Another needless, senseless, utterly predictable, totally preventable homebirth death

Dear God in Heaven, when are these people going to wake up to what is right in front of them? Homebirth kills babies who didn't have to die.

The latest needless, senseless, utterly predictable and totally preventable homebirth death is currently being discussed on the Birth Without Fear Facebook Page, which links to the original story and a picture of a beautiful baby who looks to be sleeping but who is actually dead.

I had the most simplest pregnancy, and the healthiest baby boy, decided at 8 months to ditch my OBGYN and go with a midwife and home birth to welcome my son into this world as calming and peacefully as I could. I did chose to go with an unlicensed midwife, as licensing is not required in the state of Oregon, but the greatest mistake of all was not seeing the warning signs for myself. his being my first born I put all my trust and faith into two midwives, who in the end made some bad decisions and proved to be quite negligent. After a full 8 days of labor I delivered my son at home with no heart beat. After all I had done to prepare him for his peaceful arrival, instead of living he rests peacefully....

Well she showed that obstetrician didn't she? She "ditched" him for an unlicensed midwife AND labored for 8 days AND at no point called for an ambulance to take her to the hospital where her her baby could have been saved with an "unnecesarean." Now she's a birth warrior ... with a dead baby.

And of course, there is the usual willful blindness on the part of many commentors including Nichol Miller-Doula:

I had a dear friend have a similar situation happen, baby lost at birth and the community rallied around her w/o blame seeking and I believe it helped her. I just hate to see this tragedy spread to ruin the lives of women who may have not been willfully negligent, to cause legislation that would disallow women choices in birth, or create situations where our currently birth friendly state becomes less so.

If I could I would ask doula Nichol Miller:

Exactly how many babies have to die before you get the point that homebirth is dangerous. You've already heard of two. Does it need to be 20? 50? What will it take for you to figure out the obvious?

Do you really think that our priority should be the feelings of the midwives as opposed to their competence?

How many dead babies is it worth to make sure that women have choices?

And what choices are we talking about anyway? The choice to let your baby die at the hands of grossly undereducated, grossly undertrained, utterly incompetent unlicensed women who "enjoy" birth?

By my informal count, this is the 8th preventable homebirth death that I have written about so far this year, and that doesn't count the deaths on Hurt by Homebirth. That means that there have already been twice as many homebirth deaths as should occur in the entire country in an entire year!

The old adage is true:

There are none so blind as those who will not see.

Dutch homebirth rate continues to fall

Homebirth advocates point to the Netherlands as an example of a country where homebirth is popular and safe, but Dutch women think otherwise. The Dutch homebirth rate, which has been falling for decades, continues its decline.

As reported in Dutch News:

Professor Jan van Lith of Leiden University's teaching hospital told the paper media reports about the high perinatal death rate in the Netherlands were driving women to chose hospital births. The increase in demand for pain relief is also playing a role, he said.

In other words, Dutch women find the hospital (and obstetrician care) to be safer and more comfortable.

It's not merely that perinatal death rates in the Netherlands are relatively high. The truly amazing fact is that Dutch midwives caring for low risk patient at home or in the hospital have HIGHER death rates than Dutch obstetricians caring for high risk women in the hospital.

That was the finding of the study Perinatal mortality and severe morbidity in low and high risk term pregnancies in the Netherlands: prospective cohort study published in a November 2010 issue of the British Medical Journal. The study was undertaken to investigate why the Netherlands has one of the highest perinatal mortality rates in Europe. The results of the study were nothing short of astounding:

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

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

That means that low risk women under the care of a midwife had more than DOUBLE the chance of perinatal death than high risk women being cared for by obstetricians.

This finding puts the results of the Dutch homebirth study into an entirely different light. Homebirth advocates are quick to cite Perinatal mortality and morbidity in a nationwide cohort of 529 688 low-risk planned home and hospital births as evidence that homebirth is safe because mortality rates at midwife attended births were the same whether they took place at home or in the hospital. But as several commentors pointed out at the time, the mortality rate in both locations (approximately 1/1000) was much higher than would have been expected for a low risk birth. For comparison, consider that low risk midwife attended hospital births in the US have a mortality rate of only 0.4/1000.

So what the Dutch homebirth study REALLY showed is that Dutch midwives have higher than expected rates of perinatal mortality at home AND in the hospital. Hardly an endorsement of either homebirth or midwifery.

Interestingly, health insurance companies report that the decrease in homebirth has not increased health care costs because women are willing to pay an out of pocket fee in return for the perceived increase in safety, not to mention the option of effective pain relief in labor.

This ought to be an object less for homebirth advocates. In the country with the highest rate of homebirth in the industrialized world, neither homebirth nor midwifery provides the lowest risk. That is only found in the hospital under the care of obstetricians. Dutch women know this and the popularity of homebirth has declined dramatically as a result.

Conned by Dr. Wonderful

When I was in training, someone told me that lay people judge doctors by the three A's:

Affability
Availability
and last and definitely least
Ability

I was reminded of that while read that Barbara Herrera, Navelgazing Midwife, is shocked, shocked to learn that Robert Biter, MD, aka "Dr. Wonderful," was not what he seemed.

So, I guess I'm eating huge troughs of crow right now. Embarrassed that I supported someone who seemed so genuine, who really seemed to care about women's rights in birth. And while he might believe he does, when one sets up another human being for the possibility to die from neglect, I have a really hard time understanding where that person… Dr. Biter ... is coming from.

Herrera acknowledges:

... [E]ven as we marched for him in front of the hospital that booted him, stories began emerging about his lackadaisical care, his stretching of the boundaries of safety in homebirths and eventually, I sat and listened as new moms relayed stories that made my toes curl ...

Funny. That's not how I remember it. Herrera was chief among the many women (including Ricki Lake and Rixa Freeze) competing to defend his behavior. As I wrote at the time in Why do natural childbirth advocates participate in their own humiliation?:

Barb Herrera, Navelgazing Midwife, has just written an astounding post that sets a new standard in enabling a "Dr. Wonderful". You can read the piece here. Barb acknowledges that Dr. Biter is currently facing 6 malpractice lawsuits; she confirms that Dr. Biter was reinstated only so that he could resign and avoid the consequences of a suspension; she glosses over the fact that Dr. Biter, her friend and colleague, never bothered to tell her about those lawsuits or the truth about the reasons for his suspension; she proudly declares that Dr. Biter is giving his approval to what she writes on his behalf. And then ... she ignores that information in order to continue to support the man that just abetted her public humiliation.

This is not the first time that something like this has happened. Dr. Stuart Fischbein is still receiving the support of natural childbirth advocates even after his conviction for sexual exploitation of a patient.

Why do NCB advocates routinely participate in their own humiliation, defending indefensible behavior on the part of male obstetricians?

It's because judge doctors by the three A's. They fixate on affability and willingly close their eyes to everything else. It's because NCB emphasizes process at the expense of outcome; the Dr. Wonderfuls are more than willing to collude in such beliefs because their outcomes are often less than ideal. It's because NCB advocates are desperate for praise and affirmation. They will unquestioningly accept the behavior of any male obstetrician who unquestioningly accepts their unscientific, untested methods of practice.

There is a lot that Herrera and her cohorts could learn from this shameful, completely avoidable episode:

1. When obstetricians with unorthodox methods have unsuccessful outcomes, NCB advocates should ask themselves whether the unorthodox methods are to blame, not conclude that the unorthodox methods have made them targets of unwarranted suspicion.

2. When a Dr. Wonderful loses his privileges, they should wait to find out why, not automatically assume that it is personal retaliation.

3. They should find out the malpractice history of the Dr. Wonderful. Any obstetrician who faces 6 lawsuits after less than 10 years of practice should raise alarm bells.

4. When a Dr. Wonderful is convicted of sexual exploitation, they should drop him like a rock.

5. They should never give money to a Dr. Wonderful who solicits from his patients.

6. They should never give money to charity set up by a Dr. Wonderful if the money is to be deposited in his personal bank account.

7. NCB and homebirth advocates need to look within themselves and figure out why they are so easily conned by any male obstetricians who flatter them, and why they cannot recognize that flattery for what it is, a transparent effort to drum up business and hide professional and personal transgressions.

Finally, NCB and homebirth advocates need to start judging practitioners, whether obstetricians or midwives, by their professional abilities, and recognize that affability is not the best way to choose a provider.

Five more things you shouldn't say to Dr. Amy

It's hard to fight a battle of wits with those who are unarmed.

I wrote Twelve things you shouldn't say to Dr. Amy ... unless you want to appear very foolish to save people time, trouble and embarrassment.

