Prominent midwife retires after homebirth death

Back in April Brynne Potter, CPM, in her role as a board member of NARM (North American Registry of Midwives) appeared on the Kojo Nnmadi radio show to defend Karen Carr, the midwife who pled guilty to felony charges in connection with the homebirth death of a breech baby. What Potter neglected to mention is that she was on leave from her practice for recently presiding over --- you guessed it --- the homebirth death of a breech baby.

In the wake of that death, Potter is giving up the practice of midwifery. A supportive article in a Charlottesville newspaper bemoaned the fact that her practice Mountain View Midwives was breaking up, while entirely neglecting to mention why, implying that Potter wanted to spend more time on her NARM duties.

Oh the one hand, I applaud Potter for her mature approach to the homebirth tragedy. It is devastating for any practitioner to lose a patient, even more so, if the practitioner questions her own culpability in that death. The patient was a primip who was wrongly thought to be vertex. She purportedly "declined" vaginal exams in labor. The breech was not discovered until it began to emerge during delivery in the bathtub. The head was trapped. By the time Potter cut an episiotomy and delivered the head, the baby was dead.

A period of reflection is quite appropriate in the wake of such a tragedy. Potter ultimately decided that she could no longer attend women at homebirths. That, too, is a mature decision, considering that she, like all certified professional midwives, is grossly unqualified to provide care to pregnant women. What is far less admirable, is her determination to continue defending the indefensible by hiding any information that would alert women to the dangers of homebirth.

In addition to hiding her role in a preventable homebirth death, Potter continues to defend MANA for hiding the death rates of the 23,000 planned homebirths in ther databse. I called into the Kojo show specifically to ask Potter why MANA (the Midwives Alliance of North America) the organization that represents homebirth midwives, and the sister organization of NARM, is hiding their death rates..

Potter tried to dodge and weave:

... So I can't really speak to a specific about some assumption of hiding. What I would say is that MANA's -- I know MANA stands ready to meet the needs of any reporting mandate. It is a private data set in which isolated cases of death would only be isolated cases similar to this case that we're talking about today. We wouldn't be able to make any extrapolation of a trend to homebirth. The only place we can do that is from the CPM2000, which was a cohort study that mandated all CPMs to report in prospectively all of their data for one year. And that study was published in the British Medical Journal, and it is absolutely in line with outcomes of all other published studies around homebirth, which is...

Potter almost surely knows the MANA dataset is not private, that the cases of death are not isolated and that it is simply a lie to say that we could not use the data to make a determination of the safety of homebirth with a CPM. MANA knows that homebirth substantially increases the risk of neonatal death and they are doing everything in their power to make sure American women do not find out. Potter, by acting as a spokesperson for homebirth midwifery is complicit in hiding this important information.

Potter's comments about the Johnson and Daviss CPM2000 (Johnson and Davis, BMJ 2005) study are also untrue, but she may not have known that at the time. Since then, I have gone to her blog and explained that the "outcomes of all other published studies" as well as state and national data show that homebirth with an American homebirth midwife dramatically increases the risk of neonatal death. Did Potter address my extensive explanation. No, of course not, she --- you guess it --- hid it by deleting it. Not only was she unable to defend the studies that she publicly cites as supporting homebirth safety, she found the information so compelling that she removed it so no other women could learn the truth.

Ms. Potter, if you are reading this, I have a question for you:

Presiding over as completely preventable homebirth death, you appear to be shaken to your core. You reasonably concluded that you could not continue to provide a model of care that lets babies die unnecessary deaths. You KNOW that "trusting birth" kills babies who didn't have to die. You know that MANA is hiding the death rates of CPMs because they are afraid to tell American women the truth. You know that the published data and state and local statistics confirm that homebirth kills babies.

Don't you feel any obligation to tell American women the truth?

What is Rhogam?

Raise your hand if you know a baby who died of erythroblastosis fetalis.

Not too long ago, there would have been a lot of raised hands. Before 1968, approximately 10,000 babies died each year of erythroblastosis fetalis, also known as hemolytic disease of the newborn (HDN). Then Rhogam was introduced.

It is fashionable in homebirth midwifery circles to determine what the scientific evidence shows and then reflexively recommend the opposite. Therefore, many homebirth midwives and advocates are now suggesting that women forgo Rhogam without having any understanding of what Rhogam is, what it does, and the nature, incidence and mortality rate of the disease that it prevents.

What is hemolytic disease of the newborn (HDN) It is a relatively common condition in which a mother produces antibodies that cross the placenta and destroy the baby's red blood cells. The baby becomes profoundly anemic, develops severe jaundice and heart failure. The mortality rate used to be approximately 50%.

Why would a mother make antibodies to her baby's blood cells? It happens when the mother and baby's blood type differ in an important way. Usually the difference is that the baby is Rh+ (has the RhoD antigen on its red cells) and the mother is Rh-. The baby of an Rh- mother will be Rh+ only if its father is also Rh+, but not all babies of Rh+ fathers will be Rh+.

How does the mother make antibodies against the baby's blood if the placenta prevents the mother's blood from mixing with the baby's blood? The answer is there are often small leaks of fetal blood into the maternal circulation, particularly at the time of birth. They are not large enough to have any impact on the baby, but only a small amount of Rh+ fetal red cells are needed to produce an immune response in the mother.

When such a response develops, the results are often devastating to the baby, not in the current pregnancy (especially if the sensitization occurs at delivery) but in subsequent pregnancies. What happens in future pregnancies?

... [M]aternal anti-D antibodies cross the placenta into fetal circulation and attach to Rh antigen on fetal RBCs ... These antibody-coated RBCs are [destroyed] by lysosomal enzymes released by macrophages and natural killer lymphocytes ...

... Tissue hypoxia develops as fetal anemia becomes severe... Hydrops fetalis ... starts as fetal ascites and evolves into pleural effusions and generalized edema...

... Destruction of RBCs releases heme that is converted to unconjugated bilirubin. Hyperbilirubinemia becomes apparent only in the delivered newborn because the placenta effectively metabolizes bilirubin...

This is an unmitigated disaster for the baby:

Before any interventions were available, the perinatal mortality rate was 50%. Wallerstein introduced exchange transfusion in 1945 and reduced the perinatal mortality rate to 25%. Later, Chown suggested the early delivery of those severely affected nonhydropic fetuses by 34 weeks' gestation followed by prompt exchange transfusion helped improve survival. The introduction of intraperitoneal transfusion by William Liley in 1963 and intravascular transfusion (IVT) by Rodeck in 1981 reduced the perinatal morbidity and the mortality rate was further reduced to the current rate of 16%.

Treatment for HDN has clearly improved dramatically, but a death rate of 16% is still extraordinarily high. Imagine if you could prevent your baby from ever getting HDN in the first place, and all it took was two small injections. Since 1968, when Rhogam was introduced, there has been no need to imagine.

Rhogam is human antibody to the Rh antigen. If any fetal blood cells escape into the maternal circulation, Rhogam binds to the Rh antigen and makes it "invisible" to the mother's immune system. One dose at 28 weeks, and another at the time of delivery is enough to prevent the mother becoming sensitized. Additional injections are given whenever there is any other chance of fetal cells leaking into the maternal circulation, such as at the time of miscarriage, ectopic pregnancy, or episodes of significant vaginal bleeding.

Rhogam has dramatically reduced the incidence of HDN. The incidence is still not zero, however, because there are other less common antigens that can also cause sensitization.

What are the side effects of Rhogam? Sometimes there is a localized skin reaction and occasionally, in people who are sensitive to blood products, there can be an allergic reaction to Rhogam itself.

So why are homebirth midwives suggesting that women refuse Rhogam? Because, as usual, they have no idea what they are talking about.

They are motivated by their insistence that nature is perfect and technology is harmful. First, they insist, bizarrely, that the no fetal blood cells will ever find their way into the maternal circulation unless "interventions" occur during birth. Ignorant of history, they are apparently unaware that HDN was first reported by a French midwife in 1609.

Ignorant of the scientific facts, as always, they are unaware of the Kleihauer-Betke test, a that allows us to quantify exactly how many fetal cells are in the maternal circulation at any given time. That's how we KNOW that small quantities of fetal cells often slip into the maternal circulation.

Then there is their pathological fear of technology. They are absolutely sure that Rhogam might cause some damage of some kind to babies who never needed it the first place since they had a perfect placenta. They offer no scientific facts to support this claim, since there is no evidence that it is true.

