Midwives Angling for Money Again (MAMA)

What do you do when no one will pay you the money that you want? You get your favorite Congresswomen to pass a law.

That's what the homebirth midwives of America are trying to do; in collaboration with the MAMA Campaign (Mothers and Midwives in Action) Congresswoman Chellie Pingree plans to introduce a law forcing payment to substandard practitioners who insurance companies consider unqualified to provide medical care in childbirth.

So what if no one thinks their "skills" are valuable? Who cares if people don't think they are a safe practitioners? They want money and dammit, others should be forced to pay. So much for the free market.

That's the problem facing certified professional midwives (CPMs), member of a second, inferior class of midwife that exists nowhere else but in the US. They have less education and training than midwives in ANY first world county and would not be eligible for licensure in the UK, the Netherlands, Canada or Australia. Since they hare banned from hospitals as unqualified, they are restricted to attending homebirths. All the existing studies to date, as well as state and national statistics show that homebirth with an American homebirth midwife (as opposed to a certified nurse midwife) is the most dangerous form of planned birth in the US.

Actually, some people do want to pay them. A tiny percentage of women who think that homebirth with a high school graduate supervising is just dandy would be very happy to pay the thousands they think they deserve. One problem, though. Those patients don't have the money. That's why the large corporations who insure them must be pressured to pay for services that they don't want, don't trust, and don't consider safe.

Birth junkies unite! Why should you be forced to get a college degree? That's too hard. Why bother to learn about pregnancy complications? That's too much of a downer. Just get together, give yourself a pretend degree and start collecting cash. Oh, wait. You already did that. You called the degree the CPM (to deliberately create confusion with the real degree, the CNM). But alas, no one wants to pay you to be a birth voyeur.

Enter Congresswoman Chellie Pingree and the MAMA Campaign. MAMA is supposed to stand for Mothers and Midwives in Action. The name is misleading on its face since it is sponsored by homebirth midwives with nary a mother in sight. According to their website:

Midwives & Mothers in Action, or MAMA, is a collaborative effort by the National Association of Certified Professional Midwives (NACPM), Midwives Alliance of North America (MANA), Citizens for Midwifery (CfM), International Center for Traditional Childbearing (ICTC), North American Registry of Midwives (NARM), and the Midwifery Education Accreditation Council

MANA, NACPM, NARM and MEAC and ICTC are organizations by and for homebirth midwives; indeed, MANA, NARM and MEAC are just branches of the same organization, Ina May Gaskin's self created empire. Citizens for Midwifery is arguably the only organization among the 6 that is composed of mothers, but its only purpose is to promote homebirth midwifery. A more accurate name for the MAMA Campaign would reflect who runs it and why. That's why I propose Midwives Angling for Money Again (MAMA), since that is its real purpose.

What is a CPM anyway? The CPM is a second, inferior class of midwife that exists in addition to the more highly trained nurse midwife CNM. In all other first world countries, a midwife has a four year university degree that includes in-hospital training. Certified nurse midwives in the US have a nursing degree and a master's degree in midwifery. CPMs in contrast have a post high school certificate with no in-hospital training in preventing, diagnosing and managing childbirth complications. Real midwifery training was simply too hard, so a group got together and created a pretend credential to fool unsuspecting pregnant women. And who created that credential? MANA, NARM, MEAC and CfM, of course.

The MAMA Campaign claims to be:

Advocating for CPMs as a high-value option for quality cost effective maternity care.

Curiously, the slogan does not mention the safety of CPM care. That's probably because every study done to date (even those that claim to show that homebirth with a CPM is safe) and state and national statistics show that homebirth with a CPM triples the neonatal mortality rate. Indeed, homebirth with an American homebirth midwife is the most dangerous form of planned birth in the US (See Homebirth kills babies, Homebirth with a direct entry midwife is th most dangerous form of planned birth, and Inexcusable homebirth death toll in Colorado keeps rising).

And it's not clear that certified professional midwives provide care that is either high value or cost effective. Indeed, Canada, which used to have a similar class of midwives, has banned them from practice. Now all midwives in Canada must have a four year university degree.

Ironically if CPM care were safe, high value or cost effective, the insurance companies would probably be first on the bandwagon to pay CPMs and promote their use over the more highly trained (and more highly compensated) certified nurse midwives. Yet most insurance companies do not accept the CPM credential. The cost for a CPM attended delivery may be cheaper, but when you add the cost for hospital transfers, NICU stays, and handicapped infants suffering brain damage from lack of oxygen in childbirth, it no longer seems like a cost effective alternative.

The bottom line is simple. If you want to practice midwifery, you should be required to have a real midwifery education and real midwifery training, comparable to that anywhere else in the first world. If that's too hard, you can award yourself a pretend credential (the CPM), but don't expect the rest of us to pay you to live out your fantasy. The law promoted by the MAMA Campaign is nothing more than a special interest lobbying effort. It exists for one reason, and one reason only, to force insurers to pay practitioners who are undereducated, undertrained and unsafe: Midwives Angling for Money Again (MAMA).

Parental tribalism

Imagine a cocktail party where everyone introduced him or herself with reference to a car.

Hi, I'm Debbie and I drive a Ford Explorer.

Nice, to meet you Debbie. I'm Karen and I drive a Lexus RX350. Let me introduce Kathy; she drives a Subaru. And here's Margie. She drives a Ford Explorer just like you.

Hi, Margie. I'm so glad to meet someone else who drives a Ford Explorer. It can be tough to be a Ford driver in this culture when no one else cares enough about their country to buy American cars.

What might we conclude from this brief exchange? First, it is clear that the people in this group have constructed their identity around car ownership, not simply differentiating between those who own cars and those who don't, but tying identity directly to specific brands. Second, even in this short exchange, we can see that identity creation through brand choice leads to a form of security, through a sense of belonging to a self-chosen group. Third, although the car appears to be central, this is not about cars at all; it is really about self-definition.

Sounds ludicrous to create an identity around car brands, doesn't it? Yet is strikingly similar to the current penchant for creating identity around specific parenting choices, also known as parental tribalism. According to Jan Macvarish:

The idea of 'parental tribalism' ... [is] descriptive of a tendency among individuals to form their identities through the way they parent, or perhaps more precisely, through differentiating themselves from the way some parents parent and identifying with others ...

Macvarish is a scholar in the relatively new field of "parenting culture." She is a member of the Centre for Parenting Culture Studies. The Centre's key areas of research are common topics for discussion on this blog, including (among others): risk consciousness and parenting culture; the management of emotion and the sacralisation of 'bonding'; the policing of pregnancy (including diet, alcohol consumption, smoking); the moralization of infant feeding (including breast and formula feeding, weaning); and The experience of the culture of advice/'parenting support'. Each of these topics is also a basis for parental tribalism.

Parental tribalism involves constructing an identity around parental choices, or rather constructing an identity centered on differentiating themselves from parents who make different choices. It is perhaps not coincidental that Mothering.com, the leading publication in the "natural" parenting community, refers to its individual message boards, each denoting a different parenting choice, as "tribes", thereby highlighting differences and encouraging the construction of maternal identity around these differences.

Strikingly, many of these choices, although they appear to concern the well being of children, are really about the self image of parents. As Macvarish explains:

...[T]the focus on identities reflects adult needs for security and belonging and, although the child appears to be symbolically central, in fact 'the cultural politics of parents' self-definition have eclipsed a concern with the needs of children.

I have often said that homebirth, for example, is not about babies, and it is not even about birth. Homebirth is about mothers, their experiences, their needs and their desires.

