Natural childbirth and "just so" stories

Henci Goer has finally responded to my critique of her smear of the Friedman curve. Did she address the fact that she completely misrepresented the history of the Friedman curve? No. Did she correct her mistakes about standard deviation? No. Did she acknowledged that she been utterly wrong in her statement of the purpose of the curve? No.

What did she do? She told a "just so" story. What's a "just so" story? According to Wikipedia:

A just-so story, also called the ad hoc fallacy, is a term used in academic anthropology, biological sciences, social sciences, and philosophy. It describes an unverifiable and unfalsifiable narrative explanation for a cultural practice, a biological trait, or behavior of humans or other animals. The use of the term is an implicit criticism that reminds the hearer of the essentially fictional and unprovable nature of such an explanation. Such tales are common in folklore and mythology (where they are known as etiological myths — see etiology).

Here's the tale that Goer told:

My daughter-in-law’s recent story was very much on my mind as I wrote my blog post. Her first baby, she was induced at 42 weeks for postdates. She hung up at 6 cm for many, many hours. Thanks to the watchful patience and excellent care by the staff at Kaiser Santa Clara–which included taking a break from the Pitocin for a shower and a rest (which allowed a restart at a lower dose), an epidural eventually, time to "labor down" before beginning pushing–and the knowledgeable assistance and support of her doula, my daughter-in-law gave birth spontaneously to an 8 lb 15 oz boy in the occiput posterior position...

The following explanation of the ad hoc fallacy shows that Goer's story is a perfect example:

... [W]hen someone's attempt to explain an event is effectively disputed or undermined ... the speaker reaches for some way to salvage what he can. The result is an "explanation" which is not very coherent, does not really "explain" anything at all, and which has no testable consequences - even though to someone already inclined to believe it, it certainly looks valid.

Goer's smear of the Friedman curve was blasted out of the water. She was shown to be wrong about the history of the curve, wrong about the purpose of the curve and wrong about the statistical analysis. In an effort to salvage what she could, she gave an "explanataion which is not very coherent, does not really "explain" anything at all, and which has no testable consequences." And the best part? "To someone already inclined to believe it, it certainly looks valid."

Telling her daughter-in-law's story is like suggesting that people stop wearing seat belts because her daughter-in-law drove cross country without one and didn't get hurt. It's like recommending that women refuse breast biopsies because her friend ignored a lump for 3 years and it turned out to be benign. It's no better than feeding your child a diet of Cheetos and Pepsi because your cousin did it and her child turned out fine.

Goer's original discussion of the Friedman curve was wrong in virtually every particular: history, purpose and statistical analysis. She has nothing to say on those points, so she has attempted to salvage her post by telling a story and hopes that for those inclined to believe it, it will seem valid.

This is why celebrity NCB advocates refuse to appear in any forum where they can be questioned by doctors or scientists. Their "arguments" are eviscerated in short order and they are forced to fall back on "just so" stories. That might work for the readership of Science and Sensibility, but they'd be laughed from the podium at any meeting of medical or scientific professionals.

Using a technicality to avoid responsibility for a homebirth death

Australian midwife Lisa Barrett is trying desperately to avoid responsibility for a homebirth death over which she presided. As I explained in the post Is a baby who dies during homebirth a person?, the case is the typical homebirth tragedy, the kind that demonstrates that "trusting birth" is no substitute for emergency personnel and equipment.

Tate Spencer-Koch, had a vigorous heartbeat in the moments before the birth of her head, but after her head was born her shoulders were stuck. This is known as a shoulder dystocia and is an obstetric emergency of the highest order. The umbilical cord is trapped between the baby's body and the walls of the vagina, cutting of the flow of oxygen to the baby. If the baby is not delivered within 5-10 minutes, permanent brain damage and even death can result.

In the hospital setting, shoulder dystocia is often anticipated if certain risk factors are present such as an unusually large baby, or an unusually slow labor. Shoulder dystocia is best managed by a team approach and even after the baby is delivered, an expert resuscitation including intubation is often required.

In the home setting, shoulder dystocia can quickly turn into a disaster. In the case of Tate Spencer-Koch, Barrett took an appalling 20 minutes or more to deliver the baby's shoulders a truly extraordinary amount of time. When the baby was finally born, Barrett claimed, the baby was dead.

The ambulance crew begged to differ. Although Tate had no heartbeat, an EKG revealed electrical activity of her heart, the last stage before death. The ambulance crew believes that Tate was alive at the time they arrived and therefore was certainly alive at the time she was born. The distinction is critical, because the law gives the coroner power to investigate the death of "persons" and a stillborn baby is not a person under Australian law. The coroner initially accepted the testimony of Barrett and ruled that he did not have jurisdiction over the case.

Evidently Tate's parents refused to accept this and requested and additional hearing in which the EMTs testified. After that hearing, the coroner reversed his decision and ruled that Tate had been alive and therefore her death should be investigated.

Barrett has appealed the new ruling and has taken the appeal to the Australian Supreme Court. As she writes on her blog:

Following the Coroners decision earlier this year to give himself Jurisdiction on a baby who had a PEA after birth with no sign of life, I would like to question his decision.  The transcript of his findings were in contradiction to his experts and in my opinion the law.  After seeking advice I have applied for a Judicial review.  We also applied for the inquest to be postponed until after the review.  The coroner held a small hearing last week where he declined to postpone so we went on to an emergency hearing at the supreme court.  We were granted an injunction to make the coroner postpone and the right to be heard.  A date will be set soon.  The process is massive, scary and it appears that I am up against the coroner, the Health department, the Ambulance service and the Attorney General.

This is a case of world interest, the rights of the coroner, the power of law over the common man and the definition of life.  I find it completely frustrating and frightening that when the case was at the coroners court there were press making our lives hell..

Barrett is desperate to avoid a review of Tate's death because of the possibility that she will be accused of malpractice. She has every right to use all the legal tools at her disposal, but let's be honest about what is going on here.

Midwife Lisa Barret is claiming that the death should not be a coroner's case because she was so inept at resolving the shoulder dystocia (20 minutes until delivery of the shoulders) that the baby died before the entire body was born. And because she was incapable of saving the life of an otherwise healthy baby, as opposed to merely rendering it brain damaged, she should escape investigation.. It is outrageous for Barrett to proclaim that she is fighting for anyone else's rights. A baby is dead and she wants to use a technicality to avoid investigation. This case is about nothing more than saving Lisa Barrett's right to practice midwifery, no more and no less.

Anatomy of a natural childbirth smear

Recently I wrote about the natural childbirth website Science and Sensibility, detailing how it is neither scientific, nor makes much sense. That's probably because every discussion has to be jammed into the same pre approved narrative arc: evil obstetricians, whose raison d'être is ruining birth "experiences" create a theory/practice/procedure which ignores scientific evidence, the evil obstetricians persist in using this theory/practice/procedure even though it doesn't work, but now we've learned that they are utterly wrong and still they continue what they have been doing. Since the pre approved narrative arc has nothing to do with the truth, the post misstates or misinterprets the science in critical ways.

Henci Goer's recent post, Iatrogenic Norms: How Fast Do First-Time Mothers Beginning Labor Spontaneously Actually Dilate, is a perfect example of natural childbirth as an unscientific smear. The first principle of the NCB is smear is to start with a gratuitous swipe combined with a little made-up "medicine."