What about the benefits? They don't appear to understand that nearly 10,000 babies are saved from death by Rhogam each and every year. They have apparently forgotten, if they ever knew, about hemolytic disease of the newborn.

This is yet another example of how modern obstetrics is often stymied by its own success. A dread infant killer is easily prevented by a simple injection, so easily that homebirth midwives have no idea that the risk of death is very real and still exists.

Another HBAC: another rupture, another hemorrhage, another baby dies

HBAC stands for homebirth after cesarean. You often see it written with a number included, such as HBA2C, which means homebirth after 2 C-sections. In most cases, the attending midwife is violating her professional standards to supervise an attempted homebirth after multiple C-sections, but homebirth midwives think professional standards are for other people, not for them. Maybe that's why they preside over the deaths of so many babies.

The latest completely preventable homebirth death is reported at The Guggie Daly:

Leilani had experienced two previous c-sections, with the last one being over 11 years ago...

But on June 15th, 2011, her precious son, Liam ... was born still at 12:05AM. He weighed 10lbs, 5oz and was 22 inches long. He was chubby and perfect, with reddish brown hair and blue eyes like his daddy.

Leilani's tragedy was rare and an extreme emergency whether at home or in the hospital. She had several hours of very hard labor with little progress when a severe pain across the middle of her abdomen appeared. It was extremely painful and did not go away.

The doctors verified she had experienced uterine rupture. This caused another rare emergency, a placental abruption, and this is what took Liam's life. Her waters had broken and leaked into her abdominal cavity. It is a miracle that she is alive today. The doctors proceeded with a c-section after verifying that little Liam had passed on from this world. They had to clean out her abdominal cavity. Her uterus was shredded and the doctor spent a long time repairing it, but she will no longer be able to have biological children.

The doctors also diagnosed her with severe pre-eclampsia although she did not have that diagnosis during pregnancy, nor did she have symptoms.

Let's see: a homebirth, 2 previous C-sections, a macrosomic baby, and undiagnosed pre-eclampsia. The perfect homebirth candidate!

And look how well it went. The uterus ruptured, the placenta tore away from the uterine wall and he baby died long before she ever got to a hospital. Way to trust birth!

As a bonus, the mother had a massive hemorrhage, extensive abdominal surgery and will be unable to bear any children in the future. Hey, ICAN, are you going to feature this story?

According to Guggie, uterine rupture is a:

... rare and an extreme emergency whether at home or in the hospital.

Not exactly. It's far from rare, and is a known complication of attempting a vaginal birth after C-section. It is an emergency whether it occurs at home or in the hospital, but the difference is that in the hospital, they can save the baby's life.

Even better, they can often prevent uterine rupture altogether by counseling women like Leilani that they are very poor candidates for VBAC and have a higher than average risk of this catastrophe. Had Leilani sought and followed the advice of an obstetrician, she would almost certainly be nursing and cuddling a live baby now, and probably bemoaning her "unnecessarean" as well.

This is what happens when you "trust birth." You end up with a dead baby who didn't have to die.

How many dead babies is it going to take before homebirth advocates realize that they have absolutely no idea what they are doing, and that precious babies are dying preventable deaths as a result of their arrogance and ignorance?

Lamaze censors doctors because they fear the truth

I don't have a lot of respect for the folks at the Lamaze blog Science and Sensibility, but at least under the tenure of Amy Romano, they demonstrated more integrity than any other natural childbirth or homebirth blog:

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

Now that Kimmelin Hull is editor, they've abandoned even that. Not only do they ban me, but now they've started deleting the factual comments of other doctors including anesthesiologist Gilbert Grant, MD. After all, when discussing the risks and benefits of anesthesia, we wouldn't want women to be informed by mere anesthesiologists.

Last week I wrote that even though there is no evidence that epidural affects breastfeeding, Lamaze still insists on pretending that there is.

Evidently I was not the only doctor to point this out. Dr. Nick Fogelson wrote in the comments:

Please try to find the actual data that shows that epidurals have a measurable negative effect on mothers and babies. Such data is talked about a lot, but I’ve never seen it in any obstetrics journal. The reality is that there are no prospective randomized trials of epidural or no epidural, so such 'data' is actually either a fabricated idea or retrospective analyses fraught with bias...

Dr. Grant, the anesthesiologist, weighed in:

Based on the evidence to date, we certainly CANNOT conclude that epidurals have a causal effect of impairing breast-feeding, which is a complex activity subject to many different influences...

In a series of subsequent comments, Dr. Gilbert went on to criticize the misinformation promoted by childbirth educators (including Lamaze educators) in their classes. He provided empirical evidence that Lamaze simply fabricates claims about the "risks" of epidurals that have no basis in the scientific literature.

Well, we can't have that, can we? Imagine, actual scientific evidence showing that Lamaze educators are deliberately teaching falsehoods about epidurals. So Kimmelin Hull deleted that complete with a pious claim that Dr. Gilbert violated the "standards" of the blog. Apparently, facts cannot be tolerated at Science and Sensibility.

Dr. Grant briefly expressed his surprise that Hull would delete factual comments simply because she preferred to keep women ignorant of those facts. That looked even worse.

Can't have that, can we? Not only can't Hull allow actual scientific facts, but she can't be seen to delete actual scientific facts, so she "cleaned up" the comment thread to completely misrepresent what happened.

It looks like Dr. Grant made only 4 comments when he made twice as many. It looks like Dr. Grant never mentioned the falsehoods taught in Lamaze classes when he was quite explicit in detailing just what falsehoods are being propagated. It looks like Hull never made an attempt to address Dr. Gilbert's data when, in fact, she offered a pitiful effort to dismiss those facts. It looks like Hull never acknowledged deleting Grant's comments when, in fact, she acknowledged that the truth apparently "violates" the Science and Sensibility comment policy.

Hey, Kimmelin, way to demonstrate the tactics of Lamaze!

1. Write a piece that acknowledges there is no data for a central Lamaze claim.

2. Insist that it's okay to pretend that the claim is true regardless of the lack of evidence.

3. Invite comments but be sure to censor any that provide uncomfortable scientific facts.

4. Hide evidence that you are deleting comments.

5. Rinse and repeat ad nauseum.

Wow, keeping women ignorant of the facts about childbirth is hard work!

Autonomy is NOT the right to do whatever you want

Homebirth advocates love the word "autonomy."

They believe that the principle of autonomy gives them the "right" to have a homebirth, and the "right" to have the provider of their choice attend their homebirth. Many also believe that they have the "right" to insurance reimbursement for their homebirth.

As with so many things, autonomy is yet another concept that homebirth advocates don't really understand. Most seems to think that the principle of autonomy means that an individual can do whatever she wants. That's not what it means at all. The principle of autonomy means that people are free to choose between a range of options, but it does not mean that those options are unconstrained.

Consider the Wikipedia definition of autonomy:

... [I]t refers to the capacity of a rational individual to make an informed, un-coerced decision. In moral and political philosophy, autonomy is often used as the basis for determining moral responsibility for one's actions. One of the best known philosophical theories of autonomy was developed by Kant. In medicine, respect for the autonomy of patients is an important goal as deontology, though it can conflict with a competing ethical principle, namely beneficence...

In the medical context:

... respect for a patient's autonomy is considered a fundamental ethical principle. This belief is the central premise of the concept of informed consent and shared decision making... In the 1940s, the phrase "informed consent" appeared ... Initially, discussions about informed consent focused almost exclusively on research subjects, but eventually has come to apply to the conventional physician-patient relationship as well. The seven elements of informed consent ... include threshold elements (Competence and Voluntariness), information elements (Disclosure, Recommendation, and Understanding) and consent elements (Decision and Authorization).

Simply put, the concept of autonomy means that patients must be competent and give consent voluntarily. The must receive an explanation and recommendation, and they must demonstrate understanding of what they have been told. Only the patient can make the decision and authorize the treatment.

For example, when considering treatment for breast cancer, the patient must receive an explanation of treatment options and a recommendation. Only the patient can authorize the treatment, or she can refuse the treatment. The patient can choose between surgery, chemotherapy, radiation or a combination of those options. A patient can refuse any or all of these options. But notice what autonomy does NOT encompass.

Autonomy does NOT mean that her doctor is required to offer pseudoscientific or unapproved treatment.
Autonomy does NOT mean the doctor must provide her treatment at home.
Autonomy does NOT mean that the patient can choose her own provider to administer chemotherapy or perform surgery.
Autonomy does NOT mean that the government must offer a license to practice to anyone the patient feels is qualified.
Autonomy does NOT mean that insurance companies must pay for pseudoscientific or unapproved treatment.

