Homebirth Debate

The Skeptical OB

2009-04-06T10:50:00.002-04:00

The Skeptical OBgreat free widgetsWidgetbox

I've moved my new blog to my own site where there is no need to register in order to comment. Everyone is welcome.

How to tell if a homebirth midwife is a quack

2009-02-27T17:26:00.000-05:00

The Brewer diet is the flat earth theory of homebirth midwifery. It's been discredited in every possible way, but just like the flat earthers can "see" that the earth is flat, the Brewer diet supporters can "see" that it works.

If there is anything that definitively marks a homebirth midwife as a quack, it is belief in the Brewer diet.

Continuing the discussion

2009-02-19T07:13:00.001-05:00

I've been on a temporary hiatus, but others have continued the discussion. I received e-mail requests to open a new thread for member convenience in posting. Here it is.

CDC study does NOT show bed sharing is dangerous for infants

2009-01-27T09:49:00.002-05:00

It really irks me that the CDC has claimed that a new study on accidental infant suffocation shows that bed sharing increases the risk that an infant will suffocate. The study itself shows nothing of the kind. It merely reflects a change in the reporting criteria for infant death. You can read my rant at CDC study does NOT show bed sharing is dangerous. Feel free to comment here or there.

Failure to rescue

2009-01-11T23:01:00.003-05:00

I'd like to propose a new way of thinking about preventable death at homebirth. A more accurate description might be "failure to rescue."

This phrase is used in analyzing quality of care in various aspects of medicine. It refers to the deaths that could have been prevented, either by more careful monitoring to recognize an emergency, providing appropriate care, or providing appropriate care in a timely fashion.

Not all homebirth deaths represent a failure to rescue. Some are caused by abnormalities incompatible with life. However, most homebirth deaths are caused by failure to rescue and it is easy to see how that happens. First, by the very nature of homebirth, it is impossible to provide appropriate care for an immediately life threatening emergency. Cord prolapse, massive abruption, and fetal bradycardia will result in perinatal death in the majority of cases. Simply by choosing homebirth, parents ensure that no one will be able to rescue a baby in immediate danger of death.

The lackadaisical monitoring, and the minimal knowledge base of most direct entry midwives dramatically increases the risk of failure to rescue due to failure to recognize the problem. That's why there are unanticipated homebirth deaths. The midwife has literally no idea that the baby is in serious trouble and therefore does nothing to prevent the death. A dead baby drops into her hands, a situation that is virtually inconceivable in a hospital setting.

The third type of failure to rescue, inability to provide appropriate care , is also more common at homebirth. Even if a DEM recognizes a problem, she often cannot handle it appropriately, and more importantly, she lacks the knowledge and equipment to perform the expert neonatal resuscitation that may be needed. Problems in this category include shoulder dystocia and breech with trapped head or nuchal arms. Most of these babies will simply die at home.

The key advantage of the hospital is the ability to rescue babies who need to be rescued. Parents choosing homebirth are simply betting that their baby will not need rescue. Unfortunately, if it does, the baby will most likely die as a result of failure to rescue.

"Internet Crack for Crazy Mamaz"

2009-01-06T09:58:00.002-05:00

A send up of MDC:

Truth be told, www.mothering.com is a festering cesspool of what can only be described as insane MAMAZ who put their children and the children of others at risk every single day because they essentially enjoy engaging in a pissing match over who can be crunchier.

Read and enjoy the full post at the author's website.

A lactivism project I can get behind

2009-01-03T10:27:00.002-05:00

What are the folks at Facebook thinking? Why are they labeling as obscene photos of mothers nursing their children?

I strongly support the protests of Facebook's nursing mothers. I blogged about it on OpenSalon:

100,000 women demand more breasts on Facebook

"we all know natural birth is pretty much like trying to push a football through the eye of a needle"

2008-12-29T17:50:00.002-05:00

From Orgasmic birth and other old midwives' tales written by a homebirther Avril Moore in the Australian publication The Age:

On Ina May Gaskin:

Curious to see what her contemporary take on modern birthing practices would reveal, I logged on to www.orgasmicbirth.com, only to discover a much greyer Gaskin still expounding — "it is possible to have an ecstatic birth — in fact, it is the best natural high that I know of".

... [H]aving delivered three children vaginally (two at home and one in a labour ward) and having experienced an orgasm, I can confidently report there is nothing remotely similar between them.

If ever there was a reason for women to be suspicious of natural childbirth, it is the "orgasmic" vaginal delivery and "placenta-eating" claptrap that is trotted out every time home birth is put back on the health service agenda.

On the role of men in the natural childbirth movement:

What a paradox that this "woman-centred" approach to birth, all dressed up to empower labouring mothers, remains unapologetic in its deference to men. Gaskin's book was dedicated to her husband, spiritual leader and "head honcho" of the notorious "farm", Stephen, whom she claims taught her everything she knows about midwifery, including "respect for the life force and how to move psychic energy".

A similar misguided adulation surrounded Melbourne's two sagely home-birth doctors (replete with beards and sandals) during the '70s and '80s.

Their entourage of pregnant patients, "birth helpers" and midwives became such blind devotees that they were utterly bereft when one practitioner after the other was deregistered or suspended for malpractice.

On the effect of Gaskin and her campaign for "orgasmic" birth:

This stereotype promoted by Gaskin on the Orgasmic Birth website is exactly what drives women into the arms of their scalpel-wielding obstetricians, not to mention encouraging a good dose of post-natal depression due to profound disappointment with their labour.

On the reality of birth:

But please, let's get real, and stop equating this choice with some hokey idea of "ecstasy" when we all know natural birth is pretty much like trying to push a football through the eye of a needle — imagine that, fellas, whenever you're having an orgasm.

I couldn't have said it better myself.

MacDorman studies further undermined by new data

2008-12-27T19:41:00.004-05:00

Homebirth and "natural" childbirth advocates like to claim that Cesarean section increases the risk of neonatal death almost 3 fold, based on the findings of Marian MacDorman and colleagues. What they do not realize is that MacDorman herself has already revised this claim drastically downwards, and that even then, the conclusions are false.

In September 2006, MacDorman et al. published (and heavily publicized with interviews to the lay press) a paper that purported to show that Cesarean section increases the risk of neonatal death almost 3 fold. MacDorman et al. compared outcomes of C-sections with "no indicated risk" (a blank space on the risk section of the birth certificate) with outcomes from vaginal deliveries with "no indicated risk" and found that the neonatal death rate was higher in the C-section group. However, MacDorman neglected to mention that it is well known that the risk section of the birth certificate is often left blank even when there are serious risk factors and complications. Indeed, in 50% or more of serious risk factors (heart disease, kidney disease, etc.) the space is left blank. So their assumption that "no indicated risk" means no risk is completely unjustified.

In the follow up paper Neonatal Mortality for Primary Cesarean and Vaginal Births to Low-Risk Women: Application of an "Intention-to-Treat" Model, MacDorman et al. use the same dataset, known to be flawed and incomplete, but applied a better form of analysis. Using this new, more accurate statistical analysis, MacDorman et al. went back and reviewed their incomplete, flawed dataset.

...In the most conservative model, the adjusted odds ratio for neonatal mortality was 1.6 (95% CI 1.35–2.11) for cesareans with no labor complications or procedures, compared with planned vaginal deliveries. Conclusions: The finding that cesarean deliveries with no labor complications or procedures remained at a 69 percent higher risk of neonatal mortality than planned vaginal deliveries is important, given the rapid increase in the number of primary cesarean deliveries without a reported medical indication.

MacDorman et al. adjusted their claim downward by a substantially amount. Instead of their original claim that C-section increases the risk of neonatal death by 200%, they now find that C-section increases the rate of neonatal death by only 69%. Yet even then, they failed to acknowledge the most significant flaw in the paper. MacDorman and colleagues assumed that a birth certificate that listed no risk factors for C-section indicated that there really were no risk factors. A large body of data on the accuracy of birth certificates had long ago shown that more than 50% of cases of major risk factors were never listed on the birth certificate and that, therefore, their assumption was completely unjustified.

In the January issue of Obstetrics and Gynecology there is a new paper that adds to the mountain of evidence demonstrating that it is impossible to determine C-section risk factors merely by looking at birth certificates. According to Cesarean Delivery Among Women With Low-Risk Pregnancies: A Comparison of Birth Certificates and Hospital Discharge Data:

Among 40,932 women with primary cesarean deliveries and no risk indicated on the birth certificate, 35,761 (87.4%) had a risk identified in the hospital discharge data. The overall agreement between data sources on the presence of any risk indicator was low (κ=0.18). Among primary cesarean deliveries, the percentage without indicated risk was 58.3% when using birth certificate data alone and 3.9% when using hospital discharge data in combination with the birth certificate.

CONCLUSION: Using birth certificate information alone overestimated the proportion of women who had no-indicated-risk cesarean deliveries in Georgia. Evidence of many indications for cesarean delivery can be found only in the hospital discharge data. The construct of no indicated risk as determined from birth certificates should be interpreted with caution, and the use of linked data should be considered whenever possible.

In other words, virtually all women who had primary C-sections but had no risk factors on the birth certificate, actually did have risk factors. In the case of the MacDorman study, the authors reported that there were 469 deaths out of 271,179 births to women who had primary C-sections and no risks documented on the birth certificate. Yet if 87% of the birth certificates were inaccurate, that means that over 235,000 were wrongly placed in this category, thoroughly invalidating the results of the study.

The bottom line is that there is no evidence that C-section increases the risk of neonatal death in this study or in any other study to date.

Happy Holidays

2008-12-25T16:47:00.000-05:00

Wishing everyone happy holidays!

Idiots

2008-12-17T09:59:00.002-05:00

Is there any limit to the ignorance and idiocy of homebirth midwives? It doesn't seem like it. When presented with a transverse lie, ruptured membranes, and prolapse of the baby's arm, these morons tried to "fix it." It was lucky that the cord did not prolapsed along with the arm.

Leaving aside the fact that the midwife had so little idea of what she was doing that she failed to diagnose a transverse lie (always undeliverable) at the beginning of labor, she actually moved the mother around, as if that was going to change anything. It is a miracle that she didn't manage to cause the cord to prolapse, and the baby's death. Astoundingly, even in retrospect, the midwife and the doula still don't get it. The doula who was there is still prattling about what a "courageous" warrior the mother was. The mother probably has no clue that the baby survived despite the midwife's ignorant efforts to kill it.

Consider:

The birth was straight forward, planned homebirth, baby decided to wave, hand hanging out (and grasping!) of mom's vagina ...

I knew that when she said she felt fingers in her vagina that we would transport, even before the midwife. The midwife thought it was a nuchal arm, I knew that it wasn't. I watched the midwife do Midwifery and I was impressed with her skill and knowledge and so affirmed that I do NOT want to be a midwife. I used to want to be the keeper of that knowledge ...

What knowledge? The midwife could not diagnose a prolapsed arm even when it was waving at her.

I have never seen a woman be so willing to try such odd things and she was positively graceful and acrobatic in her flexibility, not only in her spirit but in her body. She walked into the place of her greatest, deepest fears and she cried hard but she didn't run away- the word "Courageous" isn't big enough...

I can't say after my cesarean that a cesarean is 'worth it', it sounds trite and small now that I know the true sacrifice a cesarean is. Mothers are warriors and this mama, she fought and fought and her baby and she came through safely, however scarred.

"Fought and fought," "scarred"? What? They still dont understand that the only alternative was death for both the baby and the mother. They still have no idea that the worst thing to do in the case of a prolapsed body part is to move the mother around.

A prolapsed arm is an emergency. It is a miracle that the baby survived the "care" of this midwife. The midwife had literally no idea what was happening, and probably still doesn't. Direct entry midwives are grossly undereducated and grossly undertrained. What's most amazing about homebirth midwifery is not that the neonatal mortality rate is triple that of hospital birth, it's that the neonatal mortality rate is not even higher.

New Wisconsin statistics continue to show high homebirth death rate

2008-12-15T21:15:00.004-05:00

At the beginning of the year, I wrote about the neonatal mortality statistics in the state of Wisconsin, which showed that homebirth with a direct entry midwife had a neonatal death rate triple that of low risk hospital birth (at any gestational age) for the years 2000-2006. The state recently updated the its mortality module query with the statistics from 2007. In addition, it is possible to limit the data to term births and exclude premature births. The new data shows an even greater gap. Homebirth with a DEM in Wisconsin in 2007 had a neonatal mortality rate 8 times that of low risk hospital birth (with a CNM)!

This is yet more hard data confirming the increased risk of neonatal death at homebirth attended by a DEM. The real increase in risk is almost certainly greater than that depicted in the table. That's because the true CNM neonatal mortality rate for low risk women is probably lower than the data shows, and the true DEM neonatal mortality rate is almost certainly higher. The CNM neonatal mortality rate is probably lower than the rate depicted because it includes women who are not low risk, since CNMs care for all women anticipating a vaginal delivery. The DEM neonatal mortality rate is almost certainly higher because it does not include emergency transfers of the mother during labor. The attendant recorded on the birth certificate is the attendant who actually delivered the baby, not the attendant who supervised the labor, so all DEM intrapartum transfers are recorded in the MD group, not the DEM group.

So here it is: the latest hard evidence that DEM attended homebirth has a rate of neonatal death triple that of hospital birth for low risk women. Is it any wonder that MANA (Midwives Alliance of North America) is concealing their data? It is not surprising, but it is immoral.

So much for intuition

2008-12-12T09:20:00.002-05:00

As I've written many times before, intuition is not another "way of knowing." Intuition, as venerated by homebirth advocates, is merely a way to glorify ignorance. Not surprisingly, the very same forums and message boards that promote childbirth intuition are the source of a never ending parade of example that intuition among homebirth advocates is worse than worthless. Of the 14 homebirth deaths thus far on MDC this year, not one mother had any intuition that anything was wrong. Indeed, a number of them ignored known risk factors and even actual warning from their own practitioners.

As tragic as these demonstrations of the uselessness of intuition are, a far more impressive example is a story like this, written at 30 weeks of pregnancy:

...I'm in an interesting situation: I understand [my husband's] need for wanting to get the pregnancy confirmed and we've found a place nearby that will do ultrasounds. I didn't want to do it before I opened my heart because I felt that it was a dishonor to my spirit ... Now ... I know it means a lot to him and I know it will help bring us closer (with the pregnancy, at least). However, another part of me feels this might take away from the magic of bringing a baby into the world. What are your feelings on this?

Also, he is scared of being the only other adult present while I'm giving birth. He seemed very trusting during the pregnancy with our son, but once active labor set in he became very stressed and anxious. He's not as trusting of his own body so it's very challenging for him to have faith that I am very in tune with my intuition/body and will be able to give birth safely and easily... I really would like him to feel comfortable this time around, but I also would like to honor my soul. What would you do in this situation?

Followed by:

So I went to get an ultrasound yesterday and no baby was detected. The sonographer tried a few times just to make sure. I was in total shock and yet, not, given all the weird circumstances surrounding this "pregnancy". I just can't quite put my head around what has been going on inside of me, though. My intuition has been so strong about being pregnant, coupled with all the usual symptoms, plus weight gain, feeling the "baby" kick on a regular basis (I've been pregnant before, so I know the difference between gas, muscle twitches, my imagination, and a baby kicking), I've had a number of signs in the outer world that I am, in fact, carrying a baby, my abdomen is the only part of me that gained inches, which is an indicator that I'm not simply getting fat, but I never got a positive hpt, I've still been bleeding regularly, and now the ultrasound shows that there is no baby. What the?!?! ...

Laura Shanley

2008-12-10T21:09:00.002-05:00

The ABC News website is currently carrying a story about unassisted childbirth (UC). The story is brief and contains some inaccuracies and omissions, but it does convey the basic points about UC. As with any story about UC, it mentions Laura Shanley:

Supporters of home birth say the experience of bearing a child is enhanced when kept intensely personal and completely natural.

"I felt like I'd touched the eternal, when you look back at your baby and your hands are the first to touch her," Shanley said. "I mean, this experience will carry me through the rest of my life."

I left a comment:

Shanley, the woman you profile, gave birth to 5 children, not four. One was born unassisted prematurely and died for lack of medical attention. Unassisted childbirth (UC) is an irresponsible stunt, undertaken for no better reason that bragging rights. Indeed, as a cultural construct, UC shares many similarities with "extreme" sports. Advocates emphasize the fact that it is transgressive, is "authentic", values process over outcome, creates a sense of belonging, and produces feelings of empowerment.

Unassisted childbirth has no benefit to the baby and poses very serious risks to both the baby and the mother. It involves no particular skill, a belief that no expertise in childbirth is needed, has a prime objective of testing the capacity to endure pain, and risks death as the likely outcome of a mistake. In short, it is nothing more than a stunt.

Shanley has posted her own comment:

Amy Tuteur - those of us in the homebirth movement are used to your inaccurate and fear-based comments about homebirth. But your statement about my baby is an outright lie. Please provide documentation that my baby died due to a lack of medical care. This is pure speculation on your part, as a coroner stated that my baby died of a congenital heart defect, and would have died regardless of where he had been born..

My response:

You yourself have written that you knowingly gave birth to a premature baby at home, never called for medical assistance and watched him die. I'm not aware of any cardiac defects that are completely unamenable to treatment of any kind. Prenatal care could have easily revealed the cardiac defect, and appropriate resuscitation and a surgical team available for repair could have been arranged in advance. People need to know that unassisted childbirth kills babies.

That's not restricted to your case alone. On the forum run by Mothering Magazine, the UC death rate, according to proud declaration of their members is 8/1000. They don't seem to realize that that rate is 20 times higher than the neonatal death rate for low risk women in the hospital!

UC is an irresponsible stunt that kills babies. Some people like to pretend otherwise, but women deserve to know the truth.

Fill in the blanks

2008-12-07T11:01:00.003-05:00

Write your own post to the homebirth board on MDC. It’s easy. Check below for the required format. For ease in posting, we’ve included a convenient script. You can simply fill in the blanks.

Title: Seeking support. WWYD?

Hi, all,

I’ve been seeing a _____ (DEM, CNM, shadow care OB) for this pregnancy. I have a history of ______ (high blood pressure, gestational diabetes, previous C-section, all of the above). Now, I ______ (have gone postdates, have low fluid, have rising blood pressure, all of the above). My ______ (DEM, CNM, shadow care OB) is recommending ______ (NST’s, induction, C-section). She says that I am at increased risk for a stillbirth.

WWYD? My intuition tells me that this baby is just fine. I guess I am looking for encouragement to trust myself. I need someone to remind me that my body was designed for birthing my baby and that I can do it!

Homebirther Wannabe
Wife to the greatest man in the world, Mom to 2 furbabies, planning homebirth, cloth diapers, baby wearing, extended nursing and anything else that will piss off my inlaws.

Title for outcome #1: My blissful home waterbirth of Latrina K8tee Emiliana

I got my homebirth! Last night we welcomed our precious daughter Latrina K8tee Emiliana at 2:43 AM. She needed a little help to get going. There was _____ (some thick mec, a shoulder dystocia, difficulty getting started breathing, all of the above). Our midwife was amazing. She called 911 right away even though she was dealing with my (retained placenta, massive postpartum hemorrhage, seizures, all of the above). The EMTs performed ______ (mouth to mouth, ambu-bagging, CPR, all of the above) on Latrina in the ambulance. Fortunately, we live close by the hospital; it only took 30 minutes to get there.

My only regret is that I have been separated from Latrina. Dh is unbelievable. He has stayed by Latrina’s side through her transfer to the Children’s Hospital upstate and her ______ (admission to the NICU, intubation, seizures, all of the above). In the meantime, I’ve had ______ (a trip to the OR for retained placenta, several transfusions, a hysterectomy, all of the above). As soon as I stop passing out every time I stand up, I’m going to sign myself out of the hospital against medical advice so I can see Latrina.

I just wanted to thank everyone for their support. My _____ (DEM, CNM, shadow care OB) made me doubt myself, but the wonderful mamas here convinced me that I could do it. You were right!

Title for outcome #2: Update, warning sensitive (loss)

I got my home waterbirth. Last night we welcomed our precious angel Latrina K8tee Emiliana at 2:43 AM. There was _____ (some thick mec, a shoulder dystocia, difficulty getting started breathing, all of the above). Our midwife was amazing, but it was not to be. She called 911 right away even though she was dealing with my (retained placenta, massive postpartum hemorrhage, seizures, all of the above). The EMTs performed ______ (mouth to mouth, ambu-bagging, CPR, all of the above) on Latrina in the ambulance. Fortunately, we live close by the hospital; it only took 30 minutes to get there. The doctors and nurses worked for an additional hour trying to save her. I was surprised at how kind they were. The young doctor who told Dh and me of her passing had tears in his eyes.

Dh has been unbelievable. He’s stayed by my side for my ______ (trip to the OR for retained placenta, several transfusions, hysterectomy, all of the above). As soon as I stop passing out every time I stand up, I’m going to sign myself out of the hospital against medical advice to begin planning Latrina’s memorial service.

I can’t understand why this happened. I _____ (ate right, exercised, thought positive thoughts, all of the above). At least I know that I did everything I could to keep Latrina safe. I am proud of myself and of Latrina. The _______ (DEM, CNM, shadow care OB) thought we couldn’t do it, but with encouragement from the wonderful mamas here, we proved them wrong.

I just can't stop thinking: why me?

Childbirth and gravity

2008-12-03T20:37:00.002-05:00

We all know how important gravity is. When we put a turtleneck on a baby, we want gravity to work with us, not against us. So we all hold our babies upside down over the shirt and let the baby fall through the neck opening, right?

Wrong, of course. Yet that is the principle that homebirth and "natural" childbirth advocates invoke when arguing that women should be upright in both the first and second stage of labor. They are absolutely certain, based on no evidence, that gravity provides a powerful and necessary aid to labor.

Consider this from Charlotte DeVries of Lamaze:

I gained a greater appreciation for gravity when, during my second pregnancy, our midwife listened to my tale of woe about a 36-hour labor and forceps delivery with our first (very big) baby and suggested I become a dedicated walker in the months ahead. "Three things," she said. "It's a positive way to move through your pregnancy, your body will be fitter for labor and birth, and you are cooperating with gravity and getting your baby ready to make its way out." She was right on all three counts for that pregnancy and for the one that followed a couple of years later on the other side of the country. For both births, the day I went into labor I did my regular brisk two-mile loop.

...[T]hose long walks can be a time to sort out the needs from the strengths, a time to get acquainted with yourself in a different way, to better listen to your body’s cues when it comes to dealing with the purposeful pain of labor, to grow to trust something as simple as gravity on your birth day.

Or how about this gobbledy gook from the Lamaze Care Practice #5?

Upright positions—such as standing, kneeling or squatting—take advantage of gravity to help your baby move down...

Respected childbirth educator and author Penny Simkin recommends a "standing supported squat" or "dangle" position, especially for women with a long second stage. In this position, the woman is supported under her arms, putting very little weight on her legs or feet. Her trunk becomes longer, providing more space for the baby to move. Simkin also points out that, in this position, the pelvis can move freely as the baby passes through it.

Why is it gobbledy gook? Because it's based on no data at all. "Natural" childbirth advocates simply made it up.

There are very few scientific papers on the subject and the ones that exist offer show no difference in outcomes. Consider Upright position during the first stage of labor: a randomised controlled trial:

The upright position during the first stage of labor did not contribute towards a shorter duration of labor; however, it proved to be a safe and well-accepted option for the women of this study.

"Natural" childbirth advocates argue that this is the way that women give birth in nature:

Until doctors began using forceps in the 17th century, women were rarely shown giving birth in supine positions (lying on the back). With the support and encouragement of family members and community midwives, laboring women used objects such as posts and ropes to gain leverage during pushing. They often used birthing supports or stools to help them squat, crouch, or kneel.

That's not true either.

According to Mobility and maternal position during childbirth in Tanzania:

...More women were mobile at home after the labour pains started than in the labour ward at each hospital. The greatest difference between mobility at home and in the labour ward was at the district hospital (27.6% compared to 4.5%). However, a surprising finding was the apparent restriction on movement prior to admission to the labour ward; across all hospitals, most women chose to rest with little movement when at home (51.6%), and just 15% said they were mobile at home. Another important finding is that 28.3% of all women who laboured in bed in the labour ward said they wanted to be mobile.

In other words, when left to their own wishes, more than half of all women did not want to be mobile in the early stages of labor, and more than 70% did not want to be mobile during active labor. So much for "listening" to your body.

We can go beyond the fact that the Lamaze recommendations are not evidenced based, and ask just what physics tells us about the relative contribution of gravity to childbirth. The uterus generates tremendous force with each contraction, and more force is applied with coached pushing, and by a woman holding her legs under the knees and pulling them back. The uterus supplies approximately 82 newtons (N) of force. Coach pushing (a Lamaze no-no) with legs adds 47 N and pulling the legs back adds 31 N of additional pushing force for a grand total of 160 N.

