Lies, damn lies and the Midwives Alliance of North America

Stung by my piece MANA on Time.com What Ricki Lake Doesn't Tell You About Homebirth, MANA has responded.

The response is the typical disingenuous attempt of MANA executives to justify withholding their death rates ... with a twist.

The latest tactic? Changing their Handbook for Researchers just this month removing specific requirements and implying that they never existed at all.

The executives at MANA wrote:

"Our dataset is currently available to researchers, and we welcome applications. There is no stipulation that data must be used for the advancement of midwifery nor is there an agreement promising not to release death rates; this statement is completely false."

Let's analyze.

First, the executives of MANA would like to leave the impression that statistics can only be released in the context of research. That is completely untrue. Every state and the US government releases annual statistics on the number of births and the number of neonatal deaths (not to mention a myriad of other health issues). This information is publicly available to anyone for free through the CDC. MANA can and ethically should release its data to the public for free in the same form as the CDC data. There is nothing preventing them from doing this beside their unwillingness to reveal the numbers.

Second, MANA has removed key sections of the Handbook just this month to comport with their current claims.

As it happens, I originally submitted the piece to Time.com in late September. The following quotes are taken directly from the edition of the Handbook prior to this month's changes. (Through the miracle of the "Way Back Machine," you can access the edition of the Handbook as it appeared on July 2011 here.) Strike-throughs indicate the relevant text that was removed just this month.

1. A pledge to use the data to benefit the midwifery community:

"The MANA DOR [Director of Research] is responsible for representing the midwifery community in its relationship with investigators... Therefore the MANA DOR expects all investigators interested in collaboration with this community to consider how they can cooperate with these principles, and to describe how they intend to do so in their request for data access."

The Handbook does still mention that MANA endorses (a very indiosyncratice view of ) the principles of Community-Based Participatory Research. They apparently believe that it is designed to protect homebirth midwives, even though it is really designed to protect research subjects.

2. An elaborate vetting procedure, including, among other things:

"...
a. Investigator affiliations
b. The nature and purpose of the proposed research, including:
i. Basic description of the study design and methods of analysis
ii. Time frame
iii. Specifics of data requested (year, intended site of birth, provider)
...

3) Signed statement of familiarity with Community Based Participatory Research (descriptive material contained in this Handbook) - form available at
http://www.mana.org

4) Signed statement of familiarity with the Midwifery Model of Care, scope of
practice and out-of-hospital birth protocols or practice guidelines (descriptive
material contained in this Handbook) – form available at http://www.mana.org

5) Copy of Research Protocol, to include the following:
a. Description of Project and Research Questions
b. Project Background, Review of the relevant literature, and Significance
c. Methods and Procedures
d. Variables Requested for Analysis, including any time or geographic limits
e. Risks/Benefits Assessment
..."

3. A non disclosure agreement promising not to reveal any data (including death rates) to anyone:

"access will be predicated on the signing of ... a Confidentiality and Non-Disclosure Agreement"

replaced with: "A standard confidentiality/ non-disclosure agreement will be provided."

4. The substantial fee for access remains unchanged:

"Fee for individual researchers is $250 and for institutions $1000."

So what are we to make of this?

MANA is still struggling mightily to avoid releasing their own death rates. Nonetheless, they have been deeply stung by my accusations, so much so that they went to the effort to remove various offending passages. But they went a bit too far by implying that those passages never existed instead of acknowledging that they removed them.

It's one thing to call for a retraction of false claims. It's another thing entirely to amend a document to make it look like the original claims are false.

MANA took a golden opportunity to do the right thing and turned it into another example of mendacity. Instead of announcing that the inappropriate requirements for access to the data were removed, MANA executives have tried to make it look like they never existed. In my judgment, this is grossly unethical conduct and raises questions about whether we can ever believe MANA claims and statements.

And the original issue still remains:

MANA needs to tell us: how many of those 24,000 babies delivered by MANA members died?

There is no plausible reason why this information should be withheld from American women.

Advocates hail news that driving without a seatbelt is safe

Advocates of seatbelt free driving are hailing the results of the largest study ever done of driving without a seatbelt.

Investigators compared 16,000 women who drove without a seatbelt to the grocery store to 16,000 women who were wearing a seatbelt on the drive to the grocery store and found that the number of deaths was very similar. In fact, for experienced drivers driving to the grocery store, fatalities were the same.

The authors investigated only those who were at low risk for a fatal crash by applying a long list of exclusion criteria. Drivers could only be included in the study if their drive to the grocery store took place

• during daylight
• in the absence of rain
• on roads that had no potholes
• only if there were no other cars on the road during the entire route.

Overall, the number of fatal outcomes was similar in both groups, but in depth analysis revealed that most of the fatal outcomes occurred in the subgroup of first time drivers. In contrast, for women who had driven before AND

• never had an accident or speeding ticket
• never drove drunk in the past, texted or even talked on a cellphone during driving
• were driving cars with front and side airbags

the results were very similar.

Of note, the authors found a surprisingly high rate of drivers changing their minds. Between 36-45% of first time drivers actually ended up wearing a seatbelt even though they had planned not to do so. A far smaller number, 10-15% of experienced drivers also wore seatbelts even though they had not intended to do so.

The study was conducted by Seatbelt-Free America, a consortium of auto manufacturers who have long argued that the requirement to put seatbelts in all cars adds needless expense and results in only minimal benefit.

In a press conference, Ima Frawde CPG (certified professional gadfly), leader of the study explained the results:

This, the largest study of its kind, demonstrates that all women should be offered the choice of buying a car without seatbelts. Of course, women should receive adequate counseling from their auto salesman, about the slightly increased risk of fatal outcomes among first time drivers, but it they elect to buy a car without seatbelts, that it their decision.

Ms. Frawde continued:

The risk of a fatal accident was very low in both groups, suggesting that driving to the grocery store with or without a seatbelt is extremely safe. The additional protection afforded by wearing a seatbelt was relatively trivial, just a few deaths avoided per thousand drivers.

During the press conference, a reporter asked if this study of seatbelt use restricted to driving to the grocery store during daylight, in the absence of rain, on roads that had no potholes, and only if there were no other cars on the road during the entire route was generalizable to the population at large, given that many drives are far longer, it is often raining, many roads have potholes and there are usually other cars on the road.

Ms. Frawde expressed surprise:

Why wouldn't it be?

This piece is a satire on the response of homebirth advocates to the recently published Birthplace Study.

Real message of Birthplace Study? Don't trust birth!

It is interesting to see how different media outlets and different stakeholders are trying to spin the results of the Birthplace Study. Is the glass half full or half empty? Did the study show that homebirth increases the risk of perinatal death and brain damage or did it show that homebirth is safe for rigorously screened women who have had uncomplicated births in the past?

I reviewed the findings of the study this morning (It's official: homebirth increases the risk of death), but there's more to the study than just the numbers. It is valuable to look at the bedrock principles that the researchers used, because there is not much doubt about those.

Specifically, the investigators rejected the bulk of midwifery theory. The underlying assumption of the study is that birth is inherently dangerous, that there are a myriad possible complications with serious consequences and that carefully culling out anyone with even minor risk factors is critical to good outcomes at homebirth.

The real message of the Birthplace Study is this: don't trust birth.

Moreover, the various homebirth midwifery aphorisms that flow from trusting birth are treated as the nonsense they are:

Breech is a variation of normal? Nonsense.
VBACs are safe at home? Nonsense.
Twins are safe at home? Nonsense.
Elevated blood pressure not a cause for concern? Nonsense.
Gestational diabetes not a cause for concern? Nonsense.
Preterm deliveries before 37 weeks safe at home? Nonsense.
History of previous shoulder dystocia safe at home? Nonsense.
Low or high amniotic fluid safe at home? Nonsense.

The investigators have no use for other midwifery theories, either.

Trust your intuition? Nonsense.
Babies know how to be born? Nonsense.
You won't grow a baby too big to birth? Nonsense.
And my personal favorite, including the nonrational is sensible midwifery? Complete and utter nonsense.

The Birthplace Study is predicated upon the fact that complications in birth are common and that various risk factors increase the risk of complications to the point where it is unsafe to give birth at home. Therefore, the only way to assure that there are a minimal number of preventable neonatal deaths is to exclude anyone that had a problem in the past as well as anyone with the merest hint that a problem might develop.