In other words, the principle of autonomy means that a woman diagnosed with breast cancer has a right to accept or refuse the recommended options, and a right to a complete explanation of the risks and benefits of those options.

Moreover, while a patient has the right to choose a pseudoscientific or unapproved alternative "treatment," and the right to administer it to herself, it does NOT mean that the medical profession, the government or anyone else must facilitate that right.

When it comes to homebirth, the principle of autonomy means that a woman has the right to refuse obstetrical interventions and the right to refuse to go to the hospital at all. Here's what it does NOT encompass:

Autonomy does NOT mean that her doctor is required to offer pseudoscientific or unapproved treatment.
Autonomy does NOT mean the doctor must provide obstetrical care at home.
Autonomy does NOT mean that the patient can choose her personally designated "midwife" to attend her birth.
Autonomy does NOT mean that the government must offer a license to practice to anyone the patient feels is qualified to be a midwife.
Autonomy does NOT mean that insurance companies must pay for her homebirth.

The bottom line is that the principle of autonomy means that a woman does not have to go to the hospital to have a baby, but it means nothing beyond that.

Women don't understand the risks

Opponents are clear about one thing; women don't understand the risks. They aren't giving informed consent because they aren't fully informed. Sure, they may be counseled about the major risks, the ones that could kill you, but deaths are rare. The other complications are so much more common. If women only knew the myriad risks they faced, they'd never choose it in the first place.

Opponents recommend far more extensive counseling, preferably counseling that takes place long before the decision needs to be made. They helpfully offer books and websites as well as in person counseling about ALL the risks, not just the ones that doctors deign to mention. Doctors can't be relied upon to provide truly informed consent since they have a conflict of interest. They're the ones who make money if the woman elects the procedure.

Inevitably there has been a backlash against the opponents but the opponents claim the high ground with the retort: "Are you saying that there are NO risks?" Everyone knows that there are risks and that comment exposes those in favor as being the lying, evil people that they are. Opponents are providing a valuable service by carefully and extensively counseling women about the risks. Once they know, they will turn down the procedure.

Think I'm talking about natural childbirth advocates and epidurals? Think again.

I'm talking about anti-choice advocates who work tirelessly to prevent women from choosing abortion.

It's not a coincidence that NCB advocates have taken a page from anti-choice activists. They both have the same aim: to conceal their true purpose while pretending that they are concerned about informed consent, trying to place any and all obstacles to the procedure in the path of women who might choose it.

Neither group feels constrained by the truth. Reasoning that the ends justify the means, both groups routinely exaggerate and even fabricate "risks." Seeking, above all else, validation of their personal philosophical beliefs, both groups struggle to convince women who would choose differently that those choices are wrong. Focussed entirely on preventing the procedure, both groups have zero regard for what happens to women once they reject the disapproved choice. They care about women up to the moment that they are forced into the "correct" decision; whatever happens afterward must simply be endured by the women they have duped.

Most of is can easily recognize the tactics of anti-choice activists for what they are, mendacious attempts to force women to make approved decisions. Most of us can easily recognize that the pregnancy "support" centers have no interest in supporting pregnancy and certainly have no interest in supporting the babies that result from those pregnancies. They are exclusively concerned with foisting their philosophical views on everyone else. Their pious bleating about "informed consent" masks their true motivation.

We should recognize the tactics of NCB advocates for what they are, mendacious attempt to force women to make approved childbirth decisions. We should recognize that NCB "education" has nothing to do with supporting women in finding the choice that is best for them. Advocates are exclusively concerned with foisting their philosophical views on everyone else. Their pious bleating about "informed consent" masks their true motivation.

Lamaze: No evidence that epidural affects breastfeeding, but we can still pretend

Yesterday's post on the inaptly named Lamaze blog Science and Sensibility acknowledged that, contrary to the fervent wishes of natural childbirth advocates, there is NO EVIDENCE that epidurals interfere with breastfeeding.

But why let a little thing like evidence stop you? The Lamaze blogger helpfully offers a series of ridiculous reasons why NCB advocates can continue to pretend otherwise.

The blogger, Sylvie Donner, starts with a review of the literature. She notes that the studies that purported to find a link between epidural and breastfeeding were small, retrospective and of low quality. The rest of the literature finds no link between epidural and breastfeeding, or draws no conclusion after noting the fact that confounding variables make it impossible to determine whether there is a relationship.

None of this is the least bit surprising to obstetricians and anesthesiologists. When narcotics are injected along with local anesthetics into epidural catheters, only a tiny amount reaches the maternal bloodstream and an even tinier amount crosses the placenta. Epidural narcotics do not sedate mothers; therefore, it makes no sense that they would sedate the babies who receive a far lower concentration.

So there is no evidence that epidurals impact breastfeeding and no physiologic explanation for why they would affect breastfeeding, but the folks at Lamaze really, really, really want to believe that epidurals are BAD. Donna tries to help them out:

Common sense might lead us to view even these studies which find no link between epidurals and breastfeeding with some caution.

Of course, I've just explained that common sense would support the fact that there is no link between epidurals and breastfeeding because there is no evidence that babies would be sedated by tiny fractions of the same medications that do not sedate their mothers. But "common sense" among homebirth advocates apparently isn't that common and doesn't make much sense.

After all, the following need to be taken into account as well:

Epidurals are associated with a general medicalization of birth (since they usually and/or frequently involve IV lines and urinary catheters, as well as electronic fetal monitoring and ongoing monitoring of blood pressure) and this may contribute to greater maternal discomfort postnatally, meaning that breastfeeding could be affected.

Ahh, yes, the dreaded "medicalization." It may make women uncomfortable in labor and breastfeeding could be affected! Really? How? No explanation is given.

Epidurals are known to be associated with a higher rate of instrumental delivery and caesarean.  Postpartum perineal discomfort, or pain as a result of abdominal surgery, will also inevitably make breastfeeding less comfortable, and therefore less likely to occur.

Of course there is no evidence that perineal or abdominal discomfort "inevitably makes breastfeeding less comfortable" but why not pretend? How about the fact that breastfeeding itself is often uncomfortable? That, apparently, is completely irrelevant. Any caring mother would ignore cracked and bleeding nipples, but perineal pain? OMG, who could be expected to endure that?

Epidurals can influence the fluctuation of hormone levels that play an important role in breastfeeding.

Look ma, no evidence! Oh, wait, there was a study that showed that epidurals might possibly affect the interaction between the adrenals and the pituitary. And the pituitary produces other hormones ... and prolactin is one of those hormones ... so if the epidural could affect one hormone, it could affect them all!!!

Furthermore, most studies conducted so far are unlikely to have compared physiological, unmedicated active labor with epidural labors. Comparing breastfeeding success after epidural birth to opiate-medicated birth (or birth with other forms of analgesia, such as Entonox) is not the same as comparing physiological birth to epidural birth.

 How do we know they are different? Duh! Because Lamaze says so. And how do we know those "differences" have any impact on breastfeeding? Duh! Because Lamaze says so.

The conclusion is inevitable. Just because there is no evidence to show that epidurals have no impact on breastfeeding, we can still pretend that they do.

After all, any other conclusion is completely unacceptable. Epidurals are bad, bad, bad, so they must interfere with breastfeeding or else the folks at Lamaze will be sad, sad, sad.

Henci Goer's credentials : "I have books ... I have papers ..."

Who knew?

Evidently, the only thing you need in order to call yourself an expert is a few books. How do I know? Henci Goer says it's so. In response to a someone questioning the basis for her self-described expertise, Goer offers this painfully stupid response:

... I have a B.A. in biology from Brandeis University; I have a library of books and a collection of several thousand papers, including books and papers on how to analyze and interpret medical research; and I have been writing and speaking about what the consensus of maternity care research establishes as best promoting safe, healthy birth for over 20 years. That being said, my preeminent credential is illustrated by this anecdote: Penny Simkin was once called on the carpet by an anesthesiologist, irate that she had written a handout listing the potential trade-offs of epidural anesthesia when she was not a doctor (although he did not dispute her accuracy). “What are your credentials?” he demanded. “I can read,” she mildly replied. So can I.

Yippee! I didn't know that I was an expert in so many things. I love history and have lots of books and papers. I'm a historian! I have both fresh and saltwater fish and lots of books on how to care for them. I'm an ichthyologist! I love roses and peonies and own a variety of books on their cultivation. I'm a botanist! Ooooh, I am so impressed with myself.