Most of what natural childbirth and homebirth advocates think that "know" is factually false. That's why they continually parachute in to "inform" me about one or more of those 12 false claims and then are chastened to find that the claims aren't true and that they have been hoodwinked.

Evidently I've done a good job choosing the claims. Despite more than 700 comments on the post and countless pages of comments about the post on other blogs and message boards, I haven't yet seen anyone challenge the accuracy of my claims.

I had hope to save them embarrassment, by allowing them to find out that they had been duped without having to publicly reveal their gullibility, but they are bound and determined to ignore Mark Twain's famous admonition: "It is better to keep your mouth closed and let people think you are a fool than to open it and remove all doubt."

Now they parachute in to offer comments so blisteringly inane that it is difficult to believe that anyone could be so poorly informed, not only about science and statistics, but about what constitutes a logical argument or a meaningful rebuttal.

It's time to get back to basics. In addition to the 12 erroneous factual claims, I'd like to offer a few more things that you shouldn't say to me unless you want to show that you have literally no idea how to construct a logical argument.

1. You are mean.

That is not an argument or a rebuttal; therefore, it has no place in any discussion of the false factual claims. It is a logical fallacy known as an ad hominem, an attack on the person, not the argument.

2. You are really mean.

For reasons that I cannot begin to comprehend, NCB and homebirth advocates actually think this is an impressive retort when it has been pointed out to them that "you are mean" is not an argument. It's not an argument or rebuttal, either.

3. Dr. Amy is no longer licensed.

This is a more subtle version of the ad hominem, but it has a slightly different implication. It implies that if I did hold an active license, I would not write what I do. It is both ludicrous and a little pathetic.

It's ludicrous because the implication is that obstetricians who are licensed disagree with me, and the reality is that I represent mainstream (if not slightly liberal) obstetric thought.

It's slightly pathetic because the fact that celebrity NCB and homebirth advocates have NEVER had a license to practice obstetrics (or in many cases, have no license or even education in practicing anything) seems never to have even crossed the minds of those who triumphantly point out that my license is not active.

4. I'm glad you're not my doctor.

Me, too! But that isn't an argument.

And, my personal favorite:

5. The commentors on your blog who agree with you are really just you in disguise.

I love this one, because it demonstrates so clearly and so succinctly how illogical and uneducated NCB and homebirth advocates often are.

It's illogical because the accuser has obviously made it up, without making any effort to determine if it is true. It is a window into the "thought process" of NCB and homebirth advocates. They make up stuff that appeals to them without reference to the copious evidence and data that they could access if they bothered, but they don't bother.

Ironically, it is very easy to determine whether someone is posting as someone else, particularly on this blog. First, you can check the comment history of any individual by clicking on their current screen name. If they have posted other comments from the same computer under other screen names, you can see it. Second, you can often see the IP address (the unique signature of the individual computer) after the screen name. If the comment comes from a different IP address, it comes from a different computer.

Evidently, figuring that out is hard; throwing unsubstantiated, bizarre accusations is easy.

The bottom line is that if you plan to contribute one of these 5 things to the discussion, don't bother. They don't constitute an argument or a rebuttal. To the extent that they mean anything, they are just a tacit admission that my factual claims are true and that you can't find any evidence otherwise.

Is it time for a VBAC Court?

We understand the problem: the VBAC (vaginal birth after cesarean) rate is too low. It's time for a bold solution. We need a "VBAC Court."

VBAC is a safe option for most women, and almost 3/4 of women who opt a VBAC will deliver vaginally and avoid another C-section. But we also know that approximately 0.8% of women attempting VBAC will end up with a ruptured uterus, a catastrophic complication that threatens the life of both baby and mother. And we know that 10% of these babies will die or experience severe neurologic impairment.

In other words, 0.08% of babies will die or be profoundly brain damaged. It is a small risk, on the order of many other risks accepted in pregnancy. Why are the other risks accepted, and the risk of VBAC increasingly considered unacceptable by malpractice insurers, hospitals and obstetricians (who are often at the mercy of malpractice insurers and hospitals who set the rules under which they work)?

There are two main reasons:

1. We KNOW that some babies will die or be left brain damaged. Only 0.08% of babies (80/100,000) sounds like a small number until you consider how many women are suitable VBAC candidates. Nearly 400,000 women have repeat C-sections each year. Not all are candidates for VBAC, but most are. With a liberal VBAC policy, therefore, we KNOW that more than 200 babies will die or be rendered brain damaged each and every year.

2. In each and every one of those deaths, attempted VBAC will be the definitive proximate cause of death or injury. Therefore, there is no way to legally defend these cases. And despite the fact that women sign elaborate informed consent agreements prior to attempting a VBAC, when disaster occurs, many sue and claim that they didn't really understand the risk, and they win.

Not surprisingly, malpractice insurers, hospitals and obstetricians do not want to deliberately take on the KNOWN risk that some proportion of babies WILL inevitably die or be left brain damaged by a VBAC, and they will be left open to major lawsuits and multimillion dollar payouts.

It sounds like an insoluble problem until you consider that it is not the only problem of this type. It is almost exactly the same dilemma faced by vaccine manufacturers. They make a product that saves lives on a massive scale, but we KNOW that a tiny percentage of children who receive vaccines WILL die or be rendered neurologically impaired. The parents will sue and they will win because, the vaccine is the proximate cause of the death or disability. Vaccine manufacturers announced that they would simply stop producing vaccines because of inevitable lawsuits.

The government stepped in and created the Vaccine Court.

Though it is knows as the "Vaccine Court," it is, in reality, the Office of Special Masters of the U.S. Court of Federal Claims. Its creation rests on the premise that some deaths from vaccines are inevitable and that lawsuits are a cumbersome, inefficient means of addressing that reality. The Vaccine Court is a form of no-fault insurance. It allows parents and children to receive compensation for death and injuries without filing a lawsuit. It allows vaccine manufacturers to continue supplying vaccines without defending lawsuits over the vaccine reactions that we KNOW will result in a small amount of deaths each year.

The Vaccine Court is part of the Vaccine Injury Compensation Program:

On October 1, 1988, the National Childhood Vaccine Injury Act of 1986 created the National Vaccine Injury Compensation Program (VICP). The VICP was established to ensure an adequate supply of vaccines, stabilize vaccine costs, and establish and maintain an accessible and efficient forum for individuals found to be injured by certain vaccines. The VICP is a no-fault alternative to the traditional tort system for resolving vaccine injury claims that provides compensation to people found to be injured by certain vaccines...

The Vaccine Court works. Each year tens of millions of dollars are paid out to the few families affected by vaccine related death or neurologic injury.

It's time for a VBAC Court, for the exact same reasons that the Vaccine Court was created. VBAC, like vaccination, is public health good. A liberal VBAC policy would reduces unnecessary surgeries, surgical complications, and health care costs. A VBAC Court, by instituting a no fault program for the VBAC related deaths and injuries that we KNOW will occur, will indemnify hospitals and doctors against lawsuits in the same way that the Vaccine Court indemnifies vaccine manufacturers against lawsuits. VBACs will be readily available, just as vaccines are now readily available.

Frankly, I see no other solution to the problem. Malpractice insurers, hospitals and doctors cannot and will not take on the massive liability posed by VBAC. There is currently no way to accurately predict which women will suffer a uterine rupture during VBAC and there is no accurate prediction method on the horizon. Future developments may reduce the number of babies who die or are left neurologically impaired by VBAC, but that number will never be zero.

If we want to increase the VBAC rate --- and patients, doctors and health insurers very much want to increase the VBAC rate --- we have no choice but to institute a no fault compensation plan.

It's time for a VBAC Court.

Midwives responsible for nearly 1/3 of UK direct maternal deaths

It's one of the dirty little secrets of midwifery care in countries in which midwives provide primary obstetrical care. Midwives are often responsible for a disproportionate share of deaths.

As I noted in A stunning indictment of midwives in the Netherlands, a study in the BMJ in November 2010 produced a deeply shocking result:

We found that delivery related perinatal death was significantly higher among low risk pregnancies in midwife supervised primary care than among high risk pregnancies in obstetrician supervised secondary care. This difference was even greater among the cases that were referred from primary to secondary care during labour... (my emphasis)

Now the latest triennial review of maternal deaths in the UK reveals that midwives are responsible for a major proportion of maternal deaths. Indeed, the problem is so worrisome, that an entire chapter is devoted to the role of midwives in maternal deaths.

The report, Saving Mothers’ Lives: Reviewing maternal deaths to make motherhood safer: 2006–2008, was compiled by the Centre for Maternal and Child Enquiries. Chapter 13 is devoted to the role of midwifery in maternal deaths.

