Waterbirth: Barbara Harper spreads stupidity

I suppose you can't expect much from someone who admits that her entire career is based on an article she read in the National Enquirer.

My introduction to waterbirth was an article in the National Enquirer of all places! Can you imagine basing two and a half decades of work for mothers and babies on that sensational news rag??

But Barbara Harper asserts the safety of waterbirth with such breathtaking stupidity that even I am shocked. That she believes she can get away with it tells me that she assumes that her followers are gullible fools. Given her popularity, she may just be right.

Harper is surely aware that babies drown at waterbirth. She must be aware that Ireland suspended waterbirths when baby Harry Eccles died of brain damage caused by drowning. She cannot possibly be ignorant of the fact that the waterbirth babies are born directly into the equivalent of toilet water that has been contaminated with fecal material. She must know that the American Academy of Pediatrics (AAP)has declared that waterbirth is not safe for babies. She is betting on the fact that her supporters don't know about the waterbirth deaths, don't understand that the water is contaminated with dangerous microorganisms and aren't aware of the pronouncements of the AAP.

Harper clearly thinks that keeping her followers ignorant of dangers of waterbirth is justified. But I can't fathom what led her to believe that she could simply make up scientific sounding gobbledy gook and pass it off as "facts."

Purveyors of pseudoscience take note: when it comes to spewing stupidity, Barbara Harper is in a class by herself. Consider the following, taken from Harper's explanation of Waterbirth FAQs:

What prevents baby from breathing under water?

There are four main factors that prevent the baby from inhaling water at the time of birth:

1. Prostaglandin E2 levels from the placenta which cause a slowing down or stopping of the fetal breathing movements. When the baby is born and the Prostaglandin level is still high, the baby's muscles for breathing simply don't work, thus engaging the first inhibitory response.

2. Babies are born experiencing mild hypoxia or lack of oxygen. Hypoxia causes apnea and swallowing, not breathing or gasping.

3. Water is a hypotonic solution and lung fluids present in the fetus are hypertonic. So, even if water were to travel in past the larynx, they could not pass into the lungs based on the fact that hypertonic solutions are denser and prevent hypotonic solutions from merging or coming into their presence.

4. The last important inhibitory factor is the Dive Reflex and revolves around the larynx. The larynx is covered all over with chemoreceptors or taste buds. The larynx has five times as many as taste buds as the whole surface of the tongue. So, when a solution hits the back of the throat, passing the larynx, the taste buds interprets what substance it is and the glottis automatically closes and the solution is then swallowed, not inhaled.

Every word in that explanation is a lie, with the possible exception of "and" and "the." And it's not merely a collection of lies. It is a collection of strikingly stupid lies, to boot. Either the woman is an idiot, and she thinks her followers are idiots, or both.

Let's look at each claim individually.

1. Prostaglandin E2 causes a slowing down or stopping of the fetal breathing movements.

This is both a lie and irrelevant. It is a lie because there is not a single study on humans or animals to support it. It's irrelevant because fetal breathing movements (practice breathing in the womb) are NOT the source of a baby's initial drive to breath. Lack of oxygen and build up of carbon dioxide stimulate neonatal breathing.

2. Hypoxia causes apnea and swallowing, not breathing or gasping.

Another bare faced lie. Hypoxia (lack of oxygen) makes it MORE likely that a infant will try to breath, not less.

3. So, even if water were to travel in past the larynx, they could not pass into the lungs based on the fact that hypertonic solutions are denser and prevent hypotonic solutions from merging or coming into their presence.

Oh, the stupid, it burns!

I guess Harper figured the use of the word "hypertonic" would impress her followers and trip them up. In chemistry, the suffix "tonic" refers to the concentration of electolytes and other dissolve components of cellular fluids. Isotonic is the the same concentration as cellular fluids; hypertonic means higher concentration (such as seawater), hypotonic mean lower concentration (such as freshwater).

The water in the tub at waterbirth is hypotonic; that much is true. All the rest is a giant lie. Lung "fluid" (whatever that is supposed to be) is isotonic, not hypertonic. The tonicity of a fluid has NOTHING to do with what can be mixed with it. Seawater is hypertonic. Fresh water is hypotonic. According to Harper, you couldn't add freshwater to a cup of seawater because the seawater would prevent the solutions from merging. You don't even have to try that experiment for yourself to know that Harper is babbling nonsense.

4. The last important inhibitory factor is the Dive Reflex.

Another lie. Harper is four for four!

The dive reflex exists, but it is not operating during waterbirth. The dive reflex is the reason that people sometimes survive long immersion in icy water. The extreme cold suppress breathing and slows down heart rate, decreasing the body's need for oxygen. The dive reflex works in COLD water, not warm water, and, of course, the water in the birth pool is warm, not icy cold.

The bottom line is very simple. Barbara Harper is a mendacious fraud. She lies and she spreads stupidity. Tragically, many women believe her.

Tell it to the judge

I just came across this surprising comment from Dr. Michael Klein, an emeritus professor of family practice, and a prominent critic of rising C-section rates. He is explaining how inductions prevent stillbirth and why we should ignore that life saving technique because natural labor is best:

Now, anxiety looms very large in childbirth, and a lot of people like to induce because it reduces this anxiety and makes their lives easier. And what's this anxiety about? Stillbirths. We don’t like those. But you'd have to induce one thousand women to prevent one stillbirth, and people just don't get their minds around that. If you induce one thousand women and prevent one stillbirth but have a 40 percent c-section rate, what have you done?

Let's look first at Dr. Klein's numbers. Dr. Klein intimates that preventing 1 perinatal death per thousand is trivial, but it's not. In a low risk population, the late perinatal mortality rate is less than 3 per thousand. So even 1 addition death dramatically raises the perinatal death death rate. That's hardly trivial.

Moreover, Dr. Klein seems to be suggesting that a C-section rate of 40% among women means that 40% of induced women have unnecessary C-sections. The latest data, however, seems to indicate that induction double the C-section rate. So out of that 40%, 20% were going to have C-sections anyway for unrelated reasons. And of course if a woman is having an induction for medical indications related to an increased risk of stillbirth (post dates, high blood pressure, poor fetal growth), it is likely that her baby is also at risk for intrapartum complications necessitating a C-section, regardless of whether or not she was induced. A more accurate representation, then is that saving one baby's life may lead to 100-200 unnecessary (in retrospect) C-sections.

Let's restate Dr. Klein's question more accurately: If you induce one thousand women and prevent one stillbirth but do 100-200 unnecessary (in retrospect) C-sections, what have you done?

What have you done? I think the answer is obvious. You've saved a baby's life!

What Dr. Klein is actually saying is this: it's worth letting babies die in order to lower the C-section rate.

Now Dr. Klein is certainly entitled to his opinion, but I'd like to see him explain it to a mother whose baby died just so he can boast about his low C-section rate.

"Yes, Mrs. Jones, your baby is dead, but think of what we've accomplished. You've had a natural labor, and I am quite sure that natural labor is best. But that's not all! You've saved lots of other women from having an unnecessary (in retrospect) C-sections and you've allowed me to maintain my low C-section rate."

I suspect that Mrs. Jones is not going to derive much consolation from that explanation. And while Dr. Klein might garner praise from natural childbirth advocates for maintaining a low C-section rate, other doctors will consider him foolish at best and thoroughly cynical at worst. No doctor is impressed with a low C-section rate bought at the price of preventable infant deaths. Anybody can lower his C-section rate if he is he content to let babies die.

But what I'd really like to see Dr. Klein do is tell it to the judge (at the malpractice trial, of course).

"Yes, judge, I completely agree with plaintiff's counsel that I could have prevented the death of Mrs. Jones' baby by offering her induction at 42 weeks."

"You agree?"

"Of course, it would be foolish to deny it. If I had induced Mrs. Jones her baby would be alive and healthy today, but I think we have accomplished something more important."

"More important than saving a baby's life?"

"Sure, Mrs. Jones avoided a C-section. We've demonstrated that natural labor is better. "

"Better? Better than what?"

"Better than a C-section that might have turned out to be unnecessary in retrospect. And that's not all, judge. Think of the 100 or more women who got to experience natural labor AND took home a live baby."

I doubt the judge will be impressed. But perhaps Dr. Klein can dazzle him with his "big picture thinking."

... And the uterine scar left after a c-section has great consequences for the next birth. You’re more likely to have placenta previa or an invasive placenta, more likely to need another c-section, have an ectopic pregnancy, be infertile, and have a stillbirth. Now look what happened — we induced the first birth to prevent a stillborn, and now the second pregnancy is more likely to end in stillbirth. The thought process that leads to an induction is not big-picture thinking.

Let's look at the big picture, and increase Dr. Klein's cohort from 1,000 to 100,000. Using Dr. Klein's numbers, 100,000 inductions would save the lives of 100 babies and lead to 10,000-20,000 additional unnecessary (in retrospect) C-sections. Studies of stillbirth after C-section show and increased relative risk anywhere from 0-1.5. At a late stillbirth rate of 3/1000, that would mean an increased stillbirth rate of 4.5/1000 or an excess of 1.5 stillbirths/1000.

