The Trouble With Advocacy Films

Christopher Smith — Mon, 04 Feb 2008 14:44:00 +0000

On of the parenting lists I read mention a film called the business of being born, a documentary advocating midwifery, home births, and generally questioning the US’s extensive use of hospitals for child birth, as compared to Japan and Europe. I’m sure it is a great film and highly informative to lots of people, and I understand it ends with an interesting counter note as the director gives birth herself and ends up having a hospitalized birth due to complications with her pregnancy, but the trailer I find on the homepage reminds me of the perils of advocacy documentary film making; in particular how they tend to play fast and loose with facts and statistics.

The movie has the Bowling for Columbine trifecta: it’s about life and death, it’s about how America is worse than the rest of the civilized world, and it has a celebrity sponsor (in the form of Ricki Lake). Now, having grown up in Canada and generally being of the liberal persuasion on social issues, in theory I should be predisposed to embrace discussions about what’s wrong with the US, and in particular those that involve health care. However, as I watched the trailer, I had a bit of a sick feeling in my stomach.

First of all, I have to embarrassingly admit here that I am not sufficiently well informed on midwifery and/or home birthing to really be able to discuss the matter one way or the other. When it came to our own child I don’t think the issue ever came up (although there was discussion about a Doula), and I guess I lacked sufficient curiosity to investigate it myself.

That said, I have some first hand (and no, I’m NOT trying to suggest I have a clue what it is like to physically give birth to a child!) knowledge of the institutional birthing process and cultural norms in Canada and the US, and that is where I take issue.

The killer bit of the trailer for me was the bit where it was suggested that the US “stands alone” in the prevalence of “institutional” births. They are of course comparing the US with Japan and Western Europe, but the US’s friendly neighbour to the north is about even more fond of institutional births.

The trailer states “The United States has the second worst newborn death rate in the developed world”, and talks about a “maternity care in the United States is in crisis”. The implication being that these things are all related. Once again though, there’s the Canada problem. When you look at infant mortality rates worldwide you will notice that the US is one of the worst performers of what we traditionally think of as first world nations, but it isn’t like it is way outside the average for the first world. So, while it sounds ominous to be “second to last in the developed world” (and looking at the stats you might see how a number of nations have to be asking why they don’t count as developed), in reality there isn’t a huge statistical gap pointing to a “crisis”. Secondly, you’ll notice that Canada scores better than the US, pulling ahead the UK, Portugal, Ireland, Italy, New Zealand and South Korea, while giving Australia and Austria a run for the money.

An amateur statistician will look at this data and say that if anything it suggests that prevalence of institutionalized birth has at best a limited relationship with infant mortality, and certainly there is little evidence of a causal relationship. A professional statistician might demand to look at actual data on medical intervention rates in other countries and observe that many of them have nearly comparable if not equivalent levels of various medical interventions, including Cesarean births (the rise of which may actually have more to do with factors unrelated to preferences of doctors *or* patients). Indeed, staring at the data, I imagine a few factors that seem far more likely to be the key factors attributable to the US’s higher rate:

Socialized medicine. On the chart I found, the US’s infant mortality rate for 2007 is 6.4. The top country on the list is Sweden, with a 2.8. So, the difference between the US’s “bottom” ranking and a top rating is 3.6 deaths per 1000 births. As such, factors which primarily effect only a small minority of the population can have a pronounced effect. So right away, I’m thinking that the very nature of the US’s private health care system implies that poorest people in the country will get substandard health care. In fact, I’ve read about all kinds of problems with pregnant women basically not seeking health care until after their contractions start (and sometimes not even then) due to fears about medical bills, let alone those who receive substandard care because of their limited means. This of course hampers effective medical intervention for births with complications. This factor is actually highlighted in the press kit that the movie hands out, although there doesn’t seem to be a connection made to how this would explain differences in infant mortality rates relative to other developed nations. It’s a tragedy and needs to be better addressed (sadly, this is often more a problem of educating the public than an actual economic problem), but this problem is almost the opposite of overuse of hospitals and doctors for birth. Looking at the list, I can’t find a single country without socialized medicine that ranks above the US.
Immigration. Each year, the US accepts more immigrants per capita than any nation in the world, and that’s only counting the legal immigrants. That means, you’ve got a comparatively (to other nations) large segment of the population who weren’t born and raised in your medical system, weren’t treated by your public health initiatives, haven’t enjoyed your standard of living, weren’t subject to your public health education campaigns, and weren’t subject to your general public education system. Now, in some cases their public institutions at home will have better prepared them than their adopted country, but it can’t help but skew your statistics towards the global average (which is *substantially* worse than the rate for “developed nations”). Again, looking at the data, I see “developed” nations which I tend to associate with high rates of immigration (the US, Canada and Australia) ranking lower than those I tend to associate with low rates of immigration (Sweden, Japan, and Norway).
Aggressive attempts at viable births. This is one of those “lies, damn lies, and statistics” bits. There is no uniformity in how infant mortality data is collected. Each country reports its own statistics, and what counts as births and deaths is heavily impacted by political and social standards and agendas. It’s a tricky problem, where you get penalized for trying: what do you count as a birth? If you’ve got a child that for whatever reason needs to be born prematurely at say 25 weeks, the odds are really not good. In the US, they’ll give it a go anyway and their success rate under such circumstances is, AFAIK some of the best, if not the best, in the world. The thing is, if you just give up and don’t record it as a birth, you’re going to look a lot better than that other guy who gives it a go and fails three times out of ten. I found this article looking at Cuban vs. US infant mortality rates which makes exactly this point. Now, this is partially a function of the US’s institutionalization of the birthing process, but I have a hard time accepting criticism of it beyond the notion that perhaps these heroic efforts drain medical resources that might otherwise be directed towards births in poorer families with better chances for viable births.