As with all forms of tribalism, parental tribalism leads to conflicts:

[T]there is a frailty and sometimes hostility in real or imagined encounters between parents, where the parenting behaviour of one can either reinforce or threaten the identity of another. What is noticeable in contemporary mothers' descriptions of their parenting experiences is that many feel stigmatised or assume a defensive stance about their parenting choices, even those apparently making officially sanctioned choices. For example, some breastfeeding mothers express the view that society still sees breastfeeding as abnormal, despite the fact that they are very much swimming with the tide of official advice ...

Websites and publications concerned with attachment parenting, natural childbirth, homebirth and lactivism emphasize and encourage this hostility. There is an almost paranoid certainty that other mothers are watching and criticizing. The resultant defensiveness is the true source of the hostility. By aggressively promoting their own choices, aggressively demeaning the choices of other mothers, and aggressively insisting that anyone who makes different choices is implicitly criticizing them, advocates of attachment parenting, homebirth, lactivism, etc. encourage the very conflicts that they claim to deplore.

These conflicts do not benefit children, anyone's children, in any way. That's not surprising since it's not about children, but about parental self image. Indeed, constructing identity around parenting choices has the potential to harm children, by ignoring the actual needs of children in favor of promoting the mother's sense of security and belonging.

Attachment parenting causes autism

It is perhaps the ultimate irony that advocates of attachment parenting who reject vaccination because of fear of autism have ignored the possibility that it is attachment parenting itself that causes autism.

Consider the ever growing body of evidence:

1. Both autism and attachment parenting have increased dramatically in the past two decades. The origin of the attachment parenting is credited to Dr. William Sears, who first mentioned it in his book in 1988. Studies show that in the VERY SAME YEAR, the incidence of autism began to rise dramatically. (Environ. Sci. Technol., 2010, 44 (6), pp 2112–2118).

2. Regardless of who practices attachment parenting or how they define it, no one can deny that the practice of attachment parenting ALWAYS precedes the diagnosis. There are no known cases in which attachment parenting practices began after autism was diagnosed.

3. The purported mechanism is thought to be the sensory deprivation caused by baby wearing and extended breastfeeding. During the critical early months and years, when babies should be learning about the world and making millions of neuronal connections, babies exposed to AP are deprived of contact with the outside world (many are constantly carried in a position where they can see nothing but the surface of the mother's clothing) and their exposure to other individuals such as fathers, grandparents and childcare workers is severely limited.

4. No one has EVER shown that attachment parenting does not cause autism.

5. Even those who strongly reject the notion that attachment parenting causes autism acknowledge that there are MANY children raised with attachment parenting who are subsequently diagnosed with autism.

6. Many of those who deny a link between attachment parenting and autism stand to lose money if attachment parenting is shown to be harmful. Authors, lactation consultants, and sling manufacturers, among others, have a strong economic motivation for discouraging investigation of this link.

It is time to launch a comprehensive investigation of the harmful side effects of attachment parenting in general, and the relationship between attachment parenting and autism in particular. It's hardly coincidental that the same people who make money from attachment parenting have NEVER bothered to study these harmful effects. They insist that attachment parenting is beneficial, but there is no way they can know for sure.

****

Those who have read this far have probably figured out that this is a satire. I'm satirizing the "thinking" of vaccine rejectionists on the purported relationship between vaccines and autism. The purpose of the satire is to demonstrate that what seems to vaccine rejectionists to be compelling "reasoning" is nothing more than nonsense, and logical fallacies.

I've tried to highlight the major rhetorical gambits of vaccine rejectionists. Number 1 is the claim that because both vaccination and autism have risen in recent decades, vaccines must cause autism. That claim is foolish as can be seen when the same observation is made about attachment parenting and autism. Just because the incidence of two phenomena rise at the same time does not mean that one caused the other. And that doesn't even take into account the fact that rates of vaccination have actually been FALLING while rates of autism have been rising.

Number 2 is the temporal connection. Early childhood vaccination precedes the observation of autistic symptoms, but a lot of things precede the observation of autistic symptoms. That's because those symptoms typically do not appear until the early toddler years and anything that takes place during infancy (like attachment parenting practices) will precede the observation of symptoms.

Number 3 invokes a spurious mechanism of action. It is certainly plausible, but no evidence is presented that it actually occurs. Vaccine rejectionists play the same tricks with claims about the deleterious effects of "toxins" in vaccines.

Number 4 is the "argument from ignorance." The argument from ignorance dares the opponent to prove a negative and when a negative cannot be proven (since that is a logical impossibility in most cases), the conclusion is proclaimed that this "shows" that vaccines cause autism.

Number 5 is the "fallacy of the lonely fact." Since some children have developed autism after their parents practiced attachment parenting, the conclusion is drawn that large numbers of children will develop autism after their parents practice attachment parenting.

Number 6 is the conspiracy theory that undergirds almost every attempt to defend vaccine rejectionism. But when the same "reasoning" is applied to attachment parenting, it is easy to see that the conspiracy theory does not have much explanatory power. There is ALWAYS someone who stands to benefit from any recommendation or practice. That does not mean that those who benefit are actively hiding information on harms and risks from everyone else.

The concluding paragraph is the seemingly innocuous call for "more research." But we cannot and should not waste time "researching" connections that have no basis in science. If we did, we could spend a lot of time "researching" whether the moon is made of green cheese or whether clouds are made of marshmallows. The call for "more research" is just away to add gravitas to what are often ridiculous claims. We do not need to "research" every wacky idea that vaccine rejectionists devise and our refusal to "research" those ideas without basis in science or logic is not a sign that someone is hiding something.

The key point is that what passes for "reasoning" among vaccine rejectionists is not reasoning at all. It is nothing more than wild accusations, logical fallacies and conspiracy theories. There is no more reason to take seriously the idea that vaccines cause autism than there is to take seriously the idea that attachment parenting causes autism.

Vaccine conspiracies abound; why not antibiotic conspiracies?

They utterly changed the nature of infectious disease. Communicable diseases that had previously wiped out wide swathes of the population could be controlled with simple injections. Deaths dropped dramatically.

They became ubiquitous and virtually mandatory. The companies that manufactured them became extraordinarily wealthy and developed into large multinational conglomerates.

But there were side effects. Some recipients suffered serious medical consequences. Some even died. Yet despite these dire consequences, they have remained a cornerstone of medical practice.

What are they?

If you thought I was talking about vaccines you are mistaken. I am referring to antibiotics. And I want to talk about a curious paradox. Antibiotics and vaccines are the two most powerful and effective weapons against infectious diseases. Yet antibiotics are accepted without a demur and vaccines are the subject of a variety of conspiracy theories. Why should they be viewed so differently?

Both are highly effective. Both are delivered by injection (though they can be delivered in other ways). Both have serious side effects including death. Both are manufactured by large multinational corporations who profit from their sale. So why are vaccines the subject of hysterical pseudo-scientific conspiracy theories, while antibiotics are not merely accepted as necessary, but actively sought, sometimes even when they are not needed?

There are three critical differences and those differences shed light on the nature of pseudo-scientific conspiracy theories. The differences tell us why certain conspiracy theories flourish and others are rejected out of hand.

The first difference is the ease of explanation. The workings of antibiotics are, on their face, easy to understand. Antibiotics kill bacteria by poisoning them. Everyone understands what a poison is and how it can be effective. We routinely poison weeds in our lawns, and mice in our homes. Poisons figure prominently in crime shows and detective novels. When patients are told that antibiotics will cure them by poisoning the bacteria that are making them sick, patients have no trouble understanding or envisioning how the antibiotics will do the job.