What would gravity add to the 82 N pushing force of the uterine contractions? For a 7 lb. baby, gravity would add 31 N. In other words, the benefit of gravity is far less than the benefit of coached pushing with legs pulled back. Not only is there no evidence that gravity has a beneficial effect on labor, there is no reason to think that the relatively small force of gravity would have much benefit.

This is yet another example, in the endless parade of examples, that "natural" childbirth professionals advocate practices that have no basis in scientific evidence, no basis in scientific reasoning, and are simply made up to appeal to the whims of "natural" childbirth advocates.

New Dutch guidelines for epidurals

2008-12-03T10:38:00.002-05:00

According to Expatica, epidurals will now be available at all Dutch hospitals:

New guidelines mean women giving birth at any hospitals in the Netherlands can now ask for epidurals.

Women can now demand epidurals while giving birth at any hospital in the Netherlands.

The change is part of new guidelines issued by the national association of gynaecologists, obstetricians and anaesthetists.

Up to now, the Netherlands was one of the few countries where the use of epidurals during labour was not standard practice.

"Suffering due to lack of pain relief is an affront to human dignity"

2008-11-30T11:07:00.002-05:00

Many people believe, and I agree, that easy access to reliable pain relief is a matter of human rights. In the paper Pain Management: A Fundamental Human Right, published in the journal Anesthesia and Analgesia, Brennan and colleagues review the ethics of pain relief:

The importance of pain relief as the core of the medical ethic is clear. The relief of pain is a classic example of the bioethical principle of beneficence. Central to the good actions of doctors is the relief of pain and suffering. As Post et al. state, "the ethical duty of beneficence is sufficient justification for providers to relieve the pain of those in their care ..." The principle of nonmaleficence prohibits the infliction of harm. Clearly, failing to reasonably treat a patient in pain causes harm; persistent inadequately treated pain has both physical and psychologic effects on the patient. Failing to act is a form of abandonment... [F]or a patient's doctor to ignore the patient's complaint of pain or to refuse to accede to a reasonable request for pain relief arguably contravenes the autonomy of patients and self-determination of their medical care ..."

As the authors explain, cultural attitudes have had an large impact on the treatment of pain:

Societal attitudes toward pain relief during surgery and childbirth illustrate the complex interactions between cultural concepts of pain, pain relief, and social behavior...

...In the case of analgesia for childbirth, there was bitter resistance on religious grounds. Fundamentalists cited the Bible as ordaining that childbirth was a necessarily painful process. Opposing both the church and powerful obstetricians, Queen Victoria requested that James Simpson administer chloroform analgesia for the delivery of her son, thus overcoming powerful negative attitudes that discouraged relief of the pain associated with childbirth...

Despite the growing number of initiatives ... to improve pain management, powerful myths (and their proponents) are well entrenched and continue to spread with the ease of an epidemic, independent of any need for logic or rationale. The belief that pain is an inevitable part of the human condition is widespread. The word "patient" itself is derived from the Latin patiens, meaning "one who suffers." Examples of pain
myths shared by health professionals and patients alike include the notions that pain is necessary, natural and hence beneficial ...

The authors ask:

Why has it taken so long to recognize the ethical and legal importance of pain relief? There are complex and overlapping reasons for this delay. For centuries, medical and surgical treatment has emphasized saving the life of the patient rather than ameliorating the patient's pain, particularly when there were few options for the latter... At the same time, entrenched attitudes to pain and its rationalization persist, such as that pain in childbirth is biblically preordained. Redemptive qualities continue to be ascribed to pain ...

The question for midwives, and health care managers who discourage the use of pain relief in labor, or set up barriers to easy access to pain relief in labor, is this: If easy access to effective pain relief is a fundamental human right, how can you possibly justify your opposition to the use of pain relief in labor?

No epidurals in Poland

2008-11-29T11:35:00.003-05:00

According to RH Reality Check, the government of Poland plans to stop paying for labor epidurals. The article quotes Polish Ministry of Health Director Ewa Kopacz:

Kopacz, in response to the letter of the Polish Gynecological Society, which on behalf of women appealed to the Ministry to refund anesthetization, said that the state budget cannot afford to ensure free anesthetization during childbirth to all Polish women. "Childbirth is a pure physiological process and we, women, were created by nature in such a way as to run certain things in their natural way, therefore to have childbirth run in its natural way with no medicine and anesthetization," said the Minister. According to Kopacz, if anesthetization were provided for free, then hospitals would have to ensure that the services of anesthesiologists are guaranteed for female patients to a much broader extent than it is currently. And there are not enough anesthesiologists in Poland.

Will "natural" childbirth advocates rush to praise Poland for this innovation? That's unlikely once they learn that this is only the latest effort of the Polish government to control women's bodies for their own purposes. An earlier article in RH Reality Check describes Kopacz' plan to register all pregnancies in Poland:

If a woman participating in the program does not attend medical checks as previously agreed, it will be the responsibility of a midwife to establish contact with her, Minister Kopacz emphasized.

"If we find out that a woman registered in the system is not yet pregnant before her pregnancy due date, it could mean that she has had a miscarriage or she has terminated her pregnancy," said Jakub Gołąb, a spokesman of the Ministry. "That way, we shall receive information about the scope of abortion underground in Poland." Gołąb claimed that the fight against underground or illegal abortion will be an indirect consequence of introducing the program. He could not say whether doctors would be obliged to report to the Ministry and submit all data related to women who declared they had undergone an abortion. We do know that all doctors will be given instructions by the Ministry, according to which - after confirming a woman's pregnancy - they will be obliged to record it in a special register.

In other words, the decision of the Polish government to deprive women of choice in regard to pain relief in labor is of a piece with the government decision to deprive women of choice in regard to pregnancy.

I, for one, don't find that surprising. The government of Poland may invoke financial reasons to deny women epidurals in labor, but the decision rests on the premise that others can and should control what a women does to her body. They believe that they are entitled to make that decision about epidurals, as well as about abortion. Similarly, "natural" childbirth advocates wish to deny or limit access to epidurals because they believe that they know better than any individual woman what she should do to her body. Ultimately, the decision to discourage or penalize epidural use invokes the same reasoning, the idea that others know better than a woman herself.

Homebirth advocacy and immature reasoning ability

2008-11-23T11:21:00.003-05:00

One of the earliest achievements in cognitive development, occurring at approximately 5-6 months of age, is the understanding of object permanence. Babies who are only 3 or 4 months old do not understand object permanence. If you show them a toy, they will reach for it, but if you whisk it behind your back, they will not even attempt to look for it. They do not understand that the object is permanent. If they can no longer see the toy, they believe that the toy no longer exists.

Once a baby understands object permanence, he or she recognizes that the object still exists when no longer visible. Hide a little ball in your fist, and the baby will try to pry your fist open to get it.

Some people appear to have the same problem with risk that tiny babies have with objects. If they don't see it, they think it doesn't exist. If a safety measure decreases a risk, they actually think that the risk is gone, instead of recognizing that preventive measures hide the appearance of risk.

Don't believe me? Check out almost every homebirth and "natural" childbirth advocacy site. They almost always demonstrate immaturity in reasoning. MDC, for example, is a on-going festival of immature and stunted reasoning ability.

Homebirth and many "natural" childbirth advocates are generally not well educated and have some serious deficiencies in basic reasoning. They have difficulty understanding things with which they have no direct experience. Indeed, they have so little ability to understand that they actually believe that if they have no experience of a risk, that risk no longer exists. Hence the absolutely perverse insistence, in the face of massive historical and contemporary evidence, that childbirth is inherently safe. Only people who are incredibly stunted in their reasoning ability could come up with the inane motto: Birth, as safe as life gets.

In the US today, there are relatively few deaths from postdates or shoulder dystocia, or pre-eclampsia. However, that does not mean that postdates or shoulder dystocia or pre-eclampsia are either rare, or no longer dangerous. They are common and exceedingly dangerous, but bad outcomes are routinely prevented by medical intervention.

Over the past two years, at least 24 healthy, term babies of MDC members died from preventable causes at homebirth because the mothers, and the MDC members who encouraged them, could not reason beyond what they could see. Most of these women had never seen death from:

breech - but now they've seen 1 baby die unncessarily
postdates - but now they've seen 3 babies die unnecessarily and 2 sustain serious anoxic brain damage
shoulder dystocia - but now they've seen 2 babies die unnecessarily
chorioamnionitis - but now they've seen 1 baby die unnecessarily
cord accident - but now they've seen 2 babies die unnecessarily
chronic hypertension - but now they've seen 1 baby die unnecessarily
uterine rupture - but now they've seen 2 babies die unnecessarily
fetal distress - but now they've seen 9 babies die unnecessarily

Deaths from fetal distress, breech, postdates and cord accidents are not rare; they're common. Homebirth advocates have not seen or heard of them because modern obstetrics prevents them.

The toy is still there even when the tiny baby cannot see it. Similarly, the risk is still there even if the homebirth advocate cannot see it. Asking a homebirth advocate about risk is like asking a tiny baby about object permanence; neither understands that the real world extends far beyond what they can see.

MDC homebirths 2008: death #14

2008-11-22T12:25:00.001-05:00

She fired her OB because he wanted to induce her for postdates. The baby died.

My OB is insistent on an induction before I get to 42 weeks ... But when I asked today why we had to schedule an induction for monday, i was told that it would be malpractice for them not to. I then pointed out all our family babies are late, I was #4 and 3 weeks late, and told that that was the 70's and it's just not done that way anymore. I then asked what was the medical necessity for inducing me, and told that it would be medical malpractice to allow a pregnancy to go past 42 weeks. it was like talking to a wall. So I let them schedule me for Monday am- 4:45am- bleah.

what if I don't show up? can they fire me? can they just be mad at me, but still manage the pregnancy by monitoring a little longer? will I go to jail for not showing up?

I have good feelings that this pregnancy is fine, but that she's (and my body) not ready for birth yet...

Her compatriots on MDC encouraged her to risk her baby's life. Consider this from UC advocate Rixa Freeze of "The True Face of Birth":

... I would be very hesitant to agree to an induction... No need to interfere because of an arbitrary deadline, especially if that deadline may or may not be very accurate.

You were WRONG, Rixa. Do you plan on taking any responsibility for your role in this tragedy?

Early this morning, posted by another MDC member:

After a long labor, her daughter was finally born this morning (11/20) but it is not the happy ending we all were expecting.

Her daughter was born with a head full of black, curly hair, 8 pounds, 5 ounces, and she was born sleeping.

... She had a very long back labor and labored as long as she could at home with the midwives. I believe she transferred somewhere around dinner time last night to the hospital for pain relief. She and the baby were doing fine and the heart tones were good upon transfer. It's my understanding that once she arrived at the hospital ht's weren't detected and an US confirmed the baby had passed. She was started on Pit and the baby was born this morning. Txgirl said to let you all know the baby had the cord wrapped twice around her neck and the cord also appeared to be short. She went ahead and consented for an autopsy which may or may not provide more detail of what happened.

The baby was not born sleeping. Only live babies can sleep. The baby was born DEAD. Had the mother consented to the induction, the baby would almost certainly be alive today.

"Women's Primal Wisdom"

2008-11-20T16:11:00.002-05:00

Midwifery Today seems to be hiring writers from The Onion. They are starting to parody themselves. Consider Women's Primal Wisdom" by Lydi Owen, a self-described midwife of 36 years, featured on their homepage. Read it and then try to claim that direct entry midwives are trained in anything, let alone birth.

The thesis of the article is that if it happens, it must be normal. I've written about this bit of sophistry before:

Homebirth advocates like to pretend that almost anything that happens is "normal" simply by virtue of the fact that it happened. Are you still pregnant 3 weeks after your due date? Must be normal, since it happened. Are you in labor and stuck at 8 cm for the past 6 hours? Must be normal, since it has happened to some women in the past, and a few have even gone on to deliver live babies.

The corollary of the homebirth fantasy that almost everything is "normal" is the conviction that medical definitions of "normal" are utterly arbitrary and exist merely for the convenience of doctors. Nothing could be further from the truth...

The Midwifery Today article is nothing more than an elaboration of that fantasy:

There is a rule of labor that forbids a woman to push with contractions until her cervix is completely dilated to 10 cm. Women are warned that to push before this doorway is completely open and out of the way will result in a swollen and/or torn cervix...

Doctors, nurses, midwives, doulas and childbirth educators all warn that a swollen cervix will impede labor and increase the chances of tearing the cervix, thus causing hemorrhage. They have been taught that a swollen cervix is easily broken or pulverized. If this is indeed the truth, then why do most women during labor have an irresistible urge to begin bearing down before dilation is complete?

Could it be that the instinctual wisdom of our bodies has become our enemy? Is Spirit trying to destroy us instead of guiding us? ...

Let's see. Just what instinctual wisdom might the author be talking about?

Perhaps, it's the wisdom that prevents any baby from ever being born premature? Can't be that, since premature babies are born every day?

Maybe it's the wisdom that leads every woman's body to make just the right amount of oxytocin after delivery so virtually no woman ever dies of postpartum hemorrhage? No, can't be that, since women without access to pitocin die all the time.

Ah, it must be the wisdom that makes sure that no baby is ever to big to fit through the bony pelvis? That's not it either, since hundreds of thousands of women are suffering from fistula because their baby was too large to fit.

Perhaps it's the wisdom that keeps every woman's blood pressure low? No.

I could go on and on, but I think everyone gets the point.

There is no "wisdom" involved in childbirth, just like there is no "wisdom" involved in hurricanes. Both are natural phenomena and are therefore subject to the brutal laws of nature, not the magical thinking of undereducated, undertrained "midwives." Nature is arbitrary. Sometimes things work out, and sometimes everybody dies. That's the only "wisdom" of childbirth that's relevant. Any "midwife" who doesn't know that doesn't know much of anything.

Is there a connection?

2008-11-18T07:53:00.003-05:00

There has been a great deal of ferment in the homebirth and "natural" childbirth communities recently about the possible closing of the North Shore Birth Center in Beverly, MA. A statement from the birth center explained:

As with other birth centers around the nation, North Shore Birth Center is experiencing a significant rise in the cost of malpractice insurance premiums. As a result, we are currently evaluating the services provided by North Shore Birth Center.

It is certainly possible that a general risk in the cost of malpractice insurance for all birth centers may be driving this decision. I wonder, though, if a recent neonatal death at the center, discussed on MDC, may be a factor. Malpractice insurance companies rate doctors and adjust premiums upward based on bad outcomes. If malpractice carriers rate birth centers in the same way, a neonatal death would lead them to raise the premiums to exorbitant levels.

If the recent neonatal death were a factor, it would explain the apparently precipitous decision and the inability of the birth center to continue despite public protest. If the protesters want the birth center to remain open in the face of high malpractice premiums, they ought to be raising money to pay the increased malpractice costs, not writing letters and parading around with signs. If there's no money to pay the premiums, protests will have absolutely no effect.

"It was the natural part that was traumatic"

2008-11-17T10:05:00.002-05:00

I wonder if the powers that be at MDC are surprised by posts on the new birth trauma forum. I certainly am. I did not know that there were so many women on MDC who felt traumatized by unmedicated childbirth ... and had the courage to talk about their experiences.

A current thread on the birth trauma forum is illuminating. I was struck by this statement in particular:

"Anybody who says that c-sections can't be wonderful, healing experiences has never opened themselves up to the possiblity of allowing that to be the case."

The comments in response were equally unexpected:

"There was no "lesson" I needed to learn from it... well, except maybe to stop thinking I was somehow superior because I educated myself on natural childbirth - and to stop judging other for their choices."

"...The pain really blew my mind in a way that I honestly did not expect. I think it's quite presumptive for anyone to assume they know the reasons that a mom would've decided to go for pain relief; the reality is that we all feel it differently and experience it differently and none of us can judge for anyone else what is the right path."

"Me too..except mine was a UC, well, both actually....I'll never go through birth again wthout at least having drugs as an option.....even if i ended up with a "bad" hospital experience, like mean nurses or whatever, nothing they could possibly do to me would be nearly as awful as labor..nothing."

"Yeah, my body didn't care how well I'd prepared, or my positive attitude towards labor, or all the support I had.

It totally beat me."

I wonder if the moderators will allow the thread to continue or feel compelled to "lock it for review" to marginalize women who followed the prescribed path to an "empowering" birth and were nevertheless traumatized by the pain.

Mothering scrubs evidence of 13 homebirth deaths

2008-11-13T15:39:00.002-05:00

There is an article in today's New York Times about homebirth and an accompanying comment section in Well, the Times health blog. I posted comment #7 of the 276 and counting comments:

The biggest problem with homebirth is that it has an increased risk of neonatal death. All the existing scientific research to date shows that homebirth has a neonatal death rate approximately TRIPLE that of low risk hospital birth.

Even the studies that claim to show that homebirth is safe (such as the widely quoted Johnson and Daviss, BMJ 2005) study, actually show that homebirth increases the risk of neonatal death. Johnson and Daviss found a rate of homebirth death in 2000 of 2.6/1000. The rate for low risk women in the hospital that year was 0.9/1000. Johnson and Daviss simply left that information out of their paper. Johnson is the former Director of Research for the Midwives Alliance of North America (MANA, the trade union for homebirth midwives) and Daviss, his wife, is a homebirth midwife. Johnson and Daviss deceptively compared homebirth in 2000 with hospital birth in a bunch of out of date papers extending back to 1969.

Since 2003, the US government has been collecting statistics on homebirth. In 2003-2004, the hospital neonatal death rate for low risk women was 0.37/1000 and the homebirth death rate was 1.15/1000. In fact, the single MOST dangerous form of planned birth in the US is homebirth with a homebirth midwife.

Mothering Magazine maintains a message board that promotes homebirth. In the year to date, 13 women have reported preventable deaths of their babies at homebirth, among less than 300 women. That is an appallingly high rate of death.

American homebirth midwives are currently hiding their safety statistics from the public. The Midwives Alliance of North America (MANA) the trade union for direct entry midwives has been collecting extensive statistics on the safety of homebirth since 2001. Those statistics have been publicly offered to anyone who can prove they will use them for the "advancement of midwifery". Even then you must sign a legal non-disclosure agreement preventing you from revealing any data to anyone else. It does not take a rocket scientist to suspect that MANA is suppressing its OWN data because it shows that homebirth with a direct entry midwife increases the risk of neonatal death, and possibly the risk of brain damage as well.

Homebirth advocates are not honest about the fact that homebirth increases the risk that the baby will die. A woman has the right to choose where to give birth, but unless she understand that homebirth increases the risk of neonatal death by a factor of 3 or more, she is not making an informed decision.

Over on MotheringdotCommune, a member posted this excerpt:

Mothering Magazine maintains a message board that promotes homebirth. In the year to date, 13 women have reported preventable deaths of their babies at homebirth, among less than 300 women. That is an appallingly high rate of death.

The member asked if this were true, and suggested that members keep track of the MDC homebirth statistics in order to determine if homebirth is indeed dangerous.

Mothering responded as they typical do, with censorship. Rather than addressing the issue of the 13 preventable neonatal deaths (perhaps more) thus far this year, or denying the claim, they removed the comment and the entire thread for good measure.

MotheringdotCommune is probably the single best place to do "research" about the safety of homebirth. Babies of MDC mothers routinely die preventable deaths at homebirth, and the moderators routinely remove any discussions about safety in connection with these deaths. Visit MDC now and you will find that there have been not one, not two, but three preventable homebirth deaths in the past month.

There were at least 10 preventable neonatal deaths at homebirth on MDC in 2007 as well as 2 cases of profound anoxic brain damage:

Preventable homebirth deaths on MDC 2007

breech, nuchal arms (arms trapped behind head), brain dead, ventilator disconnected

shoulder dystocia, profound brain damage

unanticipated anoxic brain damage sustained during labor

normal labor, baby dead at birth

decelerations during attempted home VBAC, transfer to hospital, uterine rupture, baby dead, massive hemorrhage, hysterectomy

postdates, severe meconium aspiration

normal labor, baby dead at birth

post dates, baby dead at birth

unanticipated severe birth asphyxia

prolonged ruptured membranes, overwhelming infection

Preventable homebirth deaths on MDC so far in 2008 including:

normal labor, baby dead at birth

normal labor, baby dead at birth

normal labor, baby dead at birth

attempted VBA2C, baby dead at birth

unanticipated severe birth asphyxia

mother rejected medical care, stillbirth

shoulder dystocia

transferred for pain relief, severe birth asphyxia

cord prolapse

normal labor, baby dead at birth

abnormal cord vessels, baby hemorrhaged

In my entire career, during which I attended the births of over 1000 babies, there was a total of one unanticipated neonatal death in a term baby. MDC has had more than 20 in the past 2 years alone.

What's in the water at waterbirth?

2008-11-13T09:29:00.003-05:00

Waterbirth has been touted as part of "natural" childbirth, when, in reality, no primates give birth in water. Not suprisingly, waterbirth appears to increase the risk of neonatal death.

Perinatal mortality and morbidity among babies delivered in water: surveillance study and postal survey was published in the BMJ in 1999. Out of 4,030 deliveries in water, 35 babies suffered serious problems and 3 subsequently died. It is unclear if any of the deaths can be attributed to delivery in water. However, of the 32 survivors who were admitted to the NICU, 13 had significant respiratory problems including pneumonia, meconium aspiration, water aspiration, and drowning. Other complications attributable to water birth include 5 babies who had significant hemorrhage due to snapped umbilical cord. In all, 18 babies had serious complications directly attributable to waterbirth. The risk of serious complications necessitating prolonged NICU admissions was 4.5/1000.

Hospitals in Ireland recently suspended the practice of waterbirth after a baby died from freshwater drowning after delivery in a waterbirth pool.

The most nonsensical aspect of waterbirth is that it puts the baby at risk for freshwater drowning. The second nonsensical aspect is that the baby is born into what is essentially toilet water, because the water in the pool is fecally contaminated. In Water birth and the risk of infection; Experience after 1500 water births, Thoeni et al. analyzed the water found in waterbirth pools both before and after birth. The water in a birth pool, conveniently heated to body temperature, the optimum temperature for bacterial growth, is a microbial paradise.

The authors were aware that the water system itself can harbor bacteria, given the report of at least two neonatal deaths from Legionella pneumonia, one that occurred in the hospital, and one that occurred at home. Therefore, they tested the water before anyone entered the pool. To their surprise and dismay, analysis of the water itself revealed that 12% of samples contained Legionella pneumophila, 11% Pseudomonas aeruginosa, 19% Enterococcus, 21% coliforms, and 10% Escherichia coli. Most of these organisms can and do cause infections in neonates. After installing a special water filter, and instituting more stringent pool cleaning procedures, contamination of the water by these bacteria was reduced, but not eliminated.

The analysis of the water after birth was shocking. Almost all 200 water samples were heavily (as opposed to slightly) contaminated with various infectious bacteria.

In the samples taken after the birth there was a high rate of contamination with coliforms (82%) and Escherichia coli (64%) with concentrations of up to 105cfu/100 ml; Pseudomonas aeruginosa, Staphylocooccus aureus, and yeasts were found less frequently.

The authors claim that the fecally contaminated water did not affect the rate of infection. First of all, the study is underpowered to reliably detect the impact of the contaminated water on the rate of infection. Second, the authors express their claim in a curious way:

Only 1.34% of children (10 of 741) born in water showed infectious signs such as tachypnea and suspect skin color compared with 3.40% (15 of 440) in the [control] group.

The relevant finding is not which babies displayed signs of infection. The relevant finding is which babies actually had infections. The authors neglect to share that information, suggesting that there was a significant difference.

Waterbirth is praised for its ability to ease pain in some women, but is that really worth the risk of delivering a baby into toilet water teeming with harmful bacteria? What's "natural" about that?

New study shows that neonatal mortality increases after 41 weeks ... maybe

2008-11-10T17:16:00.002-05:00

A new study published in the American Journal of Obstetrics and Gynecology shows that neonatal mortality rises after 41 complete weeks of pregnancy. It is well known that the stillbirth rate begins to rise at the end pregnancy. The American College of Obstetrics and Gynecology (ACOG) recommends that anyone who reaches 42 complete weeks of pregnancy have labor induced. At 42 completed weeks, the stillbirth rate is approximately double that at 40 weeks, and the stillbirth rate continues to rise thereafter.

This new study demonstrates that even liveborn babies delivered after 41 completed weeks are at increased risk. The study is Increased neonatal mortality among normal-weight births beyond 41 weeks of gestation in California, by Bruckner, et al. This is a very large study:

Of all live births in California over the
test period (n=2,667,938), we removed infants with a gestational age of less than
38w0d or greater than 42w6d. We then excluded infants weighing less than 2500 g or more than 4500 g. These restrictions yielded a study population of 1,815,811 normal-weight term births.

Among normal-weight term births, CDHS registered 499 neonatal deaths, for an overall rate of 2.75 deaths per 10,000 live births. Neonatal mortality appears highest at 41w0d to 41w6d.