During this triennium, a total of 261 women died from Direct or Indirect causes. In 31 of the 107 Direct deaths (29%), the midwifery assessors considered midwifery care to be substandard, as well as in 27 of the 154 (16%) Indirect deaths. This gives a rate of 22% overall for the 261 women who died of Direct and Indirect causes ...

As a general matter, maternal deaths in developed countries occur overwhelmingly among women who are high risk patients. Midwives, of course, care only for low risk patients. Therefore, it is unexpected and disturbing that nearly 1/3 of women who died from direct pregnancy complications were under the care of midwives, and more than 15% of deaths from indirect causes (pre-existing medical conditions) occurred under a midwife, who, by the rules of the UK system, should not have been caring for the patient in the first place.

Why are midwives presiding over so many maternal deaths? Midwives failed to:

• Carry out, record and act upon basic observations for both women at low and higher risk of complications.(emphasis in the original)
• Recognise and act on symptoms suggestive of serious illness, including sepsis ...
• Provide pregnant women and new mothers with information about the prevention and signs and symptoms of possible genital tract sepsis ...
• Assess the mother’s risk adequately throughout the continuum of pregnancy and the postnatal period, re-assessing as needed if circumstances change.
• Refer and escalate concerns to a medical colleague of appropriate seniority...

In other words, midwives, charged with the care of low risk women and referral of high risk women, did not act upon evidence of complications.

In a remarkable passage, the authors note:

It was evident from some of the situations reviewed for this Report that midwives need to develop clear boundaries between advocacy and collusion. There were instances where midwives should have taken a supportive but challenging approach to ensure that women received appropriate care that was in the best interests of themselves and their babies.

Midwives colluded with patients in pretending that high risk situations were not high risk.

Midwives failed to refer low risk patients who became high risk. For example:

A woman in the postnatal period ... reported having felt unwell for a week with symptoms of breathlessness and pain on breathing; she also had swelling in one leg and calf and thigh pain. She was advised by the midwife to attend hospital or a walk-in centre. Some hours later she arrived at the Emergency Department where she collapsed, was intubated, ventilated and transferred to the Intensive-Care Unit. A diagnosis of pulmonary embolism/deep vein thrombosis was made. She went on to have several cardiac arrests later that day. She continued to deteriorate and died some days later.

In addition:

... Similar lessons can be learned from some of the 25 Indirect deaths where the women were booked for midwife-led care. Some of these women who died had co-morbidities that were either missed by the midwife or deemed to be unimportant.

That bears repeating: 25 mothers died of pre-existing medical conditions that the midwives failed to diagnose or understand!

The authors note:

There were many examples of failure to make or act upon basic observations. For instance, a woman with several risk factors for pre-eclampsia arrived at hospital with a fully dilated cervix and promptly gave birth. She was given Syntometrine and, over the next few hours, was observed to have at least four abnormal features symptomatic of pre-eclampsia. These were not acted upon until she suffered a cerebral haemorrhage as a result and died.

The authors point out that these deaths could have been prevented by "getting the basics right."

Midwives are the experts in the care of healthy, low-risk women. They have a clear duty, however, to be equally skilled in the recognition of early signs of problems and to make prompt referral for appropriate senior medical input.

The chapter concludes:

If there is a single 'take-home' message for midwives it is this: listen to the woman and act on what she tells you.

I would go one step further and point out that the relentless "promotion of normal birth" has distorted midwifery. The only thing that should be promoted is the health of mothers and babies. It is grossly inappropriate to promote a process at the expense of outcome. When you privilege process over outcome, as contemporary midwifery theory does, women and babies die.

The legal constraints on VBAC

Lay people often imagine that doctors are entirely independent. They can do whatever they want in the way of medical care, whenever they want in whatever way they want. Nothing could be further from the truth. Doctors are constrained by practice guidelines, insurance company policies and legal sanctions. No where is that more apparent than in the case of vaginal birth after Cesarean, known as VBAC.

VBAC activists like to portray obstetricians as agents of evil who arbitrarily deprived women of the option for VBAC because it was "easier" or "better" for them. The reality is that obstetricians are just as unhappy as patients over the tremendously diminished access to VBAC and they have been working to figure out how to provide easy access to VBAC and comply with practice guidelines, hospital policies and legal penalties. Hence the 2010 NIH conference on VBAC and the recent publication of an entire issue of Clinics in Perinatology devoted to recapping and expanding upon the issues raised at the conference.

The chapter VBAC: A Medicolegal Perspective by Bonanno et al. is one of the best and most concise explanations of the problem that I have read:

What are the fundamental reasons why many hospitals and physicians are no longer performing VBACs? The answer is undoubtedly risk of adverse outcomes and subsequent litigation...

What kinds of adverse outcomes?

As James R. Scott, MD, aptly put in his editorial for the recent conference publication, “VBAC is essentially a uterine rupture issue.” The greatest morbidity from TOLAC for mothers and infants clearly arises from uterine rupture. According to the recent conference statement, the risk of uterine rupture for women who undergo a trial of labor at term is 778 per 100,000 (0.778%), compared with 22 per 100,000 (0.00022%) for women who undergo a repeat cesarean at term...

For patients who have a uterine rupture, what is the likelihood of neonatal death or neurologic injury? Approximately 6% of all uterine ruptures will result in perinatal death...

Okay, but obstetrics is filled with decisions that may lead to the death or neurologic injury of babies. What is different about VBAC?

the primary reason for litigation in obstetrics is the neurologically compromised child, which seems to hold true for VBAC cases. A major difference from the non–VBAC-related cases of neurologically impaired infants is that the proximate cause for the adverse neurologic outcome in most VBAC cases is generally uterine rupture.

In other words, in most cases of neonatal death or injury, there are a variety of possible causes, some that could have been avoided by the obstetrician, others that are out of the obstetricians' control. In the case of VBAC, however, the cause is always the decision to attempt a VBAC instead of performing an elective repeat C-section. There is no possible legal defense for an obstetrician or hospital. The malpractice insurer simply has to hand over the money, sums that may run into the millions of dollars.

What is the bottom line for providers of TOLAC [trial of labor after Cesarean]? They could potentially be involved in a lawsuit in which a large settlement is paid, even if the standard of care was met.

The simplest choice for obstetricians, hospitals and malpractice insurance providers would have been to ban VBAC outright. No attempted VBACs mean no preventable uterines ruptures means no lawsuits that are impossible to defend. But obstetricians did not want to stop offering VBAC, so they hedged them around with practice guidelines meant to ensure safety and reduce the potential for lawsuits even if a bad outcome occurred. The compromise position was to require that obstetricians and anesthesiologists be "immediately" available when any VBAC patient was in labor. The reasoning is based on the fact that the standard requirement that obstetricians and anesthesiologists be "readily available" for emergency C-section, subsequently defined as within 30 minutes, is not fast enough to prevent neonatal death and disability from uterine rupture.

Why the difference in standards? Because the decision to attempt VBAC is 100% elective and, therefore, uterine rupture during VBAC is a 100% preventable complication. Yes, massive abruption, cord prolapse and severe fetal distress can be equally devastating, but none are preventable, and therefore, the decision to assume those risks is not elective at all.

Okay, but since the decision belongs to the patient, doesn't and,the reside with the patient. Evidently not.

...In the setting of adequate informed consent, in which the standard of care was met for the management of a patient undergoing TOLAC, and for which all events were sufficiently documented in the medical record, will providers still be subject to successful lawsuits? Unfortunately, the answer is yes.

Where does that leave us? The authors draw the sad, but inescapable conclusion:

The ultimate solution to the VBAC dilemma will clearly not be found within the current system. Medical courts, tighter regulation of medical experts, dispute resolu- tion, and no-fault regulation have all been described as potential ways to make the system more efficient, more equitable, and ultimately more supportive of families who need financial support regardless of whether the injury was a result of medical negligence...

In other words, the solution will not be found by blaming, pressuring or demonizing obstetricians. Obstetricians didn't cause the problem; doctors can't fix it.

Homebirth Consensus Summit is a farce even before it begins

Silly me! When I first read about the Homebirth Consensus Summit, I thought it was a conference to reach a consensus about homebirth.

After all these years, I should have known better. Homebirth advocates wouldn't dare to hold a conference where all the data would be presented and varying viewpoints aired. At such a conference, the copious data showing that homebirth increases the risk of neonatal death would be presented. Awkward!

At such a conference the CDC statistics showing that homebirth with an American homebirth midwife (CPM) triples the rate of neonatal death would be presented. Really awkward!

At such a conference, the pathetically inadequate requirements for CPM licensure might come up. Really, really awkward!

What to do? Hold a conference where only the only people who can participate must agree with the consensus beforehand. Phew, dodged that bullet.