In contrast, the explanation of how vaccines work is rather complex. It requires familiarity with the notion of the immune system in general and antibodies in particular, how antibodies function in the body, and how they are created. This is not information that can be acquired in the course of every day life. We have no direct experience with eliciting antibodies to fight disease. Antibodies are certainly not subjects for TV shows or novels. Understanding vaccination, therefore, requires specialized knowledge not easily obtained.

The second difference is the time scale. Antibiotics work quickly, in hours or days at the most. We are sick, we take antibiotics, we get well. It is easy to credit the role of antibiotics in curing illness because they are temporally connected. Cure reliably follows the administration of antibiotics. It is easy to believe that the antibiotics cause the cure.

In contrast, vaccines act over long periods time. Pertussis vaccine is give in infancy. Years go by and those infants become young children who never develop pertussis. The connection between vaccination and wellness is not directly apparent.

Third, there is something fundamentally different between curing a disease and preventing it. Curing a disease allows for certainty on the part of the person being cured. Connecting the absence of a disease with a maneuver designed to prevent it is not apparent to most people. There are other possible explanations besides vaccination for why a child does not get pertussis. He or she may never have been exposed. Some children who are exposed do not get the disease, even if they haven't been vaccinated.

Fourth, there is a difference in apparent effectiveness. The reality is that a given antibiotic will never be 100% effective, but there are almost always alternatives. If penicillin does not due the trick, another antibiotic may be more effective. Ultimately, though, the patient is cured by antibiotics, whether it is the initial antibiotic, a subsequent antibiotic or a combination of antibiotics.

No vaccination is 100% effective, either, but there is usually one and only one vaccine for a particular disease. If the vaccine fails, the person gets the disease and there is no other vaccine that can be administered to prevent it.

These differences can be readily summarized: it is easy for lay people to believe that antibiotics work, but it requires specialized knowledge to understand that vaccines work. That's why it's not a coincidence that vaccine conspiracies flourish among those who lack basic knowledge of science, immunology and statistics. They literally cannot understand the issues involved. And if the can't understand it, there is lots of room to disbelieve it and to substitute conspiracy theories for the truth.

Eat your placenta and show just how gullible you are

When it comes to nonsense, it's tough to beat homebirth advocates. They fabricate transgressive practices, label them "natural", pretend that indigenous cultures around the world have practiced them, make up all sorts of faux benefits, and even invent "scientific" explanations which are nothing more than figments of their own, uneducated imaginations.

I've written about waterbirth in the past. In contrast to the claims of its advocates, waterbirth is not natural (no primates give birth in water), has not been practiced by indigenous cultures around the world (not surprisingly, since it's not natural), provides poor pain relief, and can lead to drowning and death of the baby. Explanations of why waterbirth is supposedly safe are nothing more than mumbo-jumbo that demonstrate a profound ignorance of human physiology.

For wackiness, though, it's tough to beat placentophagia. That's the scientific term for eating the placenta. Yup, eating the bloody, rubbery placenta. You can eat it raw, and some proponents insist that this provides the most "benefits." But for those who are more fastidious, you can dry it and put it in capsules to eat later.

Why would you do that? Because you are gullible, of course.

Placenta Benefits.info provides supplies and services to help you prepare your baby's placenta. (Wacky childbirth practices almost always cost money and are a source of income for childbirth "professionals.") What are these purported benefits that Placenta Benefits is extolling?

Why should I take placenta capsules?
Your baby's placenta, contained in capsule form, is believed to:

*contain your own natural hormones
*be perfectly made for you
*balance your system
*replenish depleted iron
*give you more energy
*lessen bleeding postnatally
*been shown to increase milk production
*help you have a happier postpartum period
*hasten return of uterus to pre-pregnancy state
*be helpful during menopause

Now that you've read the fantasy, let's look at the reality.

Is eating the placenta natural?

Sure ... if you are a rat, and maybe even if you are a lemur. But how about if you are higher order primate, or a human being? Eating the placenta is variable among higher order primates, and virtually never occurs among humans.

Indeed, the anthropological literature dates the first sighting to an indigenous group of California homebirth advocates (I kid you not). In Consuming the inedible: neglected dimensions of food choice, MacClancy and colleagues report:

... In association with the natural childbirh movement from the 1960’s placentophagia was taken up in some 'Western' societies, especially in California, on the basis that it was 'natural', as 'all' mammalian species eat the placenta. The problem with this is that not all mammals are regularly placentophagous and our closest primate relatives also are not placentophagous… [M]odern placentophagia is based on an inaccurate idea of making the human birthing process more 'natural'.

In other words, eating the human placenta is not natural and it is an affectation dreamed up by California hippies.

Can eating the placenta replenish depleted iron and give you more energy?

In the world of cooking, the placenta would be considered an "organ meat" and could theoretically improve iron levels. In fact, it may do so in species that are regularly placentophagous. Of course, eating any part of any human being could probably do the same. And though it is theoretically possible, there are no studies that have shown that it occurs.

Can the placenta decrease postpartum bleeding?

In other words, does the placenta contain utero-tonic substances like oxytocin? There's no reason to believe it does and considerable reason to believe it does not.

The purpose of the placenta is to interface with the mother's circulation and thereby transfer oxygen and nutrients. Contractions of the uterus interfere with that function (when the uterus contracts, exchange cannot take place) and may cause the placenta to shear away from the wall of the uterus (an abruption). There is precisely ZERO reason to believe that eating the placenta will prevent postpartum bleeding. In fact, Placenta Benefits.info, which has a full page of bibliography salad masquerading as supporting research, can't manage to find even a single paper on the purported utero-tonic effects of placenta.

Can eating the placenta increase milk production?

In other words, is the placenta a galactagogue? I could find only two papers on the subject. One was published in the BMJ ... in 1917. The other, quoted by Placenta Benefits.info is Placenta as Lactagagon published in 1954 by Soykova-Pachnerova in the journal Gynaecologia. The study is poorly done and has never been replicated.

The bottom line is that there is no evidence that eating the placenta increases milk production.

Can eating the placenta prevent postpartum depression?

No. According to Pec Indman, a psychotherapist who specializes in postpartum mood disorders:

Although there has not been one study (not even poorly done) about the effects in humans on placental ingestion, the claims are that it prevents the blues and PPD ...which contributes the spread of misinformation about perinatal mood and anxiety disorders. There is no evidence that the freeze drying processing of placental tissues maintains the integrity of the hormones, protein, and iron. There is no evidence about any part of this process to warrant a recommendation.

Indman's comment about the integrity of placental components highlights another important issue. There is no evidence that the placenta contains hormones that are biologically active in increasing milk supply, decreasing postpartum bleeding or improving postpartum mood. But even if the placenta did contain such hormones, you'd still have to show that they survived biologically intact, did not get destroyed by the acid in the stomach, existed in a form that could be absorbed in the intestine, and are absorbed in a form that could be utilized by human cells.

When it comes to placentophagia, homebirth advocates are batting zero, as usual. Eating the placenta is NOT a natural process for humans. Indigenous peoples around the world did NOT eat the placenta. There is NO evidence that eating the placenta improves iron stores. There is NO evidence that eating the placenta prevents postpartum bleeding. There is NO evidence that eating the placenta improves milk supply. And there is NO evidence that eating the placenta prevents or treats postpartum depression.

There is one thing that eating the placenta reliably does, though. It does highlight the fact that homebirth advocates are gullible and woefully uneducated about human childbirth.