Of course I do feel a bit foolish to find out that I all I needed was a bunch of books and papers on obstetrics to consider myself an expert on all aspects of childbirth. I wasted four years and tens of thousands of dollars on medical school. I did get a couple of cool letters to put after my name (MD), but was that really worth when all it takes to be an expert is owning books? And when I think of the thousands of hours I worked during internship and residency, the thousands of patients I cared for, the thousands of deliveries I attended, I could kick myself. The hands on experience was totally unnecessary.

And what was the point of actually providing obstetrical care for women when I was working as an obstetrician? Who knew that taking responsibility for the care of a myriad of obstetric complications, as well as hundreds of women who had uncomplicated deliveries was a total waste of my time. I could have read about it in a book. That's just as good; Henci Goer says so herself.

Most of all, though, I am thrilled to learn that Henci Goer considers me the pre-eminent American expert on homebirth and its many dangers. There is simply no doubt that I own more books, more papers, more journal subscriptions relating to natural childbirth and homebirth than any other American, including her and no one has been writing as long or as extensively on the topic as me. Plus, I am a really, really good reader; I have the SAT scores to prove it.

It's undeniable, folks, that I am the true expert in all aspects of pregnancy and birth, and everyone should be listening to me. Not because of my extensive background in science, statistics and medicine. Not because I have delivered thousands of babies and been involved in the care of thousands more. Not because I actually AM an expert in pregnancy and childbirth, but because I own lots and lots and lots of books and papers on the topic.

Thank you, Henci, for your endorsement of my expertise. Your reasoning is idiotic, but I'm willing to overlook that in this instance. How do I know that you have endorsed me as an expert?

Isn't it obvious? ... I can read.

Judging other mothers

Natural childbirth advocacy is another weapon on the ongoing battle of competitive mothering. This article by Faulkner Fox, Judging Mothers, How and Why Feminists Can Stop, offers an interesting and amusing perspective. I don't agree with her Marxist analysis, but she lays out the problem quite well:

The woman who wrote to me, whom I'll call Joan, said that her 20-month-old had been playing in the sandbox before stopping to ask her mother for a snack. Ever the prepared mother, Joan pulled out a Stonyfield Farms organic strawberry yogurt in a tube.

Immediately another mother, whom Joan did not know, piped up from a nearby bench: "How can you give that to your daughter? It’s so full of sugar. What I do," she continued, "is use a syringe to extract 1/2 of the sweet yogurt from the tube, then I use a second syringe to inject plain yogurt back into the tube. That way my daughter has the same yogurt as the other kids, but I know that it’s not too sweet."

Fox's suggestions for possible responses are hilarious:

Let’s consider for a minute - just for fun - what an appropriate response could be in this situation...

Here are a few choices I came up with:

a) Thanks so much! Can I borrow your syringe?

b) Would you like the name of my psychiatrist? Zoloft has done wonders for me.

c) Do you realize that the President of the United States {at the time, George W. Bush] is an often incompetent, but still incredibly dangerous, warmonger? Why not use your yogurt time to fight any number of unethical and nonsensical policies that harm mothers, children, and everyone else? Here’s the phone number for the National Organization for Women. Or,

d) the all-purpose response to strange statements - for feminists, as well as anyone else: Huh? Say What?

Fox deftly frames the problem:

When another mother makes a statement that feels like a judgment on our mothering - and Joan certainly took this yogurt-doctoring advice as a judgment rather than an innocent food hint - how do we answer back? ... Why do mothers judge each other, sometimes on the pettiest details, in the first place? Why do mothers - at least in my experience and according to my observations - judge one another at a much higher frequency than other members of the population judge one another?

Fox's assessment:

I believe that at least some of the time, even the tiniest judgments we make are really ways of asking these two questions: 1) Is that mother selfless enough? And more personally, 2) is that mother sacrificing as much as I am? If not, I'm not sure I like her, and I'm not sure I can refrain from saying something critical to her - just to see if I can get her to feel anxious, the way I feel anxious.

In other words, women concern themselves with the details of other women's mothering because they are insecure and can feel more secure by demeaning another mother. That's what's going on when natural childbirth advocates feel compelled offer other women unsolicited advice on "what worked for them". That's what's going on when NCB advocates feel compelled to tell their birth stories to women who didn't ask to hear them. They are insecure and they can feel better about themselves by explicitly or implicitly demeaning other mothers. There are two serious problems here. One is that some women are deliberately hurting other women. The other is that natural childbirth is not objectively superior in any way.

This post first appeared 4 years ago on Homebirth Debate.

Dr. Klein is shocked

Dr. Michael Klein is shocked, shocked at how willingly women are to follow their obstetricians' advice. As an article in yesterday's LA Times details:

Doctors, led by Dr. Michael Klein of the Child & Family Research Institute and University of British Columbia, surveyed 1,318 healthy pregnant women. They found many seemingly unprepared to make their own decisions regarding childbirth options, such as whether to have natural childbirth or a Cesarean section...

"[E]ven late in pregnancy, many women reported uncertainty about benefits and risks of common procedures used in childbirth," Klein said in a news release. "This is worrisome because a lack of knowledge affects their ability to engage in informed discussions with their caregivers."

Klein's findings have been appear in the paper Birth Technology and Maternal Roles in Birth in this months' issue of Obstetrics and Gynecology Canada. Klein's distressing conclusion? Many women appear to follow the advice of their obstetricians.

Contrast that with women's relationship with other professionals. Are women seemingly unprepared to make their own decisions regarding legal options such as whether or not to sue a business colleague? Do they demonstrate uncertainty about the benefits and risks of common legal actions? Actually ... they do. That's why they consult lawyers in the first place.

Okay, law is a highly specialized profession, so that accounts for the fact that women fail to do their own "research" and "educate" themselves on all their legal options, but what about something more straightforward like building a house?

Are women seemingly unprepared regarding architectural options like structural steel roof framing vs. conventional framing? Do they demonstrate uncertainty about the benefits and risks of common structural options like the locations of walls or the framing of windows? After all, what could be more basic than walls and windows. Every women who lives in a house (and that's most women) are directly affected by their walls and windows. And yet ... most women merely rely on the advice of their architects.

Alright, women rely on the advice of their lawyers and architects, but surely they have a different approach when the decisions involve their own body.

Consider the decisions women face regarding breast cancer treatment. It is difficult to imagine when women are more vulnerable, and when their decisions directly affect their autonomy as when they are newly diagnosed with breast cancer. Do women demonstrate uncertainty about the benefits and risks of various treatment options like surgery vs. radiation, or radiation vs. chemotherapy? Um ... yes, they do.

But surely they are fully versed in the many benefits and risks of specific chemotherapy drugs. Wait, they're not? But no doubt they understand exactly when, where and how radiation should be delivered to the breast. They don't? Surely, they don't merely rely on the advice of their oncologist to make such an important decision? Actually, they do.

Okay, maybe that's because cancer is so complicated. Consider something far simpler like eye care. Every woman has eyes, and their eyes are designed to see perfectly. It's not like they are dependent on the decision of an optometrist as to whether they do or do not need eye interventions like glasses? Oh, they are?

Well, at least they understand the myriad risks of wearing contact lenses. They are undoubtedly familiar with all the rare eye injuries and diseases whose incidence is increased by contact lenses, right? How could they allow an intervention like the placement of plastic IN THEIR EYE unless they were fully cognizant that in rare cases, it could increase the risk of BLINDNESS?I Wait! What? They don't know about these things and they acquiesce to wearing contact lenses because their optometrist recommends them? That's shocking.

Of course it's not as shocking as the fact that women rely on the advice of their obstetricians. Think about how different childbirth is than these other examples. It's not surprising that women rely on their lawyers because they are legal experts, and it's hardly surprising that women rely on architects because they are experts in the construction of houses. And surely it only makes sense for women to rely on the advice of an oncologist when they have cancer, because oncologists are experts in cancer and obviously, they are going to take the advice of optometrists on eye care because optometrists are experts in diagnosing and treating vision problems.

But why, oh why, do women rely on the advice of obstetricians when obstetricians are merely ... experts in childbirth??!!

Dr. Klein is right to be terribly shocked and disturbed at this completely unreasonable, wholly inexplicable phenomenon that has no parallel in any other aspect of a woman's life.

The sexist origins of natural childbirth

In light of our ongoing discussions about the racist and sexist origins of natural childbirth philosophy, I thought I would recap a post that I wrote for Homebirth Debate in early 2007. What I find fascinating is how natural childbirth grew out of the racial prejudices at the heart of colonialism and the sexist outcry against women's emancipation, specifically women leaving the home to go to work.