To the extent that the Birthplace Study identifies a subgroup in which homebirth may be as safe as hospital birth, that subgroup is "women who can be relied upon not to experience any complication of any kind." In other words, homebirth is safe if nothing goes wrong. If there is any chance of anything going wrong, homebirth is not safe.

What does this mean for American homebirth midwifery (CPMs, certified professional midwives)? It basically blasts it out of the water.

Given what the Birthplace Study shows, we can conclude that the underlying philosophy of American homebirth midwifery is garbage, the principles that flow from that philosophy are nonsense, the rejection of risk factors is deadly, and the education and training of CPMs is completely inadequate.

Homebirth in the UK for women who have had a previous completely uncomplicated pregnancy, whose current pregnancy has no risk factors of any kind, and who are being cared for by highly educated and highly trained midwives may be safe, so long as those midwives adhere to the very strict criteria in the study. Homebirth in the UK for women who have never had a baby but whose current pregnancy has no risk factors of any kind and who are being cared for by highly educated and highly trained midwives increases the risk of perinatal death and brain damage. Everyone else isn't even a candidate for homebirth.

In other words, this study is a huge blow to Ina May Gaskin and her followers. This study does NOT support the safety of homebirth with an American homebirth midwife (CPM). In fact, it indicates that homebirth with an American homebirth midwife (CPM) cannot possibly be safe.

It's official: homebirth increases the risk of death

The largest, most comprehensive study ever done of homebirth has released its results and there's nothing left to argue about: homebirth increases the risk of perinatal death.

The Birthplace Study, a large multi-year study, was designed to address the safety of place of birth by controlling for the many factors that had not been handled properly in other studies. The study looked at intended place of birth to rule out improperly assigning transferred patients to the hospital group, and included only the lowest possible risk women. The study was conducted by The National Perinatal Epidemiology Unit in the United Kingdom.

The authors found that homebirth increases the risk of death, brain damage and serious neonatal injury.

The authors chose to evaluate the results by creating an index of primary events comprising intrapartum stillbirths, early neonatal deaths, neonatal encephalopathy [brain damage] meconium aspiration syndrome, brachial plexus injury, and fractured humerus or clavicle. Using this measurement:

... [T]here was a significant excess of the primary outcome in births planned at home compared with those planned in obstetric units in the restricted group of women without complicating conditions at the start of care in labour. In the subgroup analysis stratified by parity, there was an increased incidence of the primary outcome for nulliparous women in the planned home birth group (weighted incidence 9.3 per 1000 births, 95% confidence interval 6.5 to 13.1) compared with the obstetric unit group (weighted incidence 5.3, 3.9 to 7.3).

In other words, the risk of death and serious injury was approximately double in the homebirth group and that increase was seen mainly among first time mothers.

The authors did not include the number and distribution of specific primary events within the paper itself, but did publish a 78 page supplementary file including this information. The following tables are adapted from that file. (OU stands for Obstetric unit [hospital], AMU stands for along side maternity unit [in hospital birth center], and FMU for free-standing maternity unit [independent birth center].)

Stillbirths



Early neonatal deaths (to 7 days)



Encephalopathy [brain damage]



The authors put the best possible face on the outcome:

... Adverse perinatal outcomes are uncommon in all settings, while interventions during labour and birth are much less common for births planned in non-obstetric unit settings. For nulliparous women, there is some evidence that planning birth at home is associated with a higher risk of an adverse perinatal outcome...

What can we conclude?

Homebirth increases the risk of perinatal death and brain damage in the lowest risk women receiving care from highly trained midwives (often two) and liberal access to transfer.

Homebirth increases the risk of perinatal death and brain damage even when, at the start of labor, breech, twins, VBAC. positive GBS status, gestational diabetes and obesity were excluded. All routinely occur at homebirths in the US, the UK and Australia.

And how about the purported "risks" of interventions that homebirth advocates are always taking about?

Homebirth increases the risk of perinatal death and brain damage even though the incidence of epidural use was 5 times higher in the hospital group.

Homebirth increases the risk of perinatal death and brain damage even though the incidence of pitocin augmentation was 5 times higher in the hospital group.

Homebirth increases the risk of perinatal death and brain damage even though the incidence of operative vaginal delivery was 3-4 times higher in the hospital group.

Homebirth increases the risk of perinatal death and brain damage even though the C-section rate was 4 times higher in the hospital group.

In other words, any way you choose to look at it, no matter how carefully you slice and dice the data, there is simply no getting around the fact that homebirth increases the risk of perinatal death and brain damage.

NZ study tries to bury increased homebirth death rate

How do homebirth midwives handle mistakes? They bury them, of course, and a recent study from New Zealand is yet another case in point.

From the title,Planned Place of Birth in New Zealand: Does it Affect Mode of Birth and Intervention Rates Among Low-Risk Women?, to the conclusion, the authors refuse to address the increased neonatal death rate. In fact, the authors go so far as to deliberately obfuscate the increased neonatal death rate at homebirth.

Here's how the authors represent the findings of their study:

Women planning to give birth in secondary and tertiary hospitals had a higher risk of cesarean section, assisted modes of birth, and intrapartum interventions than similar women planning to give birth at home and in primary units. The risk of emergency cesarean section for women planning to give birth in a tertiary unit was 4.62 (95% CI: 3.66–5.84) times that of a woman planning to give birth in a primary unit. Newborns of women planning to give birth in secondary and tertiary hospitals also had a higher risk of admission to a neonatal intensive care unit (RR: 1.40, 95% CI: 1.05–1.87; RR: 1.78, 95% CI: 1.31–2.42) than women planning to give birth in a primary unit.

Here's what the authors conclude:

Planned place of birth has a significant influence on mode of birth and rates of intrapartum intervention in childbirth.

Here's what the authors deliberately tried to hide:

The neonatal death rate in the planned homebirth group was 1.1/1000. The neonatal death rate in the planned hospital birth group was 0.3/1000. In yet another example of a strikingly robust finding, planned homebirth in NZ had more than triple the neonatal death rate of planned hospital birth.

How was the study done?

Data were obtained from the [Midwifery Maternity Provider Organisation (MMPO) database] for a total of 39,677 births. Of these, 16,453 (41.47%) met the study’s low-risk criteria. Of this low-risk group, 11.3 percent were planning to give birth at home, 17.7 percent in a primary unit, 45.5 percent in a secondary level hospital, and 25.4 percent in a tertiary level hospital.

Where did the women ultimately give birth?

Most women gave birth in their planned place of birth; 82.7 percent of those planning a home birth, 90.2 percent planning to give birth in a birth center, 99.8 percent planning to give birth in a secondary hospital, and 99.8 percent planning to give birth in a tertiary hospital actually gave birth in their planned place of birth.

In other words, the transfer rate in the homebirth group was 17.3%; the transfer rate in the birth center group was 9.8%.

The authors are very excited about the difference in intervention rates among these groups, presented in the following table.



Not surprisingly, the risk of operative vaginal delivery and the risk of emergency cesarean section are much higher in the hospital. The authors do not define "emergency cesarean" but they apparently mean unplanned, not true emergency C-sections.

The authors also looked at secondary outcomes:

... Women planning to give birth in secondary or tertiary level hospitals were also at increased risk of artificial rupture of the membranes, augmentation of labor, pharmacological pain management, episiotomy, and neonatal admission to intensive care when compared with women planning to give birth in primary units. Those planning to give birth at home were at less risk of augmentation of labor, artificial rupture of membranes, pharmacological pain management, episiotomy, and perineal trauma than those planning to give birth in primary units...

So the homebirth group had lower rates of major interventions and the homebirth group had lower rates of minor interventions. How about deaths?

Well, funny you should mention that. There was a little bit of a problem there and the authors made a valiant attempt to hide it.

A total of six neonatal deaths (a death occurring up to 27 days after birth) occurred in the sample, two (0.11%) from women planning a home birth and four (0.15%) from women planning to give birth in the tertiary hospital. No intrapartum, intrauterine deaths were reported.

Hey, the death rates are exactly the same! Wait, what? The authors deliberately used the wrong denominator for calculating the hospital birth death rate?

Indeed they did. They compared the death rate at homebirth with the death rate in tertiary [high risk] facilities, but that's not what we want to know. We want to know how the death rate at homebirth compares with the death rate at all hospital births, not the death rate at tertiary facilities.

