How many babies died at the hands of Colorado homebirth midwives this year?

It's that time of year again, late October, when Colorado homebirth midwives release their death statistics as mandated by Colorado law. Before I disclose this year's death rate, let's review to put it in perspective.

Two years ago, I wrote about the horrifying death toll of homebirth in Colorado:

... [T]he perinatal death rate of LICENSED homebirth midwives in Colorado, caring for low risk patients, exceeded the perinatal death rate of 6.4/1000 for the entire state (all races, all gestational ages, all birth weights, 2003-2007)! Homebirth was the most dangerous form of planned birth by far.

Karen Robinson, CPM [President of the Colorado Midwives Association] was in denial:

I don't believe we have a poor perinatal mortality rate, but if solid data shows we do, then I will be at the forefront of the effort to improve our practices and lower the perinatal mortality rate for homebirth in Colorado.

But as I pointed out in my post:

But the death rates for for the year were even even worse. Last year's results revealed that, licensed Colorado midwives had a perinatal mortality rate at homebirth of 8.6/1000. These numbers are nothing short of horrifying.

Amazingly, last year's statistics were far worse. Colorado licensed midwives provided care for 799 women. Nine (9) babies died for a homebirth death rate of 11.3/1000! That is nearly DOUBLE the perinatal death rate of 6.3/1000 for the entire state (including all pregnancy complications and premature births).



The data is conveniently broken down by type of death and place of death. For example, there were three intrapartum deaths for an intrapartum death rate of 3.8/1000, more than TEN TIMES HIGHER than the intrapartum death rate commonly experienced in hospitals. There were 4 neonatal deaths for a neonatal death rate of 5/1000. That's TEN TIMES HIGHER than the national neonatal mortality rate for low risk hospital birth with a CNM. On hundred women were transferred in labor or after delivery for a transfer rate of 12.5%. The neonatal death rate in the transfer group was 50/1000, an appalling neonatal death rate ONE HUNDRED TIMES HIGHER than that expected in a group of low risk women.

What did we learn from these data?

1. Planned homebirth with a licensed midwife in Colorado has a death rate that is extraordinarily high and has risen in every year since statistics were first collected.

2. Colorado homebirth midwives have an intrapartum death rate 10 times higher than expected.

3. Colorado homebirth midwives have a neonatal mortality rate 10 times higher than expected.

4. Colorado homebirth midwives fail to transfer enough patients and fail to transfer them in a timely fashion.

5. One in 20 patients transferred to the hospital by Colorado homebirth midwives ends up with a dead baby.

How many babies died at the hands of Colorado homebirth midwives this year?

Drum roll please ...

The death toll of planned homebirths attended by licensed Colorado hoomebirth midwives in the last reported year is so high that the midwives, in violation of Colorado law, refuse to relase them!

Let me repeat that. After 4 years of high, rising, and nothing short of appalling death rates, Colorado homebirth midwives are now refusing to report how many babies are dying at their hands. They published an annual report. as they always do, but they left out the homebirth deaths.

They already had an intrapartum death rate 10 times higher than expected and a neonatal mortality rate 10 times higher than expected. How much higher are they now?

If this tactic sounds familiar, it should. It has happened on the state level; homebirth midwives in Oregon, led by Melissa Cheyney are hiding their death rates. And it is happenening on the national level. The Midwives Alliance of North America (MANA) collected death rates for the years 2001-2008. While they were collecting the statistics, they publicly promised they would be used to demonstrate the safety of homebirth midwives, but once they saw the results, they decided to hide them instead.

How many babies need to die before homebirth advocates acknowledge the obvious: homebirth kills babies, homebirth midwivess (certified professional midwives) are grossly undereducated and grossly undertrained, and homebirth midwives are represented by unethical leadership who are willing to let babies die preventable deaths and then hide the bodies?

Homebirth in the US is not about babies, and it is not about birth. It is about a bunch of high school graduates who couldn't or wouldn't get real midwifery training and made up a pretend credential they award to themselves to fool an unsuspecting public.

American professional homebirth advocates are unethical in the worst possible way; they don't care how many newborn lives are sacrificed, indeed that will go to great lengths to hide how many newborn lives they sacrifice, in an effort to continue collecting fees for appallingly incompetent care. The entire leadership of American homebirth, from the President of MANA on down should be ashamed of themselves.

How do American homebirth midwives handle their mistakes? They bury them --- both literally and figuratively.

Promoting normal birth is killing babies and mothers

For years, the Royal College of Midwives in the UK has been on a relentless campaign to promote "normal birth." We are now seeing the results, and they are nothing short of horrific.

Last month the focus was on Furness General Hospital in Cumbria where 6 babies and 2 mothers have died preventable deaths, including:

* Hoa Titcombe, 34, gave birth to Joshua at the end of a normal delivery. But nine days later the baby bled to death after suffering a lung infection which could easily have been treated with antibiotics.

* Thai-born Nittaya Hendrickson and her unborn son Chester both died at the hospital on July 31, 2008 after the midwife in charge of her labour dismissed her fits as ‘fainting’. Mrs Hendrickson later died of a heart attack, while her son died after suffering brain damage.

* In another case Niran Aukhaj, 29, collapsed and died in April that year. Her unborn baby also died. The mother of one, from Ulverston, had experienced a number of problems during her pregnancy, including high blood pressure. Yet midwives failed to take her blood pressure and a urine sample during a routine check-up just a week before she died.

* Liza Brady, whose son Alex was delivered in September 2008 stillborn at Furness General with the umbilical cord wrapped tightly around his neck. At 11lb 13oz, Alex was exceptionally large, yet midwives refused her request for a Caesarean — despite this having been suggested by a consultant obstetrician whom she saw during her pregnancy. During a long and painful labour, the midwives persistently refused her plea to be seen by a doctor and delayed the delivery even though the machine monitoring the baby’s heart showed he was in distress.

'A doctor offered to help as he came on duty, but he was shooed away by the midwives who said he wasn’t needed,' recalls Liza.

Lest anyone is tempted to conclude that this is a problem restricted to a single hospital, today's newspaper reports demolish such wishful thinking ('If you don’t hurry up, I'll cut you': What one mother was told by midwife at NHS Trust where five died during labour).

The [Care Quality Comission] investigated hospitals run by Barking, Havering and Redbridge University Hospitals NHS Trust in Essex.

Four women and seven newborns are believed to have died in the last 12 months on labour wards at the trust’s hospitals.

Sareena Ali, 27, from Ilford, Essex, died in January this year after staff failed to failed to notice she had suffered a ruptured womb that triggered a cardiac arrest and then later tried to revive her using a disconnected oxygen mask. Her daughter Zainab was born lifeless.

Mrs Ali’s husband Usman Javed, 29, who has since moved back to Pakistan, said she was in ‘unbearable pain’ and his pleas for help were ignored by ‘uncaring, incompetent’ midwives...

Then in April, Violet Stephens, 35, from Brentwood, Essex, died after midwives failed to spot she was suffering from pre-eclampsia, which leads to abnormally high blood pressure.

She waited four days to have an emergency caesarean and then died hours later.

Her baby son Christian was delivered healthy and is now being brought up by her sister ...

Obstetrician Prabas Misra of Furness General in Cumbria expressed his concern about the rising death toll among midwife attended patients in a letter to his colleagues (Is an obsession with natural birth putting mothers and babies in danger?):

... [Dr.] Misra wrote of ‘the risk of trying to make every labour and delivery normal and natural, and not thinking laterally (about) possible complications. I am all for having a natural childbirth — but not at any cost’.

Although talking about a specific case, Mr Misra has put his finger on an issue at the root of the problems in obstetrics today: the dangerous myth, promulgated by some midwives, that natural childbirth is not only the kindest form of delivery but also invariably the safest.

For years, the prevailing view among some leading figures in midwifery was that obstetricians were little better than trouble-makers. They were seen as over medicalising the natural process of childbirth, slowing down labour with their foetal heart rate monitors, and so increasing the risk of complications.