Grantly Dick-Read's fabrication of the notion that "primitive" women did not have pain in childbirth was a product of the eugenics movement, which was obsessed with the idea that "inferior" women were having more children than their "betters". In a fascinating article,The Race of Hysteria: "Overcivilization" and the "Savage" Woman in Late Nineteenth-Century Obstetrics and Gynecology, Laura Briggs argues that the comparisons between "overcivilized" white women and "primitive" women who gave birth easily was not merely the product of racism, but reflected the anxiety that men felt about women's increasing emancipation.

This anxiety over women's increasing education, independence and political involvement was expressed in medicine generally, and in obstetrics and gynecology particularly, by the fabrication of claims about the "disease" of hysteria and the degeneration of women's natural capabilities in fertility and childbirth compared to her "savage" peers. Simply put, the result of women insisting on increased education, enlarged roles outside the home and greater political participation was that their ovaries shriveled, they suddenly began to experience painful childbirth and they developed the brand new disease of "hysteria", located in the uterus itself.

Briggs writes:

Hysteria, we learned from feminist historical scholarship in the 1970s, was never just a disease. It was also the way nineteenth century U.S. and European cultures made sense of women’s changing roles. Industrialization and urbanization wrought one set of changes, while the women’s rights movement brought another. Together, these included higher education for women, their increasing participation in a (rapidly changing) public sphere, paid employment, and declining fertility. These cultural changes were accompanied by a virtual epidemic of “nervous weakness” largely among women, causing feminist historians to begin asking whether the diagnostic category of hysteria was simply a way of keeping women in the home.

What was "nervous weakness"?

Nervousness was often characterized as an illness caused by "overcivilization," which located it in a scientific and popular discourse that defined cultural evolution as beginning with the "savage," culminating in the "civilized," but also containing the possibility of degeneration — "overcivilization." In this literature, "savage" or "barbarian" was applied to indigenous peoples, Africans, Asians, Latin Americans, and sometimes poor people generally. As a disease of "overcivilization," hysterical illness was the provenance almost exclusively of Anglo-American, native-born whites, specifically, white women of a certain class. Second, the primary symptoms of hysteria in women were gynecologic and reproductive—prolapsed uterus, diseased ovaries, long and difficult childbirths — maladies that made it difficult for these hysterical (white) women to have children.

Furthermore:

"[O]vercivilized" women avoided sex and were unwilling or incapable of bearing many (or any) children, "savage" women gave birth easily and often, and were hypersexual. This is the discourse that was slightly later termed "race suicide."Late nineteenth-century gynecological and obstetrical literature did more than simply naturalize opposition to white women’s political struggles by insisting that contraceptive use, abortion, education, and participation in the professional workforce could cause nervous illness. It also reconceptualized these forms of white women’s struggle for social and political autonomy from white men as a racial threat.

In Brigg's analysis, pain in childbirth served a very important function in this racist and sexist discourse: it was the punishment that befell women who became too educated, too independent and left the home. The idea that "primitive" women had painless childbirth was fabricated to contrast with the painful childbirth of "overcivilized" women. It is striking how reminiscent this is to the biblical interpretation of pain in childbirth. In both cases, painful labor is explicitly a punishment for women who "forget their place" and act independently.

When Grantly Dick-Read and his peers claimed that "primitive" women had painless labors, they were not describing a real observation; they were issuing a warning to women of a certain social class: if you dare to step beyond the roles that we have prescribed for women, you will be punished with painful labor.

In light of this, it is more than ironic that some contemporary women are still insisting that childbirth is not inherently painful, that indigenous women have painless childbirth, and that if you "prepare" for childbirth properly, your birth will be painless, too.

Where are the female obstetricians?

I admit that decades after I first learned about natural childbirth and homebirth I am still shocked that anyone believes in it.

Natural childbirth was invented by a racist, sexist white male (Grantly Dick-Read) who wanted to encourage women of the "better classes" to stop fearing labor and have more children. It has been perpetuated by a cadre of Western, white, male physicians (Lamaze, Bradley, Odent) who subscribe to the notion that pain is women's heads, or failing that, should make them feel "authentic."

The "grandmother" of midwifery is Ina May Gaskin, a hippie from a bizarre commune who has no training in anything, AND let her own baby die rather than seek medical care for him. The foot soldiers in the NCB and homebirth armies are women who have no formal education in science, medicine or obstetrics and seem to think that is no problem. They are women without college degrees who enjoy attending other women's births as a hobby and who couldn't be trusted with any professional responsibility, let alone one that involves life and death.

The current "thought leaders" in the NCB and homebirth world are all Western, white men like Marsden Wagner and Michael Klein.

Did you notice that there is rather important group missing from the movement? I did, because I'm one of that group: women obstetricians.

Women obstetricians routinely favor high levels of interventions for themselves. They are open to C-section on maternal request and often have C-sections for maternal request. They love pain medication and freely use epidurals when they have children of their own.

Why aren't they on board with NCB and homebirth, like some of their male colleagues? Let me count the ways.

1. They have personally experienced the pain of labor.

2. They have personally experienced the pain of labor.

3. They have personally experienced the pain of labor.

And having personally experienced the pain of labor, they recognize Dick-Read, Bradley, Lamaze and Odent for the sexist blowhards that they are.

There are additional reasons:

They have a wealth of knowledge about childbirth and its dangers. They have more experience and skill in handling childbirth than any CNM, CPM, doula or childbirth educator. They know that most of the NCB/homebirth trope is nothing more than made up nonsense.

They do not believe their personal value resides in their breasts and vagina. They recognize that their value lies in their intelligence, insight, professional accomplishments and actions in the world. They are empowered by knowledge, not by what passes through their vagina.

They don't risk their children's lives to prove a point because they have nothing to prove. Their accomplishments speak for themselves; they don't have to create faux "accomplishments" out of bodily functions over which they have no control in any case.

I find it quite ironic that while women without formal training in science and male doctors with strong ideas about how women should react to pain prattle on and on of being "educated" about childbirth and interventions, they don't seem to notice that women obstetricians, the people with the MOST education and personal experience of childbirth, are not on board.

Who the hell is Marsden Wagner to tell me how I ought to give birth?

Who the hell is Henci Goer to tell me that obstetricians ignore scientific evidence?

Who the hell is Michael Klein to tell me how much pain in labor I ought to endure?

Wake up NCB and homebirth advocates! Women obstetricians are not on board. We don't need men to tell us how we should experience childbirth and we don't need women who could barely finish high school to tell us their pretend "facts" about childbirth.

If we don't believe their inanities, why should anyone else?

Cochrane Childbirth Reviews riddled with statistical errors

Lay people love Cochrane pregnancy and childbirth reviews. They always include plain language summaries, are systematic reviews or meta-analyses that are easy to understand, and are generally written by volunteers, many with an natural childbirth ax to grind.

Doctors are not nearly so enamored of Cochrane pregnancy and childbirth reviews. Although they agree in principle with the aims of the Cochrane project (synthesizing scientific evidence), the reviews are limited by the fact that papers included in a review are often poorly done, underpowered and differ markedly from each other in what results are measured and how they are measured. Moreover, Cochrane Childbirth reviews are often written by self-selected volunteers with an ax to grind, and therefore suffer appear to start with the conclusion and work back to include only papers that support it.

As a general matter, systematic reviews and met-analyses suffer serious limitations, some of which can be overcome with appropriate statistical analysis. However, as a new paper on the Cochrane Childbirth Reviews reveals, most are riddled with serious errors of statistical analysis that render their conclusions suspect or even useless.

Statistical methods can be improved within Cochrane pregnancy and childbirth reviews by Riley, Gates, Neilson, and Alfirevic was published in this month's issue of the Journal of Clinical Epidemiology. Coincidentally, I recently referenced Alfirevic as the author of the Cochrane Review on electronic fetal monitoring (EFM), the review that he acknowledged was underpowered to determine if EFM saves lives.

The intrinsic problems of systematic reviews have been summarized elsewhere as follows:

• There are numerous ways in which bias can be introduced in reviews
and meta-analyses of controlled clinical trials.

• If the methodological quality of trials is inadequate then the findings
of reviews of this material may also be compromised.

• Publication bias can distort findings because trials with statistically
significant results are more likely to get published, and more likely to
be published without delay, than trials without significant results...