The study showed:

Infants born at 41w0d to 42w6d of gestation appear at increased risk of neonatal mortality as compared with those born at 38w0d to 40w6d of gestation (aOR = 1.34; 95% confidence interval [CI], 1.08-1.65). Of note, gestational age of 41w0d to 42w6d confers a greater neonatal mortality risk than any other variable included in the analysis.

We tested whether our findings changed with the addition of macrosomic (ie,greater than 4500 g) infants by including this group in the multivariate analysis. The aOR differed slightly from that of the original test (aOR = 1.32; 95% CI, 1.08-1.63) and remained statistically significant.

This study has several strengths. It is impressively large, giving it greater statistical power. It eliminates babies with IUGR, an entirely separate cause of death that might otherwise skew the results. It also eliminates babies above 4500 gms, making it more likely that neither shoulder dystocia or gestational diabetes are involved in the deaths.

The one thing that bothers me about the study is the authors decision to group births over 41 completed weeks with births over 42 completed weeks. It would have been helpful to see the distribution of deaths. The authors tell us that the risk of neonatal death was greater at 41w0d to 41w6d, than at 42w0d to 42w6d. This puts the conclusion of the study in doubt. If postdates really were the cause of the increased mortality rate, we would expect to see the mortality rate rise as the gestational age increases.

It is possible that the neonatal mortality rate rises as gestational age increases, but that this effect is masked by the deaths of babies delivered between 41w0d to 41w6d for other reasons. Since a postdates induction is not required until 42 weeks, the group delivered between 41w0d to 41w6d contains babies who were delivered early for other signs of compromise such as low amniotic fluid or non-reassuring NST's or biophysical profiles. Until that issue is addressed, however, the authors cannot and should not conclude that gestational age greater than 41 completed weeks, in and of itself, increases the risk of neonatal death.

Epidural mortality only 1 per 4 million

2008-11-07T10:06:00.002-05:00

Homebirth advocates routinely overestimate the "risks" of hospital interventions and grossly underestimate the risks of homebirth. They are constantly prattling about the "risks" of an epidural for pain relief in labor, without any understanding of how very rare epidural complications are.

Hawkins et al. have presented their latest data on anesthesia related mortality in the US.

The authors reviewed maternal death certificates matched with live birth or fetal death certificates of all pregnancy-related deaths occurring during 1997-2002 associated with anesthetic complications. These were reported by states in ongoing Pregnancy Mortality Surveillance at the Centers for Disease Control and Prevention. Cases were independently reviewed by three obstetric anesthesiologists to confirm that the death resulted from anesthetic complications. The type of anesthesia involved, mode of delivery and cause of death were determined.

The pregnancy-related mortality ratio (PRMR), defined as pregnancy-related deaths due to anesthesia per million live births was calculated...

RESULTS: There were 49 anesthesia-related deaths; 31 associated with live births or stillbirths, 16 during abortion, 1 associated with ectopic pregnancy and 1 unknown outcome during 1997-2002. Among deaths following live births or stillbirths, 6 were related to general anesthesia, 16 to regional, 1 to combined regional/general, 1 to local anesthesia and 7 to unknown type of anesthesia. The regional anesthesia-related deaths occurred during spinal (7), epidural (8), and paracervical block (1). Eighty percent of these anesthesia-related deaths were associated with cesarean delivery.

... During 1997-2002, the PRMR due to anesthetic complication was 1.3 per million live births ...

Since 80% of anesthesia related maternal deaths were associated with cesarean, only 20% were associated with epidurals for pain relief in labor. That means that the pregnancy-related mortality ratio for labor epidurals was 0.26/ million or approximately 1 death per 4 million labor epidurals.

Compare that to the excess rate of neonatal death at homebirth of 1-2/1000. The risk of a neonatal death at homebirth is approximately 4000-8000 times higher than the risk of maternal death from a labor epidural. If homebirth advocates are concerned about the "risks" of epidurals, they should be appalled by the risk of neonatal death at homebirth.

Cesarean section as a narcissistic injury

2008-11-05T10:24:00.002-05:00

Narcissistic injury is a term from psychoanalysis. A narcissist in psychoanalytic theory is different from our colloquial use of the word. Rather than being a person who is obsessed with herself, a narcissist is a person who suffers a deep sense of inferiority and masks it by projecting an air of grandiosity and excessive self regard. A narcissistic injury occurs when reality threatens the narcissist's carefully constructed facade of perfection.

In reading the work of homebirth and natural childbirth advocates, I am repeatedly struck by the assumption that a not having an uncomplicated vaginal birth is viewed as an imperfection. Hence the use of words like "failed" and "broken", the insistence on comparing birth to competitive sports, and the use of goofy birth "affirmations" that are all variants of "I can do it."

I suspect that some homebirth and natural childbirth advocates experience a C-section as a narcissistic injury. A narcissistic injury is not simply an imperfection. It is an imperfection that threatens the narcissist's protections against feelings of inferiority.

For example, many people need vision correction, but the overwhelming majority are able to accept that their eyes are not perfect without viewing it as a fundamental deficiency. Similarly, many women have C-sections and view the surgery as nothing more than one of many acceptable ways to have a baby. In contrast, a small proportion of women have such a fragile sense of self, and have constructed such elaborate defenses to protect against these feelings, that a C-section is experienced as a "failure," a sign of being "broken," and an insupportable assault on a very fragile sense of self-regard.

Experiencing C-section as a narcissistic injury can explain many confusing aspects of homebirth and natural childbirth advocacy, particularly among advocates who have already had a C-section. The refusal to see a doctor (with some women even refusing to see a midwife) can be explained as the inevitable result of regarding even the possibility of pregnancy complications as personal criticism, combined with the inability to tolerate criticism of any kind.

It can also explain the seemingly inexplicable reactions to the death of a baby at homebirth. Reacting to a baby's death by being "proud" of oneself for having a vaginal birth is extremely bizarre. However, it makes sense if the mother's overriding preoccupation is to preserve her narcissistic mask of perfection and keep feelings of inferiority at bay.

The real problem, then, for women who view C-section as "failure" is not the C-section, but the outlook of the women themselves. C-section is experienced as a narcissistic injury, not because it really is an injury, but because women with carefully constructed defenses that keep feelings of inferiority at bay feel those defenses threatened by the lack of perfection.

I don't expect homebirth and natural childbirth advocates to acknowledge this. Narcissists are notorious for their lack of introspection and their insistence on blaming everything on everyone else. They could never acknowledge that the source of their distress comes from within; they are compelled to externalize it to others who are supposedly criticizing them or disrespecting them.

The blind leading the blind ... into a potential disaster

2008-11-02T23:17:00.003-05:00

Will someone please head over to the MDC UC board and do something about the clueless mother trying to UC being encouraged by the pack of nitwits who have no idea what they are talking about, but are offering "advice" anyway?

Claddaghmom has supposedly been in labor for almost 48 hours. She has been posting and updating for over 36 hours. Initially she thought she was in transition, but obviously anyone in transition would not be able to sit at the computer and type. Everyone offered encouragement, their own theories on what was going on (none correct), and "advice" that was inappropriate. The mother was simply inexperienced and didn't realize she was still in latent phase.

After more than 24 hours of contractions, the mother went to the hospital to find that she was only 4 cm, not surprisingly, and she insisted on going home. Then she got a variety of conflicting and useless suggestions on how to stimulate her labor, not to mention lots of inane encouragement ("you're doing a fantastic job;" really? how would they know? they have no idea what is happening}.

Now the mother once again believes herself to be in transition, although she reports that her contractions are petering out. She's probably not in transition now, either. This is what someone needs to tell her:

GO TO THE HOSPITAL NOW!

She needs to stop asking for "advice" from people who don't know what they are talking about and are just making things up as they go along. She needs to be cared for by knowledgeable people, and both she and her "advisors" are utterly clueless. It sounds like she needs either morphine to stop her contractions and let her sleep, or if she has made progress, pitocin to augment her labor. At a minimum, because of prolonged labor and ineffective contractions, she is at high risk for a significant postpartum hemorrhage.

She needs to go to the hospital, end this farce and get competent and knowledgeable care. The members of MDC should be ashamed of themselves for advising anything else.

Should we redefine labor arrest?

2008-11-02T09:42:00.002-05:00

A new study, just published in the November issue of Obstetrics and Gynecology, raises the possibility of redefining "arrest of labor."

The classic definition comes from the original work on the Friedman curve. Arrest of labor can only be diagnosed when specific conditions are met. First, a woman must be in active labor, which generally means that the cervical exam must be 5-6 cm or more. Second, there must be adequate contractions for at least 2 hours with no progress. In practice, that typically means 2 hours of labor with no progress followed by 2 hours of labor augmented with pitocin with no progress. The authors of the new paper asked the question: "What happens when we ignore that definition and women continue to labor?"

The paper is Perinatal Outcomes in the Setting of Active Phase Arrest of Labor by Henry et al. The study is retrospective and observational. The authors had no control over which women continued to labor and which women underwent C-sections or at what point they were operated on. That means that the study has some serious limitations. It is not a randomized control trial; the women in the group allowed to labor beyond a diagnosis of arrest might have differed in important ways from the other women; it is also quite underpowered because it contains only 1,014 women. The authors are quite forthcoming about those limitations. Nonetheless, the study has value in suggesting the design of future prospective, randomized trials structured to answer the question of whether we should redefine labor arrest.

What did the study show? Of 1,014 women who met the criteria for the diagnosis of arrest of labor, 335 (33%) went on to deliver vaginally. The women who ultimately had a vaginal delivery differed in important ways from the women who had C-sections:

Compared with women who had cesarean delivery, women who delivered vaginally had a lower BMI (mean BMI 23.4 compared with 25.3 kg/m,2 P less than .001), and delivered slightly smaller infants (mean birth weight +/- standard deviation 3,533 g (+/-658) compared with 3,700 g (+/-493), P less than .001

Maternal outcomes differed for the two groups, but neonatal outcomes did not:

When the frequencies of adverse outcomes were compared using a multivariable logistic regression model to control for potential confounders, we found that cesarean delivery was associated with an increased risk of chorioamnionitis (adjusted odds ratio [aOR] 3.37, 95% confidence interval [CI] 2.21–5.15), endomyometritis (aOR 48.41, 95% CI 6.61–354), postpartum hemorrhage (aOR 5.18, 95% CI 3.42–7.85) ... Adverse neonatal outcomes, however, were not statistically significantly associated with cesarean delivery.

The women who had vaginal deliveries after a diagnosis of active phase arrest were compared to a larger group of women who had vaginal deliveries without arrest of labor. There were important differences between the two groups.

Among women with active phase arrest, there was an increased rate of operative vaginal delivery (28% compared with 17%, P less than .001) as well as increased rates of several adverse maternal outcomes, including, chorioamnionitis (18% compared with 8%, p less than .001), third- or fourth-degree perineal lacerations (16% compared with 9%, P less than .001), and postpartum hemorrhage (26% compared with 17%, P less than .001), compared with other women having a vaginal delivery without active phase arrest... Examination of neonatal outcomes revealed increased rates of shoulder dystocia (4% compared with 2%, P less than .01) and 5 minute Apgar less than 7 (5% compared with 2%, P less than .001) among women with active phase arrest compared with those without.

The authors summarize their results:

To systematically evaluate the rates of adverse perinatal outcomes among women with active phase arrest, we made two comparisons. First, we looked only at women with active phase arrest and compared the outcomes by mode of delivery: vaginal delivery to cesarean delivery. In women with active phase arrest, cesarean delivery was associated with an increased risk of chorioamnionitis, endomyometritis, and postpartum hemorrhage. However, cesarean delivery was not associated with adverse neonatal outcomes in women with active phase arrest. These findings suggest that efforts to achieve vaginal delivery in the setting of active phase arrest may reduce the maternal risks associated with cesarean delivery without additional risk to the neonate.

Is it time to change the definition of active phase arrest of labor? Not yet. There are two critical questions that have not been answered by this observational study. First, though the authors tell us that 33% of women diagnosed with active phase arrest went on to have a vaginal delivery, they don't tell us how the decision for C-section was made for the other 66%. What proportion of those women continued to labor and then had a C-section after 3 or 4 hours of arrest? What proportion of those women proceeded to immediate C-section because there were other factors (such as chorioamnionitis) that led to a decision to operate? We want to know what happens when women are allowed to labor beyond 2 hours of arrested progress, and this study cannot tell us that. Second, what happens in larger groups. This study is underpowered, and would not be expected to demonstrate a difference in neonatal mortality rates. A much larger study is needed to explore whether extending labor beyond the definition of arrest has an increase in neonatal mortality or severe morbidity.

This study lays the groundwork for a prospective, randomized controlled trial to answer the question of whether the definition of arrest of labor needs to be changed.

No, Arwyn, homebirth is not statistically the safest

2008-10-29T07:21:00.002-04:00

The folks at MDC appear to be concerned. Someone has posted a respectful, non-inflammatory post about the many homebirth deaths among her friends. The moderator, Arwyn ("Birth Goddess") has interrupted to state the position of MDC. I'm not sure whether MDC is primarily concerned with blunting the impact of the original post, or responding to the role that MDC has in promoting practices that apparently lead to neonatal death fairly routinely.

Birth is safe, but it is not, and never can be, risk free. Every woman should birth wherever they feel safest, but we (Mothering magazine and MDC) support and promote natural birth as the default option because, statistically, it is safest. It is the "best" option overall. It is not best for every motherbaby, for every birth, for every situation, but the truth is that our maternal and neonatal mortality and morbidity rates would be lower if the majority of births were intervention-free rather than highly medicalized. Thank G-d/dess we live in a time and place where we have access to medical technology, to medications, to surgical birth, because sometimes they are needed. But they are, on the whole, overused.

Here's a newflash, Mothering magazine and MDC, homebirth is not , statistically, the safest. In fact, homebirth with a direct entry midwife is the most dangerous form of planned homebirth in the US. Let me refresh your memory in case you have not seen the data from the most recent US dataset (Linked Birth Infant Deaths 2003-2004).

As this chart shows, the neonatal mortality rate for DEM assisted homebirth is almost double the neonatal mortality rate for hospital birth with an MD. This is all the more remarkable when you consider that the hospital group contains women of all risk levels, with all possible pregnancy complications, and all pre-existing medical conditions. An even better comparison would be with the neonatal mortality rates for CNM assisted hospital birth. The risk profile of CNM hospital patients is slightly higher than that of DEM patients, but CNMs do not care for high risk patients. Compared to CNM assisted hospital birth, DEM assisted homebirth has TRIPLE the neonatal mortality rate.

Neonatal mortality would not be lower if births were "intervention-free," it would be much higher. If 10% of American babies were delivered by homebirth, homebirth deaths would vault to the 3rd or 4th leading cause of neonatal death!

Arwyn, if you want confirmation of the national data, just check your own website. There have been at least 13 preventable neonatal deaths and 2 cases of severe anoxic brain damage among MDC members in the past 10 months! Homebirth increases the risk of neonatal death. How much data, and much tragedy aided and abetted by your own site, do you people at Mothering and MDC need to see before they acknowledge the truth?

Shoulder dystocia and 13th MDC homebirth baby dies so far this year

2008-10-28T09:51:00.005-04:00

Another senseless death at homebirth. From the father's blog:

We had a terrible tragedy yesterday. L. had a long, hard labor. The child would move a bit and then stay, then move a bit more and then stay even longer...

But the shoulders were stuck. The midwives went into emergency mode and essentially pulled the child out of L., but by then it was nearly too late. He was blue when he emerged and the cord was only pulsing weekly.

All hell broke loose. 911, paramedics, the hospital, L. on the ground sobbing, it was horrible. And it is seared into my mind forever. I was the only one with him at the hospital while they worked on him at the trauma ward. They got his heart beating and he started breathing, but it had been a long time...

He was beautiful. Perfect and tiny, everything intact and finally there was a heart beating...

The doctors told me that they had done a a variety of tests on him to see how well his brain was functioning, and the news was not good. Terrible, in fact. He was brain dead, they told me and that once off the ventilator he would would pass on very soon later.

They brought me to him in the NICU and I sat and held him in my arms for a while, just us... I know that I will always cherish those hours with him despite the cords and beeps and horror of hospital. His heart was beating, he was pink and alive, and he was in my arms...

... At 3am this morning they brought him to us, once he had passed. His name was S. and he will be a part of us forever.

This is the 13th preventable homebirth death on MDC so far this year. In addition, there have been at least 2 cases of profound anoxic brain damage. That is an increase in deaths from 2007, when there were 10 preventable homebirth deaths reported. Considering that there are less than 30 homebirths per month on MDC, 13 deaths means a neonatal death rate of more than 40/1000. Compare that to the death at low risk hospital birth of less than 0.4/1000. That means that the MDC homebirth death rate in the past 10 months has been an extraordinary 100 times higher than the hospital death rate.

post edited at 9:36 PM per father's request

New study claims to show that hospital practices affect breastfeeding

2008-10-25T13:54:00.002-04:00

A new study in a supplement to the October issue of Pediatrics claims to show that hospital practice affect breastfeeding. According to Effect of Maternity-Care Practices on Breastfeeding by DiGirolamo et al:

Increased "Baby-Friendly" hospital practices, along with several other maternity-care practices, improve the chances of breastfeeding beyond 6 weeks. The need to work with hospitals to implement these practices continues to exist, as illustrated by the small proportion of mothers who reported experiencing all 6 of the "Baby-Friendly" hospital practices measured in this study.

However, reading the study and looking at the data indicates that the study shows only a very weak correlation between 3 of 6 breastfeeding initiatives and rate of breastfeeding. These weak correlations are far eclipse by the characteristics of the mothers themselves.

The study itself is well done.

This analysis of the Infant Feeding Practices Study II focused on mothers who initiated breastfeeding and intended prenatally to breastfeed for >2 months, with complete data on all variables (n = 1907). Predictor variables included indicators of 6 "Baby-Friendly" practices (breastfeeding initiation within 1 hour of birth, giving only breast milk, rooming in, breastfeeding on demand, no pacifiers, fostering breastfeeding support groups) along with several other maternity-care practices. The main outcome measure was breastfeeding termination before 6 weeks.

What did the authors find?

The first finding was that most women who intended to breastfeed for at least 2 months were still breastfeeding at 6 weeks. Over 85% of women who were still breastfeeding.

Second, the small proportion of women who had stopped breastfeeding by 6 weeks differed substantially from the women who had continued. They were much less likely to be married, have any college education, make more than $20,000/year, and this was much more likely to be their first child. These are very strong associations.

Third, all hospital practices designed to promote breastfeeding showed only weak associations with breastfeeding duration or no association at all. For example, after correcting for demographic differences, rooming in, breastfeeding on demand and information about breastfeeding did NOT have a statistically significant impact on breastfeeding duration. The hospital practices that did have statistically significant associations, breastfeeding initiation within 1 hours [OR= 0.71 (0.53–0.95)], no formula given [OR=0.47 (0.34–0.64)] and no pacifiers offered [OR=0.73 (0.54–0.99)], had only weak associations.

Frankly, I think the real message of this study is that for women who intend to breastfeed, hospital practices have no impact at all on breastfeeding duration. The claims of the authors are questionable at best. It makes no sense that breastfeeding on demand would have no impact on breastfeeding duration, but withholding a pacifier would have an impact on breastfeeding duration. All and all, it is interesting study, but it does not tell us much of anything about the value of hospital breastfeeding iniatitives on women who have already decided they will breastfeed. A much more interesting study would be to examine the impact of hospital practices on breastfeeding among women who have no strong feelings about feeding options.

A letter to Judy Norsigian of Our Bodies Ourselves

2008-10-23T17:26:00.002-04:00

Several days ago I responded to an opinion piece in the Concord (NH) Monitor written by the former Chairwoman of the New Hampshire Midwifery Council, the state organization of direct entry midwives.

I reviewed my 15 reasons for not licensing direct entry midwives:

This is fundamentally a public safety issue. The question: Is it safe to license a second class of midwife with less education and clinical training than any other midwives in the industrialized world? The answer:

1. This is NOT about having midwives in the US. We already have midwives (certified nurse midwives) who are among the best trained midwives in the world.
2. This is about creating a SECOND class of midwives with less education and training.
3. No other country has a second class of midwives.
4. The standards for direct entry midwives, in terms of educational requirements and clinical training, are far below those of any other midwives in the industrialized world.
5. Direct entry midwives are NOT trained for out of hospital birth, since no special training is required. The many taxi drivers, police officers and family members who deliver babies each year could tell you that. The only thing that requires training is dealing with unanticipated complications, and this is precisely what direct entry midwives lack.
6. Direct entry midwives are not "specialists" in out of hospital births. They are restricted to out of hospital births because they are considered unqualified for birth centers or hospitals.
7. Direct entry midwives are not "specialists" in normal birth. Claiming to be a specialist in normal birth makes as much sense as a meteorologist claiming to be a specialist in good weather.
8. Homebirth carries an increased risk of preventable neonatal death in the range of 1-2/1000 ABOVE the neonatal death rate for comparable risk women in the hospital.
9. To date there is not a single study that shows homebirth to be as safe as hospital birth. There are studies that claim to show that, but they do so by comparing low risk women at homebirth with high risk women in the hospital.
10. This is not about "choice". Any woman can choose to have a homebirth. This is about licensing of health care professionals who do not have the necessary education and training.
11. The insurance industry will not write policies for homebirth or charge extraordinary premiums because their data indicate that homebirth carries an unacceptably high incidence of bad outcomes and big payouts.
12. There is no uniformity in direct entry midwifery credentials. There are many different credentials with differing education and training requirements. Direct entry midwives cannot agree among themselves what baseline training is required.
13. Direct entry midwifery credentials were created by direct entry midwives without input from medical or public health sources. These credentials are the "seal of approval" of some DEMs in regard to other DEMs. There is no independent objective basis for these credentials.
14. The Midwives Alliance of North America (MANA), the group that collected the statistics for the BMJ 2005 study, has collected statistics for the years 2001-2006, but refuses to release them to the public. They will only be released to individuals or groups that can prove they will use them for "the benefit of midwifery." The public has a right to know these statistics.
15. There are no statistics at all for long term outcomes of homebirth with direct entry midwives. We have no idea (nor do they) about the incidence of brain damage, oxygen deprivation or birth injuries.

The bottom line is that we already have well educated, well trained, highly competent midwives in the US. We are being asked to accept the licensing of a SECOND class of midwives with less education and less training than any other midwives in the industrialized world.

Today the paper published a Letter to the Editor from Judy Norsigian, the executive editor of Our Bodies Ourselves, in response:

Re the debate about homebirth and certified professional midwives:

The distortions and inaccuracies in Dr. Amy Tuteur's comments on the Monitor website are typical of her many postings at various websites and newspapers. For evidence-based, balanced information, we refer your readers to the items noted at our website, ourbodiesourselves.org, including the new, peer-reviewed report "Evidence-Based Maternity Care: What it is and What it Can Achieve," issued Oct. 8 by the Milbank Memorial Fund, the Reforming States Group, and the Childbirth Connection.

What readers need to fully comprehend is the extent to which documented "best practices" are not followed in many hospitals across the country. That fact alone justifies retention of the option of homebirth with trained, licensed caregivers.

I promptly wrote back:

If there are truly distortions and inaccuracies, it should not be difficult to point them out, yet you could not think of one distortion or inaccuracy to include in your comment. That suggests that you are merely making accusations to change the subject. All the existing scientific evidence shows that homebirth with a direct entry midwife increases the risk of neonatal death. Direct entry midwives (unlike certified nurse midwives) have less education and less training than ANY midwives in the industrialized world.

Your mention of, and inaccurate characterization of "Evidence-Based Maternity Care: What it is and What it Can Achieve," issued Oct. 8 by the Childbirth Connection is telling. First, it does not discuss either homebirth or direct entry midwifery. Second, the title is rather Orwellian since the report is not based on the scientific evidence; it is based on the personal opinions of the activists at the Childbirth Connection. Third, it is not a peer-reviewed journal publication; it is a privately funded and privately produced position paper.

I challenge you, Ms. Norsigian, to provide proof that anything I wrote is either a distortion or inaccuracy, with the scientific citations to back up your claims. Feel free to post it here or on my website Homebirth Debate.

I look forward to her response. Of course, I am not holding my breath. If she is like Henci Goer, Judith Rooks, and Johnson and Daviss, she will find limit herself to casting unfounded aspersions from afar rather than risk debating the issues with me.

No, you did not do everything you could to keep him safe

2008-10-22T09:24:00.003-04:00

Yet another needless, senseless tragedy in the parade of needless, senseless tragedies that is unassisted childbirth.

Posted on the MDC UC board on 10/13/08:

Anyhow, thought I'd share the interesting events of today and see what you ladies think. I personally don't know WHAT to think.