Twelve things you shouldn't say to Dr. Amy ... unless you want to appear very foolish

It seems like every day a new visitor parachutes in to this blog and attempts to "educate" me. Inevitably, the visitor finds that almost everything she says is false. Indeed, almost everything she thinks she "knows" is false. So to spare these visitors embarrassment, and to reach those who are attempting to "educate" me on other blogs, I have compiled the following list. Here's what you should not say to me, and why you should not say it.

1. The US does very poorly on infant mortality.

Infant mortality is the WRONG statistic. It is a measure of pediatric care. That's because infant mortality is deaths from birth to one year of age. It includes accidents, sudden infant death syndrome, and childhood diseases.

The correct statistic for measuring obstetric care (according to the World Health Organization) is perinatal mortality. Perinatal mortality is death from 28 weeks of pregnancy to 28 days of life. Therefore it includes late stillbirths and deaths during labor.

The US has one of the lowest rates of perinatal mortality in the world.

2. The Netherlands, which places the greatest reliance on midwives, has low mortality rates.

No, the Netherlands has, and has had for some years, the HIGHEST perinatal mortality rate in Western Europe. It also has a high and rising rate of maternal mortality. The Dutch government is deeply concerned about these high mortality rates and a variety of studies are underway to investigate.

The most recent study published in the BMJ is early November 2010 revealed and astounding finding. The perinatal mortality rate for low risk women cared for by midwives is higher than the perinatal mortality rate for high risk women care for by obstetricians!

3. Obstetricians are surgeons.

I never understand how anyone has the nerve to say this to me. I AM an obstetrician. No one knows better than I what obstetricians are or are not. I went to college. I went to medical school. I spent four years in obstetric training. I delivered thousands of babies. I have cared for thousands of gyn patients. That some doula who is a high school graduate thinks that she can possibly know more than I about the nature of obstetricians defies belief.

Obstetricians do surgery as part of their practice. That does not make them surgeons. If it did, ophthalmologists and dermatologists would be surgeons too, since they do surgery as a routine part of caring for their patients. Is anyone seriously suggesting that you cannot go to an ophthalmologist for an eye exam because he or she will recommend unnecessary surgery?

4. Homebirth is safe.

No, all the existing scientific evidence and all national statistics indicate that homebirth triples the rate of neonatal death. Even studies that claim to show that homebirth is as safe as hospital birth, like the Johnson and Daviss BMJ 2005 study, ACTUALLY show that homebirth with a CPM has triple the rate of neonatal mortality of comparable risk women who delivered in the hospital in the same year.

The Midwives Alliance of North America (MANA) is well aware that homebirth is dangerous. That's why they are hiding their own mortality rates. They spent almost a decade collecting information on more than 18,000 CPM attended homebirths, announcing at intervals that they would use the data to show that homebirth is safe. So why haven't any of us seen it?

The data is publicly available, but ONLY to those who can prove they will use the data for the "advancement" of midwifery. MANA is quite up front about the fact that they will not let anyone else know what they have learned. Obviously, if homebirth had been anywhere near as safe as hospital birth, they would be trumpeting it from the mountain top. It does not take a rocket scientist to suspect that their data shows that homebirth dramatically increases the risk of neonatal death.

5. Homebirth midwives are experts in normal birth.

This one always makes me laugh. Experts in normal birth? That's like a meteorologist who claims to be an expert in good weather.

I guess they're trying to make a virtue of necessity. Homebirth midwives know virtually nothing about the prevention, diagnosis and management of pregnancy complications. That's a problem when you consider that the only reason you need a birth attendant is to prevent, diagnose and manage complications. You don't need any expertise to catch the baby and make sure it doesn't hit the floor. Ask any taxi drive; he'll tell you.

6. Childbirth is safe.

No, childbirth is INHERENTLY dangerous. In every time, place and culture, it is one of the leading causes of death of young women. And the day of birth is the most dangerous day in the entire 18 years of childhood.

Why does childbirth seem so safe? Because of modern obstetrics. Modern obstetrics has lowered the neonatal mortality rate 90% and the maternal mortality rate 99% over the past 100 years. What has the contribution of midwifery been to lowering those mortality rates? Zero? They've invented nothing, discovered nothing and tested nothing that has had any impact on perinatal or maternal mortality.

7. Childbirth used to be dangerous but that is only because sanitation was poor and women were poorly nourished.

No, the great advances of sanitation occurred in the 1800's and the early years of the 1900's. Not surprisingly, this had a big impact on deaths from infectious causes. However, rates of perinatal and maternal mortality did not begin to drop appreciably since the late 1930's and the discovery of antibiotics. In the intervening years, easier access to C-sections, epidural anesthesia, newer and better antibiotics, blood banking, and neonatology led to dramatically lower mortality rates.

8. C-section increases the risk of maternal and neonatal death.

No, women who die in pregnancy are most commonly women with serious pre-existing medical illness (heart disease, kidney disease) or serious pregnancy complications (pre-eclampsia). C-sections are often done in an effort to save the lives of these women. Sometimes it is not enough. The C-section is what is known as a "confounding factor." Both the C-section and the death can be traced back to the mother's health status; the C-section did not cause the death.

MacDorman and colleagues have attempted to show that C-sections for "no indicated risk" increase the neonatal death rate. Their papers have been roundly criticized because they used birth certificates, not hospital record. Unrelated investigations of birth certificates have shown that, while they are highly reliable for data like weight and Apgar scores, they are highly unreliable for risk factors. Indeed, unrelated studies have shown that up to 50% of women who have serious medical illnesses like heart disease, have those risk factors missing from the birth certificate.

9. Induction harms babies.

No, induction lowers perinatal mortality. The yearly CDC data on births shows that as the induction rate has risen, the rate of late stillbirth has dropped by 29% and the neonatal death rate has not increased.

10. If childbirth were dangerous, we wouldn't be here.

This represents a profound lack of knowledge about evolution as well as a profound lack of knowledge about childbirth. Evolution does not lead to perfection. Evolution is the result of the survival of the fittest, not the survival of everyone. Human reproduction, like all animal reproduction, has a massive amount of wastage. Every woman was born with millions of ova that will never be used. Every man produces billions of sperm that will never fertilize an ovum. Even when a pregnancy is established, the miscarriage rate is 20%. That's right. One in five pregnancies dies and is expelled and yet we are still here. Human reproduction is perfectly compatible with a natural neonatal death rate of approximately 7% and a natural maternal death rate of approximately 1%.

11. US maternal mortality is rising.

Despite a rather histrionic political report from Amnesty International making that claim, US maternal mortality is not rising and has even dropped in both of the past two years. Why does it look like it has risen? Because the standard death certificate has been revised twice in the past two decades in order to more accurately capture maternal deaths. The new death certificate has revealed maternal deaths which otherwise would not have been counted. There is no evidence that maternal deaths have increased; it's merely that reporting of those deaths has improved.

12. Women are designed to give birth.

Women are not "designed": they have evolved and evolution involves trade offs. Babies with big heads tend to be more neurologically mature, so having a big neonatal head has evolutionary advantages. A small maternal pelvis makes it easier for a woman to walk and run, providing her with an evolutionary advantage. Those two advantages are often incompatible. The woman with a small pelvis may have been able to survive by outrunning wild animals, but when it came time to give birth, she was more likely to die because that small pelvis could not accommodate a large neonatal head.