• Criteria for inclusion of studies into a review may be influenced by
knowledge of the results of the set of potential studies...

These limitations can be summarized by the pithy phrase "garbage in, garbage out." A meta-analysis or systematic review is only as good as the quality of the papers reviewed.

The Cochrane Childbirth Reviews suffers from these problems and more:

There are deficiencies in the use of statistical methods within the Cochrane Pregnancy and Childbirth Group (CPCG) reviews. The issue of publication bias is
rarely addressed; the process of measuring, investigating, and accounting for heterogeneity is often limited or inadequate; and random-effects analyses are
not correctly interpreted. The large number of metaanalyses per review also raises the concern of multiple testing. These problems need to be urgently
addressed...

Improved use of statistical methods is urgently needed within Cochrane reviews. Although we have only assessed CPCG reviews in the article, our findings have general implications for all Cochrane reviews... The Cochrane Collaboration must seek to engage more statisticians and methodologists within individual reviews ...

The problems identified in the Cochrane Reviews were not limited to a small subset of the reviews. For example, in assessing publication bias, the authors note:

Just 6 (7%) of the 75 reviews stated in their Methods section how they would assess publication bias; only 7 (9%) described a publication bias assessment in their Results or Discussion section or justified why publication bias assessments were not possible; and only 3 reviews described a publication bias assessment plan in their Methods section and subsequently reported an assessment in their Results or Discussion section...

The authors acknowledge that errors such as these seriously limited the validity of Cochrane pregnancy and childbirth reviews:

... It is clear that CPCG reviews must now consider the issue of publication bias in more detail, both when planning their review and when interpreting their results. This is particularly important for their primary analyses, as else misleading or overly strong conclusions may be made...

Unless and until these issues are addressed, Cochrane pregnancy and childbirth reviews will continue to dazzle lay people with incorrect conclusions, and be dismissed by doctors as poorly done and riddled with statistical errors.

No, breech is NOT a variation of normal

Natural childbirth and homebirth advocates have a distressing habit of seizing on lies and repeating them over and over again to convince themselves and others that they are true. One currently popular lie is that "breech is a variation of normal."

Here's a little hint: If it dramatically increases the risk of death, then it is NOT a variation of normal. And breech presentation dramatically increases the risk of death. Contrast that with true variations of normal like left-handedness vs. right-handedness, which have no bearing on health or life expectancy.

To understand why breech presentation dramatically increases the risk of death, it is helpful to review some basic principles of childbirth. At term, the baby's head is usually the largest part of the baby. That means that if the head fits, the rest of the baby should follow without difficult (shoulder dystocia is an exception). Moreover, the bones of the fetal skull are not fused and can slide past each other, allowing "molding" of the fetal head letting it squeeze through the pelvis. In the breech presentation, the head is still the biggest part of the baby, but now it is coming last and there is no chance for it to mold to squeeze through the pelvis. There is a high risk that the head will be trapped, often resulting in the death of the baby.

Breech babies and their mothers differ in substantial ways from the rest of the population. Breech babies are far more likely to have congenital anomalies, particularly anomalies like hydrocephalus that increase the size of the fetal head. In other words, the baby ends up breech because the head is too large to properly fit in the pelvis. Mothers who carry breech babies often have uterine anomalies that distort the shape of the uterus. In other words, the baby ends up breech because the bottom of the uterus cannot accommodate the fetal head.

The risks of labor differ substantially for breech babies. Typically, the head fills the cervix as it is dilating, making it impossible for the cord to prolapse (fall out), a condition that routinely ends in death. In contrast, the breech, being smaller, does not fill the cervix, making cord prolapse far more likely. In addition, in contrast to vaginal delivery where the baby's arms are pressed to its sides, the arms of a breech baby may end up over its head. One or both can end up behind the head crossing the neck. This is known as nuchal arms. A baby with nuchal arms cannot be delivered because the diameter of the head plus the arm(s) is too big to fit through the pelvis. Unless the provider can move the arm(s) from behind the head, the baby will die.

In addition, there's more than one kind of breech. To say that the baby is in the breech presentation means only that the bottom of the baby is coming first. The bottom may refer to the buttocks or the feet (more dangerous). The breech baby may have its chin to its chest or it may be facing upward (more dangerous).

Indeed, in studies that purported to show the safety of vaginal breech delivery, all the babies in the complete or footling breech presentations are excluded. All babies with extended heads (looking up) are excluded. All large babies are excluded. All women with a small pelvis are excluded. So much for "breech" being a variation of normal.

How dramatically does breech presentation increase the risk of perinatal death? The experience in Norway, before and after the C-section rate for breech had risen precipitously, is representative of the risks. According to Secular trends in peri- and neonatal mortality in breech presentation; Norway 1967–1994 by Albrechtsen et al.:

... The extended peri- and neonatal mortality rate in breech presentation births declined during the study period from 9.2% in 1967–76 to 5.5% in 1977–86 and to 3.0% in 1987–94. The highest relative risk of mortality in breech presentation versus the total birth population was observed in intrapartum death and in mortality less than 24 hours after delivery...

During the study period, the overall rate of perinatal mortality declined due to advances in obstetrics and neonatology. In addition, the C-section rate rose dramatically. Both contributed to the overall decline in mortality from breech delivery. But as the following graph shows. C-section for breech uniformly led to better outcomes.



The bottom line is that, any way you look at it, breech is NOT a variation of normal. Breech babies have a higher incidence of congenital anomalies and their mothers have a higher incidence of uterine anomalies. Breech babies are at much higher risk for cord prolapse and encounter complications like nuchal arms and trapped heads that simply do not occur in head first deliveries. Most importantly, any baby in the breech position has a dramatically higher risk of death.

A variation that kills babies is not a variation of normal.

Electronic fetal monitoring gives much more information

This tracing shows a baby in serious trouble.

Surprised? You might be if you thought that a fetal heart rate tracing supplied the same information as intermittent ausculation (listening) with a doppler. But electronic fetal monitoring provides a wealth of information that cannot be obtained by listening, and that allows for a more comprehensive view of fetal well being.

What information does this tracing provide? To understand, you need to know what we are looking at. We are looking at two different graphs created simultaneously by the fetal monitor. The top graph shows the fetal heart rate; the bottom graph shows the uterine contractions. The information in the top graph can only be understood in relation to the information in the bottom graph.

Let's start with the basics:

* The baseline fetal heart rate is approximately 160 beats per minute. This is a normal fetal heart rate. Therefore, if you were listening briefly at most points during which this tracing were created, you would think that the baby was doing fine.

* There is decreased variability. We know from looking at millions of tracings that the normal fetal heart rate will created a jagged line. This is known as "variability." As the circulatory needs of the fetus change from moment to moment, the heart rate adjusts from moment to moment. When the baby's brain is deprived of oxygen, the heart rate will lose variability, and the line will look smoother. This heart rate tracing has lost its variability; this baby is in trouble.

There is no way to determine variability while listening, so intermittent auscultation would not alert you to this ominous development.

* There are no accelerations. A well oxygenated baby will move from time to time. That will be reflected in temporary increases in the heart rate (accelerations) lasting for fractions of a minute or more. Without a written tracing, it is difficult to determine if there are accelerations.

* There are subtle late decelerations. A deceleration is a brief decrease in heart rate. Their significance is not in how deep they are, but in where they are located in relation to the contraction. They are categorized as early (before a contraction), variable (at the peak of a contraction), or late (staring during a contraction but continuing after the contraction has ended).

The following illustration provides a clearer view of a late deceleration. Notice how the decrease in heart rate starts during the contraction and continues after the contraction has ended:



Late decelerations are an indication that the baby is not getting enough oxygen through the placenta to "hold its breath" during a contraction when the supply of oxygen is temporarily cut off. Repetitive late decelerations are an unequivocal sign of fetal distress.

It is important to note that the depth of the deceleration has nothing to do with the severity of oxygen deprivation. Subtle late decelerations, such as those in the tracing at the top, are nonetheless extremely ominous.

Can you hear a late deceleration with intermittent monitoring? That depends entirely on when you listen, how long you listen, and whether there are contractions during time when you are listening. The subtle late decelerations in the tracing above might be very difficult to appreciate by listening alone. That's because the heart rate changes only by 5-10 beats per minute and only for a period of 15-20 seconds.

Notice what you don't see:

You don't see a bradycardia, a sustained period of abnormally low heart rate. That's because bradycardia is often a terminal event. Most babies can tolerate long periods of significant oxygen deprivation before they die, and they may not have any bradycardias until immediately before death. On this tracing, there is never a single moment when the heart rate is outside of the normal range, but the baby is nonetheless suffering from serious oxygen deprivation.

