VBA3C homebirth: ruptured uterus, brain damaged baby

In December CNN published a story that received a lot of attention and approval among homebirth and natural childbirth advocates, Mom defies doctor, has baby her way. Mom, Aneka, made the decision to risk her life and the baby's life based on the flimsiest of reasons, she watched Ricki Lake's documentary, The Business of Being Born.

She found support for her decision from ICAN (the International Cesarean Awareness Network):

"She asked me if I could find someone who would deliver her vaginally," remembers Bobbie Humphrey, who works with ICAN. "She started to cry because she'd heard 'no, no, no you can't do this' so many times."

But Humphrey told her yes, that she knew of a midwife who would be willing to deliver her baby at home.

Aneka and her son were lucky. They survived her risky choice, but Aneka and her on line supporters had no clue it was just a matter of luck:

"People were e-mailing Aneka saying 'congratulations, you're a role model," Humphrey says.

Another woman did try to emulate her, with tragic results:

A girl who I went to college with had a baby around 10 last night & both are in critical condition. This is her 4th baby. She had 3 previous c-sections & was trying for a VBAC homebirth. Her uterus ruptured in several places & she lost a lot of blood. She is intubated & had 2 blood transfusions. She isn't out of the woods yet, by any means. The baby was born blue & unresponsive, was resusitated, but showing signs of possible brain damage. She was flown to a different hospital than her mom. The baby is being kept in some sort of induced unconscious state currently. Please keep Lori & baby Vera in your thoughts & prayers!! Thanks.

Apparently Lori transferred to the hospital at some point during the homebirth attempt. Her sister-in-law wrote on her personal blog:

... Lori lost a lot of blood because the uterus tore in several places; the docs had to replace her blood twice over. She has been in the OR at Lehigh Valley Hospital from 10pm (1/27) til now 4:20am (1/28). When I left the hospital at 4:20am, the OR team was just finishing up. I was not able to see Lori or the baby. Right now, Lori will remain intubated for the next couple of days, and in the ICU. The doctor said she is not out of the woods, she is still critical, and has a long road to recovery.

Baby Vera is also having difficulties... Somewhere in the process of removing the baby, she lost oxygen. She was born blue and flaccid and needed resuscitative measures. She pinked up and her heart rate became strong, but she remained unresponsive and could not breathe on her own. Vera was medivaced via helicopter to Jefferson Hospital in Philadephia for a cooling process. The docs are hoping that by placing Vera's brain and body in a slightly hyperthermic [sic] state, that her little body will reset. She is responding to pain, but her pupils are still not dilating. Vera is also considered critical.

Lori's friend posted updates on the message board:

Lori is doing better. Her blood work, urine output, and vitals signs are strong and look good. When the nurses lighten her sedation, Lori is fighting against the breathing tube, which is a good sign (she knows it's there)....

Vera, however, is not doing as well as the doctors wanted. She has little brain activity and her pupils remain unreactive. She is still intubated and in critical condition. They have her doing the cooling treatment and will be on it for 72 hours...

Update 1/29:
Lori is doing much better - breathing & talking on her own. She still has a long recovery, though.

The doctors are trying [cooling] treatment with baby Vera. The treatment is 3 days, then it's just watch & wait to see what happens.

All of this leaves me with questions for the folks at ICAN who encourage women to take these life threatening risks:

Will you use Lori as a role model for VBA3C? Or will you wash your hands of her and pretend this never happened?

Update (2/3/11): According to the neonatalogists "...the MRI showed that a large amount of fluid had collected (hydrocephalus) and was putting pressure on parts of the brain, actually moving sections into different areas (herniation). The EEG showed minimal electrical activity from the cerebral hemispheres. The neurologist stated that there is some brain swelling as well as significant brain damage in a large part of her brain, but she is NOT brain dead. Vera still has some reflexes. What they believe Vera has is HIE, Hypoxic Ischemic Encephalopathy."

Update (2/12/11): Vera died last night.

The naked stupidity of vaccine rejectionists

Excuse me for a few moments while I catch my breath. I've been laughing so hard that I can't write.

As anyone who has read this blog knows, I have no patience for vaccine rejectionists. They are uneducated, illogical and immoral. But even I am sometimes amazed at the naked stupidity and gullibility of vaccine rejectionists.

The latest post at Age of Autism should be studied as a classic in the annals of vaccine rejectionist "reasoning." The blog breathlessly announces that there have been more miscarriage events associated with Gardasil than other vaccines.

As my children would say: Duh!

The folks at AofA seem to think this is surprising and means that Gardasil is dangerous. That's hilarious!

It's hardly surprising that Gardasil, the ONLY vaccine given exclusively to women of reproductive age has more miscarriage EVENTS than other vaccines. Was anyone expecting that vaccines given to prepubertal children were going to be associated with miscarriages? What's next: "puberty causes miscarriages" because there are more miscarriage events after puberty than before?

Here's what I can't figure out. Did the geniuses who run AofA actually think this was a "finding"? Or are they so cynical did they just fed it to their readers assuming they'd be too gullible to notice that the claim is absurd?

Moreover, the number of miscarriages in meaningless. The only meaningful measurement is the miscarriage RATE (the number of miscarriages divided by the number of pregnant women who received the Gardasil vaccine). And since the natural miscarriage rate is 20%, that number would need to be substantially higher than 20% to merit any consideration that Gardasil leads to miscarriage. But of course the AofA article does not bother to mention the miscarriage rate, doesn't even bother to calculate it.

Amazingly, when I commented on the post, the AofA folks actually printed the comment. It was followed by expressions of outrage and lots and lots and lots of words. Yet not a single person could tell us the miscarriage RATE, and some apparently didn't even understand that they had been fooled.

The only shocking aspect of this post is that some people are stupid enough and gullible enough to think it is meaningful.

What do homebirth midwives and tobacco executives have in common?

The Midwives Alliance of North America (MANA), the organization that represents homebirth midwives*, thinks it's time to reframe the debate about homebirth safety.

According to a MANA press release issue two days ago:

We believe it is time to re-frame this conversation. Midwives and obstetricians have been debating the safety of homebirth for far too long. In North America today planned homebirth for healthy women, attended by skilled providers, with access to medical consultation when necessary, is a safe option....

In other words, as the evidence mounts that homebirth leads to preventable neonatal deaths, we should stop talking about it.

Evidently, MANA and homebirth midwives have decided to copy the tactics used by the tobacco industry to divert attention from the fact that cigarette cause preventable deaths. SourceWatch explains the tobacco industry's attempt to reframe the debate:

The "reframe the debate" strategy consists of moving the topic of a contentious dispute onto a wholly different topic. This involves making dire predictions of a more extreme outcome, portraying the original action as dangerous, tying activists to the dangerous outcome, linking the originally-proposed action to a fear-inducing outcome ...

As the Tobacco Institute explained to its members:

Our judgement, confirmed by research, was that the battle could not be waged successfully over the health issue. It was imperative, in our judgement, to shift the battleground from health to a field more distant and less volatile...

Evidently MANA has made the same calculation. As I have detailed many times in the past (So tell me again why MANA is hiding its own homebirth safety data), MANA's own data shows that homebirth has an unacceptably high rate of neonatal death. MANA knows that "the battle [can] not be waged successfully over the health issue" of homebirth safety. Therefore they have to "reframe the conversation."

Let's compare the tactics used in the MANA press release with the tactics of the tobacco industry.

Choice and responsibility

MANA:

First, we must understand the bio-ethical principle of autonomy as it relates to the human right of self-determination in making health care choices. Only then can we support women in their mastery of self-determination as they navigate the complicated worlds of obstetrics and maternity care and attempt to make good decisions for themselves and their families.

Tobacco industry:

[C]reate a campaign which frames and answers this question: Does America want prohibition? Will we tolerate a puritanical wave to infringe, to restrict and possibly to eliminate personal freedoms and individual choices?

Broaden the issue

MANA:

... [W]e can no longer tolerate the abysmal maternal and child health disparities that exist for our most vulnerable women and populations of color. We have our plates full with the daunting task of improving the health status of all women and infants in the United States within a social justice framework.

Tobacco industry:

The tobacco industry typically diverts attention away from a problematic topic by broadening the issue to encompass other issues. For example, the industry broadened problem of secondhand tobacco smoke or environmental tobacco smoke into a discussion of overall indoor air quality, and moved discussion of the issue to include pollutants in the air other than tobacco smoke, such as wood smoke or automobile exhaust, or shifted the focus to the efficiency (or lack thereof) of mechanical ventilation systems.