***

The above statements have two things in common. First, they are wrong. Second, they are passed back and forth between natural childbirth advocates who "teach" each other they are true. That's why it is impossible to become "educated" by reading natural childbirth books and websites. Most of their information is flat out false, and they are entirely insulated from scientific evidence. Natural childbirth advocates make up their "facts" as they go along. They don't read the scientific literature. They don't interact with science professionals. Indeed, professional natural childbirth advocates take special care to never appear in any venue whether they might be questioned by doctors or scientists. They know they'd be laughed out of the room. That's okay with them as long as there is a large pool of gullible women out there who will believe them and buy their products.

It is important that those who are parachuting in to "educate" me understand that they literally have no idea what they are talking about. Most of what they think they "know" is factually false. And they demonstrate that every time they utter one or more of those twelve statements.

Childbirth with fear

That's not a typo.

Natural childbirth originated with the publication of Grantly Dick-Read's book, Childbirth Without Fear, but in the intervening years, NCB advocates have made fear the centerpiece of their philosophy. Not fear of childbirth, despite the fact that is is inherently dangerous for babies and mothers. And not fear of pain; evidently only losers, the weak and the unempowered, fear pain. No, the centerpiece of natural childbirth philosophy, and its chosen and most potent marketing tool, is fear of doctors.

This strategy makes tremendous sense from a marketing point of view. After all, who is going to buy the services of someone who hectors you to avoid pain relief when you are in agonizing pain (a doula) unless you are afraid of something "worse"? And who is going to let her precious baby be delivered by a high school graduate who knows nothing about science and thinks gems have "energy" and flowers having healing "essences" (a CPM, a certified "professional" midwife) unless she is convinced that the alternative is "worse"? Who is going to waste hundreds of dollars on goofy ideas that rarely if ever work, like Hypnobabies, unless they are told that without it, they might actually break down and listen to those evil doctors?

Craig Thompson, professor of marketing at University of Wisconsin wrote about this tactic in Consumer Risk Perceptions in a Community of Reflexive Doubt the in the September 2005 Journal of Consumer Research. Thompson marveled at the ability of homebirth advocates to market a "product" by directly defying common sense:

Advocates of natural childbirth seek to inculcate reflexive doubt by countering two commonsense objections to their unorthodox construction of risk: (1) medicalized births would have never gained a cultural foothold if they were so risk laden and (2) the medical profession would not support obstetric practices that place laboring women at risk.

In other words, it is absolutely critical to the natural childbirth project to convince women that doctors don't know what they are doing, and willfully and cheerfully risk the lives of women and babies to promote a secret agenda.

How do doctors promote that secret agenda?

... [T]he cultural dominance of medicalized childbirth is explained as the historical artifact of a fin de siecle struggle between midwives and physicians, where the latter group held a decided economic and sociocultural advantage. As this critical narrative goes, the medical profession leveraged its emerging economic-political clout and cultural affinities toward ideals of scientific progress and technological control to displace midwives (both socially and legally) as the authoritative source of childbirth knowledge.

Obviously, the only people who will believe such clap-trap are people who know nothing about history, childbirth or science. That's why it is absolutely imperative for natural childbirth advocates to hid the fact that in the 100 years after its advent, modern obstetrics dropped the neonatal mortality rate 90% and the maternal mortality rate 99%.

Only if women don't know that modern obstetrics has been so spectacularly successful can they be convinced that technological intervention serves no other purpose than to allow doctors to show off.

Through this cultural shift, the obstetric profession also imposed medical preferences for heroic, technological interventions on the birth process. Childbirth reformers interpret these innovations—such as forceps deliveries—as unnecessary intrusions whose primary function was enabling physicians to display technical skill.

Wait! It gets even worse:

... [O]bstetricians are trained in a technocratic model of labor management that has been institutionalized through hospital protocols and technological systems. This technocratic model is condemned for treating pregnancy and labor as a mechanistic process in which the woman's body is fraught with treacherous design flaws that necessitate the administration of corrective technologies. As a result, women are routinely subjected to the unintended consequences of a cascade effect, whereby one technological intervention creates a problem that must be managed by yet another. The driving cautionary tale, oft repeated in the natural childbirth literature, is that the labor process can be so disrupted by this escalating series of technological interventions that a C-section becomes medically necessary.

The message, integral to natural childbirth advocacy is clear: Obstetricians can't help women because their technology is useless (except in the rarest of circumstances). Obstetricians don't want to help women; they want to make money, show off, and get to their golf games as quickly as possible. In fact, obstetricians actually want to HURT women by imposing their fancy technologies to ruin otherwise perfect labors simply so that they can apply even more technology. And (this is the big finish), the only way you can prevent obstetricians from victimizing you, hurting you and profiting from you is .... to buy our NCB products!

You need to buy books and visit websites, because if you don't you will have no idea that you are lamb being led to the medical slaughter. You need to pay for classes and tapes to gain the fortitude to resist the apparently helpful intentions of doctors and nurses to prevent complications and even death. You need to pay a layperson to stay with you during labor to be sure that you don't succumb to those apparently helpful medical professionals. And for the truly committed, you need to pay a high school graduate who is "trained" in normal birth (kind of like a meteorologist who is trained in forecasting only good weather) to do basically nothing except call 911 and disappear if things go wrong.

That's a tall order when you consider that for women with health insurance, childbirth in the hospital costs almost nothing. NCB advocates must convince you to spend tens of dollars on books, hundreds of dollars on classes, and thousands of dollars for the company of women who are incapable of doing a blessed thing if complications occur. Very few women would hand over that kind of money unless they had been convinced to fear the medical professionals who can help them without expecting a cash payment.

Make no mistake: NCB advocates must work hard to market their product and thereby make a profit. They must fill women with misinformation about childbirth and keep those same women ignorant of what science actually shows. They must train women to suspect that those who seem to have good intentions secretly have only sinister intentions. Better yet, they must convince women to be belligerent in demeanor and obnoxious in their demands so that there is no possibility that they will form trusting relationships with their doctors.

Simply put, NCB advocates must create an alternative universe entirely unmoored from the reality of childbirth dangers, unmoored from scientific evidence, and unmoored from the truth that people in the helping professionals are actually trying to help.

The stakes are high. If NCB advocates do not successfully create a culture of fear and suspicion, no one will pay money for their books and courses, or pay thousands of dollars for what are essentially lay companions with no particular knowledge of childbirth and a function restricted to inculcating fear of anyone who does have knowledge.

When it comes to natural childbirth, follow the money. Without fear, NCB advocates won't make money. Therefore every woman must be convinced to approach childbirth with fear.

Rape and the promiscuous use of language

Have you noticed that the word literally has actually come to mean its opposite, figuratively? According to Dictionary.com, literally is the adverb form of literal, defined as:

in accordance with, involving, or being the primary or strict meaning of the word or words; not figurative or metaphorical

But consider the following sentence: I heard a crash from my son's room and I literally flew up the stairs. Did the speaker actually fly? Of course not; she used the term as if it were an audible exclamation point, to provide emphasis and to garner attention. The truth is that the speaker figuratively flew up the stairs, but she is trying to emphasize how frightened she was and how quickly she responded.

This example highlights an ongoing problem in communication, the promiscuous use of language. By that I mean the use and abuse of language for the express purpose of drawing attention. The example above is trivial. Yes, the speaker changed the meaning of a word to imply its opposite, but no listener believes that the speaker actually flew.

It's more problematic, however, when the speaker deliberately intends to convey a meaning far different than the actual meaning of the word. Such is the case with the promiscuous use of the term rape as in the currently fashionable accusation of "birth rape".