If 20,000 women had unnecessary (in retrospect) C-sections, we would expect an extra 30 stillbirths if everyone in that group had a subsequent pregnancy. What's the big picture? The worst case scenario (assuming a high relative risk of stillbirth in subsequent pregnancies, and a subsequent pregnancy rate of 100%) is that in saving 100 existing babies in current pregnancies, we would theoretically put at risk a maximum of 30 babies in future pregnancies. So the big picture is a net saving of the lives of 70 babies.

Let me be very clear. I'm not suggesting that an even one unnecessary C-section is desirable. I would be the first one to promote any technique that improved our ability to accurately detect babies in distress and thereby avoid unnecessary C-sections. But until such technology arrives, we must work with what we have. And what we have a system that leads to unnecessary C-sections but saves substantial numbers of lives in the process. As I explained in a recent post, the induction rate is rising and perinatal mortality is falling. Therefore, I strongly disagree with Dr. Klein's rather disingenuous argument; a natural labor is not best, a live baby is best. Period.

Is breastmilk food?

That's a bizarre question. Obviously breastmilk is food. Why would anyone say otherwise? To get a tax-break, of course.

Lactivists are angry that the Internal Revenue Service has ruled that breastfeeding is not a form of medical care and therefore, breastfeeding supplies such as pumps cannot be purchased with money from tax sheltered health accounts.

According to an article in today's New York Times, Breast Pumps Lack Tax-Sheltered Status:

Denture wearers will get a tax break on the cost of adhesives to keep their false teeth in place. So will acne sufferers who buy pimple creams.

People whose children have severe allergies might even be allowed the break for replacing grass with artificial turf since it could be considered a medical expense.

But nursing mothers will not be allowed to use their tax-sheltered health care accounts to pay for breast pumps and other supplies.

Why? Because the IRS considers breastmilk to be food, not medical care.

This is nothing new. Breastfeeding supplies have never qualified as medical care, but lactivists and pediatricians were advocating for a change in the rules.

Despite a growing body of research indicating that the antibodies passed from mother to child in breast milk could reduce disease among infants — including one recent study that found it could prevent the premature death of 900 babies a year [debunked here] — the I.R.S. has denied a request from the American Academy of Pediatrics to reclassify breast-feeding costs as a medical care expense.

Perhaps lactivists overreached by dramatically inflating the cost of breastfeeding supplies:

... The cost of buying or renting a breast pump and the various accessories needed to store milk runs about $500 to $1,000 for most mothers over the course of a year, according to the United States Breastfeeding Committee, a nonprofit advocacy group.

That might have been true two decades ago when my oldest children were born, but it is a gross exaggeration now. State of the art double electric breast pumps can run $300 or more, but electric breast pumps can be purchased for under $100 and manual pumping supplies for less.

But the IRS' stated reason for denying tax sheltered status is the characteristic enthusiastically embraced by lactivists themselves: breastfeeding is natural.

I.R.S. officials say they consider breast milk a food that can promote good health, the same way that eating citrus fruit can prevent scurvy. But because the I.R.S. code considers nutrition a necessity rather than a medical condition, the agency’s analysts view the cost of breast pumps, bottles and pads as no more deserving of a tax break than an orange juicer.

Where does that leave lactivists and breastfeeding mothers? It leaves them free to push for tax breaks for breastfeeding on the grounds that it is a behavior we wish to encourage and we promote tax breaks for all sorts of behaviors we wish to encourage (replacing refrigerators with more energy efficient models, rewarding retirement planning, etc). But pretending that breastfeeding is medical care is not going to work.

Best nutrition advice ever!

When it comes to high profile nutrition studies, Dr. John Ioannidis has some surprising advice: Just Ignore It!

Who is Dr. Ioannidis and why should you listen to him? Dr. Ioannidis was recently profiled in The Atlantic under the provocative title Lies, Damned Lies, and Medical Science. Dr. Ioannides is a physician and meta-researcher. In other words, he is a researcher who studies research.

... He and his team have shown, again and again, and in many different ways, that much of what biomedical researchers conclude in published studies ... is misleading, exaggerated, and often flat-out wrong. He charges that as much as 90 percent of the published medical information that doctors rely on is flawed.

Dr. Ioannidis was an early proponent of evidence based meedicine (EBM) a movement designed to regularize medical practice by determining the evidence and then applying it. He quickly ran into a very serious problem:

... Ioannidis was shocked at the range and reach of the reversals he was seeing in everyday medical research... Baffled, he started looking for the specific ways in which studies were going wrong. And before long he discovered that the range of errors being committed was astonishing: from what questions researchers posed, to how they set up the studies, to which patients they recruited for the studies, to which measurements they took, to how they analyzed the data, to how they presented their results, to how particular studies came to be published in medical journals.

It's not really all that surprising when you consider the rationale behind medical journals. Lay people, and even some scientists, treat publication in a scientific journal as the end of the scientific process. In fact, it's merely the beginning. Publication in a scientific journal does NOT mean that the paper is true; it merely means that it is worthy of being considered as part of the conversation.

Anyone who has ever read a scientific journal knows that research papers are divided into four parts: introduction, methods, results and discussion. The methods section requires the author to explain exactly what was done and how it was done, with the express purpose of allowing other scientists to repeat the experiment to verify it. The results section must include the actual findings as well as the statistical analysis that led the authors to their conclusions. Again, the purpose is so that other scientists can evaluate whether the data was analyzed using the correct statistical methods. In other words, the underlying assumption is that each and every scientific paper might be wrong and the only way we can know for sure is if we try to repeat the experiment and/or analyze the results for ourselves. It turns out that a lot of scientific papers are nothing more than junk.

Consider high profile nutrition research:

When a five-year study of 10,000 people finds that those who take more vitamin X are less likely to get cancer Y, you’d think you have pretty good reason to take more vitamin X, and physicians routinely pass these recommendations on to patients. But these studies often sharply conflict with one another. Studies have gone back and forth on the cancer-preventing powers of vitamins A, D, and E; on the heart-health benefits of eating fat and carbs; and even on the question of whether being overweight is more likely to extend or shorten your life. How should we choose among these dueling, high-profile nutritional findings? Ioannidis suggests a simple approach: ignore them all.

Why?

... even if a study managed to highlight a genuine health connection to some nutrient, you’re unlikely to benefit much from taking more of it, because we consume thousands of nutrients that act together as a sort of network, and changing intake of just one of them is bound to cause ripples throughout the network that are far too complex for these studies to detect, and that may be as likely to harm you as help you.

Moreover:

... Even if changing that one factor does bring on the claimed improvement, there's still a good chance that it won't do you much good in the long run, because these studies rarely go on long enough to track the decades-long course of disease and ultimately death. Instead, they track easily measurable health “markers” such as cholesterol levels, blood pressure, and blood-sugar levels, and meta-experts have shown that changes in these markers often don’t correlate as well with long-term health as we have been led to believe.

That's why short term studies are often later over turned when the results of long term studies become available:

For example, though the vast majority of studies of overweight individuals link excess weight to ill health, the longest of them haven’t convincingly shown that overweight people are likely to die sooner, and a few of them have seemingly demonstrated that moderately overweight people are likely to live longer.

And caveats don't even include the errors that often riddle scientific publications:

... ubiquitous measurement errors (for example, people habitually misreport their diets in studies), routine misanalysis (researchers rely on complex software capable of juggling results in ways they don't always understand), and the less common, but serious, problem of outright fraud...

So where does that leave the average consumer? Dr. Ioannidis' advice is spot on. When it comes to breathless nutritional claims, ignore them all. Vitamin supplements are generally useless except when treating documented vitamin deficiencies (like scurvy and pellagra), specific foods do not prevent cancer and will not help you to live longer, and just because something is harmful in large amounts does not mean that moderate amounts are moderately harmful (obesity is bad, mild to moderate overweight may actually be good).

Don't change your eating habits based on the latest research results reported in newspapers. It may be spurious, flat out false or only true in the short term and not over time. Don't be the first on your block to try the newest supplement or dietary advice. Wait until data has been collected from tens of thousands of people over many years. And above all, don't mistakenly conclude that because something has been published in a peer reviewed scientific journal, it must be true. Many papers published in scientific journals are nothing more than junk.

Pseudo-knowledge

Alternative health advocates, regardless of their specific beliefs, are all supremely confident about one thing. Whether they are vaccine rejectionists, natural childbirth advocates or aficionados of vitamins and supplements, they are absolutely sure that they are more "educated" than the rest of us. They are not "sheeple" who blindly follow whatever advice their doctor offers; they have done extensive "research" on the internet, and they know things that they did not know before, and that the rest of us do not know at all.

It is certainly true that advocates of alternative health have often done a great deal of reading. And it is true that they have learned lots of new things. But what they fail to understand is that they have acquired pseudo-knowledge. It has the appearance of real knowledge; it uses lots of big words, and it often includes a list of scientific citations. There's just one teensy problem; it's not true.