This is almost certainly what is happening in hours before a dead baby drops into a homebirth midwife's hands. The midwife may be intermittently listening to the baby's heart rate, but unless she is listening for long enough AND frequently enough AND exactly at the right times AND can distinguish subtle changes in heart rate, she will be blissfully unaware that a baby is dying right in front of her.

Homebirth advocates and their midwives who insist that the baby's heart rate was "fine" until just before delivery are completely wrong. The baby's heart rate was not fine; they just couldn't tell what was happening because they only listened intermittently.

Homebirth advocates and their midwives who insist that no one could have predicted that the baby would need an expert resuscitation are completely wrong. The baby was not fine; they simply couldn't tell one way or the other.

Homebirth advocates and midwives who insist that the same thing would have happened at the hospital are completely wrong. The pattern would have been picked up, probably hours before the baby's death, and a C-section would have been done. The baby would have been born healthy and screaming and the mother and midwife would have been fuming about the "unnecessary" C-section.

Homebirth advocates and midwives who insist that intermittent monitoring is just as safe as electronic monitoring are completely wrong. If you can't pick up subtle changes in heart rate, you can't diagnose and treat fetal distress early, before the baby's brain has been permanently damaged.

Look at the tracing above again. Ask yourself:

Could you (or anyone) hear that heart rate pattern?

If not, then you can understand how very easy it is to listen intermittently to a "normal" heart rate, and then unexpectedly have a dead baby drop into your hands.

Electronic fetal monitoring halves early neonatal mortality

The American Journal of Obstetrics and Gynecology has just published a "Report of Major Impact" that demonstrates that electronic fetal monitoring saves lives.

Electronic fetal heart rate monitoring and its relationship to neonatal and infant mortality in the United States by Chen et al. is the largest study ever done on electronic fetal monitoring (EFM). The authors reviewed 1,732,211 singleton live births (elective C-sections and congenital anomalies were excluded. Of these births); 89% involved EFM while 11% did not. They found:

The corrected early neonatal, late neonatal, postneonatal, and infant mortality rates for all subjects were 0.9, 0.5, 1.7, and 3.1 per 1000 births, respectively... The risk of corrected mortality rate was different between those with vs without EFM during the early neonatal period (0.8 vs 1.7 per 1000 births, respectively; P ‹ .001), but not in late (0.5 vs 0.6; P ‹ .402) or postneonatal periods (1.7 vs 1.8; P ‹ .296).

In other words, EFM cut the rate of early neonatal death in half (death from birth to 7 days), but had no impact on late neonatal death (from 7-28 days of life) or postneonatal death (from 1 month to 1 year of age). This is exactly what you would expect to find if EFM prevents peripartum death from hypoxia (lack of oxygen). The results are represented graphically below.



There were secondary findings as well:

... Use of EFM was associated with an increased likelihood of operative vaginal delivery for all indications, as well as for fetal distress. In addition, use of continuous monitoring was associated with an increased risk of primary cesarean delivery for fetal distress ...

...[U]se of EFM was associated with a lower likelihood of 5-minute Apgar score ‹4...

The secondary analysis also indicates that the rate of neonatal seizure was significantly lower only among high-risk women who had EFM...

What are the differences between this study and the Cochrane review that purported to show that EFM increases operative delivery rates without improving neonatal survival? The Cochrane review, encompassing 37,000 women, was simply too small.

The combined sample size of 12 RCTs is insufficient to determine whether EFM can significantly lower neonatal mortality. Alfirevic [the author of the Cochrane review] noted that to test the hypothesis that continuous monitoring can prevent 1 death in 1000 births, more than 50,000 women need randomization...

Moreover, as the Cochrane review authors themselves noted, of the 12 RCTs included in the analysis, only 2 were high quality studies.

Chen et al. conclude:

According to the Cochrane review and the most recent ACOG recommendation, the use of fetal heart rate monitoring increases operative delivery rate without a concomitant decrease in longterm neonatal outcomes. Thus, understandably there has been continued angst about using fetal heart rate monitoring during labor. The main implication of our study is that now there is reassuring evidence for the use of EFM; its use is linked with ... a significant decrease in early neonatal and infant mortality ... [F]etal heart rate monitoring can be used in daily practice with some assurance.

A conclusion of the study is the large sample size necessary to demonstrate improvement in neonatal outcomes. One reason the ... Cochrane review did not demonstrate benefit of EFM is small sample size of published reports. Alfirevic et al acknowledged that over 50,000 women need to be randomized to demonstrate improvement in mortality. The issue of sufficient sample size ... remains unachievable in modern day obstetrics... Thus, when the outcomes are uncommon and randomized trials are not plausible, we should consider evidence from "reality-based medicine," for it, along with this study, demonstrates improvement in mortality
with EFM.

Of note, this study, which contains only live births, almost certainly underestimates the benefit of EFM. EFM appears to save lives by decreasing the risks of hypoxic brain injuries associated with low Apgar scores (‹4). The study did not include intrapartum deaths (Apgar 0), where the benefits of EFM are similar or even larger.

The bottom line is that the largest study of electronic fetal monitoring to date shows that EFM cuts the rate of early neonatal death in half. That is a dramatic benefit.

A healthy baby is not the most important thing

Homebirth advocates have countless fallback positions.

A homebirth advocate says: I'm having a homebirth because it is safe or safe than hospital birth.

Present the copious evidence that homebirth triples the rate of neonatal death and the homebirth advocate falls back to: I'm having a homebirth because even if it isn't safest, it is safe enough.

Show her that homebirth has a truly unacceptable rate of neonatal death and she falls back even further: My intuition tells me that homebirth is safe enough for me.

The ultimate fallback position, when all the information is on the table, is this: A healthy baby is not the most important thing.

What are we to make of this?

First, it not true. For the vast majority of women (99+%), a healthy baby is the most important thing. That's why they go to the hospital in the first place. It certainly isn't for the fabulous food and the wonderful decor. It's for the obstetric interventions that make childbirth dramatically safer and much more comfortable.

It's not true even for most homebirth advocates because it misrepresents what the she believes. The average homebirth advocate is completely ignorant of the real risks, so she thinks there are no risks. The few who recognize the risks use their "intuition" to predict that they are not going to have life threatening complications; they are going to have a healthy baby regardless of whether they give birth at home or in the hospital. What they really mean is: Since I'm going to have a healthy baby regardless, a healthy baby is not the only important thing.

To a certain extent, these homebirth advocates are right. A healthy baby may be the most important thing, but that doesn't mean that it is acceptable to be treated poorly as long as you go home with a healthy baby.

There is a tiny group, a fraction of a fraction of a percent, that really does believe that a healthy baby is not the most important thing. That tiny group can be further divided into two distinct subsets. One subset truly does not care about the baby. They may be ambivalent about the pregnancy or even in denial. They may have lives disordered by substance abuse and be incapable of thinking beyond feeding their habit. It is simply not important to them whether the baby lives or dies; in fact, it may be better for them if the baby dies.

The other subset contains women for whom the experience of childbirth is literally more important than the child. Most proponents of unassisted childbirth (UC) fall into this category as well as a few homebirth advocates. The baby is secondary to the self-image they are building.

Some will admit that they got pregnant or would like to get pregnant not to have a baby, but merely to have a birth. Some will proudly announce that they love the child of unassisted birth more than their other children if they have them. They are narcissists in the true sense of the word. Nothing, not even the life or death of their own child, is as important to them as their own self-image. Everyone in the world, even their own infants, are just props in the drama that is their life story.

They talk the talk and they walk the walk. Their number includes UC advocates Janet Fraser and Laura Shanley, as well as Ina May Gaskin, the doyenne of homebirth midwifery. All of them have let their own child die; Shanley and Gaskin actually watched their premature infants struggle for hours before finally succumbing. Then they went on to make careers out of the belief system that killed their own children. It's difficult to imagine anything more narcissistic than that.

For some women, a healthy baby is not the most important thing, but those women deserve our pity and our condemnation. For everyone else, a health baby IS the most important thing and nothing else even comes close.

Mothering.com death toll continues to rise

There has been yet another death of a healthy, full term baby on Mothering.com. This one happened at a birth center. It was caused by a rare complication, but it didn't have to happen.

The mother claims:

I don't ever want anyone to fear a VBAC, or to fear going over their due date, or to fear having their baby in a birthing center because of our situation. Those things had nothing to do with what happened to our little angel, and there isn't anything that could have been done to prevent it either.