Change the focus MANA:

... We must address the fact that certain costly obstetrical practices that are not supported by science are overused, while other beneficial, low-tech practices are overlooked. Of particular concern to the Midwives Alliance and the clients we serve is the trend of increasing rates of cesarean sections, contributing to increased rates of premature birth, low birth weight infants and rising healthcare costs, while women across the country still struggle to find providers willing to attend vaginal births after cesarean (VBACs).

Tobacco industry:

...Finally, we try to change the focus on the issues. Cigarette tax become[s] an issue of fairness and effective tax policy. Cigarette marketing is an issue of freedom of commercial speech. Environmental tobacco smoke becomes an issue of accommodation. Cigarette-related fires become an issue of prudent fire safety programs. And so on.

Clearly MANA and the tobacco industry have followed the same playbook for the same reason: to divert attention from the issue of safety.

The MANA press release concludes:

... We can no longer be diverted by the distractions of disagreements among maternity professionals. We have serious work to do that cannot wait...

But homebirth safety is NOT a distraction. It is the central issue. And the only people who "cannot wait" to confirm the fact that homebirth has an unacceptably high rate of neonatal death are homebirth midwives.

The Midwives Alliance of North America already KNOWS that homebirth increases the risk of neonatal death; their own data tells them so, and that's why they are desperately trying to hide that data. MANA "cannot wait" because they understand that more research will only confirm that fact. They need to act now before everyone learns that homebirth kills babies.


*American midwives who hold a post high school certificate (CPMs and LMs), as opposed to American certified nurse midwives and European, Canadian and Australia midwives who have university degrees

Why does childbirth hurt?

Several days ago I wrote about the philosophy of natural childbirth advocacy and its indifference to women's need for pain relief (Natural childbirth and the invisibility of women's needs). To the extent that natural childbirth advocates acknowledge the existence of childbirth pain, they subscribe to the "if only" school of pain management.

The "if only" school insists that a woman would not experience childbirth as agonizing ...

... if only she were more knowledgeable about childbirth.
... if she hadn't been socialized to believe that labor is painful
... if only she had eaten right and exercised.
... if only she had better support.
... if only she hadn't had an IV and/or electronic fetal monitoring.

In other words, the "if only" crowd believes that pain is not intrinsic to childbirth; it's someone's fault. But pain is intrinsic to childbirth, and to understand why, requires knowledge of the neurological basis of pain itself.

Contrary to the false dichotomy of "good" pain and "bad" pain imagined by natural childbirth, which has no basis in neurology, there are two sources of pain in childbirth, exactly the same as the two sources that exist everywhere else in the body. These two types of pain are visceral and parietal (or somatic) pain.

Here's the technical explanation from a paper written by a certified nurse midwife:

... During the dilatation phase of labor (first stage), visceral pain predominates, with pain (nociceptive) stimuli arising from mechanical distention of the lower uterine segment and cervical dilatation... These nociceptive stimuli of the dilatation phase are predominantly transmitted to the posterior nerve root ganglia at T10 through L1. Similar to other types of visceral pain, labor pain may be progressively referred to the abdominal wall, lumbosacral region, iliac crests, gluteal areas, and thighs... As the pelvic or descent phase of labor advances (late first stage and second stage), somatic pain predominates from distention and traction on pelvic structures surrounding the vaginal vault and from distention of the pelvic floor and perineum. Sharp and generally well localized, these stimuli are transmitted via the pudendal nerve through the anterior rami of S2 through S4.

Translation:

The pain of contractions is visceral pain caused by the uterine effort to push the baby into the vagina. This visceral pain is the type of pain that comes from internal organs, exactly the same as the visceral pain of a gall bladder attack or a kidney stone. The visceral pain signals are transmitted to the spinal cord through the spinal nerves of the lower thoracic and upper lumbar vertebrae and thence to the brain.

The vaginal and perineal pain of the end of labor is parietal or somatic pain. Parietal pain is sharp and well localized. The parietal pain impulses of crowning and birth are transmitted to the spinal cord through the spinal nerves of the sacral vertebrae and thence to the brain.

An epidural blocks the visceral pain of labor by "numbing" the nerves that transmit the pain to the spinal cord. The parietal pain of labor can be eliminated by "numbing" the spinal nerves that transmit the pain or, in the case of local anesthesia, by "numbing" the nerves located where the pain begins.

The key point is that the two types of labor pain are exactly the same as the two types of pain that can occur in other parts of the body. The nerve impulses are the same, they travel to the spinal cord on similar pathways, and they are sent to the brain in exactly the same way. They can also be abolished in exactly the same way.

Therefore, to understand why the "if only" school of management is wrong, not only in their understanding of pain, but also in their claims about what can and cannot "cause" pain, it helps to apply their claims to other forms of pain.

Consider gall bladder pain, a classic form of visceral pain that occurs when the gall bladder attempts to squeeze out bile but cannot because the duct is blocked by gallstones. Would a patient in the midst of a gall bladder "attack" have less pain if only she were more knowledgeable about gall bladder attacks? If she hadn't been socialized to believe that gall bladder attacks are painful? If only she had eaten right and exercised? If only she had better support? If only she hadn't had an IV and/or electronic blood pressure monitoring? The answers of course are no, no, no, no and no.

And why are all the answers "no"? Because gall bladder pain arises from the contractions of the gall bladder attempting to push out a gallstone, is transmitted to the spinal nerves and thence to the brain. The pain impulses from a gall bladder attack aren't modified by knowledge, socialization, diet and exercise, nursing support or the presence of basic medical safety measures. There's no reason to expect that they would be modified by these factors. Similarly, there's no reason to expect that labor pain would be modified by these factors, either.

How about parietal pain? Consider pain from a broken bone, and ask the same questions. The answers will be "no" once again and for exactly the same reason. Just like knowledge, socialization, diet and exercise, nursing support or the presence of basic medical safety measures would not be expected to modify the pain of a broken bone, they cannot be expected to modify the pain of crowning and birth, either.

So why does childbirth hurt? Because of the pain! The pain that is produced by nerve signals, transmitted to the spinal cord, and carried to the brain in exactly the same way as visceral and parietal pain from any other part of the body.

There is no scientific basis for the claims of the "if only" school of childbirth pain. It's just another attempt to render women's needs invisible.

Incompetent and unaware of it

One of the biggest problems in homebirth midwifery is that homebirth midwives* don't know what they don't know. Their background in obstetrics, science and statistics is very limited; so limited, in fact, that they have no idea how little they know compared to those who have far more education and training in these subjects.

The classic paper on this phenomenon is Unskilled and Unaware of It: How Difficulties in Recognizing One's Own Incompetence Lead to Inflated Self-Assessments by Kruger and Dunning published in Journal of Personality and Social Psychology in 1999. The paper reports on a variety of experiments that were used to evaluate individuals' actual performance compared to predicted performance.

For example, study subjects were given a test of basic logic:

...Participants ... completed a 20-item logical reasoning test that we created using questions taken from a Law School Admissions Test (LSAT) test preparation guide. Afterward, participants ... compared their "general logical reasoning ability" with that of other students from their psychology class by providing their percentile ranking. Second, they estimated how their score on the test would compare with that of their classmates, again on a percentile scale. Finally, they estimated how many test questions (out of 20) they thought they had answered correctly...

The results are displayed in the following graph:



The dark lines represent the test subjects' rating of their logical reasoning ability and the score they predicted they would get. The dotted line represents the actual score. The graph demonstrates that the ability to correctly predict one's score is directly related to the actual score. Those who scored poorest on the test of logic grossly overestimated their ability; those who did slightly better slightly overestimated their performance; and those who scored moderately well were accurate in predicting their own performance.

In other words, those who knew the least were also the least capable in understanding how little they knew.

The authors also found that improving the subjects knowledge of logic led to more realistic personal assessments. They divided a new group of test subjects in two. One half received a lesson in logic before the test; the other half received a lesson in an unrelated subject. Those who received the lesson in logic were much more likely to accurately predict performance on the test.

... Before receiving the training packet, these participants [in the lowest quartile] believed that their ability fell in the 55th percentile, that their performance on the test fell in the 51st percentile, and that they had answered 5.3 problems [out of 10] correctly. After training, these same participants thought their ability fell in the 44th percentile, their test in the 32nd percentile, and that they had answered only 1.0 problems correctly...

No such increase in calibration was found for bottom-quartile participants in the untrained group.

As the authors explain:

Participants scoring in the bottom quartile on a test of logic grossly overestimated their test performance — but became significantly more calibrated after their logical reasoning skills were improved. In contrast, those in the bottom quartile who did not receive this aid continued to hold the mistaken impression that they had performed just fine.