We are surrounded by pseudo-knowledge in everyday life and most of us understand that it isn't true. Advertisements of all sorts of products, both legitimate and bogus, and filled with pseudo-knowledge. Most of us are quite familiar with the language of pseudo-knowledge:

"Studies show ..."
"Doctors recommend ..."
"Krystal S. from Little Rock lost 30 pounds in 30 days ..."

In the era of patent medicine, claims like these were usually enough to sell a product. But consumers have become more jaded and the language of pseudo-knowledge has become more sophisticated as a result. Consider this explanation of the benefits of acai, the current favorite among the scourge of bogus nutritional claims. According to Dr. Perricone (a real doctor!):

The fatty acid content in açaí resembles that of olive oil, and is rich in monounsaturated oleic acid. Oleic acid is important for a number of reasons. It helps omega-3 fish oils penetrate the cell membrane; together they help make cell membranes more supple. By keeping the cell membrane supple, all hormones, neurotransmitter and insulin receptors function more efficiently. This is particularly important because high insulin levels create an inflammatory state, and we know, inflammation causes aging.

This exerpt is classic pseudo-knowledge. It contains big, scientific words and sounds impressive. It contains actual facts, although they are entirely unrelated to the benefit being touted. It contains completely fabricated claims that have no basis in reality ("they make the cell membrane more supple") and which, not coincidentally trade on the gullibility of some lay people (if my skin is no longer supple, it must be because the membranes of the individual cells are not supple) and it asserts that "we know" things that are flat out false.

Acai has been little more than a giant credit card scam. After tricking people with such language, unscrupulous advertisers have offered to send a "free supply" in exchange for a credit card number. The acai may or may not show up, but the credit card is billed for a large amount regardless.

Vaccine rejectionists are being scammed in exactly the same way. They are proud that they are not pathetic "sheeple." Just because their doctor tells them that vaccines are safe, effective and one of the greatest public health successes of all time doesn't persuade them. They want to "educate" themselves to understand the issues involved.

What might you need to know to evaluate the safety and effectiveness of vaccination? Obviously, you need an understanding of immunology including an understanding of the difference between cellular and humoral immunity, and the formation of antibodies. You need a basic understanding of virology with emphasis on protein coats, and the difference between live, attenuated and fragmented viruses. And of course, you need an understanding of statistics as applied to large populations over long periods of time.

But wait! Science is hard and that's unfair. Who has the time, the background or the ability to understand the fundamentals of immunology? Not vaccine rejectionists. Their knowledge of virology does not extend beyond a recognition that there are two kinds of "germs," bacteria and viruses. And their knowledge of math often trails off at basic arithmetic, leaving them no way to understand statistics, even if they bothered to read the relevant texts.

So if they're not reading about immunology, and if they're not reading about virology, and if they're not analyzing statistics, what exactly are they doing when they "educate" themselves? They are simply acquiring a large body of pseudo-knowledge.

Much of what they think they know is flat out false ("the incidence of vaccine preventable diseases was falling before vaccines were introduced"), is anecdotal information proving nothing about anything ("Jenny McCarthy cured her son of autism!"), or goofy conspiracy theories that are ludicrous on their face (the entire medical pharmaceutical complex is aware that vaccines are not safe and not effective but they're giving them to their own children anyway.).

The natural childbirth crowd, is, if anything, even more aggressive in its ignorance. Vaccine rejection is touted by quacks and charlatans, Playboy bunnies and physicians who stand to profit from encouraging fear of vaccination (Dr. Andrew Wakefied, Dr. Bob Sears). No one in the medical profession takes them seriously; they are professional embarrassments. In contrast, the natural childbirth philosophy is part and parcel of midwifery. Both academic midwifery experts and celebrity midwives spew absolute nonsense and call it "knowledge".

Barely a week passes on this blog without a lay person parachuting in to boast of all she has "learned" from the likes of Henci Goer, Amy Romano, Barbara Harper or Ina May Gaskin. And don't even get me started on Ricki Lake; she just makes it all up as she goes along. Their assertions mark them just as effectively as if they had tattooed "gullible" on their forehead."

"The US ranks poorly on infant mortality." But that's a measure of pediatric care, not obstetric care. Perinatal mortality is a measure of obstetric care and the US does very well on that measure.

"The majority of births in the Netherlands are homebirths and it ranks highly on measures of obstetric care." Only 30% of births in the Netherlands are homebirths and the Netherlands has the highest perinatal mortality rate of any Western European country.

"Johnson and Daviss published a paper in the BMJ that showed that homebirth is safe." The Johnson and Daviss paper is a bait and switch that shows exactly the opposite of what it claims.

"Homebirth is Canada is safe." Canadian homebirth midwives have far more education, training, supervision and restrictions than American homebirth midwives.

When it comes to homebirth and natural childbirth advocates just about everything they think they "know" is factually false. The same is true for vaccine rejectionists and most other purveyors or advocates of alternative health.

The truth about health education is both simple and stark. You cannot be educated about any aspect of health without reading and understanding scientific textbooks and the scientific literature. Period!

Don't waste your time perusing the internet. Unless you are willing to confirm what you read on the internet by reading the scientific literature, you can't be sure you've learned anything.

Don't bother to tell the rest of us that you are "educated" because you've demonstrated nothing more than your gullibility. You haven't acquired knowledge, you've acquired pseudo-knowledge, and it marks you as a fool.

Informed refusal: the natural childbirth fantasy

The natural childbirth literature is replete with references to informed refusal. Curiously, this same literature does not explain what informed refusal involves, or type of information a patient might require to be capable of making an informed refusal. Perhaps most importantly, natural childbirth literature counseling informed refusal neglects to mention the most important component: the risks of forgoing treatment.

Consider Judith Lothian's article Saying "No" to Induction, published in the Journal of Perinatal Education, a publication of Lamaze International. The article is anything but neutral on the issue. The underlying assumption of the article is that induction is not necessary and is done for doctor convenience.

According to Lothian:

... Women are encouraged to appreciate the last days and weeks of pregnancy and to have confidence that when a woman's body and her baby are ready, labor will begin spontaneously. This information, as well as knowledge of how induction alters the process of normal labor and birth and increases the possibility of having a near-term infant, is the foundation for informed refusal.

Let's look at the legal definition of informed refusal:

Just as a patient needs adequate information to be able to accept proposed treatment, he or she needs information to be able to decline or refuse it. However, because the informed consent doctrine grew out of the tort of battery, it has not always been clear that a physician has an obligation to provide information in a situation where the patient is forgoing treatment. Truman v. Thomas, decided by the California Supreme Court in 1980, is often cited for the principle of "informed refusal." Truman held that a physician who recommends a procedure—in that case, a diagnostic Pap smear test—must ensure that a patient who rejects this recommendation understands the consequences of not having the test.

In other words, the foundation of the doctrine of informed refusal is an understanding of the consequences of refusing the intervention. A discussion of the possible disadvantages of the intervention is, of course, part of the process, but it doesn't meet the basic requirement.

Lothian continues:

... To make an informed decision—either informed consent or informed refusal—women need to know the value of waiting for labor to start on its own. The last days and weeks of pregnancy are vitally important for both the mother and her baby. The end of pregnancy is as miraculous as its beginning. It's a lot easier to say “no” to induction if the mother knows the essential and amazing things that are happening to prepare her body and her baby for birth.

Fair enough. But Lothian's discussion of these issues veers from inane to factually false. The inane:

Thinking of, and clinging to, the "due date" as "the day" makes it difficult for women to trust nature's beautiful plan for the end of pregnancy and the start of labor.

No. Nature is not a person. Nature does not have a "plan," beautiful or otherwise, and it is quite possible for a pregnancy to "naturally" end in a dead baby. Indeed the risk of stillbirth begins to climb before the due date (40 weeks), and rises dramatically after 42 weeks.

The factually false:

... Pitocin does not cross the blood-brain barrier; therefore, endorphins are not released in response to the increasingly strong and painful uterine contractions. Laboring women do not experience the benefits of endorphins as they try to manage their contractions. Additionally, without the help of endorphins, they are likely to require an epidural...

That's a bunch of baloney. There is no evidence that pitocin is required to cross the blood brain barrier for endorphins to be produced. There is no evidence that women with higher levels of endorphins have less pain. And there is no evidence that a deficit in endorphins is what leads women to request and epidural.

Lothian goes on to bemoan the potential increase morbidity of early induction (although she has not established that most inductions are done "early"). Curiously, she is entirely silent on the issue of mortality. That's a rather strange omission considering that the primary reason for induction of labor is usually to prevent a stillbirth from postdates, pre-eclampsia, or other causes. Perhaps she left it out because it completely undermines her case. As the rate of labor induction has risen in the past two decades, the rate of late stillbirth has dropped dramatically. In other words, labor induction appears to do precisely what it is designed to do.