Iatrogenic norm: a defined range of normal values for a biological process that, rather than describing actual normal physiology, instead measures the consequences of a health care provider’s beliefs, actions, or therapies or the effects of exposure to a health care facility.

Oooh, sounds fancy and scientific. Too bad Henci Goer just made up that "definition," which exists nowhere else.

The body of the post is an attempt to smear "the famous 'Friedman curve'." Recent research, looking at the ways in which epidurals influence labor, suggest new norms. Goer is outraged that anyone would presume to define any "arbitrary" norms to distinguish normal from abnormal labor.

Nevertheless, while revising norms to match reality would take a big step in the right direction, I would argue it doesn’t go nearly far enough because it still sticks us with the assumption that active first-stage dilation progresses smoothly. Anyone who has spent time with laboring women knows that this is often not the case. Neat graphical lines (or curves) come from averaging many highly variable individual labors, so the very expectation of how labors progress, at whatever pace, is itself an iatrogenic norm.

That sounds fancy and scientific, too. What a shame, then, that is nothing more than made up baloney centered around a made up "definition." Then there is this witless gem:

Moreover, the published review points out that both the old and the proposed new threshold for “abnormal” are statistically derived (e.g. two standard deviations beyond the mean). No study links a cut point for “abnormally slow” with an increase in perinatal morbidity, but averting adverse outcomes should form the basis for intervening medically because of the risks of intervention. In fact, even if a study tried to establish an outcome-based threshold, it would be hard to determine whether the increase was due to labor duration per se or to the interventions used to treat slow labor...

Statistically derived? Two standard deviations beyond the mean? Well, duh. That's not some nefarious plot; that's the entire point of statistical analysis.

And finally there's this:

... No study links a cut point for “abnormally slow” with an increase in perinatal morbidity, but averting adverse outcomes should form the basis for intervening medically because of the risks of intervention. In fact, even if a study tried to establish an outcome-based threshold, it would be hard to determine whether the increase was due to labor duration per se or to the interventions used to treat slow labor. So we have yet another iatrogenic norm, this one having to do with a definition of “abnormal” with no clinical significance.

No link with perinatal morbidity? No fooling! That's because the curve has nothing to do with perinatal morbidity and no one ever claimed that it did.

There are so many mistakes and misinterpretations in this piece that it's hard to know where to begin. I'll confine my discussion to the three most egregious mistakes, one historical, one statistical, and the third a serious misrepresentation of the purpose of the curve itself.

I know a bit about the Friedman curve because I trained with Dr. Friedman himself. He was the chief of my department at Beth Israel in Boston for the four years of my residency. He was an extremely difficult man to work with, but he was brilliant and a strong advocate for women.

How and why did Dr. Friedman define the curve?

Dr. Friedman did his residency in the 1950s. He was not a man to suffer fools gladly and he considered a lot of his superiors to be fools. He felt that they made medical judgments based on their intuition and not on science, and he set out to accumulate the research data necessary to give the profession a firm scientific foundation.

During his residency, when he was on call every other night, he used his “spare” time to compile detailed observations about every laboring woman who came through the hospital. The goal was no less than to find out what normal labor looked like. Using observations from tens of thousand of women, he created a curve. Women who followed the curve were almost certain to have a vaginal delivery. Women who fell off the curve were more likely to need a C-section.

Dr. Friedman was the first to say that you should not section a woman in latent phase because a long latent phase was not a sign that the baby doesn’t fit. He insisted that you should not section a woman in the active phase of labor unless she failed to make a certain amount of progress in a certain amount of time. Dr. Friedman used to express the utmost disgust for doctors who would say, “she looks like a C-section to me”, instead of adhering to established criteria.

So Goer has thoroughly misrepresented the Friedman curve. It was created precisely to AVOID unnecessary C-sections, not to justify them. And it is hardly "arbitrary." It reflects the observation of thousands of labors, both normal and abnormal and graphically represents those observations.

But perhaps Goer is confused into thinking that the curve is arbitrary since she completely misunderstands and misrepresents standard deviation.

NCB advocates like to claim that medical definitions of “normal” are utterly arbitrary and exist merely for the convenience of doctors. Nothing could be further from the truth. Often, “normal” is based on knowing the outcomes from previous experience. We can confidently say that having an Apgar score of 1 at 5 minutes of life is not normal, because babies who have Apgar scores of 1 at 5 minutes always have serious medical problems of one kind or another.

Sometimes “normal” is defined as a range. That is not an accident, and it does not mean that a range was chosen arbitrarily. A normal range in medicine is almost always based on a basic and widely accepted form of statistical analysis, the standard deviation.

There is an excellent simple explanation of standard deviation on SensibleTalk.com. It is written for journalists who have no background in statistics:

Let’s say you are writing a story about nutrition. You need to look at people’s typical daily calorie consumption. Like most data, the numbers for people’s typical consumption probably will turn out to be normally distributed. That is, for most people, their consumption will be close to the mean, while fewer people eat a lot more or a lot less than the mean.

When you think about it, that’s just common sense. Not that many people are getting by on a single serving of kelp and rice. Or on eight meals of steak and milkshakes. Most people lie somewhere in between.

When you graph the data with calories on the x-axis and numbers of people on the y-axis, you will get a bell shaped curve. The curve is a graphical representation of all the possible things that can happen. The important point, though, is that every possible thing that can happen is not necessarily normal. How do we tell the difference between normal and abnormal? We start by calculating the standard deviation. The formula for calculating the standard deviation is complicated, but the result is relatively simple to understand. The standard deviation is a reflection of distribution of all possible outcomes.

Mathematically, one standard deviation on each side of the mean (the average) encompasses 68% of individuals. Two standard deviations encompasses 95% of individuals. Therefore, only 5% of individuals will be outside of two standard deviations from the mean. This is always true, regardless of whether the bell curve is tall and narrow or short and extended. “Normal” is usual defined as within two standard deviations. That means that “normal” is a range, but the range is hardly arbitrary. It reflects the actual distribution of results among large populations of human beings.

So when we look at how long a first labor lasts, for example, we can graph the labors of large numbers of women and we will get a bell curve. Ninety-five percent of women will fall within two standard deviations of the mean. It is only those women who are outside of two standard deviations that are considered abnormal. That does not mean that a woman whose labor is lasting longer than two standard deviations from the mean cannot possibly have a vaginal delivery, but it does mean that a woman whose labor is lasting longer than two standard deviations from the mean is far less likely to have a vaginal delivery.

The bottom line is this: defining normal as a range is not arbitrary. It is a reflection of what we know about human variation. The range of normal accounts for most of human variation. Anything that lies outside the range of normal is very unlikely to be normal.

Finally, the swipe at the curve for not being related to perinatal morbidity and therefore being clinically irrelevant is just plain bizarre. The Friedman curve has NOTHING to do with morbidity and mortality. That wasn’t its purpose when it was developed and it is not its purpose today. It is, however, quite important clinically because it tells us the likelihood that woman will deliver vaginally.

Oh dear, it seems that the story of the Friedman curve does not fit the predetermine arc of the NCB smear. The Friedman curve was NOT created to ruin women's birth experiences; it was created to reduce unnecessary C-sections. The Friedman curve is NOT arbitrary; it is simply a graphical representation of thousands of labors. Standard deviation is NOT arbitrary; it is at the foundation of statistical analysis. No matter. Who cares about the truth? Certainly not Henci Goer.

Noted childbirth educator behind My OB Said What

Recently I asked Why are the owners of "My OB said WHAT" hiding?