Childbirth activists use the term "birth rape" for the same reason anyone promiscuously uses language: to garner attention. They don't like certain practices in modern obstetrics; they've whined and complained and tried to pretend that they represent the majority of women, but no one is paying much attention to them.

They've figured out that "I didn't like the way the obstetrician treated me when he was trying to save my baby's life" is not particularly compelling, since anyone who has ever suffered a serious medical problem knows that doctors give priority to saving lives in life threatening situations, rather than respecting emotional sensitivities. Let me be very clear about this point: I'm not saying that doctors are right. Often more compassion could be shown without compromising life saving efforts in the least. I'm merely pointing out that this is nothing more than a commonplace occurrence in our society.

Birth activists are dismayed that no one is particularly moved by their complaints. So they've decided to ratchet up the stakes by promiscuously using the word rape.

What is the actual definition of rape?

the unlawful compelling of a woman through physical force or duress to have sexual intercourse.

The legal definition has been expanded to include other forms of sexual touching that do not involve intercourse. And while it is true that we have come to understand that rape is often more about power than sex, we limit the meaning of rape to sexual contact. We have a different word for non-sexual harm; that word is assault. This is a critical point. We don't discount any form of abuse or harm, but we do insist on precision in describing and punishing it.

Crying "birth rape" is just a more toxic example of the abuse of the word literally. The accuser is not claiming to be literally raped and meaning instead figuratively raped. She's going one step further. She's claiming that she was literally, actually raped. And she justifies this promiscuous use of the word rape by insisting that the only thing relevant fact is her feelings. If the victim "feels like" she has been raped, then she has been raped.

But we do not determine whether a crime has occurred by referencing the feelings of the victim. The feelings of the victim matter not at all; what matters are the "feelings" of the perpetrator. We a name for the perpetrator's feelings: intent.

All crimes require more than a physical act. They require intent, legally known as mens rea or the guilty mind. Consider the crime of murder. A person run down by a driver who was texting is every bit as dead as a person run down by a professional hit man intending to cause the death. But only the latter case is murder, while the former is manslaughter at most. Intent is absolutely critical to determining whether a crime has been committed and what type of crime has been committed.

It does not matter how the victim feels about the crime (or in the case of murder, how the victim theoretically would feel about the crime). It does not matter that the relatives of the victim run down by a texting driver "feel like" the victim has been murdered, and that's not because we discount their feelings. We are actually quite sympathetic to the anger and sense of loss of the victim's relatives.

Let's look again at "birth rape." Rape requires sexual touching. A man can punch a woman and it is not rape. It might be assault, but it is not rape. Why? Because it is not sexual touching.

And it's not merely a matter of the identity of the body part that has been touched. A woman can kick a man in the crotch, but that is not rape either. It might be assault, but it is not rape. Why? Because intent matters.

The victim's feelings about the matter are irrelevant. The woman who was punched can "feel" like she was being raped, but that doesn't make it so. A man who was kicked in the crotch might "feel" like he was being raped, but that doesn't make it so.

What are the implications for the accusation of "birth rape"? Simply put, there is no such thing as "birth rape." The accusation is merely the promiscuous use of the word rape with the express intent of drawing attention to one's self or one's cause.

It does not matter that the self-proclaimed victim was treated roughly. It might be assault, but it is not rape. Why? Because it is not sexual touching.

It does not matter that the part of the body involved has a sexual function. Why? Because intent matters.

And most importantly, it does not matter what the victim feels. Her feelings may be relevant to her; and, of course, they may be critical in providing psychological help to her. But they are entirely IRRELEVANT to the determination of whether or not a rape has occurred.

"Birth rape" does not exist. It is a promiscuous abuse of the term rape for the sole purpose of garnering attention. The term is legally meaningless and ethically suspect. It is morally wrong to insist that a rape has occurred when nothing of the kind happened. It is ethically unjustified to misuse the term rape regardless of how worthy the motivation. And it is insupportable to base the accusation of a crime on how the victim "feels" about it.

Feeling validated vs. being correct

It is ironic that one of our greatest technological advances has provided an incomparable boon to scientific illiteracy. I'm referring, of course, to the internet. Prior to the advent of the internet, wacky pseudo-scientific "theories" were relegated to the fringes and had to be deliberately sought out. Now pseudo-scientific mumbo jumbo can be widely disseminated.

But perhaps more important than the actual dissemination of misinformation is that feeling of validation that internet communities provide. Pseudoscience can thrive when believers congregate on message boards that validate bizarre beliefs and ban information that undermines those beliefs. They don't call it validation, though; that's too clinical. They call it "support."

Hart et al. explore this phenomenon in their paper Feeling Validated Versus Being Correct: A Meta-Analysis of Selective Exposure to Information. The authors explain:

... Receiving information that supports one's position on an issue allows people to conclude that their views are correct but may often obscure reality. In contrast, receiving information that contradicts one’s view on an issue can cause people to feel misled or ignorant but may allow access to a valid representation of reality. Therefore, understanding how people strive to feel validated versus to be correct is critical to explicating how they select information about an issue when several alternatives are present. (my emphasis)

Avoiding cognitive dissonance is central to the search for validation:

... According to dissonance theory, after people commit to an attitude, belief, or decision, they gather supportive information and neglect unsupportive information to avoid or eliminate the unpleasant state of postdecisional conflict known as cognitive dissonance.

Minimizing cognitive dissonance requires selective exposure, seeking out information sources that confirm existing beliefs and avoiding sources that undermine those beliefs. For example:

In one of the initial studies testing selective exposure, mothers reported their belief that child development was predominantly influenced by genetic or environmental factors and then could choose to hear a speech that advocated either position. ... [M]others overwhelmingly chose the speech that favored their view on the issue.

There is an exception, however. People were happy to view uncongenial information if they felt it was easy to refute.

Internet communities that promote pseudoscience are quite overt in their preference for validation over accuracy. Consider this reminder that appears at the top of the Mothering Unassisted Childbirth Forum:

... This is a forum for support, respectful requests for information, and sharing of ideas and experiences. While we will not restrict discussions only to those who birth without professional attendants, proselytizing against UC will not be permitted...

Mothering is even more overt in its insistence on selective exposure to information about vaccination:

... Though Mothering does not take a pro or anti stand on vaccinations, we will not host threads on the merits of mandatory vaccine, or a purely pro vaccination view point as this is not conducive to the learning process.

They're not anti-vaccine but they refuse to print a pro-vaccine point of view? Whom do they think they are kidding? Of course, it's hardly surprising if the primary purpose of the forum is to provide readers with validation, rather than to transmit accurate information.

The authors and publishers of pseudoscience books and websites are quite upfront about their determination to minimize cognitive dissonance by restricting the free flow of information. Only information that supports a predetermined point of view is allowed. Anything else must be deleted. To the extent that any real scientific papers are discussed, they are limited only to those that can be easily refuted. The rest of the vast scientific literature is ignored.

That's why it is impossible to become "educated" when reading pseudoscience websites.

Ricki Lake's website offers postdates advice

Homebirth advocates are like celebrity pundits. TV and print pundits make predictions about elections, stock market behavior, and the expected results of international diplomacy, yet they never, ever review whether their predictions were correct. That would be embarrassing since they are often wrong. Instead they simply move on to new predictions.

Homebirth advocates go them one better. They do review their decisions and improbably declare that the wrong decisions were actually right, or right at the time, or right because it wouldn't have made any difference. It does not matter how spectacularly wrong they were; they stubbornly, pigheadedly, childishly insist that they were right.

Consider this discussion on the website of celebrity homebirth advocate Ricki Lake.