Why hadn't the study participants realized their own deficiencies in basic logic simply by interacting over the course of their lifetime with other people who knew more basic logic?

... [S]ome tasks and settings preclude people from receiving self-correcting information that would reveal the suboptimal nature of their decisions. [And], even if people receive negative feedback, they still must come to an accurate understanding of why that failure has occurred.

That's why homebirth midwives have no idea how little they know. Because homebirth midwives never encounter anyone in their training besides other homebirth midwives, they have no opportunity to observe that many other health professionals have a much larger knowledge base and a much greater skill set. When disasters do occur at homebirth, midwives fail to understand that they were responsible and simply dismiss tragedies with the all purpose adage that "some babies die."

Moreover:

... [I]ncompetent individuals may be unable to take full advantage of one particular kind of feedback: social comparison. One of the ways people gain insight into their own competence is by watching the behavior of others... However, [our study] showed that incompetent individuals are unable to take full advantage of such opportunities. Compared with their more expert peers, they were less able to spot competence when they saw it, and as a consequence, were less able to learn that their ability estimates were incorrect.

This problem is greatly aggravated in homebirth midwifery because homebirth midwives are literally taught to view anyone who does things differently as objects of contempt. Doctors are supposedly greedy, incompetent and ignore scientific evidence. This attitude is best illustrated by the perjorative appellation of certified nurse midwives as "medwives." Though CNMs have far more education and training than homebirth midwives, homebirth midwives prefer to pretend that CNMs spent that extra time being "socialized" (i.e. brainwashed) in "techno-medicine."

The authors conclude:

... [W]e present this article as an exploration into why people tend to hold overly optimistic and miscalibrated views about themselves. We propose that those with limited knowledge in a domain suffer a dual burden: Not only do they reach mistaken conclusions and make regrettable errors, but their incompetence robs them of the ability to realize it.

Similarly, homebirth midwives hold overly optimistic views about their knowledge base and their clinical skills. Not only do they reach mistaken conclusions and make deadly errors, but their incompetence robs them of the ability to realize it.



*American midwives who hold a post high school certificate (CPMs and LMs), as opposed to American certified nurse midwives and European, Canadian and Australia midwives who have university degrees

Natural childbirth and the invisibility of women's needs

I have often commented that the philosophy of "natural" mothering (natural childbirth, lactivism, attachment parenting) rests on fundamental assumptions that are often unrecognized and therefore unexamined. Last week I wrote about the social construction of risk within our culture and the social imperative that everyone (mothers and doctors) do everything possible to minimize risks to babies without ever considering the trade-offs that reducing specific risks imply.

But risk is not the only thing that is socially constructed within the philosophy of "natural" mothering. Women's needs are also socially constructed; specifically, in the philosophy of natural mothering, women's needs are rendered invisible. Natural childbirth advocacy and its approach to the issue of pain in labor is perhaps the paradigmatic example of the way in which natural mothering erases the needs of women.

Natural childbirth advocacy uses several different strategies to render women's needs invisible. To understand how these strategies work it makes sense to start with the empirical facts that most of us agree upon:

1. Childbirth is excruciatingly painful. Indeed the pain of childbirth is so impressive that ancient cultures imagined that the only possible explanation was divine punishment of women for their transgressions.

2. Severe pain should be treated. No one would ever suggests that cancer pain be ignored or that pain from a broken bone should go untreated.

3. Medical professionals have an obligation to treat pain. Every human being is entitled to the medical treatment of pain if that's what he or she desires.

Natural childbirth advocates employ a variety of strategies to render invisible women's need for pain relief. The first strategy is to insist that a mother's need for pain relief is insignificant when compared to the "risks" of epidurals. This strategy is all the more remarkable when one considers that the "risks" of epidurals are not empirical, but purely speculative. Presumably, the baby has a need and a right, to avoid any potentially harmful effects from epidurals that might be discovered as some unspecified future time. And that need (even though theoretical) trumps the mother's need for pain relief, despite the fact pain of this magnitude would always be treated if it were from any other source.

The intellectual sophistry of such a claim is all too apparent. The natural childbirth project involves invoking risks that may not even exist and inflating both the severity and the likelihood of such risks. And it rests on the assumption that no matter how theoretical or how small these risks may be, they automatically trump a woman's need for pain relief. A woman's need for pain relief is therefore of no consequence and not even worthy of consideration.

Even when natural childbirth advocates concede that women might feel a need for pain relief, they employ a variety of strategies to diminish the importance of that need. These strategies involve

Blaming the woman for her own pain - if she did it "right," childbirth would not be painful.
Blaming the woman for not using "natural" methods of pain relief - regardless of their questionable value in providing adequate relief.
Blaming the woman for not embracing the pain as an "empowering" aspect of her biological destiny.

Simply put, according to natural childbirth dogma, a woman's pain in labor is irrelevant, of no importance compared to the baby's need to avoid theoretical risks, and her own fault.

It is important to note that in natural childbirth philosophy, it makes no difference how small the risk to the baby might be, and it makes no difference how large the mother's need for pain relief might be. To put that in perspective, it helps to consider another, far more trivial, example of balancing risk and need that all mothers must address.

Consider the issue of driving with a baby in the car. There is no doubt that riding in a car exposes a baby to a real risk of injury and death in a car crash, a risk whose magnitude is far greater than the theoretical risk of an epidural. And consider that the mother's "need" to go to the grocery store is trivial, and can easily be met at another time without putting the baby in danger of injury or death in a car accident. So why aren't natural childbirth advocates berating women for driving with infants in their cars? They consider that larger risk socially acceptable. In that case, convenience trumps whatever needs the baby might have.

The reality is that every choice has risks and benefits, and those risks and benefits must weighed against each other. But when a woman's need for pain relief is rendered invisible, natural childbirth advocates can act as if there is no benefit to pain relief in labor and can pretend that no weighing of risks and benefits is necessary.

It is difficult to imagine any other situation in which ignoring a woman's severe pain would be socially and ethically acceptable. But for natural childbirth advocates, a woman's needs are invisible, and therefore merit no consideration.

New ACOG opinion on planned homebirth

No surprises here. ACOG looked over the scientific evidence once again and found that it still shows that homebirth increases the risk of neonatal death.

The ACOG practice bulletin, Committee Opinion No. 476: Planned Home Birth appears in the February issue of Obstetrics and Gynecology. The Committee notes that many of the existing scientific papers are of poor quality, and almost all are observational:

Observational studies of planned home birth often are limited by methodological problems, including small sample sizes (Wiegers 1996, Ackermann-Liebrich 1996, Davies 1996, Janssen 2002); lack of an appropriate control group (Woodcock 1995, Anderson 1995, Murphy 1998, Johnson and Daviss 2005); reliance on birth certificate data with inherent ascertainment problems (Wax Maternal and newborn morbidity by birth facility among selected United States 2006 low-risk births 2010, Pang 2002); ascertainment relying on voluntary submission of data or self-reporting (Wiegers 1996, Anderson 1995, Johnson and Daviss 2005, Lindren 2008); a limited ability to accurately distinguish between planned and unplanned home births (Pang 2002, Mori 2008); variation in the skill, training, and certification of the birth attendant (Johnson and Daviss 2005, Pang 2002, Scramm 1978); and an inability to account for and accurately attribute adverse outcomes associated with antepartum or intrapartum transfers (Ackermann-Liebrich 1996, Pang 2002, Parratt 2002).

Then they turn to the most recent Wax study (Home versus hospital birth—process and outcome 2010):

... Although perinatal mortality rates were similar among planned home births and planned hospital births, planned home births were associated with a twofold-increased risk of neonatal death. When limited to only nonanomalous newborns, the increased risk of neonatal death was even higher––almost threefold higher in planned home births. These results did not change when the investigators performed sensitivity analyses excluding older studies or poorer quality studies. No maternal deaths were reported among 10,977 planned home births. When compared with planned hospital births, planned home births are associated with fewer maternal interventions ...

They emphasize that all the existing scientific studies that show that homebirth is as safe as hospital birth comes from other countries that have strict selection criteria, dedicated transport systems, and highly trained midwives.

In summary:

... Women inquiring about planned home birth should be informed of its risks and benefits based on recent evidence. Specifically, they should be informed that although the absolute risk may be low, planned home birth is associated with a twofold to threefold increased risk of neonatal death when compared with planned hospital birth. Importantly, women should be informed that the appropriate selection of candidates for home birth; the availability of a certified nurse–midwife, certified midwife, or physician practicing within an integrated and regulated health system; ready access to consultation; and assurance of safe and timely transport to nearby hospitals are critical to reducing perinatal mortality rates and achieving favorable home birth outcomes.