So, we plan to uc again after our last success. I chose to seek traditional prenatal care due to having chronic hypertension for which I need low dose meds. I never told doc that, he only knows that I have homebirthed in the past. Everything has been pretty low key for the most part considering my " high risk" status - according to their standards. Until 37 weeks that is. At that point an air of unease started to set in for no reason with the ob, his mw and staff. It was as though they became determined to find a problem even mentioning pulling the plug so to speak on a few occasions... Indicating there would come a reason to induce. I was asked to come in for repeated u/s and then they wanted me to have a level 2 on one day as well as a hospital nst and then come directly to the office for yet another nst so they could compare info... You can imagine I was slightly stressed before I left when he asked me what I would do for child care had he needed to induce me that day. Uh, walked out?

... I decided the best thing to do for my peace was to not go back for now. I have all the tools I need at home to manage myself and would never hesitate to get help should I need it. Well they literally called every day since and today-2 weeks later a visiting nurse showed up on my door step!

It ended up a very good experience but I'm still very wierded out and not sure what to think…

She received 11 responses expressing outrage and declaring that the doctor was out of line, including this one on 10/17, ending:

I am sure everything is fine, and that we will be reading an awesome story about you and your babe very soon.

Posted on the MDC UC board this morning:

Our baby ... was born still on oct 19th at 5:48 am. He was 7 lbs 10 oz. 19 1/2 in and as beautiful as an angel. We had him at the hospital as I didn't feel him and couldn't find his heartbeat that day. The cause is a mystery ... He was perfect. I am completely devistated and in shock. I just can't understand how or why after all that I did to keep myself and him safe... How could he just stop for no reason? My precious baby is gone.

CPM who presided over 2 deaths in 6 weeks reaches plea agreement

2008-10-20T17:46:00.002-04:00

Kristina Zittle, the CPM who presided over 2 homebirth deaths in the span of 6 weeks (CPM presides over 2 separate deaths in 6 weeks) has agreed to surrender her license and not contest her suspension from the practice of direct entry midwifery. According to the Virginia Pilot:

A Virginia Beach woman has agreed to give up her state license to be a midwife rather than go before the Board of Medicine on allegations she failed to adequately treat two pregnant women whose babies were born dead.

Michael Goodman, an attorney for Kristina Zittle, said in an e-mail that Zittle "vehemently disagreed" with many of the allegations in the Board of Medicine notice that led to the suspension of her license in September.

He said she was able to sign a consent order without admitting or denying any of the allegations, and decided that was the best course at this time.

"She did not feel that she was financially equipped to battle this although she felt that most of the statements were either untrue or jumped to unfair conclusions," Goodman wrote in an e-mail sent on Monday.

Zittle was scheduled to go before the Board of Medicine for a formal hearing on Friday. A consent order relinquishing that right was signed by the Board of Medicine executive director William Harp last Friday, which made it public record.

I'm not surprised that she voluntarily entered into the agreement. Her lawyer almost certainly told her that she was going to lose her license anyway, and that the information entered into the public record during the hearing process would simply provide better high quality transcripts for the malpractice attorneys who will prosecute future malpractice suits against her.

From the Board's point of view, this was a victory. The entire purpose of the hearing process would have been to show that she was such an incompetent practitioner that she should be deprived of her license permanently. It is of no consequence to the Board whether she admits her culpability or not.

With cases like these, it's not surprising that the Midwives Alliance of North America (MANA) refuses to release the detailed safety statistics that it has collected. Their own statistics almost certainly show that homebirth increases the risk of neonatal death.

Circumcision has no effect on breastfeeding

2008-10-19T10:46:00.002-04:00

Anti-circ activists have made many unsubstantiated claims about the purported risks of circumcision. The claim that circumcision disrupts breastfeeding has been widely disseminated even though there is no scientific evidence to support the claim. A 2007 paper in the Journal of Paediatrics and Child Health is the first long term study to investigate the affect of circumcision of breast feeding.

Neonatal circumcision: Effects on breastfeeding and outcomes associated with breastfeeding followed 635 male infants for breastfeeding outcomes, health outcomes in infancy and cognitive outcomes in later life.

According to the authors:

circumcision status was not significantly associated with breastfeeding outcomes. Circumcised and uncircumcised infants did not differ in terms of: (i) starting breastfeeding;(ii) the likelihood of being breastfed at age 1 month;(iii) the likelihood of being exclusively breastfed until at least age 4 months; (iv) the risk of stopping breastfeeding by age 4 months due to poor response; and (v) the mean duration of breastfeeding. The findings show that in all cases, rates of breastfeeding were similar for circumcised and uncircumcised children...

The study also demonstrated that circumcision had no impact on childhood health, and no impact on later cognitive performance.

The authors conclude:

While there has been often strong advocacy for the view that circumcision has adverse effects on childhood outcomes by disrupting breastfeeding,this study produced no evidence to support these claims. Circumcised and uncircumcised male children had similar histories of both breastfeeding and the outcomes associated with breastfeeding. These results strongly suggest that claims about the adverse effects of neonatal circumcision on breastfeeding and child health are not sound ...

The results of the study also suggest that it may be unnecessary to balance the medical benefits of circumcision against the medical benefits of breastfeeding. If breastfeeding is not disrupted by circumcision, then it may be possible to provide male infants with the benefits of both circumcision and breastfeeding. This may be of particular benefit in areas of the developing world in which there are high levels of HIV/AIDS transmission, as well as malnutrition and infectious disease...

Sensitivity, specificity and fetal monitoring

2008-10-16T12:39:00.004-04:00

I've spent the better part of the last few hours doing calculations and drawing tables, trying to figure out the best way to explain some very difficult statistical concepts. I apologize in advance for how confusing this is. I welcome any suggestions on how to better illustrate the concepts, and, of course, any corrections of math mistakes.

For every screening test, there is a sensitivity rate and a specificity rate and these numbers dramatically affect the way that the test can or cannot be used. In the context of a screening test like fetal monitoring (which is screening for fetal distress), specificity is the proportion of times that result a result indicating no fetal distress actually reflects the fact that there is no fetal distress. In contrast, a sensitivity is the proportion of times that an abnormal fetal heart rate actual indicates real fetal distress. The primary problem with electronic fetal monitoring is that it has a relatively low specificity rate. In contrast, intermittent auscultation has a relatively low sensitivity rate.

In studies, continuous fetal monitoring appears to provide no advantage over strict intermittent auscultation, but that does NOT mean that electronic fetal monitoring is useless, and it does NOT mean that intermittent auscultation is just as good as electronic monitoring. To understand why this is the case, you need to know something about the way that sensitivity and specificity affect outcomes. In the following examples, I am going to assume that electronic fetal monitoring has a sensitivity rate of 99.9% and a specificity rate of 88.8%. I will also assume that intermittent auscultation has a sensitivity rate of 88.8% and a specificity rate of 99.9%. These are not actual values, but they serve as representations of the trade offs made between EFM and intermittent auscultation. We are also going to assume that every woman who shows signs of fetal distress, on EFM or intermittent auscultation, will have a C-section.

Let's take a look at a sample population of 1 million low risk women in labor, and let's assume (for ease of calculation) that this population will have a 1% rate of true fetal distress. What would the results be if all the woman in this group had EFM during labor?

The table shows that for our hypothetical low risk population of 1 million women monitored with EFM:

9,990 babies saved, 116,880 unnecessary C-sections, and 10 neonatal deaths

Compare that to 1 million women monitored using intermittent auscultation, which has a lower sensitivity level, but a higher specificity level.

Look at the dramatic difference:

8,880 babies saved, 99 unnecessary C-sections, and 110 neonatal deaths

Using intermittent auscultation resulted in more than 100,000 fewer C-sections, but an additional 100 babies died. You can make an argument (and many people do) that the life of 1 baby is not worth 1000 unnecessary C-sections, and hence, intermittent auscultation should be substituted for EFM. Of course, that means acknowledging that 100 babies would die who might otherwise be saved.

But that's not the end of the discussion. All screening tests perform better in at risk populations as opposed to the general population.

Let's create a hypothetical population of high risk women and assume that this group will have a 10% rate of true fetal distress. It should work out the same way, right? No, not even close. The performance of screening tests improves as the risk increases within the population, even though the sensitivity and specificity remain the same.

If our hypothetical group of 1 million high risk women were to be monitored with EFM, we might see something like the table below.

While the number of unnecessary C-sections is the almost the same, the number of lives saved has increased dramatically:

99,900 babies saved, 100,800 unnecessary C-sections, 100 neonatal deaths.

Once again, we can compare that to 1 million women monitored using intermittent auscultation, which has a lower sensitivity level, but a higher specificity level.

These change due to the increased risk level is dramatic:

88,800 babies saved, 900 unnecessary C-sections, 11,200 neonatal deaths

This result is clearly unacceptable.

We can summarize the data in a final table, showing the results of switching from EFM to intermittent monitoring.

In a low risk group, it may be feasible to replace EFM with intermittent auscultation. There will be a dramatic reduction in unnecessary C-sections, but there will be a small rise in preventable neonatal deaths. In contrast, in a high risk group, there is a comparable reduction in unnecessary C-sections, but there is a massive increase in neonatal deaths.

Looking at these numbers (even though they are all hypothetical), it is possible to make several claims. First, in order to determine how intermittent auscultation compares with EFM, it must be tested in hundreds of thousands of women. No studies like that have been done. Second, in small studies (like the ones that have been done to date) we would expect to see only small differences or even no difference in mortality rates. That does not mean that the two techniques are comparable. Third, the risk level of the population has a dramatic impact on the relative merits of the two methods of monitoring. There is no role for routine intermittent monitoring in high risk patients.

What is wrong with these people?

2008-10-14T17:55:00.004-04:00

Today on MDC a mother posted that she is so proud of herself and her baby for her HBA2C.

Too bad the baby was unexpectedly born dead.

What is wrong with these people? Her own baby is dead and her first thought is for her birth "performance". Perhaps it had not yet crossed her mind that if she had a scheduled C-section her baby would be alive. I cannot imagine any other reason for being "proud" of herself for a decision that killed her baby.

Her reaction is a powerful indictment of the homebirth movement and its grotesque cultural construct that literally places more importance on transit of the baby through the vagina than on the baby's life.

Is vaginal delivery so important that it's worth killing your baby in the process?

Addendum: Yet another homebirth death was just posted on MDC this evening. Fetal distress was noted at home. By the time they drove to the hospital, the baby was dead.

New Cochrane study promptly misinterpreted by midwifery advocates

2008-10-12T11:13:00.003-04:00

A new study was published by the Cochrane Review this week, and midwifery advocates wasted no time in misunderstanding the results. Midwifery advocates are exulting that the study proves that midwifery care is superior to other models of care. Just one problem: that's not what the study looked at. The study compared midwifery-LED team care with other forms of team care. That's why the name of the study is Midwife-led versus other models of care for childbearing women.

This incident is instructive on two levels. First, it is an excellent example of why systematic reviews are NOT the gold standard of scientific evidence. Second, it shows how midwifery and "natural" childbirth advocates don't bother to read the scientific papers they cite, don't understand what they say, and promptly disseminate misinformation to others.

First, let's look at what the study was trying to investigate. According to the authors:

Midwife-led care has been defined as care where "the midwife is
the lead professional in the planning, organisation and delivery of care given to a woman from initial booking to the postnatal period". Some antenatal and/or intrapartum and/or postpartum care may be provided in consultation with medical staff as appropriate. Within these models, midwives are ... the lead professional ...

Here's how the authors describe the other models of care that served as the comparison group:

Care is often shared by family doctors and midwives, by obstetricians and midwives, or by providers from all three groups. In some countries ... the midwifery scope of practice is limited to the care of women experiencing uncomplicated pregnancies, while in other countries ... midwives provide care to women who experience medical and obstetric complications in collaboration with medical colleagues. In addition, maternity care in some countries ... is predominantly provided by a midwife but is obstetrician-led, in that the midwife might provide the actual care, but the obstetrician assumes responsibility for the care provided to the woman throughout her pregnancy, intrapartum and postpartum periods.

In other words, this study compared two different models of team care. This study did not compare midwife care to doctor care. Virtually every woman in both arms of the study was cared for by midwives AND doctors. The study only looked at the role of the midwife within the team.

Let's look at the problems within the study itself. As I mentioned above, systematic reviews are not the gold standard of scientific evidence. That's because they depend entirely on what studies are included, and which are excluded. How did the authors determine which studies to include in this review?

Our search strategy identified ... 31 studies for potential inclusion. Of those, we included 11 trials involving 12,276 randomised women in total ... Included studies were conducted in the public health systems in Australia, Canada, New Zealand and the United Kingdom with variations in model of care, risk status of participating women and practice settings...

Seven studies compared a midwife-led model of care to a shared model of care, three studies compared a midwife-led model of care to medical-led models of care and one study compared midwife-led care with various options of standard care including medical-led care and shared care.

Note that not a single study compared midwife care with doctor care.

How did the authors decide that only 11 of the 31 studies should be included, and the other 20 excluded? The authors never say. This review contains 130 pages of text and tables, and as far as I can determine, the authors offer no justification or even explanation for their decision to use only 11 of the 31 studies. It seems that they simply picked the studies they liked and excluded the ones they didn't like.

I'm rather surprised that the editors of the Cochrane Review were willing to accept this review. It conclusions are essentially useless because studies were included and excluded on an arbitrary basis, and the 11 studies that were included had wide variations in the comparison group. So this study tells us nothing about anything.

The bottom line is that is a poorly done study that is designed to compare midwife led team care with other forms of team care. Did it show that midwife-led care is superior to other forms of team care? The authors think that it did, but that may be simply because the data selection was biased.

One point, though, is undeniable. The study NEVER compared midwife care to doctor care. Therefore, midwifery advocates who are exulting that the study shows that midwife care is superior are only demonstrating that they never even bothered to read the study.

UC neonatal death 20 times higher than hospital rate

2008-10-09T18:38:00.003-04:00

An MDC member has just updated the statistics for planned unassisted births among MDC members. The death rate for UC is appallingly high at 8/1000. Compare that to national statistics for low risk hospital births attended by a CNM with a death rate of 0.37/1000. That means that the UC death rate on MDC is 20 TIMES the death rate that would be anticipated for low risk women in a hospital.

UC is a form of medical neglect, and babies are paying the price. Indeed, yet another UC death was reported on MDC within the last few days. The baby was born and appeared to be well. The parents fell asleep and when they woke up, the baby was dead. The presumed diagnosis, pending an autopsy, is undiagnosed heart disease.

Childbirth Connection publishes its latest attempt to smear modern obstetrics

2008-10-08T19:00:00.003-04:00

Childbirth Connection is a lobbying organization for the "natural" childbirth industry. In an ongoing effort to promote the socially constructed values of a small subgroup of women, it publishes papers that purport to show that "natural" childbirth is supported by the weight of scientific evidence, and is desired by the majority of American women. There's just one problem; it's not supported by the weight of scientific evidence and it does not represent the desires and values of American women.

It's Listening to Mothers Survey II is a case in point. The report concludes that obstetric technology is overused, there are too many interventions, there are too many C-sections and women are not appropriately informed of the risks of interventions. Yet their conclusions are completely belied by the evidence in the report.

Mothers generally gave high ratings to the quality of the United States health care system and even higher ratings to the quality of maternity care in the U.S... [M]ost felt that the malpractice environment caused providers to take better care of their patients.

By law ... women are entitled to full informed consent or informed refusal before expriencing any test or treatment. Most mothers stated that they had fully understood that they had a right to full and complete information ... and to accept or refuse any offered care...

A small proportion of mothers reported experiencing pressure froma health professional to have labor induction (11%), epidural anesthesia (7%) and cesarean section (9%)... Despite the very broad array of interventions presented and experienced ... just a small proportion (10%) had refused anything ...

The people at the Childbirth Connection wrote a report about listening to mothers, and then proceeded to ignore that mothers were pleased with American obstetric care. Why did they ignore their own evidence? They ignored it because it did not match the predetermined conclusion that the socially constructed values of the "natural" childbirth industry represent the "ideal" way to give birth.

Today they published their latest effort to substitute their personal values for the scientific evidence and for the values of the majority of women in the US. As usual, they start with the conclusions and work backward. As usual, they present no evidence to support their claims. You can read the entire 128 page report here. I cannot summarize all 128 pages, but I will offer 4 specific examples of the way in which the Childbirth Connection attempts to pass off personal opinions as scientific evidence.

First, the title of the report is truly Orwellian, Evidence Based Maternity Care: What Is It and What Can It Achieve. The title is Orwellian because virtually none of the conclusions are supported by evidence in the paper or any evidence at all. The fundamental claim, that "natural" childbirth with minimal intervention is better, safer and healthier is not supported by scientific evidence. This is a classic example of using "scientese" to trick people. Obstetrics is evidence based medicine. "Natural" childbirth is values based opinion. Trying to hide that fact does not fool anyone who is familiar with the actual scientific evidence.

Second, the willingness to place personal opinion above scientific evidence is best exemplified by the section of the report on epidurals.

... Labor epidurals alter the physiology of labor and increase risk for numerous adverse effects. Undesirable maternal effects include immobility, voiding difficulty, sedation, fever, hypotension, itching, longer length of the pushing phase of labor, and serious perineal tears.

The authors provide ZERO references to back up these claims. The central claim, that epidurals alter the physiology of labor is flat out false. The scientific evidence shows the opposite.

The authors have simply fabricated several of the so called "undesirable" maternal effects including immobility, and sedation. That begs the larger question: undesirable to whom? The answer is that the side effects (the real ones, not the made up ones) are undesirable to the members of Childbirth Connection. The authors provide no evidence that the patients consider these side effects to outweigh the benefits of effective relief.

Indeed, the authors acknowledge that the majority of women do not share their disdain for epidurals, but in the classic manner of "natural" childbirth advocates, they ascribed it to ignorance without offering any proof.

Many laboring women welcome the pain relief of epidural anesthesia, but they do not appear to be well-informed about the side effects.

Once again the authors present ZERO evidence for their implication that women would forgo pain relief if they were "better" informed.

Third, the report, like virtually all "natural" childbirth and homebirth advocacy is filled with deliberate distortions. The authors compare neonatal mortality rates among countries, and fail to compare the more accurate measurement of perinatal mortality. The authors discuss the "charges" for obstetric procedures instead of the actual reimbursements. The authors claim that systematic reviews "give the most trustworthy knowledge about beneficial and harmful effects of specific health interventions," but that is flat out false. Systematic reviews are completely dependent on the quality of the studies that the authors choose to include and whether those studies are representative of the existing scientific literature. Systematic reviews are a good starting point for evaluating obstetric procedures, but they are hardly the "most trustworthy" sources of scientific information.

Fourth, in case you were unclear on the fact that this report is intended to be smear of modern obstetrics, the authors helpfully mention the history of diethylstilbesterol (DES) to suggest that even though the scientific evidence does not support their claims of harm from various interventions, it does not mean that harms might not be discovered in the future. In other words, they feel free to ignore the existing scientific evidence if it does not support their predetermined conclusions.

This report from the Childbirth Connection is not consistent with the scientific evidence, and is not consistent with the desires and values of the majority of American women. It is nothing more than an extended attempt to promote the personal opinions of a small group of "natural" childbirth advocates.

Making false claims and then wondering why no one takes you seriously

2008-10-07T15:52:00.002-04:00

Here's a typical example of a homebirth advocates simply making up an utterly false claim, and passing it off as true. As far as I can tell, she made zero effort to establish the veracity of her claim. It seemed reasonable to her, and, in her mind, that was enough to qualify as "proof". Homebirth advocates wonder why no one takes them the least bit seriously and this is why. They prattle away without having any idea of what they are talking about.

According to Nicole D of Bellies and Babies:

Well, let's get straight to the point: hospitals make a lot of money from epidurals.

Actually, hospitals and anesthesiologists LOSE money on epidurals. Consider the paper How much labor is in a labor epidural? Manpower cost and reimbursement for an obstetric analgesia service in a teaching institution published in the journal Anesthesiology.

With intermittent staffing, labor cost was $325 per patient. Actual practice at Duke University Medical Center is around-the-clock (dedicated) staffing, which requires 4.4 FTEs at a cost of $728 per patient. Neither average indemnity reimbursement ($299) nor Medicaid reimbursement ($204) covered the cost per OAS patient. Breaking even is possible under indemnity reimbursement because operating room reimbursement subsidizes Obstetric Analgesia Service costs. Breaking even cannot occur with Medicaid reimbursement under any circumstances.

CONCLUSIONS: Obstetric analgesia services requires a minimum of 2.5 FTE attending anesthesiologists at Duke University Medical Center. With the current payer mix, positive-margin operating room activities associated with the obstetric service are not sufficient to compensate for the losses incurred by an OAS. Around-the-clock dedicated obstetric staffing (4.4 FTEs) cannot operate profitably under any reasonable circumstances at our institution.

This is only the most glaring of Nicole D's made up claims. She's wrong about the action of epidurals; she says they "cause your uterus to relax." Then after assembling a variety of made up claims, she proceeds to her utterly inane conclusion:

Now things begin to line up... why women are being refused VBACs because of hospital policy or individual practice, why a nurse refuses to adhere to one request out of many on her birth plan: that medication not be routinely offered, why the AMA refuses to acknowledge that home birth is as safe as hospital birth for low-risk women and why they are attempting to outlaw home birth all together, and why hospitals across the board are pushing for the 'safety' of medication in birth... profit.

Makes perfect sense to her, because she has no idea what she is talking about.

What's the real story? Epidurals are not profitable for anesthesiologists or hospitals. Except in large institutions, it is very difficult to cover the costs of 24 hours obstetric anesthesia. Therefore, hospitals are unable to offer VBACs because they can't afford to maintain the services necessary to offer them safely.

Nicole D throws in a few extra made up claims for good measure. No, Nicole, all the existing scientific evidence shows that homebirth is not as safe as hospital birth. No, there is no financial incentive in claiming that epidurals are "safe" since insurance companies reimburse less than the cost of the epidural and the anesthesiologist who must be available to administer it.

We have already seen that homebirth advocates live in Birth Fantasyland, pretending that birth is inherently safe, pretending that complications are rare, and pretending that thinking positive thoughts can affect the outcome of birth. Now it seems that Birth Fantasyland extends to the hospital, where homebirth advocates pretend that epidurals generate profit, in order to pretend that doctors and nurses offer pain relief for reasons other than relieving pain.

Patient preferences and mode of delivery

2008-10-05T10:34:00.004-04:00

Susanne suggested that I review the article in this month's journal Obstetrics and Gynecology, Mode of Delivery: Toward Responsible Inclusion of Patient Preferences. The article is written by seven women, two obstetricians and five professors of philosophy, including Rebecca Kukla. I have quoted Kukla's philosophical work on mothering in previous posts.

The paper is interesting, but I found it curiously out of touch with the current realities of obstetric care. I was also confused by the emphasis on "cost effectiveness," and societal consideration which really has no place in a discussion between patient and provider, and can only be addressed on a system wide basis.

It seems to me that the authors started with their conclusions and then worked backward to justify them. Their conclusions were that women should have more choice in determining mode of delivery for VBAC, breech and twins, and essentially no choice in maternal request C-section. Their desired conclusions rest on unexamined assumptions, that vaginal delivery is inherently "better" than C-section delivery, and that the current C-section rate is "too high." The authors offer no discussion or justification of these assumptions, which guide all subsequent reasoning.

Let's first look at what the authors said:

We believe that responsible guidelines around mode of delivery are a function of four considerations, which interact in complex ways. First and foremost are clinical considerations of safety and efficacy, which include the extent to which the provider is comfortable with managing the specific approach. Second are considerations of cost effectiveness, which are especially important for options whose use would be prevalent. Third are the broader clinical and social consequences of expanding choice. Considerations here include the potential for diversion of resources, unintended shifts in institutional practices and provider expertise, as well as potentially subtle shifts in the pressures or untoward cultural presumptions subsequent patients will face. These three factors circumscribe boundary conditions on what providers can responsibly provide to individual patients. They also provide comparative information key to informing choices within the range of broadly safe
and cost-effective options.

Fourth are considerations of patient values and preferences, including the extent to which patients would trade one set of possible outcomes for another, how important differences in potential outcomes are to them, and how robustly variable preferences are across the population. In general, the stronger the preferences, and the greater the divergence among them, the stronger the case for patient-flexible guidelines. For one thing, the standard for acceptable medical risk and cost is in part a function of what patients value — as elsewhere in medicine, an option that brings a slightly higher risk or cost can be acceptable if it has a benefit that some patients value highly. Further, where outcomes are broadly equivalent in aggregate risk of adverse outcomes or cost, patient preferences are of obvious importance.

These four considerations are critical to defining what constitutes responsible care. The higher the probability of significant harm, the more restricted the range of reasonable options, even in the context of divergent patient preferences; the stronger and more variable the patient preferences, the more they should be given directive weight; the higher the externalities, and the less cost-effective an option, the more justification for prescriptive guidelines.