What does Lothian have to say on the benefits of labor induction?

Nature is not perfect. However, when it comes to babies and birth, unless there is a clear medical indication that induction of labor will do more good than harm, nature beats science hands down. For both mothers and babies, it is safe and wise to wait patiently until labor begins on its own.

What are those clear medical indications? Lothian doesn't say, and if you don't specify the indications, a woman cannot give informed refusal. It is safe and wise to wait until labor begins on its own? Where's the evidence for that claim?

Lothian is vague on when induction is appropriate, but she is quite sure that it is the job of childbirth educators to encourage patients to refuse.

Saying "no" to induction and to other interventions that are becoming routine takes courage and confidence, as well as the knowledge that women have the right to informed refusal. What women learn from you about nature's plan for labor and birth, including the beauty of waiting for labor to start on its own and the risks of interfering without clear medical indication, will insure that the women you teach will have the information they need to confidently say "no" to routine induction.

But "saying no" is not the same thing as informed refusal. Yes, women have to right to refuse treatment, but they can only be informed if they understand the risks. Saying no does not require courage or confidence, nor are courage and confidence remotely relevant when making medical decision. Information is what is required, and Lothian provides precious little. She leaves out the most important piece of information, the mortality rate, and she does not bother to quantify the purported risks.

The law is clear on what is necessary to be informed:

... [The] elements are: the diagnosis; the nature and purpose of the proposed treatment; the risks and consequences of the proposed treatment; reasonably feasible alternatives; and the prognosis if the recommended treatment is not provided.

Lothian provides essentially no information on any of these critical elements. Without them, there is no such thing as informed refusal. There is only petulantly "saying no" and possibly living to regret the consequences.

Childbirth, risk and the illusion of control

Garrison Keillor famously explained that all the children in Lake Woebegone are above average. Maybe homebirth and natural childbirth advocates come from Lake Woebegone. They appear to believe that when in comes to childbirth complications, all of them are at below average risk.

Natural childbirth and homebirth advocates like to tell themselves and each other to "trust birth." They consider it a practical strategy, and appear not to realize that it is a common cognitive error known as "optimistic bias." Simply put, individuals tend to underestimate their risk of various bad outcomes, regardless of known statistics and often in the face of known risk factors. For example, many smokers rationalize their smoking by estimating that their personal risk of getting lung cancer is much lower than it really is.

The paper Unrealistic Optimism About Susceptibility to Health Problems: Conclusions from a Community-Wide Sample, written by Neil Weinstein, was published in 1986. It has been cited by no fewer than 962 other scientific papers because its descriptions and insights are so important. The article explores different reasons for optimistic bias. Although the paper is not specifically about childbirth, its descriptions and conclusions seem particularly apt in considering the current emphasis among childbirth advocates on "trusting birth."

There are two sources of optimistic bias that seemly particularly apt in describing the outlook of natural childbirth and homebirth advocates. The first is a cognitive error that is often made in connection with uncommon events:

... Any factor that makes us think our own risk is low could lead us to claim that we are below average in risk if we fail to recognize that the same factor may apply to others as well. From this point of view, hazards rated low in frequency could lead to optimistic biases in comparative risk judgments because we forget that the hazards are just as unlikely to strike our peers. Similarly, lack of experience with a problem may make it difficult to imagine how it might affect us and lead us to claim that our own risk is below average....

When considering the chance of being affected by an uncommon event, NCB and homebirth advocates believe that however uncommon the even is, it is even less likely to happen to them than the average person. They fail to realize that they are average persons.

Second:

... [P]eople use their past experience to predict their future vulnerability. For many hazards, people seem to hold the mistaken belief that if they have not yet experienced the problem, they are exempt from future risk (absent/exempt)... [P]eople may believe that vulnerability is a constitutional matter, so if the problem has not appeared, their bodies must be resistant. Furthermore, some problems may seem to be caused by one's behavior or personality (e.g., obesity and drug addition), and people may conclude that the absence of a problem at their age means that they do not have the weakness of character that allows it to develop.

This strategy is also favored by NCB and homebirth advocates. They never had a health problem before, so they assume they will not develop a problem during childbirth. They had a successful homebirth in the past, so they assume all future homebirths will be successful. They "eat right" and stay "informed" so they will not be prey to childbirth complications.

Weinstein conducted interviews with almost 300 individuals, evenly divided between men and women. The participants were asked to evaluate their risk of developing each of 32 different conditions. The most remarkable finding is the most basic. Participants judged themselves to be less likely than average to develop virtually every single condition or disease (31 out of 32).

Although respondents believed themselves to be at less risk than average for virtually every event ranging from developing asthma, to breaking a bone, to being mugged, there were difference in how much less they thought they faced.

Consistent with predictions and with previous studies, optimistic biases increase with perceived preventability, with perceived embarrassment, and most strongly, with the belief that one is exempt from risk if the problem has not yet appeared...

Moreover:

Optimistic biases decrease with experience, perceived frequency, and the perceived extent of others' worry. Optimism was unrelated to perceived seriousness.

In other words, respondents judge their risk of experiencing a bad outcome as markedly lower than average if they thought that they could prevent the outcome, if the outcome was embarrassing, or if they had no personal experience of the outcome. That sounds like an excellent description of NCB and homebirth advocates' approach to the inherent risks of childbirth. They falsely believe that they have the power to prevent bad outcomes; they will be embarrassed in front of their peers in the NCB or homebirth movement if they have a bad outcome; and they erroneously believe that if they have no personal experience of the bad outcome it isn't likely to happen to them.

Weinstein found that, amazingly, actual risk factors don't seem to moderate individuals' assessment of personal risk:

... Cigarette smoking is a powerful risk factor for many illnesses. It is strongly correlated with subjects' judgments of lung cancer risk, has a small correlation with risk judgments for heart attack and cancer in general, and has no significant correlation with the perceived risk of stroke. Furthermore, except for frequency of drinking, none of the other behavioral risk factors is correlated with perceived risk. There is no association between auto safety belt use and perceived risk of injury in an auto accident, between excercise or dietary cholesterol and heart disease risk, or between flossing of one's teeth and vulnerability to gum disease. Even for drinking, the relationship between the behavior and the perceived risk is optimistically skewed. What one finds is that 77% of the people who never drink place themselves in the lowest comparative risk category, but of those who drink alcoholic beverages four or more times a week, only 18% place themselves in any of the above average risk categories. In other words people give themselves credit when they do not drink but do not acknowledge that frequent drinking may place them in a higher than average risk category.

NCB and homebirth advocates practice the same strategy of denial. Twins, breech and VBAC are well known risk factors for bad outcome yet NCB and homebirth advocates (including homebirth midwives) insist that these are not "high risk" situations.

Weinstein concludes:

... The principal characteristics determining the amount of bias elicited by the 69 different hazards that have been considered were (1) the belief that if the problem has not yet appeared, one is exempt from future risk; (2) the perception that the problem is preventable by individual action; (3) the perception that the hazard is infrequent; and (4) lack of experience with the hazard. If a hazard had such characteristics, people had a strong tendency to conclude that their own risk was less than the risk faced by their peers...

Not only do these factors account for individuals' underestimation of their personal risk, I suspect that the same factors account in large part for the difference in outlook between obstetricians on the one hand and NCB and homebirth advocates on the other. Doctors KNOW that just because a problem has not developed in the past does not mean it can't happen in the future; doctors KNOW that most pregnancy complications have nothing to do with individual action; doctors KNOW that infrequent events do happen; and, perhaps most importantly, doctors have direct personal experience of these complications occurring in low risk women.

NCB and homebirth advocates like to pretend that doctors "pathologize" birth. The reality is exactly the opposite. NCB and homebirth advocates are in denial about the risk of developing childbirth complications. They trumpet their philosophy of "trusting birth" without having any idea that it marks them as hopelessly ignorant of actual risks, in deep denial about their personal risk, and so naive that they believe that if they haven't heard of it, it can't happen to them.

Alternative health and the evidence double standard

Proponents of "alternative" health have a deeply fraught relationship with scientific evidence. On the one hand, even the most outlandish forms of pseudoscience attempt to invoke the imprimatur of science. Their claims range from the simple ("studies show ...") to the elaborate (lists of scientific citations of papers that appear to support the claims being advanced, but actually do not). On the other hand, when scientific evidence undermines their claims, advocates of "alternative" health suddenly discover that scientific evidence is not "applicable" to their claims or is "not enough" to guide clinical decision making.

As Professor Rory Coker explains:

Pseudoscience appeals to the truth-criteria of scientific methodology while simultaneously denying their validity. Thus, a procedurally invalid experiment which seems to show that astrology works is advanced as "proof" that astrology is correct, while thousands of procedurally sound experiments that show it does not work are ignored...

Something similar plays out in virtually every pseudoscience. Consider vaccine rejectionism. On the one hand, vaccine rejectionists brandish scientific papers that show deleterious effects of various vaccine components like thimerosol or, the current favorite, aluminum. Leaving aside for the moment that the papers are typically not directly relevant (involving related but different chemicals, involving massive amounts as compared to the minuscule amounts present in vaccines), these are real scientific papers containing valid scientific evidence.