The website "My OB said WHAT?" is supposed to highlight "stupid" things said by obstetricians. It is a slick, professionally designed smear campaign, clearly requiring a fair amount of money to create and maintain. Yet the owners feel that they have something to hide --- their own identities.

Apparently they are hiding their identities because they don't want it known that a nationally prominent childbirth educator is behind "My OB Said What?" Teri Shilling, former president of Lamaze International.

In addition to her role as past president of Lamaze International, Ms. Shilling is Founder and CEO of Passion for Birth Childbirth Education, board member of Regional Association of Childbirth Educators of Puget Sound (REACHE), a DONA doula trainer for the Seattle Midwifery School/Bastyr U. She serves as the Media review chair for the Journal of Perinatal Education, and volunteers as the Lamaze International development member of the Education Council.

Readers of this blog will know her better as MaryM who has posted here repeatedly in the past week or so under that pseudonym and as "guest." She posted such gems as:

The reason there is nothing personal on MOSW is probably because it is a forum - it's for the women who want to submit what they have been through. Your theory about a stealth marketing campaign with an astro turf appearance is even more paranoid then your original attacks.

I privately offered Ms. Shilling the opportunity to comment on her involvement. She did not deny it; her only response was that the organization Passion for Birth is not involved. She mentioned nothing about the other organizations with which she is associated, but that could be because I did not ask her specifically about those other organizations.

Ms. Shilling is not the only person behind MOSW. As more information becomes available, I will share it.

Natural childbirth, a philosophy of privilege

Natural childbirth is the project of Western, white women from first world countries who are relatively well off. It does not have much resonance among women of other cultures, nor among women of color within first world countries. In other words, "natural" is about and absolutely depends upon social privilege.

It's been that way from the very beginning. Grantly Dick-Read, widely considered to be the father of the natural childbirth movement, viewed natural childbirth as a way for white women of the "better" classes to avoid "race suicide." Ornella Moscucci explains the thinking of Dick-Read and his eugenicist peers:

[T]hese health reformers were concerned about the differential birth rate—the tendency of poorer, less healthy sections of society to have larger families than their "betters". Thus, as well as endorsing plans for the sterilisation and detention of "degenerates", they also sought to encourage the middle classes to have more children... Female education and employment were seen as a particular evil, insofar as they led women to regard motherhood a burden and to neglect hearth and home...

... Dick-Read ... claimed that primitives experienced easy, painless labours. This was because in primitive societies the survival value of childbirth was fully appreciated and labour was regarded as nothing more than "hard work" in the struggle for existence. In civilised societies on the other hand a number of cultural factors conspired to distort woman’s natural capacity for painless birth, producing in woman a fear of childbirth that hindered normal parturition...

In other words, "natural" childbirth was created as a philosophy for privileged women, and it remains so to this very day.

Political scientist Candace Johnson explores the role of "natural" childbirth as a philosophy of privilege in contemporary society (The Political "Nature" of Pregnancy and Childbirth, 2008). She starts by framing the question:

... [W]hy do some women (mostly privileged and in developed countries) demand less medical intervention in pregnancy and childbirth, while others (mostly vulnerable women in both developed and developing countries) demand more ...? Why do the former, privileged women, tend to express their resistance to medical intervention in the language of "nature," "tradition," and "normalcy"? ...

The answer?

The evidence seems to suggest that arguments about the negative impact of medical intervention in the lives of women, "medicalization," seem to resonate only among privileged populations. As indicated by Laura Purdy, medical intervention in pregnancy and childbirth is evaluated very differently in different contexts, and the expression resistance among privileged women in developed countries often appeals to "nature":

"When we learn that African-American women in the United States die more often in childbirth than white women, and that horrifying numbers of Third World women are dying as we speak, nobody concludes that preventive action would be morally intrusive. Yet we tend to be bewitched by the claim that menstruation or pregnancy are natural processes and thus inappropriately dealt with in the medical realm."

In poor countries, communities or under-serviced areas, medical care is a necessity, upon which exercise of agency and autonomy is contingent. But the refusal of pharmaceuticals and clinical care among affluent or well accommodated (by a universal health system, for example) women is at once a form of political resistance and an assertion of identity.

It is precisely for this reason --- that rejection of medicalization is an assertion of identity --- that explains its restriction to privileged women. Only women of privilege, with enough to eat, easy access to medical care, and the leisure to contemplate their "identity" are attracted to "natural" childbirth.

In developing countries, appeals are continually made for more medical intervention in pregnancy and childbirth, not less... [I]n the United States, higher rates of maternal mortality among African American women serve as evidence for the need for better access to medical care ... However, the preference expressed by many privileged women in affluent countries, such as Canada and the United States, for midwifery care and home births, is curiously at odds with public health data and ethical arguments.

As Johnson explains:

It is a rejection of privilege that simultaneously confirms it. Therefore, the problem of medicalization seems to apply disproportionately to privileged women. In fact, some of the most serious pronouncements of medical interference in pregnancy and childbirth as a "natural, normal, woman-centered event" come from women of considerable privilege and authority.

It is not surprising then that "natural" childbirth, a philosophy of privilege is rejected by women who lack social privilege, women of color and women from non first world countries. But there is a further reason for rejection, the romanticization of the experience of non-privileged women:

... Third World women's experiences with traditional or natural birthing practices have been appropriated and romanticized by first world women, often to the detriment of the subaltern women. Sheryl Nestel claims that "conceptually, images of Third World women have served to define middle-class white women's midwifery identities through both negative comparison and fantasized idealization"

To put it bluntly, privileged women construct a view of childbirth that explicitly ignores the vast suffering endured by real women forced to experience childbirth "naturally."

... The fantasy of Third World women's natural experiences of childbirth has become iconic among first world women, even if these experiences are more imagined than real. This creates multiple opportunities for exploitation, as the experiences of Third World women are used as a means for first world women to acquire knowledge, experience and perspective on 'natural' or 'traditional' birthing practices, while denying the importance of medical services that privileged women take for granted.

Natural childbirth is rejected by women of color and by women from countries outside the first world. Natural childbirth is a philosophy that presumes economic security, ready access to medical technology, and the leisure to construct an "identity." It does not merely ignore the suffering that childbirth entails for many non-privileged women, it actively erases their suffering by pretending that it does not exist and never existed.

Breastfeeding and what it means to be a good mother

This month's issue of the journal Health, Risk & Society includes an article on the moralizing discourse used to promote breastfeeding, Contextualising risk, constructing choice: Breastfeeding and good mothering in risk society. Stephanie Knaak, a sociologist, claims that breastfeeding promotion in first world countries is about much more than what an infant eats.

... this discourse is not a benign communique about the relative benefits of breastfeeding, but an ideologically infused, moral discourse about what it means to be a 'good mother' in an advanced capitalist society.

Knaak starts by noting that "risk management" has become a major feature of contemporary mothering.

As one of the primary concerns of modern post-industrial societies, we are becoming increasingly concerned with understanding, calculating, communicating, managing, and otherwise minimising or eliminating myriad risks associated with everyday life. So it is for the arena of parenting and motherhood. Indeed, it is argued that the role of motherhood in contemporary society is being redesigned in such a way that mothers are being increasingly positioned as veritable 'risk managers'.

Within this ideology, mothers are seen as having a moral and social responsibility
to be risk conscious...