Simply put, the authors believe that the four considerations for decision making should be:

1. safety
2. cost effectiveness
3. social consequences of expanding choice
4. patient preferences

In my judgment, the authors are pretty far off the mark in their conclusions. They include two considerations that have no place in patient-provider discussions, and they ignore two considerations that have tremendous impact on the current situation in obstetrics today.

Neither cost effectiveness, nor social consequences have any place in patient-provider discussions of treatment choices. I'm surprised that the authors included them. Change the specialty from obstetrics to oncology, and the problem becomes glaringly obvious. When cancer patients face the failure of first line treatment for their disease, and are considering the next step to prevent inevitable death, neither cost effectiveness, nor social consequences have any place is a discussion of options.

Should an oncologist suggest to a patient that it would be cheaper or better for society if the patient would just go home and die? Of course not. Undoubtedly, once a patient has failed first line treatment, it WOULD be cheaper and generate far few problems for "society" if the patient just gave up. That's not how we make medical decisions. A core principle of medical ethics is "beneficence," determining what is good for the patient. The interests of society (or the insurance company) have no place in the patient-provider relationship.

As far as I can tell, cost and societal considerations mask the handwaving necessary to reach the authors' predetermined conclusions. Allowing greater choice in mode of delivery, but prohibiting maternal request C-sections can only be intellectually justified by including the interests of society (or so the authors believe). Otherwise, it would make no sense to assert that women who value vaginal birth as an interest in and of itself should be allowed to incorporate that value, but women who value C-section birth should not be allowed to act on their personal values.

Secondly, and inexplicably, the authors fail to consider two interrelated factors that are driving the currently high C-section rate, malpractice claims and the inability of patients to understand risks. The authors acknowledge that C-section IS the safer mode of delivery in the situations under consideration:

VBAC: "After a number of well-publicized reports of complications of trials of labor after previous cesarean, and motivated by the small but real risk of uterine rupture"

twins: "the small but statistically significant risk of complications in delivery of the second twin."

breech: "In 2000, a large, randomized trial of cesarean compared with vaginal delivery for breech, the Term Breech Trial, found that combined perinatal and neonatal mortality and serious neonatal morbidity were significantly lower in the planned cesarean delivery group compared with the planned vaginal delivery group (1.6% compared with 5%)."

Therefore, since C-section is known to be the safer mode of delivery, there is essentially no defense in a malpractice case when complications occur during vaginal delivery in the three settings under discussion: VBAC, twins and breech. I find it inexplicable that the authors fail to address this critical point: C-section IS safer, and doctors have no defense for failing to perform a C-section in these settings.

So when it comes to the authors' first consideration in these situations, safety, C-section is almost always the safer option.

The authors, appropriately, devote a great deal of attention to the issue of patient preferences:

For example, as with women who have not had a prior cesarean, many women facing birth after cesarean strongly value the opportunity to deliver vaginally... For these women, decreased access to VBAC can be experienced as a significant loss...

And:

... Women who place high value on vaginal birth may also wish to avoid the significant discomfort and small risk of emergent cesarean associated with external cephalic version and articulate a reasoned preference for vaginal breech delivery.

Those preferences are real, but the authors fail to address the basic issue that the standard for determining treatment is informed consent, not preferences. Simply preferring a vaginal delivery does not constitute informed consent for refusing a medically indicated C-section. This is not a trivial distinction, and the authors' failure to address it calls into question their conclusions about the role of preferences.

I find the paper very disappointing. It does not offer any practical advice for a systematic way of incorporating patient preferences into decisions about mode of delivery. In its failure to acknowledge the central role of malpractice litigation when C-section is known to be the safer option, and its failure to address the critical issue of informed consent, it mischaracterizes the problem and offers merely a weak justification for predetermined conclusions.

Homebirth is like smoking cigarettes

2008-10-03T09:10:00.004-04:00

Homebirth is like smoking cigarettes. In both cases, the people that do it evince a curious contempt for preventive measures, a bizarre fatalism about the bad things that might happen, and an outsize faith in the ability of doctors to save people from their own mistakes.

There isn't a smoker around who doesn't know that smoking causes cancer, yet people smoke anyway. Some people continue to smoke long after they want to quit, because they are addicted to nicotine. Yet many others like to pretend that bad things won't happen to them. They tend toward a fatalism that predicts that bad things are going to happen anyway; might as well enjoy life's simple pleasures. Of course, in the back of their minds they're counting on the fact that if they do develop cancer, they will receive extremely high tech, highly expensive care that will prolong their life and perhaps even cure their cancer.

As for homebirth advocates, yesterday's post about a predictable shoulder dystocia at a homebirth illustrates the bizarre contempt and fatalism of homebirth advocates. The patient had had an unpredicted severe shoulder dystocia at her previous birth. The odds were high that she would have another, and therefore she was strongly advised to give birth in a hospital where an team of medical professionals, including an expert in neonatal resuscitation, would be available to render all possible insistence. The patient and her midwife (oops, I mean "support person") viewed any and all attempts at preparing for shoulder dystocia with utter contempt. They ignored the advice to deliver in a hospital because they reasoned, correctly, that the doctors would do everything they could to prevent a fractured arm, neurologic injury and anoxic brain damage, and that would likely mean interfering with the patient's birth "experience."

The fatalism of the patient and her midwife (oops, I mean "support person"} is truly astounding. It's not that they didn't believe that another shoulder dystocia could happen. They simply didn't care. Bad stuff happens; why do anything to prevent it? Of course, in the midst of the emergency, they did call for medical assistance. The same people who are sure that medical help won't be needed, and equally sure that it will fix everything when they've guessed wrong.

What the patient and her midwife didn't understand, because neither knows very much about childbirth, is that successfully delivering a baby during a shoulder dystocia depends to a large extent on the experience and training of the person delivering the baby. Coincidentally, this month's journal Obstetrics and Gynecology, has a paper on the impact of training on preventing injury during shoulder dystocia. According to the abstract of the article Observations From 450 Shoulder Dystocia Simulations:

Poor neonatal outcomes after shoulder dystocia have been associated with inappropriate management. Until there are significant developments in the prediction and subsequent prevention of shoulder dystocia, improving shoulder dystocia management through practical training may be the most effective method of reducing the associated morbidity and mortality. Four hundred fifty simulated shoulder dystocia scenarios, managed by 95 midwives and 45 doctors from six U.K. hospitals during the course of 1 year, were video recorded during a study of obstetric emergency training. Analysis of recorded data revealed that, before training, 57% were unable to deliver the baby, almost two thirds failed to call for pediatric support, and 1 in 27 used fundal pressure. Recurring difficulties in management were observed: poor communication, inability to gain internal access, confusion over internal maneuvers, and the application of excessive traction. Significant improvements in management were observed after training and persisted up to 1 year after training. The lessons learned from this study can inform and improve future training and management...

The simulations were performed on a specially designed mannequin that was set to release the baby if the appropriate obstetric maneuvers were performed. In addition, the mannequin could measure the force applied to the baby during attempts to deliver it. The authors found:

Pretraining data revealed that 80 of 140 (57%) were unable to
deliver the fetus ... Before training, 75 of the 113 participants (66%) applied a force above 100N (22.5 lbs), and 12 (11%) applied more than 200N (45.0 lbs). However, after training there was a significant improvement in the proportion of participants who successfully achieved the simulated delivery, from 60 of 140 (42.9%) pretraining to 110 of 132 (83.3%) posttraining; the majority retained the ability to achieve delivery up to 1 year after training, with 80 of 95 (84%) able to deliver at 6 months and 75 of 82 (85%) at 12 months.

These findings are consistent with the results from studies of neonatal deaths due to shoulder dystocia:

The 5th Confidential Enquiry into Stillbirths and Deaths in Infancy (CESDI) in England and Wales found grade three suboptimal care ... in 66% of neonatal deaths after shoulder dystocia ... The 2003 National Health Service for England and Wales Litigation Authority Report on 264 claims for obstetric brachial plexus injury in England judged 46% (72/158) of the reviewed cases to involve substandard care. The most common criticism is related to failure to carry out standard shoulder dystocia resolution maneuvers. Furthermore, a study conducted in two English hospitals reported that 70 of the 166 (42%) midwives and junior obstetricians surveyed did not feel confident in the management of shoulder dystocia.

In addition:

The CESDI report into fatal cases of shoulder dystocia found a pediatrician was present at the time of delivery of the body in only 55% of cases and recommends that a pediatrician should be called as soon as shoulder dystocia is identified...

We know for a fact that in the case of shoulder dystocia, experience is key to successfully delivering the baby without injury or anoxic brain damage. Deliberately ignoring that reality in order to preserve a particular birth "experience" is like deliberately smoking cigarettes: irresponsible at best, and criminally negligent at worst.

Oops! Repeat shoulder dystocia, fractured arm, Apgar 1

2008-10-01T21:35:00.005-04:00

The midwife who writes Homebirth: A midwife Mutiny had an "oops" homebirth. Really, they were planning to go to the hospital to have this baby. She had a history of a severe shoulder dystocia with the previous baby. And yes she was in active labor when the midwife got there to be her "support" person, but, no doubt, they were planning to go to the hospital all along, but then (who could have forseen it?) the mother was pushing, the baby was crowning and it was just too late.

Guess what? Another shoulder dystocia. What a coincidence.

Baby comes very quickly to eyes and then each contraction only brings a little more baby,few more and baby's mouth is half in half out, she's on all fours so we are just waiting. chin is barely out just waiting, no contraction for a number of mins so I don't touch but ask her to change position, touching before any sign impacts the shoulder, she changes position baby does a bit of a turtle neck thing but tries to swallow. another 5 mins on peri and I ask them to call an ambulance but all is very calm, I'm well aware of their last experience so we keep chatting. I felt shoulder abdominally and just tried to put them in the AP and I asked her to turn back onto all fours, Still nothing baby is looking a little off colour so with next contraction about 5 mins on, I put in my hand and with some difficulty, (lots actually) I move the posterior shoulder and as it's birthing I hear it snap. FUck, However the arm came through and I was able to pull the baby out. I am so over this!! baby had great cord pulse apgar is 1. I mouth to mouth baby and after 2/3 mins feel a few resps under my mouth ...

It's only a matter of luck that the baby is not dead. Hopefully, the only lasting effect is a broken arm and not permanent nerve damage. Of course, it will be a while before they can determine whether the prolonged interval without oxygen caused permanent brain damage. Good thing all this is no one's fault, because really they were planning on transferring to the hospital, they were, but who could have predicted that a multip labor would proceed so fast?

Petition request

2008-09-29T21:07:00.002-04:00

Last month, I wrote about the heartbreaking story of a mother who lost her sixth child at a homebirth. She wrote:

... You know when people would tell me that babies used to die because they were born at home, I had my "research and statistics" to back me up and prove they were wrong. Wanna know one thing I have learned now??? We don't hear about deaths after homebirths because of the stigma. Your baby dies in the hospital and people feel sorry for you. Your baby dies after a homebirth and people automatically blame you, even if it wasn't your fault...

. Now she and her husband have created a petition to demand stricter standards for DEMs in Ohio. She asked if I would post a link to the petition on Homebirth Debate and I am pleased to be able to help: Practicing Midwives should be Licensed and carry Insurance.

Measuring mothering

2008-09-27T17:48:00.003-04:00

Rebecca Kukla, a feminist scholar, has written a brilliant article in the International Journal of Feminist Approaches to Bioethics entitled Measuring Motherhood. I have quoted Prof. Kukla before in a post discussing the way that attachment parenting advocates fetishize physical proximity of mothers to babies (See Proximity).

Now Kukla has turned her attention to the middle class penchant of evaluating other women's mothering by signal moments, and her insights are quite penetrating.

Our cultural insistence that women make "proper" birth choices and maintain control over their birth narratives is not about minimizing real risks; rather, it supports our desire to measure mothering in terms of women’s personal choices and of self-discipline exercised during signal moments. What is at stake is not the health of babies but an image of proper motherhood, combined with the idea that birth should function as a symbolic spectacle of such motherhood.

This is what I have been arguing all along. Homebirth and "natural" childbirth advocacy are not about birth, and they are not about what is good for babies. They are culturally constructed, purely subjective, efforts to elevate the preferences of a subgroup of women over the preferences of all other women.

As a culture, we have a tendency to measure motherhood in terms of a set of signal moments that have become the focus of special social attention and anxiety; we interpret these as emblematic summations of women’s mothering abilities. Women’s performances during these moments can seem to exhaust the story of mothering, and mothers often internalize these measures and evaluate their own mothering in terms of them. "Good"” mothers are those who pass a series of tests — they bond properly during their routine ultrasound screening, they do not let a sip of alcohol cross their lips during pregnancy, they give birth vaginally without pain medication, they do not offer their child an artificial nipple during the first six months, they feed their children maximally nutritious meals with every bite, and so on. This reductive understanding of mothering has had counterproductive effects upon health care practice and policy, encouraging measures that penalize mothers who do not live up to cultural norms during signal moments, while failing to promote extended narratives of healthy mothering.

Kukla situates "natural" childbirth within a larger pattern of judging women by their "performance" at key moments:

The rhetoric surrounding these moments suggests, on the one hand, that they will determine the success of the future mothering narrative (whether the mother will bond properly with her baby; whether the baby will develop a lifetime of secure relationships and healthy eating habits) and on the other hand, that they reveal the truth about a woman’s fitness to mother (whether she is sufficiently engaged, self sacrificing,risk-adverse, disciplined, etc.).

My primary purpose in exploring these issues has been exposing them as purely social standards without basis in scientific facts. Kukla is more concerned about the ways in which these purely social standards implicitly disadvantage and demean women who are not privileged culturally and economically.

Thus to the extent that we take "proper" maternal performance during these key moments as a measure of mothering as a whole, we will re-inscribe social privilege. We will read a deficient maternal character into the bodies and actions of underprivileged and socially marginalized women, whereas privileged women with socially normative home and work lives will tend to serve as our models of proper maternal character.

The bottom line is that a small group of privileged women hold their own choices up as standards to which all women should aspire. This is wrong on several levels: there is no objective evidence that the claims of "natural" childbirth advocates are true; there is no objective evidence that single moments of motherhood determine the long term well being of a child or determine the strength of the mother-child bond; and insisting that the cultural rituals of a privileged group of women are the standards to which all other women should aspire reinforces existing cultural and economic prejudices.

Momzillas

2008-09-25T08:12:00.002-04:00

We've all heard about bridezillas, the women who are so obsessed with having the perfect wedding that they become tyrants toward everyone else. There's an argument to be made that many homebirth and "natural" childbirth advocates are "momzillas" who justify their hypersensitivity, obsessive need for control, and rudeness to everyone else with the all purpose excuse "It's my special day."

Consider:

Obsessive need for control - One of the hallmarks of the bridezillas is the obsessive need for control. No detail is too small for consideration, planning and decrees.

Momzillas? It's difficult to imagine anything more obsessive than birth plans. Birthplans, in addition to being useless for their stated purpose of improving the birth, are attempts to plan the unplannable. You might as well have a "weather plan" for the day of birth for all the good it's going to do you. Birthplans, like obsessive wedding plans, have the added drawback of irritating everyone around you. The need to ruminate on every aspect of the day, and share those ruminations with everyone else is boring at best and narcissistic at worst.

Hyersensitivity - Bridezillas spend a lot of time being angry. Things aren't going according to plan. People are not taking their desires as seriously as they take them. People don't behave as instructed. Everything is perceived as a slight. Flowers the wrong color? Have a fit. Napkins not folded just so? Accuse the caterer of incompetence. Groom expresses a different preference that has not been preapproved? Who does he think he is? After all, it's not about him. It's all about, exclusively concerned with, revolving only around Bridezilla.

Homebirth and "natural" childbirth advocates spend a lot of time being angry. The birth is not going according to plan. The hospital staff are not taking their desires as seriously as they take them. The hosptial staff is not behaving as instructed. Everything is a slight. Offered an epidural? Have a fit. Labor support not exactly as desired? Accuse the nurses of evil intentions. Baby needs something different than the preapproved birth plan? Who does that baby think he is? After all, birth is not about the baby. It's all about, exclusively concerned with, revolving only around Momzilla.

Outsize feelings of disappointment - Bridezillas are psychologically very fragile, and make no apologies for their fragility. Cake filling the wrong flavor? The wedding is ruined.

Momzillas are psychologically very fragile and make no apologies for their fragility. Baby need resuscitation before being placed skin to skin with Momzilla? The birth is ruined. C-section needed to deliver a healthy baby? That no longer qualifies as a birth at all!

Using others as characters in performance art - This is perhaps the worst of the many unattractive traits of Bridezilla. Everyone, from the guests, to the bridesmaids, to the groom himself, are nothing more than bit players in Bridezilla's ultimate piece of performance art, her wedding. Bridezilla feels free to dictate what the guests should wear, how much the bridesmaids should weigh, and every possible details of the groom's existence. What if those people feel badly about the way they're treated? Bridezilla doesn't care. It's her day and that means she's entitled to use people any way she wants.

Momzilla is the same. Everyone, medical personnel, her partner, even the baby are nothing more than bit players in Momzilla's ultimate piece of performance art, "her" birth. Momzilla feels free to dictate what everyone involve is allowed to do or say. What if her requests compromise the obligation of medical personnel to provide safe care? Momzilla doesn't care. It's her day and that means she's entitled to use people any way she wants.

Bridezillas are narcissists. They have an outsize view of their own importance, a hypersensitivity to slights, a feeling a being persecuted when things don't go their own way, and an insensitivity to others who work with or for them. Homebirth and "natural" childbirth advocates often behave like narcissists, too. They have an outsize view of their own importance, a hypersensitivity to slights, a feeling of being persecuted when the birth does not go as planned, and an imperiousness and insensitivity to others who work with or for them.

Ultimately, both bridezillas and momzillas are psychologically fragile. Instead of integrating the inevitable disappointments associated with a wedding or birth, they get psychologically "stuck." They experience their disappointments as narcisstic injuries and respond with rage and accusations of persecution. They have no time for and no interest in the feelings of others, and feel entitled to use other people for their own ends. Ironically, the behavior of momzillas often fails to produce the perfect birth, just as the behavior of bridezillas cannot produce the perfect wedding. Because of their psychological neediness and fragility, they are unable to appreciate that every change in plan is not the "fault" of someone, unable to accept that unwillingness of providers to follow commands is not a sign of persecution and, worst of all, unable to enjoy what they have.

Homebirth advocacy and self-awareness

2008-09-24T09:26:00.004-04:00

Homebirth advocates display a startling lack of self-awareness. It's not that they are unaware of themselves. Quite the contrary. They are obsessively focused on themselves, their feeling and their needs. They lack self-awareness because they fail to realize that their feelings and needs are restricted to themselves, and do not mirror the feelings and needs of other women. There is a tendency among homebirth advocates to consider themselves as models for other women, and believe as if they the right to speak for other women. It never even occurs to them that what they want is merely their personal preference, not a universal standard adopted by all women.

That accounts, in large part, for the contempt in which homebirth advocates hold other women who are not as "educated" as they are. Leave aside for the moment the fact that homebirth advocates are generally among the least educated people around when it comes to childbirth issues, since most of what they think they "know" isn't actually true. They are sure that there is one and only one valid way to approach having a baby, and that is to demand information and control.

In an interesting study, Rhetoric versus Reality: Exploring Consumer Empowerment in a Maternity Setting, researchers Geiger and Prothero investigate the different ways that women plan for childbirth. They point out that the woman who wants to control the entire experience is uncommon, and what she demands from the midwifery and obstetric professions is not what most women want.

They describe Leah, the controlling consumer:

... Leah is a very active consumer who desired to be in complete control of her pregnancy and labour. To achieve this consumer sovereignty she went to great lengths to gather information from various sources and to build up intense relationships with her service providers. From the outset, she researched carefully which hospital to have the baby in and chose the one she felt would best suit her needs for having a "natural childbirth"...

Leah wanted to know about everything that was happening throughout her pregnancy, so that any decision making would ultimately be based on complete knowledge of all available options and final decisions would rest with her as an empowered and informed client... This information provided her with a very specific idea of how she wanted things to be... [E]mpowerment for her translated into the ability to control the service process throughout, using her knowledge to ensure the service provided to her was the one that would most allow her to achieve her objectives of a natural birth.

Leah had briefed her husband extensively about what type of labour she wanted and she was relying on him as a proxy agent to make sure this happened:

'...I said to him Cian if you don’t advocate for me I will kill you. If they come near me with an epidural even if I’m saying get me the epidural, get me the epidural, and you say get her the epidural, I will kill you.'

... Leah ... reflected most on her relationships with the service providers. She worked incredibly hard at her relationships with all of the service providers she encountered because she strategically calculated the importance of all those who would be involved in helping her achieve her dream childbirth...

... In her desire to remain in control of the situation, Leah sometimes appears to be a highly confrontational character to those caring for her...

Indeed, a couple of Leah’s relationships with midwives became difficult. She felt that the service providers, in her eyes a mere instrument to facilitating her dream birthing experience, brought “too much personality” into their jobs. She knew she depended on them to realise her dream maternity experience...

Thus, across our research participants, Leah was the woman for whom empowerment translated most readily into control. She accumulated a great amount of information and developed and nurtured relationships with all types of service providers to ensure that her voice would be heard and heeded, and the pregnancy and labour would develop as she wished...

People like Leah know what they want. What they don't realize is that other women don't want the same things. The authors explain:

... [C]onsumers have vastly different ways in negotiating empowerment in a maternity setting. Roth (1994) ...stresses that "empowerment is facilitated when consumers have a comprehensive understanding of a health issue" and that "consumers feel in control by maintaining awareness and currency, facilitated by using easily obtainable and understood information sources". What our study shows, however, is that some women during their pregnancies may actually feel empowered by having less information — while they may have the ability to obtain and to utilise information, they actually choose not to do so if this proves less stressful and/or worrying. All four women presented here were highly educated and could have garnered considerable knowledge to allow them to make informed choices of their "ideal" birth should medical reasons not dictate another course of action; however, only Leah actively sought to be in a position to do so in order to control the process. Two of the other participants, Martina and Alice, used their knowledge to build a trusting relationship with their service providers, while Emer decided not to gain information that may leave her more frustrated and worried than necessary with her service provision...

Likewise, this study has confirmed a suggestion made by Wathieu et al. (2002) that what we conventionally understand as "consumer empowerment" — process control — can easily lead to cognitive overload and anxiety, especially when confronted with complex and novel situations. In this study, this was clearly the case for all of our participants, who devised different strategies to deal with their anxieties and to become empowered even if they chose not to exert control...

The literature talks of empowered consumers needing to take responsibility for the outcome of the choice process. Given the high stakes involved in a maternity situation, it is hardly surprising that to take such responsibility causes great anxiety for new mothers and their partners and may help explain why some women chose to become a passive patient rather than an active agent — though being passive to them was empowering.

In summary:

Our study adds to the literature on consumer empowerment by showing that consumer control and empowerment are by no means the same. Empowerment is thus a much more complex phenomenon than often portrayed in the literature and it is very much a subjective experience that can range from highly active and controlling to reliant and passive.

Doctors used to encourage VBAC; what changed?

2008-09-22T07:35:00.000-04:00

Have a problem with the decreasing VBAC rate? Take it up with the women and lawyers who are responsible, and stop pretending that doctors are depriving women of choice.

When I was practicing, obstetricians encouraged VBAC. I had a high rate of patients attempting VBAC and a high success rate as well. So when I first heard that ACOG had changed their guidelines, I was stunned. Why had ACOG changed? They changed the guidelines for one and only one reason: they listened to women. Despite being counseled about the risks of VBAC, women who experienced a uterine rupture routinely sued their obstetrician and routinely won. ACOG was simply recognizing the reality that women believed that they did not and could not understand the risks of VBAC.

One of the most egregious cases involved a woman who claimed that her doctor withheld material information about the risks of VBAC. Although the obstetrician had told the patient that not only could a uterine rupture happen, she had seen one happen, the patient asserted that she wasn't adequately informed because the doctor did not mention that the baby in that case died:

... Flagg advised the plaintiff that, statistically, there were risks associated with the procedure, including uterine rupture and even a small chance of death of the child. Flagg reassured the plaintiff that all necessary steps would be taken to minimize or eliminate the risk to either the plaintiff or the plaintiff's decedent and that the risk was "very, very small . . . ." ... [T]he plaintiff asked ... whether Flagg had had any negative outcomes. In response, Flagg stated that one of her previous patients suffered a uterine rupture as a result of a VBAC delivery. She did not mention, however, that the uterine rupture had caused the infant's death and had placed the mother’s health at risk.

When patient lost her original lawsuit against the doctor, she was appealed using a new theory.