What the authors should have told us was that there were two neonatal deaths (0.11%) among women planning a home birth and four (0.03%) from women planning to give birth in the hospital. In other words, the homebirth death rate was more than triple that of the hospital birth death rate. Oops!

The authors of this paper should be ashamed of themselves. They didn't want anyone to know that homebirth had triple the neonatal death rate of hospital birth, so they deliberately obscured it by using the wrong denominator in their calculations.

The authors brazenly assert that no differences for planned place of birth were noted. That is simply a lie.

Homebirth in New Zealand has triple the neonatal death rate of hospital birth. The finding of lower intervention rates in the homebirth group is nothing to celebrate when more babies died as a result.

A failure from the moment of birth

Finally, a natural childbirth advocate willing to say what she desperately needs to believe really means. In a Facebook thread about women who have had C-sections, "Joni" pulls no punches:

Yes, they have failed at birth. They succeeded at making a baby and hopefully of caring for it, but they did fail the birth. And birth is so important for baby too. You can be scarred for life by it. There are women being persecuted so that all of us can have the birth that we want! There is a woman in Australia who is in trouble just because she wants every woman to have the choice to home birth! All of these people are anti choice for woman! Birth matters. It might matter most of all in life for woman!

Joni is pathetic brave. Joni doesn't have any real achievements pander to those feeble excuses for women who couldn't push a baby through their vagina.

But Joni doesn't go far enough. When it comes to birth, it takes two to tango, and babies should accept their share of the blame. It isn't just women who have failed by having a C-section; their babies have failed, too, and it's time to be honest about it.

Babies who are premature? Failures.

Babies who have abruptions? Big failures.

Babies who suffocate and die during labor? The ultimate failures!

Now some of you might be thinking that we shouldn't blame babies for things that they can't control. Hello, babies are supposed to know how to be born. If you can't get the timing right, if you can't keep your placenta together, if you can't get enough oxygen during uterine contractions, you obviously didn't know how to be born.

How about the babies who don't fit through the mother's pelvis? Big babies, babies with asynclitic heads, transverse babies? Failures, failures, failures.

But is it really the baby's fault if it grows bigger than a mother's pelvis can accommodate? Duh! Everyone knows that a mother's body won't grow a baby too big for her to birth; therefore, it must be the baby's fault.

And let's be honest here. Some babies aren't merely failures, they are evil failures. Evil because they gave their mothers pre-eclampsia, or gestational diabetes or even deadly peripartum cardiomyopathy.

It may sound harsh, but it's true. Just like women are perfectly designed to give birth, babies are perfectly designed to be born through the vagina. If they can't get with the program and have to come out by C-section, they are failures just like their mothers are failures.

Frankly, if they don't know how to be born the right way, they don't deserve to be born at all. We should just let them die and their failed mothers die with them. Because really --- when it comes right down to it --- the entire purpose of birth to push something through your vagina and if you can't do that like Joni can, you don't deserve to live.

If natural childbirth is so natural, why must it be taught?

If there's one thing that all natural childbirth advocates agree upon, it is that natural childbirth requires preparation and education. Such education includes classes, books and websites. No natural childbirth advocate would ever propose doing what women have done for most of human existence, nothing. Here's what I want to know: If natural childbirth is so natural, why must it be taught?

The answer, of course, is that the philosophy of natural childbirth has little if anything to do with childbirth in nature. It is an elaborate set-piece, designed to give participants the illusion that they have recreated nature. It bears about as much relationship to childbirth in nature as an infinity pool in your backyard bears to the local watering hole.

Indeed, in the paper The social nature of natural childbirth (Social Science and Medicine, December 2007), Professor Becky Mansfield, claims that rather than representing a return to nature, natural childbirth posits a specific set of social and cultural practices. Mansfield begins by asking the obvious:

... If childbirth is so natural, how can there be strategies to facilitate it? If it is instinctive, why does it need to be learned? ...

The answer, of course, is that it is a conceit of privileged white women in first world countries in which a a specific set of cultural practices is imagined to represent "nature."

Mansfield reviews natural childbirth books written for lay people, and identifies 3 types practices that appear to be required for natural childbirth to be natural. Although Mansfield concentrates on books, websites and childbirth classes exist to promote the same information.

1. Activities during birth

The first theme is the variety of activities during labor and delivery that the books represent as necessary for making a non-medicalized birth possible. This theme is "social" because the books represent natural childbirth as something women must do; according to these books they cannot do nothing or just anything.

Not only is doing nothing forbidden, but special equipment and preparations are necessary:

... Books promote having a range of props to help a woman be active (e.g., squat bars or birth balls) ... The books place even greater emphasis on using the environment to help women be emotionally comfortable, on the premise that the wrong environment increases fear and anxiety (thereby inhibiting labor) while the right one reduces them...

2. Preparation

The second theme of these books - preparation - emerges from this emphasis on activities and learning. According to these books, women wanting birth without intervention must prepare themselves by doing a variety of things in advance...

Prescribed forms of preparation include physical preparation "as for an athletic event", emotional preparation and elaborate "birth plans," written documents meant to establish choices in advance.

3. Social support

The emphasis on choice of caregiver and place of birth is one indication that social support ... is considered an integral part of natural childbirth... The books contend that social support makes natural childbirth possible by helping women build "trust" in themselves, their bodies, and the "natural" process of childbirth...

In other words, childbirth isn't natural unless you pay money to someone to facilitate it.

The role of the caregiver as presented in these books is a complicated one... As a result (and despite their emphasis on instinct), books imply that women ... rely on someone with knowledge, training, and experience to help figure out what is happening and what to do...

And let's not forget all the "natural" interventions recommended by the caregiver, including

... a whole host of "non-pharmacological" practices meant to change the course of labor. Examples include herbal remedies, homeopathy, acupuncture, ... massaging the perineum to prevent tearing, and transcutaneous electronic nerve stimulation (TENs machines) for pain relief. While books represent such interventions as "gentle" or "natural," the message they send is that natural childbirth often does involve actively intervening in the birth process...

Evidently:

... "letting nature take its course" requires a complex sociocultural milieu that must be fostered through a range of social interactions.

Mansfield concludes:

... The books ... represent natural childbirth as requiring social practice to make it successful... Thus, although the central theme first appears to be about letting nature take its course ... [t]he central finding of this study is that proponents represent natural childbirth as a set of very specific social practices that are seen as facilitating nature, and in so doing, they also present a vision in which nature depends on social practice...

In other words, natural childbirth bears about as much relationship to childbirth in nature as an elaborately designed infinity pool in your backyard bears to the local watering hole. A quick look reveals a superficial resemblance, there's a hole in the ground, water, rocks at the margins and plantings surrounding it all. But a more detailed analysis demonstrates elaborate planning, paid help, special tools to place the rocks, set in and care for the plantings and hidden technology like a water filter. There's nothing natural about it.

Similarly, a quick look at natural childbirth reveals a superficial resemblance, but a detailed analysis demonstrates elaborate planning, paid help, special tools and hidden technology, such as fetal monitoring, blood pressure measurements, herbal supplements, chiropractic, and acupuncture.

Why must natural childbirth be taught? Because it is not natural; it is a simulacrum of natural designed to promote the conceit that privileged white women in first world cultures have returned to nature.


Adapted from a piece that first appeared on Homebirth Debate in January 2008.

There are none so blind as homebirth advocates who think they've "researched"

You knew it was coming. When Sarah Kerr was asked why she risked and lost the life of one of her children at a homebirth, she responded by insisting that she had "researched" the issue, and made her decision accordingly.

Kerr, like most homebirth advocates, was supremely confident about one thing. She was sure that she was more educated than the rest of us. She had done extensive "research" on the internet that had, in her view, qualified her to understand the risks and choose accordingly.

No doubt Kerr had done a great deal of reading. But what she, and other homebirth advocates, fail to understand is that their "research" has equipped them with nothing more than pseudo-knowledge.

Pseudo-knowledge has the appearance of real knowledge; it uses lots of big words, and it often includes a list of scientific citations. There's just one serious problem; it's not true and baby Tully is in a coffin in the ground because it isn't true.

We are surrounded by pseudo-knowledge in everyday life and most of us understand that it isn't true. Advertisements of all sorts of products are filled with pseudo-knowledge. Most of us are quite familiar with the language of pseudo-knowledge:

"Studies show ..."
"Doctors recommend ..."
"Krystal S. from Little Rock lost 30 pounds in 30 days ..."