It makes sense that mothers would be encouraged to minimize risks to their children, but the attention given to various risks appears to have no relationship to their magnitude. As Knaak explains:

Risk, however, is socially and ideologically mediated... Indeed, 'risk consciousness' and associated decision-making is often related more to the emotive consequences and meanings attached to certain identified risks than to any rational calculation of probability ...

The efforts to encourage breastfeeding represent a perfect example. Breastfeeding has real health benefits, but those benefits are small. Yet breastfeeding promotion has taken on moralizing tone typically associated with grave threats to children's health:

...[T]oday's dominant infant feeding discourse functions more as a vehicle of persuasion than as a vehicle of education, characterised by informational biases, moral overtones, and a restrictive construction of choice. Attention has also been given to the increasingly hegemonic and homogeneous character of pro-breastfeeding discourse, where alternative choices about infant feeding tend to be interpreted as acts of moral deviance rather than counter-discourses or acts of resistance...

Since the benefits of breastfeeding are small, it is really no one else's concern what method of infant feeding an individual mother chooses. But women cannot keep themselves from criticizing other women's choices and they rationalize this by a conception of public health that is growing ever more intrusive:

The increasing moralisation of public health is another part of what lends power to this feature of contemporary breastfeeding discourse. Namely, the tendency in public health discourse to increasingly frame personal health choices/practices as issues of social and moral responsibility makes breastfeeding much more than just a personal decision. Within this kind of discursive environment, breastfeeding becomes part of how good (i.e. socially responsible, moral) motherhood is defined.

Knaak draws from interviews with new mothers to describe how this moralizing works:

... [M]any of the mothers viewed commercial infant formula not only as nutritionally less superior, but in specifically negative terms. In as much as the larger discourse acknowledges both breastfeeding and formula feeding as 'acceptable' choices, there is an ever-increasing discursive gap between these two options; namely, that breastfeeding has become more and more idealised, and formula feeding ever more devalued.

Breastfeeding advocates have gone far beyond simple attempts to educated women about the benefits of breastfeeding. They have explicitly framed one feeding choice as "good" and another as "bad." And they imply that only those women who make "good" choices can be good mothers.

... [T]his association of breastfeeding with 'good mothering' and formula feeding with 'not so good mothering' has been argued to be a key characteristic of today's dominant infant feeding discourse. In large part, this can be attributed to the fact that pro-breastfeeding discourse is organised and mediated by: (a) a moralising public health ideology; and (b) the 'ideology of intensive mothering', today’s dominant parenting ideology.

Breastfeeding advocates disingenuously claim that they are merely trying to convey the facts about infant feeding methods. In reality they are attempting to promote one particular ideology of mothering and to shame women who refuse to conform.

The Coalition for Improving Maternity Services emphatically denies supporting smear campaign

Note: Several hours after writing this post I received a definitive response to my query sent to Denna Suko of CIMS.

Good afternoon, Dr. Amy. Thank you for contacting CIMS. We appreciate your inquiry.

CIMS does not provide funding, technical support, personnel, nor any other type of support to the "My OB Said What" website, and we do not know who is responsible for the site...

I appreciate Ms. Suko's quick and emphatic response.

*****

Several days ago I asked Why are the owners of "My OB said WHAT" hiding?:

The website "My OB said WHAT?" is supposed to highlight "stupid" things said by obstetricians. It is a slick, professionally designed smear campaign, clearly requiring a fair amount of money to create and maintain. Yet the owners feel that they have something to hide --- their own identities.

I speculated that:

The amount of money involved and the desperate effort to conceal themselves suggest that "My OB Said What?!?" is run by a professional natural childbirth advocacy organization that has seen its previous efforts to control women's childbirth choices fail dismally.

There are several clues that raise the possibility that the Coalition to Improve Maternity Services (CIMS) may be behind the site. The most suggestive is that the site's only outbound link is to The Birth Survey, a project funded by CIMS. It shares many of the same characteristics of MOSW: it is a non-scientific solicitation of birth stories masquerading as "survey." Since ads for The Birth Survey are placed almost exclusively on websites promoting alternative beliefs about childbirth, it is designed to collect unfavorable stories about obstetricians and hospitals. CIMS intendeds to use the information to pressure obstetricians and hospitals without making any effort to determine if the stories they receive are representative or even true.

MOSW does essentially the same thing. It solicits brief stories about unpleasant or contentious interactions with obstetricians with the explicit aim of promoting ridicule of obstetricians (hence the name "My OB Said What!?!). Once again there is no effort to determine if the stories are representative or even true.

I have no special skills to conduct an investigation of the ownership of a site whose owners are trying to conceal their identity, but it seemed like the first step would be to query to site owners. So I left the following message on their site:

I'd like to ask the sponsors of the site a direct question:

Since the only outbound link on the entire site is to The Birth Survey, and since this site is run by self-described birth professionals, it seems very possible that this site is an anonymous smear campaign sponsored by the Coalition to Improve Maternity Care (CIMS), the same organization that sponsors The Birth Survey.

I can’t imagine why the owners of this site would be hiding their identity unless it were because it would be professionally embarrassing to engage in such behavior publicly.

The best place to start in figuring out who is responsible for this site is to ask the owners, so I'm asking:

Is CIMS funding this site? If not, who owns and runs this site?

It seems rather ironic that the same people who demand "transparency" in maternity care are hiding their identities when discussing maternity care.

As expected, the owners of the site refused to answer. I know they saw the post because the site is moderated. Moreover, they became concerned and stripped out any potentially identifying data from their code.

If they won't answer, it seems like the next step is to ask CIMS directly. Denna Suko is the Executive Director of CIMS. I've sent her the following e-mail:

No doubt you are familiar with the web site "My OB Said What?!?" As the only outbound link on the entire site is to The Birth Survey, and since the site is run by self-described birth professionals, it seems very possible that the site is sponsored by the Coalition to Improve Maternity Care (CIMS), the same organization that sponsors The Birth Survey. I have queried the site owners by placing a public comment on their site, but they have refused to answer.

The next logical step is to ask CIMS. Does CIMS provide funding for the website "My OB Said What?!?" Does CIMS provide technical support, personnel or any other support to MOSW?

I have shared the contents of this e-mail with the readers of my blog, The Skeptical OB, and I will share your response with them.

Thank you for your consideration.

I will report back when and if I get a response.

Addendum: As promised, I am sharing the response from Dena Suko.

Good afternoon, Dr. Amy. Thank you for contacting CIMS. We appreciate your inquiry.

CIMS does not provide funding, technical support, personnel, nor any other type of support to the "My OB Said What" website, and we do not know who is responsible for the site...

I appreciate Ms. Suko's quick and definitive response.

UK's leading midwife caught making up "facts"

Oops! Cathy Warwick, the general secretary of the Royal College of Midwives, has been caught making up "facts" to support homebirth.

According to the Mail:

... 'There is a danger that risk during childbirth is presented in a way which is leading women to believe that hospital birth equals a safe birth. It does not.

'There is no hard and fast guarantee that a woman will have a safer birth in hospital than at home.'

She also said there had been a trend for some doctors to cast birth as a ‘medical problem and not a natural process'.

She proceeded to offer this doozy in support of homebirth:

Mrs Warwick is determined to prove the critics wrong. She pointed to the Netherlands, which has the lowest perinatal mortality levels for babies in Europe.

It is also a country where a third of women have home births. In the UK the figure is just 3 per cent.