The plaintiff's informed consent claim rested on the allegation that Flagg had given an incomplete and misleading response to the plaintiff's inquiry about prior experience with VBAC deliveries. The plaintiff maintained that Flagg told the plaintiff that, in a prior VBAC delivery, she had one complication that resulted in a uterine rupture, but failed to tell the plaintiff that the uterine rupture resulted in an infant’s death. The plaintiff asserted that this evidence supported her claim that Flagg had not provided her with adequate information required for informed consent ... The plaintiff also claimed that if Flagg had informed her that the prior VBAC delivery resulted in the death of the infant, she would not have elected the VBAC procedure.

The Appeals Court agreed with the mother and granted a new trial on the theory that the mother had not given informed consent.

It is cases like these that led to the dramatically more stringent ACOG recommendations. Obstetricians wanted to offer VBACs but women insisted, and courts agreed, that the women weren't capable of understanding the risks. A journalist writing about his wife's successful VBAC gives us insight into the position of obstetricians:

Given his support of VBACs, I was surprised to learn that Burgee himself doesn't perform them. He did for two decades, but he stopped in 1990 when he reduced his practice to half-time while he got a law degree (so far unused). When he resumed his full-time practice, he didn't take them up again. He stopped, he says, partly because his legal education made him see his legal risks more starkly. Managing the cases thus seemed more complicated than ever: The OB in him would be pulling for the VBAC, while the surgeon, lawyer, and potential trial defendant would worry that he should wheel the mother to the O.R. Now he explains to his patients why he doesn't perform VBACs, outlines the odds as well as the arguments for and against, and offers the names of midwives and doctors who will perform the procedure...

Are doctors overreacting? It's hard to make that claim when you learn how lawyers are advising women. The title of this law firm's webpage is VBACs Too Often Result In Injury and Death:

While the promotion of VBACs may save insurance companies money, the risks simply cannot and should not be ignored. It is known that patients who fail a trial of labor are at increased risk for infection and death. Infants born by repeat caesarian delivery after a failed trial of labor also have increased rates of infection. Recent reports indicate that major maternal complications such as uterine rupture, hysterectomy, and operative injury were more prevalent in women who attempted a VBAC than those who underwent repeat caesarians.

If the uterine scar ruptures, it can be life-threatening for both the mother and the infant. For the mother, uterine rupture can require hysterectomy and can result in death.

For the infant, uterine rupture can result in both neurological damage and death. Uterine rupture can result in a sudden disruption in the blood flow to the fetus, resulting in deprivation of oxygen to the blood and tissues. This deprivation can lead to death of brain tissues and serious harm to other vital organs within only minutes. Accordingly, it is imperative that no VBAC be attempted at a facility where emergency staff are not capable of performing an emergency caesarian in minutes in order to prevent this potential harm or death to the infant and mother.

Contrary to the ravings of VBAC activists, obstetricians did not "take away" women's option for a VBAC. That was done by women themselves. If enough women claim that they cannot possibly understand the risks of VBAC and enough lawyers encourage lawsuits based on that theory, obstetricians and hospitals have no choice but to respond to their demands.

Have a problem with the decreasing VBAC rate? Take it up with the women and lawyers who are responsible, and stop pretending that doctors are depriving women of choice.

CPM presides over 2 separate deaths in 6 weeks

2008-09-19T09:50:00.003-04:00

A Virginia CPM was suspended from practice last week concluding that she posed a "substantial danger to public health or safety. She presided over, and appears to be responsible for, not one, but two separate neonatal deaths in a 6 week period.

The midwife made so many egregious errors during the care of both mothers, that they can't possibly fit into one post. The evidence presented at her suspension hearing is chilling. Regarding Patient A:

... Ms. Zittle did not perform a vaginal examination of Patient A until ... approximately six hours after contractions began and approximately 27 hours after the spontaneous rupture of membranes, at which time Ms. Zittle incorrectly identified the presence of a nuchal hand.

Although a vaginal examination at 5:02 a.m. ... revealed Patient A to be 8 centimeters dilated with the foot, thigh, and shin of the left foot presenting, Ms. Zittle ... did not transfer Patient A to the hospital. Even though Ms. Zittle had never before performed a breech delivery, she opted to continue with a home delivery ..

Delivery of Patient A's infant began at approximately 6:06 a.m., when the left foot delivered... Ms. Zittle ... did not physically intervene to assist the delivery of the infant until approximately 6:35 a.m., when the pulsating umbilicus emerged and Ms. Zittle used her right hand to prevent cord compression. The infant's buttocks emerged at 6:22 a.m. and by 6:38 a.m. the chest, only to the nipple line, had cleared the cervix. Although Ms. Zittle subsequently noted that the umbilical pulse was getting weaker and, at 6:40 a.m., documented the absence of a fetal heart rate, she did not initiate a 911 call until after the infant was born at 6:42 a.m. in a lifeless condition... Ms. Zittle immediately began performing Delee suction of the mouth, then nose, and began performing CPR, which she had never performed before on an infant.

An autopsy on Patient A's infant revealed that the liver had ruptured, spilling 55 cc's of blood into the abdomen, and also that the infant was positive for Group B strep infection. The Medical Examiner who performed the autopsy stated that the condition of the liver indicated that the infant had been breech for some time; that the rupture had developed over time, most likely from being pressed against Patient A's hard pelvic floor; and that "a c-section would have been life saving in this case."

Patient B, expecting her 3rd child:

Ms. Zittle failed to respond in a timely fashion to ... the intensification [of patient's contractions] around 10:O0 p.m. on June 9, 2008, in that she did not leave to go to Patient B's home to attend her labor and delivery until approximately 12:34 a.m. ... notwithstanding the 45-50 minute drive anticipated to Patient B's home and the fact that Patient B was located approximately 17 miles from the nearest hospital and lacked transportation at that time...

En route to Patient B's home, after Ms. Zittle was aware that Patient B was in the midst of a footling breech delivery, EMT personnel informed Ms. Zittle by telephone that Patient B's infant had been delivered up to the chest but they were unable to further deliver the infant. Notwithstanding this information, Ms. Zittle instructed EMT personnel not to take Patient B to the hospital, but instead to assist Patient B in delivering her infant at home in the birthing tub. Ms. Zittle also instructed EMT personnel to wait for her arrival, estimated to be approximately 30 minutes later, before transporting Patient B to the hospital.

After transport to the emergency room by EMS, at approximately 1:37 a.m. ..., Patient B delivered an infant with a distended abdomen and without respiration, color, movement, or a heartbeat, who was pronounced dead... The cause of death listed on the death certificate was umbilical cord entanglement and compression subsequent to breech delivery.

This midwife is still advertising her services on her own website, although she claims she is available only as a monitrice despite her status as a certified midwife.

Homebirth death in Australia

2008-09-18T15:04:00.003-04:00

Unfortunately, I run across stories of homebirth deaths so routinely, I've stopped blogging about each one individually. I thought that this one was worth mentioning because of the knee jerk reaction of the doula. Although no cause of death has yet been determined, the doula claimed: ""I can assure you, this wasn't home birth-related."

You can find the complete story here:

A newborn died after a woman ignored the pleas of doctors and nurses and gave birth at home without medical support.

The tragedy, which has been referred to the coroner, confirms the fears of maternity experts who are alarmed at the trend of women shunning the health system in favour of risky, unsupervised home births.

The baby died last Sunday three days after the mother presented at Nepean Hospital. Doctors found the baby was fine but warned the woman she was at high risk of complications, including the rupture of a scar from a previous caesarean. They said they wanted to induce labour immediately.

She refused and returned to her Blue Mountains home where she later gave birth to a stillborn baby.

Two doulas, who are not medically trained but provide emotional support for women before and during childbirth, and a qualified independent midwife were called but arrived too late.

The baby's father told The Sun-Herald the doulas had told him the baby was stillborn due to an infection contracted inside the womb.

He said: "Would the baby have lived had we been in hospital? I have no idea. The suspicion is that there was an infection prior to birth. I'm told it was a freakish occurrence that happens one in a thousand cases."

The man said his wife was "in a very bad way"...

One of the doulas present at the birth said: "I can assure you, this wasn't home birth-related. There was an infection a long time before."

So let me get this straight. The baby died from a long standing infection, but she's sure that has nothing to do with the homebirth? Does she think they wouldn't have noticed this at the hospital? Does she think they wouldn't have treated it? Does she think that they wouldn't have monitored the baby during labor and waited to find out it was dead when it was finally born, as she did?

If the baby died of infection, the likely cause is group B strep sepsis. In that case, it almost certainly was treatable, and very likely preventable.

How can homebirth providers learn anything when they won't take responsibility for their own disasters?

PTSD after homebirth

2008-09-15T15:22:00.002-04:00

MDC recently inaugurated a new message board about birth trauma. In very short order at least 3 stories of PTSD after homebirth were posted. According to homebirth advocates, that is not supposed to happen. It is not birth itself that leads to trauma, it is the way that birth takes place in hospitals that traumatizes women. Wrong again!

Two stories about birth trauma involve the intense pain associated with labor. The first mother wrote:

My son's labor was beyond painful. I really cannot come up with words to describe the horrible pain I experienced... I felt like I was screaming the whole time. My MW called it vocalizing but it felt like screaming to me, if that makes sense. It was horrible...

... I am a doula and a MW's assistant, and a childbirth educator. I hardly know anyone who has had this kind of experience at a homebirth. I feel uncomfortable even talking about it. It is not supposed to be this way. I thought my endorphins were supposed to kick in and help.

According to the second mother:

DS is 2 weeks old, and I cry everytime I talk about the birth. My first labor and birth were long and intense, but very wonderful... With this birth, it was so painful. SO painful... During the 4 hours before pushing, I never stopped vocalizing, even tho my mw kept telling me to be quiet and "give my voice a rest." I couldn't, it hurt too much.

I'm also traumatized by the treatment I received. The first vag exam I received made me sob and scream and when I asked the mw why it hurt so bad she didn't answer me. By the second exam I was terrified of my mw touching me, and during pushing she held back a cervical lip and I begged her to get her hands out of me...

I too am a doula and birth assistant. I expected this birth to go "easier" and "smoother" than the first birth. That was my only expectation. Obviously a bad one, but everyone including the mws told me to expect an easier time now that my body knew what it was doing.

I'm impressed by the willingness of these women to break the MDC taboo that homebirths are empowering and that birth trauma is inevitably the result of medical staff as opposed to the birth itself.

The third mother wrote about her near death from postpartum hemorrhage after a UC (Latest on MDC: massive maternal hemorrhage). Now, ironically, her despair is intensified by the reaction of other women:

... I lost the entire blood volume of one person in 40 minutes. Most people don't seem to get this. They tell me how common it is to hemorrhage, because it happened to their mother, sister, friend, etc. When that happens, I feel extremely minimized. Like it's no big deal to lose all that blood, when it really is. The term hemorrhage means anything over a few cups (or maybe even one cup? I can't remember without looking it up). I lost 6-7 liters.

MDC members have a penchant for discounting the bad experiences of other women (On MDC: making fun of women whose babies might have died). They simply will not believe anyone whose birth experience does not follow the approved narrative. As this mother shows, the unwillingness of other women to accept the reality that bad things can and do happen during birth has added to her frustration and despair.

In all three cases illustrate that birth trauma is about birth itself, not about the medical professionals involved with birth. Birth is both agonizing and dangerous. Unfortunately, homebirth advocates like to pretend otherwise, and that pretending adds to their misery when things do not go as planned.

How do we know a substance works?

2008-09-13T10:11:00.002-04:00

I often assert that most of "alternative" medicine is a scam. It doesn't work, and it is simply a way to part gullible people from their money. How do I know? I know that it is a scam because the various substances and techniques of "alternative" medicine have never been subjected to investigation for either efficacy or safety. Lay people generally do not realize that there are entire branches of science devoted to determining whether substances and techniques work and whether they are safe. Let's look at therapeutic substances (medications, chemicals, herbs) to see what I mean.

How do we decide if a substance works? Lay people are often confused on this point. They assume that if a person ingests a substance, and then feels better, that means the substance "worked". Those with a little more sophistication understand that anecdotes are not enough because the placebo effect will always lead to some proportion of people feeling better even if the substance didn't work at all.

Anyone with minimal understanding of basic science and statistics knows that the randomized control trial, and statistically significant results are required to determine efficacy. However, most laypeople do not realize that the RCT and statistically significant results are the tip of the iceberg. There is much more to determining substance efficacy, dosage and safety than successfully demonstrating a difference in an RCT.

The study of drug efficacy and safety is pharmacology. Pharmacology can be roughly divided into two areas: pharmacodynamics, how the substance acts on the body and pharmacokinetics, how the body acts on the substance. These lecture notes provided a more detailed description. In brief:

In order for a drug to work, it must enter the body and somehow be distributed in such a way that it gets to its site of action. In most cases the site of action is a macromolecular "receptor" located in the target tissue. Most drug effects are temporary, because the body has systems for drug detoxification and elimination.

Here are some basic questions that must be answered to find out how the drug works on the body:

[Mechanism of Action.] Agonist is a drug which binds to its "receptor" and produces its characteristic effect... An antagonist binds to the receptor without causing an effect, thereby preventing an active substance from gaining access...

Dose-Response. The sine qua non of drug effect. Simply put, as the dose of drug increases, the response should increase...

ED50. The median effective dose, or the dose which produces a response in 50% of subjects...

Efficacy. Also called Maximal Efficacy or Intrinsic Activity. This is the maximum effect of which the drug is capable...

Therapeutic Window. For every drug, there exists some concentration which is just barely effective (the Effective Concentration) and some dose which is just barely toxic (the Toxic Concentration). Between them is the therapeutic window where most safe and effective treatment will occur...

These are some basic questions that must be answered to show how the body interacts with the substance:

[How does the substance enter the body?] The drug may enter the body in a variety of ways: as an oral liquid, pill, or capsule; as an inhaled vapor or aerosol; absorbed through intact skin or a mucous membrane; injected into muscle, subcutaneous tissue, spinal fluid, or directly into the bloodstream...

[How does the substance get absorbed into the circulation?] ...If it is absorbed from the skin, mouth, lungs or muscle it will go directly into the systemic circulation. If drug is injected directly into the bloodstream (e.g., intravenous injection), 100% of it is available for distribution to tissues. This is not usually the case for other modes of administration. For example, drug which is absorbed via the portal circulation must first pass through the liver which is the primary site of drug metabolism (biotransformation). Some of the drug may therefore be metabolized before it ever reaches the systemic blood...

[What happens to the substance in the circulation?] Once the drug is in the bloodstream a portion of it may exist as free drug, dissolved in plasma water. Some drug will be reversibly taken up by red cells and some will be reversibly bound to plasma proteins... [This] is also important because protein-bound drug can act as a reservoir which releases drug slowly and thus prolongs its action.

[How is the substance distributed around the body?] The unbound drug may then follow its concentration gradient and distribute into peripheral tissues. In some cases, the tissue contains the target site and in others the tissue is not affected by the drug. Sites of non-specific binding act as further reservoirs for the drug...

[How is the substance removed from the body?] ... The liver metabolizes most drugs into inactive or less active compounds which are more readily excreted. These metabolites and some of the parent compound may be excreted in the bile and eventually may pass out of the body ...

Parent drug and metabolites in the bloodstream may then be excreted: most are filtered by the kidney, where a portion undergoes reabsorption, and the remainder is excreted in the urine... Smaller amounts of drug are eliminated in the sweat, tears and breast milk...

This brief overview demonstrates that determining drug efficacy and safety is complex. An RCT with statistically significant results can demonstrate that a substance has an effect, but that is just the starting point. It is absolutely imperative to determine the pharmacodynamics and pharmacokinetics of a substance before you can claim that it is effective and safe. When it comes to herbs and other substances used in "alternative" health, these questions have usually not even been asked, let alone answered.

Uterine rupture on MDC

2008-09-10T16:23:00.002-04:00

Someone should charge these women with criminal stupidity. The folks on MDC were heedlessly encouraging a mother in her pursuit of a VBA4C. Yes, you read that correctly, a VBAC after FOUR previous C-sections. Her "plan" was to labor at a hotel near the hospital and present at the hospital when she was ready to push. Instead she ruptured her uterus (she felt it). At the time of the emergency C-section, the baby was unexpectedly found to be breech. Fortunately, neither she nor the baby was harmed, but that was just a matter of luck. This mother took a completely irresponsible risk, but at least she did not pay the ultimate price.

Despite all this, she still doesn't get it. She is bemoaning her loss of confidence. Loss of confidence in what? Was she supposed to have confidence in her scar integrity? Was confidence supposed to make a difference?

I so wanted to, I did everything I thought of. I didn't include my ob in my plans because I didn't want them to drop my care- looking back, I might include them in my plans at the last minute. I decided I was not going to change the system so I would go ahead and do what I need to for me and fill them in when they need to know. It caused quite the panic in the OR and I regret that I put them through that. They are after all human and mean well. Also, I would have gotten a last minute u/s to verify baby position. Hindsight...

The folks at MDC really need to reexamine what they are doing to women. Why are they encouraging them to risk their lives? Why are they encouraging them to risk their babies lives? Why are they encouraging women to judge themselves by whether a baby passed through their vagina? Why are they undermining their self confidence and self image by perpetuating unrealistic "ideals" of birth? Who is being served by this irresponsible behavior? How many disasters and deaths will it take before they come to their senses?

Extended breastfeeding support does not improve breastfeeding rate or duration

2008-09-09T07:53:00.003-04:00

Lactivists refuse to acknowledge that many women do not breastfeed because they do not want to do so, or because it is incompatible with other responsibilities like paid work. It's not because they don't understand the benefits of breastfeeding; it's not because they lack breastfeeding support; they just don't want to do it. A recent study in the journal Midwifery demonstrates that a program of extended breastfeeding support has no impact on rates or duration of breastfeeding.

Effect of an extended midwifery postnatal support programme on the duration of breast feeding: A randomised controlled trial reports the results of a randomized controlled trial involving 849 women who had given birth to a healthy, term, singleton baby and who wished to breast feed. This is a critical point. The authors were not trying to influence the behavior of women who did not intend to breastfeed; they were trying to support the efforts of women who wanted to breastfeed.

According to the authors:

...[P]articipants were allocated at random to EMS, in which they were offered a one-to-one postnatal educational session and weekly home visits with additional telephone contact by a midwife until their baby was six weeks old; or standard postnatal midwifery support (SMS). Participants were stratified for parity and tertiary education.

The study revealed:

there was no difference between the groups at six months postpartum for either full breast feeding [EMS 43.3% versus SMS 42.5%, relative risk (RR) 1.02, 95% confidence interval (CI) 0.87–1.19] or any breast feeding (EMS 63.9% versus SMS 67.9%, RR 0.94, 95%CI 0.85–1.04).

The authors concluded:

the EMS programme did not succeed in improving breast-feeding rates in a setting where there was high initiation of breast feeding. Breast-feeding rates were high but still fell short of national goals.

Are C-section mothers less responsive to baby's cry?

2008-09-07T11:21:00.002-04:00

You may have read recently about the widely publicized study by Swain and colleagues claiming that mothers who had C-sections respond to their baby’s cry differently than mothers who had vaginal deliveries (Maternal brain response to own baby-cry is
affected by cesarean section delivery). The study shows nothing of the kind, and the authors have been utterly irresponsible in the way that they have publicized their findings.

The study itself suffers from so many serious problems that it is hard to know where to begin. At a minimum we can say: The study is too small to draw any conclusions, let alone the conclusions drawn by the authors. We don’t know if there is any validity to the image of brain activity that the authors were looking at. There is no evidence that this image is correlated in any way with maternal care taking.

These problems are easier to under stand in the following thought experiment:

Suppose I asked my children to toss coins. My son tossed a coin 6 times and got 6 heads, and my daughter tossed a coin 6 times and got 6 tails. Then suppose I wrote a study claiming that gender determines whether a coin lands heads or tails. Wait a minute, you’d say, your study doesn’t prove anything, and you’d be right. My study would prove nothing for the exact same reasons that the Swain study proves nothing.

First, my study, like the Swain study, is underpowered. I haven't included enough coin tosses for my son or my daughter. We know from probability theory that if I repeated the experiment with my son tossing the coin 6000 times and my daughter tossing the coin 6000 times, they would get the exact same proportion of heads to tails; they would both get 50:50. My results are not valid because I didn’t include enough coin tosses.

Swain and his co-authors looked at the brain imaging patterns of 6 women who had vaginal deliveries and found that they were different from the 6 women who had C-sections. Just like the heads-tails study, the results could simply reflect the fact that the study is far too small.

Second, drawing the conclusion in my coin experiment that gender determines the result of a coin toss rests on the assumption that correlation equals causation. However, we know from the rules of statistics that correlation does not demonstrate causation. Correlation means that two events appear to be related. Causation means that one event caused the other. In my coin toss experiment, gender and coin toss result appeared to be correlated, but that does not mean that gender caused the coins to land heads or tails. It was just a coincidence.

Similarly, in the Swain study, the two different modes of birth appeared to be correlated with brain image, but that does not mean that the mode of birth cause the specific brain image pattern. It could just have easily been coincidence.

Third, my study claiming that gender determines the result of a coin toss would have rest on another flawed assumption, that there is something fundamentally different, beyond appearance, between a coin landing heads and a coin landing tails. In reality, though, there is no difference; it’s just a matter of chance whether a coin lands heads or tails.

Similarly, Swain and colleagues have made a seriously flawed assumption that the two different brain image patterns they observed reflect a fundamental difference in the actual reaction of the mother, not just a matter of chance. In reality, the authors present no evidence that the brain image pattern has anything to do with the mother’s response to her baby’s cry.

This study shows nothing. It could potentially represent an interesting finding that deserves more investigation, or it could be entirely the result of chance. It is extremely irresponsible for the authors to claim that they showed that mode of delivery determines a mother’s response to an infant. It is no better than a coin toss study claiming that gender determines the result of a coin toss.

Homebirth advocacy is obnoxious and vicious

2008-09-03T20:46:00.003-04:00

Homebirth and "natural" childbirth advocates get a real charge out of demeaning other women. Sometimes I think that is the whole point, making themselves feel good by making other women feel bad. In short, they are bullies. What is even more appalling is that homebirth providers, who can't figure out why no other medical professionals takes them seriously, are simply professional bullies.

It's not like this is news to me, but every now and then I come across something that is so breathtakingly cruel that I am shocked. That's the feeling that I got when I first read Michel Odent's obnoxious lie that women who don't have painful labor don't bond to their children. That's the feeling that I get when I read this piece of garbage posted by Red Pomegranate, who purports to be a nurse, doula and midwife wanna be.

I'm not going to link to it. I'm sure it will be easy to find. It is the work of a "mean girl". You know the kind, the ones who cannot feel good about themselves unless they hurt someone else.

Red Pomegranate's post manages to epitomize the most distasteful aspects of homebirth advocacy: the nastiness, the self congratulation, the looking down on other "uneducated" women, the complete unwillingness to acknowledge that other women's choices are equally valid. Red Pomegranate is undoubtedly proud of herself for her little humor piece. Instead, she should be embarrassed. I'm simply disgusted.

WHO 2007 report on long term effects of breastfeeding

2008-09-03T00:02:00.004-04:00

Lactivists are incensed when anyone points out that although the benefits of breastfeeding are real, they are actually relatively small. Perhaps they will believe the World Health Organization.

Evidence on the long-term effects of breastfeeding was published by the WHO in 2007. It is a comprehensive 52 page study, Evidence on the long-term effects of breastfeeding, by Horta et al. According to the authors:

...[T]here is some controversy on the long-term consequences of breastfeeding. Whereas some studies reported that breastfed subjects present a higher level of school achievement and performance in intelligence tests, as well as lower blood pressure, lower total cholesterol and a lower prevalence of overweight and obesity, others have failed to detect such associations.

Objectives: The primary objective of this series of systematic reviews was to assess the effects of breastfeeding on blood pressure, diabetes and related indicators, serum cholesterol, overweight and obesity, and intellectual performance.

The authors reviewed the existing scientific literature on 5 specific claims.

1. Does breastfeeding leader to lower blood pressure?

The authors reviewed two meta analyses and three studies:

According to Owen et al, the association between breastfeeding and lower blood pressure was mainly due to publication bias, and any effect of breastfeeding was modest and of limited clinical or public health relevance. In spite of not being able to exclude residual confounding and publication bias, Martin et al concluded that breastfeeding was negatively associated with blood pressure. They argued that even a small protective effect of breastfeeding would be important from a public health perspective... Three large studies were published since the last review, two of which found no association and one found a protective effect of
breastfeeding.

Both meta-analyses may have been affected by publication bias... Lack of control for confounding is another methodological issue, as pointed out by Martin et al...

In summary, the present updated meta-analyses show that there are small but significant protective effects of breastfeeding on systolic and diastolic blood pressure. Publication bias is unlikely to explain this finding because a significant protective effect was observed even among the larger studies. However, residual confounding cannot be excluded because of the marked reduction in effect size after adjustment for known confounders.

