new-zealand/about-lead-maternity-carer-lmc-services)

What that means is, that if your LMC detects a complexity in your pregnancy she refers you to other services.  They may not be the person responsible for care at all times, especially if the situation becomes life threatening.  They are responsible instead for ensuring that the most appropriate professional is providing care, but retain responsibility for coordinating that care throughout.  Often in poor outcomes a whole team of people is involved.

New LMC’s (newly qualified or new to this type of practice) frequently end up with a higher risk population of late booking or medically complex clients, as they have “space’ in their case load for these clients.  Experienced LMC’s are often booked up well ahead of these women presenting to the system.  This does not mean that the LMC isn’t doing her very best possible work, it merely means she likely has a higher risk population. And because this study didn’t measure risk factors, we don’t know how much impact that may have had on the numbers.

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The analysis of the actual research by our mainstream media also was…. well wrong. “Researchers are calling for an urgent review of New Zealand’s midwife training system after a study found that babies have a 30 per cent greater chance of dying if being looked after by a newly qualified midwife.” (http://www.nzherald.co.nz/nz/news/article.cfm?c_id=1&objectid=11532738).

Ok.

No. Sorry. Wait.  I need a second to stop myself from cursing on my blog.

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Feeling super trustworthy right now.

Right, I have it in hand.

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Do you think for a second that if we even thought that was possible we wouldn’t move heaven and earth to change everything about everything we do? It is a math game they have played here, and is a basic and blatant misrepresentation of the numbers.  It is insulting and absolutely unbelievable to suggest that we would a) not detect that level of risk and b) would do nothing about it during the comprehensive review we just undertook of our education system for new midwives!  Imma stop right there before I lose my composure again. 8728ktdI can’t write a post debunking the whole of the research because I have real work to do.  But I can share this information on how to read a research article critically.

If anybody could get it to the writers at our newspapers, who reported this absolute bollocks, I would be ever so grateful!

And to the commenters out there in the world of the interwebs. Around 90% of women in NZ are cared for mainly by midwives through their child bearing year.  100% receive some midwifery input.  And our system is renowned for its positive outcomes. Our perinatal mortality outcomes are at an all time low.  We are improving outcomes, year on year.  What more do you want from us?

resized_creepy-willy-wonka-meme-generator-why-don-t-you-just-tell-me-what-you-want-me-to-do-06b49cFinally, to my new graduate midwfery colleagues.

I stand in support of you. Not complicit in silence as you are attacked, but grateful for your energy, enthusiasm and the care you give the women of this country.  You are the future of our profession. We were once you and you are possibly even better than we were.  You are more prepared, more engaged, more adept at managing the complex depths of this job we hate to love.  You are valued by your colleagues and the women for whom you give up your family life.  Please don’t leave!

But, seriously. This is not a political blog.

But, seriously. This is not a political blog.

26 thoughts on “On Witch hunts and how to read research

  1. Kathy says:

    Thank you and love your direct,piece – no one could doubt the truth after reading that, despite your quirky sense of humour and no swear words – congratulations!

    Like

  2. adriannemaule says:

    Thank you for writing this as a midwifery student this helps me to stand tall and help others to understand what is really going on 🙂

    Like

  3. Emma says:

    Thank you so much – from a new grad struggling through all the media witch hunting – it’s SO good to read a positive message and a fabulous argument!
    Now if only the rest of NZ could read this. Xx

    Like

  4. V says:

    Thank you, as a new grad midwife, our goal for the year as competent midwives is to also become confident midwives. As is the nature of the job i’m sure we all have good days and bad days and we seek support from our colleagues, friends and families. However it does get really hard to continue to hold your head up high when these witch hunt, blame it on the midwife cases and out poor education gets splattered through the media. Getting my degree was no walk in the park, the academic years were so long compared to others, the workload was intense 4 years delivered in only 3, at times i wasn’t a mother just a woman who was present to feed and provide the basics for her children, a women with struggles in her personal life, yet had no time to grieve for lost loved ones. I had to study and work hard for this degree, i earned it, especially after all the research we needed to do and learn how to interpret it all, to look at inclusion/exclusion criteria, for bias and limitations and for results of significance etc. So thank you again for breaking down this piece of research and exposing it’s flaws, it will take a lot to undo the seed of fear and mistrust that has been planted into the minds of women and society, but it’s a start.

    Like

  5. Nat says:

    I think the term “witch hunt” is apt. I’d like to see some studies on the incidence of intervention and its relationship to obstetricians…

    Like

    • imcbcd says:

      I want to be very clear that I do not want to flip this into a them and us battle with our obstetric colleagues. I could not provide safe care to all women without them. We are all human, and are all capable of improving/learning/doing better. My issue is with attacks on a profession and I’m not at all ok with doing that same thing to another profession. Defending ourselves does not justify attacking others.

      Like

      • Paulus says:

        I support mid-wives but didn’t you just do to the media profession that which you say others do to midwifery? Or is it just the typical case of the media is an easy scape goat?

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      • imcbcd says:

        Nope. I pulled apart a single piece of research that the media chose to present poorly, and without critical analysis, as a specific response to an ongoing problem. I did not vilify them, or call them lazy or dangerous or unethical. I did not reference a particular subset of media as being less than. I did accuse them of using us an easy target. Because, well, they Do. But what this post really did was explain to the reader how to read what is presented to them with a critical eye. Which doesn’t attack anyone. I believe everyone should always ask those questions, of any piece of reporting, medical or not. That’s not an attack on the media, it’s what I learned in primary school social studies.

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      • Nat says:

        Please don’t get me wrong, my comment wasn’t designed as an attack on other professions. I understand and appreciate that everyone should and must work alongside each other in the medical profession. The issue I have, and it’s an entirely personal opinion, is that studies such as this seem to be designed to undermine midwifery – as though it somehow exists outside of medicine – that was the point I wanted to make (though it was done badly 😀).

        Like

      • imcbcd says:

        I agree that studies such as these are/seem to be designed to undermine midwifery. I think it’s likely that much bigger forces play into that than just the fact that it is considered non medical. We all know (as in its a fact) that throughout history, women’s health has been poorly researched and poorly funded as compared to make health. But now I’m starting to get into gender inequality!

        Like

  6. Kim says:

    Thank you. A million times, thank you! This is the perfectly written easy to read piece that I tried and failed to write. Read: swear words and rambling.

    Like

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