On the Summit website, buried among the obfuscations, the real goal of the Summit is apparent, as well as the way that the Summit sponsors plan to get to that goal.

The Home Birth Consensus Summit will assemble a diverse multidisciplinary group of individuals with the goal of discussing a common agenda for the provision of home birth services in the United States. (my emphasis)

And if that's not clear enough:

The point is not to debate the "rightness or wrongness" of homebirth. The goal is to establish what the whole system can do to support those who choose homebirth, and provide the care, safety net, consultation, collaboration and referral necessary to make homebirth the safest and most positive experience for all involved-moms, babies, families, communities, health care workers, hospital personnel, administrators, payors, and so on.

The rightness or wrongness of homebirth? What does that mean? It is doublespeak for the safety of homebirth. They couldn't simply say, "The point is not to debate the safety of homebirth" because that would leave open the possibility that it isn't safe. Awkward!

So anyone who wants to create a consensus around the provision of homebirth care is welcome? No, of course not. Only those vetted for agreement with the predetermined outcome of the Summit could possibly be allowed to attend.

The invitation selection process has been an iterative process with many rounds of vetting, internally and externally. Many individuals were nominated ... Short lists were created by multidisciplinary subcommittees chaired by the Vision Team members who were most familiar with representatives of certain stakeholder groups. Each subcommittee went through a detailed vetting and weighing process and considered the balance of perspectives, ethnicities, gender, age, geography and other factors... We also prioritized those who were likely to respect the process by fully engaging in open-minded dialogue.

So the only participants can be those who were invited and you can only be invited if the "Vision Team" knows you, knows what you are going to say and and knows that you won't bring up any issues that the team would prefer to hide. Anything else would be awkward.

It's pretty clever when you think about it. The "Vision Team" wanted to hold a meeting about homebirth without mentioning the safety of homebirth. Since safety is the single most important issue, that is quite a challenge. The only way to make sure that it provides the predetermined "consensus" is to have only invited participants who are undergo "many rounds of vetting" to be absolutely, positively sure that they won't provide any information isn't pre approved, any perspective that isn't pre approved, and above all else, any of that pesky data that homebirth advocates don't want women to see.

Anything else could be very, very awkward.

A new meme in natural childbirth

The media is to blame for the pain of childbirth!

That's the new meme in the world of natural childbirth and it is getting a great deal of play. Childbirth is not inherently painful; its depictions in popular media like TV shows and movies tricks women into believing that childbirth is painful. Hence the otherwise inexplicable preoccupation on NCB blogs with how childbirth is portrayed in specific TV shows and movies.

The meme has received positive attention from all the usual suspects: the Lamaze blogs, Rixa Freeze, Midwifery Today, and even RH Reality Check. Australian midwife Lisa Barrett has been doing an ongoing series called "Absurd Birth Scenes" exploring each TV show or movie in depth.

On the surface, it sounds intriguing, cutting edge and thought provoking. In reality, it is the same dreary sexism masquerading as midwifery theory. You know those silly women! They can't be trusted to perceive their own pain. It's all in their heads. They're all hysterical ... and we know that hysteria, a form of emotional reaction based on distorted thinking, starts in the uterus.

That must be it, since no one is exploring how any other form of severe pain is an illusion fostered by the media. I haven't noticed any documentary movies (direct to DVD or otherwise) that investigate how it doesn't really hurt to have an anvil dropped on your head and we only think it does because it appears to hurt Wile E. Coyote in Looney Tunes.

And no one suggests (or would dare suggest) that men's pain is an illusion fostered by the media. I haven't seen any theories that men getting kicked in the groin don't really experience severe pain but only think they do because of the way that America's Funniest Home Video's portrays getting hit in the groin by a baseball.

This is just the modern iteration of Grantly Dick-Read's profoundly racist and sexist claim that primitive (i.e. black) white have painless childbirth. Childbirth pain is an artifact of cultural indocrination. The new version is that primitive women (i.e. those who aren't exposed to Western media) have painless childbirth. Childbirth pain is (you guessed it) an artifact of media indoctrination.

The concept received its ultimate exegesis in the direct to DVD film Laboring Under an Illusion. The title explicitly claims that childbirth pain is nothing more than an illusion. According to the movie website:

Anthropologist Vicki Elson explores media-generated myths about childbirth. As a childbirth educator for 25 years, she observes daily how our culture affects our birth experiences.

An anthropologist? Not really. Just a childbirth educator who studied "the anthropology of childbirth pain" at the University of Massachusetts.

There is an area of study known as the "anthropology of pain" but the anthropology of childbirth pain differs from it in one major respect. In all other areas of pain anthropology, it is the experience and meaning to the sufferer of pain that is studied. No anthropologist suggests that the pain itself does not exist.

For example, there are studies of the anthropology of the pain of female genital mutilation: how and why women and men in cultures that practice FGM believe that the pain is necessary. And there are studies about the anthropology of the pain associated with extreme sports: how and why women and men are willing to endure the extreme pain of marathon running, for example. However, there are no studies that I could find that argued that female genital mutilation is not inherently painful, or that the pain described by marathon runners does not really exist.

Childbirth pain is real. It's meaning may be culturally mediated, but the pain itself is no more culturally mediated than the pain of being kicked in the testicles. The primary purpose of this ridiculous claim is to justify the existence and high fees of "childbirth educators" and the self-aggrandizing rhetoric of natural childbirth advocates. Many lie about the pain, lie about what works to ease the pain, and lie about the benefits and risks of pain relief in labor. It is ultimately nothing more than self-serving posturing. More lies = more money; more lies = more admiration (or at least self-admiration).

The original theory of "natural" childbirth espoused by Grantly Dick-Read was a racist and sexist lie. This updated theory of childbirth pain is the same sexist lie with the racism stripped out. Both are premised on the same claims: women's perceptions of pain cannot be trusted; the pain is all in their heads; if only women were "educated," they would not have pain in childbirth. It was a disgusting and demeaning theory then; it is a disgusting and demeaning theory now.

Midwifery: last bastion of evidence-free practice?

Is midwifery one of the last bastions of evidence-free practice?

That's what Edzard Ernst wants to know. Who is Ernst? As I wrote last year when discussing the evidence double standard in "alternative" health:

Edzard Ernst MD, PhD, FMedSci, FSB, FRCP, FRCPEd ... is the bete noire of "alternative" health. His credentials are impeccable. He was the first Professor of Complementary Medicine in the UK. Born and trained in Germany, he began his career at a homeopathic hospital. His belief in "alternative" health was so complete, he set out to show that its various remedies are both safe and effective.

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

Writing in a British medical journal last week, Prof. Ernst notes:

... Numerous surveys have shown that, in most countries, including the UK, midwives employ CAM liberally and usually without the supervision or knowledge of obstetricians. Recently published data from Sweden add to this picture.

Ernst pointed to a recent study in the journal Midwifery, Martensson et al., national survey of how acupuncture is currently used in midwifery care at Swedish maternity units. Midwifery 2011; 27:87-92.

The study found that 60% of Swedish midwifery units prescribe acupuncture for "milk stasis" and afterpains; more than 80% prescribe it for retained placenta; and fully 97.8% prescribe it for both relaxation and pain relief in labor.

Ernst explains:

There is some trial data supporting the use of acupuncture for reducing the types of pain listed above. Yet this evidence is far from being uniformly positive and is therefore not convincing. With all other conditions listed above, there is no good evidence at all.

Prof. Ernst bemoans the willingness of midwives to prescribe "alternative" remedies in the absence of supporting evidence, but this is hardly surprisingly when you consider that almost every recommendation exclusive to midwifery was instituted in the absence of scientific evidence or in direct contravention to scientific evidence that shows it doesn't work.

This behavior is not restricted to the grossly undereducated and grossly undertrained American homebirth midwives (CPMs). Obviously it is only to be expected among a group that shuns formal learning and practice standards in favor of "intuition." Unfortunately, as the Swedish study shows, better trained midwives (particularly those in the UK and Australia, havens of midwifery "theory") have no problem ignoring scientific evidence or issuing recommendations in the absence of evidence.

Not only do they ignore scientific evidence, they clumsily try to justify their behavior. Consider the paper Including the nonrational is sensible midwifery, by Parratt and Fahy:

... Our thesis is that midwives and women need to take conscious account of nonrational knowledge and power during the childbearing year. We argue that pure rational thinking limits possibilities by excluding the midwife's embodied ways of knowing along with the ways of knowing embodied by the woman. The inclusion of women's and midwives’ nonrational ways of knowing in childbearing situations opens us up to knowledge and power that provides for a more complete, and therefore a more optimal, decision-making process.