But, unfortunately for vaccine rejectionists, there are tens of thousands of scientific papers that demonstrate the safety and effectiveness of vaccines. It is difficult even for vaccine rejectionists to ignore this large body of evidence. In contrast to the scientific papers that they like, this mass of scientific research, is not accepted on its face. When trying to persuade the unsophisticated, scientific evidence is explicitly rejected ("vaccine preventable diseases were decreasing BEFORE vaccines were invented"). If the audience is more sophisticated, a more subtle approach is required. In that case, specific poorly done papers are critiqued, never mind that they aren't particularly representative of the literature as a whole.

This double standard is deftly summarized by Edzard Ernst MD, PhD, FMedSci, FSB, FRCP, FRCPEd in a brief editorial in the journal he edits, Focus on Alternative and Complementary Therapies (FACT). Prof. Ernst is the bete noire of "alternative" health. His credentials are impeccable. He was the first Professor of Complementary Medicine in the UK. Born and trained in Germany, he began his career at a homeopathic hospital. His belief in "alternative" health was so complete, he set out to show that its various remedies are both safe and effective.

But what he found apparently shook him to the core. His 700 published papers represent a lifetime of research that led him to conclude that only 5% of "alternative" medicine is backed by scientific evidence. The other 95% has either not been studied or has been definitely shown to be ineffective, unsafe, or both. Not surprisingly, Dr. Ernst is now viewed as "the scourge of alternative health."

Dr. Ernst begins by reviewing the relationship between "alternative" health and evidence based medicine:

I have said it so often that I hesitate to say it again: the concepts of EBM are not a threat but an unprecedented opportunity for CAM [Complementary and Alternative Medicine]. EBM does not focus on mechanisms of action or basic sciences ... It merely asks, 'does it work?' This open-minded approach is therefore uniquely suited for testing the value of CAM ...

Alas:

What I have seen happening recently is almost the opposite. If the results do not fit the preconceived ideas of CAM proponents, the findings tend to be dismissed. In such instances CAM enthusiasts tend to declare the studies in question to be fatally flawed. If trial after trial is negative, the old argument re-emerges ... Scientific rationality, they argue, is for testing washing machines and guns but 'for understanding what passes between humans… [it] is not adequate'...

In other words, there is a double standard:

Rigorous proof, it seems, is the standard for conventional health care, and study designs that cannot possibly generate a negative result are being promoted as the standard that CAM enthusiasts would like to see applied to CAM. Observational data might then masquerade as proof of effectiveness, while unbiased studies are deemed to be not applicable to CAM.

... Scientific testing of CAM is acceptable, perhaps even desirable ... but the results have to be positive. If they are not, then the level of scientific rigor is swiftly lowered until finally – BINGO – a (false)-positive result is being generated. Science has thus become a tool not for testing (its true purpose) but for proving that one's preconceived ideas were correct.

Increasingly, that double standard is being wielded by midwifery and natural childbirth advocates. For example, the recently published Wax study that showed homebirth to have triple the neonatal mortality rate of hospital birth was excoriated by midwives and homebirth advocates for a variety of methodological flaws. Suddenly midwives and homebirth advocates were deeply concerned about sample size, data quality and methodological rigor. Curiously, they have never demonstrated the same concern for the most widely quoted study on homebirth, the Johnson and Daviss BMJ 2005 study, which suffers from such grievous methodological flaws that it is completely invalid.

In other words, midwifery and homebirth advocates follow the playbook for pseudoscience:

If the results do not fit the preconceived ideas of natural childbirth advocates, the findings tend to be dismissed. In such instances NCB advocates declare the studies in question to be fatally flawed. If trial after trial is negative, the old argument re-emerges: evidence doesn’t hold all of the answers.

Rigorous proof is the benchmark for conventional health care. It is not the benchmark in NCB advocacy. Scientific research is acceptable, but the results have to be positive. If they are not, then the level of scientific rigor is swiftly lowered until finally the desired (but false) result is achieved. Science has thus become a tool for proving that one's preconceived ideas were correct... And that's a double standard.

The top 5 reasons to ignore homebirth deaths

Dead babies are difficult to sweep under the rug. Everybody notices.

The standard strategy of homebirth advocates is to claim that homebirth is as safe as hospital birth. They point to poorly done studies published by those with a vested interest in promoting homebirth. They compare mortality rates at homebirth with high risk hospital birth. They point to international comparisons of infant mortality (which is a measure of pediatric care, not obstetric care). You can fool lots of laypeople with that misinformation, but it's not particularly persuasive when there are repeated reports of homebirth deaths.

On Mothering dot com there is approximately 1 homebirth death per month and has been for years. National mortality statistics for homebirth midwives are dismal and individual states like Colorado have truly appalling death rates at homebirth. Perhaps most difficult to sweep under the rug are the individual stories of homebirth deaths such as those recounted in The Daily Beast or on personal blogs. As much as homebirth advocates would like to pretend that these deaths don't happen, they can't pretend that these stories are not real. At that point, the fallback strategy is to insist that these homebirth deaths don't count.

Although homebirth advocates have many reasons for ignoring homebirth deaths, some reasons are more popular than others. What follows is a list of the "Top 5 Reasons to Ignore Homebirth Deaths." Feel free to suggest others that should be added to the list.

Number 5: It was the mother's fault.

This is always the first reason. We should blame the mother because ...

... the baby was breech; there were twins; it was a VBAC. Never mind that homebirth midwives in states like Oregon insist that these women are not high risk. If the baby dies, suddenly risk becomes important.

... the mother ignored the midwife. The story typically does not mention that, but homebirth advocates love to pretend that is what happened and then rhapsodize on the midwife's professional obligation to attend the patient anyway.

... the mother dared to complain that her baby died. This isn't the cause of death, but it shows that the mother is a bad person and we don't need to be upset that her baby died.

Number 4: It was the midwife's fault.

Surely the midwife must have handled the situation improperly. A "good" homebirth midwife never has a perinatal death, so the fact that the baby died "proves" that a bad midwife was attending in this case. All the other homebirth midwives in the world, with the exception of this midwife, are safe practitioners.

Number 3: This baby would have died in the hospital.

This excuse is almost always rendered in the following fashion: "We don't really know the details in this case; it's just as likely that this baby would have died in the hospital." In other words, it's basically the baby's fault and no one could have saved it. There's never any explanation as to why the hospital would not have been able to save this particular baby. No real explanation is ever needed in order to counsel others to ignore the death.

Number 2: Some babies died in hospitals.

Okay, maybe this baby could have been saved at the hospital, but so what? Some babies die in the hospital, right? Therefore, that proves that giving birth in the hospital is just as dangerous as giving birth at home.

Umm, no it doesn't. Yes, some babies die in the hospital, but those babies are almost always premature or have congenital anomalies incompatible with life. The issue is not whether some babies die in hospitals, but whether babies die of preventable causes in the hospital.

This also ignores the fact that MORE babies die at home than in the hospital. More dead babies means homebirth is more dangerous. The fact that some babies die in hospitals tells us nothing about the relative safety of homebirth and hospital birth.

And the Number 1 reason why we should ignore homebirth deaths: Babies die.

Homebirth advocates express a surprising amount of fatalism about homebirth deaths. The following comment is representative of this viewpoint:

First of all, Amy, babies (and mothers) die. It's a fact of life. You will never have 100% survival rate. So what's acceptable? Knowing that there was nothing that could have been done or that if you had have done something, you may well have ended up with a baby that was so damaged, it would have been better off dead. For others, it's knowing that it's God's Will. You are arguing against religious and personal freedom by saying that we should treat all women the same.

Weitz and Sullivan quote a homebirth midwife in Licensed Lay Midwifery and the Medical Model of Childbirth:

Basically one of the things I object to about the medical profession is their one hundred per cent rule, their unwillingness to accept the fact that sometimes people are just supposed to die or babies are just supposed to die or that there is a place for less than perfect and less than one hundred per cent.

So there you have it, folks. No need to worry about those dead homebirth babies. It was the mother's fault. Or maybe it was the midwife's fault. Or maybe it was the baby's fault. If all else fails, just declare that "babies die." It's sad, but "shit happens." Sure a lot of "shit happens" at homebirths, but that doesn't mean that homebirth isn't safe, does it? Does it? Nah ... it's just an unfortunate coincidence.

Inexcusable homebirth death toll in Colorado keeps rising

Heads up, Colorado Legislature!

You will be conducting a sunset review of Colorado's Midwives Practice Act 2011. According to the Colorado Office of Midwifery Regulation:

...The Sunset process is an opportunity to look critically at the statutes – whether regulation by the Department of Regulatory Agencies is necessary to protect the public health, safety and welfare. In addition, the operation of the agency is reviewed to ensure consistency, efficiency and effectiveness; and evaluate if administrative and statutory changes are necessary to improve the regulation of its practice...

