The shameless tactics of Russ Fawcett and the North Carolina Friends of Midwives

How do homebirth midwives and their supporters handle their mistakes? They bury them, of course.

It has belatedly occurred to Russ Fawcett, President of the North Carolina Friends of Midwives (NCFOM), that the arrest of a homebirth midwife* in the wake of the death of one baby and the serious injury of another is perhaps not the most persuasive reason for legalizing homebirth midwives.

In the wake of his bone headed move sending out a 450 NCFOM word press release without devoting a single word to the baby still hospitalized and still fighting for its life, Russ has rushed to compound the damage with an even more bone-headed "urgent message" to the NCFOM mailing list.

URGENT Request

This message in being sent to all NCFOM members.

The leadership of NCFOM is moving to change the direction of the media. We will be crafting a new press release that is ENTIRELY focused on Wednesday's Birth Freedom March and legislation, with NO mention of the investigation.

At this time, please STOP ALL COMMUNICATION WITH ALL MEDIA INQUIRES that may arise that have any connection with Amy. Direct all media inquiries to myself (Spigget@aol.com) and Amber Craig (ambercraig@nc.rr.com).

Friends - I think this has been very successful, but not without concern over worsening Amy's circumstance. Nevertheless, there is a lot of positive press out there, and some negative, but had we done nothing, it could have been all negative.

Please DO NOT CONTACT OR DISCUSS with any media outlets until further notice. This includes leaving comments on newspaper, television and other media's web pages. It would be better to miss an opportunity at turning around a bad article, or celebrating a good one, than to negatively affect our need to now change the conversation. Please direct any questions about media to myself, or Amber Craig.

I love your enthusiasm! Please help to make our Birth Freedom Walk NCFOM's biggest event ever. There is lots to do to prepare for Wednesday and we can ONLY do it wit YOUR help. Get on our Yahoo group and get involved. If you are not yet a member of the Yahoo group, please email Rebecca Walton (rw@nchomebirth.com) so that she can invite you.

Thanks,
Russ

As I wrote just last week:

That is what is known as "reframing the conversation." North Carolina homebirth advocates aren't going to persuade anyone of anything by discussing the babies injured under the care of CPMs. They don't even bother to try to justify the conduct of the CPM, her medical judgment (or lack thereof), or the appropriateness of a homebirth in either case. That argument is a total loser, so effort is expended to divert attention from the homebirth disasters.

Once again there has been a homebirth disaster (actually multiple disasters) and NFCOM is following the homebirth playbook. But this time, no one should let the NCFOM get away with it.

How about sending emails to Russ and Amber to let them know precisely what we think of the shameless attempt to bury the babies hurt by homebirth, both literally and figuratively? For those who live in North Carolina, it may be helpful to pass on Russ' message in full to your state legislator. And it can't hurt to send a copy to any newspaper or TV station covering the arrest of the midwife or the forthcoming rally to alert them to the deliberate attempt to manipulate press coverage.

It is time to put an end to the legalization of a second, inferior class of midwife, with less education and training than any other midwives in the industrialized world. The evidence of their incompetence continues to mount. Indeed, their own organization, the Midwives Alliance of North America (MANA), spent 8 years collecting safety data on homebirth midwives and is now refusing to to release the number of babies who have died at the hands of homebirth midwives. They, too, are trying to bury the incompetence of homebirth midwives.

The behavior of NCFOM is repugnant. First they planned a rally in support of a homebirth midwife who has been arrested twice and involved in the serious injury of two babies and the death of a third. Then when their callousness was exposed they had two options: acknowledge the injuries and investigate the midwife or ignore the injuries and hope that no one else will notice. When faced with a choice between protecting babies or protecting themselves, they chose themselves.



*American midwives who hold a post high school certificate (CPMs and LMs), as opposed to American certified nurse midwives and European, Canadian and Australian midwives who have university degrees. American homebirth midwives have less education and less training than ANY midwives in the industrialized world.

The foreskin fetishists have struck again

The foreskin fetishists have struck again. Those who devote their lives to the preservation of foreskins are hurriedly gathering signatures to put a circumcision ban on San Francisco's November ballot. The measure would assess fines as high as $1,000 and provide for up to one year in jail for someone who performs a circumcision.

The signature-gathering is being run by a committee of about 10, he said. Schofield would not divulge the identities of the committee members, but said several are spending their own money to pay for signature-gatherers to help out. Schofield said he is out there himself — not being paid — collecting the signatures outside grocery stores and in neighborhoods like SoMa, the Castro, the Haight and Noe Valley.

"We say: 'Would you like to help protect the children from forced circumcision? This is a human-rights issue,'" Schofield said.

Actually, it's a First Amendment issue, and a ban on circumcision is unconstitutional, because it violates the right to free expression of religion. Circumcision is an integral aspect of Jewish religious practice and is important in the practice of Islam. Of course the foreskin fetishists are not concerned with anything as piddling religious belief.

In fact, [the] proposal contains language that could be construed as an intentional poke in the eye to organized religions calling for circumcision: "No account shall be taken of the effect on the person on whom the operation is to be performed of any belief on the part of that or any other person that the operation is required as a matter of custom or ritual."

According to Peter Keane, dean emeritus at Golden Gate University School of Law and a constitutional law professor:

San Francisco can have its proposed circumcision ban, or it can have the First Amendment. But it can't have both...

"It's not Constitutional. It would be a violation of the First Amendment right to Freedom of Religion -- religions like Judaism that require [circumcision] as an essential part of the belief system."

As Keane explains:

There's a general First Amendment right stating you cannot make any laws that infringe the exercise of religion," says Keane. "And a parent has a First Amendment Constitutional right to make choices for his or her child.

Anti-circ activists insist that cirumcision is barbaric. Would a court agree? Keane says no.

If I'm an Aztec and my religion says I have to go high atop a pointed building and tear out someone's heart -- that's nice, but there's a murder statute that trumps that. But in terms of state interest in preventing the foreskin of male infant from being detached -- that interest is very, very minor... [T]he interest is so marginal, the state does not have the right" to trump freedom of religion.

Anti-circ activists have gone a step too far by trying to ban circumcision. And in so doing, they have revealed their contempt for both organized religion and the US Constitution.

Do epidurals change labor?

Have epidurals changed labor?

Of course they have. They've made labor much less painful and much less feared than ever before. But Science and Sensibility guest blogger Dr. Michael Klein doesn't care about that. He's concerned that epidurals have changed the course of labor. Why is this important? Dr. Klein would like women to believe that epidurals increase the likelihood of C-section.

Dr. Klein has returned with part 2 of his post "Epidural Analgesia—a delicate dance between its positive role and unwanted side effects." After the appearance of part 1, I wrote about Dr. Klein's effort to delegitimize women's need for pain relief in labor and how that fits with the tendency of natural childbirth advocates to treat women's needs as invisible.

In a 1200 word post, Dr. Klein utterly fails to mention the excruciating pain of childbirth. There is not a single word about how women feel about pain and pain relief in labor.

True to form, Dr. Klein writes yet another screed on "the positive role and unwanted side effects" without bothering to mention the positive role or how women feel about relief of their labor pain.

In typical NCB fashion, Dr. Klein wants to talk only about the risks, whether real or imagined. Dr. Klein tells us what he personally found in his research on epidurals and why he believes that and not the Cochrane Review that showed epidurals have no impact on the C-section rate.

It is because of these studies that we had trouble accepting the results of the 2004 Cochrane meta-analysis that concluded that epidural analgesia did not raise the cesarean section rate. This conclusion was the same in the most recent Cochrane meta-analysis ...

Here's what Dr. Klein and his colleagues found:

We found that physicians with mean epidural rates under 40% for women having their first baby, had cesarean section rates of about 10%. In contrast, those family doctors with mean epidural rates of 71-100% had cesarean section rates of 23.4%, the others having rates between the two extremes. The women cared for by the three groups were similar. Thus it appeared that only physician practice difference could have accounted for such large differences in outcome...

In other words, Dr. Klein FAILED to show that epidurals increased the rate of C-section, but wait! The same doctors who had lots of patients who opted for epidurals had high C-section rates. And that means .... nothing!