Anyone who has been following this blog will not be surprised since I've written about almost all of these studies and pointed out that with the exception on the recent Dutch and Canadian studies (de Jonge 2010, Janssen 2009), there are no properly done studies that show that homebirth is safe. With the exception of the most recent Dutch and Canadian studies, all the existing studies that claim to show that homebirth is safe suffer from serious methodological flaws that render their conclusions invalid.

Although the Committee does not address this issue, recent data from The Netherlands suggests that the results of the de Jonge study are also in question. There may be no difference in mortality rate of midwife attended hospital and homebirth, but obstetricians have better outcomes in hospitals, even when caring for high risk patients, putting the safety of all midwife attended births (hospital or home) in doubt.

I wish the Committee had not place such reliance on the most recent Wax study, because as I wrote when it was released, it's not a great study. No doubt American homebirth advocates will leap on this to discredit the Committee report, but that's merely an attempt to divert attention from the key points which are indisputable:

There is not a single study that shows that American homebirth is as safe as hospital birth. All of them suffer from serious methodological flaws, particularly the use of inappropriate control groups designed to make the homebirth outcomes look better by comparison.

The only places where homebirth might potentially be as safe as hospital birth is The Netherlands and Canada, both of which have strict eligibility criteria, dedicated transport systems and highly trained midwives. Of these three criteria, American homebirth lacks ALL of them. And, as I pointed out above, the meaning of the Dutch results are now in doubt since the mortality rates of all midwife attended births are higher than the mortality rates for physician attended hospital births.

So homebirth advocates can jump up and down about the inclusion of the Wax study, but that doesn't change the basic facts. There is NO evidence to show that American homebirth is safe, and a great deal of evidence to suggest that it is not.

Defensive mothering

Last week I wrote about how contemporary societal beliefs about risk lead to defensive medicine.

There have always been risks, of course, but they have traditionally been viewed as outside the control of human beings. The risk society has arisen because of new beliefs that we can and (especially) that we should control every aspect of risk...

What does this have to do with defensive medicine? Consider that in our risk society we are supposed to reduce our risk to zero. How do we do that? We do that by acting to reduce risk regardless of how small the risk might be.

Defensive medicine is a direct result of our societal beliefs about risk, but doctors are not the only ones whose stance has become defensive in response. In our risk society we have come to believe that mothering itself is about managing risks. Ironically, those most obsessed with risk belong to the "natural" mothering crowd. In fact, it is hardly an exaggeration to say that "natural" mothering is really "defensive mothering" at the extreme. And natural childbirth is no exception.

Joan Wolf, in a fabulous new book entitled Is Breast Best?: Taking on the Breastfeeding Experts and the New High Stakes of Motherhood explains that in a society obsessed with risk:

... In a risk culture, when virtually everything from conception through childbirth can ostensibly be either controlled or optimized, nature becomes a beacon ...

But nature, apparently, is just as obsessed with reducing risk as doctors are with reducing liability. While natural childbirth advocates claim to reject science as the primary lens through which we should view childbirth:

In natural mothering advice ... the virtues of nature are filtered by science and expertise and much of what opponents of medical intervention champion is less a rejection that a selective embrace of scientific authority. Natural childbirth and parenting are mediated by classes and experts, and books are written by authors whose credentials are prominently displayed next to their their names.

The advice dispensing Sears' family is paradigmatic examples. Father and son (William and Bob) are pediatricians and mother (Martha) is a nurse. While the Sears' claim to disavow the belief that experts know more about parenting than parents:

The eponymous Sears Parenting Library ... is itself an example of the expert culture that that infuses the discourse of total motherhood ... The back cover of The Baby Book seeks to establish Sears as an authority in pediatric science. He and his wife are "the pediatrics experts to whom American parents are increasingly turning for advice and information ...

So much for trusting your intuition.

Not only do Sears' books position him as a scientific expert, he, too, is obsessed with risk. After identifying a seemingly interminable list of risks posed by various maternal behaviors:

...Sears and Sears suggest that even hypothetical risks should be avoided... The Sears state that "there is no pain-relieving drug that has ever been proven to be totally safe for mother and baby" in childbirth. But this is true, without exception, of every drug and consumer on the market; no medication has ever been shown to be completely safe for anyone...

Moreover:

Sears and Sears selectively employ science in ways that exacerbate public misunderstanding of risk. They ignore costs and trade-offs, and they hold decision making in pregnancy to an impossible standard. In embracing the notion that mothers are responsible for elimination all conceivable risks to their children, natural mothering furthers an ideology of total motherhood that is fundamentally similar to more mainstream approaches.

... Pregnancy in total motherhood literally embodies the essence of risk culture: the hyperawareneness of potential danger, the illusion of control, and the conviction that proper planning can eliminate risk...

Total motherhood is really defensive motherhood because:

[It] stipulates that mothers' primary occupation is to predict and prevent all less-than-optimal social, emotional, cognitive and physical outcomes; that mothers are responsible for anticipating and eradication every imaginable risk to their children, regardless of the degree or severity of the risk or what the trade-offs might be; and any potential diminution in harm trumps all other considerations ...

Sound familiar? It ought to, because that is the rationale for defensive medicine, the expectation that obstetricians must anticipate and eradicate every imaginable risk regardless of severity or what the trade-offs might be.

When we, as a society, become obsessed with risk, everyone is forced to behave defensively, not just doctors. That's why solution to defensive medicine does not lie with doctors, it lies with all of us. Defensive medicine is not the only, or even the worst, manifestation of our obsession with risk. Defensive mothering is far more pervasive, entirely unrecognized, and is having a far greater impact on our children and ourselves than defensive medicine ever could.

Salon withdraws infamous vaccine article

Ordinarily I'd say, better late than never. In this case, though, all the damage has already been done.

I'm referring to the decision of Salon.com to withdraw its infamous 2005 piece written by Robert F. Kennedy, Jr. and alleging that thimerosol in vaccines had caused neurological damage in children and that a vast conspiracy had covered it up.

Why did they withdraw the article? Because it was flat out false, had been flat out false at the time it was written, represented the unsubstantiated musings of a celebrity who was in no way qualified to analyze vaccine safety, ... and oh, by the way, one of their former writers has just published a book containing an entire chapter on the fact that Salon.com had broken just about every rule of professional journalism in publishing it.

Unfortunately, Salon.com continues to offer weasel words in its defense:

The piece was co-published with Rolling Stone magazine -- they fact-checked it and published it in print; we posted it online. In the days after running "Deadly Immunity," we amended the story with five corrections ... that went far in undermining Kennedy's exposé. At the time, we felt that correcting the piece -- and keeping it on the site, in the spirit of transparency -- was the best way to operate. But subsequent critics, including most recently, Seth Mnookin in his book "The Panic Virus," further eroded any faith we had in the story's value. We've grown to believe the best reader service is to delete the piece entirely.

They fact checked it? If by fact checking they mean making sure the spelling of all the big words was correct, perhaps they did. But if they mean checking to see whether there was any factual basis for the claims in the piece, no one did any fact checking. The entire piece was a series of false empirical claims that could easily be debunked by any vaccine expert.

Author Seth Mnookin is far more critical in the interview he did with Salon.com about his new book. He bluntly states that the media bares the bulk of the blame for creating hysteria by publishing falsehoods that, even at the time, did not withstand the most basic scrutiny.

Mnookin identifies a variety of journalistic standards that were violated with the publication of Kennedy's article.

1. Creating false equivalence:

One is this false sense of equivalence. If there's a disagreement, then you need to present both sides as being equally valid. You saw with the coverage of the Birther movement; it's preposterous that that was an actual topic of debate. The fact that Lou Dobbs addressed that on his show on CNN is an embarrassment. It's not a subject for debate just because there are some people who said it was.I do think that the media has more -- we have more responsibility for this than really any other single entity... And I think it's an absolute cop-out for reporters to say, "I've fulfilled my responsibility by presenting two sides." Sometimes there aren't two sides.

2. Letting reporters and editors who have no education, background or training on judging the validity of a scientific claim judge the validity of a scientific claim.

... You wouldn't ask me to go write about hockey, because I don't know anything about hockey. But if something came in over the wire about a cancer study ... that assignment could end up on a general reporter's desk. You wouldn't ask me to cover business or the movie industry without knowing something basic about it. I don't know how this happened, but I think there has to be some sort of movement away from, oh, like, we're going be the first ones with this juicy story. And then in the days and weeks to come, we'll figure out what the reality is ...

3. Believing that it is acceptable to publish outlandish claims as long as you retract them later:

... It's sort of like putting the genie back in the bottle... It's the same thing with Obama and the Birther movement. Most outlets now certainly say that he was born in the United States. But once it's introduced as a topic of discussion it's really hard to un-introduce it.