Here's what you need to know:

The death toll of homebirth in Colorado is enormous and RISING!

Last year I wrote about the horrifying death toll of homebirth in Colorado:

... [T]he perinatal death rate of LICENSED homebirth midwives in Colorado, caring for low risk patients, exceeded the perinatal death rate of 6.4/1000 for the entire state (all races, all gestational ages, all birth weights, 2003-2007)! Homebirth was the most dangerous form of planned birth by far.

Karen Robinson, CPM [President of the Colorado Midwives Association] was in denial:

I don't believe we have a poor perinatal mortality rate, but if solid data shows we do, then I will be at the forefront of the effort to improve our practices and lower the perinatal mortality rate for homebirth in Colorado.

But as I pointed out in my post:

If she's going to be at the forefront, then she had better get out there. The just published statistics for the year 2008 are even worse. Last year, licensed Colorado midwives had a perinatal mortality rate at homebirth of 8.6/1000. These numbers are nothing short of horrifying.

Amazingly, the 2009 statistics are far worse. In 2009 Colorado licensed midwives provided care for 799 women. Nine (9) babies died for a homebirth death rate of 11.3/1000! That is nearly DOUBLE the perinatal death rate of 6.3/1000 for the entire state (including all pregnancy complications and premature births).



The data is conveniently broken down by type of death and place of death. For example, there were three intrapartum deaths for an intrapartum death rate of 3.8/1000, more than TEN TIMES HIGHER than the intrapartum death rate commonly experienced in hospitals. There were 4 neonatal deaths for a neonatal death rate of 5/1000. That's TEN TIMES HIGHER than the national neonatal mortality rate for low risk hospital birth with a CNM. On hundred women were transferred in labor or after delivery for a transfer rate of 12.5%. The neonatal death rate in the transfer group was 50/1000, an appalling neonatal death rate ONE HUNDRED TIMES HIGHER than that expected in a group of low risk women.

What can we learn from these data?

1. Planned homebirth with a licensed midwife in Colorado has a death rate that is extraordinarily high and has risen in every year since statistics were first collected.

2. Colorado homebirth midwives have an intrapartum death rate 10 times higher than expected.

3. Colorado homebirth midwives have a neonatal mortality rate 10 times higher than expected.

4. Colorado homebirth midwives fail to transfer enough patients and fail to transfer them in a timely fashion.

5. One in 20 patients transferred to the hospital by Colorado homebirth midwives ends up with a dead baby.

I recently asked how many dead babies does it take to convince a homebirth advocate of the dangers of homebirth? Evidently, there is no limit to the number of dead babies that Colorado homebirth midwives think is acceptable.

Hopefully the Colorado Legislature is not nearly so irresponsible. The sunset review should conclude by letting Colorado direct entry midwives ride off into the sunset permanently. Like all American direct entry midwives, they are grossly undereducated, grossly undertrained, and, as a consequence, unbelievably dangerous.

Is natural childbirth a form of quackery?

I wouldn't go as far as claiming that the philosophy of natural childbirth is purely quackery, but as science systematically eviscerates their claims, natural childbirth advocates are falling back on the defense mechanisms classically associated with pseudoscience.

This represents a radical departure from recent strategies. Unlike traditional pseudosciences (homeopathy, creationism) which have always denigrated scientific research, in the last decade, natural childbirth advocates have based the validity of their philosophy on the claim that it is supported by science while modern obstetrics is not. Indeed, as I have noted in the past, Lamaze International has titled its blog Science and Sensibility to emphasize the purported scientific basis of natural childbirth.

But it turns out that the central claims of natural childbirth advocates are NOT supported by scientific evidence, and many of their claims are completely undermined by existing scientific evidence. Modern obstetrics, in contrast, has always been, and continues to be based on scientific research. Midwifery theorists have recognized this, and celebrity natural childbirth advocates are becoming aware of this problem. To solve it, they are resorting to the tried and true tactics of pseudoscience.

I wrote yesterday about Amy Romano's parting shot on Science and Sensibility. She is leaving one special interest group (Lamaze International) to work for a natural childbirth lobbying group (The Childbirth Connection), and I find it fitting that she uses her departure to firmly situate natural childbirth as quackery.

Consider what Romano wrote:

... [W]e all arrive at the point of healthcare decision making with a different constellation of factors that affect our choices. We may have different financial resources, health situations, hopes and plans for the future, tolerance to pain, tolerance to risk, prior experiences, and so on.

In other words, with the exception of practices that cause harm with no counterbalancing benefit at all or benefit with no risk of harm at all, there is no such thing as a good or bad healthcare decision. There’s only such a thing as a good or bad healthcare decision for a certain person. Evidence cannot guide practice without the other piece of the equation – the person to which the evidence is to be applied. (emphasis in the original)

Now compare it to a style of pseudoscience defense described by Boudry and Braekman in the recently published paper Immunizing Strategies and Epistemic Defense Mechanisms as "changing the rules of play":

By undermining the standards of reasoning employed in a rational debate, one can safeguard one's position from valid criticism. In many instances of this immunizing strategy, the very attempt at criticism is condemned as fundamentally misguided...

For example, in discussions about alternative medicine one often hears the claim that each person or patient is "radically unique", thus frustrating any form of systematic knowledge about diseases and treatments. Of course, advocates of unproven medical treatments use this argument as a way to deflect the demand for randomized and double-blind trials to substantiate their therapeutic claims. If each patient is radically unique, there is no point in lumping patients together in one treatment group and statistically comparing them with a control group... The argument is so convenient that it has been borrowed as an immunizing strategy by countless alternative therapists ...

Romano follows this description almost exactly. She is clearly attempting to undermine the use of scientific evidence as the standard of reasoning used in rational debate. She directly appeals to the notion that since each person is "radically unique," there's no point in basing clinical decisions on scientific evidence. Indeed, Romano is basically saying that scientific evidence is irrelevant, and can and should be ignored when it conflicts with cherished personal beliefs.

I doubt Romano even realizes it, but her post allows me to declare victory. I have been writing for years that natural childbirth has nothing to do with scientific evidence. Natural childbirth philosophy was developed by a eugenicist (Grantly Dick-Read) who lied about the pain of childbirth with the explicit intention of convincing white women of the "better" classes to have more children than "primitive" (read: black) women. It has been perpetuated by people who have disregarded scientific evidence. And now, in 2010, Amy Romano writing under the aegis of Lamaze is trying to provide a justification for explicitly ignoring scientific evidence.

The days of declaring that natural childbirth is based on science are over; they have come to an abrupt end because it has finally penetrated the consciousness of natural childbirth advocates that their claims are not and never were based on science. At this point, natural childbirth is perilously close to becoming nothing more than a form of quackery.

Lamaze: garbage in, garbage out

Amy Romano got tired of me making her look like a fool. No, she didn't stop writing foolish things; she just deleted my latest comment that exposed her writing as foolish, and untrue to boot. Evidently I spoke too soon when I wrote last week:

Henci Goer has banned me: too hard to address my points. The Unnecessarean has banned me: too hard to address my points. Jennifer Block doesn't let anyone comment on what she writes: good idea since she can't address anyone's points. Only the folks at "Science" and Sensibility haven't banned me. I don't know why since I have torn apart multiple posts that they have written. I guess that while they may not know much about science, they appear to understand integrity.

They apparently agree that I have torn apart what they have written and they don't want to let me do it again. Fortunately, I have my own blog on which I can reply.

Amy Romano has discovered that:

I was wrong. Evidence doesn’t hold all of the answers.

In other words, she has caught up to the midwifery theorists who have already found out that the scientific evidence does not support their claims. I wrote about this problem almost a year ago in Midwives have a problem with scientific evidence:

... [M]idwives and childbirth educators like Lamaze have a problem. The scientific evidence often conflicts with their ideology... [Therefore] they've tried to justify ignoring scientific evidence.

As midwives Jane Munro and Helen Spilby have documented in The Nature and Use of Evidence in Midwifery, midwives were initially enthusiastic about basing clinical practice on scientific evidence. That's because they had long told each other that midwifery was "science based" while obstetrics was not...

But (surprise!) it turned out that obstetrics had been based on scientific evidence all along and it was midwifery that ignored the scientific evidence in favor of ideology...

... As Munro and Spilby explain:

'... [S]ome midwives have not been so enthusiastic [about evidence based practice], viewing the drive to create and implement evidence as a threat to their clinical freedom.'

In other words, cherished ideological beliefs conflict with scientific evidence. Thus began the attack on scientific evidence.

Romano is following that tactic. She writes:

There are many reasons I have come to believe [that scientific evidence doesn't hold all the answers], but there are two I want to write about today. The first is that the way research is currently funded, conducted, and disseminated, it simply doesn't address many outcomes that women care about.

Those evil doctors and scientists are concerned with what is safe and what is dangerous, but midwives don't care about THAT.