To understand why Dr. Klein's findings are meaningless, we can apply one of Hill's criteria: consideration of alternative explanations. Is there an alternative explanation for Dr. Klein's findings? Of course there is, possibly more than one.

Remember, Dr. Klein failed to show that women who had epidurals were more likely to have C-sections, which is, of course, is what he MUST show in order to impute causation. He only showed that certain doctors were more likely to a. have patients who requested epidurals and b. have a high C-section rate. The alternative explanations are rather obvious. Either the patients differed in important ways from doctor to doctor, or the doctors differed in important ways from each other.

We can use a related example to illustrate. Suppose I claimed that epidurals caused higher rates of admission to Harvard. First I looked to see if women who had epidurals were more likely to have children subsequently admitted to Harvard and found that they were not. Then I discovered that the patients in Dr. A's practice had both a high epidural rate and a high rate of subsequent admission to Harvard, and the patients in Dr. B's practice had a low epidural rate and a low rate of subsequent admission to Harvard. Would I have proven that epidurals cause Harvard admission? Of course not. Why not? Because an alternative explanation (for example, the fact that Dr. A practiced in a wealthy suburb whereas Dr. B practiced in the inner city) is far more likely to account for the difference.

In other words, Dr. Klein's research most certainly does not show that epidurals increase the C-section rate, ... but it does make a compelling case for Dr. Klein's desperation to dramatically inflate the purported risks of epidurals and render the benefits invisible.

Homebirth advocates ignore baby, rally for midwife

Another day, another homebirth tragedy:

... [A] newborn was born in an east Charlotte home and rushed to the hospital.

Family members of the 24-year-old mother said the baby was still in the hospital Wednesday night and was not doing well.

The birth was attended by a homebirth midwife, also known as a certified professional midwife (CPM). Certified Professional Midwives are grossly undereducated, grossly undertrained and are not eligible for licensure in ANY other first world country. They lack a college education, and sport only a post high school certificate awarded by other CPMs.

You might think that this would be an opportunity for soul searching in the North Carolina homebirth community, but you'd be wrong. The North Carolina Friends of Midwives and the Charlotte chapter of the International Cesarean Awareness Network (ICAN) view this as an oppportunity to promote the interests of CPMs. No one knows whether the baby will live or die, but homebirth advocates have already "moved on" to the really important issue, the fate of the midwife.

Amy Medwin, the CPM in question, was arrested after the baby was transported to the hospital. CPMs are illegal in North Carolina. Certified nurse midwives (CNMs, the equivalent of midwives in every other industrialized country) are the only legally recognized midwives in North Carolina. Medwin was arrested for practicing illegally and for failure to provide appropriate medical care to the infant, resulting in serious injury.

This isn't the first time Medwin was arrested. According to the Charlotte News and Observer, she was arrested in the wake of another poor homebirth outcome in 1998.

The baby was big, 10 pounds, 15 ounces. But then, midwife Amy Medwin hadn't been expecting a peanut. The mother ... had had two other babies that weighed more than 9 pounds. Still, attending the woman's home birth in Davie County last September, Medwin watched cautiously as this baby's head emerged; it was coming a bit too slowly.

Then it stopped.

The infant's shoulder had caught on the mother's pelvic bone and wouldn't budge. Medwin, who has attended more than 750 births over the past 19 years, ordered the mother into different positions. They tried seven until finally the baby dislodged. He wasn't breathing, and his body was blue.

So began the case that ultimately led to Medwin's unprecedented arrest March 5: ... she became the first woman in North Carolina charged with practicing midwifery without a license.

That's a misdemeanor under state law and, without a prior record, Medwin could easily pay a fine and walk away. But Medwin says she cannot in good conscience tell a judge she will give up her practice. She believes she is called by God to help women deliver their babies in the comfort of their own homes.

The baby was transferred to the hospital and survived after a 6 day hospital stay. The case was ultimately dropped because the mother, who had filed the original complaint, refused to testify.

Now, once again, Medwin has presided over a serious complication at homebirth, and once again, a baby fights for its life in the local hospital. But who cares about that? Certainly not homebirth advocates.

The North Carolina Friends of Midwives has issued a 450 word press release and NOT A SINGLE WORD is devoted to the baby. The Charlotte chapter of ICAN has also issued a press release with NOT A SINGLE WORD about the baby's condition. Instead, the press releases have usual suspects talking the usual talking points. Katie Prown (Look at the death rate in Katie Prown's state) expresses pious concern for the taxpayers money that will be "wasted" in prosecuting Ms. Medwin. Russ Fawcett bemoans the "bullies and special interests" who dare to place the health and well being of babies above the economic interests of homebirth midwives. They are planning a rally in support of Ms. Medwin.

That is what is known as "reframing the conversation." North Carolina homebirth advocates aren't going to persuade anyone of anything by discussing the babies injured under the care of CPMs. They don't even bother to try to justify the conduct of the CPM, her medical judgment (or lack thereof), or the appropriateness of a homebirth in either case. That argument is a total loser, so effort is expended to divert attention from the homebirth disasters.

Only homebirth advocates could consider the life threatening damage sustained by infants at homebirth as an opportunity to rally support. According to them, the problem is not that babies are injured and die at homebirth. And the problem is not that CPMs have less education and training that midwives in ANY other first world country. The real problem, according to homebirth advocates, is that these underqualified, dangerous practitioners who have already hurt babies don't have legal sanction.

Hopefully the people and the legislature of North Carolina will recognize these tactics for what they are, a desperate attempt to change the subject from the risks of homebirth to the economic and social welfare of homebirth midwives.


Addendum: The latest news reports indicate that Medwin's current arrest was prompted by TWO bad outcomes in one month. The first case was an intrapartum death in which Medwin attended the labor but claims she left before the birth of the dead baby. The second is the case discussed above in which the baby is still hospitalized and fighting for its life.

Ten lies my natural childbirth educator told me

Several people have expressed reluctance to join a Facebook group entitled Fed up with natural childbirth on the grounds that they have no objection to choosing unmedicated birth, or more generally, no objection to women making whatever choices they prefer. But natural childbirth is not simply a specific set of choices; it's a philosophy that idealizes a specific set of choices and makes value judgments about women who choose differently. Moreover, it is a philosophy that rests on specific empirical claims; claims that are disingenuous, untrue, or occasionally outright lies.

Below is a list of the most popular NCB falsehoods and lies, the ones that are promulgated by natural childbirth celebrities and organizations, and faithfully transmitted even by purportedly neutral childbirth educators:

#1. Childbirth is inherently safe.

This is an outright lie. Childbirth is inherently dangerous. Childbirth is and has always been, in every time, place and culture, a leading cause of death of young women. For babies, the day of birth is the single most dangerous day of the entire 18 years of childhood.

This lie is a bedrock assumption of natural childbirth philosophy. On this false belief that childbirth in nature is inherently safe rests the claim anything that modifies childbirth must be dangerous or not as good as childbirth in nature.

#2. Fear causes the pain of childbirth.

This stems from a spectacularly racist lie. Grantly Dick-Read, the father of the NCB movement, was a eugenicist whose primary goal was to prevent "race suicide" by encouraging white women of the better classes to have more children. He claimed that primitive (i.e. Black) did not have pain in labor, in keeping with the pervasive racist beliefs of the age that Black women were hypersexualized, and gave birth without pain because they did not fear their natural role. Grantly Dick-Read based his entire philosophy on this lie, hence the title of his book, Childbirth Without Fear.

Contemporary natural childbirth advocates no longer make the absurd racist claims, but they are stuck on the notion that the pain of childbirth is inherently controllable by the mind, and that the mind can therefore be trained to minimize and manage the pain.

#3. Labor is not inherently painful.

This bizarre claim rests on a false assumption that labor pain is qualitatively different than other forms of pain. It's not. It is exactly like any other form of pain, is initially received by the same types of neurons, passes exactly the same way up the spinal cord to the brain, and is perceived by the brain in exactly the same way as any other form of pain.

#4. Epidurals are dangerous and unnecessary

NCB advocates insist that epidurals are unnecessary because the pain of labor should be managed in other ways, or better yet, should be endured. The claim is both philosophical and empirical. The philosophical claim rests on the naturalistic fallacy and belief in essentialism. The naturalistic fallacy is the claim that because something is a certain way in nature, it ought to be that way all the time. Essentialism is the belief that women share an essential nature and are "empowered" by expressing that nature.