There's a final factor that Mnookin didn't mention.

4. The willingness to publish anything uttered by a celebrity. Mnookin notes:

... If I said that, oh, I have a report that Derek Jeter's going to quit baseball, no one would run that because it would be embarrassing. Because there's no information to support it. If I said that I have good information that Boeing is about to buy IBM, you know, people wouldn't run that. But for some reason when it comes to health and science, you don't get that...

That "some reason" is the willingness to repeat any drivel uttered by a celebrity in order to grab readers. Had the vaccine piece been written by "Robert Keene, Jr." instead of Robert Kennedy, Jr., it never would have seen the light of day. Why publish the uneducated musings and conspiracy theories of a private individual? But when a celebrity commits his or her uneducated musings and conspiracy theories to paper, media outlets fight for the privilege of publishing them.

This is not a trivial issue. Children have died and will continue to die of vaccine preventable illnesses because of the fear generated by media outlets like Salon.com who have been more concerned with page views than with the truth. As Mnookin points out, introducing outlandish conspiracy theories into mainstream media publications legitimizes them, and it is impossible to un-introduce those topics.

Salon.com offers a qualified mea culpa, but we would be better served if Salon.com promised to put journalistic protections in place. We would benefit from a commitment to avoid false equivalence. We would benefit from a commitment to have science issues covered by reporters who know something about science? We would benefit from a commitment to have science articles fact check with scientific experts, not lay people. And we would benefit from a commitment to stop recycling the bizarre conspiracy theories of celebrities.

How about it Salon?

Battle Hymn of the Koala Mother

In the wake of the controversy over Amy Chua's new book "Battle Hymn of the Tiger Mother," I decided it was the right time to offer my mothering philosophy to the world. Ms. Chua, a Harvard educated Yale Law Professor believes that the rest of us are frantically trying to figure out how Asian parents raise such high achieving children. She is ready to share the secret with us: She is a "Tiger Mother," a mother who bares her teeth and growls all manner of threats, taunts and jeers at her children.

Here's my secret: I am a "Koala Mother." I'm warm and fuzzy and offer a safe place to escape from the pressures of the world.

According to her piece in the Wall Street Journal charmingly entitled Why Chinese Mothers Are Superior, Ms. Chua reveals:

Here are some things my daughters, Sophia and Louisa, were never allowed to do:

• attend a sleepover

• have a playdate

• be in a school play ...

• watch TV or play computer games

• choose their own extracurricular activities

• get any grade less than an A ...

In contrast, as a Koala Mother, I didn't merely let my four children do all those things; I encouraged them. And it gets worse: the TV was on in our house from dawn to dusk and video games were the order of the day when homework was done.

For those who wish to be Tiger Mothers, Ms. Chua offers a few helpful examples:

The fact is that Chinese parents can do things that would seem unimaginable—even legally actionable—to Westerners. Chinese mothers can say to their daughters, "Hey fatty—lose some weight..."

Chinese parents can order their kids to get straight As. Western parents can only ask their kids to try their best. Chinese parents can say, "You're lazy. All your classmates are getting ahead of you..."

In contrast, as a Koala Mother, I would never taunt my children (I would be ashamed of myself if I did) and I would do my utmost to protect them from taunting from others.

Ms. Chua proudly relates how "coercion works." Describing 7 year old Lulu's reaction to her mother's demand that she practice piano 3 hours a day to master "The Little White Donkey," Ms. Chua reports:

Back at the piano, Lulu made me pay. She punched, thrashed and kicked. She grabbed the music score and tore it to shreds. I taped the score back together and encased it in a plastic shield so that it could never be destroyed again. Then I hauled Lulu's dollhouse to the car and told her I'd donate it to the Salvation Army piece by piece if she didn't have "The Little White Donkey" perfect by the next day. When Lulu said, "I thought you were going to the Salvation Army, why are you still here?" I threatened her with no lunch, no dinner, no Christmas or Hanukkah presents, no birthday parties for two, three, four years. When she still kept playing it wrong, I told her she was purposely working herself into a frenzy because she was secretly afraid she couldn't do it. I told her to stop being lazy, cowardly, self-indulgent and pathetic.

Here's how I put my strategy into action:

Rather than demanding that my children achieve high grades, I pointed out that it was up to them to determine what they would make of their lives. Their father and I had made our choices: we had already finished high school, college and graduate school because it was very important to us. If it was important to them, too, they would work hard so that they could always choose what they wanted instead of being forced to accept the limitations of bad grades.

No doubt, Ms. Chua would consider me one of those Western parents who "are concerned about their children's psyches. Chinese parents aren't. They assume strength, not fragility, and as a result they behave very differently."

I plead guilty! As a Koala Mother, I think that a child's inner strength is built with support, not with taunts and jeers. I figure that the world will send each of them enough disappointments and difficulties; I want to build their inner strength so they can meet those disappointments and difficulties, not tear them down so they can start practicing their coping skills as toddlers.

What Ms. Chua does not seem to understand is my commitment to being a Koala Mother is not because I'm afraid of being a Tiger Mother. It's because I think Tiger Mothers are self-absorbed narcissists. They have serious problems with boundary issues; apparently they think that their children are extensions of themselves, and exist to advertise the superiority of their Tiger Mothers.

I, and mothers like me, recognize that my children are independent human beings with needs and desires that might be different from mine. I had the opportunity to make my own choices and I am very happy with them. They deserve the opportunity to make their own choices and choose their own path to happiness.

Oh, one other difference between Ms. Chua and myself: we have entirely different goals. She's aiming for children who have all the outward marks of professional success. I'm hoping for children who are happy with what they choose, regardless of whether my friends will be impressed.

It's ironic then, that Ms. Chua's children are not really more successful than mine. True, none of mine played at Carnegie Hall, but they've attended top flight universities, are going to graduate school or have a highly technical, high paying job. And the best part is their accomplishments are their own.

No, let me amend that, the best part as far as this Koala Mother is concerned when they are happy with their own choices.

What is defensive medicine?

The Defensive Medicine series on The Unnecessarean has tried to be inclusive, offering the perspective of two obstetricians, two lawyers, two sociologists and a lay person. There's one thing that's missing from the series, though: an explanation of how defensive medicine works.

According to Wikipedia:

Defensive medicine is the practice of diagnostic or therapeutic measures conducted primarily not to ensure the health of the patient, but as a safeguard against possible malpractice liability. Fear of litigation has been cited as the driving force behind defensive medicine...

Defensive medicine takes two main forms: assurance behavior and avoidance behavior. Assurance behavior involves the charging of additional, unnecessary services in order to a) reduce adverse outcomes, b) deter patients from filing medical malpractice claims, or c) provide documented evidence that the practitioner is practicing according to the standard of care, so that if, in the future, legal action is initiated, liability can be pre-empted. Avoidance behavior occurs when providers refuse to participate in high risk procedures or circumstances.

What about defensive medicine in obstetrics?

Consider the explosion in the rate of C-sections and inductions. They satisfy the requirements of assurance behavior.

Reducing adverse outcomes? Check.
Deterring medical malpractice claims? Check.
Pre-empting liability? Check.

Consider the precipitous decline in the rate of VBAC. That's avoidance behavior: malpractice insurers have forced providers and hospitals to refuse to participate in VBACs.

There's an important subtext that undergirds defensive medicine that often goes unrecognized and therefore unanalyzed. Defensive medicine is driven by the fact that we live in a "risk society," a society that is organized around a new understanding of risk.

There have always been risks, of course, but they have traditionally been viewed as outside the control of human beings. The risk society has arisen because of new beliefs that we can and (especially) that we should control every aspect of risk.

In our risk society, we are obsessed with the risk of auto accidents and outfit our cars with ever more airbags and safety features. We are obsessed with risks to our children, and restrict their play outdoors and their independence, and we are obsessed with illness and death, literally passing laws to control personal habits like smoking.

How does the "risk society" impact obstetrics? We have become obsessed with the perfect child, and we construct ever more elaborate requirements to ensure that everything we do contributes to the perfect outcome.

There have always been risks in childbirth. Indeed, it has traditionally been the leading cause of death of babies, and one of the leading causes of death of young women in every time, place and culture. The "risk society" demands that we do everything possible to reduce those risks to zero.

Lay people often conceptualize risk as a dichotomy: an individual is either low risk (it won't happen) or high risk (it will happen). But that's not how risk works. Risk exists on a continuum; the risk varies from individual depending on a complex interaction of numerous factors. What's the risk that a baby will die of group B strep meningitis? That depends on the presence of GBS in the mother's genital tract, the exposure of the baby when delivered, and the presence or absence of antibiotics. We can determine the risk of GBS meningitis in large populations, but for the individual woman who carries GBS, we cannot predict the risk that her infant will be infected.