The second is that we all arrive at the point of healthcare decision making with a different constellation of factors that affect our choices. We may have different financial resources, health situations, hopes and plans for the future, tolerance to pain, tolerance to risk, prior experiences, and so on.

In other words, with the exception of practices that cause harm with no counterbalancing benefit at all or benefit with no risk of harm at all, there is no such thing as a good or bad healthcare decision. There’s only such a thing as a good or bad healthcare decision for a certain person. Evidence cannot guide practice without the other piece of the equation – the person to which the evidence is to be applied.

So clinical practice SHOULDN'T be guided by scientific evidence, because scientific evidence does not support the central claims of natural childbirth. Better to pretend that scientific evidence cannot tell us about individuals and only they can figure out what is "safe" for them.

In support of this nonsense, Romano offers the typical NCB lie:

In May 2009, Science & Sensibility contributor, Henci Goer, presented the findings of her review of the literature on cesarean surgery and a little-known complication: new onset endometriosis. She wrote:

'So why is this reasonably common serious adverse effect of cesarean surgery something you have never heard of?…Cesarean wound endometriosis would never turn up in a randomized controlled trial (RCT). Even if the problem made it onto the researchers’ radar, the trial would have to be extremely large and follow-up impractically long to detect it. Where RCTs are considered the only evidence worth having, outcomes that cannot be picked up on by RCTs functionally don't exist.'

Endometriosis is not a "little-known" complication of C-section. Just a brief search of the internet brought up a paper from 1965 and it had been well described long before then. That same brief search revealed literally hundreds of papers on the topic (I stopped counting at 400). Oh, and those papers were not RCT's because, contrary to Goer's assertions, RCT's are not required in order to recognize a phenomenon.

How can supposedly "educated" women fail to be aware that there are hundreds of papers on the topic extending back many decades? They lack basic knowledge of science, statistics and obstetrics. They actually think that because THEY didn't know something, it must be unknown.

At least Romano has inadvertently acknowledged what I have been writing all along: scientific evidence does not support the central claims of natural childbirth advocacy. In the world of Lamaze, if the evidence doesn't support the claim, you have to throw out the evidence, ... and then you have to delete it if anyone dares to post it on your blog.

Midwives: Ignore homebirth deaths

Homebirth midwives are worried. I keep posting accounts of homebirth deaths. Now you might think they were worried about the number of homebirth deaths, but you'd be wrong. Apparently homebirth midwives Janelle Wahlman of Birthsense and Kitty Ernst are worried that women might be influenced by these accounts. Therefore, they've set out to try to neutralize them.

Janelle is shocked, shocked that I might use accounts of homebirth deaths to illustrate the dangers of homebirth. After all, that's the favored tactic of homebirth advocates to support homebirth. Every homebirth advocacy website and publication is chock to the brim with birth stories about wonderful, "empowering" homebirths. Evidently homebirth midwives want women to read only the stories with good outcomes; the many stories of homebirth death shouldn't be published at all.

Too late for that. I already posted the story. The only thing left to do is to try to undermine the points that I have made. Unforuntely, it attempting to do so, Wahlman trots out many of the inane logical fallacies that characterize homebirth advocacy. Janelle starts by quoting me:

I understand that a tragic story is a more powerful way to convey risk than any set of statistics will ever be. That's why I post stories of homebirth deaths, to illustrate that childbirth is inherently dangerous, that childbirth emergencies occur in low risk situations, and that being close to a hospital is often not close enough to matter.

She continues:

Let's dissect Dr. Amy's rationale for posting stories of homebirth deaths:

1. To illustrate that childbirth is inherently dangerous. I disagree with this point of view. Certainly, childbirth carries the potential for danger, but when birth is supported in such a way that interventions are avoided unless they are clearly beneficial, birth occurs safely the majority of the time...

She disagrees. She disagrees? Funny, but it isn't a matter of opinion; it is an empirical fact. The idea that disagreeing means we can discard facts we don't like is an immature error of cognitive reasoning favored by all believers in pseudoscience.

Second, the fact that childbirth "occurs safely the majority of time" is one of those meaningless truisms favored by homebirth advocates. Driving drunk "occurs safely the majority of time," too. That doesn't mean that driving drunk is safe.

2 Childbirth emergencies occur in low-risk situations. True enough. However, if this were really a primary concern of obstetricians, why would they not be present in the hospital, at the bedside of their patients, for the duration of every low-risk labor? ...

The "but he did it" defense is well known to mothers everywhere. When confronted with an episode of wrongdoing, many young (and not so young) children attempt to defend themselves by accusing a sibling of doing something similar. Homebirth advocates further embellish this childish "defense" by insisting that no difference exists between home and hospital, since an obstetrician is definitely not present at home and might not be present at the hospital. That conveniently elides the fact that nurses, anesthesiologists and other obstetricians ARE present at the hospital and emergencies can be handles by doctors other than the patient's personal physician.

3. Being close to a hospital is often not close enough to matter. ...

Sometimes babies die. Sometimes there are deaths that cannot be prevented, no matter where we give birth. Sometimes there are deaths due to negligence on the part of the midwife or doctor, no matter where the birth occurs.

This is probably the stupidest of the many stupid arguments advanced in support of homebirth. The fact that some babies die is NEVER a justification for the death of a specific infant. The key point about homebirth is that MORE babies die at homebirth than in the hospital. In fact, homebirth TRIPLES the risk of neonatal death. No amount of bleating that "sometimes babies die" justifies increasing the risk of preventable neonatal death.

Kitty Ernst wrote:

As always, [Amy's blog post] points to the urgent need to get the "teams" working together, assure that who is with the mother is competent and working within a system of care - and stop arguing about the place of birth – AND collect and publish on-going, real-time data on what we all are doing! Once we do that the place of birth will become a non-issue.

No, there's no need for "teams." We already know that American homebirth midwives do not meet the most basic standards of education and training. We already know that homebirth with an American homebirth midwife TRIPLES the risk of neonatal death. We already know that homebirth with a CNM DOUBLES the risk of neonatal death. And we already know that MANA (the Midwives Alliance of North America)is withholding their own safety data that almost certainly shows that homebirth dramatically increases the risk of neonatal death.

Here's what we do need:

We should ban direct entry midwifery.
We must counsel women that homebirth increases the risk of neonatal death.
We should force MANA to reveal their data to the American public.

If American women still want to choose homebirth after that, it's their right to do so. But hiding homebirth deaths, dismissing homebirth deaths and attempting to justify homebirth deaths as Wahlman has tried to do, is precisely what we DON'T need.

Foreskin intact, heart missing

I understand that a tragic story is a more powerful way to convey risk than any set of statistics will ever be. That's why I post stories of homebirth deaths, to illustrate that childbirth is inherently dangerous, that childbirth emergencies occur in low risk situations, and that being close to a hospital is often not close enough to matter. There's nothing wrong with circumcision activists illustrating their concerns with stories of circumcision gone wrong, but there is something wrong with posting this on a mother's website:

My heart sure doesn't break for her. On the contrary, she got exactly what she deserved. If every baby who was mutilated died, it might put a stop to the practice. This so-called tragedy is good publicity for outlawing genital mutilation. I hope she feels guilty for the rest of her miserable life & my sympathy for her is ZERO.

This is just one of a long series of vicious comments posted by intactivists on the mother's website in the hours following her baby's death. That's not education; that's hatred. Anti-circ activists may revel in intact foreskins, but they should also have a heart.

Should circumcisions be banned? Well meaning people may think so, claiming that mothers who circumcise DESERVE dead babies in something else altogether. And bemoaning the fact that only a very tiny fraction of babies die from circumcision complications makes no sense at all. If intactivists oppose circumcision because it is purportedly too dangerous, they should not be wishing that it was more dangerous.

Baby Joshua was born with hypoplastic left heart syndrome, a severe, often fatal, heart defect. He had already survived two heart surgeries and was still in the hospital having a rocky recovery from his second heart surgery. His parents had been requesting circumcision, but it had been postponed repeatedly because doctors did not think he was stable enough to withstand the surgery, and because medications for his heart condition put him at greater risk for bleeding complications.

I can't imagine why anyone thought that this was a good time to perform a circumcision. A first principle of surgery is that elective surgery should never be performed in the setting of an acute event. For example, it might be convenient to have that tummy tuck at the same time you are undergoing open heart surgery, but no doctor in his right mind would consent to do it because it dramatically increases the risk of complications and death.

There was no religious imperative for circumcision, and, in any case, Judaism is quite clear on the point that circumcision should not be done if the baby is ill or has a bleeding disorder. Long term protection against HIV is not really an issue in a baby struggling to survive a major cardiac defect. Therefore, this was essentially cosmetic surgery. I can't envision performing cosmetic surgery on anyone recovering from heart surgery.

The baby did suffer bleeding complications and bled enough that a transfusion was being contemplated. Ultimately the baby suffered a cardiac arrest, and while it is not clear that the circumcision led to the cardiac arrest, it certainly didn't help. Indeed, the stress and blood loss certainly could have been too much for a baby with a compromised heart to handle.