NCB also insist that epidurals are "dangerous" to both baby and mother. That's nothing more than a lie, created by grossly inflating the purported risks of epidurals.

#5. Interventions are "bad."

Obviously, if you operate under the mistaken belief that childbirth is inherently safe, it is impossible to recognize the benefits of interventions. However, if you recognize reality, that childbirth is inherently dangerous, interventions represent nothing more than preventive medicine. Knowing that complications are common and often preventable, it follows quite logically that pregnant women should be monitored for a variety of complications so they can be prevented, or treated early when there is the greatest chance of successful treatment.

Since NCB advocates insist that interventions are generally worthless, they are forced into the bizarre position of arguing that medical professionals deliberately offer worthless practices and technology because they are benefiting financially.

#6. Inductions are dangerous and unnecessary.

This lie was adopted by NCB advocates only recently. It flows inevitably from two other mistaken beliefs, the belief that childbirth is inherently safe and the belief that since there are no inductions in nature, there must be no need for inductions.

NCB advocates bemoan the rising induction rate while conveniently ignoring the fact that the stillbirth rate has dropped as a result.

#7 Cesareans are almost always unnecessary.

Again, this is nothing more than an empirical lie. It is well known that in countries where the C-section rate is under 5%, mortality rates are appalling. Indeed, in countries that have C-section rates less than 10%, mortality rates are still extraordinarily high. At a minimum, then 1 in 10 women derive major benefit from a C-section. That is hardly a procedure that is unnecessary.

#9. Vaginal birth is inherently superior

This is a philosophical claim that rests on the naturalistic fallacy. Since everything that is natural is "better" and vaginal birth is natural, it must be "better." Most women consider that a birth that results in a live baby and live mother is inherently superior, and for a significant proportion of women, that birth is a C-section.

#10. Women who love their babies choose NCB

This is the most hateful claim, but a claim that flows inevitably from all the other lies. When you erroneously believe that natural is inherently safe and that everything else is inherently dangerous, interventions wrongly take on the specter of unnecessary risks. When you wrongly believe that epidurals are dangerous, opting to treat your own pain implies that you value your feelings over the risks to your baby.

***

Natural childbirth advocates will be the first to tell you that NCB is not merely a vaginal birth without pain medication. It is a belief system that necessitates choosing vaginal birth without pain medication and without interventions of any kind. As we have seen, it is based on a variety of philosophical and empirical claims that range from false to outright lies. Natural childbirth explicitly idealizes certain childbirth choices and derides others. More importantly, it asserts that women who make those idealized choices are better women and better mothers than everyone else. And that's why I'm fed up with natural childbirth.

Fed up with natural childbirth

Birth "activists" dominate the conversation about childbirth in the US, giving the erroneous impression that they speak authoritatively and for a large proportion of women. Nothing could be further than the truth.

They dominate the conversation for several reasons. First, birth has a profound hold on their imagination. While most women view birth as a way for the baby growing inside to get outside, there is a small group of women for whom birth has an outsize importance. These "birth junkies" will cheerfully admit to being obsessed with birth, and get a great deal of their apparently limited self-confidence from their belief that giving birth vaginally without pain medication counts as an "achievement."

Second, the internet and social media have magnified their voices. As in the case of vaccine rejectionism, natural childbirth advocates have created an alternate world where facts are fabricated, scientific evidence is ignored, and there is no context for understanding the information presented because the advocates lack basic knowledge of childbirth, science and statistics.

Third, it is a money making industry. Natural childbirth advocates love to accuse obstetricians of making money from the care of pregnant women. Those accusations generally ignore the current realities of reimbursement for medical care, and grossly exaggerate the purported "economic benefits" to health professionals of childbirth interventions. Meanwhile they carefully neglect to mention that natural childbirth represents 100% of the income of natural childbirth educators, homebirth midwives, and doulas, not to mention natural childbirth authors.

Fourth, they feel compelled to proselytize. It is not enough for a "birth junkie" to have the birth that she desires. YOU must also have the birth that she desires in order for her to feel validated in her choices. And, as is often the case with proselytism, natural childbirth advocates aren't content with selling the virtues of their beliefs; they feel compelled to criticize everyone else's beliefs in the strongest possible terms. Birth choices are not simply choices; they represent an epic battle between the forces of the purportedly "educated" and uneducated. They symbolize a conflict between "good" mothers and bad mothers. Perhaps most offensive of all, they are portrayed as a Manichean struggle between those who love their children and those who don't love them enough.

I, for one, am fed up with the posturings of natural childbirth advocates, and there's no question that I'm not alone. The vast majority of American women do not subscribe to the central beliefs of the natural childbirth philosophy: that vaginal birth is superior, that epidurals symbolize weakness, and that all women can and should breastfeed their infants for a year or more.

I am fed up with the assertion that vaginal delivery is the only way "real" women give birth.
I am fed up the the claim that C-sections are the avoidable result of not trying hard enough to have a vaginal delivery.
I am fed up with the canard that C-sections are "unnecessareans."
I am fed up with the belief that pain relief in labor is dangerous and that forgoing pain relief is an achievement.
I am fed up with the claims that labor pain is "good" pain, "pain with purpose" and the remarkably hateful claim that "less pain equals less joy."
I am fed up the idea that childbirth educators are qualified in any way to give medical advice on any topic.
I am fed up with self-proclaimed natural childbirth "experts" who lack basic understanding of science and statistics.
I am especially fed up with anyone who dares to assert that childbirth choices separate those who love their babies from those who don't love them enough.

I've created the Facebook group Fed up with natural childbirth for "women who don't need labor pain to feel authentic, don't need a vaginal delivery to feel like a woman, and don't need sanctimommies telling them how to feed their babies."

Join me if you feel the same.

Celebrity blasts natural childbirth zealots on Twitter

Twitter is the latest venue for the battle against the sanctimommies of natural childbirth advocacy.

British TV host Kirstie Allsopp is angry:

[She] has launched a scathing attack on natural childbirth experts, accusing them of 'stigmatising' women who have Caesareans.

The TV presenter – whose two sons were delivered by C-section – claimed that she and thousands of other mothers were being made to feel a 'failure'. She criticised the National Childbirth Trust for being 'reckless' in not providing enough information about the procedure in their antenatal classes, which are attended by 100,000 couples every year.

Ms. Allsopp appealed to her Twitter followers:

[She] then asked her 95,000 Twitter followers: 'Anyone been on an NCT course recently? Was there any info/discussion on what happens in the event of you needing a C-section?'

Hundreds responded, many of them agreeing that they had been given minimal information. One new mother had apparently been banned from the class held after the birth because she had needed a Caesarean.

Her husband wrote: 'After C-section my wife and I were the only couple not invited back to NCT group to tell expecting couples about it.'

Allsopp is fed up with the obnoxious attitude of professional natural childbirth advocates:

They seem to be saying if they had been in our position they would have managed somehow, despite all the medical advice, to give birth naturally,' she said.

'There are very few organisations that get away with suggesting you should ignore medical advice, but the NCT does.'

Brenda Phipps, president of the National Childbirth Trust (who has only 536 followers), rushed to inadvertently confirm Allsopps claims.

First, she offered the feeble excuse that the NCT did not cover C-sections in their childbirth classes, because it's difficult 'fitting everything in.' But if Ms. Phipps and the NCT have chosen to ignore C-sections, they should have own their decision and not make absurd excuses.

Then Phipps, like all professional NCB advocates, could not resist being obnoxious. She claimed that NCT ignores C-sections in their classes in order to help women avoid them. When Allsopp pointed out that knowledge is more helpful than ignorance, Phipps joked that watching a car crash might constitute knowledge for avoiding a car crash but no one would want to do that.



Thereafter Phipps slips into the truly ridiculous:

imagining what you don't want makes it more likely

followed by:

say to a child don't spill that and it will

Make up your mind Ms. Phipps. Does the NCT fail to provide information about C-section because there isn't enough time? Or does it deliberately refuse to provide information about C-section on the astoundingly inane theory that thinking about a C-section will cause a woman to have one?