What does this have to do with defensive medicine? Consider that in our risk society we are supposed to reduce our risk to zero. How do we do that? We do that by acting to reduce risk regardless of how small the risk might be.

That represents an entirely new approach. Until the advent of the risk society, we determined which tests and procedures to use by establishing a risk threshold. For example, we know that the risk of stillbirth begins to rise in the last weeks of pregnancy (from about 36 weeks onward). The risk of stillbirth begins to increase precipitous at 42 weeks. So we arbitrarily established the risk threshold for postdates induction at 42 weeks.

Lay people, with their dichotomous view of risk, tend to imagine that there is no risk of stillbirth prior to 42 weeks, and there is a risk of stillbirth after 42 weeks. But the reality is that risk exists on a continuum. Defensive medicine can best be conceptualized at lowering the risk threshold. In the case of induction, the risk of stillbirth starts rising long before 42 weeks. Since the risk society mandates that we reduce risk to zero, doctors feel they have no choice, but to offer postdates induction to women by 41 weeks, or even 40 weeks. That's really the only way to reduce the risk to zero.

This is a critical point. Lay people imagine that defensive medicine offers no benefits to patients and is undertaken solely to protect doctors, but that's not a complete picture. Defensive medicine is simply lowering the risk threshold. It benefits patients in that the risk of a particular outcome (like postdates stillbirth) is reduced as far as it can be reduced.

So what's wrong with defensive medicine? Defensive medicine rests on the premise that we must do things to reduce risk. It completely ignores the risks posed by doing things. But that's not only a feature of defensive medicine, it is a feature of every aspect of a risk society.

Yes, we make cars safer by putting in more safety features, but we increase the price of cars. Yes, we reduce the risk of kidnapping if we don't let our children play outdoors, but it's not good for children to grow up cowering inside their houses. Yes, we reduce the risk of illness when we pass laws regulating private habits, but we also reduce freedom. And when we do more inductions for postdates we lower the risk of postdates stillbirth, but raise the risk of C-section.

In our risk society, though, we apparently don't care. We consider ourselves required to reduce risk to zero, regardless of the other risks or costs that increase as a result.

Where does that leave us in regard to defensive medicine?

First, we can see that defensive medicine is not the use of tests and procedures on people who don't need them. It's lowering the risk threshold for using tests and procedures that we previously reserved for higher risk individuals.

Second, defensive medicine is not really a medical issue, but rather a societal issue. As a society, we need to give up the idea that we can and should reduce all risk to zero. We need to recognize that there are negative consequences to reducing risk, as well as positive ones. Most important, we need to figure out how much risk we are willing to tolerate. Zero risk is not achievable, and the price for attempting to achieve it can be very high.

What does this mean for birth activists?

It means that blaming doctors for defensive medicine not only isn't working, but it can't work. It means recognizing that low risk is not no risk and that, therefore, doctors need guidance on what patients believe is acceptable risk. And most of all, it means deciding, as individuals in a risk society, what trade offs we are willing to accept in order to reduce risk.

Cesareans and brain damage

One of the articles in the Unnecesarean's series "Defending Ourselves Against Defensive Medicine" was written by a plaintiff's attorney. The piece, The Necesarean: The Perspective of a Plaintiff's Birth Trauma Attorney, was rather long and a bit unwieldy, but I took away several important points from it.

1. Hesitation in performing C-sections damages or kills babies:

For too many families, delays in performing Cesarean sections have transformed the most joyous occasion in the life of a family, the birth of a child, into a tragedy. Like other human beings, fetuses need a constant supply of oxygen, a supply that can be compromised during labor and delivery. Delays in restoring the oxygen supply by performing a Cesarean can cause brain damage or even kill the child. The daily struggles of the survivors, and that of their families to support them, are heroic...

2. Cesarean activists spread misinformation about C-sections. He tries to remedy that:

... Cesareans are not inherently bad. Some Cesareans have benefits and are medically necessary. Every human, including a fetus, needs a constant supply of oxygen. The fetus depends entirely on oxygen that passes through the placenta and umbilical cord. (Think of the fetus as a deep-sea diver, and the placenta as the oxygen tank.) Events which impair the function of the placenta (e.g. placental abruption) and umbilical cord (e.g. cord compression) threaten the oxygen supply necessary for fetal metabolism. Without oxygen, the baby’s brain cells can be injured or die within minutes. Restoring the oxygen lifeline to the baby may require a Cesarean.

3. Doctors spread misinformation about anoxic brain injuries to provide ammunition for their defense attorneys to use at trial:

Sadly, the debate has been clouded by medical literature written to defend birth trauma lawsuits... Some of the misinformation comes from respected sources of medical information... The misinformation usually appears in articles about whether events in labor and delivery cause, or a Cesarean might prevent, fetal oxygen deprivation and resulting cerebral palsy... If there was scientific evidence that events in labor and delivery, and particular fetal asphyxia, did not cause cerebral palsy, that evidence could be used to defend malpractice cases.

I don't doubt that this is true. Anoxic brain injury cases rely in large part on portraying the hardship and medical expenses of the brain injured child. But they also rely on scientific evidence. Every trial has dueling medical experts wielding lots of scientific papers. The medical literature provides a great deal of evidence that lack of oxygen in labor leads to brain injuries. Some scientists believe that the brain injuries occur before labor even begins. If that could be shown to be true, it would provide a powerful defense for obstetricians being sued.

4. Cesarean activists seize upon the same (mis)information and use it to make the same case that defense attorneys make. They wield the information in different ways, though. The defense attorney insists that the brain damage had nothing to do with delaying a C-section; the brain damage occurred before labor. Cesarean activists insist that Cesareans don't prevent brain damage, so it is pointless to do them.

5. Tilson explains the typical approach of the plaintiff's attorney (the lawyer for the baby and parents):

Most birth asphyxia cases with which I have been involved share a common pattern. After fetal heart monitors display an abnormal fetal heart pattern, the nurses and staff undertake what is called "intrauterine resuscitation." ...

Many litigated birth asphyxia cases involve repeated attempts at intrauterine resuscitation. The Cesarean is not performed until the fourth, fifth, or sixth attempt at resuscitation relieves the signs of fetal distress ...

The proposition that intrauterine resuscitation must fail before Cesareans are indicated and before surgical teams can be assembled creates an unconscionable risk of fetal asphyxia, injury and death.

6. Defense attorneys and Cesarean activists, each for their own reasons, argue the opposite: there's no reason to do a C-section until attempts at resuscitation fail completely, the baby's heart rate becomes extremely slow, and the baby does not recover.

7. Tilson strongly disagrees and delivers what is probably the coup de grace of his legal presentations:

... A successful intrauterine resuscitation strongly indicates that the fetus needs oxygen. A successful intrauterine resuscitation is not an "all clear" sign, but a warning sign. It is as clear of a warning sign as nature can give us that the fetus is not getting enough oxygen. If oxygen solves the problem, a lack of oxygen might have caused it.

Tilson's message to Cesarean activists is important. As I understand it, he is saying, first: Beware scientific papers that claim to show that brain damage occurs before labor begins and cannot be prevented by C-section. Rather than representing "proof" that C-sections are unnecessary, they are cynical attempts to get doctors off in malpractice suits.

And second: The fact that episodes of abnormal heart rate (fetal distress) may end after oxygen is administered does not mean that those episodes can be ignored. They are warning signs that the baby is not getting enough oxygen and is depleting its own reserves. The baby is not "fine," it is "hanging on" and needs to be rescued by C-section before things get worse.

Maybe defensive medicine works

Jill Arnold at the Unnecesarean is running a special series this week entitled Defending Ourselves Against Defensive Medicine. Defensive medicine is a problem in obstetrics. Obstetricians report that they are ordering tests, planning inductions, or performing C-sections that may not be necessary, not merely in hindsight, but which have no medical indication at the time they are done.

The first piece in the series is Myths of Malpractice in America by Louise Marie Roth, PhD who makes a rather bizarre claim:

Physicians and the public at large often attribute this to a "malpractice crisis," whereby obstetricians perform c-sections routinely to avoid malpractice litigation... One of the things that I have learned is ... the belief that a high risk of malpractice litigation has caused the rise in cesarean delivery rates is empirically false.

... The simple fact, however, is that cesarean rates in the United States have increased for 12 consecutive years, while malpractice litigation has remained the same or decreased. Data from the National Practitioners Data Bank reveals that obstetric malpractice suits fluctuated from 1991-2004 rather than increasing over time. This is not what one would expect if a malpractice crisis were causing the rise in cesarean rates.