Amie writes:

Hello ladies, I am 41 + 1 today and my midwife has suggested that I see her OB for induction. I have no effacement, no dilation and the baby has not completely dropped so she feels that it is in my best interest to have a hospital birth. I have been taking orally and inserting the prime rose, walking, having lots of sex and have taken castor oil and nothing has helped. I am not comfortable with being medically induced but would rather try that then have a repeat cesarean... I still want to stay far away from an epidural but am afraid that the pitocin will make the contractions too powerful and will limit me to my bed.

Here are the replies.

Sheila:

... I also was overdue with my VBAC attempt (41 wks 3 days) and induced with pitocin. But my body wasnt ready, and I had another csection for failure to progress. If you and baby are fine, refuse intervention...

Jennifer:

You may not be "41 weeks" exactly. And 40 is only an average. All of my babies were born at 41.5 weeks; dates based on ultrasound measurements in early pregnancy. I was 44 weeks according to the calendar...

Meredith:

... My mother was over 44 weeks when she had my sister (he first birth), she was 43 weeks when she gave birth to me and 41 weeks when she had my younger sister. So women just carry longer and it's completely natural...

Sara:

... Induction itself is a slippery slope to many, many medical interventions including c-sec. It keeps your body from going through the natural chemical process that helps you handle the pain...

Trust you body, follow your intuition. I am sending you lots of "labor dust" :)

***

Instead of addressing the real issue, the increased risk of stillbirth as a pregnancy advances, the replies offer such gems of wisdom as 'I ignored my doctor and my baby didn't die' and 'maybe you are not really postdates.' Of course no homebirth "advice" would be complete with the immature magical thinking that is intrinsic to homebirth advocacy: 'follow your intuition.'

Amie responds:

Thank you so much for all of the info. I honestly feel like he is not ready and all of my castor oil milkshakes and walking are not helping because of that fact...


Amie's update 42+1 weeks:

Well the OB appt went well, I had an NST and an ultrasound. The fluid levels still look good and the heartbeat was beautiful... I have an appt on Thursday with the midwife and hopefully I will have some dilation by that point. Thank you for all of your encouragement, it has really helped me.

Amie's update 43 weeks:

My son Evan was still born by cesarean section... OB said that the cord had clotted and was in knots. It has been a very hard time for me as I am second guessing all the decisions I made throughout the pregnancy...

***

It is appropriate that Amie is second guessing her decisions since her decisions directly led to the preventable death of her baby. She was told that she was at increased risk for a stillbirth and she ignored that information.

What about the folks at Ricki Lake's website who "advised" her. They're not second guessing their "advice" at all. They appear to be delusional.

Susan:

... I am glad that you know you are not to blame, and are not wasting time and energy on second-guessing your decisions.

Meredith:

... You did and fought for, what you knew in your heart, to be the best path and never second guess that.

Irene:

... please don't blame yourself in any way, you did what any other Mom would have done!

***

Only among homebirth advocates is the road to death "the best path" and the choices that led to that death "what any other Mom would have done."

Here's a bit of unsolicited advice: When the baby dies after you tell someone that their baby won't die, have the decency to be embarrassed. You've already demonstrated that you were spectacularly wrong. Don't compound it by pretending, against all the evidence, that you were right.

Unassisted birth leads to death of baby AND mother

Regular readers know that among all the supposedly "natural" childbirth practices, I reserve special contempt for unassisted birth. Unassisted childbirth (and its companion, unassisted pregnancy) involves shunning medical care of any kind, even a lay midwife. Known by afficianados as freebirth or UC, it is perhaps more accurately called stuntbirth. As I have written in the past:

... Advocates emphasize the fact that it is transgressive, is "authentic", values process over outcome, creates a sense of belonging, and produces feelings of empowerment.

Unassisted childbirth has no benefit to the baby and poses very serious risks to both the baby and the mother. It involves no particular skill, a belief that no expertise in childbirth is needed, has a prime objective of testing the capacity to endure pain, and risks death as the likely outcome of a mistake. In short, it is nothing more than a stunt.

Both of the leading advocates of UC have lost babies as a result. American Laura Shanley claims that she had 4 wonderful unassisted births, but she has actually had 5. She deliberately and knowingly gave birth to a premature baby alone at home and, over the next several hours, watched him die.

Last year, Australian Janet Fraser gave birth to an baby who had died during labor. In the weeks leading up to the birth, Fraser had proudly boasted to an Australian paper that she had no prenatal care of any kind, and planned to have no medical assistance at the birth. Her baby paid the ultimate price for her inane ideas.

This week the inevitable happened. Both the baby and the mother died at an unassisted birth. I learned from two separate unrelated sources of the tragic death of a first time mother who died within hours of delivering a stillborn baby. The reports indicate that the mother died suddenly and without apparent warning. It's not clear if this means a sudden event like an amniotic fluid embolus or an ongoing medical complication like pre-eclampsia or hemorrhage that went unrecognized by the couple. An autopsy is being performed.

It is a horrible, senseless and needless tragedy.

A stunning indictment of midwives in the Netherlands

Homebirth and midwifery advocates point with pride to a recent study that showed that homebirth with a midwife in the Netherlands is as safe as hospital birth with a midwife (Perinatal mortality and morbidity in a nationwide cohort of 529 688 low-risk planned home and hospital births). They tout this study as evidence that homebirth is as safe as hospital. A new study suggests an entirely different explanation: Dutch midwives have unacceptably high rates of perinatal mortality both at home and in the hospital. Indeed, the perinatal mortality rate for LOW risk women cared for by Dutch midwives is HIGHER than the perinatal mortality rate for HIGH risk women cared for by Dutch obstetricians!

The new study, Perinatal mortality and severe morbidity in low and high risk term pregnancies in the Netherlands: prospective cohort study, appears in this week's issue of the British Medical Journal. The authors explain that the study was undertaken to investigate why the Netherlands has highest perinatal mortality rate in Europe.

Several factors are mentioned as possible explanations for this high mortality, such as differences in registration and maternal characteristics of the Dutch childbearing population, restricted management of premature babies, and the absence of standard screening for congenital anomalies. The numbers of older mothers, multiple pregnancies, and mothers belonging to an ethnic minority are relatively high in the Netherlands. However, this can only partly explain the high perinatal mortality. Whether the Dutch obstetric care system contributes to this relatively high mortality remains unclear.

This is an important question because the Dutch system of maternity care relies primarily on midwives and those midwives perform a relatively high number of homebirths. This study, a cohort study of severe morbidity and mortality of term fetuses or neonates, called ATNICID (Admission of Term Neonates to Intensive Care or Intrauterine Death), was begun in 2007 with the express intent of examining the relationship between the organization of the Dutch maternity care system and the high rate of perinatal mortality.

The study ultimately enrolled 37,735 term infants without congenital anomalies:

16,672 (44.2%) infants of nulliparous women (including 143 (0.9%) twin pregnancies) and 21,063 (55.8%) infants of multiparous women (including 226 (1.1%) twin pregnancies). Data on 91 (0.2%) infants were missing; we excluded these from further analysis... 18,686 (49.5%) infants were born to women who started labour in primary care as low risk, of whom 5492 (29.4%) were referred to secondary care during labour; 13,194 (35.0%) infants were born under the supervision of a midwife in primary care, and 24,450 (64.8%) infants were born under the supervision of a gynaecologist.

The results were astounding:

Of the 60 antepartum stillbirths, 37 occurred in primary care and 23 in secondary care...