One thing is crystal clear, though. The NCT stigmatizes C-sections just as Allsopp claims. Phipps presumes that vaginal delivery is always superior to C-section, that C-section is an "accident" to be avoided at all costs, and that merely mentioning it could cause the dread event to come to pass.

Allsopp has had enough:

... [I]t makes me want to cry that some women don't have the information they need at such an important time. It has to stop.

Janet Fraser: dead baby not as traumatic as birth rape

You might think that freebirth advocate Janet Fraser would be chastened by the death of her baby at homebirth. You'd be wrong. In fact, according to Fraser, it wasn't even traumatic.

My birthrape with my first child is traumatic. My stillbirth was not.

Fraser is the premier Australian advocate of unassisted childbirth (UC) also known as freebirth. That's right, a birth unattended by any medical professional of any kind, no matter how poorly educated. And Fraser added an extra fillip, no prenatal care of any kind. As she went into the labor that eventually resulted in a dead baby, she actually gave an interview to an Australian newspaper on March 22,2009 in which she boasted of her choices:

Janet Fraser is in labour... Has she called the hospital to let them know what's happening? "When you go on a skiing trip, do you call the hospital to say, 'I'm coming down the mountain, can you set aside a spot for me in the emergency room?' I don't think so," says Fraser, whose breathing sounds strained...

... She hasn't seen a doctor or any health professional since becoming pregnant this time. No ultrasound, no genetic testing, no internal examinations, no stethoscope. Does she have any feeling for how long the labour will go? "I could do this for days. My daughter's birth was 50-something hours. You just do it — it's just birth, a normal physiological process."

The baby was not born for another five days. The death was described in another newspaper report:

... [T]he natural water birth of her third child, a girl, at her home went horribly wrong in the early hours of March 27.

Ambulances were sent to the address following a triple-0 call made at 1.13am.

An ambulance service spokesman said paramedics were called to a Croydon Park address for a newborn baby who had suffered cardiac arrest and was not breathing.

Paramedics failed to revive the baby throughout the journey to the Royal Prince Alfred Hospital at Camperdown.

"They were basically working on the baby all the way to the hospital," the spokesman said.

It boggles the mind that Fraser could describe the death of her daughter as less traumatic than the live birth of her son, but evidently "having it your way" is much more important than having a live baby.

Fraser may not have been traumatized by her daughter's death, perhaps a coroner's inquest will change that. Fraser, like Australian homebirth midwife Lisa Barrett, has tried to argue that her irresponsibility led to a stillbirth, not a live birth, and therefore it should not be investigated. The New South Wales police investigators disagree:

A Coronial inquest will be held into the controversial death of a baby girl during a home birth where doctors or midwives were banned from assisting a delivery - a practice known as "free-birthing".

The inquest comes two years after initial confusion as to whether the baby took a breath after delivery or died in utero. The latter instance would have prevented a coronial inquiry.

The Sunday Age understands New South Wales police have conducted an extensive investigation to present a brief of evidence to the coroner.

The matter is listed as a mention in the Glebe Coroner's Court on March 18, almost two years to the day the controversy broke.

Presumably, Fraser is going to claim that her daughter was dead at the moment of birth. No one thought so at the time. Someone at Fraser's house requested an ambulance and EMTs performed CPR all the way to the hospital.

Fraser may not have been personally traumatized birth the death of her daughter, but she certainly recognized that the death could have a traumatizing effect on others. Therefore, she deleted the story from her freebirth message board, Joyous Birth. Deaths are so very, very inconvenient when you are trying to pretend that irresponsible choices are safe. Better to obliterate all mention of it.

It's hard to imagine anything more selfish and self absorbed than choosing freebirth, but Janet Fraser has topped that with something even more reprehensible. There's nothing uglier than trying to erase all mention of your dead child and declaring that the death wasn't that traumatic at all. Fortunately, the coroner is not going to let her get away with it.

Why safe choices are viewed as dangerous

How extraordinary! The richest, longest-lived, best-protected, most resourceful civilization, with the highest degree of insight into its own technology, is on its way to becoming one of the most frightened. - Aaron Wildavsky

There's a big difference between assessment of risk and the perception of risk. As Wildavsky points out above, Americans are frightened of risks. He and other scholars of risk have located that fear in the large gulf between assessment and perception.

What's the difference between risk assessment and risk perception?

Risk assessment is the mathematical determination of a specific risk, and is usually carried out by professionals in statistics or related disciplines. Risk perception is the belief about a specific risk and is typically the province of lay people. As scholars of risk have noted, there is often a wide gulf between actual risk and lay belief about risk. When it comes to advances in health and science, the American public often perceives far more risk than the risk assessment demonstrates. The actions taken in response to that fear, can often be more dangerous than the particular risk that is feared.

Alternative health practices like vaccine rejectionism and homebirth, arise in that wide gulf between assessment and perception. Risk perception is modified by factors that have nothing to do with actual risk. According to David Kane in Science and Risk: How Safe is Safe Enough, these factors include "newness" of the risk, control, and benefits.

What does he mean by "newness of the risk"?

Generally, a risk that has always existed is regarded as an acceptable risk, while newer risks that are brought to the public eye receive greater scrutiny. This intense examination makes the new risk appear to be more dangerous.

That is especially true when the magnitude of the risk is unknown to many (the risk of death during childbirth) or has not been directly witnessed (the risk of death from vaccine preventable diseases). It is also affected by the naturalistic fallacy, the claim that the way that things were is the way that they ought to be. Natural childbirth advocates routinely believe that the risks of technology are far higher than the risks of "natural" birth.

The second factor is control.

An individual is more willing to accept the risk of an activity of which he or she is in direct control... This underlying factor explains why ... indirectly controlled activities have a high perceived risk.

A key type of control is the decision to be exposed to a risk. Voluntary risks involve this kind of choice, while involuntary risks lack this element of control. Because voluntary risks involve a choice based on an individual's own set of values, [research has shown that] the acceptance levels are a thousand times greater than those of involuntary risks.

For example, even when homebirth advocates are apprised of the increased risk of neonatal death, many will still choose homebirth. It seems to them that the risk they choose (to have a homebirth) must be smaller than risk of hospital birth.

The third factor is benefits.

The public is only willing to tolerate a minute level of risk for activities which it considers to be of little value, such as constructing nuclear power plants. Conversely, for those events which the public perceives great benefit, the acceptance level is quite high.

Kane includes a graph that dramatically illustrates this phenomenon. Here's a modified version of the graph.

As the graph demonstrates, large risks are considered acceptable if the benefits are valued highly.

For these reasons, vaccine rejectionists' perceived risk of vaccination is much higher than the actual risk. Vaccine rejectionists perceive the risks of "new" vaccinations are far higher than "old diseases." They are more frightened of risks posed by mandated vaccination than the far higher dangers of voluntarily rejecting vaccines. And since they don't understand the magnitude of the benefit, they erroneous conclude that risk of vaccination is not acceptable.

Similarly, for homebirth advocates the risk of hospital technology are perceived as far higher than the risk of birth in the traditional venue of the home. They are far more frightened by the risks of undesired hospital policies than the far higher dangers of freely chosen homebirth. And for those who understand that the risk of neonatal death is higher at homebirth, it is judged acceptable because the perceived benefits are valued so highly.

Both vaccine rejectionists and homebirth advocates need to understand that their perceptions of risk are totally out of line with actual risk. Until they do, they will continue to erroneously believe that dangerous choices are safe, and safe choices are dangerous.

If correlation is not causation, what is?

Even those who can't tell the difference between a t-test and a chi-square are familiar with a basic principle of epidemiology: correlation does not equal causation. In other words, even if Event A happened before Disease B, it does not mean that A caused B.

For example, in last 100 years deaths from infectious diseases has declined precipitously. During the same time span, the recreational use of marijuana has also increased. Yet no one would suggest that the decline in infectious disease deaths was caused by smoking marijuana.

So if correlation does not equal causation, what does?

To determine if Event A caused Disease B, we need to investigate whether it satisfies Hill's Criteria. These are 9 criteria, most of which much be satisfied before we can conclude that Event A is not merely correlated with Disease B, but Event A actually causes Disease B.