In other words,there is no malpractice crisis. How does Prof. Roth support this claim? She uses one graph, and a series of personal interviews:

In addition to examining data on lawsuits, I am interviewing malpractice attorneys and birth attendants. I interviewed Jane,[1] a malpractice defense attorney (i.e. represents physicians) who has practiced for 15 years.

[1] All names are pseudonyms

That's the goofiest thing I've heard in a while. For an article on medical malpractice she interviews a few friends who won't even go on record with their real names? Since Roth has made no effort to ensure that the people she interviews are representative of lawyers, I can't imagine why she expects such drivel to be taken seriously.

So here entire thesis rests on only one empirical observation, a graph that portrays the relationship between the number of obstetric malpractice claims. Here's the graph:



Prof. Roth thinks this demonstrates that fear of being sued is not driving the rising C-section rate. Her conclusion is wrong because it is based on assumptions that are wrong. First, she assumes that obstetricians judge the likelihood of being sued by using the number of malpractice claims filed per year as a proxy for the risk of being sued. But obstetricians don't need to use a proxy, they know their risk of being sued. The latest data indicates that 77% of obstetricians have been sued at least once in their career. So obstetricians know that almost all obstetricians ARE sued.

Second, she assumes that the deterrent effect is tied to the number of malpractice suits per year. That assumption is the equivalent of saying that bank robbers decide whether or not to rob a bank based on how many people went to jail last year for bank robbery. What keeps aspiring bank robbers from robbing the local bank is the belief that if they are caught, they will go to jail. It makes no difference to them how many individuals actually go to jail for bank robbery each year; the idea that they would reason that way is absurd.

The deterrent effect of malpractice suits on obstetricians is similar to the deterrent effect of jail sentences on potential bank robbers. The fact that the likelihood of being sued is high is what drives doctors' actions, just like the fact that the likelihood of going to jail is high is what restrains people from robbing the local bank whenever they need cash.

I look at Prof. Roth's graph and see the opposite of what she sees. The graph suggests that defensive medicine works.

First of all, the graph represents an anomalous time in obstetrics. Although Prof. Roth neglects to mention it, from 1991-2003, the rate of VBAC rose dramatically and then declined dramatically; that's the reason for the relatively flat C-section rate in those years. Over all, the C-section rate has risen steadily and dramatically since 1970. And while the rate of obstetric malpractice filings may have been flat between 1991-2004, the rate rose steeply in the prior 2 decades.

In other words, since 1970 the C-section rate has risen steadily except for an anomalous period when VBACs became popular. Rates of obstetric malpractice filings rose steadily from 1970 and flattened out in the 1990's. Looking at the data from the longer period suggests that the flattening of the malpractice filing rate may have been caused by the increased C-section rate.

In other words, defensive C-sections have done exactly what they are intended to do, prevent the filing of lawsuits. When I pointed this out to Prof. Roth (after being personally invited to comment by Jill), she replied:

With respect to Amy Tuteur's comment, the reason that the malpractice lawsuit rate stabilized and started to decline is not because of the increase in cesareans. The reason that malpractice litigation is declining is because it has become increasingly difficult for injured patients to find legal representation.

Yes, that's my point; it is increasingly difficult to find legal representation when your case is unwinnable.

Malpractice litigation is done by lawyers on a contingent fee basis. That means that the client pays nothing. The lawyer pays for everything and takes one third of any financial award. It is expensive to mount these cases, but there is the potential for multimillion dollar payouts that cover all expenses and leave millions left over.

Since lawyers use their own money to bring the malpractice cases, they will only take cases they believe they are likely to win; otherwise they will have wasted their entire investment in the case. In order to win a malpractice case, the lawyer must show that outcome of the medical situation would have been different if the doctor had done something different. In the case of obstetrical malpractice that typically means that the lawyer must show that if the doctor had done a C-section, or done one sooner, the baby would have been perfectly healthy.

So if an obstetrician performs a c-section at the first sign that something might be wrong, or even before anything goes wrong, any lawyer is deprived of the heart of the case. The case becomes unwinnable and no lawyer will take an unwinnable case. The entire purpose of a defensive C-section is to make sure that the case is unwinnable and therefore will never me brought.

If the rate of obstetric lawsuits has stabilized because lawyers are refusing to bring lawsuits, then the dramatic rise in the C-section rate is working exactly as intended.

New website: Hurt by Homebirth

Over the years I've received pleas from women who have lost their babies at homebirth. Each woman has suffered unimaginable tragedy and she wants to know that her baby's death will not be ignored.

She cannot change the choices that she made, cannot bring her baby back, but perhaps the story of her baby's death can open the eyes of other women to the dangers of homebirth. Each woman is different and the details of her story is different, but one refrain is common to them all: "if only I had known the truth about homebirth, I would not have chosen it." The irony of homebirth is not lost on them; they thought they were making a loving choice and instead they were taking a terrible risk.

Unfortunately, women contemplating homebirth don't know the risks and homebirth advocates aren't about to tell them. In fact, adding insult to injury, when a bereaved mother attempts to share her baby's story with other homebirth advocates, the baby is figuratively erased out of existence. Homebirth websites delete homebirth tragedies. They don't want women to know the truth.

Enough is enough. Hurt by Homebirth has been created as a safe place where women can tell the stories of the babies who died or who were left injured by homebirth.

The babies who have died at homebirth will be hidden no more.

Table of contents

Amie Newman thinks it's okay to hide the death toll of homebirth

I've participated in a number of on line discussions this week, and although the topics vary and identity of the homebirth advocates vary, one thing is always the same. When I mention that MANA is hiding the number of babies who died at the hands of CPMs, the silence is deafening.

Most homebirth advocates try desperately to pretend that I didn't say it. They don't deny that MANA (the Midwives Alliance of North America) is hiding the death rates at 18,000 homebirths attended by CPMs (certified professional midwives, formerly known as lay midwives). How could they? They don't respond. What could they say? Instead they try to ignore this glaringly unethical behavior and hope that women will forget they ever heard about it.

Finally, though, someone decided to take a stand. Amie Newman, who blogs for RH Reality Check, explained why it is okay for MANA to hide the number of babies who died. After tangling with me through several back and forth comments, Newman wrote:

I 100% believe that women deserve the right to know how safe planned homebirth is with a Certified Professional Midwife. I also 100% believe that we have that information currently.

I replied:

You believe that we know the number of babies who died at the hands of CPMs in the 18,000 case MANA database?

Well, if you know the number, don't keep us in suspense! Exactly how many babies died at those 18,000 CPM homebirths?

Or ... will you simply acknowledge the obvious: we don't have that information, MANA is hiding it, and you think it's just fine for MANA to hide their own death rates from American women if those death rates are appallingly high.

At that point Newman simply stopped responding.

Honestly, I simply cannot fathom how a site that exists to support reproductive rights can produce a blogger and commenters that think women have no right to accurate information about the death toll of homebirth. Of course they join a long list of homebirth advocates who blithely ignore the issue that MANA is hiding homebirth deaths.

Ina May Gaskin thinks it's just fine if MANA hides the number of homebirth deaths from American women.

Jill Arnold of the Unnecesarean claims to believe that "all maternity care data should be readily accessible to consumers and the general public," but apparently thinks that does not apply to MANA.

Gina Crossley-Corcoran, the Feminist Breeder, offers the usual homebirth prattle without recognizing the irony:

I thought providers took an oath to help people? Putting their business ahead of reproductive choices isn't keeping anybody safer, and the science proves that. Shame on them for ignoring the vast body of evidence from their own collegues.

Yes, shame on MANA for HIDING the vast body of evidence about homebirth deaths from their own colleagues, but especially from American women.

And Danielle Ellwood, the blogger who wrote the original piece on Babble performed the typical homebirth flounce:

Today, in true internet style… the poster [Dr. Amy] who started it all tried to call me out, and this is when I knew I needed to have my final word.

“And where’s Danielle who claims to care so much about mothers and babies? Why isn't she demanding that MANA release their death rates?”

... Reply?

@Amy – There is no reasoning with someone like you. I care about women, I work on a local level, I work in my community, and I have actively been working for better maternal outcomes since entering the birth community 6 years ago, before even having my first child.

I am not going to feed into this debate anymore because it is clearly useless...

I am done.

In other words, she had painted herself into a corner and was too embarrassed to continue. Plus, she has all the right "birth cred" and everyone knows that means she really, really cares about women.

For these women and other homebirth advocates, I have a message:

You should be ashamed of yourselves.