As a result of these views, UK midwives embarked on a campaign to promote "normal birth." But what is normal birth? As I wrote in a post last month:

... [N]ormal birth has nothing to do with normal and nothing to do with birth. The definition of normal birth is simple and straightforward: If a midwife can do it, she calls it normal. If she lacks the skill to provide the needed care, she insists that the birth is not normal even if it results in a healthy mother and a healthy baby. "Normal birth" and "midwives" are interchangeable. In other words, "normal birth" is nothing more than a marketing term.

In other words, "normal birth" is about turf, as explained by a British malpractice attorney:

Gill Edwards, a leading clinical negligence solicitor with the firm Pannone, is in no doubt why these fatal mistakes continue.

'Too often, we see a desire for autonomy, sometimes verging on arrogance, on the part of some midwives,' she says.

'It leads them to ignore National Midwifery Council rules that require them to call on the skills of other health professionals whenever something happens which is outside their sphere of practice...'

'Some of our worst cases occur because the drive to achieve a "normal" delivery clouds the judgment of midwives about when to call in specialist help from an obstetrician, or for a paediatrician to be present at the birth to assist with resuscitation when there are signs of foetal distress during labour,' says Ms Edwards.

The promotion of normal birth is more than just a disingenuous ploy to promote midwifery, it is wrong on its face.

The mounting death toll of midwife attended preventable neonatal deaths and preventable maternal deaths demonstrates that efforts to promote normal birth kill babies and mothers. That's not surprising when you consider that promoting normal birth is fundamentally unethical.

An ethical medical professional recommends whatever is safest for the patient, not whatever is most beneficial for the provider.

Is high risk homebirth a form of medical neglect?

Despite counseling about the risk of a fatal outcome, a mother elects to attempt a VBA3C at home, her uterus ruptures and her baby dies.

A woman with a breech baby is advised that birth at home carries higher than average risk. The woman ignores the medical advice, the baby's head is trapped during birth and the baby dies.

A women is told that her twins are in an unfavorable position for successful vaginal birth. The woman elects to have a homebirth and, as she was warned might happen, the second baby dies.

The women in these cases, didn't simply choose to have a homebirth. They chose to ignore the guidelines for homebirth safety by attempting a high risk homebirth. They may argue about their right to choose and their actions may be legally protected, but that doesn't change the fact that, morally, they have committed medical neglect.

What is pediatric medical neglect?

According to the American Academy of Pediatrics position paper Recognizing and Responding to Medical Neglect, written by Carol Jenny of the AAP Committee on Child Abuse and Neglect:

Several factors are considered necessary for the diagnosis of medical neglect:

1. a child is harmed or is at risk of harm because of lack of health care;
2. the recommended health care offers significant net benefit to the child;
3. the anticipated benefit of the treatment is significantly greater than its morbidity, so that reasonable caregivers would choose treatment over nontreatment;
4. it can be demonstrated that access to health care is available and not used; and
5. the [mother] understands the medical advice given.

In each of the cases above, a child died because of lack of appropriate healthcare. The recommended treatment (C-section) offers significant net benefit to the child. Access to healthcare was available, and the mother did understand the advice she received from physicians.

Homebirth advocates often argue that they don't believe that a C-section is necessary in these high risk situations, but a parental belief system, whether religious or secular, is not a defense against medical neglect. For example:

Some families may refuse advice because they lack trust in physicians or organized medicine because of what they have heard from friends or the media or because of previous negative experiences with the health care system.

And:

Medical neglect evaluations should focus on the child’s needs rather than the caregiver’s motivations or justifications. Religious objections, therefore, should not be granted fundamentally different status from other types of objections.

Although competent adults have the right to refuse life-saving medical care for themselves, the US Supreme Court has stated that parents do not have the right to deny their children necessary medical care. The court made this clear in 1944 in Prince v Massachusetts. "The right to practice religion freely does not include the liberty to expose the community or child to communicable disease, or the latter to ill health or death. . . . Parents may be free to become martyrs themselves. But it does not follow they are free, in identical circumstances, to make martyrs of their children. . . ." The American Academy of Pediatrics has taken a firm stance on the rights of seriously ill children to receive lifesaving medical care even if their parents subscribe to religious beliefs that are antithetical to medical care.

In other words, there is no special status granted to medical neglect motivated by religion or by subcultural belief systems.

So it doesn't matter if a mother thinks that birth is to be "trusted."

It doesn't matter that self proclaimed midwives, doulas and childbirth educators tell her that a C-section is not necessary.

And it doesn't matter that she believes she will be traumatized in the hospital.

It is still, morally, medical neglect.

Of course, in the case of high risk obstetric situations, the medical needs of the unborn child are balanced by the medical needs and the personal wishes of the mother. Since every competent adult is legally entitled to refuse surgery, even indicated surgery, a pregnant woman cannot be compelled to have a C-section. Furthermore, since unborn children have no legal rights, the mother is legally entitled to place her medical needs, or simply her personal wishes, above the medical needs of her baby.

Legally, then, the mother cannot be prevented from committing this form of medical neglect, but that does not change the fact that in high risk situations homebirth is morally a form of medical neglect.

Are you still a birth goddess if the baby is dead?

I admit it; I don't understand it.

I understand if you let your baby die by choosing homebirth because you gullibly accepted the "trust birth" nonsense and didn't believe that it could happen. And I understand if you let your baby die by choosing homebirth because you had faith that your God would not let it happen, or if He did it would be for a good reason.

But I don't understand how you can let your baby die a preventable death at homebirth just because you valued your the birth experience more than the life of your baby. Most women I know (including me) would cut off their right arm rather than let harm come to one of their children. But as Lisa Barrett and her supporters make clear, they don't feel the same way. Homebirth, for them, is about their experience and their rights, indeed ultimately their right to let their baby die if they feel like it. They don't even bother to pretend otherwise.

Barrett herself has no qualms about the 5 deaths over which she presided. She doesn't bother to insist that homebirth is a safe choice. She doesn't bother to insist that it is a loving choice. The key point is the element of choice itself. Sure, 5 women chose to have Barrett preside over the preventable deaths of their babies, and, according to Barrett, that is their right. At no point does Barrett express any regret for 5 separate completely preventable tragic outcomes. Why would she when whether the baby lives or dies is beside the point? She facilitated women's choices. That's all that matters for her.

The comment section is filled with one stomach-turning diatribe after another. Not a single one of Barrett's supporters expresses any regret over the deaths of 5 babies, either. Instead, they are deeply incensed that their "right" to let their own baby die might be threatened.

But for sheer cold-bloodedness, nothing beats yesterday's testimony of Sarah Kerr, mother of the twin who died less than 2 weeks ago. Kerr asserts, and offers evidence, that she was well aware that one or both of her babies could die.

She had been told by a doctor that homebirth was dangerous for twins:

Ms Kerr said she was admitted to the Women's and Children's Hospital for rehydration during her most recent pregnancy when a doctor advised against home birth and said an epidural was mandatory for the delivery of twins in hospital, which she opposed.

She knew that Ms. Barrett had presided over at least 2 neonatal deaths. Indeed, she was at the recent coronial inquest to support Barrett.

In the Coroner's Court yesterday, Ms Kerr said she was not discouraged from a home delivery despite in August hearing of the adverse outcomes of home births. Ms Kerr told Deputy State Coroner Anthony Schapel she took full responsibility for her actions and was aware of the increased risk of the delivery of twins.

"No one can say I didn't make an informed choice, I sat through every day of evidence," she said.

And:

Ms Kerr told the inquest that she and her partner understood and had weighed up all the risks before deciding to have the twins at home.

"My babies aren't expendable. I love my babies," she said.

"I didn't make decisions to put them in danger."

But her actions belie her testimony. She did make decisions that put those babies in danger and one of the babies died as a direct result. Evidently, those babies were expendable when compared with the birth experience that Kerr desired.

Lisa Barrett has done us a favor. She has stripped the issue of homebirth down to its essentials: the right of the mother to choose her birth experience regardless of whether or not that choice kills the baby. That's the essence of the homebirth debate, not (purported) safety. It's all about whether the pursuit of the birth goddess fantasy is more important than the life of a baby.