In the era of patent medicine, claims like these were usually enough to sell a product. But consumers have become more jaded and the language of pseudo-knowledge has become more sophisticated as a result. Contemporary pseudo-knowledge contains big, scientific words and sounds impressive. It also contains completely fabricated claims that have no basis in reality and which, not coincidentally trade on the gullibility of lay people. And it always contains citations to scientific papers that often don't actually support the claims being made.

What do you really need to know to evaluate the safety of homebirth, particularly in the case of high risk like Kerr's twins? Obviously, you need a thorough grounding in basic science and advanced knowledge of obstetrics. You need to have read and analyzed all the relevant textbooks and especially the relevant scientific papers (not simply the abstracts), and that, of course, requires an understanding of statistical analysis.

But wait! Science is hard and that's unfair. Who has the time, the background or the ability to read and analyze all the relevant papers on homebirth? Not homebirth advocates. They lack knowledge of basic science and of obstetrics.Their math ability often trails off at arithmetic, leaving them no way to understand statistics, even if they bothered to read the relevant texts.

So if they're not reading obstetric textbooks, and if they're not reading the relevant scientific papers, and if they're not analyzing statistics, what exactly are they doing when they are doing "research?" They are simply imbibing the views of other people who know just as little as they do.

Consider the lay bloggers. Who in her right mind could imagine that reading the nonsense spewed forth by simpletons like January of Birth Without Fear is "research"?

How about the self-described "experts"?

Barely a week passes on this blog without a lay person parachuting in to boast of all she has learned from her "research" encompassing the works of Henci Goer, Amy Romano, Barbara Harper or Ina May Gaskin. Don't even get me started on Ricki Lake; she just makes it all up as she goes along. Their assertions mark them just as effectively as if they had tattooed "gullible" on their forehead."

When it comes to homebirth and natural childbirth advocates their "research" is worse than worthless because they've acquired nothing more than pseudo-knowledge. Just about everything they think they "know" is factually false.

The truth about health education is both simple and stark. You cannot be educated about any aspect of health without reading and understanding scientific textbooks and the scientific literature. Period!

Don't bother to claim that you are have done "research" on the internet or by reading the books and websites of other homebirth advocates. You haven't acquired knowledge, you've acquired pseudo-knowledge, as well as the dangerous conceit that you know far more than you really do. Internet "research" marks you as a fool. That becomes a serious problem when you, like Sarah Kerr, decide to risk your baby's life on no better foundation than your own "research."


Adapted from a piece that first appeared in October 2010.

New study of delayed cord clamping shows no clinical benefit

Proponents of delayed cord clamping are really, really sure that it is better for babies, and they're willing to look at ever more trivial outcomes to support their belief. Consider the paper published on Tuesday in the British Medical Journal, a major study of delayed cord clamping. Four hundred full term infants born after a low risk pregnancy were randomized to early or delayed cord clamping groups and after 4 months, the groups showed ... no clinical difference.

No problem! The authors were apparently thrilled to discover some differences in lab values, despite the fact that both groups had normal lab results and are trumpeting this "benefit" far and wide in press releases.

Proponents of delayed cord clamping typically claim that it is beneficial primarily because it reduces anemia. This study, Effect of delayed versus early umbilical cord clamping on neonatal outcomes and iron status at 4 months: a randomised controlled trial, by Andersson et al., divided infants into two groups, early cord clamping (at ≤ 10 seconds after birth) and delayed cord clamping (≥ 180 seconds after birth). The main outcome measures were:

Haemoglobin and iron status at 4 months of age with the power estimate based on serum ferritin levels. Secondary outcomes included neonatal anaemia, early respiratory symptoms, polycythaemia, and need for phototherapy.

The results:

At 4 months of age, infants showed no significant differences in haemoglobin concentration between the groups ...

... There were no significant differences between groups in postnatal respiratory symptoms, polycythaemia, or hyperbilirubinaemia requiring phototherapy.

Though there were no clinically relevant differences, the authors went looking for differences in laboratory values.

... infants subjected to delayed cord clamping had 45% (95% confidence interval 23% to 71%) higher mean ferritin concentration (117 μg/L v 81 μg/L, ≥0.001) and a lower prevalence of iron deficiency (1 (0.6%) v 10 (5.7%), P=0.01, relative risk reduction 0.90 [at 4 months of age] ...

The authors trumpet these findings as supporting delayed cord clamping, but, in fact, they are basically meaningless. While it is of theoretical interest that infants in the delayed clamping group have higher normal iron stores, iron stores in and of themselves are not meaningful since they don't affect health. The health parameters of interest are hemoglobin level and hematocrit (amount of red blood cells) and those are exactly the same.

The authors define iron deficiency as ≥2 indicators of iron status outside reference range (ferritin <20 μg/L mean cell volume <73 fL, transferrin saturation <10%, soluble transferrin receptor >7 mg/L). In both the early and delayed cord clamping groups, values for all parameters were well in the normal range. There is no reason to believe that that the having higher normal values (as in the delayed clamping group) offers any advantage over having mid-range normal values.

Of note, the authors chose to report on the two groups at 4 months of age. Other studies of delayed cord clamping have shown that differences in iron stores disappear by 6 months of age.

The authors make much of the difference in laboratory values, despite the fact that both groups were in the normal range:

We conclude that delayed cord clamping, in this randomised controlled trial, resulted in improved ferritin levels and reduced the prevalence of iron deficiency at 4 months of age... Two meta-analyses of clamping studies performed in low or middle income countries with a high general prevalence of anaemia found similar effects on ferritin as we did and concluded that this effect is clinically relevant and should lead to a change in practice. Iron deficiency even without anaemia has been associated with impaired development among infants. Our results suggest that delayed cord clamping also benefits infant health in regions with a relatively low prevalence of iron deficiency and should be considered as standard care for full term deliveries after uncomplicated pregnancies...

Let's parse this carefully. Here's what we can conclude:

• Delayed cord clamping had NO effect on hemoglobin levels at 4 months of age.
• Delayed cord clamping had NO effect on the health of the infants at any point.
• Delayed cord clamping improved certain laboratory parameters, but both groups were normal.
• In countries with a high prevalence of anemia (low and middle income countries), increased ferritin may be clinically relevant, but there is no evidence that increased ferritin is clinically relevant in high income countries.
• Iron deficiency in the absence of anemia might be associated with impaired development, but there is no evidence that lower but normal iron stores are associated with impaired development.

What is really going on here? It is quite possible that although infants in the delayed cord clamping group received additional red blood cells, they did not need those red blood cells. Their bodies destroyed those cells and did not replace them, so that by 4 months of age, there was no difference in hemoglobin levels in the two groups. While this study indicates that the delayed group had higher iron stores at 4 months, this effect is known to disappear by 6 months and may simply represent the fact that the body has not yet been able to dispose of the excess iron left over from the extra red blood cells that it did not need.

In other words, this data could just as easily be interpreted to mean that, far from benefiting from delayed cord clamping, infants had to work to get rid of the excess (and unneeded) red blood cells and iron over a period of 6 months.

In any case, the key point is that the authors failed to show any demonstrable clinical benefit to delayed cord clamping in term infants.

Two questions for Australian midwife Hannah Dahlen

Yesterday I wrote about the callous and clumsy attempt of national media spokesperson for the Australian College of Midwives, Hannah Dahlen, to change the subject from the fact that homebirth increases the risk of perinatal death to ... well to anything else.

In Home births: it's time to broaden the focus of the debate, Dahlen makes the bizarre and morally indefensible claim that preventable perinatal mortality is an acceptable component of safe homebirth.

When health professionals, and in particular obstetricians, talk about safety in relation to homebirth, they usually are referring to perinatal mortality. While the birth of a live baby is of course a priority, perinatal mortality is in fact a very limited view of safety.

In light of her self-serving, obfuscatory piece, I have two questions for Hannah Dahlen.

1. Why don't you say what you really mean?

Instead of struggling mightily with bizarre formulations attempting to justify broadening the definition of "safety" to include unsafe practices, Dahlen should just come out with the truth:

Australian midwives know that homebirth increases the risk of perinatal death, but we like homebirths and we are going to keep doing them.

Dahlen is not the first to struggle to make an intellectually and morally indefensible claim palatable by wrapping it in nonsensical language. Including the nonrational is sensible midwifery, by Jenny A. Parratt, and Kathleen M. Fahy, published in the Australian midwifery journal Women and Birth is a masterpiece of the genre.