Just one problem: The Netherlands has one of the HIGHEST perinatal mortality rates in Europe. As I detailed less than a month ago:

Homebirth and natural childbirth advocates often approvingly cite the maternity care in the Netherlands. Homebirth rates are the highest in the world (30%, but down considerably and falling every year) and midwives are the mainstay of the system, caring for any woman who does not require the care of a doctor.

What homebirth and natural childbirth advocates fail to realize is that The Netherlands has one the highest perinatal death rate in Europe and a high and rising rate of maternal mortality. Indeed, the Dutch have become so alarmed at the perinatal and neonatal death rates that the government has convened a variety of investigations to determine the cause.

The Guardian, which conducted the interview, has already been informed of Ms. Warwick's error. Their story contains the following notification:

This article was amended on 16 august 2010. The original reported Cathy Warwick as saying that Holland has Europe's lowest perinatal mortality levels for babies. This has been removed from the article temporarily, pending clarification.

One of my central claims about homebirth advocacy is that it is based on mistruths, half truths and out right lies. Although Ms. Warwick's claim is flat out false, I'm not sure that it was a lie. That would imply that she had actually bothered to investigate the perinatal mortality rate in the Netherlands before she made her claim. It is more likely that she simply made it up, or passed along information that she had heard from someone else who made it up.

Ms. Warwick was determined to prove critics of homebirth wrong, but instead she proved them right. Homebirth advocacy is based on mistruths, half truths and outright lies.

Why are the owners of "My OB said WHAT" hiding?

The website "My OB said WHAT?" is supposed to highlight "stupid" things said by obstetricians. It is a slick, professionally designed smear campaign, clearly requiring a fair amount of money to create and maintain. Yet the owners feel that they have something to hide --- their own identities.

According to the website:

Who are the people behind My OB said WHAT?!?

We are a group of birth care professionals who have worked around birthing women for many years, and felt that there needed to be a forum for people to share comments like those found on our blog.

English to English translation:

'We are a group of professional natural childbirth advocates who want to make fun of obstetricians, but know that our personal reputations would suffer if we did so publicly. Our public efforts to discredit obstetricians are not gaining as much traction as we would like and we believe that a smear campaign might attract more attention than actual scientific evidence.'

Information about website ownership is supposed to be public. Indeed there is an internet database, Whois, maintained for the express purpose of making that information available. In order to hide their identity, the owners of "My OB Said WHAT?!?" pay a fee to Domains by Proxy, an organization that exists solely to hide the identity of website owners. If you are willing to pay money to hide your identity, you must really want to hide.

The fact that the owners are hiding reveals several things about them:

1. They know that their tactics are unprofessional.
2. They know that the scientific evidence is not on their side.
3. They know that their professional reputations lead most people to believe that they and their organizations are fringe groups that publicize ridiculous ideas about childbirth.

The amount of money involved and the desperate effort to conceal themselves suggest that "My OB Said What?!?" is run by a professional natural childbirth advocacy organization that has seen its previous efforts to control women's childbirth choices fail dismally.

It may be entirely coincidental, but Lamaze has made no secret of their vigorous efforts to influence women's childbirth choices. According to Sharon Dalrymple of Lamaze:

For the past 50 years Lamaze International has been promoting normal birth practices in North America and more recently worldwide. Despite these educational efforts women are being over-treated more now than they have been in over 30 years...

One of the reasons these educational efforts may not have been as effective as desired is that our conversations may not be persuasive enough or clear enough...

Lamaze International hired a public relations market research firm to conduct research and identify which messages are the most effective for persuading women to adopt normal birth practices...

As a result of these and other findings, Lamaze International updated our six evidence-based key practice papers in Fall 2009 to ensure women realize that these practices simplify the birth process with a natural approach that helps alleviate fears and manage pain, with the ultimate goal of keeping labor and birth as safe and healthy as possible for each individual woman...

And it may be entirely coincidental, but it was also in the Fall of 2009 that "My OB Said What" was registered and launched.

If "My Ob Said What" was funded, created and maintained by Lamaze International or its employees, that would be extremely damaging to its reputation. The owners of "My OB Said What?!?" should publicly identify themselves. Women deserve to know who is behind this professional smear campaign.

Ignorant AND stupid, a winning homebirth combination

Homebirth advocates are constantly wondering why no one takes them seriously. Here's a perfect example.

The website My OB said WHAT? is supposed to highlight "stupid" things said by obstetricians, but it's a hoot for another reason. Many of the supposedly "stupid" things said by obstetricians are actually true and the only thing that is being highlighted is the ignorance and blockheadedness of homebirth advocates. No one bothers to learn if what they were told was factually accurate; they just sit around and make fun it, but the joke's on them.

Sometimes, though, the ignorance and stupidity reach extraordinary heights. Consider this supposedly "stupid" explanation of the risks of childbirth

Childbirth is one of the most dangerous things a woman can do today.

I have a newsflash for homebirth advocates: As a matter of fact childbirth IS one of the most dangerous things a woman can do.

Childbirth is and has always been, in EVERY time, place and culture, a leading cause of death of young women. And of the eighteen years of childhood, the day of birth is the most dangerous by far.

In nature, the neonatal mortality rate is 7% and the maternal mortality rate is 1%. Childbirth is far safer now because modern obstetrics has decreased the neonatal mortality rate 90% and the maternal mortality rate by 99% in the past 100 years.

This is why obstetricians have a hard time taking NCB advocates seriously. They don’t know the most important fact about childbirth, which is that it is INHERENTLY dangerous. If you don’t know that, you don’t know much of anything.

The responses are appalling. My personal favorite is this comment from Sada:

ROTFLMBO…

You say the current maternal mortality rate is 1%, and “modern obstetrics” has reduced it by 99%? Soooooo…that means that “before modern obstetrics” ***100%*** of women died in childbirth? And the neonatal mortality rate now stands at 7%, and has been reduced by 90%…which means that “before modern obstetrics” 97% of babies died as the result of being born?

If that is the case…my great-grandmother never gave birth to 4 children, and I never met her. Unless she was a zombie the whole time! Dang zombie great-grandmothers and their zombie babies!

Way to go, Sada!

I realize that homebirth advocates don't know any statistics, but I guess some of them had serious trouble with fourth grade arithmetic. Sada needs to get her hands on a basic math book and review fractions, decimals and percent.

Other comments include Jane's bit of fantasy:

Can you please explain why women and babies in the USA have the HIGHEST rate of maternal and neonatal death n the modern world then?

They don't, Jane. According to the World Health Organization 2006 report on perinatal mortality, the US has one of the lowest rates in the world, less than Denmark, the UK and the Netherlands.

Sheva says:

Actually, sweetie, the leading causes of death in women are heart disease, cancer, stroke, respiratory diseases, alzheimer’s, injuries, diabetes, pneumonia, kidney disease, and septicemia.

Actually, Sheva, "sweetie", I said that childbirth is a leading cause of death of YOUNG women in every time, place and culture. Look it up; you'll find out that it's true.

Homebirth advocates wonder why no one takes them seriously. This is why. When you can't even be bothered to investigate whether a statement might be true before you ridicule it; when it never even occurs to you that YOU might be wrong; and when you can't even master 4th grade math, it's not surprising that no one takes you seriously.

How natural childbirth educators construct the past

Childbirth educators like to portray themselves as helpmates of expectant women, offering scientific evidence about various childbirth choices, thereby allowing women to make choices that are right for their personal circumstances. The reality of childbirth education is quite different. Childbirth educators have very strong opinions about which choices are "right" and which are "wrong." And as a thought provoking paper in the Journal of Health Psychology explains, they use a strange an biased view of the past to subtly (and not so subtly) promote their personal opinions.