So here's what I want to know;

Are you still a birth goddess if the baby is born dead?

After all, you exercised your rights. You didn't submit to any of those evil interventions. You were free to move in labor. You "trusted your body," and most importantly, the baby came out of the only approved orifice. Does it matter that the baby was dead?

I suspect that for Lisa Barrett, her supporters, and above all for the mothers of the 5 dead babies who continue to champion her, the fact that the baby was dead is perhaps unfortunate, but definitely not the most important thing.

Oops, reducing early elective delivery leads to more deaths

You could have seen this coming.

In a flourish of righteous zeal, the March of Dimes went on record strongly opposing early elective delivery before 39 weeks gestation. They railed against the increase in NICU admissions; they railed against the increase in C-sections; and they railed against the increase in costs. What they inexplicably failed to take into account was the inevitable increase in stillbirths.

When the Christiana Care Health System in Delaware implemented the March of Dimes recommendations, NICU admissions decreased, C-section rates decreased and cost decreased. And more babies died.

Neonatal Outcomes After Implementation of Guidelines Limiting Elective Delivery Before 39 Weeks of Gestation by Ehrenthal et al published in the forthcoming issue of the journal Obstetrics and Gynecology looked at neonatal outcomes before and after limiting elective delivery prior to 39 weeks of gestation.

All singleton deliveries 37 or more completed gestational weeks during the periods of interest were included. Any fetal death was considered a stillbirth; all others were considered live births and were analyzed separately. Each stillbirth was verified and cause of death determined by review of the hospital medical record by the study investigators...

We assessed change in obstetric practice by determining the percentage of neonates delivered during the early term if the delivery was at 37 or 38 weeks compared with full term if the delivery was 39 or more completed weeks...

We had three primary neonatal outcomes for this study: admission to the NICU for at least 24 hours, fetal macrosomia, and stillbirth...

What did they find?

The new policy achieved the objective of lowering births prior to 39 completed weeks gestation:

... the overall percentage of deliveries during the early term fell from 33.1% to 26.4% (P<.001) after the guidelines were introduced when compared with before. This changed for the cohort overall and for both cesarean and vaginal deliveries. The magnitude of the change was greater for those women with an induced labor and repeat cesarean delivery; the change was greatest for those undergoing an electively induction of labor...

NICU admissions dropped:

The overall rate of admission to the NICU was significantly different between the two periods; before the intervention, there were 1,116 admissions (9.29% of term live births), whereas after, there were 1,027 (8.55% of term live births) and this difference was significant (P=.044). Multivariable logistic regression revealed a reduced odds of a NICU admission (adjusted OR 0.92, 95% CI 0.84–1.01) after the intervention...

But the stillbirth rate more than tripled:

... The overall rate of stillbirth of nonanomalous fetuses differed between the periods with an overall increased risk of stillbirth after the intervention (relative risk 2.14, 95% CI 0.87–5.26, P=.06); this overall increase was not statistically significant. However, stratification by gestational age group of the stillbirth revealed the increased risk in the after group was limited to stillbirths before 39 weeks, which increased from 2.5 to 9.1 per 10,000 term pregnancies (relative risk 3.67, 95% CI 1.02–13.15, P=.032), whereas there was no change in risk of stillbirth at 39 weeks or more (relative risk 0.91, 95% CI 0.23–3.64, P=.896).

Because this increase in stillbirths is so large, the authors reviewed each stillbirth to be sure that they were not the result of risk factors that would have triggered a medically indicated induction.

The authors carefully reviewed the medical records of each stillbirth to identify cause of death and the presence of a maternal risk factor ... No definitive cause-of-death pattern emerged.

The reduction in early elective delivery achieved the aims for which the March of Dimes advocated. The reduction in early elective delivery reduced NICU admissions, reduced both the induction rate and the C-section rate, and (although the authors did not measure this) presumably reduced costs. However, these benefits were achieved at a very steep price. The stillbirth rate increased from 2.5 to 9.1 per 10,000 term pregnancies. Instead of 3 stillbirths between 37-39 weeks among 12,000 patients, there were 11 stillbirths between 37-39 weeks among a similar number of patients after reduction in early elective deliveries.

This finding is not unexpected. CDC data shows that the stillbirth rate rises from approximately 3 per 10,000 at 37 weeks to 4.5 per 10,000 at 39 weeks. An increase of 6 stillbirths in a population of 12,000 women is almost exactly what you would expect from reducing deliveries between 37-39 weeks.

This brings us to the heart of the matter. We have traditionally approached the inherent dangers of childbirth by attempting to reduce perinatal mortality. Our efforts have been so successful, that we have turned our attention to reducing perinatal morbidity under the assumption that any reduction in morbidity would be added on to the existing reductions in mortality.

That assumption in clearly not justified. That's because low rates of perinatal mortality have been achieved, in part, by exchanging mortality for morbidity. There are fewer deaths when you deliver babies before 37-39 weeks (whether for indicated or elective reasons); those babies who otherwise would not have lived experience relatively mild, self limited problems related to borderline prematurity. Attempts to reduce these morbidities by preventing borderline premature delivery may simply result in the deaths of these babies, not an overall improvement in outcomes. That's certainly what the existing data on stillbirths and gestational age would predict and that's precisely what happened in this study.

New Dutch study raises troubling questions about the safety of homebirth

A new Dutch study of homebirth appears in the forthcoming issue of the journal Obstetrics and Gynecology. Planned Home Compared With Planned Hospital Births in The Netherlands by van der Kooy et al. is large, comprehensive and raises troubling questions about the safety of homebirth.

The large amount of data is analyzed in a bewildering number of ways, but the bottom line is that homebirth is safe when nothing goes wrong; in the presence of life threatening problems, homebirth increases the risk of death. Moreover, while homebirth with a Dutch midwife in the absence of complications is nearly as safe as hospital birth with a Dutch midwife, the perinatal mortality rate in both groups is 33% higher than comparable risk women delivered in hospitals by obstetricians just across the border in Flanders.

This study is one of many undertaken in the Netherlands to investigate the high perinatal mortality rate.

The debate on the safety of home births continues in the literature ... In The Netherlands, approximately 50% of women give birth under the supervision of a community midwife. The community midwives are independent health care professionals in The Netherlands operating either solely or in group practices.

The proportion of home birth deliveries in The Netherlands has steadily decreased over the last decade but is currently stable at 25% of all births. Several Anglo-Saxon countries are considering the reintroduction of home births based on recent claims of sufficient safety. The reverse trend is observed in The Netherlands, where the debate has intensified since the national perinatal mortality rate showed it to be one of the highest in Europe.

The authors started with a very large and comprehensive database, and analyzed it in a variety of ways. They started with 679,952 births: all the low risk births attended by midwives from 2000-2007. They looked at the difference in perinatal death rates (defined restrictively as intrapartum deaths and neonatal deaths up to 7 days of age) between home and hospital birth, first by analyzing what actually happened, then by constructing hypothetical groups of patients, all of whom were ideal candidates for homebirth.

As primary analysis, we present the results of the natural prospective approach resembling an intention- to-treat analysis. For comparison, we added a perfect guideline approach resembling a per-protocol analysis. The natural prospective approach establishes, within observational constraints, the intrapartum and early neonatal death of planned home compared with planned hospital births.

They further analyzed the data by removing deaths due to the "Big 4": congenital anomalies, premature births, intrauterine growth retardation and low Apgar scores. The decision to analyze the data with these deaths removed is baffling. It's baffling because it removes patients who received potentially substandard midwifery care during pregnancy (failure to diagnose anomalies and intrauterine growth retardation as well as failure to appropriately refer patients delivering before term) and it is baffling because it removes babies in need of expert resuscitation. This group is of prime concern when investigating the safety of homebirth because it is this group that faces the greatest risk when born outside the hospital.

Of note, both groups (real-world and hypothetically perfect) differed substantially by maternal characteristics.