Who was Hill and why should we care about his criteria?

... These criteria were originally presented by Austin Bradford Hill (1897-1991), a British medical statistician as a way of determining the causal link between a specific factor (e.g., cigarette smoking) and a disease (such as emphysema or lung cancer)... [T]he principles set forth by Hill form the basis of evaluation used in all modern scientific research... Hill's Criteria simply provides an additional valuable measure by which to evaluate the many theories and explanations proposed within the social sciences.

What are the criteria?

1. Temporal relationship: It may sound obvious, but if Event A causes Disease B, Event A must occur before Disease B. The is the only absolutely essential criterion, but it is NOT sufficient. Lay people often erroneously assume that because it's the only essential criterion, it is the only criterion that counts. For example, vaccine rejectionists often point to the fact that childhood vaccinations usually occur before the onset of autism, but that does not mean that vaccination causes autism. Consider that learning to walk usually precedes autism, but obviously learning to walk does not cause autism.

2. Strength: This is measured by statistical tests, but can be thought of as similar to the closeness of the relationship. Is Disease B always preceded by Event A? Sometimes? Only rarely? Does Event A always cause Disease B? Sometimes? Only rarely? Lung cancer is not always preceded by cigarette smoking, but it usually is. Cigarette smoking does not always lead to lung cancer, but it does often lead to lung cancer. In other words, the relationship is fairly strong.

In the case of vaccines and autism, vaccines usually precede the diagnosis. However, most children who receive vaccines don't develop autism. Thus the relationship is weaker.

3. Dose-response relationship: If cigarette smoking causes lung cancer, we would expect that smoking more cigarettes would increase the risk of lung cancer, which it does. In contrast, there appears to be no dose-response relationship between the number of vaccinations and the risk of developing autism.

4. Consistency: Have the findings that purported to show a relationship been replicated by other scientists, in other populations and at other times? If studies fail to consistently show the relationship, causation is very unlikely.

This is a critical point. One experiment or even a few experiments is NOT enough to determine causation. A large number of experiments that consistently show the same result is required. This is particularly important for vaccine rejectionists to note. The fact that a few studies claim to have shown that vaccination causes autism is meaningless when a very high proportion of studies show that there is not even a correlation between vaccination and autism.

5. Plausibility: In order to claim causation, you MUST offer a plausible mechanism. In the case of cigarette smoking, certain components of the smoke are known to cause damage to the cells inside the lungs, and cellular damage has been shown to lead to cancer. In contrast, no one has yet offered a plausible explanation for how vaccines "cause" autism. In fact, no one can even agree on the specific component that is supposedly responsible.

6. Consideration of alternative explanations: This is self explanatory. In the case of vaccination and autism, there is a very simple alternative explanation. Autism cannot be diagnosed before the age of 2 and most vaccines are given before the age of 2.

7. Experiment: If you alter Event A do you still get Disease B. In the case of smoking, if you quite smoking, the risk of lung cancer goes down. In the case of vaccines and autism, if you forgo vaccination, the risk of autism remains unchanged.

8. Specificity: Is Event A the only thing that leads to Disease B? This is the least important of the criterion. If it is present, it is a very powerful indicator of causation. For example, among young women who developed a rare form of vaginal cancer, all of them were found to have been exposed to DES (diethylstilbestrol) while in utero. That is a highly specific effect.

However, even if the relationship is not highly specific, that does not preclude causation. Though there are non-smokers who get lung cancer, it does not change the fact that the other criteria show that smoking causes lung cancer.

9. Coherence: The explanation of action must comport with the known laws of science. If the purported mechanism of causation violates the law of gravity, for example, then it isn't acceptable. That's why religious arguments against evolution are wrong. They are "incoherent" since they invoke forces outside science.

What do Hill's criteria look like in action?



In the case of cigarette smoking and lung cancer, 8 out of 9 Hill's Criteria are satisfied. In contrast, in the case of vaccines and autism, only 3, possibly 4 criteria are satisfied. This is why we can say that the scientific evidence shows that vaccines do not cause autism.

While it is true that vaccinations usually precede the diagnosis of autism, that is an essential criterion, but not enough. The fact that there is no dose-response relationship, that the few studies that showed a purported relationship cannot be replicated and that studies in which people who were not vaccinated did not have a lower incidence of autism, demonstrates that vaccines do not cause autism.

Are vaccine rejectionists killers?

The folks at Age of Autism are shocked, shocked that Bill Gates blames vaccine rejectionists for the preventable deaths of innocent children.

In an interview with CNN's Sajay Gupta, Gates expressed tremendous frustration with vaccine rejectionists.

"Well, Dr. Wakefield has been shown to have used absolutely fraudulent data. He had a financial interest in some lawsuits, he created a fake paper, the journal allowed it to run. All the other studies were done, showed no connection whatsoever again and again and again. So it's an absolute lie that has killed thousands of kids. Because the mothers who heard that lie, many of them didn't have their kids take either pertussis or measles vaccine, and their children are dead today. And so the people who go and engage in those anti-vaccine efforts -- you know, they, they kill children. It's a very sad thing, because these vaccines are important.”

According to AoA:

We think this type of extreme language is both insulting, and is a calculated way to cut-off questioning and debate on issues that Gates doesn’t want the public looking at very closely.

Here's a news flash: it was meant to be insulting. Vaccine rejectionists are ignorant, lack basic education in science, statistics and immunology and take medical advice from ex-Playboy Playmates. That part about cutting off debate? Here's another newsflash: there is no debate; there's only pathetically ill informed people vilifying the greatest public health advance of all time. And what possible motivation does Bill Gates have for stifling the free flow of information about vaccination? AoA can't thing of any reason at all.

Let's parse what Gates said:

Wakefield used fraudulent data. True.
He had a financial interest in the law suits. True.
Multiple additional studies demonstrated that there is no connection between vaccination and autism. True.
The claim that vaccines cause autism is a lie. True.
Children have died preventable deaths because they were not vaccinated. That's true, too.

If Gates can be accused of anything, it is getting his terms wrong. Vaccine rejectionists aren't killers; strictly speaking they are manslaughterers. That's because there have no intent to kill children; the vaccine rejectionists don't understand immunology, virology or statistics, so they can't be expected to comprehend the immense, detailed and highly technical scientific evidence supporting the safety and efficacy of vaccination.

Instead of bleating that they are being insulted, vaccine rejectionists should consider why they are being insulted. Bill Gates is spending billions of dollars of his personal fortune to vaccinate as many children for as many illnesses as possible. It's difficult to argue that he's less "educated" than people who get their education from websites like AoA. And he certainly has no financial interest in increasing the sales of vaccines.

So why is he speaking out in this way? Because the time is long overdue for the American public to get a rude awakening. Vaccines save lives. Vaccine rejectionism leads to preventable deaths of innocent children. It may not be killing, but you could make a good case that it's manslaughter.

Penny Simkin: ignore labor pain

I ought to sent a thank you letter to the folks at the Lamaze blog Science and Sensibility. No sooner do I make a claim, then they rush to confirm it.

Barely a month ago, I wrote about the natural childbirth project of ignoring women's need for pain relief in labor.

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.

Less than 2 weeks later, Science and Sensibility showed us just how it's done. They published a guest piece by a family practice physician, and darling of the NCB movement, that purported to discuss the risks and benefits of epidurals without mentioning the most important benefit, the ability to relieve the agonizing pain of childbirth.

Now Penny Simkin explains why it's okay to render women's need for pain relief in labor utterly invisible. Ms. Simkin is the doyenne of the doula movement. Indeed, Ms. Simkin is so famous within the NCB movement that there is a Simkin Center at the Seattle School of Midwifery:

The Simkin Center for Allied Birth Vocations at Bastyr University trains social, practical and clinical care providers for pregnant and new families, including: Birth doulas [and] Postpartum doulas ...

In other words, Ms. Simkin is a stalwart in the industry that has the most to lose from recognizing and abolishing labor pain. That's why it's more than a bit ironic that Ms. Simkin decries the epidural "industry."

An enormous industry exists in North America to manufacture and safely deliver pain relieving medications for labor.

Who faces the real economic threat, Ms. Simkin? There's no greater economic threat to doulas than an epidural; when women have effective pain relief, there's no reason to pay someone whose entire purpose is to keep them from getting effective pain relief.