2. Does breastfeeding lead to lower cholesterol levels?

[N]o significant effect was observed in children or adolescents, mean cholesterol levels among adults who were breastfed were 0.18 mmol/L (6.9 mg/dl) lower than among non-breastfed subjects... [T]he observed reduction associated with breastfeeding corresponds to about 3.2% of [the] median.

3. Does breastfeeding reduce the risk of overweight and obesity?

The evidence suggests that breastfeeding may have a small protective effect on the prevalence of obesity. In spite of the evidence of publication bias, a protective effect of breastfeeding was still observed among the larger studies (>1500 participants),.. This effect seems to be more important against obesity than against overweight.

Because the great majority of the published studies were conducted in Western Europe and North America, we are not able to assess whether this association is present in low and middle-income settings.

4. Does breastfeeding lower the risk of type 2 diabetes?

Evidence on a possible programming effect of breastfeeding on glucose metabolism is sparse. Studies assessing the risk of type-2 diabetes reported a protective effect of breastfeeding, with a pooled odds ratio of 0.63 (95% CI: 0.45–0.89) in breastfed compared to non-breastfed subjects. On the other hand, two other studies failed to report an association between HOMA index, a measure of insulin resistance, and breastfeeding duration, and a study on fasting blood glucose levels was also negative. At this stage, it is not possible to draw firm conclusions about the longterm effect of breastfeeding on the risk of type-2 diabetes and related outcomes...

5. Does breastfeeding raise the level of school achievement or intelligence?

This meta-analysis suggests that breastfeeding is associated with increased cognitive development in childhood, in studies that controlled for confounding by socioeconomic status and stimulation at home. The practical implications of a relatively small increase in the performance
in developmental tests in childhood may be open to debate. However, evidence from the only three studies on school performance in late adolescence or young adulthood suggests that breastfeeding is also positively associated with educational attainment.

The issue remains of whether the association is related to the properties of breastmilk itself, or whether breastfeeding enhances the bonding between mother and child, and thus contributes to intellectual development. Although in observational studies it is not possible to disentangle these two effects, the positive results from the randomized trial carried out by Lucas et al suggest that the nutritional properties of breastmilk alone seem to have an effect.

In the case of these five longterm outcomes, the existing scientific evidence shows that breastfeeding has either no benefit or a small benefit.

Willingness to accept risk; patients vs. clinicians

2008-08-31T09:43:00.002-04:00

A study in tomorrow's British Journal of Obstetrics and Gyaecology has been receiving a lot of press. Unfortunately, the study is grossly underpowered, poorly conducted, and the authors misinterpret their own results. The study is Vaginal delivery compared with elective caesarean section: the views of pregnant women and clinicians. The authors interviewed women expecting their first baby as well as a variety of clinicians (obstetricians, midwives, urogynecologists and colorectal surgeons). The authors claim to have found that patients and midwives were much more willing to tolerate risk of serious adverse outcomes than obstetricians, urogynecologists and colorectal surgeons.

The technical problems with the study are rather straightforward and call the validity of the results into question. There are very few participants in the study [Nulliparas (n = 122), midwives (n = 84), obstetricians (n = 166), urogynaecologists (n = 12) and colorectal surgeons (n = 79)], too few for any meaningful results. In addition, the recruitment process for pregnant women introduced bias into the sample; women who did not speak fluent English were barred from participating in the study, as were women who were obese, had underlying medical conditions, or pregnancy complications. Of 193 women who were approached for the study, 58 refused to participate and 30 additional women were subsequently excluded.

The authors introduced further bias providing their view of the complications of C-section:

A detailed explanation of caesarean section and its possible complications (major abdominal surgery, anaesthesia requirements, wound pain and need for more analgesia, decreased mobility, longer hospital stay, inability to drive for 6 weeks; increased risk of uterine, pelvic and bladder infection, wound breakdown, blood loss, transfusion, thrombosis; potential risks in future pregnancies, placenta accreta, uterine scar rupture; and neonatal respiratory problems with potential neonatal intensive care unit admission, jaundice, and temporary feeding difficulties)...

The authors do not reveal whether women were provided with information about the incidence of these complications, or merely told that they could occur.

The study participants were presented with a variety of complications of vaginal delivery, and asked to quantify the amount of risk they were willing to accept for each specific complication before they would abandon vaginal delivery in favor of elective C-section. Clinicians were asked the same questions, but were instructed to respond as if they or their partner were the pregnant patient. In virtually every category, both patients and midwives expressed a higher tolerance than obstetricians, urogynecologists and colorectal surgeons for accepting complications of vaginal delivery rather than choosing an elective C-section.

The authors offer this interpretation of their findings:

Our findings demonstrate that women are able to quantify the risks of VD they would be prepared to accept before they would request an elective caesarean section. Compared with clinicians, pregnant women tend to have a much higher threshold for the potential complications of VD, especially those associated with the pelvic floor. Anal incontinence was the potential complication with the lowest utility score for pregnant women. All groups ranked pelvic floor problems fourth of the top five reasons for preferring an elective caesarean section over VD. Pregnant women’s views more closely resembled those of midwives than those of other clinicians...

The caesarean section rate has risen in most developed countries over the past 10–15 years partially because of maternal request and lower thresholds among physicians
to perform the operation due to increasing levels of litigation. Florica et al. found an increase in caesarean section over a 5-year period to be due to suspected fetal distress, maternal request and labour dystocia. Our study demonstrates
that low-risk obstetric women are more accepting of many of the risks of VD than clinicians. However, when faced with the alternative choices of potential severe
complications either for themselves or for their baby from VD, many will preferentially choose delivery by caesarean section...

We have shown that both pregnant women and clinicians are able to quantify the different levels of potential risks (utility scores) they would be prepared to accept before requesting an elective caesarean section, while being aware of the potential complications of elective caesarean section.

Actually, they've shown nothing of the kind. First of all, the authors failed to include main complication that elective C-section is typically used to prevent: injury to the baby. They only looked at willingness to accept risk of specific maternal complications of vaginal delivery.

Secondly, and far more important, they showed that people with little or no experience of bad outcomes (women and midwives) were more willing to accept the risks of complications they had never seen than clinicians who were directly acquainted with those complications. That does not tell us anything about their tolerance of risk, it merely tells us about their understanding of risk.

This study reminds me of studies that compare teen driver and adult driver tolerance for risk during driving. According to studies like Hazard and Risk Perception among Young Novice Drivers:

Research indicates that young drivers underestimate the risk of an accident in a variety of hazardous situations. At the same time, they overestimate their own driving skill. Young drivers are also more willing to accept risk while driving than experienced drivers.

The willingness of teenagers to accept risk tells us nothing about their willingness to accept poor outcomes, it only tells us that they do not have a mature understanding of the risks.

Similarly, this study does NOT indicate that women are more willing to accept the complications of vaginal delivery than clinicians. It tells us that women do not have any basis for understanding the risks. Unless and until the authors can demonstrate that women and midwives who do have experience with the specific complications are willing to accept those complications, they've told us nothing.

Different cultures initiate breastfeeding at different times

2008-08-30T15:16:00.001-04:00

A cornerstone of midwifery practice is that it attempts, as far as possible, to recapitulate nature. Actually, as we have discussed here many times, it does no such thing (Birth Fantasyland). Instead, it has simply created a new set of cultural constructs.

One of these cultural constructs is that breastfeeding must be initiated within the first hour after birth in order to be successful. The claim is that breastfeeding in nature is initiated almost immediately. However, an interesting cross cultural study shows that not only are there is great variation across cultures in the timing of breastfeeding initiation, there are two predominant patterns, one of early initiation (in the first several hours) and one of late initiation (after several days). The paper is Patterns for the Initiation of Breastfeeding in Humans by Holman and Grimes, Am. J. Hum. Biol. 15:765–780, 2003.

The authors start with a hypothesis that there is one "natural" time for the initiation of breastfeeding:

In this article we examine cross-cultural behavior in the initiation of breastfeeding. An attempt is made to uncover general patterns for the initiation of breastfeeding that are common to all humans... In short, this approach asks the following hypothetical question: If we could eliminate the effects of culturally mediated changes in the initiation of breastfeeding, how much time would elapse between parturition and initiation of breastfeeding? We expect that there exists an underlying distribution of times to initiation of breastfeeding that is shared by all Homo sapiens. Culturally mediated decisions on initiation of breastfeeding in contemporary humans may ordinarily mask some underlying pattern of natural breastfeeding.

After examining 25 separate studies comprising more than 25,000 mother-infant pairs from a variety of countries and cultures the authors found something unexpected. The paper is very complicated and the mathematical modeling is very arcane, but the basic point it this: the authors expected to find that breastfeeding was "naturally" initiated relatively shortly after birth, with the only exception being late initiation prescribed by particular cultural mores. In other words, when graphing initiation of breastfeeding by culture, each culture would have some pairs who initiated breastfeeding immediately, and some pairs who initiated breastfeeding at a culturally prescribed time, unique to each culture.

... [M]uch variation is found among cultures in the onset of breastfeeding. Cultural attitudes about the acceptability of colostrum are one important component that affects a mother’s decision about when to begin breastfeeding. In many settings, colostrum is viewed as harmful to the health of newborns; some women routinely delay breastfeeding for several days postpartum until a more mature breastmilk is expressed. Other culturally mediated factors that play a role in determining when a child is first breastfed include ... prelacteal feeding rituals.

Much to their suprise, the authors found that in every culture they studied, there were both early and late initiation pairs, but both early and late initiation did not vary across cultures. Some mother infant pairs initiated breastfeeding within the first several hours, while others initiated breastfeeding at approximately 66 hours postpartum, presumably coinciding with the production of true milk.

Every culture had a substantial proportion of mother-infant pairs who initiated breastfeeding almost 3 days after birth. The authors believe that this demonstrates that there are two distinct "natural" behaviors that are compatible with successful breastfeeding.

The results presented here strongly suggest that there are two distinct behavioral patterns in the timing of the initiation of breastfeeding. We began with a model in which the first subgroup represents a "natural" behavioral pattern, which might reflect a more general mammalian behavior expected to occur in the absence of culturally mediated changes in the onset of breastfeeding. If this first component were purely instinctual, then we would expect that it would not be affected by cultural covariates. Yet many of the covariates had some effect on this first component, some that caused substantial delays in time to onset of breastfeeding. We interpret this to mean that the behavior captured in the first component of the model is more complex than simply instinct. Contrary to a dichotomy of pure instinct for the first component and purely culturally mediated behaviors for the second, the results suggest that the first component is composed of both preprogrammed and culturally mediated behaviors directed toward the newborn.

The authors are not suggesting that breastfeeding initiation be deliberately delayed. They are simply pointing out that existing cross-cultural evidence does not support the claim that breastfeeding is "naturally" initiated in the first hours after birth.

The impact of C-section on women who are not part of the NCB culture

2008-08-27T08:27:00.004-04:00

I came across a relatively old article that discusses a number of themes that I have stressed. Cesarean Birth Outside the Natural Childbirth Culture was published in Research in Nursing and Health in 1986. It highlights the fact that "natural" childbirth is a philosophy that is not universal, but rather the product of a particular subculture. It points out that "natural" childbirth emphasizes process over outcome, and it concludes that C-section itself is not particularly emotionally traumatic, but has the power to be traumatic among women schooled in the rhetoric of "natural" childbirth.

The authors do an excellent job of describing the philosophical underpinnings of natural childbirth:

There is a new emphasis on cesarean birth as a psychosocial rather than a surgical event. Since the mid-l970s, a small body of literature has emerged describing the negative "soft" outcomes of what is increasingly viewed as the "unkindest cut of all".

Women experience cesarean birth not only as a somatic wound, but also as a psychic one; women who have cesarean births are literally and figuratively scarred. This psychosomatic wounding of women may impact on infants, fathers, and families.

A notable feature of the literature describing the negative psychosocial consequences of cesarean birth is its emphasis on a particular group of women. Specifically, this literature emphasizes the values, expectations, and experiences of women who belong to what can loosely be termed the "natural childbirth culture". For women interested in natural childbirth, typically from the middle classes, the experience of birth is an end in itself, and cesarean birth is a devastating interference with nature.

In other words, "natural" childbirth philosophy does not represent universal truths; it is merely a reflection of the cultural pre-occupations of subset of Western, white, middle class women.

The authors are concerned that "natural" childbirth advocates spend a lot of time studying themselves, as if they are representative of women as a whole. The authors are concerned that the values, expectations and reactions of women outside the charmed circle of NCB advocates are simply being ignored. The basis of this study is open ended interviews with 50 women who were medically indigent. In contrast to NCB advocates, the interviewees were predominantly African-American, of limited economic means, and of limited educational achievement.

When discussing the births, the interviewees were very unlikely to refer to standard NCB tropes like "normal" birth or empowerment.

The women viewed cesarean birth as similar to and different from, as well as better and worse than, vaginal birth... The women described vaginal, or what they called "natural" or "regular" birth in terms of physical features and sensations, normality, and mastery... Only 4 women expressed the normality theme in such comments as: "the way other people have children," "normal," "coming out the way it’s supposed to come," and "more like a woman." Only 3 women expressed the mastery theme in such remarks as having the baby "by my own body movements" and "having it yourself."

Not surprisingly, since the women were not particularly concerned with concepts of normality or mastery, their responses to cesarean were very different from those associated with NCB advocates.

... In contrast to published reports of women agonizing over what might have been and blaming themselves for constitutional and emotional flaws, the majority of women accepted the cesarean as fate, and a few managed to display pride in themselves.

The women emphasized the outcomes of birth rather than the process of birth, and frequently rated those outcomes high despite complaints about the process... Childbirth literature, oriented to the middle class model of childbirth, increasingly emphasizes the process of birth as separate from its outcomes. Women suffer when the birth process itself is not as imagined or desired. While failed expectations concerning the birth process is a major theme in the natural childbirth culture, the women in this study had few expectations or clear imaginings concerning birth-giving, and as a consequence were less likely to be disappointed. In fact, neutrality or an "it’s OK" feeling prevailed over intense joy or intense sorrow...

The authors conclude:

Despite its limitations, the study raises key questions about ways of coping and helping in childbirth. The findings suggest a model of childbirth other than the middle class model that emphasizes choice, control, preparation, self-reliance, and nature. Indeed, for the women who equalized vaginal and cesarean birth, natural childbirth is indistinguishable from cesarean birth...

The critical finding of this study is that it is not the experience of C-section itself that leads to disappointment, feelings of failure, and psychic "wounding". Rather it is the expectations encouraged by NCB philosophy that lead to these negative outcomes.

There is nothing objectively "better" about having a vaginal delivery; only women who have been socialized to believe that vaginal delivery is best are disappointed when the baby is born by C-section instead. There is no objective reason to promote the process of birth as something separate from and equally or more important that the outcome of birth. Only women who have been socialized to believe that "choice, control, preparation, and self-reliance" are paramount actually believe that those factors are important.

All of which raise the question: who is being served by the philosophy of natural childbirth? Obviously the "natural" childbirth industry is served by maintaining a set of values that must be taught through books that must be read, and classes that must be taken, and assistants who must be hired.

How about women giving birth? How are they being served by the socially constructed expectations of "natural" childbirth? Those who managed to achieve the socially constructed aims are granted a faux "achievement" that they can point to and use to denigrate other women. However, that is realized only at the price of setting unrealistic expectations virtually guaranteed to result in feelings of disappointment, failure and psychic "wounding" in a large proportion of women. Clearly "natural" childbirth is beneficial for the natural childbirth industry. It's difficult to see, though, how it is beneficial for women.

Evidence based practice?

2008-08-25T20:22:00.004-04:00

Homebirth advocates are always prattling about evidence based practice, and yet the practices that are most closely associated with homebirth midwifery have no evidence to support them. The following are axiomatic in homebirth midwifery today:

eating in labor
moving during labor
squatting at birth
delayed cord clamping.

Amazingly, not one of these practices is supported by the weight of scientific evidence. What is especially amusing is that organizations such as Lamaze go to the trouble of publishing papers that claim to support a particular practice, but actually do no such thing.

Consider what passes for "evidence" for Care practice #2: Freedom of Movement in Labor:

In fact, no woman who participated in any of the research studies said that she was more comfortable on her back than in other positions (Simkin & Bolding, 2004). No study has ever shown that walking in labor is harmful in healthy women with normal labors (Storton, 2007). One study published in The New England Journal of Medicine in 1998 did not find that women who walked had shorter labors; however, the women in the study who walked were so satisfied that 99% of them stated that they would like to walk again during future labors (Bloom et al., 1998).

In other words, no research has demonstrated any benefit, but none has demonstrated any harm. If the only thing to recommend a particular practice is that it doesn't harm anyone, should it really be elevated to a cornerstone of care? I'm not suggesting that women shouldn't be allowed and encouraged to move freely in labor, but based on the scientific evidence, it does not appear to make any difference.

How about Care Practice #5: Spontaneous Pushing in Upright or Gravity-Neutral Positions. Once again this is a cornerstone of contemporary homebirth midwifery practice, and once again there is no evidence to support it:

According to the Cochrane Pregnancy and Childbirth Group, a respected international organization that defines best practices based on research, the use of any upright or side-lying position, compared with supine or lithotomy positions (lying on back, legs supported by stirrups), is associated with the following results:

* shorter second stage of labor;
* a small reduction in vacuum or forceps-assisted birth;
* fewer episiotomies;
* less chance that the woman will report severe pain;
* fewer abnormal fetal heart rate patterns;
* a small increase in second-degree lacerations (in the upright group only); and
* an increase in estimated blood loss, although there was no evidence of serious or long-term problems from the extra blood loss (Gupta, Hofmeyr, & Smyth, 2004).

In other words, it really makes no difference.

As I have discussed in the past, there is no evidence that eating in labor improves labor outcomes and there is evidence that it increases the risk of maternal death from the rare complication of maternal aspiration. Also, as I have discussed in the past, there is no evidence that delayed cord clamping provides any benefit except perhaps in premature babies, who are prone to anemia. Indeed, there is evidence that active management of the third state of labor, which includes early cord clamping, improves maternal outcomes by decreasing the risk of postpartum hemorrhage.

Claiming that at least it doesn't harm anyone, or if it harms someone it only does so occasionally, is hardly an evidence based justification for these practices that are integral to contemporary homebirth midwifery.

Natural childbirth advocate sued for recommending vaginal breech delivery

2008-08-23T16:52:00.001-04:00

From UPI:

Dr. Yehudi Gordon is known for advocating natural childbirth. Elizabeth Hammond claims he advised her she could have natural childbirth even though her fetus was in breech position and other doctors had advised a Caesarean section.

James Hammond, now 16, was later diagnosed with severe brain damage and cerebral palsy, The Telegraph reports.

A High Court writ says Gordon admits responsibility for James Hammond's injuries. But his lawyers and those representing the mother have been unable to agree on how much compensation should be paid.

Homebirth midwifery: missing the point

2008-08-23T14:44:00.004-04:00

I have written about Homebirth: A Midwife Mutiny, Lisa Barrett's website, before (A homebirth midwife has a problem). Every time I think I cannot read anything more ridiculous from a homebirth midwife, I am proven wrong. Consider this gem in response to a news story about the tragic death of a premature baby born during an airplane flight:

I hope the baby was stillborn at 34 weeks and they didn't cut the cord creating the problem. If the baby was still born why would they try to cut the cord even if they felt it was the right thing for a live born? You'd think they would all be too upset to worry about that.

I hope that they post explaining what really happened. It goes to show the lack of knowledge surrounding the third stage in general and the ridiculous belief that after the baby is born you MUST get that cord cut. How we have forgotten about physiological birth in the rush to try and get rid of risk and control it.

Barrett appears to be suggesting that death from prematurity can be prevented by delayed cord clamping. This is absolutely mind boggling.

First of all, to the extent that there is any benefit to delayed cord clamping, it is in preventing anemia of prematurity. To my knowledge, there is no scientific evidence showing that delayed cord clamping is a treatment for hypoxia, let alone prolonged hypoxia.

Second, even if delayed cord clamping were to decrease hypoxia, the placenta stops functioning and is expelled in a matter of minutes.

Third, if delayed cord clamping is a treatment for prematurity, why did the overwhelming majority of premature babies die before the advent of modern medicine?

Talk about willful ignorance. If the baby did die from prematurity, it died because there was no equipment or personnel available to perform an expert resuscitation. In fact, the baby died in exactly the same way that a homebirth baby needing an expert resuscitation would die. This is the part that homebirth midwives cannot seem to absorb. Their techniques and fetishes (like delayed cord clamping) DON'T improve neonatal mortality. Homebirth INCREASES neonatal mortality; it doesn't lower it.

On MDC: Making fun of women whose babies might have died

2008-08-19T10:37:00.003-04:00

Here is an excerpt from a typical MDC post, typical because of its ignorance, arrogance and sanctimony.

I'm reading an article about freebirthing and in the comments, I have seen no less than ten women declaring that without a C-section/doctor/vacuum/whatever, both they and their baby would have died. Why is every woman who ends up with a complication so absolutely certain that (1) they AND their baby would definitely have died, (2) there would have been absolutely nothing that could have been done to help them at home, and (3) the midwife would never have suggested transfer to the hospital because it's a HOME birth. I'm getting SO irritated with the attitude that homebirthers (UCers especially) are just so dead-set on the comforts of home that they won't go to the hospital no matter what and that it's all about their comfort, since we all know it's safer for the baby in the hospital...

How selfish do they think we are? Yeah, I'm going to have a UC because I don't want a stranger elbow-deep in my yoni. But you know what? That is not the most important thing about having a homebirth. And yes, I know that women used to die in childbirth. People used to die of a lot of things we don't consider serious now - chicken pox for example. Scurvy. Mumps. Anemia. Etc. Yes, if I start developing symptoms of pre-eclampsia, I'm going to the hospital... A healthy baby is the most important thing, which is why we're staying out of the germ-infested hospitals!

Here's a little history to contemplate. In the past 100 years American obstetrics has lowered the neonatal mortality rate 90% and the maternal mortality rate 99%. That means that each and every year over 220,000 babies and over 39,000 mothers are saved who would have otherwise died. So approximately a quarter of a million women EACH YEAR can honestly say that they or their babies might have died in the absence of obstetric technology. That doesn't even count the additional hundreds of thousands who might have had near misses, serious injuries or brain damage in the absence of modern technology.

The inane MDC comment highlights the lack of basic knowledge among homebirth advocates. They live in Birth Fantasyland where childbirth is inherently safe and complications are rare. Hence they immediately disbelieve and even make fun of women who would have certainly died or lost their babies without obstetric technology. In the real world childbirth is inherently dangerous and complications are surprisingly common. That's why so many babies and women died prior to the advent of modern obstetrics and why millions of babies and women continue to die each year in places where modern obstetrics is not available.

Think about it: Almost a quarter of a million lives are saved by modern obstetrics each year. That's a tremendous number of women who can honestly say that if they had not been at a hospital, they or their babies would have died.

Prevention vs. pretending

2008-08-17T23:57:00.002-04:00

One of the most important differences between obstetrics and homebirth midwifery is that obstetrics rests in large part on the idea that preventing obstetric complications is better than treating them. In contrast homebirth midwifery pretends that complications will not occur, and assumes that if they do occur, the patients can be dumped in the emergency room where obstetricians will care for them.

Consider major complications of childbirth. Let's start with hemorrhage. Hemorrhage is one of the most common causes of death in childbirth in places without access to modern obstetrics. In contrast, death from hemorrhage is rare in industrialized countries. Both prevention and treatment are used to reduce the death rate from this common complication. These measures include a hep lock for emergency IV access, a blood sample sent to the hospital lab to be available for immediate cross matching if necessary, multiple medications available to stop hemorrhage (pitocin, ergotrate, hemabate), and IV fluid to prevent shock. Treatment measures are immediately available as well, including transfusion, obstetricians available for manual removal of the placenta if necessary, and for surgical intervention in the event of life threatening hemorrhage that cannot be stopped by other means.

What does homebirth midwifery do to prevent postpartum hemorrhage? Nothing, beyond pretending that it won't happen. There is no IV access, no preparation of blood products (no blood products are even available), only injectable medications to stop hemorrhage (no IV medications), no IV hydration to prevent shock, no one to perform a manual removal of the placenta and no one to undertake surgical intervention.

Another serious complication of childbirth is group B strep sepsis of the newborn. Until preventive measure were instituted, group B strep sepsis was the single most common cause of infectious death among newborns. Obstetricians routinely screen for group B strep, and give IV antibiotics in labor for prophylaxis. The rate of group B strep sepsis has dropped dramatically in response.

In contrast, some homebirth midwives simply pretend that group B strep sepsis won't happen. They don't culture for group B strep, or they don't treat it if they find it. They pretend that the incidence is "too low" to justify preventive care.

