Postpartum Experts Aren’t Always Wrong, but They Are Often Unreliable

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If you spend enough time seeking out postpartum experts, you will hear the same advice over and over. Some suggestions are evidence-based, some are not, and some fall in-between. For example, we are all familiar with the recommendation to kegel, a recommendation that is good, although a bit limiting. Plenty of data supports the kegel, and this is why your doctor will offhandedly tell you to get squeezing. However, kegels can only do so much for the pelvic floor, especially when structural supports have been torn or stretched too far. A lot of women also do them incorrectly or imprecisely, which turns a decent recommendation into a counterproductive one.

Therefore, some other postpartum practitioners, often physical therapists or personal trainers, have stepped into the void with their own programs and methods and oft-repeated advice on how to rehabilitate the postpartum body. Indeed, many of these new experts disparage the lowly kegel and promise something better in its stead. They tell you to align properly, breathe properly, lift properly, stretch properly, etc… with the promise that doing so will improve pelvic floor and abdominal strength.

Is this new advice any good? Honestly, I don’t know. Maybe. Maybe not. Either way, these approaches are ubiquitous. The internet parrots the same few people, which lends an air of finality to the suggestions, but without much actual evidence to back them up.

Breathing methods, posture modifications, and precise biomechanics are hard to study and certainly don’t deserve the uncritical acclaim heaped upon them. Therefore, after years of experimentation, I mostly approach these methods with a bemused shrug.

Again, I don’t know if these postpartum experts are wrong, and I’m not sure it even matters. Sometimes their advice directly contradicts recent studies (for example, the notion that a certain pelvic tilt will CAUSE pelvic floor disorder is not true), but, overall, large scale evidence on what helps the postpartum body is scant, and if I waited for studies to prove everything, I’d be old and no better. In general, moving and doing something is better than sitting still and feeling sorry for yourself. Therefore, I’m less interested in whether a method definitively works than in whether it’s worth a try.

Veracity Versus Reliability

In the absence of strong evidence either way, I try to distinguish between veracity and reliability. They are not the same. Veracity means specific advice will provide expected and consistent results that can be objectively measured. Conversely, reliability means the methods of coming up with this advice are sound. The difference matters.

More often than not, I can’t speak to the veracity of the new experts’ suggestions. What will work for one person won’t work for another, and a good deal of trial and error is likely the best individual approach, as long as the trial and error works within the framework of the evidence we have so far.

Without good studies, we are left with anecdote and some biologically plausible explanations. I can try their methods on myself, but I’m only one biased person like everyone else. This doesn’t mean I shouldn’t try them, just that I shouldn’t trust my own experience too much, or even that of other women, or even that of the experts themselves. Why? Because anecdote is not evidence and sometimes the experts are very good at convincing themselves of their own veracity without letting a healthy dose of skepticism guide their practice. As the physicist Richard Feynman said, “The first principle is that you must not fool yourself — and you are the easiest person to fool.”

I don’t blame someone for being wrong. But I do blame them for not accepting the possibility that they could be wrong.

Fooling Themselves

How do the experts fool themselves? The story usually goes like this. In this scenario, I’ll call the expert “Cindy” (Cindy is not a real person, but an amalgam of postpartum trends).
Cindy noticed when she did X, Y improved (or at least she thought Y improved). Y is very amorphous, but she convinced herself and her patients/clients that it improved, then she tried X with other patients and, lo and behold, more improvement of Y.

She realized she had stumbled upon something to replace Z— the outdated stuff other therapists, trainers, and doctors recommend. She searched Pubmed and found some preliminary case studies or small not well controlled studies to support doing X. Then she created a course and started certifying other practitioners in “Method X.”

Women started to praise Method X and linked to the super qualified and smart Cindy who “discovered” Method X, a method the stuffy establishment doctors know nothing about because they are locked in their ivory towers and don’t really know how to help women, unlike Cindy who is on the postpartum front lines.

Viola. Public acclaim (and affiliation opportunities) mean Method X spreads like wildfire. I’m pretty sure this is how the TvA obsession got started, and I’ve seen the same thing happening with certain posture prescriptions.

Only problem: Method X could be complete bunk. Or not. Maybe it helps some women. However, not being totally wrong doesn’t mean being right, especially in light of Cindy’s monetization of a method without good evidence to support it. Cindy has invested, metaphorically and literally, in Method X, so she won’t spend any time contemplating the null hypothesis or looking for confounding variables to explain why X seems to work for Y. She won’t pursue large scale studies because she is not a researcher and real women need the help that Method X can provide right now. Fair enough.

However, if any studies come out undercutting Method X, Cindy will discount those studies, unaware that her own biases are preventing her from adapting to new evidence. She will continue to un-ironically call Method X “evidence-based” because she deems her experiences and those small case-studies as sufficient evidence. She will interpret every study in a way that bolsters the truth she already knows—that Method X works. In other words, Cindy is NOT a reliable expert, regardless of whether Method X has any validity or not. Nothing will change her mind.

Again, Method X MIGHT be helpful, and Cindy has a right to profit just like anyone else. But, unfortunately, Cindy has unleashed hordes of devotees who will defend Method X without applying healthy skepticism to the claims. Taking away healthy skepticism and discourse is the surest way to bulldoze the postpartum conversation and create neurotic new moms who think they NEED to do Method X to see results.

Now we are left in a soup of anecdote pretending to be evidence. Everyone tells you about the great soup, but every time you take a bite, it tastes like burnt marshmallows covered in salsa. You don’t want to say anything because Cindy is a culinary genius, right? In other words, when Method X doesn’t work for you, you are quick to blame yourself rather than the Method.

What’s the Solution?

What’s the solution to overconfidence in underpowered evidence? The solution is skepticism and an understanding of how evidence works. The most trustworthy experts are those who can pivot. This type of expert doesn’t trust herself too much, which sounds counter-intuitive. Shouldn’t an expert have confidence? Yes. But there is a difference between confidence and conceit. Confidence means believing you are working with the most up to date evidence to give individualized advice. Conceit means you have discovered a revolutionary way to fix the postpartum body (“revolutionary” and “unreliable” are bedfellows).

Cindy isn’t confident. She is conceited. Don’t be like Cindy.

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