How clever, then, of Ms. Simkin to explain precisely why it's okay to ignore women's pain: pain should be ignored because "suffering" is more important. In a completely unexpected, who would have imagined, can't make this stuff up coincidence, pain cannot be treated by doulas but suffering can.

Whom does Simkin reference for her astounding insight that women's labor pain is irrelevant. Another natural childbirth advocate, of course:

Lowe also points out that "suffering," can be distinguished from pain, in that by definition, it describes negative emotional reactions, and includes any of these: perceived threat to body and/or psyche; helplessness & loss of control; distress; inability to cope with the distressing situation; fear of death of mother or baby. If we think about it, one can have pain without suffering and suffering without pain.

Those silly medical people! They think that agonizing pain equals suffering. No, no, no. Those silly women in labor, they think that agonizing pain equals suffering. No, no, no. They're too stupid to know what's good for them. They "grasp" at the opportunity for relief of pain even when Penny Simkin knows that they are not suffering.

When staff believe that labor pain equals suffering, they convey that belief to the woman and her partner, and, instead of offering support and guidance for comfort, they offer pain medication. If that’s the only option, women will grasp for it.

The unmitigated gall of the woman! Who, exactly, is Penny Simkin to tell women they are not "suffering" when they are experiencing pain?

And what is suffering? I know you are going to be super duper shocked to find out that while agonizing pain is meaningless, "birth trauma" is the legitimate cause of suffering.

... the definition of trauma comes very close to the definition of suffering. "Trauma" involves experiencing or witnessing an event in which there is actual or perceived death or serious injury, or threat to the physical integrity of self or others, and/or the person’s response included fear, helplessness, or horror. (3) Neither suffering nor trauma necessarily includes actual physical damage, although it may do so.

One's perception of the event is what defines it as traumatic or not. As it pertains to childbirth, "Birth trauma is in the eye of the beholder"(4), and whether others would agree is irrelevant to the diagnosis.

Evidently women are smart enough to define trauma for themselves; it's in the eye of the beholder. Women are evidently too stupid to define suffering for themselves; that's in the eye of Penny Simkin.

But not all women are too stupid to define suffering for themselves. Only women in labor are too stupid to define suffering for themselves and need Penny Simkin to define it for them. A woman who has pain in ANY other situation, in ANY other area of the body, for ANY other reason can figure it out for herself. It's just women in labor who can't be trusted.

This "reasoning" is simply obnoxious, not to mention patently self-serving, and entirely unscientific. Pain is a neurological phenomenon. Pain is what the WOMAN says it is. Pain can and usually does cause suffering. Pain SHOULD be treated if a woman wants it treated; no other reason is necessary, and no possible excuse mitigates the ethical obligation to treat it.

We do owe Penny Simkin thanks for one thing, though. By offering this inane, convoluted and incredibly self serving justification for ignoring labor pain, she has made it crystal clear that to NCB advocates women's pain in labor is meaningless.

How midwives market homebirth

On Friday I wrote about midwives and the commodofication of birth. In order to create a perceived "need" for their services, midwives must convince women that a safe birth in the hospital attended by highly knowledgeable, highly trained providers is not enough. They attempt to create that need by selling the "birth experience."

In Great Expectations: Emotion as Central to the Experiential Consumption of Birth by Markella Rutherford and Selina Gallo-Cruz deconstruct midwives' websites to examine the 5 components of the midwifery marketing plan.

1. Safety

Here homebirth midwives* find themselves with a problem. Homebirth increases the risk of neonatal death. American homebirth midwives are grossly undereducated and grossly undertrained. Indeed, they have less education and training than midwives in ANY other first world country. Faced with this dismal reality, midwives do something simple and straightforward: they lie.

... [M]idwives deal with potential clients' anxieties and fears about the safety of birth in two ways: they attempt to convince them both that midwifery care is competent and safe and that hospital care is risky and suspect, at least for most healthy women.

Those overarching lies rest on a variety of other, smaller lies of omission and commission:

... [Midwives] point out that many complications in birth often arise because of hospital practices and procedures. Midwives describe the increased likelihood that hospital births will result in stalled labor and unnecessary cesarean sections, expose mothers and babies to infections, and cause respiratory distress in newborns. In addressing safety concerns midwives attempt to shift anxieties about the risks of birth in general to a fear of the often-cascading interventions of hospital birth.

2. Fear of pain

Homebirth midwives have yet another problem; they cannot dispense the only truly effective relief for labor pain, the epidural. Therefore, midwives work to discount the reality of labor pain. That involves a variety of marketing strategies: minimizing the actual pain, grossly exaggerating the effectiveness of non-pharmacologic methods, and glorifying the pain itself.

... [Midwives] recommend using visualization, hypnotherapy, affirmation, and psychological empowerment to approach labor as a positive experience that does not have to be painful. A sense of empowerment to overcome pain is a notable feature of the narrative of natural birth ... [T]hese websites reinforce the narrative themes of empowerment and the natural ability of women to give birth by including graphic pictures of women in labor. By depicting women's laboring bodies and their facial expressions of strength, determination, and joy, these websites reinforce the idea that giving birth [should be] embraced and celebrated as an empowering experience.

3. Choice

Choice is portrayed as the sine qua non of the "birth experience." Certain choices are portrayed as superior (particularly those that are transgressive) and defying medical advice is framed as being "educated." This is integral to the overall project of creating a specific self image.

A major selling point of non-medical birth services is women's desire to experience the personal autonomy fostered by a view of the woman as active agent and rational consumer.... One of the ways that midwives encourage this sense of control is through their promotion of knowledge and education ... In general, limited choice is an affront in consumer culture; midwives construe hospital birth as limiting the birthing woman's choices and diminishing her autonomy. Instead midwives promise to offer a wide range of choice and to hand over control to the consumer...

Moreover:

As marginal providers of a commodified experience, midwives specializing in alternative birth cannot afford to overlook their clients' satisfaction, which is often based more upon a romantic idealization of the birth experience than upon a rational calculus... [M]idwives ... claim that women who birth outside of the hospitalized, medical model are more satisfied with the experience of giving birth..."

4. Intimacy

Emotional intimacy with the midwife is deemed critical to the "birth experience."

... Intimacy between midwife and client begins to develop before birth through time spent together in prenatal visits that may last up to an hour or more. In these visits, midwives not only attend to the physical health of the pregnant woman, they also spend time talking with her about her anxieties, concerns, desires, and expectations...

But emotional intimacy is also critical to homebirth midwifery in a way that midwives never discuss. It is critical to the midwives themselves to forge an intimate emotional connection. That is why homebirth midwives feel free to turn down clients who do not share the midwives' view on approved choices. The midwife needs to feel validatation and emotional fulfillment produced by rendering the client as an intimate friend.

5. Symbolic Meaning and the Idealization of the Birth Experience

This is really what homebirth midwives are selling: the creation of "meaning."

The alternative birth is an idealized experiential commodity... [I]t is the idealization of birth that transforms the experience itself into a desired consumer experience. Midwives encourage the idealization of the alternative birth experience through the emphasis they place on emotions, symbolic meaning, imagination, and planning.

Homebirth is not about birth, and it is certainly not about the baby. It's all about creating a desired consumer experience, an experience (midwives encourage clients to believe) that defines them as women and as mothers.

The idealization of birth emphasizes its symbolic meaning and enchants the experience through a romantic ethic... Midwives refer to birth as a spiritual, sacred, and miraculous event. Giving birth is described as "an opportunity for spiritual and emotional transformation", "a peak human experience", "a sacred rite of passage", and "a magical, transformative, and truly empowering experience"...

In their concluding remarks Rutherford and Gallo-Cruz once again stress the similarity to weddings:

In conceptualizing natural birthing as an emotional and idealized consumption experience, we see that birth has come to mirror aspects of the wedding, another heavily commodified rite of passage... [W]e see that the woman planning for alternative birth also exercises calm control, rational decision making, and has the illusion of autonomy over her choices at the same time that she is a romantic fantasizer hoping for wish fulfillment... the idealization of the birth experience offers a legitimate opportunity to orchestrate another emotional consumer experience in which the bride-now-turned-mother produces, directs, and
plays the starring role.