The film also wonders why insurance companies freak out about home births (duh! when you are an insurance company you don’t care much about marginally –from an economic standpoint– better outcomes in the normal case: what you’re scared about are those really bad outcomes where “you could have done better” that involve trial lawyers, massive jury awards, and completely blow your actuarial tables to smithereens!). It talks about various medical mistakes made over the years, from X-rays to thalidomide, without recognizing the extend to which modern medicine has learned from these examples (there’s a reason why almost every medication on the planet says, “pregnant women should consult their physician before taking this medication” and why hospitals are now cautious about overly invasive mechanisms for monitoring births that are without complications). It also talks about the dramatic change in the rate of institutionalized births from 1900 to present day, but fails to mention the improvements in infant mortality rates that occurred concurrently (I’m sure this was to avoid having the audience make assumptions about correlation being causation with regards to infant mortality rates ;-).

This is the kind of analysis and discussion that often is conveniently overlooked by advocacy films, which by their nature are focused on the emotional core of a story more than facts. This is exactly why I find it so hard to treat such films much differently from pure fiction.

I have little doubt that there are issues with our cultural and medical norms with regards to childbirth. I know that medical liability is so skewed that doctors are often better off ordering tests and prophylactic procedures and medications that address 1% cases, even if there are negative outcomes for the patient (I have to imagine a doctor’s worst nightmare is working on the birth of a child whose parents are trial lawyers ;-). I know that pressures from increased medical care costs have lead to patients being pushed in and out of hospitals at faster and faster rates. I’m sure there are things that could have gone better with my own child’s birth. However, much as I’m aware of the dangers of judging a book by its cover, I have a hard time feeling like the best way for people to become informed about these issues is by watching this film.

Oscar Peterson Is Dead

Christopher Smith — Mon, 24 Dec 2007 11:15:00 +0000

Canada’s greatest Jazz pianist has passed away.

When my family moved to Mississauga, we moved in to one of those suburban real estate projects with a corny name. Yes, we lived on Robin Drive, and Will Scarlett Drive, Maid Marion Place, and Lionheart Crescent were streets that we frequented. One of the kids I spent a lot of time lived next door to “the Petersons’”. I remember we were over there a few times to play with one of their kids. I remember thinking he was kind of young for us, and wasn’t too interesting, but they had a rear projection TV screen. Yup, that’s right. I was in the house of Oscar Peterson, who was probably within ten feet of me, and I was thinking his kid was young and boring, but the really cool thing was that they had a rear projection TV screen and an impressive collection of movies. Of course, at the time I was too young to have half a clue who he was.

Looking back on those times later, I don’t feel quite so bad. After all I was a kid, but more importantly, when I thought of the look on his face, he seemed pretty happy. I think the fact that we paid him no heed pleased him. Sometimes it is nice to be ignored. Sometimes it is nice be around people who are completely transparent and treat you with no more respect than you’ve earned in the last five minutes.

I hope it made him happy.

Halloween Fun

Christopher Smith — Tue, 30 Oct 2007 23:13:00 +0000

So, the other day, we took the kid to see Boney Island. My wife had somehow found out about it (I’m guessing from LAist), and boy did she pick a winner. It’s a private home that has been converted over to be a mini-Coney Island…. run by skeletons. It’s all outdoors, and includes all the key elements of Coney Island, including a ferris wheel, bands, a ticket vendor, fortune teller, etc. It seemed to be just the right balance of scary and not scary for our three year-old. He found the crowds (and they were legion… enough that a firetruck was parked outside to keep an eye on things… and yes, the kid loved that too) more intimidating than the house itself. It was a good family experience, got rave reviews from the kid, and generally not a bad way to spend fifteen minutes, maybe half an hour, on a Halloween night. Our biggest problem is that now the kid thinks every house he sees on Halloween should be comparably equipped.

His First Pun

Christopher Smith — Thu, 24 May 2007 22:54:00 +0000

My son came up with his first pun tonight. He was snacking on crackers with his mother, and decided that they were both ducks. After imitating ducks for a bit, he declared, “We’re ducks! We’re eating quackers!” He giggled afterwards, indicating he knew he was being funny.

I actually missed the initial moment itself because I was late getting home from work (not exactly the first of “firsts” I’ve missed), but he performed the joke for me as well.

I’m going to have to be more careful with the humor I use around him now. He’s liable to recognize the all-too-common case when my jokes are lame.

Xblog: Category Parenting

The Trouble With Advocacy Films

Oscar Peterson Is Dead

Halloween Fun

His First Pun