Compared with women who planned birth in the hospital or with an unknown location, the women with a planned home birth were more likely to be multiparous, 25 years of age or older, of Dutch origin, and to live in a privileged neighborhood (all of which are favorable conditions). In home birth women, neonatal case mix compared also favorably. Premature delivery was less common as was the prevalence of a Big 4 condition (natural prospective approach home birth 8.7% compared with hospital 10.8% compared with unknown 10.5%; perfect guideline approach home birth 6.5% compared with hospital 8.2% compared with unknown 7.5%, P <001 in both cases).

In other words, the homebirth group was much lower risk than the hospital birth group.

What did the investigators find?

In the natural prospective approach population, crude mortality risk was significantly lower for women who planned to give birth at home (relative risk 0.80, 95% confidence interval [CI] 0.71– 0.91) ... compared with those who intended to give birth in hospital (P <.05). All maternal and neonatal risk factors, except living in a deprived neighborhood, showed significant effect sizes in agreement with the expected direction. Mortality was significantly increased in neonates with a Big 4 outcome, especially in those with multiple Big 4 conditions (relative risk 276.6, 95% CI 240.3–318.3).

When looking at what actually happened, the death rate at home was lower than in the hospital, but that reflects both the difference in risk factors between the two groups and the difference in "Big 4" bad outcomes between the two groups. After adjusting for these risk factors and differences in Big 4 outcomes, home and hospital had similar perinatal mortality rates:

The nested multivariable logistic regression analysis showed that in the presence of adjusting maternal factors only (model 2), the intended place of birth had no significant effect on outcome. The maternal factors showed risks similar to the univariable (crude) analysis. The addition of Big 4 case mix adjustment (model
3) showed the intended place of birth to be a significant covariable, yet the contrast of planned home birth (odds ratio 1.05, 95% CI 0.91–1.21) compared with a hospital birth (reference <1) turned out to be nonsignificant. The effect of maternal risk factors was affected to a limited degree by the introduction of the Big 4 case mix.

The perfect guideline approach yielded similar results.

What does this mean? It means that when nothing goes wrong at homebirth, it is just as safe as midwife attended hospital birth. Since complications are uncommon, the overall rates of homebirth and hospital birth perinatal mortality are very similar. However, in the event of an unanticipated bad outcome, homebirth has a much higher perinatal mortality rate than midwife attended hospital birth.

In a nod to the BMJ study published by their colleagues last year, which showed that low risk birth with a Dutch midwife (home or hospital) has a higher mortality rate than high risk hospital birth with a Dutch obstetrician, the authors acknowledge that the mortality rate for midwife attended births, both home and hospital, are higher than expected:

... The data from an otherwise very similar country such as Flanders suggest that more favorable results may be expected in low-risk women in general from a hospital-based system. In Flanders, perinatal mortality is approximately 33% less than in The Netherlands, whereas the cesarean delivery rates show little difference.

The authors compare their results with other homebirth studies, noting that home and hospital populations differ markedly in risk profile and that any study of homebirth outcomes must correct for these differences.

Our conclusions apparently contradict those of De Jonge et al who concluded equal intrapartum and early neonatal outcome of planned home birth compared with hospital birth in apparently the same population... Our principal approach (natural prospective approach) compares neonatal mortality in the actual populations delivering at home compared with the hospital, whereas the approach of De Jonge et al compares neonatal mortality in a hypothetical group resembling our perfect guideline approach population.

What's the bottom line?

Homebirth is as safe as hospital birth when nothing goes wrong. But when complications occur unexpectedly at birth, hospital is much safer than home.

The Lisa Barrett whine

Lisa Barrett has presided over 5 newborn deaths in the past 4 years and now she is being persecuted just because of a few dead babies:

They have raided my house so I no longer have a computer or a telephone, my husband can’t carry on his business as they took his computer and the children can’t do their school projects as they took their computer too. They have the power to prevent a grieving mother from being reunited with her baby. All for a political agenda, to scare and humilitate...

Five babies are dead and Lisa Barrett insists that she is the victim. It is, as usual, all about her.

Any expressions of sympathy for the 5 sets of bereaved parents? Nah. Any sense of regret for the 5 lives lost? Nope. Any explanation of why those deaths were inevitable? Not in 4 of the 5 cases, and in the 5th she offers an explanation at odds with the one the mother gave and not particularly believable in any case. According to Barrett:

It’s one thing to slander me and reprint downright lies about me, it’s totally another to take a woman’s story of her baby born with hydrops due to a brain infarct at 30 weeks (backed up by an MRI when baby was alive) ...

1. Hydrops is whole body swelling generally the result of congenital heart failure. It has nothing to do with the brain.

2. Maybe Lisa just got her terms wrong and she meant hydrocephalus (excess fluid in the brain) instead of hydrops. We know that babies in the breech position have a higher incidence of hydrocephalus. That's why it is IMPERATIVE, before attempting a breech delivery, to determine the exact position of the breech and whether the baby has any anomalies. So, if the baby did have hydrocephalus, that could have been determine beforehand, and the disastrous vaginal delivery could have been avoided.

3. Brain infarcts (strokes), while rare, are not incompatible with life. Depending on the extent of the damage, babies with prenatal brain infarcts can have mild impairment or none at all.

4. The technology for MRI has improved dramatically, but no MRI machine can tell when an old brain infarct occurred. Barrett's claim that an MRI showed that an infarct occurred at 30 weeks is bizarre, and, as I mentioned above, does not comport with the mother's claim that a non-specific brain defect existed that was present "at conception."

But, hey, what's a few absurd claims among friends? And why mention those four other dead babies anyway when it's all about her. The 5 dead babies are merely a pretext for "a political agenda to scare and humiliate" her. It's all a horrible coincidence. The government wants to prosecute Lisa Barrett for unsafe practice and for practicing without a license and they conveniently found 5 dead babies with which they can do it. Or, as a supportive commentor on Barrett's site described the babies, "new carcasses to pick over."

I have news for Barrett and her followers, it's not about her; it's about those 5 babies who died preventable deaths. No one cares enough about Lisa Barrett to persecute her; she's just not that important, and not particularly threatening to anyone but innocent newborns. It's about the "concept that must not be named" in homebirth midwifery circles: accountability.

Far from being an example of government persecution, Lisa Barrett is an example of rogue practitioners who deny the legitimacy of any regulation, who refuse to acknowledge their own limitations, who recklessly preside over multiple preventable deaths, and who feel accountability is for everyone else but them.

The government of Australia is not making an example out of Lisa Barrett. Lisa Barrett is making an example out of herself. She's made herself Exibit A in a demonstration of the incompetence, recklessness and mind-boggling narcissism of rogue homebirth midwives.

Five babies are dead, Lisa. At least pretend that you care.

Home Birth Consensus Summit

The Home Birth Consensus Summit is underway. There are quite a few people tweeting. I've put a a twitter gadget in the sidebar so we can follow the tweets. The tag #hbcs is being used to aggregate the tweets into one stream.

You can add your comments to the Twitter stream. Just include #hbcs somewhere in the tweet.

Why lie about childbirth pain and bonding?

The theory of the "big lie" is that if you say it loud enough and long enough, people will believe it regardless of how ridiculous it is. Such is the case with Dr. Michel Odent's claim that childbirth pain is necessary for mother-infant bonding. It is ridiculous, there is no evidence for it, which is not surprising since he made it up.

Odent went public with his fabrication in July 2006:

Women who choose to have Caesarean sections may be jeopardising their chances of bonding properly with their babies, a leading childbirth expert has claimed.

Obstetrician Michel Odent said that undergoing the planned procedure prevents the release of hormones that cause a woman to 'fall in love' with her child.

Speaking at a conference in Cambridge, Dr Odent warned that both C-sections and artificial inductions with drugs somehow interfere with the natural production of the hormone oxytocin.

The French expert said: "Oxytocin is the hormone of love, and to give birth without releasing this complex cocktail of love chemicals disturbs the first contact between the mother and the baby...