Stop pretending! We all know that those statistics are being hidden because they show that an appalling number of babies died at homebirths with CPMs. Otherwise MANA would have published them and sent out a thousand press releases to boot.

It is time for American women to learn the truth about homebirth deaths, and homebirth advocates should be the first to call for transparency, not the first to offer the pathetic excuse that women already have all the information they need.

Don't like the findings? Pretend they're not true!

Sigh. Another day, another goofy Science and Sensibility post.

It may be a new year, and there may be a new editor, but the Lamaze blog appears to have merely traded one form of incompetent analysis for another. The previous editor Amy Romano, CNM, left to take a position with the lobbying organization Childbirth Connection. The new editor is Kimmelin Hull,

a Lamaze Certified Childbirth Educator, Physician Assistant, American Red Cross First Aid/CPR instructor, novelist and freelance writer for local and international parenting magazines.

In other words, she has no experience in caring for pregnant women, has no background in science or statistics, and essentially no qualifications for analyzing scientific literature. Not surprisingly, she's off to a very unimpressive start.

Her first blunder didn't even involve science. She wrote with a piece praising the Lamaze policy on conflicts of interest. Explaining why she declined to teach a class on breastfeeding at a local store, she wrote:

The slippery slope, however, became evident in this business owner’s expectation that the content of my presentation would directly entice class participants to buy certain products, based on my recommendations under the guise of authoritative knowledge.

But then I asked:

So why does Lamaze International license and recommend baby toys, women’s body lotions and women’s apparel? Clearly is trying to women to buy certain products based on their recommendations and under the guise of authoritative knowledge.

Cue the backpedaling. Hull tried to make an exception:

... if you truly believe in the healthy, helpful aspect of a product/service, providing information on it (or samples of it) to your clients becomes an act of "helping" vs. "promoting." ...

We're supposed to believe that Lamaze collects licensing fees on baby toys, women’s body lotions and women’s apparel because they like "helping"?

Today Hull tries her hand at analyzing a scientific paper, The impact of maternal age on fetal death: does length of gestation matter? published in the December issue of the American Journal of Obstetrics and Gynecology. The authors found that women 40 and older had the highest risk of fetal death throughout pregnancy.

Hull accurately explains the methodology and findings of the paper, but then offers this startling assertion:

... other factors that have not garnered much attention in the literature but, in my estimation, certainly influence a woman’s general state of health and well-being (and thus potentially, the health of her pregnancy) are factors such as: diet, exercise routine and overall stress level. Designing a future study which could control for these additional variables would undoubtedly alter the data tremendously ...

What??!! In her estimation? Based on what evidence? Apparently none.

Hull really, really wishes that advanced maternal age did not increase the stillbirth rate, so she is casting about for reasons she can ignore the evidence. Hmmm, let's pretend that some easily modified factors (diet! exercise! stress!!) negate the impact of maternal age. Oooh, that sounds good! And as long as we're pretending, let's go all the way: these variable would undoubtedly alter the data tremendously! Really, Kimmelin?

Hull then proceeds to offer the "tremendously" altered data. Too bad she just made it up. But wait! She's not finished making things up:

Despite the mention of induced labors being included in the cohort, there are no numbers on how many of the 2 million + pregnancies ended in induction—leaving a potentially HUGE confounding variable unchecked.

Yes, inductions may be a confounding variable because they REDUCE the risk of stillbirth. If inductions are a confounding variable, correcting for them would INCREASE the association between advanced maternal age and stillbirth, not decrease it, as she mistakenly believes.

The editor may have changed, but the quality of the scientific analysis at Science and Sensibility is still pathetic. Here's some helpful advice: If you are going to dispute the results of a scientific paper, you need to offer scientific evidence to support your claims. Merely pretending the results aren't true if they don’t fall in line with your personal beliefs does not represent scientific analysis, merely the wishful thinking that is so characteristic of contemporary NCB advocacy.

Is the new midwifery merely unreflective defiance?

Years ago I wrote a brief piece about homebirth midwifery entitled Whatever the scientific evidence shows, do the opposite. It turns out that I was echoing a feminist criticism of the "new" midwifery.

Among the most influential commentators on the subject are Ellen Annandale and Judith Clark, authors of the widely quoted paper, What is gender? Feminist theory and the sociology of human reproduction published in Sociology of Health & Illness Vol. 18, No. 1, 1996. The paper is long and filled with academic jargon, but has important insights that have created controversy among feminist theorists. The heart of Annandale and Clark's criticism of the new midwifery is almost exactly the same claim that I made:

... the lived experience of midwifery ... is revealed only as the largely unresearched antithesis of obstetrics. An alternative is called into existence in powerful and convincing terms, while at the same time its central precepts (such as 'women controlled', 'natural birth') are vaguely drawn and in practical terms carry little meaning.

This is a stunning criticism. Midwifery is described as unscientific and based on reflexive defiance. How did the new midwifery get to this point? Annandale and Clark believe that it starts with biological essentialism. They approvingly quote the work of a colleague:

... what both feminists and phallocentrists see as hegemony based on masculine perceptions of domination, performance, hierarchy, abstraction, and rationality, finds its antipode in a woman's community proclaiming itself as naturally nurturant, receptive, cooperative, intimate, and exulting in the emotions . . . [feminists] assume that such principles exist and that they have been fixed and dichotomous since the dawn of patriarchal history. . . . Thus it is that the dominant culture and the counterculture engage in a curious collusion in which . . . a rebellious feminism takes up its assigned position at the negative pole.

Peeling away the jargon leaves us with the basic point, biological essentialism perpetuates women's oppression by validating men's belief that women are emotional and irrational. Or as Annandale and Clark write:

... Thus ... reproduction is still centred for women and put on the agenda as if it were central to all women's lives. This may serve to lock women into reproductive roles which may be politically problematic since the centrality of reproduction, contraception and childbirth to biomedicine is transferred to women's experiences. This may be the reality of their experience, but equally importantly, it may not. To a certain extent this may be seen as an unavoidable consequence of a critique which appears as if it must engage the dichotomies of biomedicine to develop its own narrative.

The authors identify Sheila Kitzinger as an exponent of this false dichotomy.

'Altematives' to male-biomedicine were heavily valorised in research in the 1970s and 1980s. This was particularly evident in suggested alternatives to mainstream gynaecological and obstetric care. Sheila Kitzinger, for example, wrote that

the new midwifery has a vital part to play in the woman's movement and is at the very centre of the great creative upheaval which is taking place as we reclaim our bodies and come to learn about, understand and glory in them. This new midwifery gives vivid expression to the way in which women are discovering strength and sisterhood as we turn to help and support one another during the intense, exhilarating and powerful experience of childbirth (1988:18).

A clear line of demarcation tends to be drawn in the literature between obstetrics and midwifery: each is portrayed as a unitary and intemally coherent body of thought and practice which is at odds with the other. The 'alternative' female-midwifery is clearly put forward as the better model...

Not only are such assumptions wrong, they are also elitist:

... The charge of elitism evidenced in the privileged white middle-class voice of much research, and the silence around differences between women, applies well to Barbara Katz Rothman's influential 1982 work ... which ends with an implicit call for a home-based natural birth experience .... This is made in joyous terms with little recognition that many women may not be in the position to avail themselves of such an 'alternative' even if they wanted to.

Annandale and Clark ask a critical question about the new midwifery. Are midwives "with women" or exploiting women for their own ends?

If we conceive of power as a fundamentally male preserve we are led to gloss over ways in which women may exert power over others, including other women . In these terms, as recent institutional reforms stimulate community midwifery midwives may begin to consider the notion of affinity with women embedded in such concepts as 'continuity of care' ... as masking the potential exploitation of midwives by their clients.

Who, after all, is being served by this concept of midwifery?

In my view, the ultimate irony of the new midwifery is that the very people who bemoan the supposed inability of modern obstetrics to cooperate with midwifery are the very people who have made such cooperation impossible.

By insisting that all women are the same, that childbirth has a biological "essence" that must be preserved and, especially, that midwifery is defined by its opposition to modern obstetrics, midwifery theorists have created a false dichotomy that is by definition unbridgeable. Midwifery theory ignores the interests of many, if not the majority of women. Indeed, the new midwifery goes beyond ignoring women who refuse to subscribe to the theory of biological essentialism and questions the very "authenticity" of their womanhood and motherhood.

Most women in contemporary first world countries have rejected essentialism, embrace technology, and have no use for a philosophy that presumes that midwifery exists only insofar as it rejects defies modern obstetrics. If midwifery is to survive, midwifery theorists had better wake up to that reality and stop pretending that unreflective defiance is a virtue.