Twenty-two intrapartum stillbirths and 14 delivery related neonatal deaths occurred. Infants of pregnant women at low risk had a significantly higher risk of delivery related perinatal death (relative risk 2.33, 1.12 to 4.83), compared with infants of women at high risk whose labour started in secondary care under the supervision of an obstetrician. Infants of women who were referred to secondary care during labour had a 3.66 times higher risk of delivery related perinatal death than did infants of women who started labour in secondary care (relative risk 3.66, 1.58 to 8.46)...

A total of 210 infants were admitted to the NICU:

... resulting in an overall incidence of admission to NICU of 5.58 (4.83 to 6.33) per 1000 live births.... Half of the women (51%, n=107) started labour in primary care. Of these, 70% (n=75) were referred to secondary care during labour... The incidence of admissions to the NICU was 2.43 per 1000 term births in primary care, 13.7 per 1000 term births if referral to secondary care during labour occurred, and 5.45 per 1000 term births managed exclusively in secondary care.

Nearly half the NICU admissions were the result of one cause: asphyxia. Among the 17 infant deaths:

71% (n=12) [were] because of asphyxia and 29% (n=5) because of an infection. Fourteen cases were classified as directly related to circumstances during labour.

Of the 26 deaths related to labor presided over by midwives, 65% were attempted homebirths.

These results are deeply shocking.

We found that delivery related perinatal death was significantly higher among low risk pregnancies in midwife supervised primary care than among high risk pregnancies in obstetrician supervised secondary care. This difference was even greater among the cases that were referred from primary to secondary care during labour. Unfortunately, we were unable to adjust for confounding variables because we used aggregated data from a large birth registry database. However, the results are unlikely to have been overestimated, because risk factors such as low socioeconomic status, higher age, or non-Western ethnicity were more prevalent among the women at high risk. (my emphasis)

The authors express their concern:

In summary, the Dutch obstetric care system is based on the assumptions that pregnant women and women in labour can be divided into a low risk group and a high risk group, that the first group of women can be supervised by a midwife (primary care) and the second group by an obstetrician (secondary care), and that women in the primary care group can deliver at home or in hospital with their own midwife. When complications occur or risk factors arise antenatally, during labour, or in the puerperium in primary care, the women is referred to secondary care. We found that the perinatal death rate of normal term infants was higher in the low risk group than in the high risk group, so the Dutch system of risk selection in relation to perinatal death at term is not as effective as was once thought. This also implies that the high perinatal death rate in the Netherlands compared with other European countries may be caused by the obstetric care system itself, among other factors. A critical evaluation of the obstetric care system in the Netherlands is thus urgently needed.

In contrast to the claims of homebirth and midwifery advocates, the Netherlands is far from being the ideal model of obstetric care. The Netherlands has the highest perinatal mortality in Europe, and midwifery care may very well be the cause of this calamity.

Pseudoscience, common sense, and the problem of scale

Scientists are increasingly frustrated by laypeople's willingness to embrace pseudoscience. In an age of extraordinary technical achievement, the persistence of nonsense beliefs like creationism, vaccine rejection, and homeopathy is difficult to fathom. But Scott Lilienfeld, a psychology professor at Emory University, argues that we should be anything but surprised.

Explaining Why Scientists Shouldn't Be Surprised by the Popularity of Intelligent Design, Lilienfeld asserts:

... [F]rom the standpoint of psychological science, the only thing about [intelligent design's] popularity that should surprise us is that so many scientists are surprised by it...

It's just a matter of common sense. No, advocates of pseudoscience aren't lacking in common sense. The problem is precisely the opposite. They believe that they can use common sense to evaluate scientific claims.

The foremost obstacle standing in the way of the public's acceptance of evolutionary theory is not a dearth of common sense. Instead, it is the public's erroneous belief that common sense is a dependable guide to evaluating the natural world...

Yet natural science is replete with hundreds of examples demonstrating that common sense is frequently misleading. The world seems flat rather than round. The sun seems to revolve around Earth rather than vice-versa. Objects in motion seem to slow down on their own accord, when in fact they remain in motion unless opposed by a countervailing force.

Fundamentally, this is a problem of scale. What is common sense? It is a body of knowledge derived from common experience. Even toddlers know that objects always fall down not up and objects that are out of sight still exist. These rudimentary scientific observations form the bedrock of common sense. But for something to be common sense, it must take place on a level we can appreciate with our senses. Simply put, common sense can only tell us about events that are common to human experience.

Yet what we can apprehend with our unaided senses represents only a small fraction of what is going on. Our distance vision is limited. Microscopic organisms and particles are invisible to us. No individual has personal experience of a time span longer than 100 years or so. Therefore, many scientific processes take place at a scale that is impossible for us to perceive. Whether that scale is distance measured in light-years, size measure in microns or time measured in millennia, they are entirely outside the realm of common sense.

... The human brain evolved to increase the probability that the genes of the body it inhabits make their way into subsequent generations. It did not evolve to infer general principles about the operation of the natural world, let alone to understand itself. It also did not evolve to comprehend vast expanses of time, such as the unimaginable tens or hundreds of millions of years over which biological systems evolved. Consequently, it is hardly surprising that many intelligent individuals ... glance at the remarkably intricate biological world and conclude that it must have been produced by a designer.

Lilienfeld is referring to the "watchmaker" theory of intelligent design: Imagine walking through a barren desert and finding a functioning watch in the sand. Common sense tells us that such an intricate and complicated object could not have arisen spontaneously. Even though we cannot see a watchmaker, we can infer that a watchmaker must exist.

Yes, that is what common sense tells us, because in our common experience, complex objects do not arise spontaneously. But our common sense draws on what humans have learned during the 10,000 years of recent history. However, evolution takes places on an entirely different scale, over hundreds of thousands of years. No amount of common sense can tell us how it works because it is outside the realm of our common experience.

This is the same reason why it took almost all of human existence until we figured out that the earth is round, not flat. Common sense tells us that the earth is flat because it looks flat when we observe it, and it feels flat when we walk upon it. In other words, it seems flat to us at the scale that we are able to observe with our unaided senses. We cannot see vast distances and we cannot feel minute curvature. Take us to a different vantage point, though, the shape of the earth is easy to appreciate. Looking at the earth from space, it is obvious that it is round.

Common sense tells us that the universe revolves around the earth. That's the way it looks to us, but, again, that is only because we are restricted by the limitations of the human frame of reference. Once the telescope was invented, and Copernicus and Galileo were able to discern other planets and take precise measurements of what happens in the sky each night, it became apparent that the earth was moving through space rather than space moving around the earth.

Common sense is often useless in evaluating scientific phenomena because they take place outside the scale of common experience. Yet scientists have not appropriately emphasized this fact. According to Lilienfeld:

To a substantial extent, the fault in the current [intelligent design] wars lies not with the general public, but with scientists and science educators themselves. Generations of biology, chemistry, and physics instructors have taught their disciplines largely as collections of disembodied findings and facts. Rarely have they emphasized the importance of the scientific method as an essential toolbox of skills designed to prevent us from fooling ourselves...

... [Scientists] must inculcate in students a profound sense of humility regarding their own perceptions and interpretations of the world. They should teach students about optical illusions, which demonstrate that our perceptions can mislead us...

Believers in pseudoscience do not lack common sense. Rather, they lack an understanding of the limitations of common sense. Anything that takes place at a scale too large, too small, or over a period of time too long to be perceived by unaided human senses is not amenable to understanding through common sense. Common sense is helpful in judging only what we commonly experience. When it comes to phenomena that occur on a scale we are incapable of experiencing, common sense is virtually useless.