Not exactly. Had the mother had an elective repeat C-section at term, the baby would definitely be alive today. Had the mother had continuous electronic fetal monitoring, the baby would almost certainly be alive today. Had the mother given birth in a hospital, the baby would likely be alive today.

As in the case with all out of hospital births, including birth centers not located at hospitals, the mother gambled with her baby's life. Unfortunately, she lost ... or rather the baby lost.

The baby died during labor of a rare, generally unpredictable complication:

At about 7 am, the midwife came and we listened to his heartbeat again, and again it was perfect, before, during and after a contraction. I was only 4 cm dilated, so I decided to start moving and swaying to some music, using the birthing ball and walking a little to help dilation along. I did this for about an hour. While I was sitting on the birthing ball I felt [him] kick a couple of times ... I didn't know then that it was the last time I would feel him move.

An hour later my midwife checked my dilation again and I was 5-6 cm, we listened for the heartbeat on the doppler and we couldn't find it. We tried to stay calm and went straight to the hospital, hoping that they would confirm with ultrasound that he was fine and was just so low in the pelvis that we couldn't get his heartbeat on the doppler at that point, but sadly, they confirmed what we quietly feared. He didn't have a heartbeat. Sometime in that hour, he had passed away.

What happened?

The pathology reports came back ... and we found out that he had what is called an Umbilical Cord Torsion. It is very rare, and is when the umbilical cord twists in on itself and forms a kink. It essencially cut off all blood supply and oxygen to him immediately and there was nothing that could have been done to prevent it...

Umbilical cord torsion happens when the cord becomes so twisted upon itself that the blood vessels within are kinked, closing off the blood flow to the baby. Imagine twisting a short length of garden hose over and over again. At first, the twists make no difference to water flow, but if you twist it enough times, the flow can be cut off completely.

This is a rare complication and can cause stillbirth at any point in pregnancy. As long as the cord is not twisted completely closed, the baby can survive, but as I explained in Trust Placentas?:

... During contractions, blood flow to the uterus (and therefore the placenta) is cut off. During each contraction, the baby is, in essence, holding its breath. Most babies tolerate this pretty well, because between contractions the placenta is providing so much oxygen that the baby has a reserve to draw upon during the contractions.

A partial torsion of the cord can dramatically reduce oxygen reserve. A baby with a partial torsion may be fine until labor begins, but without an adequate oxygen reserve, the baby may die during labor.

This tragedy sheds light on the nature of risk during pregnancy. The baby was alive at 38, 39, 40 and even 41 weeks. An elective repeat C-section at any point during those weeks would have prevented the baby's death. It would have been another one of those "unnecessareans" that are bemoaned by NCB and homebirth advocates.

That does not mean that the mother should have had an elective repeat C-section, merely C-sections are less risky for babies than vaginal birth.

The baby was alive at 7 AM. Had the baby been monitored with continuous electronic fetal monitoring, it may or may not have showed a pattern of increasing fetal distress prior to complete closure for the cord vessels. It certainly would have shown the bradycardia that occurred in the wake of complete closure of the cord vessels, and there may have been time to deliver a live, healthy baby by emergency C-section.

That does not mean that every woman should have continuous electronic fetal monitoring during labor. It does mean, though, that in the absence of continuous electronic fetal monitoring, rare acute events like these can kill a baby without anyone knowing about it.

Of course, had there been continuous or even more frequent intermittent monitoring during labor that showed the bradycardia, the fact that the mother was at a birth center, far from an operating room, means that the baby probably would have died anyway.

That doesn't mean that no one should give birth in a birth center, but it does mean that when a woman chooses a birth center, she is implicitly gambling that there will be no acute life threatening events in labor. If one does occur, the baby will die long before the mother can be transferred to the hospital.

This baby did not have to die. The mother and the providers gambled that the baby had no rare conditions, that nothing more than intermittent monitoring would be necessary, and that there was plenty of time to transfer to a hospital in case of emergency. The odds were in their favor, but they lost anyway.

When gambling, you should never bet the mortgage money, because no matter how good the odds, you still might lose. If you shouldn't bet the mortgage money, should you bet something infinitely more precious, the life of your baby? At a minimum, you ought to consider that no matter how good the odds, you still might lose.

It has zero to do with what is safe for the baby, but is all about the midwife.

Navelgazing Midwife has written an terrific post excoriating natural childbirth "professionals" for disseminating misinformation.

Her post is specifically about group B strep, but, as she recognizes, it can be easily extrapolated to many other areas of natural childbirth and homebirth advocacy.

The post was precipitated by medical advice found on a doula's website:

Recently, I was asked to view a blog post on the Babies in Bloom site, written by Amber Plyler of Heath Springs, South Carolina. She is a doula, a midwifery student and an admitted "birth junkie." Amber’s post, now pulled, was entitled "GBS+" ...

Plyler's piece advised using Hibiclens instead of antibiotics to prevent group B strep neonatal sepsis. As I detailed in a recent post (Wash your vagina out with soap):

Why are homebirth and natural childbirth advocates washing the vagina out with Hibiclens instead of using IV antibiotics?
It certainly can't be because it works, since large scale studies show that it doesn't.

It certainly can't be because it doesn't matter since GBS is the leading infectious cause of newborn death.

It certainly can't be because IV antibiotics don't work since they have reduced neonatal GBS deaths by 80%.

It certainly can't be because Hibiclens [chlorhexidine gluconate also known as (1,1'-hexamethylene bis [5-(p-chlorophenyl) biguanide]di-D-gluconate)] is "natural."

So why do women like The Feminist Reader wash their vaginas out with soap to prevent their babies from dying of Group B strep pneumonia or meningitis?

Because it fulfills the MOST important criteria for an NCB "treatment"; it is a form of ignorant, immature, self absorbed defiance of authority. And if that isn't a good enough reason for NCB advocates to risk killing their babies, what is?

That's why natural childbirth and homebirth advocates follow bizarre and incorrect advice, but why do natural childbirth professionals offer bizarre and incorrect "advice"? Navelgazing Midwife is spot on in her explanation:

... One of my major irks about (too many) non-nurse midwives is they 'sell' the treatment they are good at or are allowed to do. All too often, it has zero to do with what is truly safer for the baby, but is all about the midwife.

Natural childbirth professionals often have a vested economic interest in ignoring or discounting scientific facts and appropriate medical treatments. If a midwife cannot provide the necessary service, she is ethically obligated to refer the patient to someone who can. Instead of risking the loss of the income that the patient represents, however, some midwife (and their enablers, doulas and childbirth educators) simply announce that the treatment is unnecessary or can be replaced with a more "natural" treatment.

Plyler tries to defend herself in the comments section with the classic excuse NCB explanation; she "educated" herself by reading it on other NCB websites.

The instructions for the vaginal flushes with Hibiclens are not my own ... it is from several midwifery ... websites and resources. Gentle Birth is a collection of articles written by various midwives, including studies to back those articles up. This is where I was directed (by another midwife) to the Hibiclens protocol for flushes during labor.

This highlights one of the biggest problems in NCB and homebirth advocacy. It is a large echo chamber where misinformation, often deadly misinformation, bounces back and forth among NCB websites, and midwives, doulas or childbirth educators never bother to examine whether the claims are true. This is why it is impossible to become "educated" by reading NCB websites. They spread misinformation, not knowledge.

This is an object lesson for homebirth and natural childbirth advocates. When assessing the information on NCB and homebirth websites, readers need to ask themselves whether the midwife stands to gain financially from discounting mainstream medical practice. Most NCB and homebirth claims have "zero to do with what is safe for the baby," but is all about what is good for the midwife.

C-sections are bad? What a coincidence, midwives can't do them.

Fetal monitoring is unnecessary? What a coincidence, midwives don't have the equipment.

Postdates inductions aren't necessary? What a coincidence, midwives can't do inductions.

Antibiotics aren't needed for GBS? What a coincidence, most midwives can't access them.

Hospitals aren't the safest place to give birth? What a coincidence, homebirth midwives are considered unqualified to practice in hospitals.

The bottom line is, as Navelgazing Midwife says, for women to give informed consent, they must have:

ALL the information; not just the information that's the crunchiest or easiest to employ.

NCB and homebirth websites do not provide all the information. That's because NCB and homebirth advocacy is based in large part of mistruths, half truths and lies. They can't offer all the information, because, for many birth professionals, there's no money in telling the truth.