The paper also argues for "broadening" the definition of the safety to include irrational beliefs and actions.

...What is deemed as safe is aligned with what is rational and what is unsafe is aligned with what is irrational. As irrationality is not acceptable this essentially forces the definition of safety to be thought of as 'true' even though it may not fit with personal experience and all situations...

Yes, that's a real problem with rationality. It blasts apart the irrational claims of homebirth midwives. And homebirth midwives love the irrational:

... During birth, making room for the nonrational broadens both midwives' and women's knowledge about trust, courage and their own intuitive abilities ...

This is just another (particularly pathetic) attempt to "broaden" the definition of safety to include unsafe practices that Australian midwives like. They know that many of their homebirth beliefs and practices are irrational and (by definition) not supported by scientific evidence of any kind, but they like them and they are going to keep doing them.

2. Aren't you embarrassed to ask whose fault it is that women fear mainstream care when it's your fault?

So when these women seek care outside our mainstream system, whose fault is it really? ...

... When a woman chooses to have a homebirth with risk factors present, the question we need to ask is not ‘what is wrong with her’ but rather ‘what is wrong with a maternity care system that provides such limited options and inspires such fear that she would take on the added risk’?

These women do not love their babies less, they fear mainstream care more and this is a terrible indictment of our care.

This is what is known as "chutzpah," a Yiddish word whose definition is best explained by example. When a man who has murdered both his parents begs the judge for mercy because he is an orphan, that's chutzpah.

When a midwife who has made a career of demonizing mainstream care asks "who's fault is it that women fear mainstream care?", that's chutzpah.

Dahlen is on record promoting fear of mainstream care, including claims that:

obstetricians want to restrict women's choices

Hannah Dahlen, of the Australian College of Midwives, says [Dr. Pieter Mourik's] comments represent the latest salvo in a ”scaremongering campaign” by obstetricians determined to stymie efforts to give women greater choice.

obstetricians perform unnecessary surgery because they are surgeons

Part of the reason we have such a high intervention rate is because normal, low-risk women are being cared for by highly specialised surgeons trained in surgery.

obstetricians care more about money that about women

We have a very powerful medical lobby in this country. They are desperate not to lose their sizeable market share of births…there’s huge money to be made.

and, my personal favorite, maternity hospitals mix up babies

University of Western Sydney professor and ACM (Australian College of Midwives) spokesperson Hannah Dahlan said that baby mix ups are one of the common errors that occur in maternity units.

Whose fault is it that Australian women fear mainstream care? It is, in large part, the fault of Hannah Dahlen and her colleagues, who never miss an opportunity to portray obstetricians as money grubbing surgeons who delight in forcing unnecessary interventions on women in facilities that routinely mix up babies.

Let's be honest, Ms. Dahlen. Homebirth midwives like homebirths because they are in charge and they are not constrained by any petty concerns like rationality or whether the baby lives or dies. Your piece about "broadening the home birth debate" is nothing more than a justification for midwives continuing to do what they like regardless of whether it comports with the scientific evidence and regardless of whether it kills babies.

At least have the intellectual honesty and moral fortitude to tell the truth, instead of hiding it in obfuscatory language: homebirth midwives will continue to encourage, promote and attend homebirths, and the dead babies be damned.

Mortality a limited view of homebirth safety?

The ever growing list of homebirth deaths has become so long that even Australian midwives have recognized that it is foolish to claim that homebirth is safe. The new tack? Proclaim that "mortality is in fact a very limited view of safety."

That's what Hannah Dahlen, national media spokesperson for the Australian College of Midwives, has to say in a piece in the Australian press that is a masterpiece of callousness and obfuscation, Home births: it's time to broaden the focus of the debate.

First, Dahlen acknowledges what everyone but homebirth advocates have always recognized:

... studies have shown that when women with high-risk pregnancies give birth at home the perinatal mortality is increased. In fact, the evidence is now substantial enough that we can identify where the greatest risk lies; for example, women giving birth to twins (especially the second twin) and breech babies.

In other words, one of the prime motivations for homebirth, to ignore medical advice on twins, breech, postdates and VBAC on the theory that avoiding a C-section is "safer" than hospital birth, is completely contradicted by "substantial" scientific evidence.

But wait! Whether the baby lives or dies is a "kindergarten" view of birth!

When health professionals, and in particular obstetricians, talk about safety in relation to homebirth, they usually are referring to perinatal mortality. While the birth of a live baby is of course a priority, perinatal mortality is in fact a very limited view of safety.

Really? On what planet would that be?

Can you imagine an obstetrician saying to patient that we ought to take a broader view of obstetrics than whether her baby lives or die? Can you imagine hospitals declaring to expectant parents that there is more to consider in choosing a place to give birth than whether the baby lives or die?

There may be factors in addition to perinatal mortality that contribute to safety, but there is no possible view of safety that does not place mortality (perinatal and maternal) at the center of obstetric care. I'd be the first to agree that there is more to safety than merely ensuring the baby lives, but there is no possible justification for a definition of "safety" that includes letting the baby die.

Dahlen's claim is not simply an exercise in extreme callousness, it is a particularly clumsy effort at "re-framing the conversation." Just like MANA (Midwives Alliance of North America), Australian midwives are taking a page out of the tobacco company playbook (What do homebirth midwives and tobacco executives have in common?).

As the Tobacco Institute explained to its members:

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

Now Australian midwives have recognized that the homebirth debate cannot not be waged successfully over the issue of safety, since hospital birth is clearly safer. Therefore, it's time to change the battle field.

Let's compare:

Tobacco industry:

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

Dahlen:

Freedom? Check.

Women's right to control what happens to their bodies during pregnancy and birth may be enshrined in law but this right is frequently violated in practice. I find it ironic that the same professionals who fight for the right for a woman to terminate her pregnancy will fight against her right to give birth at home. The law in this country is on the side of women and self-determination.

Accommodation? Check.

It is time to stop talking about the statistics and start working together to make home birth and hospital birth as safe (physical, cultural, emotional, social, psychological and spiritual) as it can be.

Prudent safety programs? Check.

Home birth will not go away, it is here to stay, so let us all share the responsibility for making it safe and satisfying, as should be our goal with all maternity care options.

And, above all else, changing the focus? Check

The debate around home birth is about more than place of birth or associated perinatal mortality, it raises deeper and more complex issues: the right of women to have control over their bodies during childbirth, the rejection of the prevailing medical model and risk paradigm of pregnancy and childbirth, societies’ belief that they have an investment in the product of childbirth and therefore should determine what is considered safe, the culture of childbirth in a country and the position and status of women within a society.

Nice try, Ms. Dahlen, but the rest of us are not fooled.

Dahlen has essentially conceded the homebirth debate. She acknowledges that the scientific evidence shows that hospital birth is safer. Now she's merely making callous and clumsy attempts to change the subject.

Dahlen should be ashamed of herself. The birth of a live baby is not a priority, it is the priority. Any midwife who believes otherwise demeans the profession.

How many babies died at the hands of Oregon homebirth midwives?

No wonder Melissa Cheyney refuses to release the death rate of Oregon homebirths.

In August, I wrote:

The minutes of the August 5, 2010 Board meeting reports that the state of Oregon asked for the ability to retrieve information on Oregon midwives from the database:

"Cheyney stated that the MANA board's official policy is to give state-level accounts to professional organizations as a tool to evaluate areas where more training might be needed for the purpose of self regulation, and to not provide the data to regulatory entities."

In other words, the database is only to be used by MANA itself, and not shared with anyone who could potentially identify unqualified midwives and discipline them.

It doesn't take a rocket scientist to speculate that there have been an extraordinary number of deaths. Now comes information from a new source that confirms that suspicion.

A new website, Oregon Homebirth Midwife Info, has compiled a Midwife Directory that makes for stomach-churning reading. The directory lists midwives by name and includes reports of deaths as well as other major morbidity and actions taken against the midwives.

It is an incomplete list; not all Oregon midwives are included and there may have been additional deaths that are not recorded. Nonetheless, the statistics are no less than horrifying.

In the past decade, no less than 19 babies have died at the hands of Oregon homebirth midwives.

To put that in perspective, consider that there are approximately 1000 homebirths per year in Oregon and that the neonatal death rate for low risk women in a hospital setting is 4/10,000 (0.4/1000). That means that you would expect approximately 4 homebirth deaths per decade. Instead there were at least 19 deaths, for a rate more than 4X higher (375%) than expected.

