Homage to Dr. Murray Enkin and the complexity of <scp>evidence‐based</scp> medicine

Our dear friend and mentor, Murray Enkin, died at age 97 on June 6, 2021. His passing was a huge loss, personally and to the birth community, both because of who he was and what he represented. Murray was a pioneer in family-centered maternity care (FCMC) in the 1960s and 1970s, during a time when partners were excluded from birth and routine nonevidence-based interventions were the norm. FCMC was successfully pushed by women but not by professionals. Despite the positive influence of FCMC, Murray worried that so many of today's women, based on flawed research and professional convenience, consider vaginal childbirth as just an opportunity for things to go wrong—a way to experience rectal, bladder, sexual, and pelvic floor problems. Murray's history is unique. Starting out as a GP, he soon reinvented himself, the first of several reinventions, when he retrained as an obstetrician. Murray questioned everything, including his own ideas about what was normal. Often a curmudgeon, he was ready to challenge nonevidence-based practices, the “authorities,” his colleagues, as well as politicians. A Jewish man heading a department of obstetrics and gynecology in a Catholic hospital, he set out to question what was considered routine; “What was the evidence? Why do we do this? Who started this nonsense? How do we change it?” Undoubtedly influenced by his grandmother's death during childbirth and witnessing dehumanized care for women while in medical school, he found himself unable to accept the way women were treated. When McMaster Medical School was founded, Murray left private practice to be one of the first medical faculty members, beginning a path that engaged him with many of today's leaders and all types of maternity care providers. Embarrassed to learn that epidemiologist, Archie Cochrane, considered obstetrics was the least scientifically based specialty, he joined the movement to make obstetrics evidence-based. With colleagues at the National Perinatal Epidemiology Unit in Oxford, they set out to question all procedures and approaches used in caring for pregnant and laboring women. In doing so, they developed the Oxford Database of Perinatal Trials, systematically studying the field of obstetrics, to determine what was needed or not, as well as what was useful and what was harmful. In those heady days of the 1970s and 1980s, Murray became one of the principal spokespersons for the randomized controlled trial (RCT) as the only serious way of knowing. Collaborating with Mark Keirse and Iain Chalmers, their efforts culminated in the massive two-volume book: Effective Care in Pregnancy and Childbirth,1 the “bible” of the field and counted as the main force in the development of evidence-based medicine (EBM) throughout medicine and not just obstetrics. In the process, Murry mentored countless clinician researchers throughout the world. I will be forever grateful to Murray for encouraging me to do an RCT of episiotomy in Canada. The study clearly showed that routine episiotomy caused the very vaginal and pelvic floor trauma that it was supposed to prevent.2, 3 Not only was the result accepted in North America, but the section in obstetrical textbooks on episiotomy had to be completely rewritten. Over the next 10 years, episiotomy rates in North America dropped from 65% to 70% or more to 12% to 20%, and severe trauma rates dropped from 4.5% to 1.5%, saving many women from unnecessary birth trauma. The struggles to get funded and published for an RCT of episiotomy that challenged conventional wisdom are detailed in my book: Dissident Doctor—My Life Catching Babies and Challenging the Medical Status Quo.4 This study of episiotomy became the start for virtually all my research to follow. Without Murray's influence, it is likely that none of this would have happened. But even as EBM was developing and becoming accepted, Murray himself began to question RCTs as the only way of knowing. He pointed out that the RCT was ideal for studying complicated but not complex issues. RCTs worked for simple problems like comparing drug A with drug B, but not for issues that involved human behavior and beliefs, practice setting, and practitioner skill sets.5 For that, difficult and specialized methods would be needed. Murray was an early promoter of the re-emergence of regulated midwifery, doulas, and home birth with trained, integrated midwifery. His arguments and history were so respected that his voice could not be ignored. However, he once told me that he regretted even getting involved with RCTs. Perhaps overstated, this is because he understood that even RCTs could be distorted and misused. He developed what some of us call “Enkins First Law”: “The RCT is perfectly designed to show the results for the conditions under which the RCT is conducted—BUT only for those conditions.” For example, if the RCT is conducted in a university hospital where only obstetricians and hospital-based nurses practice, and the background cesarean delivery rate is, let us say 12%–15%, the study has relevance (internal validity) for such settings and practices. But that result may not be relevant or applicable (external validity) for community, family, or midwifery practices, or in settings with much higher cesarean delivery rates that are today's norm. Murray clearly understood that politically motivated, biased RCTs could be designed to produce the desired results. This concept was best stated by a mutual friend, the late obstetrician, Philip Hall, who said: “We have moved from evidence-based decision-making to decision-based evidence-making.”6 Murray receiving the Order of Canada from the Governor General for his efforts on behalf of the women of Canada. Murray and his wife, Eleanor, together always.

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