"It is this hormone flood that enables a woman to fall in love with her newborn and forget the pain of birth."

He added:

What we can say for sure is that when a woman gives birth with a pre-labour Caesarean section she does not release this flow of love hormones, so she is a different woman than if she had given birth naturally and the first contact between mother and baby is different.

Why is this a big lie?

1. There is no evidence that oxytocin is required for bonding.
2. There is no evidence that a complex interaction like maternal-infant bonding is mediated simply by hormones
3. If oxytocin were the source of bonding, women who received pitocin would be more bonded to their babies than anyone else.
4. Odent and his supporters get around this difficulty by claiming that pitocin is different from oxytocin (false) or that the only oxytocin produced within the brain can have an effect on the brain (there's no evidence for that).

The claim that childbirth pain is required for bonding is nothing but an offensive smear. No doubt Odent and his supporters wish it were true, so that simply asserted it.

Interestingly, this is not the only time that Dr. Odent has made up a theory to support his personal prejudices. Evidently, he could not stand to support his own wife when she was in labor, so he has made up a theory that the presence of fathers at birth is "dangerous."

In April 2008, Odent declared:

That there is little good to come for either sex from having a man at the birth of a child.

For her, his presence is a hindrance, and a significant factor in why labours are longer, more painful and more likely to result in intervention than ever.

As for the effect on a man - well, was I surprised to hear a friend of mine state that watching his wife giving birth had started a chain of events that led to the couple's divorce?

What is the genesis of this theory? Dr. Odent's personally discomfort with attending the births of his children.

As it happens, at the exact moment our son arrived in the world, the midwife was on her way down the street and I, having made my excuses realising he was about to be born, was fiddling with the thermostat on the central heating boiler downstairs.

My partner did not know it, but I had given her the exceptionally rare, but ideal situation in which to give birth: she felt secure, she knew the midwife was minutes away and I was downstairs, yet she had complete privacy and no one was watching her.

I raise the issue to point out that Michel Odent fabricates his theories about childbirth out of thin air. In this case, as in the case of his offensive claims about childbirth and bonding, he announced a brand new scientific theory without any research and without any evidence. He seemed to think that it was enough that the theory made sense to him and confirmed his personal preferences.

It is easy for lay people to understand that Odent's "theory" of fathers at birth is nothing more than a projection of his own anxieties and prejudices. It is important for lay people to understand that his "theories" of natural childbirth and bonding are also nothing more than projections of his own anxieties and prejudices.


This piece first appeared in July 2009.

Lisa Barrett presided over a 5th homebirth death

I have received information that Lisa Barrett presided over a 5th homebirth death. The baby boy was born on May 31, 2009 and died due to brain damage on June 2, 2009. This was the mother's second homebirth with Lisa Barrett. According to the mother:

Sunday at about 8:40 pm our son Ian was born at home. He didn't breathe at birth despite our midwives' best efforts. We went to hospital with him where he was put on a ventilator to help him breathe while they worked out what was wrong with him. Long story short, he had severe brain damage and other problems that the doctors reckon happened weeks or months ago, or even at conception. It's just one of those things that's out of our hands. He died this afternoon (Tuesday) at about 2:00 in my arms at Flinders medical centre with Darrin & Caleb in attendance as well.

Several days before the birth, the mother, Melissa, had posted that the baby was breech:

... Mine's breech at the moment, I'm sure he/she will turn anyway, but even if that doesn't happen, breech babies still come out in one piece most of the time. And my midwife is a big believer in that too, babies come out whatever way they're positioned and there's usually a good reason they chose an 'unfavourable' one if it turns out that way.

Barrett presided over the homebirth of the mother's first child (story on Barrett's website).

The mother continues to support unrestricted access to homebirth. Only 3 months after burying her baby, she attended a pro-homebirth march protesting proposed regulations for homebirth:

And the legislation, if/when it goes through, will NOT stop me birthing at home next time. Yeah there’s a few publicly funded home birth programs, but I wouldn't qualify for them now because one of my babies died. Never mind that Ian was damaged long before his birth, and in the unlikely event I had another baby with the same issues, there's nothing the almighty 'they' could do about it anyway...

Of note, Barrett presided over this homebirth tragedy, an apparent breech birth, only a month after the death of Jahli Jean Hobbs, a breech baby who also didn't breathe at birth and died shortly thereafter.

Lisa Barrett's betrayal of midwifery

Lisa Barrett's ears must be burning. They're talking about her in the Australian Parliament:

South Australian Deputy Coroner Anthony Schapel recently completed an inquiry into the deaths of two babies in separate incidents in 2007 and 2009.

Former midwife Lisa Barrett attended both births.

South Australian Health Minister John Hill told state parliament on Tuesday he had been advised that Ms Barrett was associated with two other incidents involving home births.

On October 7 this year, a twin died, with the Women's and Children's Health Network advising the state coroner of the death.

And on October 12, a woman presented at an Adelaide hospital in established labour.

A baby was born safely, but Mr Hill said the mother then took the newborn home, against medical advice.

The minister said the mother subsequently returned to get medical treatment for the infant, accompanied by Ms Barrett.

Mr Hill said he was also advised that Ms Barrett was involved in a coronial investigation in Western Australia relating to the death of a twin during another home delivery.

But Lisa Barrett has done more than recklessly put at risk and then lose the lives of four babies. She has betrayed the ideals of midwifery itself.

Everyone knows that midwife is the person (usually female) who assists women with childbirth. Where did the word "midwife" come from? According to the Free Dictionary:

... Wife in its earlier history meant "woman," as it still did when the compound midwife was formed in Middle English (first recorded around 1300). Mid is probably a preposition, meaning "together with." Thus a midwife was literally a "with woman" or "a woman who assists other women in childbirth." ...

Why would women need assistance with a perfectly natural function like childbirth? Childbirth is inherently fraught with life threatening dangers and having an assistant is known to improve the chances that both baby and mother will survive. A more complete definition of "midwife" would be "a person who provides life saving assistance to women during childbirth."

Note that the definition is not "a person who helps mothers self-actualize by having the birth of their dreams." Yet midwives like Lisa Barrett, who repeatedly preside over preventable neonatal deaths, have implicitly rejected the traditional lifesaving purpose of midwifery in exchange for a role as new-age life coach, exhorting women to self actualize through giving birth in a non-traditional setting while defying any notion of safety.

To understand just how much someone like Lisa Barrett betrays the heritage of midwifery, it helps to imagine how an African-American midwife of the 1920's, or a European midwife of the 1500's or even an aboriginal midwife of the Neolithic period would have greeted the notion that her job was to facilitate self-actualization through birth. They would have been utterly incredulous, assuming that they even understood the concept of self-actualization as opposed to mere survival.

How did some midwives go so wrong? It's all about market share.

Midwives had the job description "a person who provides life saving assistance to women during childbirth" to themselves until relatively recently. In the past 100 years, though, it has become apparent that obstetricians can fulfill the primary purpose of keeping mother and baby alive well, and in many situations better than midwives themselves. To retain or gain market share, some midwives chose to diversify by redefining midwifery itself.

Instead of striving to give a healthy baby to a healthy mother, these midwives re-purposed birth as an exercise in self-actualization. They turned birth into an extreme sport whereby women are supposed to derive a sense of power and mastery by completing a self imposed task in the face of tremendous physical exertion or pain. It is a deft bit of marketing; the reality is that, in contrast to completing a marathon or climbing a mountain, any woman can have a baby without pain relief and in defiance of safety precautions and most mothers who have ever existed have already done it (or died trying). No matter; these midwives portray unmedicated birth as a rare accomplishment. The midwife's role is not to prevent death, but to coach women in this effort to self-actualize.

Looked on from that point of view, the inexplicable becomes understandable. The claim that "a live baby is not the most important thing" is impossible to square with the midwife's traditional role to prevent neonatal and maternal mortality, but it makes sense if the midwife believes her role is to facilitate maternal self-actualization.