No less than 16 midwives have presided over at least one death. Interestingly, only 2 were unlicensed midwives. The rest were licensed at the time of the death(s) and almost all had complaints filed against them with the Board of Direct Entry Midwifery. In other words, this information is available to Melissa Cheyney in her role as a member of the Board.

Homebirth kills babies. No one knows that better than Melissa Cheyney, who has, until now, successfully hidden the number of homebirth deaths at the hands of Oregon homebirth midwives, and who continues, in her role as Director of Research at MANA (Midwives Alliance of North America), to hide the number of babies who died at the hands of homebirth midwives across the country.

Midwife : UK deaths result of failing to meet the needs of ... midwives ?

Two weeks ago I reported on 15 deaths at two hospitals in the United Kingdon (Promoting normal birth is killing babies and mothers). The 15 tragedies were united by the fact that midwives were so busy promoting "normal" birth that they failed to recognize complications or refused to refer patients to specialists in the face of complications.

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.

Last week I posted the story of Joshua Titcombe, whose needless, senseless, entirely preventable death occurred at the hands of midwives who refused to acknowledge that he was ill and never alerted a pediatrician.

Today I came across the response of a midwifery professor published in The Guardian. According to midwife Sarah Davies, we need a new model for maternity care, not blame for individuals, a piece which could more aptly be titled "mistakes were made ... but not by us."

It's a masterpiece of the genre employed by errant politicians and corporate malfeasors, the non-apology apology.

Ms. Davies acknowledges that mistakes were made, specifically mentioning:

... two maternal deaths at Queen's hospital in Romford that should never have happened, and the abusive and neglectful behaviour by midwives ...

... individual midwives treated women with disrespect – one midwife was heard to say: "Hurry up, or I'll cut you." ...

Concluding:

But blaming individuals for failing to care is no solution when the whole system is wrong.

Actually, blaming individuals for their unacceptable, unprofessional behavior is an excellent solution. We even have a special word for that solution. The word is "accountability." Health professionals who commit malpractice (for that is precisely what happened in these instances) should be held personally accountable for their failings.

According to Ms. Davies, though, the midwives are not responsible for those deaths, "the system" is responsible. In a remarkable bit of rhetorical jujitsu, Ms. Davies insists that the failure of the midwives to obtain help from other clinicians (obstetricians and neonatologists) is the result of a shortage of ... midwives!

... the circumstances described reflect the continuing neglect of pregnant women's core needs. The government has chosen not to recruit the 5,000 additional midwives the Royal College of Midwives has repeatedly stated are required.

Those two sentence sum up what is wrong with the UK maternity system, though not in the way that Ms. Davies had in mind.

First, Ms. Davies deliberately conflates the needs of pregnant women with the needs of the midwives who care for them. The core need of pregnant women is for safe, professional, compassionate maternity care. The core need of UK midwives is apparently full employment for UK midwives.

Second, is there a shortage of midwives in the UK? Perhaps, but this is not an example of it. These were not overworked midwives who did not have the time to attend to their responsibilities. These were midwives who had more than enough time to "care" for patients who should have been cared for by specialists.

These tragedies occurred because midwives deliberately took on work that properly belonged to others in an apparent effort to protect their turf. The preventable deaths at both hospitals include cases in which obstetricians were told that their help was not needed and parents were told that the expertise of pediatricians was unnecessary.

Thirteen babies and mothers are dead at the hands of midwives, but Ms. Davies apparently thinks that this is the perfect opportunity to praise midwives:

All the research indicates that continuity of midwifery care gives the best physical and psychological outcomes for women and babies ...

Apparently not, since thirteen babies and mothers are dead specifically because their midwives did not provide the best care.

Student midwives ... are dedicated, caring individuals who make many sacrifices as they learn how to help women have a safe, satisfying birth experience ...

How nice, but what does that have to do with the disasters that occurred? Nothing.

Because of the lack of recruitment, many newly qualified midwives struggle to find posts.

How sad, but what does that have to do with the disasters that occurred? Nothing.

For the long-term health of mothers, we desperately need a different model for maternity care – one that is community based; gives midwifery continuity; and where birth takes place at, or close to home for most healthy women.

Really? Would community based care, homebirth and midwifery continuity have prevented any of the thirteen deaths? Of course not, but it would lead to greater employment opportunities for midwives and that's more important.

What led to the deaths of these babies and mothers? Midwives putting their needs ahead of the needs of patients. Ms. Davies is doing the exact same thing in this piece: putting the needs of midwives ahead of the needs of mothers.

We can't control C-section rates if we ignore doctors' liability concerns

The CDC has just released its annual report on birth statistics, Births: Final Data for 2009. Once again, the C-section rate has risen:

In 2009, the total cesarean delivery rate reached a record high of 32.9 percent of all births, a 2 percent increase from 32.3 percent in 2008. This is the 13th consecutive year in which the cesarean delivery rate has risen ...

There are a number of reasons for the continuing rise, but one of the most important is obstetrician liability concerns. I wrote about a spectacular example yesterday, the recent $144 million verdict against a Michigan hospital for neonatal injuries sustained by a large baby due to shoulder dystocia. The cause of action was failure to offer a C-section. Shoulder dystocia cannot be predicted in advance and the scientific evidence is that prophylactic C-section for macrosomia does not improve outcomes. But that didn't stop the lawyer from arguing or the jury from believing that a prophylactic C-section should have been recommended.

There is simply no way we are going to get a handle on C-section rates if we continue to ignore obstetricians' concerns about liability. As I first wrote in March 2010, obstetricians have been desperately trying to explain how liability concerns are driving the rising C-section rate, yet they are consistently ignored.

It's rather surprising since obstetricians perform the C-sections and have much greater insight into their motivations than anyone else. But everyone from insurance company executives to health policy experts to natural childbirth advocates disparage and ignore doctors' explanations. How do they justify ignoring the very people whose behavior they wish to change?

Law professor Sandra Johnson offers insights into doctors' concerns and how they are ignored in, of all places, a law review article entitled, Regulating Physician Behavior: Taking Doctors' "Bad Law" Claims Seriously.

Doctors frequently claim that the very law intended to improve the lot of their patients is instead making the doctors provide poor care. These "bad law" claims are levied against malpractice litigation that makes doctors practice "defensive medicine"; ... against antitrust laws that prevent doctors from organizing themselves in ways that would produce more cost-effective and accessible care; and against regulations that impede important medical research. These “bad law” claims assert that the law's effort to promote patient health and well-being has actually caused significant harm.

And why have these concerns been ignored?

Medicine’s complaints ... [have come] to be characterized as the work of a self serving guild, rather than a profession motivated by altruism and armed with expertise, or at least as the work of the recalcitrant "bad apples" who continued to resist improvements that the more enlightened among them embraced. These narratives marginalized physicians' ... claims and diminished them as a source of legitimate information about the effectiveness of reform efforts.

Rather than addressing the substance of doctors' arguments, experts and lay people have denied that there the complaints are legitimate, ascribing them to greed and self interest. Yet in the case of medical liability, as in other areas of medical "reform," doctors are often right.

Professor Johnson explains that doctors' liability concerns are not simply ignored; even when they are directly addressed, they are often dismissed as irrelevant by those who don't or won't understand their impact on individual practitioners. She identifies a number of these dismissive behaviors.

All's not well that ends well

Policy experts and lay people alike often point to the fact that physicians win most malpractice suits as evidence that doctors shouldn't worry about being sued. But as Prof. Johnson notes:

The enforcement process itself [in this case, the lawsuit] also imposes significant penalties in the course of identifying violators. These penalties are distinct from formal penalties levied after a conclusive finding that a violation has occurred. These “penalties of the process” exert their own deterrent effect. When substantial, they will produce avoidance behaviors on the part of those who might fall within the investigative net even though the likelihood that they will be subject to formal sanctions is nil or close to it.

In other words, the risk of being sued has a deterrent effect, regardless of whether the doctor wins or loses. And who would know better than the doctors themselves?

The deterrence effect of these informal penalties may produce results that actually undermine the goals of the formal legal requirements. Yet, they are all but invisible—they make no appearance in the formal description of the standards and procedures incorporated in the law. The best information available concerning the operation of this shadow system of enforcement comes from the people who experience it, those doctors who claim that there is "bad law" causing them to avoid doing the right thing.