The paper is entitled 'Golden Age' versus 'Bad Old Days': A Discursive Examination of Advice Giving in Antenatal Classes. As the authors, Abigail Locke and Mary Horton-Solway explain:

... We identify a pattern of advice giving in which class leaders construct 'golden age' or 'bad old days' stories variably to contrast the practices of the past ('then') with current practices ('now'). These contrasting repertoires operate against a backdrop of medicalization and societal expectations that are both current and out-dated, providing a constitutive framework to support class leaders' evaluations and advice on pregnancy, childbirth and infant care.

An objective view of the history of obstetrics over the last 1-2 centuries reveals an ever growing body of knowledge, a greater range of tools to improve outcomes, and an extraordinary improvement in neonatal and maternal survival. Indeed, modern obstetrics has led to a drop in neonatal mortality of 90% and a drop in maternal mortality of 99% in the past 100 years alone. In other words, the advances of obstetrics have occurred in parallel with other advances in medicine, leading to better methods of prevention, better methods of treatment, longer life expectancy and longer periods of disease free life.

Natural childbirth educators ignore the real history of obstetrics and substitute an idiosyncratic and biased "history" of their own. Instead of viewing obstetrics as a progression toward improved outcomes, the recent past is characterized as "the bad old days" and the distant past is constructed as a "golden age." The authors explain:

In theme one, ... the class leader ridicules maternity care and medical practices in times gone by, and sets up a contrast with how medical care has since improved. Extract one shows a typical example of how the extremity and 'horror stories' of the past are constructed when the early stages of labour are being discussed.

For example:

The class leader begins a discussion of what to do in the early stages of labour through the comparison of the 'good old days'(produced in an ironic way) when women in early stage labour were advised to 'rush' into hospital when they had their first contraction. A three part list) documents the routine horrors that awaited them 'enema … pubic shave … pethidine' in the old days... The listing represents the old fashioned practices as an inclusive package deal that was delivered to all women. The final coda that there were 'wards full of women … not really with it' parodies the old days as a humorous but shocking story... By implicit contrast, current practices are evaluated as much improved...

The authors offer a perceptive analysis of this theme:

The ridiculing of out-dated medical practices served to position, and locate, those practices as 'then' rather than 'now'. The 'then' practices were constructed as unnecessary, out-dated and at times constructed as 'horror stories'. In contrast, the class leader did not criticize [her preferred] ... policies, rather she invoked the 'horror' of the past at precisely the moment when the practices of the present could be called into question.

While the recent past is portrayed as "the bad old days," the distant past is constructed as a "golden age." The authors analyze a specific example in which the class leader "explains" a completely made up theory that in the distant past, all babies stated labor positioned head down:

[The class leader} constructs a time when childbirth was more 'natural' and it was usually women who did housework. She lists the activities that ‘people’ would do: 'washing by hand ... sweep ... make fires' and the resulting 'leaning forward' from all of this activity... [T]here is a linking of these activities and the desired 'birthing position' for the baby 'head down ... spine out'. This she contrasts with the common working position of today's 'women') describing how the birthing position of the baby is negatively affected ... by pregnant women who 'sit around a lot at work'... 'sit back in settees and things.'

This is classic NCB gobbledly gook, a made up theory of what happened in a mythical past that never existed.

Childbirth educators attempt to influence women's childbirth choices by use of this idiosyncratic view of the past as recent decades of "bad old days" preceded by eons of a "golden age." The fact that this view of the past bears no relationship to what actually happened, utterly neglecting the dramatic improvements in outcome of the past decades and completely ignoring the appalling levels of neonatal and maternal mortality prior to modern obstetrics, is ignored.

Throughout our data set the class leaders' advice giving is constructed in two ways through stories of the 'bad old days' and 'golden age' narratives. Both kinds of account are used variably in the context of making evaluations of good or bad practices, advice giving or offering reassurances about current medical practices...

... [C]ertain practices are constructed as more 'natural' and women are implicated in a range of competing moralities and accountabilities about their antenatal and postnatal activities. It is of particular interest how 'horror stories' of the past are invoked as a contrast to current medical practices which are positioned as better by comparison. Maternity care is thereby portrayed as greatly improved...

Natural childbirth educators are not unbiased individuals who aim to provide women with accurate information about their childbirth choices. They attempt to position their preferred choices as correct. As this paper details they use bizarre and inaccurate characterizations of the recent and distant past to promote what is nothing more than their personal preferences.

Homebirth (and Dr. Amy) in the news

Homebirth has been in the news a lot lately in the wake of the Lancet editorial Homebirth --- proceed with caution:

Women have the right to choose how and where to give birth, but they do not have the right to put their baby at risk... Home delivery is an option for mothers with uncomplicated pregnancies, provided they are advised of the risks involved, have one-to-one midwife care (that includes good resuscitation skills and accreditation by a local regulatory body), and live in a location that allows quick access to obstetric care.

In other words, American women would need to be advised that homebirth with a homebirth midwife (CPM) is unsafe because the midwives do not meet the education and training standards for safety, have no experience with expert neonatal resuscitation, and there is no dedicated transport system that allows quick access to expert obstetric care.

These are among the points that I made when interviewed yesterday on FoxNews Fox & Friends. Also interviewed was Joanne Davis, CNM, PhD who pointed to flaws in the most recent homebirth study. That study may indeed be flawed, but the fact is that ALL the existing evidence on homebirth in the US shows that homebirth increases the risk of neonatal death. Indeed a paper published earlier this year in the Journal of Perinatology analyzed homebirths attended by a certified nurse midwife (CNM) and found that they had double the risk of neonatal death of CNM attended hospital births, even though the hospital birth cohort included high risk patients.

I was also interviewed for a CNN print article Home births: No drugs, no doctors, lots of controversy:

"Going to hospitals and dealing with the doctor is not a pleasant experience," she said. "We have an awful lot to apologize for. People are fed up with doctors. They need to be nicer, more forthcoming, explain things more."

But that distrust has turned into a form of "reflexive doubt" that constantly challenges conventional wisdom in a belief that "smart, empowered people don't listen to their doctors," said Tuteur.

Some mothers have become increasingly competitive about how natural their births are, she said.

"First it was, 'I had my baby in a hospital, but I didn't have an epidural,' " said Tuteur, who doesn't support home births. "Then it was, 'I had a baby with a midwife at home, not in the hospital.' The cutting edge is now unassisted birth -- 'I had my baby at home, and I had no one there except for my husband.' "

And I emphasized to the interviewer that American women need to be aware of the biggest red flag of all: MANA (Midwives Alliance of North America), the trade and lobbying organization for homebirth midwives, has collected neonatal death rates for homebirth since 2001 but they are hiding that data from American women. Even homebirth midwives know that homebirth increases the risk of neonatal death, but they are doing everything they can to make sure that American women do not find out the truth.

Gisele Bundchen, sanctimommy extraordinaire

Sanctimommies of the world, rejoice! You have a new spokesperson, and even though she is a super model, she's just like you: obnoxious, self-congratulatory and anxious to make all the other mommies feel bad. Gisele Bundchen, model, and wife of Patriot's quarterback Tom Brady knows what's best, not just for her baby but for your baby, too.