In marketing her services, the midwife portrays herself as crucial to creating the "experience":

With a midwife's guidance and through her own idealization of the birth experience, the birthing mother is both a producer and a consumer of the birth experience. Not only is her physical labor a productive activity, but she also produces her emotional response to the experience. Furthermore, as with other extraordinary experiences, consumption of a birth experience is an active form of symbolic identity construction through which women give coherence to their own sense of self. The mother who selects an alternative birth outside of the medical model consumes her birth experience for the purpose of producing her own self-image and her family’s lifestyle.

Homebirth midwives are no different than wedding purveyors, or even certain drug manufacturers. They are hawking a product that no one really needs.

You can have a wedding without all the expensive trappings, save thousands of dollars, and be just as married. Drug manufacturers often find themselves with products that aren't needed, so they set out to create a new "condition" that requires treatment with the otherwise useless drug. Homebirth midwives are not as knowledgeable as other medical providers, are terribly unskilled, and add no real value to childbirth. You can have a baby in a hospital, pay only a copay and get a healthy baby, which is presumably the goal of pregnancy.

Since homebirth midwives add no value to birth, they have created the "birth experience" with themselves as guides. Women are encouraged to believe that the "meaning" of childbirth does not rest in the baby, but rather in the mother's emotional connection to her caregiver, the mother's ability to exercise autonomy and, above all, the mother's creation of a specific self-image. She may no longer be the princess at her own wedding, but now she is the queen at her own child's birth.


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

Midwives and the commodification of birth

... [W]hen selecting alternative providers of birthing services, women are not simply purchasing health care, they are choosing and purchasing guides for and co-creating an event that is idealized and emotionally charged.

The above quote comes from Great Expectations: Emotion as Central to the Experiential Consumption of Birth by Markella Rutherford and Selina Gallo-Cruz. They offer a unique perspective on homebirth midwifery from outside both the midwifery and medical communities. Rutherford and Gallo-Cruz draw attention to an aspect of homebirth midwifery that we are all aware of but rarely mention. Homebirth is a product and homebirth midwives, like any product manufacturers, are heavily engaged in marketing that product to consumers.

In fact, the foundational philosophy of midwifery, the "midwifery model of care," serves as one of its key marketing emphases. A crucial component of midwives' care work is what Hochschild calls emotional labor: "the emotional style of offering the service is part of the service itself." ... [In] theorizing ... emotional labor as a commodity to be sold, we ask how we might conceptualize the emotional aspects of the experiences offered in this transaction as a commodity to be consumed.

What are homebirth midwives offering? Their product is the idealized birth experience.

Midwifery is not simply a service to be purchased, but is also an embodiment of cultural meaning; through its consumption women make the ordinary experience of childbirth a symbolically charged and extraordinary experience of "meaning transfer." ... [Campbell] argues that "the essential activity of consumption is…not the actual selection, purchase or use of the products, but the imaginative pleasure seeking to which the product image lends itself ...

In marketing homebirth, midwives unconsciously copy the wedding industry.

... [T]he wedding industry ... commodifies the wedding experience by constructing the bride as the "heroic creator of her big day." [Similarly], births are increasingly embellished with the advertised opportunities for luxury and amenities as well as the gendered conceptualization of femininity associated with the transition. [This] work raises important questions ... about the role of anticipation and imagination in the birth experience. In particular ... the creator of such a rite of passage must negotiate between romantic or hedonic fantasies and rationally planning the event...

Like any manufacturer, midwives strive to create a "need" for their product within the mind of the consumer:

... [T]he midwife's role is critical ... because she is fluent in the alternative symbolic orientations to and understandings of natural birth ... [She] also provides her association and emotional support either by sharing beliefs about the experience or by affirming the woman's right to assign her own unique beliefs to birthing. This seemingly simple service of association and presence is a critical social need in the context of extraordinary experiences and rites of passage that depend a shared cultural consensus for their significance.

Rutherford and Gallo-Cruz point out the striking similarities with the marketing tactics of the wedding industry.

In conceptualizing natural birthing as an emotional and idealized consumption experience, we see that birth has come to mirror aspects of the wedding, another heavily commodified rite of passage. Drawing on [the] insight that the bridal role involves a rational-romantic duality, we see that the woman planning for alternative birth also exercises calm control, rational decision making, and has the illusion of autonomy over her choices at the same time that she is a romantic fantasizer hoping for wish fulfillment.

Indeed:

... [T]he idealization of the birth experience offers a legitimate opportunity to orchestrate another emotional consumer experience in which the bride-now-turned-mother produces, directs, and plays the starring role. Thus commodified birth experiences play an important role in consumer society by continuing the trajectory of pivotal consumption events across the family life course.

Homebirth is not about the baby, and it isn't really about birth.

... [C]onsumption of a birth experience is an active form of symbolic identity construction through which women give coherence to their own sense of self. The mother who selects an alternative birth outside of the medical model consumes her birth experience for the purpose of producing her own self-image ...

That's what homebirth midwives are selling.

WA: 20-fold increase in hypoxic deaths at homebirth

Another day, another database showing an appalling homebirth death rate.

The latest evidence comes from The 13th Report of the Perinatal and Infant Mortality Committee of Western Australia for Deaths in the Triennium 2005–07 full report (here). This report includes the most comprehensive analysis of homebirths yet in Western Australia. In the wake of the 12th report, which showed that homebirth in WA had triple the perinatal death rate of hospital birth, the Perinatal and Infant Mortality Committee was charged with more than identifying homebirth deaths. The Committee was charged investigating the cause of preventibility of homebirth deaths.

The results are truly appalling AND entirely consistent with the terrible homebirth death rate in the US. The major finding is that homebirth QUADRUPLED the risk of perinatal death compared to hospital birth. Indeed, homebirth dramatically increased the risk of death at every level, from stillbirth to infant death.



Keep in mind these statistics UNDERCOUNT the risk of death. That's because there may have been deaths that occurred in the hospital that actually belong in the homebirth group. Moreover, the comparison is between homebirth and all hospital births (including high risk and premature births). To understand the full magnitude of the problem, homebirth deaths should be compared to low risk hospital birth, not all risk hospital birth.

In the wake of the 12th annual report that showed homebirth tripled the perinatal death rate, the Committee was charged with determining the causes of perinatal deaths at homebirth, and whether the deaths were preventable. Once again, the results are nothing short of appalling:

The greatest discrepancy in mortality risks for planned home births compared to planned hospital births was in deaths due to peripartum hypoxia. There were 28 perinatal deaths attributed to hypoxic peripartum insult in the 2005-07 triennium (24 in planned hospital births and 4 in planned homebirths). The risk ratio for stillbirth attributed to peripartum asphyxia was 21.5 times higher for the planned home birth group compared to the planned hospital group. The risk ratio for infant death due to peripartum asphyxia was 18.2 times higher for the planned home births compared with planned hospital births...

The Committee also assessed whether the homebirth deaths were preventable. Of the 7 homebirth deaths:

Four of these cases were coded as ‘hypoxic peripartum deaths’ ... They occurred in term or post term pregnancies. These four cases had preventable medical factors (preventability scores >=2) and three were considered potentially avoidable deaths (preventability scores >=4). The proportion of deaths in planned home births with preventability scores >=2 was 57.1%, which was higher than the proportion of 10.3% of all investigated deaths with preventability scores >=2. The proportion of potentially avoidable deaths with preventability scores >=4 was 42.9% in planned home births and 2.4% of all investigated deaths.

To summarize, the WA data show that the risk of perinatal death at homebirth is quadruple that of hospital birth; the risk of perinatal death at homebirth due to hypoxia is approximately 20-fold higher than hospital birth; and, 51.7% of the homebirth deaths were potentially preventable compared to 10.3% of the hospital deaths.

The Committee made the following recommendations:

a) Home births are associated with preventable stillbirths and infant deaths. Midwives offering home birth services should obtain informed consent from women to acknowledge that they have been informed of the increased risks of perinatal death associated with home birth.

b) A formal independent audit of implementation of the Recommendations of the Review into Homebirths should be performed. This audit of practice should encompass all home births, whether the midwife is under the auspices of the Community Midwifery Program (CMP) or is independent.

c) There are insufficient data about morbidity associated with homebirth in WA. A prospective cohort study to assess mortality and morbidity outcomes for women with planned home births in WA should be arranged as a priority. This cohort study should be performed by an independent group of researchers.