The interminacy of law

Lay people in particular like to claim that if the doctor "does the right thing," he or she has nothing to worry about. That is startlingly naive view.

... It is hardly ever the case that lawyers can tell doctors: "I assure you that you have nothing to be concerned about ... You are safe." ... So, instead, what doctors often hear lawyers say is: "Well, anyone with a filing fee can sue you, but they are not going to win." This consolation ... has to ring hollow to anyone who has been the defendant in any suit, even one that is eventually dismissed. Instead of reassurance, one could understand that this phrase would be heard as confirmation of the unpredictability of the legal hammer.

Asymmetrical legal risk

At times, legal risk is lined up entirely on one side as the doctor looks at the risks of particular decisions... [W]hen we began our work on pain management in 1995, only the doctor who prescribed opioids for his patients in pain faced investigation, sanctions, and liability claims. The doctor who used the less effective medications and neglected their patient’s pain faced no legal risk at all.

The same asymmetrical risk applies to C-sections. An obstetrician who fails to perform a C-section can be accused of negligence if there is anything wrong with the baby. An obstetrician who performs a C-section, even one that is not medical necessary, faces no legal risk at all.

Professor Johnson's most important message is that it is time to start taking physician liability concerns seriously instead of dismissing such complaints are motivated by greed and self interest:

[We] must accept that well-intentioned regulatory standards and enforcement systems can have negative outcomes as physicians react, and patients suffer as a result. Taking physicians' "bad law" complaints seriously brings physician behavior to the table as a credible and legitimate factor in evaluating the performance of the law... Taking “bad law” claims seriously appreciates that the behavior-inducing effects of the enforcement effort may thwart the goals of the regulation itself.

The bottom line? If we continue to ignore obstetricians liability concerns, the C-section rate will continue to rise.

Jury awards $144 million for failure to perform a C-section

Geoffrey Fieger, famous for representing Dr. Jack Kervorkian, is now notable for a new reason. He just won one of the largest medical malpractice verdicts in history in an obstetric case. The claim? Failure to perform a C-section, of course.

A Detroit-area newspaper reported:

In what appears to be the largest medical malpractice lawsuit verdict ever awarded in Michigan, a Macomb Township family has been granted $144 million in a case against William Beaumont Hospital of Royal Oak...

Markell was born with cerebral palsy and hypoxic-ischemic encephalopathy, and attorneys argued the condition was a result of a traumatic labor and delivery at Beaumont Hospital in Royal Oak...

Markell was 10 pounds, 12 ounces when she was born Dec. 1, 1995 ...

The birthing process also caused a brain hemorrhage and bruises to Markell's body...

She suffered a fractured left clavicle during the delivery and "had no respiratory effort," as well as seizures, according to court documents.

In other words, Markell was a macrosomic baby who suffered a severe shoulder dystocia.

Shoulder dystocia cannot be predicted in advance although the risk rises in babies over 10 pounds. The scientific evidence, often touted by homebirth and NCB advocates, is that prophylactic C-section for macrosomia does not improve outcomes.

But that didn't stop Fieger from arguing or the jury from believing that in this case a prophylactic C-section should have been recommended:

In the lawsuit, attorneys for the VanSlembrouck family accused the hospital and its physicians of being negligent in many ways, including failure to recommend or offer a cesarean section procedure ...

And though we know, as NCB and homebirth advocates are fond of declaiming, that, due to limitations in the existing technology, estimates of fetal weight vary as much as 2 pounds in either direction in the 3rd trimester, that didn't stop Fieger from arguing or the jury from believing that the hospital could have obtained an accurate fetal weight prior to the onset of labor:

The VanSlembroucks also accused the hospital of providing negligent prenatal care, including a failure to establish a reliable estimation of fetal weight.

This case is an excellent illustration of the pressures on obstetricians.

Yet no less an authority than our friend Jill Arnold, counseling women on how to avoid an "unnecesarean," decries prophylactic C-sections for macrosomia, going to far as to disparage the "dead baby card."

... Is this "recommendation" of a c-section based on evidence or is it merely the practice of defensive medicine? The burden of proof is on the doctor wanting to schedule a primary c-section for a non-diabetic woman.

At this juncture, doctors are known to share a personal anecdote about shoulder dystocia in which the baby died or suffered nerve damage during birth to support their recommendation and scare the pregnant woman into compliance. This is also referred to as "playing the dead baby card." Such events are tragic for all parties involved, including the labor and delivery staff. They are also EXTREMELY rare and unpredictable.

The American College of Obstetrics and Gynecology does not support prophylactic cesarean delivery for suspected fetal macrosomia with estimated weights of less than 5,000 g, stating that " ...it is safe to allow a trial of labor for estimated fetal weight of more than 4,000 g."

Jill appropriately cites 7 specific studies that recommend against prophylactic C-section for macrosomia.

But it did not matter to this jury that the scientific evidence does not support prophylactic C-section for macrosomia. It did not matter that, due to limitations in existing ultrasound technology, it was literally impossible for doctors to establish a fetal weight any closer than 2 pounds in either direction. All that mattered was what was clear in hindsight: a C-section would have prevented the tragedy that befell this specific child.

Jill Arnold is correct that a C-section for macrosomia is defensive medicine, but as I have argued before, and as this case demonstrates, defensive medicine works. It prevents heartache for patients and it prevents massive judgements for failure to perform a C-section.

Kim Mosny presides over homebirth tragedy

They say that the best defense is a good offense, and perhaps that's what Kim Mosny, CPM had in mind when she publicly posted the story of a perinatal loss on her Facebook page. Mosny has appeared across the internet proclaiming the safety of homebirth. Perhaps she fears that her association with a tragedy might raise doubts about her claims.

On October 8, 2011..., [the baby] died inutero (while inside the uterus) as a result of a hidden, complete placental abruption (where the placenta shears off the uterine wall). [The baby] was stillborn at 12:19am on October 9, 2011, taken by cesarean section to protect [the] mother's health...

Clinically, there is no explanation for this rare event other than to acknowledge the biological risk of all pregnant women because they have a placenta attached to their uterus...

Kim wants you to believe that there was no way this could have been prevented.

... Midwives care only for low-risk women, who have healthy life-styles; who do not smoke, drink alcohol, or abuse drugs, and who's medical status is determined to be healthy, without medical conditions or diseases that would risk them out of care. Thus, there were no other risks that could be determined as causal for this client's placental abruption. As a result of the abruption, the baby was very quickly deprived of oxygen and he died. He felt no pain. Thankfully, the mother remained stable and did not suffer medical complications herself.

And she wants to be sure that we know that the parents are not blaming her:

Our clients wish to convey their satisfaction with and confidence in their care providers, both the midwives of the Home Birth Midwifery Service ... stating the course of their care was thorough and comprehensive. They received excellent care throughout.

Technically speaking, everything that Mosny wrote may be true. However, she left out some critical details that cast a very different light on the tragedy.

1. The patient was 42 weeks and 1 day when this stillbirth happened. While the actual precipitating event that led to the baby's death may not have been preventable, the death itself may have been preventable. The stillbirth rate rises steadily at the end of pregnancy, and 42 weeks is considered the outermost cut-off for induction and delivery of the baby. Had this patient been induced in the hospital before 42 weeks, the outcome would likely have been a healthy baby.

2. Mosny is silent on whether the patient was in labor at the time of the abruption. She does not claim that the patient experienced decreased movement or sudden onset of pain. Whether the patient was in labor at the time that the abruption occurred is highly relevant.

3. Mosny is silent on when and how the patient was diagnosed and transferred to the hospital. If the transfer was during labor, it took place too late to save this baby's life. Homebirth advocates are fond of claiming that even when an emergency occurs at homebirth, there is plenty of time to transfer to a hospital. But there are a number of obstetric emergencies, none of which are rare, that must be treated within minutes or the baby will die. One of these is a major placental abruption.

4. The treatment for an abruption that results in a perinatal fatality is vaginal delivery. There are two exceptions: if the patient had a previous C-section and requests a repeat, or in the case of massive bleeding. In this case, the baby was a first child, and, according to Mosny, the bleeding was confined to the area behind the placenta (hidden abruption). Therefore, a C-section in this case was probably the result of obstetric indications unrelated to the baby's demise, such as cephalo-pelvic disproportion.