Bundchen, who gave birth to her first baby less than a year ago, is yet another self appointed expert on what babies need. In fact, she is so sure that she is right that she thinks her personal preferences should be the law of the land. According to Bundchen:

"... Some people here think they don't have to breastfeed, and I think, 'Are you going to give chemical food to your child, when they are so little?'" she tells Harper's Bazaar UK, The Daily Mail reports.

"There should be a worldwide law, in my opinion, that mothers should breastfeed their babies for six months," she adds.

Gisele, like all sanctimommies, is an expert on how you should raise your children. No, she's not a pediatrician, a child psychiatrist or a child psychologist, but that doesn't matter. She knows what food your baby should eat, and dammit, if you don't know any better we'll have to make a law to set you straight.

The best part about sanctimommies like Gisele is that they are always ready to share their wisdom with the rest of us. Gisele doesn't hesitate to point out the deficiencies of other women's parenting practices (in other words, how your parenting choices differ from hers). She doesn’t hesitate to make dire predictions about what the future holds for your children ("You feed him chemicals? You know he's never going to be able to ..."). She never hesitates to bemoan your lack of understanding of the key issues of childrearing, letting you know that you are not as "educated" as she is.

The ultimate irony is that Gisele is busily criticizing women who don't breastfeed as if breastfeeding is a matter of life and death. It's not. The benefits of breastfeeding, while real, are actually quite small. Yet Gisele deliberately exposed her own child to a risk of death by choosing to have a homebirth.

Bottling feeding has no measurable impact on neonatal mortality rates, whereas homebirth in the US triples the risk of neonatal death! Yup, Gisele pretended that her son's birth was a piece of performance art and she was the star. She valued her "birth experience" over the well being of her son for no better reason than that she could brag about it later. And this is the same woman who thinks she knows what is best for babies?

Sanctimommies are not sticklers for intellectual consistency. If someone were to propose a law that mandated hospital births for all babies and criminalized homebirths, the sanctimommies would be braying that their right to control their own bodies was being violated. Yet they cheerfully propose laws that regulate women's breasts and fail to see the hypocrisy.

And of course, Gisele, like all sanctimommies, is shocked that other women are offended by her intemperate and self-aggrandizing comments. She never meant to "judge" anyone! How could anyone think that? According to the Telegraph:

In her blog, Bundchen, a 30-year-old Brazilian, insisted she was not trying to judge other mothers who fed their offspring from a bottle

She said: "My intention in making a comment about the importance of breastfeeding has nothing to do with the law."

... Stung by the criticism, Bundchen said that she understood that "everyone has their own experience and opinions, and I am not here to judge I think as mothers we are all just trying our best".

Really, people, just because she said that breastfeeding should be mandated by law ... that has nothing to do with the law. And just because she derided women for feeding their babies chemicals ... that doesn't mean she is judging anyone.

Sanctimommies can never understand why other women think they are being judged. The classic sanctimommy lament is:

Please do not accuse me of judging those other mothers who don't love their children as much as I love mine. I'm well aware that different ways of mothering are right for different families. Of course women who are obsessed with their own convenience find that bottle feeding is right for them and their families...

Sanctimommies are judging you and even when they are apologizing for judging you, they are still judging you.

The problem with Gisele (paraphrasing the words of the late, great governor of Texas, Ann Richards) is that she was born on third base and she thinks she hit a triple. She had an easy birth, a healthy baby, and no difficulty breastfeeding. Instead of thanking her lucky stars, she's trying to claim credit for it. And instead of offering sympathy to women who have difficulties or support to women who make different choices, she offers blame and condemnation. Best of all, she can't figure out why you think she's judging you.

Who is Henci Goer?

In yesterday's post Do obstetricians ignore the scientific evidence? I discussed the current natural childbirth public relations ploy of choice, the claim that there is a vast body of scientific evidence that obstetricians are ignoring. I focused on Amy Romano in her role as editor of the Lamaze blog ironically titled Science and Sensibility and the fact that she lacks an understanding of the true depth and breadth of the obstetric literature, not to mention and inability to critically analyze that literature. But she is not the originator of that public relations ploy. That honor goes to her colleague Henci Goer who has staked her professional life on the bizarre claim that obstetricians ignore the scientific literature that they create and that only NCB advocates assiduously scour the literature and change their recommendations based on research.

So who is Henci Goer? And who believes what she has to say?

According to Goer:

You may be wondering about my credentials to write this book since I am not a doctor -- either M.D. or Ph.D -- a midwife, or a nurse. I am a certified childbirth educator with a degree in biology from Brandeis University. Beyond that, I am self-taught.

So Henci Goer is not a medical professional and has no experience in the field of obstetrics. That, in itself is not a complete bar to understanding the obstetric literature if it is replaced by a PhD in a hard science or statistics. But, Goer doesn't have those qualifications, either. In other words, Goer is a teacher of childbirth classes who reads the scientific papers that she likes, but has no independent way of assessing the full depth and breadth of the obstetric literature.

I will say that Goer, in contrast to the other self-appointed "experts" in the scientific literature does have a real grasp of the literature that she reads and a real understanding of statistics. That makes her false claims less understandable. Amy Romano actually believes what she writes. Someone told her it was true and she is repeating it. Henci Goer, on the other hand, knows better.

Goer's typical modus operandi is the smear campaign. She tries very, very hard not to be pinned down on specifics, but instead hurls insults.
Ask Goer whether the Johnson and Daviss 2005 BMJ study shows homebirth to be as safe as hospital birth, and she will refuse to answer, because she knows that it is a bait and switch. Instead she will launch into a riff about comparing apples and oranges in order to divert attention from the factual question.

Consider Goer's response to Atul Gawande's excellent article on the success of modern obstetrics:

Gawande applauds doctors for trying whatever appeals to them without “wait[ing] for research trials to tell them if it was all right.” It is sufficient that obstetric innovators “looked to see if results improved,” although how they would know this without a controlled evaluation of safety and effectiveness, he does not say. Neither does he bring up the obstetric disasters that have followed in the wake of this approach. DES, thalidomide, retrolental fibroplasia (blindness in premature newborns), and misoprostol (Cytotec) inductions come to mind ...

Instead of addressing Gawande's factual claim that modern obstetrics has saved more lives than any other branch of medicine, Goer resorts to the smear. Not only does she favor the smear, but she doesn't trouble with the truth of her claims, either. The implication is that obstetricians deliberately created tragedies by foisting unrested medications on unsuspecting women. Yet that is a lie.

Thalidomide is a medication was used in Europe during the early 1960's. It was prescribed as a sedative. Thalidomide taken in the early weeks of pregnancy causes limb defects. Typically, the babies were born with flipper like appendages instead of fully developed arms.

Was thalidomide use promoted by obstetricians? No. Furthermore, thalidomide was never used in the US. An official in the Food and Drug Administration refused to allow the drug to be used in the US because she had read the case reports in the European literature. As a result of the European experience, the FDA instituted studies to see if other medications could cause birth defects. So the reality is that thalidomide was never used by obstetricians and was never even allowed in this country.

How about retrolental fibroplasia? Oxygen supplementation for prematurity was instituted in the 1940's. Thousand of lives were saved by it. The side effect of blindness (retrolental fibroplasia) was noted almost immediately thereafter in the survivors. It was not until the early 1950's that it was recognized that the cause was high concentrations of oxygen.So retrolental fibroplasia has nothing to do with obstetricians. No matter, Henci Goer is not bothered by a trivial matter like the truth of her claim.