The reckless encouragement to "trust birth" in the face of even the most serious complications makes no sense for the midwife who views her purpose as preventing death, but it makes perfect sense if she think that increased difficulty and risk (higher mountain, longer distance) equals greater accomplishment.

And it also explains the obsessive invocation of "choice" whenever the issue of safety comes up. The African-American midwife of the 1920's, European midwife of the 1500's and the aboriginal midwife of the Neolithic period privileged safety over "choice" whereas the midwife/facilitator privileges choice above all else.

Lisa Barrett may be a particularly egregious case of the betrayal of midwifery, but she is far from alone. Contemporary midwifery theorists, particularly those in Australia and the UK have provided the philosophical rationale for abandoning the traditional role of the midwife in preventing neonatal and maternal death for the more appealing (to them) role of midwife as facilitator of self-actualization. The emphasis on "normal birth" as a goal in itself, the rejection of rationalism for "other ways of knowing," and the insistence that "a healthy baby is not the most important thing" represent a betrayal of the essence of traditional midwifery in which the health and safety of baby and mother is paramount.

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We are surrounded by visible and invisible toxins that cause cancer, autism, ADD/ADHD and chronic fatigue syndrome. There are toxins belched into the atmosphere by greedy corporate moguls, toxins in vaccines, even toxins produced by own bodies. That's why everyone needs to vigilant in refusing anything that isn't 100% natural, and to constantly detoxify using preparations/supplements/guidebooks you can buy on this website.

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A question for Navelgazing Midwife

Earlier this week I wrote about how Navelgazing Midwife has come to accept some basic realities about pregnancy and childbirth that many homebirth midwives reject. It has been a long time coming.

I first wrote about Barb Herrera, Navelgazing Midwife, almost exactly 4 years ago when she transferred a patient to the hospital so someone more experienced could suture a tear. She acknowledged that she really didn't have enough experience to suture a tear or insert an IV.

A few months later Barb described her experiences with two births, one a face presentation where the baby would have died without a C-section, the other a serious shoulder dystocia that could have led to the death of the baby. Then she offered surprisingly harsh criticism for another homebirth advocate who questioned the judgment of a provider:

In ignorance, for there is no other way to say it but this, [she] says that whenever a doctor or midwife speaks about induction because the baby is getting large, that that is a threat. Only someone who hasn’t struggled with a shoulder dystocia – either in her own vagina OR with one in her hands as a midwife – would say something so amazingly dangerous...

Once again, she acknowledged that experience had taught her many valuable lessons.

... [W]hen women came to me and said, "I don't want you to do anything but sit in another room," I used to obsequiously tell them I would. It is the woman’s birth, after all, right?

Then, with more experience, I woke up and figured out I couldn't help if I didn't monitor the mom and baby. It's not like I'll do vaginal exams that aren't warranted or intrude in women's space, but there are minimums that I feel are necessary for competent care and I no longer will compromise on that belief...

In fact, she went so far as to declare that the reason to hire a birth attendant is because of her experience:

When I am hired to be someone's midwife, I am being hired as a consultant. I am being asked to share my experience and knowledge, to utilize my skills – the ones that can save a life...

Over the intervening years, NGM has gained more experience and has changed her views based on that experience. That is what a good practitioner does. In fact, she has come to believe that the experience required for certification or licensing as a homebirth midwife is so deficient that homebirth midwives are not safe practitioner. She has put her money where her mouth is, suspending her practice as a homebirth midwife until such time as she has greater education and experience. She deserves kudos for that decision and for having the wisdom and humility to publicly acknowledge her evolving views.

Yet there is a deeper issue here, one that I would like to ask Barb about. There are people out there who have the requisite experience that Barb knows she lacks. We call them certified nurse midwives. And there are people out there who come out of their training with even more experience than that. We call them obstetricians. Those CNMs and obstetricians could have (and probably did) point out to Barb that she did not have enough experience to be a safe practitioner and she blithely ignored them.

In other words, Barb demonstrated the Dunning-Kruger effect. She had so little knowledge on the topic that she couldn't fathom how little knowledge she had. She had a dramatically over inflated view of her own education and experience. Simply put, she didn't know what she didn't know.

It is a problem endemic to homebirth midwifery and is probably inherent to homebirth midwifery. Homebirth midwives disparage experience because they have so little of it. To acknowledge the value of experience would mean acknowledging their woeful inadequacy as practitioners. So here's my question for Barb:

Was there anything that anyone could have said to you at the time you embarked on your career that would have brought home to you the absolute necessity of copious experience in becoming a safe practitioner? Put another way: Is there anything anyone could have told you to convince you that you didn't know nearly enough?

If I had to guess, the answer would be "no" because the philosophy of homebirth midwifery disparages the value of experience. And that's why the homebirth midwifery credential (certified professional midwife) must be abolished. It was created for, designed by, and administered under the auspices of a group of women who have so little clinical experience that they don't understand the value of clinical experience.

The CPM is a pretend credential for women who want to call themselves midwives but can't be bothered to (or don't have the academic skills to) obtain a college level degree in midwifery. It is a pretend credential for women who don't want to spend the time and energy necessary to acquire the experience that is mandated for all other midwives in the industrialized world.

But maybe Navelgazing Midwife would disagree. Barb, is there anything we could say to homebirth midwives to wake them up to the fact that their education and training is deficient? Is there any way we could convince them of the value of experience?

Choosing mothering vs. mothering choices

Since the subtext of the natural childbirth and attachment parenting movements is the notion of the good mother, it's worth asking what makes a good mother. My whole approach to writing about childbirth and mothering choices is based my rejection of currently popular beliefs about good mothering. Simply put, I believe that good mothering is about choosing mothering and not about mothering choices.

What does choosing mothering mean? It means actively embracing the role of caretaker, confidante, educator and moral guide that mothering entails. It means worrying, planning, consulting, advising and ultimately letting go. Should he be the youngest in kindergarten or wait a year and be the oldest? How should she handle the playground teasing? Am I expecting too much from him or does he have a learning disability? Should I let her go to the dance with the older boy or is she still too vulnerable?

It is kissing the boo-boos, helping them face the fears, stepping aside and allowing them to talk to the doctor in private when they are old enough. It is piano lessons, orthodontia, religious services, holiday celebrations. It is not responding when she says "I hate you" and never failing to respond when you see him teasing another child. It is hard, damn hard, with weeks or months that leave you exhausted or emotionally drained. Yet it is also rewarding at the deepest level, forging a bond to last a lifetime, launching a happy young adult into the world.

It is NOT about specific mothering choices. Breast or bottle? That's the mother's choice and nobody else's business. Natural childbirth? Irrelevant. Baby wearing? It depends on the baby and on the mother. Extended breastfeeding? Meaningless in the long run (and often in the short run, too).

How do we know a woman is a good mother? We know because she cares; she cares about her children and cares about the impact that she is having on those children. To love a child is to choose mothering. In contrast, specific mothering choices have nothing to do with love, because there is not only one way to express love.

My fundamental objection to the philosophies of natural childbirth and attachment parenting is not the emphasis that they place on mothering; I object to the fact that they privilege specific mothering choices over others. In other words, adherents believe their own mothering choices proclaim their "goodness" and that different choices on the part of other mothers identify them as bad mothers.

Instead of viewing mothering as a service they willingly give their children, they view it as a social identity that they construct for themselves, boosting their own egos in the process. That's why discussions about NCB, breastfeeding and attachment parenting are such a source of discord between women. None of those discussions are about the best way to mother a baby; they're all about who is the best mother. It may seem like a trivial difference, but it is an immense difference and most women recognize it as such.

The most critical ingredient of good mothering is love. A child who is loved has the advantage over any other child, regardless of the specific parenting choices his mother made. It's time to acknowledge and value the power of choosing motherhood and stop judging other women based on mothering choices.


This piece first appeared in June 2010.

Dr. Amy on Time.com

Time.com has inaugurated a new section called Ideas, and I contributed a piece:

Myths of Natural Childbirth

Navelgazing Midwife on choosing a homebirth midwife

Barb Herrera, Navelgazing Midwife, has written a series of posts (starting here) on choosing a competent homebirth midwife. In reading the posts, I am struck by how much of what Barb writes comports with what I have written over the years.