Is this a cautionary tale about circumcision? I'm not sure. It seems to me more like a cautionary tale about performing elective surgery on critically ill newborns. Nonetheless, it is entirely legitimate for "intactivists" to use this as a cautionary tale. It is entirely heartless, however, for them to post hateful comments on the mother's website.

If this story illustrates anything, though, it is not the perils of circumcision, but rather the perils of posting on the internet. People who maintain personal blogs don't seem to understand that they are not posting merely to a close circle of friends. Rather, they are posting to the WHOLE WORLD. If they do not want the whole world to be aware of their personal lives and to discuss their personal lives, they should not be posting details on the internet, at least not without password protesting their sites.

I am horrified and frankly incredulous that this tragedy has occurred. I wish it had not happened, but failing that, I wish the mother had not publicly posted it on the internet, exposing herself to the misery of having her personal decisions criticized by everyone from coast to coast.

How many dead babies does it take to convince a homebirth advocate?

You might think a nurse would know better. But evidently not and her infant daughter paid with her life.

... She told me the stories of her home birth experiences with her other 3 children and how she absolutely LOVED the labor experience. Anna knew we would all think she was absolutely insane for saying that, but didn't care. She really is a free spirit and speaks her mind. She was studying to become a midwife herself and did not have much longer to go before she graduated.

Anna had a midwife. She had been found to colonized with group B strep. She had received a prescription for penicillin but it is not clear whether this was oral penicillin or the IV antibiotics that are needed during labor.

... Anna's water broke at 9pm. She labored through the night at home... The next day she continued to labor and her midwife came to her house in the late afternoon. The midwife brought with her, the Doppler monitor to assess the babies heart rate. It was at that moment that they discovered the heart rate to be in the 60's (normal fetal heart rates are about 120-160). This was alarming and Anna quickly got herself onto our unit. There they discovered that yes, the baby's heart rate was in the 60's. Without a way to know how long this had been going on they quickly got Anna admitted and began interventions to get the baby's heart rate back to normal. It did return to normal for a while, but dropped again and would not come up. They rushed Anna back for a c-section in desperate attempts to save the baby's life.

Anna had had ruptured membranes for more than 18 hours and it appears that she did not have IV antibiotics. She had labored for those 18 hours without checking the baby's heart rate and by the time it was checked, the baby was having deep bradycardias (abnormally slow heart rate). She transferred to the hospital immediately, and, as we know, homebirth advocates think that is all that is needed to save a baby's life. Evidently not.

As they cut into her uterus they quickly discovered the meconium the baby had passed as a result of being very stressed out, along with the umbilical cord tightly wrapped around the baby's neck twice). They finally got the baby out (IT'S A GIRL) and passed her off to the resuscitation team... [S]he'd aspirated (breathed in) a lot of the meconium. Slowly her condition began to deteriorate... Dr's and nurses struggled to save this baby girl's life. They got her stable enough to be able to transport to another facility [for] more intensive care...

Within 12hrs of her arrival at the other facility. Anna lost her sweet baby girl. A result of sepsis and DIC, her sweet angel baby was gone forever.

This appears to be an entirely preventable death. While the mother was reveling in her freedom to labor in her own home, her baby was being ravaged by group B strep, AND asphyxiating because of a tight nuchal cord. Despite an expeditious transfer to the hospital, an emergency C-section, and expert neonatal resuscitation, the baby died.

As Anna's friend, also a nurse, points out:

... I want everyone out there to know that you just don't know what can happen at any given moment, and even if you live 5 minutes from the hospital, things can still go very very wrong and not turn out ok. Even with all of her knowledge as a RN working in L&D and a midwife in training, Anna could not stop this tragedy from happening.

Even among the tiny group of superstars in the homebirth movement, at least 3 have forfeited their babies' lives in exchange for their philosophy. Laura Shanley, Janet Fraser and Ina May Gaskin let their babies die rather than seek medical care. And all continue to promote the philosophy that killed their own babies, staunchly insisting that their philosophy won't kill yours.

How many babies have to die at homebirth before homebirth advocates wake up to the reality that homebirth kills babies?

Homebirth: like riding a motorcycle without a helmet

Who said:

For the record, no one is saying [hospitals] don't provide safety benefits. They do. But, there is also evidence that there are safety risks...

Or how about:

Instead of confusing the public with [complication] statistics that have no relation to the ability of a [hospital] to provide enough safety to even think about a mandate, many officials don't quote, or even know, whether [hospitals] have had an effect on the ratio of the number of deaths from [complications] as related to the number of [complications].

And let's not forget this:

So why all the disinformation? Follow the money trail. The [healthcare] industry can't control [complications], but they can control the number of [lawsuits]. This all dovetails nicely with the prejudice and propaganda against [homebirth].

Who made those statements? They were made by the folks at Bikers' Rights Online.

Well, not exactly. The people at Biker's Rights Online were talking about motorcycle helmets and their ability to prevent death from head injury, not the ability of hospitals to prevent death from childbirth complications. Amazingly, the arguments are exactly the same.

Don't believe me? Let's compare the major features of both arguments.

1. They cause more complications than they prevent.

This claim, if it were true, would represent a powerful argument. I'm not familiar with the scientific literature on motorcycle helmets, but the claim that motorcycle helmets cause more injuries and deaths than they prevent seems nonsensical on its face. No mechanism is even suggested whereby motorcycle helmets would cause injuries.

In the case of childbirth in hospitals, the claim is not nonsensical. One can imagine how a hospital might cause more injuries and death than it prevents. However, I am familiar with the literature on childbirth and hospitals, and that is very definitely not what it shows. There are masses of data, examined from every possible perspective, and all of it demonstrates the same thing. Hospitals have prevented millions of injuries and deaths related to childbirth. It is not coincidental that as the homebirth rate dropped from 95% in 1900 to less than 1% in 2000, the neonatal mortality rate dropped by 90% and the maternal mortality rate dropped by 99%.

2. No one has ever studied their safety.

According to Bikers' Rights Online, "there is little data on the effects of a helmeted body in motion from a bike crash." That is untrue, but it sounds compelling.

Homebirth advocates love to claim that "no one has ever studied the safety of hospital birth," but that claim is every bit as fantastical.

3. It's a conspiracy on the part of a powerful industry to make money.

It's fun to smear people and entire industries with the accusation that their claims of safety mask a corrupt desire to profit at the expense of individuals. I don't doubt that some industries are corrupt, and that some companies profit by harming individuals. But to go from the general to the specific requires more than accusations; it requires data, precisely what is missing from this argument.

Bikers Rights Online claims that helmet laws are a conspiracy of the insurance industry, a convoluted conspiracy at that. "The life insurance industry can't control their car drivers from hitting us, but they can control the number of targets their drivers can hit by backing helmet laws that reduce riding." In other words, according to Bikers Rights Online, helmets don't prevent injuries and death, they just deter people from riding motorcycles and so motorcycle fatalities fall. You have to give those folks credit for creativity.

Homebirth advocates aren't content to smear only one industry. They are even more creative. It's the doctors! It's the lawyers! It's the insurance companies! Evidently millions of professionals have been recruited to prevent homebirths because they are afraid of losing money by losing patients. Or is it losing money by getting sued? Or is it losing money by paying out large malpractice settlements? It doesn't matter. Someone is profiting from hospital births and that's why everyone lies and says hospital births are safer. Strangely enough, the fact that the homebirth industry can only profit by convincing women that homebirths are safe is simply ignored.

4. It's a matter of personal freedom.

It's my body and I have the right to do with it what I want! The same argument can be made by a motorcyclist and a homebirth advocate. And the same retort can be given: it's not just you; others will pay for your decision, with money or with their lives.

In the case of motorcycle helmets, there is almost no one who can pay out of pocket for a traumatic brain injury. First the insurance company pays millions, raising the cost of healthcare. Then the government foots the bill for millions more, passing the costs along to taxpayers. The decision to forgo a motorcycle helmet is only a personal decision so long as you intend to pay the costs of your choice. If you expect the rest of us to pay for your care, then we have a right to insist that you make safer choices.

The case of homebirth is more complicated. It is a woman's right to control her own body, and were she the only one to be harmed by her decision, very few people would care what she chooses. But the baby may live or die based on her decision. Indeed it is approximately 100 times more likely for a baby to die in childbirth than for a mother to die. The rest of us have an interest in protecting that baby. It may not override the mother's right of autonomy, but just because her decision to avoid a hospital is legally allowed does not mean that it is morally correct.

The folks at Bikers Rights Online call themselves "freedom fighters" as if there were a constitutional right to sustain a traumatic brain injury and have the rest of us pay for it. Homebirth advocates like to think of themselves as freedom fighters, too, explicitly adopting the language of abortion rights activists and insisting that they have a "right to choose." They do have a right to choose, but what they're choosing is very similar to riding a motorcycle without a helmet ... except in their case, it's usually the baby who sustains the brain injury, not the person who made the choice.