This is yet another stream to add to the growing flood of information on the dramatically increased risk of perinatal death at homebirth. In addition, this data confirms that the primary cause of homebirth deaths is hypoxia (lack of oxygen) and that most of these deaths are preventable.

The strength of this data lies in the fact that the deaths themselves were analyzed, both for cause and for preventablity. Does similar data exist for American homebirth? Indeed it does. The Midwives Alliance of North America (MANA) the group that represents American homebirth midwives, has assembled a data collection far larger than that of Western Australia. The MANA database contains 18,000 homebirths and has been analyzed for cause of death. What does it show?

We don't know because MANA is hiding that data. MANA performed an analysis similar to that of Perinatal and Infant Mortality Committee of Western Australia and almost certainly obtained a similar (or possibly far worse) result. The state of Western Australia made their results public in an effort to reduce the death rate from homebirth. MANA refuses to make their results because in an effort to hide the death rate from homebirth. The WA Committee is concerned with the health and well being of newborns; MANA is concerned only with its own reputation.

Infant dies after craniosacral "therapy"

Craniosacral "therapy" (chiropractic) is another one of those pseudoscientific disciplines marketed to the gullible that claims cures for just about every ailment under the sun. How does it supposedly work? According to Biodynamic Craniosacral Therapy Association of North America:

... [A]ll healthy, living tissues subtly "breathe" with the motion of life - a phenomenon that produces rhythmic impulses which can be palpated by sensitive hands. The presence of these subtle rhythms in the body was discovered by osteopath Dr William Sutherland over 100 years ago, after he had a remarkable insight ... that cranial sutures were, in fact, designed to express small degrees of motion. He ... eventually concluded it is essentially produced by the body's inherent life force, which he referred to as the "Breath of Life." Furthermore, ... the motion of cranial bones he first discovered is closely connected to subtle movements that involve a network of interrelated tissues and fluids at the core of the body; including cerebrospinal fluid (the 'sap in the tree'), the central nervous system, the membranes that surround the central nervous system and the sacrum.

Gobbledygook to English translation: disease can be treated by manipulating bones. That's obviously ludicrous, but what's the harm? Plenty as it turns out.

The Dutch Medical Journal reported on a case of infant death at craniosacral therapy.

Patient A was a three-month-old, healthy girl. Because their child exhibited mild motor unrest, the parents contacted a so-called "craniosacral" therapist who, after a short introductory interview, started administering the craniosacral therapy. He placed the child on her back on a changing mat, after which he palpated the neck and the skull. The patient cried vehemently at this. Then she was turned to her right side and a deep bending of the vertebral column was applied at which the chin touched the chest...



After the vertebral column was bent deeply in this manner during several minutes, the child lost faeces and several loud intakes of breath were clearly audible. The therapist interpreted this as a deep sleep, which he said was normal during the treatment. After about 10 minutes the girl was placed on her back and blue discolouration of the lips was apparent. The child was limp now and did not react to touching. The father started mouth-to-mouth resuscitation. Alerted ambulance personnel on arrival saw a deceased infant with asystolia...

The infant was resuscitated but removed from life support 12 hours later after testing revealed catastrophic brain injury.

A brief review of the literature reveals that this is not the first such tragedy. According to Adverse Events Associated With Pediatric Spinal Manipulation: A Systematic Review published in the journal Pediatrics, there have been at least two other infant catastrophic injures, a 3 month old boy who died as a result of a subarachnoid brain hemorrhage, and a 4 month old boy render quadriplegic after treatment for what turned out to be a spinal tumor.

It seems obvious to me, looking at the picture above, that craniosacral "therapy" cannot possibly be therapeutic and has tremendous potential to create catastrophic injuries. Parents should be very wary of practitioners offering to bend an infant's spine as a form of therapy. Not only is craniosacral "therapy" absurd; it can kill.

Ten illogical arguments

In addition to the problem of possessing inaccurate information, homebirth advocates have another, more serious problem, the tendency to construct illogical arguments. It is apparently such a pervasive problem that a brief review of these arguments is in order.

Let's look at the various types of illogical argument constructed against my core claim "the death rate at homebirth is higher than the death rate at low risk hospital birth." To make this exercise easier to understand, lets substitute a claim of the same form that is obviously true, so we will not get sidestepped by issues of truth or falsity and can focus only on whether an argument is logical or illogical. This is important because illogical arguments are automatically invalid arguments. We'll use the claim "there are more black cars in the US than lime green cars."

I say: There are more black cars in the US than lime green cars.

Don't say:

I saw a lime green car. - Can you understand how the fact that you personally saw a lime green car tells us nothing about the relative number of black cars and lime green cars in the US? That you saw a lime green car is perfectly consistent with black cars outstripping lime green cars 100 to 1, or even 1,00,000 to 1? Similarly, the fact that babies die in the hospital tells us nothing about whether the death rate is greater at homebirth.


I know ten people and not one of them has a black car. - This is an illogical claim based on an unstated assumption. The assumption is that the small slice you observe accurately represents the whole. However, tiny samples are often unrepresentative. Knowing 10 people who own black cars is perfectly consistent with the number of black cars exceeding lime green cars, BUT it is also perfectly consistent with lime green cars exceeding black cars, so it can't be used to support a specific claim. Similarly, the fact that you know ten women who had homebirths and not a single baby died tells us nothing about whether the homebirth neonatal death rate exceeds the low risk hospital death rate.


Lime green cars are prettier than black cars. - I hope it is obvious why value judgments about lime green cars tell us nothing about whether there are more or less black cars than lime green cars. Therefore, it should be obvious that claiming that women are more satisfied with homebirth tell us nothing about homebirth death rates.

You say that because you sell black cars. - Whether or not I sell black cars is immaterial; it has absolutely no effect on the number of black cars or lime green cars. This is essentially an accusation that I am lying and offering as "proof" the fact that I have a reason to lie, but a reason to lie is not proof of lying. So don't tell me that the fact that I am an obstetrician means that I am lying about neonatal death rates.

The people who make black cars have oppressed the people who make lime green cars. - Maybe yes, maybe no, but in either case, it does not affect how many black and lime green cars are on the road. Similarly, whether doctors have oppressed midwives has no bearing on whether the neonatal death rate at midwife attended homebirths is higher than hospital births.


There is a conspiracy against lime green cars. - We are supposed to believe that the number of lime green cars would equal black cars except for a public relations campaign designed to make lime green cars less desirable. It is theoretically possible that there is a conspiracy against lime green cars, but it is far more likely that other factors account for the difference in numbers. And in any case, it doesn't tell us anything about the relative numbers of black and lime green cars. So when confronted with the fact that homebirth death rates exceed hospital rates, it is illogical to counter with a claim that a conspiracy against homebirth exists.


There would be more lime green cars if the makers of black cars helped out. - That might be true, or it might not. In either case, it tells us nothing about the truth of the claim that black cars exceed lime green cars. And while it might be true that the death rate from midwife attended homebirth would be lower if doctors were more supportive of midwives, it doesn't change the reality of the current situation.

The Association of Lime Green Car Makers say that there are more green cars than black cars. - Cherry picking certain claims and ignoring all others is likely to lead people to the wrong conclusion. A lobbying group that disagrees with almost everyone else is not a reliable source of information. Similarly, professional NCB advocates and organizations are not reliable sources of information when they disagree with the bulk of the scientific evidence.

The color of cars is influenced by culture. - That is a non sequitur. It does not oppose the claim; it simply attempts to pin responsibility somewhere else and it is irrelevant. That's why the claim that hospital birth is culturally favored is irrelevant to any argument about homebirth death rates.

There are more important things about cars than the color. - That is what is known as "reframing the debate". It is a tacit acknowledgment that there are more black cars than lime green cars and a barely concealed effort to divert everyone's attention. That's why when someone announces that there are more important things than whether babies live or die, I know they have accepted the fact that homebirth leads to preventable neonatal deaths.