I've written that homebirth midwives claiming to be "experts in normal birth" is worse than useless. It's like a meteorologist claiming to be an expert in good weather. If nothing goes wrong, there's no need for an attendant of any kind. The entire purpose of a birth attendant is to prevent, anticipate, diagnose and manage birth complications.

Barb writes:

But, whomever you’re hiring, it is someone to, ultimately, save the life of you or your baby if a tragic emergency occurs. When a complication occurs in the hospital, there is a team of folks to do the various parts of the job in keeping someone alive. If there are mistakes being made, there is almost always another person there to see it and fix the mistake. In a homebirth setting, you have one, usually two and sometimes three people to save the life/lives. If each person isn’t meticulous in their abilities, there is no back-up team to take over or even witness the mistake/s. This is why choosing the right homebirth midwife is so important.

I have written repeatedly that there are unanticipated life threatening emergencies that can and do happen at homebirth. If a baby needs an immediate C-section or if a baby is born requiring an expert resuscitation including intubation, the baby will simply die at home. The baby will be long dead before the mother and/or baby can be transferred to a hospital.

Barb writes:

It is vital for women and their families to understand that ... there are also emergencies that happen in the home that would be able to be handled better and safer if mom and/or baby were in the hospital. If a massive hemorrhage occurs, there are no blood products in the home, nor are there the plethora of means to control bleeding like they have in the hospital. Also, if a baby needs more than minimal resuscitation, the hospital is the place to be for their teams of personnel trained to attend to such emergencies...

I have written that, contrary to the fantasy of the informed homebirth advocate, it is absurd to place responsibility for assuring the competence of a homebirth midwife on the mother herself.

Barb apparently agrees heartily:

... But, how is the client supposed to learn how to be a midwife and be able to gauge whether the interviewees are wise enough to fulfill their promises during their pregnancy – all the while getting care from these midwives? It’s absurd to expect a woman hiring a midwife to know more than the midwife herself. This is where a standardized education and skills system being in place can not only save the pregnant woman time and energy, but perhaps also her life or that of her baby.

Barb moves on to specific questions to ask a homebirth midwife. The questions appear to be designed to differentiate between midwives who follow scientific evidence and midwives who ignore scientific evidence. Although Barb is careful to state that the mother has a right to choose midwives who ignore scientific evidence, it is pretty clear that she does not think much of such midwives.

For example:

I have written repeatedly about the penchant for evidence-indifferent homebirth midwives to insist that any complication is a variation of normal, when it is not. Breech is not a variation of normal, neither is twins.

Barb writes:

Does she say a breech or twin birth is a "variation of normal"? This lets you know she’s on the liberal side of midwives, more amenable to delivering breeches and twins at home. If she is on this side of the spectrum, you might ask these next questions.

* "What is your experience seeing breeches and twins born?" ...
* "Have you ever been the primary with them? How many and what were the outcomes?"
* "How did you learn your breech and twin skills?" ...

Pre-eclampsia is a potentially life threatening condition for both baby and mother.

Barb points out:

... If you are looking for a conservative midwife, it's important to know the standard of care is to transfer a woman if her blood pressure is 130/90 or 30/15 above her normal blood pressures. (If your blood pressure is usually 90/56, by the time your BP is 130/90, you could be having a stroke!) If you're looking for a more liberal midwife, one who doesn't stick to the rules of what most (medical folks) would consider safe, then knowing her answers will help you here as well. How she answers gives you pieces of the total picture of the type of midwife she is and a decent guideline-roadmap for a normal and inching-out-of-normal pregnancy and birth.

And pre-eclampsia cannot be prevented or treated with diet:

... I guess if you want to know if she's still of the belief that the Brewer Diet can help a woman avoid or if she has preeclampsia already, the Diet can relieve the condition, that would be good to know, demonstrating she is not an evidenced-based midwife (some of the links have been locked for privacy), despite her possibly saying she is.

Barb is quite clear that, as I have pointed out in the past, friendship has nothing to do with safe midwifery:

... Choosing a midwife is not just about personality meshes. It definitely has elements of that, but it is not crucial to become friends with your midwife. In fact, I've found (through my own many mistakes) that not being friends keeps the boundaries clear and allows for decisions to be made autonomously by both provider and client...

In summary, Barb Herrera, Navelgazing Midwife, acknowledges that

• Homebirth has a very real risk of death.
• if certain life threatening emergencies occur at home the baby will simply die.
• The purpose of a birth attendant is to deal with emergencies.
• Midwives ought to be licensed and meet certain minimum standards.
• Breeches and twins are not variations of normal.
• "Liberal" homebirth midwives are indifferent to scientific evidence or ignore it.
• Friendship has nothing to do with safe homebirth midwifery.

In other words, Barb agrees with me.

The philosophy of natural childbirth is perverse and dysfunctional

There is something perverse and dysfunctional about a philosophy that leads a new mother to react with disappointment to the serendipitous rescue of her baby from certain death.

...I dont feel like I gave birth, I feel like he was taken from me...stolen...I dont feel like a mom yet and when Im not holding him I feel like I should still be pregnant.

According to her post on Mothering.com, that's how Jasper's mom feels after the emergency C-section that was necessary to save his life.

What happened?

So, last Friday (the 7th) was my 40 week OB appointment, I went in and got settled in for an NST like usual and Jasper ended up having some heart-rate decelerations which concerned my OB ...

I got over there and they hooked me up for the NST for about an hour and Jasper had 9 decels, it was terrifying, at one point his heart rate dropped into the 50s.

At that point I was pretty re-signed to an induction, they took me back to a labor room and my OB came in and started the c-section spiel....

During this time my doula showed up and she was shocked too but she also saw the NST results and was very adamant that a c-section looked like the best option ...

Did it turn out, in retrospect, to be a necessary C-section? It certainly did. The next day:

Then they told me he had pneumonia....

Turns out he had aspirated some of the meconium and was having some respiratory distress....they were transferring him to the local childrens hospital later that evening and starting antibiotics.

At the children's hospital on Sunday:

His doctor came in (way young, way cute and way nice!!) and told us what was going on, he was still on dextrose for his sugars but they were weaning him off of that and onto tube feedings.

He was also on oxygen but NOT on a ventilator so that was a good thing, function wise his lungs were a- OK when it came to that.

His respiratory rate was not OK though due to the fluid in there causing him to have to work harder, they had started antibiotics the night before and expected to continue them for AT LEAST 3 more days, possibly up to 5 depending on what his labs look like tomorrow.

Let's review:

Jasper, for no obvious or anticipated reason, was profoundly oxygen deprived and on his way to certain death (stillbirth).

Through an incredibly fortunate coincidence, his mother had an OB appointment while he was struggling for life.

The obstetrician noted evidence of fetal compromise, carefully evaluated Jasper with an NST and found that he was losing his battle, even before the stress of labor started.

There is absolutely no possible way that Jasper would have been born alive if labor had been allowed to start and continue naturally.

Jasper's mother clearly understands all of this. She knows that she came within a hair's breadth of losing Jasper. And yet:

I don't know how to explain how I feel in regards to the c-section, I dont feel traumatized really...I know it was medically needed for him and it scares me to think what would have happened to him if I had been more stubborn about trying to induce first.

But I don't feel like I gave birth, I feel like he was taken from me...stolen...I don't feel like a mom yet and when Im not holding him I feel like I should still be pregnant.

I'm not sure I'm truly depressed at this point but I am frustrated and sad and feeling defeated and helpless.

Only someone thoroughly indoctrinated in the NCB philosophy that privileges process over outcome would have ever contemplated, let alone concluded, that she had not given birth as if giving birth was synonymous with passing through a vagina.

The reality is that this woman hit the jackpot. Despite having a placenta that could not adequately support Jasper, he didn't die. Through an amazing stroke of good fortune, while Jasper was in the process of dying, he happened to be monitored. Because of that monitoring, his life was saved. It was an incredibly close call. He was so close to death that he aspirated meconium and would have died anyway after the C-section if it were not for the availability of NICU care.