English to English translation:

Science is hard. We don't want to learn it and we certainly don't want to follow it.

In other words, midwifery does appear to be the last bastion of evidence-free practice.

My article in today's Times of London

Yesterday the UK Royal College of Obstetricians and Gynecologists (RCOG) issue sweeping plans for an overhaul of women's health care.

The impetus for the recommendations sounds lofty. According to a Letter to the Editor in yesterday's Times of London, Anthony Falconer, President of the RCOG, writes:

Within women's health there is too much variation in outcomes from cancer to stillbirth, as well as a lack of choice... Today, we publish a report that sets out strong recommendations to ensure that our women's services are world-class and well commissioned. Women's healthcare should focus on preventing illness rather than firefighting after women become sick.

In maternity, we need to co-ordinate services so that women receive the best care in the right place. Many women need only simple interventions, which can be done out of hospitals. This will mean more midwifery-led units and fewer consultant units so that the most specialist care can be concentrated and available around the clock.

In an interview, Falconer insisted that pregnant women "should no longer think of hospital as the default option when giving birth."

The real impetus is rather more grim. There is not enough money to staff and equip health facilities. Services are going to be taken away, but rather than admit to de facto rationing, the RCOG is trying to dress it up as a series of benefits instead of a series of losses.

The Times of London asked me to write a piece in response to the RCOG's recommendation to increase the rate of homebirth. You can find the article here, but it is unfortunately only accessible to subscribers.

The problem is certainly real:

The number of UK births has risen dramatically, 723,165 live births in England and Wales last year, 22 per cent more than a decade ago. The media has been filled with stories of substandard obstetric care, women in labour not getting the attention they require, and maternity units closing.

But the reaction is not appropriate:

In response, the RCOG is calling for change. No, not higher-quality care; not more maternity units, not greater staffing of those units. That costs money! Let’s just convince women they don't need the services. Tell them to give birth at home.

There are two important reasons why it is inappropriate. First, there is no evidence that homebirth is as safe as hospital birth in the UK. In fact:

There is a study of home birth in the UK that has just been completed: the NPEU is set to publish the results of the BirthPlace study, comparing home and hospital birth, in September. That is the study that will show if home birth in the UK is as safe as hospital birth, and it is deeply perplexing that the RCOG has chosen to publish its recommendations ahead of the release of the study findings. Shouldn’t the RCOG first determine whether home birth is safe before insisting that it is?

Second, there is no evidence that homebirth saves money. Homebirth is more personnel intensive:

In contrast to the hospital, where one midwife can care for multiple women in various stages of labour, home birth requires two midwives to care for one woman who may be in labour for many hours. And that’s only if there are no complications. If a low-risk home birth suddenly turns high-risk, the same costs of a hospital birth are incurred, plus the additional costs of transport to the hospital.

So why is the RCOG encouraging homebirth?

It is desperately looking for a way to put a good face on a bad problem. There are not enough providers to care for women in hospitals. Instead of insisting that high-quality care requires more providers, they’ve chosen to pretend that keeping women out of hospitals will make the lack of providers acceptable.

They are wrong, but they won’t pay the price for their wishful thinking. Unfortunately, British women and their babies will.

She still doesn't get it

Last week I wrote a post about the sheer stupidity of Erin Ellis' claims about postpartum hemorrhage. Erin has now written her reply and it seems that she hasn't learned anything.

To recap, Erin claimed that there is a lower incidence of postpartum hemorrhage outside of the hospital because:

Midwives honor the biological importance of the hormonal bubble after birth and do not intervene unless the mother or baby needs help.

As I pointed out, postpartum hemorrhage has nothing to do with bubbles, hormonal or otherwise. Here's what we know about postpartum hemorrhage:

1. It is common in nature; in fact, it is the LEADING cause of maternal mortality world-wide.
2. It is typically caused by failure of the uterus to contract effectively or by pieces of the placenta that have broken off and remained in the uterus.
3.It is far better to prevent postpartum hemorrhage than to treat it.
4.Active management is much more effective than watchful waiting in preventing postpartum hemorrhage.

I advised Erin that she should delete her grossly inaccurate post before she misleads even more women than she has done already. Instead of removing the post, Erin has written a reply. Her reply demonstrates that she has learned absolutely nothing.

Did she acknowledge that postpartum hemorrhage is common in nature? No.
Did she explain that most partpartum hemorrhages are caused NOT by interventions by uterine atony and retained pieces of placenta? No.
Did she acknowledge that, far from causing hemorrhage, routine interventions dramatically reduce the risk of hemorrhage? No, she didn't do that either.

What did she do? She complained that she was misunderstood.

I use hemorrhage to illustrate the larger point that events in typical hospital births — and their outcomes — cannot automatically be extrapolated to out-of-hospital settings.

Don't worry, Erin, I didn't misunderstand what you were trying to do. I pointed out that what you were trying to do was based on claims that are flat out false.

You specifically used the example of postpartum hemorrhage to make the point that interventions cause hemorrhage and endogenous hormones (you remember the "hormonal bubble," right?) are all that is necessary to prevent it. You were trying to make the point that most postpartum hemorrhages that occur are caused by intervention, but you are flat out wrong about that.

Erin, you apparently feel aggrieved but you ought to feel embarrassed. You write:

I will not, however, publish vindictive comments that reflect more of a personal attack than honest questioning or critical discourse.

No one asked you to publish any comments. I didn't submit any comments to your blog. I asked you to publish correct information and to remove the inane garbage that you originally posted.

And, if you remember, I also asked you to get an obstetric textbook and read the FACTS about postpartum hemorrhage. Clearly, you didn't even bother.

The pathetically minimal certification requirements for homebirth midwives

Want to know why the certification process for homebirth midwives (certified professional midwives, CPMs) is a joke? Just take a look at the certification requirements.

You can read all about it here.

What kind of background education is required for certification? Anything goes!

.. including programs accredited by the Midwifery Education Accreditation Council (MEAC) ... apprenticeship education, and self-study... If the midwife is preceptor-trained ... s/he must complete the NARM Portfolio Evaluation Process (PEP).

Seriously? Self-study is considered a valid means of acquiring a degree?

Who can be a preceptor and attest to the adequacy of the candidates educational background? Anything goes!

The NARM Portfolio Evaluation Process (PEP) involves documentation of midwifery training under the supervision of a preceptor. This category includes entry-level midwives, internationally educated midwives, and experienced midwives.

Anyone who calls herself "midwife" is automatically accepted as a qualified "preceptor." Moreover, there is no effort to check a preceptor's report of a candidates competency:

The preceptor holds final responsibility for confirming that the applicant provided the required care and demonstrated the appropriate knowledge base for providing the care.

That means that the only real requirement for becoming a CPM is taking the test. It doesn't matter what your educational background is. It doesn't matter how you got your clinical training. They aren't even going to check whether you actually met the minimal clinical requirements. They'll take your preceptors word for that and your preceptor can be anyone else who has passed the test.

Surely, the portfolio process is exercised by only a small number of women who have special circumstances? Wrong.

Consider this unbelievably scary statistic offered by the North American Registry of Midwives (NARM):

Of the more than 5000 births included in the CPM 2000 study published by the British Medical Journal, 99% were attended by midwives who received the CPM credential through the NARM Portfolio Evaluation Process.

In fact:

The majority of CPM candidates continue to become credentialed through NARM’s Portfolio Evaluation Process and all indications are that consumer demand will continue to drive aspiring midwives to seek the apprenticeship, community-based midwifery educational model that PEP validates.

So although there are midwifery schools, most certified professional midwives have never bothered to attend.

Compare that to the educational requirements for European, Canadian and Australian midwives. They must have a 3-4 year university degree, as well as home AND hospital based clinical training supervised by a variety of different instructors. Compare that to the educational requirements for American certified nurse midwives (CNMs). They have a masters' level degree that involves even more education and clinical training.

The certification requirements for an American homebirth midwives (CPMs) are nothing more than a joke. Anyone can become certified so long as she pays the money and takes the test. There are essentially no barriers to certification, so any birth junkie can not only call herself a midwife, she can pay for a nice certificate to fool others into believing that she has completed an actual program of education and training, even if she has not.

How did this strange set of circumstances come about? As Robbie Davis-Floyd explains in Pathways to Becoming a Midwife: Getting an Education, A Midwifery Today book. Eugene, Oregon: Midwifery Today, 1998.

[Homebirth midwives] do not accept the argument that formal, standardized education is necessary to provide safe and competent practitioners.

That's fine; they don't have to "accept," it, but that doesn't mean that the rest of us should follow suit. Whether or not homebirth midwives accept it, formal, standardized education IS necessary to provide safe and competent practitioners.