As soon as I read Mosny's Facebook post about the tragedy, I suspected that there was more to this story than she was revealing. In the first place, it is unusual for any provider to publicly announce a stillbirth. Second, it seemed that the purpose of the announcement was to publicly absolve herself of blame. But that begs the question: why would she feel it was important to publicly renounce blame for a stillbirth in the absence of risk factors?

It turned out, however, that there was at least one major risk factor for stillbirth, and that her description of what happened, while technically true, omitted key facts that shed a very different light on the situation.

I contacted Mosny to offer her an opportunity to comment on the specific circumstances surrounding a perinatal death that would justify a public announcement that it was unpreventable. She did not offer any clarification.

Unfortunately, there is a real possibility that this was a classic homebirth tragedy. A patient who should have been risked out from homebirth, who should have been induced earlier, experienced a catastrophic complication, and by the time the patient was transferred to the hospital, the baby was dead.

Oregon homebirth midwives don't want to obtain informed consent

Isn't every patient entitled to give informed consent for medical care, with the provider explaining risks and benefits of each available option? Oregon homebirth midwives don't think so.

New state regulations enacted earlier this year mandated informed consent:

Beginning on June 1, 2011, each LDM [licensed direct entry midwife] must provide risk information as published on the agency’s website www.Oregon.gov/OHLA, and obtain informed consent for the following circumstances:

(a) Out-of-hospital birth;
(b) Vaginal birth after cesarean (VBAC);
(c) Breech;
(d) Multiple gestations; and
(e) Pregnancy exceeding 42 weeks gestation.

It's now November, yet Oregon homebirth midwives are NOT obtaining informed consent in these high risk situations. That's a remarkable turn of events for two reasons.

First, it is notable because a specific regulation was required to address the fact that Oregon homebirth midwives were not fulfilling their ethical obligation. Every healthcare provider is ethically and legally required to provide accurate information about the risks of any medical care. Oregon homebirth midwives SHOULD HAVE been providing information about the increased rate of perinatal death at homebirth, and the further increase in risk posed by VBAC, breech, twins, and postdates pregnancy. Oregon homebirth midwives flagrantly disregarded this obligation and Oregon officials felt compelled to make informed consent mandatory for license maintenance.

Second, it is remarkable that Oregon homebirth midwives have still not begun obtaining consent for these high risk situations, arguing repeatedly that they need "more time" to create consent forms. Homebirth midwives petitioned for and were granted an extension until October 15, and as the date drew near, they petitioned to postpone the requirement for informed consent until January 1, 2012. That request was formalized on 9/26/11. A little over a week later, having postponed compliance with the requirement for 6 months, Oregon homebirth midwives petitioned to postpone a further 6 months.

The idea that they needed any extension at all is bizarre. The increased risks posed by VBAC, breech, twins and postdates pregnancy are well known and have been quantified for years. For example, obstetricians have been obtaining informed consent for VBAC for at least 20 years. The Board of Direct Entry Midwifery could easily assemble and print the information in one day.

Moreover, the requirement for informed consent does not depend on provider convenience. Can you imagine a doctor arguing that he didn't obtain informed consent for gall bladder surgery because he hadn't had time to prepare a consent form? Can you imagine an oncologist arguing that he didn't obtain informed consent for a patient to refuse chemotherapy in favor of herbs because he didn't have time to prepare an consent form? Of course not.

Can you imagine a doctor insisting that he needn't obtain informed consent for gall bladder surgery for any patient in the next year because that's now long he would need to prepare a consent form? Can you imagine an oncologist arguing that he needn't obtain informed consent for any patient in the next year to refuse chemotherapy in favor of herbs because he didn't have time to prepare an consent form? Of course not.

Yet that's precisely what Oregon homebirth midwives are arguing:

Amend OAR 338-025-0120 to extend the implementation date for risk information packets by requiring that each LDM provide risk information as published on the agency’s website regarding out-of-hospital birth, malpresentation birth (breech), multiple gestations (twins), vaginal birth after cesarean (VBAC), and births exceeding 42 weeks gestation (post-dates) beginning June 1, 2012.

There is no plausible reason to take a year to amend a consent form, especially since the information has been known for decades and can be accessed in moments on Google. So why are Oregon homebirth midwives arguing for repeated extensions to the informed consent requirement?

It's simple. They don't want to obtain informed consent.

If Oregon homebirth midwives are are required to provide patients with accurate information about the real risks of homebirth, and particularly about the increased risk of high risk homebirth, they will have many fewer clients.

The state of Oregon should refuse to grant any further extensions. Informed consent is a requirement for all healthcare providers and there should be no exception for Oregon homebirth midwives.

Dr. Amy on Time.com 11/7/11.

Tomorrow, Ricki Lake is releasing More Business of Being Born, a direct to DVD sequel to her first movie.

My piece on Time.com details What Ricki Lake Doesn’t Tell You About Homebirth.

Homebirth Summit consensus statements: much ado about nothing

Organizers of the Home Birth Consensus Summit are trumpeting the nine statements of common ground that emerged from the meeting. According to the press release:

Although many of the participants represented stakeholders who have long been on opposite sides of the fence when it comes to the practice of delivering at home or in a freestanding birth center, the group was able to reach agreement on core sets of principles and to forge a shared commitment to quality maternity care for women and their babies in all birth settings.

Frankly, it is much ado about nothing.

Here are the statements statements:

1. We uphold the autonomy of all childbearing women...
2. We believe that collaboration within an integrated maternity care system is essential for optimal mother-baby outcomes...
3. We are committed to an equitable maternity care system without disparities in access, delivery of care, or outcomes...
4. .. [A]ll health professionals who provide maternity care in home and birth center settings have a license that is based on national certification that includes defined competencies and standards for education and practice...
5. We believe that increased participation by consumers ... is essential to improving maternity care...
6. Effective communication and collaboration across all disciplines caring for mothers and babies are essential for optimal outcomes across all settings...
7. We are committed to improving the current medical liability system ...
8. We envision a compulsory process for the collection of patient ... data on key ... outcome measures in all birth settings....
9. We ... affirm the value of physiologic birth ... and the value of appropriate interventions based on the best available evidence to achieve optimal outcomes for mothers and babies...

The are so banal as to be nearly meaningless, and everyone agreed with them prior to the Summit. It put me in mind of a summit between two bitterly warring countries that is declared a great success because everyone agrees that ... peace is good. There's nothing substantive here and the most critical issues are not addressed.

I was interviewed by a reporter for Medscape about by impressions of the Summit results:

"On any substantive issues there was no agreement: The idea that women should have autonomy...that there should be some sort of standard,...everyone agreed on that beforehand as no-brainers."

Dr. Tuteur takes exception to the summit's wishes "not to examine, debate, or form a consensus statement regarding the evidence published regarding safety or maternal–newborn outcomes of planned home birth."

"One of the things that I found most disturbing about the summit was that one issue was off the table from the get-go: there would be no discussion of whether home birth is safe, and that's really the key issue," ...

I commented on the fact that the existing scientific evidence and state and national statistics show that American homebirth has triple the death rate of hospital birth for comparable risk women. The problem is so serious that MANA refuses to release the death rates for homebirth midwives.

"It does not take a rocket scientist to surmise that [the Midwives Alliance of North America's] own data show that homebirth with an American homebirth midwife is not safe," Dr. Tuteur noted. "Withholding that information from patients is both unethical and immoral."

And, of course, I mentioned the inadequacy of the CPM credential:

"One thing that most Americans don't realize is that American homebirth midwives have a pretend credential they give themselves, called 'Certified Professional Midwife,' and any similarity to Certified Nurse Midwife is confusing and deliberate, ... There is no possible way that a high school graduate with a mail-order certificate is qualified to take care of anyone," ...

I am no diplomat (that's no surprise to anyone who reads this blog regularly), so perhaps in the world of diplomacy it is a great achievement to hold a conference and announce you agree on a bunch of things that everyone already knew you agreed upon, while simultaneously refusing to address critical substantive issues. But it seems to me that this Summit was nothing more than a public relations ploy to elevate the status of homebirth midwives, giving the impression that they were "invited to the table" by the expedient of creating the table and issuing all the invitations.

The two principle issues in American homebirth did not produce consensus, and one was off the table from the start. The two critical issues, threshold issues on which everything else is based, are these: American homebirth increases the risk of perinatal death, and the CPM credential does not meet the standards of any other first world country. If homebirth advocates refuse to acknowledge or even discuss these issues, the results of any consensus summit are meaningless.