The NCB emphasis on process as opposed to outcome perverts maternal bonding. Instead of enjoying her new baby and basking in her good fortune, this poor woman is reduced to concluding that she hasn't given birth, and that she should be upset about it.

In my judgment, the essence of mothering is about providing for your child's needs to the best of your ability. NCB is perverse to insist that good mothering means following a specific performance that ignores the needs of the individual child.

Jasper "told" his mother in the only way he could that a vaginal birth would kill him. Why should his mother feel bad for responding to his plea to protect him from certain death?

Has Lisa Barrett attended another homebirth tragedy?

I thought Lisa Barrett was demonstrating contempt when she publicly tweeted during the recently completed Coroner's Inquest convened to examine her role in two homebirth deaths but that pales in comparison to this.

According to a source, Barrett spent Friday evening at a twin homebirth that resulted in one healthy baby and a second on life support and declared brain dead.

I have asked Barrett to comment but have received no response.

addendum 10/14/11: Yes, Lisa Barrett did preside over another homebirth death. The story has just appeared on Adelaide now, aptly titled Inquest midwife Lisa Barrett helped deliver twins, one which later died:

The State Coroner was notified of the death last week of a newborn twin treated at the Women's and Children's Hospital.

The Advertiser has learned that birthing advocate Lisa Barrett presented to the WCH with the child's mother in a taxi.

She had been assisting the mother with a homebirth when complications arose following the delivery of the first child, after which a taxi was called.

Ms Barrett is already at the centre of a coronial inquest into the deaths of Tate Spencer-Koch and Jahli Jean Hobbs during homebirths in 2007 and 2009 respectively.

Closing submissions in the inquest were heard last month and Deputy State Coroner Anthony Schapel has reserved his findings.

During the inquest the court also heard that a coronial investigation was under way in Western Australia regarding the death of one twin during a home delivery in July this year.

The court heard Ms Barrett attended that birth as a doula, not a midwife, and provided a statement to police.

So Lisa Barrett has presided over at least 4 deaths in the past 4 years!

The winner of the homebirth narcissist sweepstakes is ...

I've been writing for years that homebirth is viewed by a homebirth advocate as a piece of performance art with herself as the star. Everyone, midwives, her partner, even the baby are nothing more than bit players in "her" birth. That's certainly what Marni Kotak thinks.

Eat your heart out Feminist Breeder. Sure you broadcast your homebirth to the world, and you got a corporate sponsor. Nancy Salguiero has gotten lots more attention because she hired a publicist to promote her homebirth. But now poor Nancy, who hasn't even had her baby yet, has already been eclipsed by Marni Kotak.

... Enter the very pregnant performance artist Marni Kotak, who is transforming the Microscope Gallery into a home-birth center where she will turn the birth of her baby into a work of art... Starting Saturday, she'll be making the gallery home as she waits for the contractions to start ... Then, she'll have her baby right there with the assistance of a midwife and a doula...

According to Marni:

... I will be completely engrossed in the act of giving birth before a live audience. I will be focused on delivering my child into the world in the healthiest manner possible, rather than on how I look or what the audience may think. Everything I have learned about the birth process is that the more you surrender your mind and don't try to control the event, but let your body do what it naturally knows how to do, the better your labor progresses. This, to me, provides for the most authentic performance art situation. And the ultimate creation of this life performance will be a living being!

And if that's not selfish enough:

... her long-term project "Raising Baby X," ... will document her child's upbringing "from birth through attending college and developing an independent life," according to her website.

The child psychiatrists out there are already salivating over the patient Baby X will become. Just imagine the therapy sessions:

X (no longer a baby): It seems like my mother doesn't care about me as a person. She sees me as nothing more than an extension of herself whom she can manipulate for her own ends.

Child Psychiatrist: It's hard to argue with that assessment since she has used your for her own self aggrandizement from the moment of your birth, deprived you of privacy, and seen you as little more than an art project.

Marni actually claims:

I am driven to hold onto an authentic personal experience in a world that has essentially become consumed by an unreal hyper-reality.

Riiiight, because pushing out a baby in an art gallery in front of a live audience is the authentic experience of indigenous women in all times and cultures ....NOT!

Marni is ever so superior to those women who are immersed in our media driven culture:

... I do feel that people today are desperately seeking a sense of meaning in their lives. Facebook is feeding into that and providing -- what I see as an ultimately empty -- solution for a hyper-mediated world... Sadly, the more time that people spend on social networking sites and the less time they spend engaging in authentic experiences with friends and family in the real world -- and yes, I do still think there is a real world -- the more they are denying the significance of their own human experience. This in turn leads to a greater sense of desperation to find meaning in their lives, more wasted hours on Facebook ...

Or perhaps to a desire to give birth in an art gallery in front of a live audience.

... And in giving birth in front of the audience, I am showing them, as in my previous performances, that real life is the best performance art, and that, if our eyes can be opened to it, all of the meaning that we seek is right there in our everyday lives.

Or maybe, like many homebirth advocates, she's just an attention seeking narcissist.

The trouble with trolls

Far be it from me to complain about the participation of trolls in the comment sections of this blog. Trolls serve a very valuable function here. They drive conversation, illustrate various deficiencies in the thinking of NCB and homebirth advocates, and provide endless entertainment.

Every science based website with a comment section has trolls, and they share several important characteristics.

1. Trolls invariably have essentially no education on the topic under discussion. Whether it is anti-vax trolls who have no knowledge of immunology, creationism trolls who have no understanding of evolution, or NCB and homebirth advocacy trolls who lack basic education in science, statistics and obstetrics, trolls literally have no idea what they are talking about.

2. Despite profound and crippling ignorance, trolls generally believe that they are knowledgeable. This is a result of the Dunning-Kreuger effect. As Dunning and Kreuger wrote in their original paper, Unskilled and Unaware of It: How Difficulties in Recognizing One's Own Incompetence Lead to Inflated Self-Assessments:

We propose that those with limited knowledge in a domain suffer a dual burden: Not only do they reach mistaken conclusions and make regrettable errors, but their incompetence robs them of the ability to realize it.

3. Trolls have a serious problem with scientific evidence; they don't understand what it is. Contrary to what trolls believe, websites written for lay people are not a source of scientific evidence, long lists of citations copied for those websites are not scientific evidence, and the mere existence of a paper that expresses a particular point of view is not scientific evidence.

4. Trolls seem to be entirely unaware that you have to READ a scientific paper (the whole paper, not just the abstract) before you can declare that it is scientific evidence that supports your point of view. They are also unaware that publication in a peer review journal does not mean that a paper's conclusions are scientific evidence, merely that the author's views are worth being included in an ongoing discussion of an issue.

5. Trolls have terrible problems will logical fallacies. They love and frequently employ the fallacy of the lonely fact, the argument from ignorance, and the ad hoc fallacy.

6. Trolls have serious problems with basic logic.

7. Trolls suffer from hubristic self-assessment. Sure it takes a real doctor 4 years of college, four years of medical school and 3-5 years of residency to become knowledgeable about his or her field, but the troll assumes that is for mere mortals. For a troll, reading a bunch of websites written for laypeople is all that is necessary to achieve a level of expertise high enough to advise and criticize professionals.

8. Trolls love conspiracy theories.

9. Trolls are convinced that they are "brilliant heretics."

10. Trolls are easily frustrated when others fail to recognize their blinding (to themselves) brilliance. In very short order, they start personally insulting those who frustrate them by demanding scientific evidence that they cannot provide.

11. Trolls inevitably flounce. As Skeptico advises in his hilarious Handbook of Woo:

Finally, when you’ve used up all the above tactics, say you’re not going to waste any more time with the [critics] you’ve been debating because they’re too sad, stupid, closed-minded, ______ (insert other flaw the [critic] has) to understand your brilliant arguments. Make a big grandiose statement and exit to start anew somewhere else.