Homebirth in The Boston Globe

It has been quite a week for homebirth stories in the mainstream media. There have been three major stories including a long piece in The Boston Globe Sunday Magazine entitled Her home-birth battle. It tells the story of Jenifer Holloman, a woman who had had a C-section 24 years ago, who chose homebirth with lay midwife Deborah Allen for her second child for the usual reasons:

She was studying to be a midwife, she wanted to maximize her chances for having a vaginal birth this time around, and she believed maternal care in the United States had become overmedicalized. Still, there was another, even more important reason Holloman says she and her husband, a carpenter, were interested in home birth. They didn’t have insurance, couldn’t afford the $179 monthly premiums for Commonwealth Care ...

Holloman ruptured her membranes on February 7, 2009, and didn't begin labor until February 10 at 1:45 AM. By waiting longer than 24 hours for her labor to begin after memebranes ruptured, Holloman and her midwife chose to accept a dramatically increased risk that the baby would develop a serious infection.

Holloman abandoned herself to her contractions and recalls that through the lens of her single-minded focus, time seemed all but suspended. But not for Beetz [her husband]. "As the day wore on, I got more and more concerned," he says. "On numerous occasions I asked Deb, 'Is this normal?' She’d say, 'Yeah, it's normal.' I started getting texts and calls. People were starting to worry. I was starting to worry."

By late afternoon on the 10th, Holloman entered the final phase of labor. Each time she pushed, Beetz says, he thought he was about to meet his baby. But each time, there was nothing. "At 5:30, I was nervous," he says. "At 7:30, I was really nervous. At 8, I was terrified, and I didn’t know what to do."

Then they could no longer hear the baby's heartbeat.

... Allen moved her and tried to find the heartbeat again. The medical charting all but stops by this point, but according to what Holloman and Beetz recall, Allen told them that the monitor must not be working. She reached in her bag for new batteries and changed them. Still no heartbeat. Allen picked up the phone and called the hospital...

Nonetheless, they didn't actually leave the house for at least an hour, according to Holloman and Beetz, and they drove themselves to the hospital... Holloman says Allen first suggested they take a car instead of an ambulance, and then that they stay home. "I remember looking at her and saying, 'Deb, I want a full medical intervention,'" Holloman says... "I picked up the telephone and called Cape Cod Hospital myself. I said: 'My name is Jenifer Holloman. I am having an obstetrical emergency. I'm coming in.'"

By that point, the baby had been dead for hours.

At her request, Holloman was put under general anesthesia so she wouldn't be awake when the baby was pulled from her via C-section. When she awoke, she found out she had had a boy. They named him Emmet... After Holloman awoke, she pulled up the list [of family and friends] on her laptop and sent out an e-mail announcing the death of their son.

... When Holloman was released from the hospital, she and her husband went home to the place their baby had died. "Everywhere I looked, all I could see was that I didn’t have my son," says Beetz. Still, they rarely left the house, because venturing out was just as painful. Everywhere they went people asked for the baby. The lady at the bank, the people in the supermarket, visitors at the farm. They started doing their shopping a half an hour from home, where no one knew them.

"It was the longest, saddest year of my life," recalls Holloman.

The official cause of Emmet's death was infection with group B strep (GBS). Obstetricians routinely test women for the presence of GBS because it is the leading infectious cause of death of newborns. Women who are found to be positive for group B strep are routinely treated with antibiotics in labor, and, not surprisingly, cannot be allowed to wait hours after rupturing membranes for labor to start, since that further increases the risk that a deadly infection will develop.

Homebirth midwife Deborah Allen never did a test for group B strep, failed to recommend hospital care when membranes had been ruptured more than 24 hours and ignored Holloman's low grade fever and chills.

In the wake of her baby's death, Holloman evinces a touching faith that things would have been different had Deborah Allen been a licensed certified professional midwife (CPM). If only homebirth midwives were legal and regulated in Massachusetts, everything would have been different.

"A better-trained midwife would never have allowed what happened to transpire," Holloman says. She and Beetz wanted their case to be investigated by an entity that could, if appropriate, sanction Allen and prevent her from delivering more babies. Holloman went to the police, the district attorney, the attorney general, the Department of Public Health, the Board of Nursing, and the Board of Medicine. "No one could do anything. They told us she's neither fish nor fowl in the eyes of the law," Holloman says. Last year, she and Beetz filed a lawsuit in Superior Court against Allen alleging negligence. "We didn't want to sue anyone," Holloman says. "This is the last house on the left for us."

Her faith is entirely unjustified. Within the past several months alone, two certified professional midwives in two different states presided over homebirth deaths. Rather than an investigation by local CPMs, both midwives were treated to fundraisers by their peers to pay the legal costs incurred by their arrests.

Holloman has testified at the State House in support of the bill [that would license homebirth midwives] and has lobbied representatives directly. Two weeks after Holloman made one of these visits in late 2009, her neighbors ... brought her some sad news. Their niece, who also resides in Massachusetts, had just lost her baby in a home birth. She had also been attended by a lay midwife.

Holloman might be even less optimistic if she learned that the Midwives Alliance of North America the organization that represents CPMs KNOWS that homebirth with a CPM leads to preventable neonatal deaths. They have refused to release the death rates of the 23,000 planned homebirths in their database. Rather than investigating substandard care, they are actively hiding it.

Holloman clings to the notion that it was not homebirth but rather the homebirth midwife that deserves the blame for Emmet's death.

... She says she asks herself whether she isn't telling herself some sort of vital lie, but does not believe she is; she doesn’t think home birth caused her son to die, but rather the care she received from Allen...

There is no doubt that Holloman received substandard care, but substandard care is standard for homebirth midwives. Homebirth midwives (CPMs) should not be licensed; they should be abolished. That's what Canada has done, putting it in line with all other countries in the industrialized world.

And nothing changes the fact that homebirth increases the risk of neonatal death. All the existing scientific evidence says so and all the state and national statistics confirm it. The only people who appear to be unaware of the dangers of homebirth are homebirth advocates themselves.

Homebirth and Dr. Amy in the LA Times

On the heels of the AP's completely one sided piece about homebirth comes a piece in the LA Times that explicitly tries for balance. The effort to present both sides starts with the title, At-home birth has pros and cons.

I am quoted in the article:

"All the existing scientific evidence, as well as state and national statistics, make it ultra-clear that home birth increases the risk of death," says Dr. Amy Tuteur, a Boston-based physician and former clinical instructor in obstetrics at Harvard Medical School who opposes home births. "What I had seen of it during my years of practice were only disasters."

And:

The problem with home birth, Tuteur adds, is that the distance to the nearest emergency room can sometimes mean the difference between life and death. "Saying, 'trust birth' is like saying 'trust the weather,'" she says, referring to a slogan occasionally used in natural-birth groups.

The article also notes that:

Much of the opposition to home births is directed at certified professional midwives, not nurse midwives. Critics say the certification for such professional midwives is inadequate for those without a prior nursing background. (Certified professional midwives counter that their training is as rigorous as that of nurse midwives and that their programs are specifically geared toward low-risk home delivery.)

It would have been helpful if it explained that certified professional midwives (CPMs) have less education and training that ANY midwives in the first world, and would be ineligible for licensure in the UK, the Netherlands, Canada, Australia or ANY industrialized country.

And they didn't include the quote from me that I consider most compelling:

The Midwives Alliance of North America (MANA), the organization that represents homebirth midwives refuses to release the death rate of the 23,000 planned homebirths in their database. If their data showed homebirth to be safe, they'd be shouting it from the rooftops. The fact that they won't reveal how many of those 23,000 babies died at the hands of homebirth midwives indicates that even MANA knows that homebirth is unacceptably dangerous.

The piece includes the usual suspects extolling the putative virtues of homebirth and repeats some of the usual mistruths favored by homebirth advocates, including the claim the Johnson and Daviss BMJ 2005 showed that homebirth is as safe as hospital birth, without mentioning that Johnson and Daviss didn't compared homebirth to hospital birth in the same year. That data (available publicly years before the BMJ paper was written) wasn't used because it showed that homebirth had a mortality rate nearly triple that of hospital birth in he SAME year.

The power of the article is to be found in the brave testimony of Liz Paparella, a frequent commenter on this blog:

In 2009, Austin, Texas, mom Liz Paparella's fourth child was stillborn on her living room couch because her midwife failed to take Paparella to the hospital when she began bleeding during labor.

"I never thought it was more dangerous to have a baby at home than at the hospital," says Paparella, who had given birth successfully at home two times previously. "In birth, the risk can change from low to high in a matter of minutes."

Homebirth kills babies ... babies who didn't have to die. All the scientific evidence, and state and national statistics are clear on this point. Most importantly, MANA, the organization that represents homebirth midwives refuses the release the death rates for the 23,000 planned homebirths in their database.

