What Do Episiotomy and Cesarean Have to Do with Copernicus, Galileo, and Newton?

Like those who thought the world was flat and the sun revolved around the earth, believers in routine episiotomy considered its use as based on “normal science,” as defined by Thomas Kuhn (1), and fully accepted within the obstetrical/gynecological community—a discipline that saw birth as inherently abnormal, and whose scientific questions were based on this conception of reality as the only framework for legitimate inquiry. Kuhn defined “revolutionary science,” as opposed to “normal science,” as the study of “anomalies,” or the failure of the accepted paradigm to explain or take into account observed phenomena. In the 1970s and 1980s, beliefs about childbirth were coming under intense scrutiny. Worldwide, many people had come to believe that routine episiotomy did not make sense, was anomalous and in need of formal study. In the early 1980s, I pondered how to get funded for a randomized controlled trial of an accepted procedure that I thought was inappropriate when applied routinely. Later I struggled to get the episiotomy trial published when the dominant culture wanted the results buried. In this context, I thought about how strongly held beliefs came about and the critical importance of timing. And then I discovered “paradigm shift,” as coined by Kuhn. I had been reading the seminal work of Joseph B. DeLee and was struck by the way that he put together both the need for a new way of providing protection for the mother and the fetus and the need of his professional discipline. DeLee was in the process of developing the field of Gynecology into a new discipline to be called “Obstetrics and Gynecology.” His presidential address to the then American Gynecological Society in Chicago was a masterpiece that proposed a new way to save babies and the perineum and pelvic floor by his combination of outlet forceps and episiotomy—this while simultaneously creating a new professional discipline and wrestling the territory away from “incompetent general practitioners and midwives” (2). DeLee exhorted his audience to take up this new approach, claiming that since GPs and midwives would have neither the tools (forceps) nor the inclination to use a surgical technique (episiotomy), the new discipline of Obstetrics and Gynecology would gain hegemony. DeLee’s timing was impeccable. Mothers and babies were indeed in trouble in the 1920s—especially in the slums of Chicago. Society needed a new way of looking at birth, and gynecologists needed a strengthened discipline. To accomplish this goal, they had to situate themselves as scientifically providing the solution to a problem, a new way of viewing birth—from a natural phenomenon to a process fraught with danger, a danger that would be mitigated by the new discipline. And society was ready for this way of seeing birth. Kuhn would say that the old paradigm was about to be shifted. When I proposed a randomized controlled trial of a procedure that was considered established, the initial response from funding agencies was negative. The reviewers from the Medical Research Council of Canada were dismissive. When the trial was finally funded by Health Canada, it was because women inside the agency, not the reviewers, wanted it to be funded. Later we had great trouble getting the study published. The reviewers made misogynistic comments and were harsh in their desire to see the research disappeared. I wrote about this fascinating process (3), using the actual words of the reviewers as substrate, but before gaining the insight required to write, I turned again to Kuhn. Through his powerful little book I had come to realize that I must not take these rejections personally. What do you expect when you are contesting the current paradigm or orthodoxy? When the research was finally published (4, 5), it was because the discipline of obstetrics and gynecology itself had within their leadership (and a key editor) significant players who were also skeptical of the old paradigm and believed that, routinely applied, episiotomy did more harm than good. My colleague, Janusz Kaczorowski, and I found that belief structures about episiotomy were firmly grounded in a strongly held paradigm of birth. If you knew how practitioners saw episiotomy, you knew how they viewed birth itself (6). So our timing was on, and so was a scientific revolution. Today, there remain only a few holdouts who still believe that routine episiotomy is beneficial and deny the improvements in perineal and pelvic floor damage that accrued from abandonment of routine episiotomy (7). Kuhn: “A new scientific truth does not triumph by convincing its opponents and making them see the light, but rather because its opponents die, and a new generation grows up that is familiar with it” (1, p 151). I turned to Kuhn once again to explain a new and evolving paradigm. As an old obstetrician friend told me: “You know, Michael, it hurts me to have to admit that episiotomy does not do what we thought that it did. But you know what the real problem is? It’s vaginal childbirth itself!” So we are on the cusp of a new potential paradigm, but it is, in fact, a return to an old one. This time the tool is cesarean section rather than prophylactic forceps with episiotomy, but the problem to be solved is the same—damage to the mother (pelvic floor and perineum) and the baby (preventing brain damage). And the language and justification sound so familiar. Never mind that the evidence for cesarean section as the technique to prevent both is not there. However, fear-based practice and the desire to control the uncontrollable are present for both the maternity care professions and society as well. But just as the new paradigm is emerging, new evidence is arising in both Canada and the United States: indicators of maternal and newborn health are going in the wrong direction—as they have done in high cesarean environments in Latin America (8). Kuhn would say that a new “normal science” is not yet established. The new candidate for paradigm status, cesarean section as just another way of having a baby—in fact, a better way, struggles with the old “conservative” notion that cesarean section is major, risky surgery to be reserved only for specific indications. This debate is far from over. We are in a period of conflicting paradigms, as the adherents of each paradigm design new studies to prove their view is the right one. And some studies will be seriously biased, going from what Phil Hall has called “evidence-based decision-making to decision-based evidence making” (9).

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