Goer has attempted to use this smear tactic recently in response to my claims that obstetricians do follow the scientific evidence and it is NCB advocates who don't even know what the scientific evidence shows. In the comment section of Science and Sensibility, Goer writes:

"Amy Tuteur, MD: Obstetricians are following the evidence, and it is bizarre for NCB advocates, who don’t have a clue as to the entire depth and breadth of the scientific evidence, to suggest otherwise.

Obstetricians are following the evidence? Really? Let’s just list a few routinely and commonly used obstetric management practices about which there is NO controversy in the obstetric research that they are ineffective, harmful, and generally both when used routinely or frequently and in some cases, with any use at all:

* induction for suspected big baby
* artificial rupture of membranes
* no oral intake other than ice chips
* I.V.
* continuous electronic fetal monitoring
* confinement to bed
* active management of labor (treating labor progress slower than average with high-dose oxytocin)
* directed pushing
* pushing on one’s back or in a semi-reclined position
* episiotomy (Episiotomy is on the decline, but it was still used in 1/4 of women having vaginal birth in 2005.)
* immediate umbilical cord clamping
* separating newborns from their mothers shortly after birth
* cesarean surgery (The research literature supports a rate of no more than 15%. At rates higher than this, maternal and perinatal morbidity and mortality rates begin to climb.)

I’m sure I’ll think of others after I submit this, and, of course, this list does not include anything from the much longer list of practices and policies about which there is controversy but a good case can be made against them for routine or frequent use.

Standard Goer smear tactics:

1. Evil is implied but Goer presents no evidence for her claims.
2. Goer deliberately and falsely implies that hospital policies are obstetric policies. Separation of mother and baby is a hospital policy. You can argue against it, but you certainly can't claim that obstetricians said that scientific evidence showed that mothers and babies should be separated.
3. Goer does not consider herself constrained by the truth. A lie is fine if it serves the cause. Goer knows as well as I do that there is NO scientific evidence that a 15% C-section rate is optimal. The World Health Organization has even admitted that there is no scientific evidence for their recommendation and there never was any scientific evidence for that claim.

Goer presents herself as an "expert" on the obstetric literature, yet no one else seems to agree with her grandiose self-description. She is not called for expert testimony in court cases that turn on the obstetric literature. The government does not invite her to join expert panels on obstetric topics. In fact, the only people who consider Goer an "expert" on the obstetric literature are lay people who have no way to evaluate her self-proclaimed expertise.

Ms. Goer never appears in any venue where she can actually be questioned on her supposed expertise. She knows that her claims would be eviscerated in short order. She just continues to spread misinformation by flattering trusting women into believing that accepting her smears means that they are "thinking."

Do obstetricians ignore scientific evidence?

Natural childbirth advocates love mantras. They spread through the community, are quoted over and over, and become received wisdom as though by saying something enough times it might make it true. Classic NCB mantras include "pain is caused by fear" and "animals need privacy to birth successfully; so do humans." And let us not forget the infinitely stupid "trust birth."

Mantras change with time and in response to cultural values. In an age in which science is greatly respected, the most popular mantra is "obstetricians ignore the scientific evidence." All the celebrity natural childbirth advocates insists that this is so, and some of them might even believe it. Lamaze has taken the mantra to new heights, by renaming their blog Science and Sensibility, presumably to imply that NCB is based on science and common sense, though it is based on neither.

Barry Beyerstein, a professor of psychology at Simon Fraser University, wrote about the technique of applying a veneer of scientific respectability as a way to improve the status of pseudoscientific beliefs. As Beyerstein explains:

The prestige and influence of science in this century is so great that very few fields outside of religion and the arts wish to be seen as overtly unscientific. As a result, many endeavors that lack the essential characteristics of a science have begun to masquerade as one in order to enhance their economic, social and political status. While these pseudosciences are at pains to resemble genuine sciences on the surface, closer examination of the contents, methods and attitudes reveals them to be mere parodies. The roots of most pseudosciences are traceable to ancient magical beliefs, but their devotees typically play this down as they adopt the outward appearance of scientific rigor. Analysis of the perspectives and practices of these scientific poseurs is likely to expose a mystical worldview that has merely been restated in scientific-sounding jargon.

And that almost perfectly captures the current public relations ploy of choice among NCB advocates. What could sound more impressive that shouting from every hilltop that obstetricians ignore the scientific evidence, while NCB advocates are slaves to scientific rigor? The fact that the claim is a lie is beside the point. NCB advocates neither know the truth, nor care.

Let's examine the claim on the two levels apparently favored by Lamaze: sensibility and science.

If you say "obstetricians ignore the scientific evidence" fast enough, people won't stop to consider if it makes sense. But if we do stop to consider it, we might amplify it as follows:

We are supposed to believe that obstetricians (with 8 years of higher education, extensive study of science and statistics, and four additional years of hands on experience caring for pregnant women), the people who actually DO the research that represents the corpus of scientific evidence, are ignoring their own findings while NCB advocates (generally high school graduates with no background in college science or statistics, let alone advanced study of these subjects, and limited experience of caring for pregnant women), the people who NEVER do scientific research, are assiduously scouring the scientific literature, reading the main obstetric journals each month, and changing their practice based on the latest scientific evidence.

See what I mean? That makes no sense at all.

Consider someone like Amy Romano, the CNM who writes Science and Sensibility. It seems like Ms. Romano is a nice person; her heart is definitely in the right place. Nonetheless, she repeatedly presents her opinions as scientific facts, and routinely misrepresents the scientific literature. That's not surprising since she doesn't read it and, because of her deficits in basic science knowledge and understanding of statistics, is literally incapable of interpreting it on her own. She needs someone to tell her which papers are "important" and what they supposedly "mean." She does not review the literature before writing, she just assembles the papers that she likes, never bothers to read them, let alone analyze them. She makes this clear every time she is pressed to substantiate her claims; she can't do it, so she falls back on refusing to discuss anything with anyone who is "disrespectful" as if challenging her claims is a sign of disrespect.

And what does the scientific evidence on childbirth really show? There is virtually no support for ANY of the central tenets of NCB advocacy. Let's start with a favorite NCB claim that "lots of scientific papers show that homebirth is safe." When it comes to homebirth in the US, ZERO scientific papers show that homebirth is safe. Indeed EVERY paper written on the subject shows that homebirth increases the risk of neonatal or perinatal death, even the Johnson and Daviss BMJ paper that claims to show otherwise. National statistics on homebirth collected by the CDC from 2003-2005 (the only years published thus far) show that homebirth with a non-CNM midwife triples the rate of neonatal death, and homebirth with a CNM doubles the rate of neonatal death.

Consider other, easily verifiable claims:

Proper position speeds labor? No, no evidence for that.

Eating in labor gives women "strength" and improves outcomes? No, no evidence for that.

Babies won't breathe if delivered under water because of the diving reflex? The diving reflex works in cold water, not warm water.

Epidurals are dangerous? No, no evidence for that, either.

Indeed, I am hard pressed to come up with even a single NCB tenet that is based on scientific evidence. Oh, wait. I can think of one: breastfeeding is beneficial for your baby. But even that scientific evidence is misrepresented by NCB advocates, since the benefits are actually quite small.

The bottom line is that the NCB claim that "obstetricians ignore the scientific evidence" is a big lie. NCB advocates seems to think that if they say it loud enough and long enough everyone will believe. Unfortunately for them, both "Science" and "Sensibility" demonstrate that obstetricians follow the scientific evidence and NCB advocates don't even know what the evidence shows.