The leaders of homebirth midwifery KNOW that homebirth has an unacceptably high rate of perinatal death. Unless and until they release that information, it is impossible for any American women to make an educated decision about homebirth.

The napalm grade stupidity of Erin Ellis homebirth midwife.

It would be funny if it weren't so deadly.

I'm referring to the napalm grade stupidity of 'Erin Ellis homebirth midwife.' Erin wrote a blisteringly ignorant post entitled "If I were at home, I would have died" — The trouble with extrapolating hospital birth events to homebirth.

It is a textbook example of what passes for "knowledge" among homebirth midwives and their terrible propensity to make stuff up instead of actually learning something.

Erin "explains" that obstetric hemorrhage only occurs in the hospital, and rarely at home. That would come as news to the 140,000 women who die of obstetric hemorrhage each year, almost all of whom come from developing countries, and most of whom give birth at home. Postpartum hemorrhage is the leading cause of maternal mortality world wide. In fact, around the world, 1 woman dies of postpartum hemorrhage every 4 minutes.

Erin, of course, is entirely oblivious to this grim reality. In Erin's fantasy world, women don't hemorrhage at homebirth because:

Midwives honor the biological importance of the hormonal bubble after birth and do not intervene unless the mother or baby needs help.

Here's the problem Erin: postpartum hemorrhage has nothing to do with hormonal "bubbles."

Let's look at the epidemiology of postpartum hemorrhage:

The increased frequency of PPH in the developing world is more likely reflected by the rates given above for expectant management because of the lack of widespread availability of medications used in the active management of the third stage. A number of factors also contribute to much less favorable outcomes of PPH in developing countries. The first is a lack of experienced caregivers who might be able to successfully manage PPH if it occurred. Additionally, the same drugs used for prophylaxis against PPH in active management of the third stage are also the primary agents in the treatment of PPH. Lack of blood transfusion services, anesthetic services, and operating capabilities also plays a role...

In other words, in direct contrast to Erin's assertion, postpartum hemorrhage is MORE likely in the ABSENCE of interventions.

The key factor in preventing death from postpartum hemorrhage is actively working to prevent the hemorrhage in the first place. That means giving medication like pitocin BEFORE hemorrhage starts. It means giving more pitocin, or more powerful uterine stimulants like ergotrate, if hemorrhage is not prevented. It means blood transfusions and it means surgical intervention.

What causes postpartum hemorrhage? Erin has no clue; she thinks:

When you hear someone say 'I would have died if I had a homebirth' or 'my baby would have died' please remember that these are very emotionally charged declarations. In many cases, unnecessary interventions have caused the complications that women and babies suffer from.

It is unlikely that Erin would babble such utter nonsense if she had ever bothered to learn the basics of postpartum hemorrhage. Postpartum hemorrhage is so common, and its causes so well known, that there's a mnemonic, the four T's: tone, tissue, trauma, and thrombosis.

Tone stands for uterine atony, the failure of the uterus to fully contract after delivery. Tissue stands for retained placenta, which makes it impossible for the uterus to contract fully after delivery. Trauma is lacerations, and thrombosis refers to the clotting disorders that often accompany pregnancy.

Atony is the most common cause of postpartum by far.

Uterine atony and failure of contraction and retraction of myometrial muscle fibers can lead to rapid and severe hemorrhage and hypovolemic shock. Overdistension of the uterus, either absolute or relative, is a major risk factor for atony. Overdistension of the uterus can be caused by multifetal gestation, fetal macrosomia, polyhydramnios, or fetal abnormality ...; a uterine structural abnormality; or a failure to deliver the placenta or distension with blood before or after placental delivery...

Unlike other areas of the body, uterine bleeding does not stop by clotting. The bleeding comes from the blood vessels of the uterus that are wide open and exposed after the placenta detaches from the uterine wall. The ONLY way to stop uterine bleeding is for the uterus to contract forcefully to clamp the blood vessels closed. Uterine atony can occur in any woman, but it is more common if the uterus has been distended either by the baby before delivery, or with blood after delivery.

It is also more common in women who have labors that are very short or very long. Long labors are often a sign of poor uterine contractility, and in developed countries, such labors are stimulated with pitocin. Not surprisingly, the same women who needed pitocin to achieve contractions strong enough to deliver the baby, will need pitocin to achieve uterine contraction strong enough to halt uterine bleeding after the baby is born.

The second most common cause of postpartum hemorrhage is "tissue," pieces of the placenta that have broken off and remained inside the uterus. The uterus cannot contract effectively if there is anything in the uterine cavity. Contrary to the fantasies of homebirth midwives like Erin, retained pieces of the placenta is extremely common in "nature," and with traditional birth attendants.

The common causes of postpartum hemorrhage are rounded out by lacerations and by clotting disorders, either pre-existing or triggered by pre-eclampsia or other conditions.

How can postpartum hemorrhage be prevented? Hint: it's not by facilitating a "hormonal bubble."

High-quality evidence suggests that active management of the third stage of labor reduces the incidence and severity of PPH. Active management is the combination of (1) uterotonic administration (preferably oxytocin) immediately upon delivery of the baby, (2) early cord clamping and cutting, and (3) gentle cord traction with uterine countertraction when the uterus is well contracted (ie, Brandt-Andrews maneuver).

The value of active management in the prevention of PPH cannot be overstated. The use of active versus expectant management in the third stage was the subject of 5 randomized controlled trials (RCTs) and a Cochrane meta-analysis...

How effective is active management in preventing postpartum hemorrhage? There is an 80% reduction is cases of postpartum hemorrhage requiring treatment.

... The results indicate that for every 12 patients receiving active rather than physiological management, one PPH would be prevented. For every 67 patients so treated, one patient would avoid transfusion with blood products.

Let's summarized what we (but evidently not Erin) know about postpartum hemorrhage:

1. It is common in nature; in fact, it is the LEADING cause of maternal mortality world-wide.
2. It is typically caused by failure of the uterus to contract effectively or by pieces of the placenta that have broken off and remained in the uterus.
3.It is far better to prevent postpartum hemorrhage than to treat it.
4.Active management is much more effective than watchful waiting in preventing postpartum hemorrhage.

The stupidity of homebirth midwives like Erin Ellis is downright appalling. She apparently knows nothing about the leading cause of maternal death. That's bad enough. What's worse is that she is unaware of her ignorance. And what's even worse than that is that in her arrogance and ignorance she actually presumes to educate laypeople on a topic that she knows nothing about.

Erin, if you read this, and I'm sure you will, do the world a favor and take down your idiotic post. Oh, and before you do ANYTHING else, get a textbook and read about obstetric hemorrhage. Your ignorance and stupidity are nothing short of appalling ... and potentially deadly.

Leanne Italie: What ever happened to journalistic values?

Associated Press reporter Leanne Italie has written a valentine to homebirth by ignoring two fundamental principles of journalism. She saw no need for balance and no need for fact checking. Had she bothered with either, she would have written a very different piece.

Just about everything in the piece is wrong, starting with the title Home birth on the rise by a dramatic 20 percent. Leanne, better check out a statistics book; 20% of a tiny number is not only not a "dramatic" rise, it is trivial.

Let's look at the issue of balance, on the pro-homebirth side I count 8 proponents of homebirth, on the anti-homebirth side I count ZERO. So Leanne, tell us, you thought that it was okay to ignore opponents because ... you couldn't find their e-mail addresses? ... you could only find one obstetrician who would say what you want? ... you couldn't care less about the truth?

Leanne interviewed the usual suspects:

A homebirth midwife.
Three women who gave birth at home, including two who were high risk, because they did not want to listen to or did not want to pay for medical expertise.
Robbie Davis-Floyd, anthropologist and feminist anti-rationalist who asserts that intuition is just as accurate as medical knowledge.
An obstetrician who prefers to ignore the dangers of homebirth.
And ... Johnson and Daviss, still trying to promote their deeply disingenuous and entirely inaccurate BMJ 2005 paper. And still refusing to come clean about the fact that they are both professional homebirth advocates.

I don't know if the homebirth rate is rising or not, Leanne, but if women have to rely on fluff like yours, it's no surprise that they gullibly believe that homebirth is safe. Reporters like you don't bother to address the fact that homebirth kills babies...

That ALL the existing scientific evidence (INCLUDING the Johson and Daviss paper, as well as state and national statistics) show that homebirth triples the rate of neonatal death.

That there are women who have lost babies to prentable cause at homebirth and are desperately trying to get the word out that homebirth kills babies.

That the Midwives Alliance of North America (MANA), the organization that represents homebirth midwives, is HIDING the death rates of the 23,000 planned homebirths in their database.

Leanne, being a reporter and all, doesn't that make you a teensy bit suspicious? If MANA's data showed that homebirth was safe, they'd be shouting it from the rooftops. Instead, they absolutely refuse to tell us just how many of those 23,000 babies died at the hands of homebirth midwives. Let me guess. You didn't call MANA to ask them about those death rates because you didn't bother to find out that they collected that data and, of course, your interviewees didn't bother to clue you in.

Well, Leanne, if you care, you can still salvage something of your journalistic reputation by trying to set the record straight. You can reach me at DrAmy5 at AOL dot com. I'd be happy to:

Explain what the research really shows.
Inform you of the appalling death rates of homebirth in states like Colorado that collect accurate statistics.
Put you in touch with MEDICAL EXPERTS who could detail exactly how and why homebirth leads to preventible neonatal deaths.
Introduce you to women who lost their precious babies at homebirth and are desperately trying to inform other women of the real risks.

You wrote a piece that ignored the very real dangers of homebirth, and as a result, more babies may die preventable deaths. Did you really want to write a puff piece or did you end up writing a puff piece by accident? Either way, you ignored two fundamental principles of journalism: fact checking and balance.

Want to write a balanced and factually based piece about homebirth? Don't hesitate to let me know. I'd be happy to show you the other side of homebirth, the side that the people you interviewed are desperately trying to hide.

Homebirth midwifery: follow the money

Let's do a little thought experiment. Instead of evaluating the claims of homebirth midwives through the prism of ideology, let's assess each claim by asking whether or not homebirth midwives profit. I'm going to go out on a limb here, and repeat a prediction that has been made by regular commentors on this blog: homebirth midwifery recommendations are driven by whether they impact midwives' ability to make money.

1. Pain is empowering and pain relief is unnecessary.

This is probably the central therapeutic recommendation of homebirth midwifery, and (surprise!) it has a tremendous impact on the ability of homebirth midwives to make money. Simply put, homebirth midwives can't make any money from women who want pain relief. Therefore, considerably energy is spent trying to convince women that they don't need and shouldn't have pain relief. That involves a variety of false assertions:

childbirth isn't really painful
childbirth is actually pleasurable (orgasmic birth!)
childbirth pain is empowering
relieving childbirth pain is harmful to the baby
relieving childbirth pain increases the risk of C-section

Pretty clever when you think about it; they cover all the bases: childbirth isn't painful; it is painful but the pain is good for you; and it is painful but relieving the pain is bad for you. This is the threshold issue for homebirth midwives; if they can't convince you that pain relief is unnecessary or harmful, they can't make money from you.

2. Electronic fetal monitoring is unnecessary

Yet another amazing coincidence! Homebirth midwives can't provide EFM so it is critical to convince women that it is unnecessary or, better yet, harmful: it restricts women and slows labor; it leads to "unnecessareans"; it doesn't improve outcomes. It doesn't matter whether those claims are true; all that matters is convincing potential fee paying patients that they are true.

3. Birth is inherently safe.

The entire rationale for hospital birth is the incontrovertible fact that childbirth is inherently dangerous. Without liberal use of the technology and interventions of modern obstetrics, an appalling number of mothers and babies will die in childbirth. Who's going to pay thousands of dollars to be attended by a layperson whose primary qualification is that she is a "birth-junkie" if that means taking on an increased risk of death? Almost no one.

Therefore, it is critical to pretend that childbirth is inherently safe and to hide the mounting evidence that homebirth with an American homebirth midwife kills babies who didn't have to die. That's why MANA (the Midwives Alliance of North America) is strenuously attempting to hide their death rates from the American public.

4. There's no reason to prophylactically treat group B strep, or (an equally efficacious lie) group B strep can be prophylactically treated with (surprise!) stuff you can buy in the store like garlic (?) or antibacterial soap.

Most homebirth midwives don't have access to IV antibiotics, the ONLY effective treatment for group B strep. If they intend to get any money from women who are group B strep positive they must convince them that IV antibiotics aren't necessary or can be replaced by things from the local grocery store.

5. Rh- women don't need Rhogam.

Most homebirth midwives don't have access to Rhogam or getting access to Rhogam would require them to interface with real medical professionals and expose their illegal status. In acknowledging the need for prenatal Rhogam, homebirth midwives risk loss of money and legal action. Far better to lie about the need for Rhogam.

This brief list merely scratches the surface. I'm sure if we put our heads together we can compile a far longer list. The list will contain a variety of heterogenous and even contradictory claims, but every element will be united by one common theme. For homebirth midwives; if you can't make money from it, you must convince women that it is unnecessary or even harmful.

Dr. Klein is publicly chastised

I recently satirized one of the inane papers published by Dr. Michael Klein. Klein has heavily publicized his papers in the mainstream press and on natural childbirth blogs like Lamaze's Science and Sensibility. The conclusion that drew the most press attention was Klein's claim that women who seek care from obstetricians are undereducated about childbirth decisions.

The study was ludicrous on its face because it never actually assessed women's knowledge of the risks and benefits of various childbirth interventions. It only assessed women's self-perceptions of their level of education. In other words, Dr. Klein never showed that women who seek the care of midwives know more about childbirth interventions, only that women who seek the care of midwives THINK they know more about childbirth interventions.

The study is sloppy and lazy; sloppy because it did not control for when in pregnancy the self-assessments were made. It assume that women who felt that they didn't know much about childbirth interventions during the first trimester would feel the same way in the third trimester. It is lazy because Klein didn't bother to do the difficult work involved in assessing what each woman knew; he took the lazy way out and relied on each woman's personal assessment of her knowledge.

Klein, a family practice physician, has in the past worked in conjunction with the Society of Obstetricians and Gynecologists of Canada (SOGC) in efforts to lower the C-section rate and increase the rate of breech deliveries in Canada. Yet in a nearly unprecedented move, the SOGC has issued a position paper condemning Klein personally for his shoddy and irresponsible conclusions.

The Society of Obstetricians and Gynecologists of Canada is concerned that the conclusions highlighted in the UBC media release issued on 13 June 2011, regarding a trio of studies, has oversimplified the issues related to the use of technology in childbirth. While the SOGC has be a strong proponent for normal childbirth and the reduction of C-sections rates in the country, the issues related to decision-making in obstetrics is far more complex than the conclusions drawn by Dr. Michael Klein.

As Dr. Ahmed Essat, president of the SOGC points out:

It is inappropriate to draw conclusions based on attitude alone. The decision making process during labor and delivery is far more complex than that.

The SOGC objects to Klein's underlying assumption that technology is bad, pointing out that:

Society, including the new generation of health-care professionals (not only obstetrician-gynecologists), favor the use of technology.

Dr. Andre Lalonde, executive vice president of the SOGC, rejects Klein's studies and his claims about what they show:

The SOGC feels that comments and conclusions expressed by Dr. Michael Klein are too simplistic and do not take into account a large number of factors that affect the care of pregnant women ...

I couldn't have said it better myself.

Babies die in the hospital, too?

At least several times a month, natural childbirth advocates parachute into this blog with the declaration:

"babies die in the hospital, too."

Duh? That's why we encourage hospital birth in the first place. Childbirth is inherently dangerous, babies die all the time in nature and hospitals save a vast proportion of those who would otherwise die. Let's leave aside for the moment the fact that MORE (a greater proportion of) babies die at homebirth, or that the most common reason babies die in the hospital is due to prematurity, to envisage why the claim is inane on it's face.

Consider:

Non-smokers die of lung cancer, too. Does that mean that smoking is a safe?

Of course not. Smoking INCREASES the risk of lung cancer; it doesn't kill everyone who smokes, and it kills people who don't smoke. That doesn't make smoking either a smart of a responsible choice.

Or:

People wearing a seatbelt die in car crashes, too. Does that make foregoing a seatbelt safe?

Of course not. Foregoing a seatbelt INCREASES the risk of dying in a car accident; not everyone who foregoes a seatbelt dies and some people wearing a seatbelt die anyway. That doesn't make foregoing a seatbelt a smart or responsible choice.

Or:

People who aren't drunk get into fatal car accidents. Does that mean that drunk driving is safe?

Of course not. Drunk driving INCREASES the risk of a fatal crash; not every drunk driver has a fatal accident and drivers have fatal accidents even if they are not drunk. That doesn't make drunk driving a smart or responsibly choice.

Similarly:

Babies die in the hospital, too. Does that make homebirth safe?

Of course not. Homebirth INCREASES the risk of perinatal death; not every homebirth baby dies and babies born in the hospital die, too. That doesn't make homebirth a smart or a responsible choice.