A less common cause of neonatal death is breech delivery with a trapped head. Obstetricians try to prevent this outcome by recommending external version to turn the baby to head first position, or C-section to prevent trapped head by preventing breech delivery. Homebirth midwifery simply pretends that trapped heads won't happen. If they do happen, the baby simply dies. There is no time for transport to the hospital and there is no one to perform expert resuscitation if the baby is delivered after a period of entrapment.

Obstetrics tries to prevent complications, homebirth midwifery cavalierly dismisses the possibility of complications or pretends that it is just as safe and easy to treat life threatening complications as it is to prevent them. On this issue, homebirth midwives are dead wrong.

Who practices evidence based medicine, doctors or DEMs?

2008-08-15T09:22:00.003-04:00

Homebirth advocates are fond of claiming that obstetricians do not practice evidence based medicine. That could be a devastating critique, if it were true, so let's investigate whether it is true.

"Evidence based medicine" (EBM) is a specific philosophy of medical care. A 1995 editorial in the British Medical Journal announcing the creation of the journal Evidence-Based Medicine gave this definition of EBM:

... evidence based medicine is rooted in five linked ideas: firstly, clinical decisions should be based on the best available scientific evidence; secondly, the clinical problem - rather than habits or protocols - should determine the type of evidence to be sought; thirdly, identifying the best evidence means using epidemiological and biostatistical ways of thinking; fourthly, conclusions derived from identifying and critically appraising evidence are useful only if put into action in managing patients or making health care decisions; and, finally, performance should be constantly evaluated.

Let's analyze each component individually and determine how closely obstetrics and direct entry midwifery (homebirth midwifery) adhere to each.

1. Clinical decisions should be based on the best available scientific evidence: Notice that the requirement is NOT perfect evidence, simply the best available evidence at the time.

Does obstetrics adhere to this model? Yes, it does. Obstetricians are constantly gathering evidence, testing hypotheses, and using the evidence gathered by themselves and other doctors and scientists to formulate treatment algorithms. Old evidence is constantly being replaced by new and better evidence. Treatment decisions change in response to the new evidence. How important is the role of scientific evidence in obstetrics? It is so important that every obstetrician is expected to follow the scientific literature on a monthly basis. In addition to scientific journals that report the latest studies and evidence, there are journals devoted solely to instructed obstetricians on how to incorporate the latest evidence into clinical practice.

Is direct entry midwifery based on the best available scientific evidence? No. In fact, it is not based on scientific evidence at all. DEMs do no research, test no hypotheses and have no treatment algorithms. There is no scientific evidence in support of virtually any practice exclusive to direct entry midwifery.

2. The clinical problem - rather than habits or protocols - should determine the type of evidence to be sought. Obstetricians base their practice on identifying the clinical problem and treating it. DEMs do not even acknowledge the existence of many clinical problems, and have no experience in the diagnosis and management of clinical problems. Of course, they don't even bother to seek out evidence on treatment.

3. Identifying the best evidence means using epidemiological and biostatistical ways of thinking: Once again, obstetrics meets the criterion, but direct entry midwifery doesn't even bother to try. Moreover, direct entry midwifery is actually opposed to this philosophical principle of evidence based medicine. Hence the reliance on intuition, tradition, and "other ways of knowing", all of which are fancy names for ignorance.

4. Conclusions derived from identifying and critically appraising evidence are useful only if put into action in managing patients or making health care decisions: In other words, there should be timely incorporation of new evidence into clinical practice. Obstetrics follows this criterion, although there are times when it could do even better. Not every obstetrician incorporates new evidence as quickly as he should. Of course, direct entry midwifery doesn't bother gathering new evidence, let alone incorporating it into practice in a timely fashion.

5. Performance should be constantly evaluated: Once again, while obstetrics tries to adhere to this criterion, obstetricians could do better. The Federal and state government collect statistics on every aspect of obstetric care, analyze them, and make them publicly available for free every year. Recent initiatives have upgraded evidence collection in areas of particular concern, such as maternal mortality. In contrast, direct entry midwifery has made evidence collection voluntary, hides its own statistics, and is publicly dishonest about the safety of its practices.

So how do obstetrics and direct entry midwifery compare in their adherence to evidence based medicine? If I were grading, I would give obstetrics an 85%. There is considerable room for improvement particularly in implementing the latest clinical recommendations, and in collecting statistics. In my judgment, the greatest deficiency of obstetrics in the realm of EBM is the failure to provide the public with universal statistics on every hospital and every doctor.

On the other hand, direct entry midwifery gets a 0%. There is no effort, not even lip service, paid to any principle of evidence based medicine. Not only does direct entry midwifery fail to comply with the principles and practices of EBM, it is actually philosophically opposed to many of the basic goals of EBM. There is no place in EBM for "intuition", tradition, or "other ways of knowing". There is no place in EBM for "trusting" birth.

When it comes to evidence based medicine, direct entry midwifery is a complete and utter failure.

Consumer trust: benevolence vs. expertise

2008-08-13T08:53:00.003-04:00

There is an old saying in medicine that patients judge their doctors on the "three A's", affability, availability, and last (and least) ... ability. New research in psychology confirms this old aphorism, and helps explain why some women may ignore the advice of experts in favor of the advice of people they like better.

According to Tiffany Barnett White, writing in the Journal of Consumer Pyschology (Consumer Trust and Advice Acceptance: The Moderating Roles of Benevolence, Expertise, and Negative Emotions):

... Participants solicited advice from experts when their decisions were low in perceived emotional difficulty but favored the advice of predominantly benevolent providers when making highly emotionally difficult decisions. Although consumers who faced emotionally difficult decisions were willing to trade off expertise for benevolence, they did not perceive this non-normative trade-off to influence decision quality. Instead, ... consumers were more confident in the accuracy of predominantly benevolent providers' advice.

In other words, somewhat paradoxically, the more important a decision is, the less likely people are to rely on expertise and the more likely they are to rely on how much they like the advice giver. White suggests that people facing high-stakes decisions are unconsciously searching for ways to buffer stress, while consciously believing that they are making decisions based on evidence.

White identifies several factors that impact high-stakes decision making:

... [H]ighly emotionally difficult decisions appear to be distinct in that they also trigger the desire to cope with (i.e., minimize) negative decision-related emotions. Thus, individuals may be motivated to make the best decision ... [but] they must also manage the negative emotions that are associated with the decision... Drolet and Luce noted that in such decisions, consumers often "sacrifice decision accuracy in order to minimize negative emotions, even (and perhaps especially) in consequential decisions"...

People facing difficult decisions are often seeking emotional support:

Individuals who anticipate stressful or negative outcomes often seek the social support of others in an attempt to cope with such stress ... To the extent that the goal of minimizing negative decision-related emotions may dominate the goal of maximizing decision accuracy when decisions are emotionally difficult, the motivation to seek the advice and support of providers who can help to minimize these negative emotions may be preferred.

White asks:

When consumers trade off the accuracy-enhancing skills and abilities of predominant experts for the emotion-enhancing caring and empathy of predominantly benevolent providers ... do such trade-offs reflect a conscious choice? That is, do consumers actually believe they are sacrificing accuracy in such conditions?

She answers her own question:

Theory and research on social support has suggested that the positive effect of emotional support ... is ... the "psychological buffer" it provides against real or imagined stressful outcomes... [T]his buffering occurs because emotional support seekers are optimistic that they can avoid potentially negative outcomes as a result of this support... Thus, although consumers may trade off perceived expertise for perceived benevolence, such a trade-off does not reflect a motivated decision to accept less accurate advice. Rather, consumers may actually perceive the advice of predominantly benevolent providers to be more accurate.

This has obvious and important implications for the decision to employ a DEM rather than an obstetrician. Even though DEMs claim they are "experts" in normal birth, there are probably very few women who would not admit that obstetricians have far greater expertise. Homebirth advocates justify the decision to employ a provider with far less knowledge by a variety of conscious and unconscious strategies.

The conscious strategies include claims that childbirth is inherently safe, that DEMs are "experts" in normal birth, and that there is plenty of time to seek expert advice (by transferring) if unanticipated complications develop. The unconscious strategies involve an effort to manage the emotional stress of childbirth. Simply choosing a provider who is more personable and supportive reduces stress. Indeed, this stress reduction strategy is consciously justified by claiming that reducing stress ("fear") improves outcomes (though it does not). Second, and more importantly for our discussion, women often judge the advice of a supportive provider to be more accurate than the advice of someone less supportive, even though there is no correlation between benevolence and expertise.

Women contemplating employing a DEM would benefit from thinking about these issues. Is the decision to hire a DEM made because she truly has enough knowledge and experience to provide childbirth care, or is it made because it is less stressful to deal with a DEM at home than an obstetrician at a the hospital? Are homebirth advocates confident in the decision making ability of DEMs or does the more supportive nature of DEMs encourage women to believe in their decision making ability even though the two characteristics are not related? And can homebirth advocates come up with a more accurate way of assessing a DEM's knowledge and experience than deciding by whether how much they like her?

Post currently appearing on the front of Open Salon

2008-08-12T17:33:00.001-04:00

My second post for Open Salon, Ricki Lake: Please stop lying about homebirth is currently appearing on the homepage of Open Salon.

Vaccine rejection: a flat-earth theory for the 21st century

2008-08-12T09:00:00.001-04:00

Salon Magazine, an online magazine, has started a new blogging platform to publicize bloggers. I posted on vaccine rejectionism to give the site a try: Vaccine rejection: a flat-earth theory for the 21st century.

Misinformation direct from Citizens for Midwifery

2008-08-11T23:44:00.005-04:00

In this week's Time Magazine, there is an article on homebirth. Citizens for Midwifery,a homebirth advocacy group, is advising homebirth advocates to write Letters to the Editor about the article, complete with suggestions of what they should say. It makes an excellent compendium of the mistruths, deceptions and outright lies that are fundamental to homebirth advocacy.

Here are the "suggestions", complete with my comments:

SUGGESTED WRITING POINTS (Do not copy put into your own words!)

* For a variety of profound reasons, some women are always going to choose home birth, and we need care providers to be recognized by all 50 states so home birth can be better integrated into the healthcare system, and so that there will be enough providers to attend home birth. Simply put: home birth women need certified professional midwives. (If you can, briefly summarize your own difficulties in accessing home birth midwifery care.) No one "needs" grossly undereducated, grossly undertrained providers.

* There is a lot of literature showing home birth with midwives is very safe, and in some ways safer. Organized medicine is comparing apples to oranges in the 2 or 3 flawed studies they cite. Only poor, uncontrolled studies misrepresent planned home birth with a midwife in an unfairly bad light. (Pang study from Washington State included unplanned emergency births. Australian study involved women living in very rural Australia and included higher risk categories.) Property conducted studies all show home birth as safe as hospital (excluding women with medical problems) A lie: ALL the existing scientific evidence shows that homebirth increases the risk of neonatal death. There is not a single study that shows homebirth to be as safe as hospital birth for low risk women. The latest data from the CDC shows that PLANNED homebirth with a DEM is the most dangerous form of planned homebirth in the US.

* All the states (and Canadian provinces) that license certified professional midwives for home birth show good results. Laws licensing CPMs are renewed instead of repealed, and in some states the practice is actively encouraged. A lie: MANA is HIDING the state results for CPMs. The states that collect their own statistics, such as Wisconsin and Utah, show HIGHER neonatal death rates for homebirth. In addition, as mentioned above, the US statistics for 2003-2004 (the latest statistics) show that planned homebirth with a DEM has a neonatal death rate that is triple that of low risk hospital birth. Finally, Canadian provinces have much more stringent requirements for midwives than the CPM requirements.

* The American College of Obstetricians and Gynecologists is in stark contrast to their Canadian and British counterparts (Royal College of OB/Gyns and Society of OB/GYNs of Canda). In Canada and Britian the OB groups embrace midwifes as the experts in normal, natural birth, including home birth. In Great Britian it's a woman's officially recognized civil RIGHT to have a home birth. A deliberate deception: American CPMs are grossly undereducated and grossly undertrained compared to European and Canadian midwives. Both countries require extensive hospital based training in the diagnosis and management of complications. American CPMs cannot meet the licensing requirements in Canada or the UK or ANY first world country.

* Complication statistics quoted by physicians are based on birth that has been chemically or mechanically manipulated by hospital and medical procedures. Those same complications have a lower risk at home with a midwife. Therefore, it's understandable that hospital OBs fail to understand home birth; doctors are used to riskier hospital birth, and then using their surgical skills to fix the problems they created in the first place. At home, the midwife herself is there through much of the labor, carefully monitoring to make sure things are proceeding normally. In addition to lower risk of complications to begin with at home, many things may be detected sooner with one-on-one care that does not exist in hospitals. (If you can personally or professionally speak to wonder how doctors would know how quickly problems arise in a birth, since they're not there in hospital births until the last x# of minutes. A lie: Neonatal death rates for low risk hospital birth are LOWER than homebirth death rates.

There you have it, straight from Citizens for Midwifery: 3 lies, 1 deliberate deception and a bonus bit of inanity.

Heartbreaking story

2008-08-09T09:58:00.002-04:00

I have been following a new blog since it was started several weeks ago. The blog is called One More Day and it is beautifully and powerfully written. I have received permission from the mother who writes the blog to link to it and to quote some of her writing about the loss of her daughter after homebirth. I'm sure that everyone understands that if they have comments that are anything less than totally supportive, they should make the comments here and not on her blog.

From her first introductory post:

I am a mother to 5 wonderful children here on earth. My youngest child passed away after her birth... My children mean everything to me and losing one has been devastating... I was a totally crunchy mom but am now questioning all of that. I have had two homebirths. One turned out awesome and the other, turned out horrible. I feel that if I had just trusted the actual professionals, my baby would be here. Now, since I feel homebirth was wrong, I question my not vaxing philosophies. I am seriously thinking about catching my last three children up. I hate second guessing myself.

In her current post, A note about homebirth she recalls:

... You know when people would tell me that babies used to die because they were born at home, I had my "research and statistics" to back me up and prove they were wrong. Wanna know one thing I have learned now??? We don't hear about deaths after homebirths because of the stigma. Your baby dies in the hospital and people feel sorry for you. Your baby dies after a homebirth and people automatically blame you, even if it wasn't your fault...

She writes about how women are lulled by being low risk:

We talk about how if your low risk home is much safer. I have NEVER been high risk before yet home was the worst place my daughter could of been after her birth. Please, please think about how you promote homebirth as being so safe and wonderful. My daughter is dead because of homebirth. You don't want to be a number or a statistic.

She offers words that should be read by anyone contemplating a homebirth or promoting the safety of homebirth:

My 4 hospital babies are here and healthy. Out of my two homebirth babies one is here and healthy while the other is in a cemetery. She is proof that homebirth isn't as safe as we all think.

Johnson and Daviss are still trying to salvage their study

2008-08-07T09:57:00.003-04:00

Johnson and Daviss are still trying desperately to salvage their BMJ 2005 study, now that it has been exposed that the study actually shows homebirth with a CPM in 2000 had almost triple the neonatal death rate of hospital birth.

The paper itself relied on a scam, and the excuses are meant to obscure, minimize the scam, or to pretend that it didn't matter anyway. Now the excuses have been published as a PDF designed to look like a scientific paper.

Johnson and Daviss are offering it as a free download on their website Understanding Birth Better. Through the miracle of modern technology, PDF documents can be marked up with comments. I have taken the liberty of commenting directly on the document to point out the various inaccuracies. You can access the document with comments here.

Is there any justification for a 15% C-section rate

2008-08-05T23:45:00.005-04:00

Homebirth advocates love to point out that the World Health Organization has recommended that the C-section rate should be 10-15%. Unfortunately, the WHO appears to have pulled those numbers out of thin air. Its own data shows that a 15% C-section rate does not result in the lowest possible levels of either neonatal mortality or maternal mortality. Indeed, Dr. Marsden Wagner, who has probably done more than anyone to promote the idea of a 15% C-section rate as ideal, is a co-author of a study that actually demonstrates the opposite.

The paper is Rates of caesarean section: analysis of global, regional and
national estimates (Paediatric and Perinatal Epidemiology, 2007; 21:98–113.) The article explicitly acknowledges that the 15% C-section rate recommendation was made without any data to support it. This paper is actually the first paper that attempts to compare international C-section rates with maternal and neonatal mortality.

Since publication of the WHO consensus statement in 1985, debate regarding desirable levels of CS has continued; nevertheless, this paper represents the first attempt to provide a global and regional comparative analysis of national rates of caesarean delivery and their ecological correlation with other indicators of reproductive health.

The data regarding C-section rates below 10% is stark:

...[T]he majority of countries with high mortality rates have CS rates well below the recommended range of 10–15%, and in these countries there appears to be a strong ecological association between increasing CS rates and decreasing mortality.

How about the data on C-section rates above 15%? The authors claim:

Interpretation of the relationship between CS rates and mortality in countries with low mortality rates is more ambiguous; nevertheless, the sum total of the evidence presented here supports the hypothesis that, as has been argued previously, when CS rates rise substantially above 15%, risks to reproductive health outcomes may begin to outweigh benefits.

Not exactly. Indeed, not even close. The data show that low maternal mortality and low neonatal mortality are associated almost exclusively with high and very high C-section rates.

The article contains a variety of charts that make this clear. Of note, the charts are of an unusual kind. Rather than graphing C-section rates against mortality rates, the authors chose to graph the log (logarithm) of C-section rates against the log of mortality rates. A log-log graph has the advantage of exposing tiny differences when all the values are bunched close together, but all the values are not bunched together in this situation. C-section rates occur along a broad range, and mortality rates occur along a broad range. As a consequence, the log-log graph magnifies the effect of tiny differences and minimizes the effect of large differences. Therefore, you need to be very careful in interpreting the graphs.

addendum: I've added an adaptation of the chart that appears in the paper. The area representing a C-section rate of 10-15% has been highlighted in yellow. The vertical blue line represents a mortality rate of 15%. Lower mortality rates are left of the blue line and higher mortality rates are right of the blue line.

The data themselves are quite clear. There are only 2 countries in the world that have C-section rates of less than 15% AND low rates of maternal and neonatal mortality. Those countries are Croatia (14%) and Kuwait (12%). Neither country is noted for the accuracy of its health statistics. In contrast, EVERY other country in the world with a C-section rate of less than 15% has higher than acceptable levels of maternal and neonatal mortality. There nothing ambiguous about that.

The authors claim:

Although below 15% higher CS rates are unambiguously
correlated with lower maternal mortality; above this range, higher CS rates are predominantly correlated with higher maternal mortality.

No, that's not what it shows at all. It shows that all countries with high C-section rates have low levels of maternal and neonatal mortality EXCEPT Latin American countries (represented on the chart by open diamonds) with high C-section rates. The only conclusion that you can draw is that high C-section rates for medical indications are associated with low rates of maternal and neonatal mortality, and high C-section rates for social reasons (as in Latin America) do not lead to low rates of maternal and neonatal mortality.

What the data actually shows is this: The only countries with low rates of maternal and neonatal mortality have HIGH C-section rates (except Croatia and Kuwait). The average C-section rate for countries with low maternal and neonatal mortality is 22%, although rates as high as 36% are consistent with low rates of maternal and neonatal mortality.

The authors claims are not supported by their own data. There is simply no support for a C-section rate of 15%, since virtually none of the countries with low rates of maternal and neonatal mortality have a C-section rate of 15% or below, and most have rates that are far higher. There is also no support for the claim that "the sum total of the evidence presented here supports the hypothesis that ... when CS rates rise substantially above 15%, risks to reproductive health outcomes may begin to outweigh benefits". When C-sections are performed for medical indications, there is no evidence that rising C-section rates lead to rising rates of maternal or neonatal mortality.

The authors own data indicate that a C-section rate of 15% is unacceptably low, and that the average should be at least 22%, with rates as high as 36% yielding low levels of maternal and neonatal mortality.

More on eugenics and "natural" childbirth

2008-08-04T09:05:00.001-04:00

There are several critical points that must be understood about the philosophy of "natural" childbirth. As Ornella Moscucci has explained in Holistic obstetrics: the origins of "natural childbirth" in Britain,

* Natural childbirth is an approach characterised by a bias towards physical and mental hygiene in the management of pregnancy and birth.
* It emerged in Britain in the interwar period as a conservative, antifeminist reaction to the demographic crisis of the early 20th century...
* Health reformers offered social regeneration through health policy. They believed that both reformist and hereditarian health policies were necessary for biological progress...
* The "philosophy of the natural" elaborated by health reformers entailed a return to the "state of nature" represented by the primitive.
* The definition of the "primitive" as physiological norm was bound up with beliefs about the pathological effects of civilisation...

The philosophy of "natural" childbirth cannot be separated from its basis in eugenics. It is this origin that explains how and why novel "biologic" theories of childbirth were simply fabricated in service of the eugenicist idea. Clare Hanson, in Save the Mothers? Representations of Pregnancy in the 1930s, explores the social and cultural mileiu in which the philosophy of "natural" childbirth was created. Hanson locates the philosophy of "natural" childbirth within the eugenics movement:

Eugenic thought in Britain had its origins in the work of Francis Galton ... Galton argued that heredity would ensure that like would breed like and implied that social classes thus corresponded to biological sub-types. The Malthusian question, for him, was of the relative breeding rates of the different classes...

In these debates of the twenties and thirties, the question of the relative importance of heredity and environment was being played out across the body of the pregnant woman. With the focus of medical interest moving towards foetal rather than maternal health, it was the viability of the foetus (in the broadest sense) which was becoming a crucial – and political – question in the thirties...

Hanson describes the influence of Grantly Dick-Read.

... One of Read’s principal arguments is that pregnancy and childbirth are not inherently burdensome or painful. He distinguishes between primitive women, defined as those 'whose mental development has not attained a state of civilisation', and cultured women who have for centuries been imbued with fear and told that 'labour entails peril and agony'. For Read, 'racial experience' impacts on the experience of pregnancy and childbirth, and it is the 'primitive' approach which he favours. He argues that Nature (sic) never intended pregnancy to be an illness, and describes the primitive woman continuing her work during pregnancy, so that 'the child develops while she herself lives a full and natural existence . . . the child then is born – small, hard and easily'...

Grantly Dick-Read started with his conclusions and simply fabricated "facts" that supposedly corroborated them.

Seventy five years later, when apprised of the origins of their philosophy, "natural" childbirth advocates claim that Grantly Dick-Read's sexism and racism do not undermine the validity of his philosophy. They point to the racist beliefs of the early birth control advocates, who were also motivated by eugenic concerns, and argue that racism does not impact the value of birth control. There is a critically important difference, however. Birth control advocates did not locate their claims of efficacy of birth control in racist or sexist beliefs. Their racist and sexist beliefs determined WHO should be given access to birth control, not HOW birth control works.

In contrast, the efficacy of "natural" childbirth depends almost entirely on the original racist, sexist claims of Read. They are so integral to "natural" childbirth, that these same racist, sexist fabrications are repeated verbatim by contemporary "natural" childbirth advocates:

"Childbirth in nature is not painful" is the modern formulation of "primitive" women do not experience pain in labor.
Women are "socialized" to believe that labor is painful" is the modern formulation of "Civilization has rendered cultured white women unfit to bear children."
"The cause of pain in labor is fear" is the modern formulation of "women must be socialized to their responsibility to bear children."
"Unmedicated childbirth is 'empowering'" is the modern formulation of "women should not refrain from having children because they are afraid of the pain."

Regardless of the way you dress it up, the philosophy of "natural" childbirth cannot be separated from its racist, sexist origins. There is no inherent value to "natural" childbirth. The value assigned to unmedicated birth is a social construct, predicated on racist, sexist assumptions about childbirth. Without those racist, sexist assumptions, the philosophy of "natural" childbirth is ideologically incoherent.

A bias against women in the treatment of pain

2008-08-01T23:26:00.003-04:00

The assertion by "natural" childbirth advocates that childbirth is not inherently painful, or that the pain of childbirth is best managed by preparation dovetails quite well with sexist notions about women and pain. A large body of scientific literature shows that women's pain is much less likely to be taken seriously than men's pain.

The Girl Who Cried Pain: A Bias Against Women in the Treatment of Pain, Journal of Law, Medicine & Ethics, 29 (2001): 13–27, provides a disturbing description of the ways in which the pain of women is systematically devalued, disbelieved and undertreated.

Given that women experience pain more frequently, are more sensitive to pain, or are more likely to report pain, it seems appropriate that they be treated at least as thoroughly as men and that their reports of pain be taken seriously. The data do not indicate that this is the case. Women who seek help are less likely than men to be taken seriously when they report pain and are less likely to have their pain adequately treated...

The study by McCaffery and Ferrell of 362 nurses and their views about patients' experiences of pain found that while most of the nurses (63 percent) agreed that men and women have the same perception of pain, 27 percent thought that men felt greater pain than women. Only 10 percent thought that women experienced greater pain than men in response to comparable stimuli. This result has no justification in the literature ... The same study also found that almost half of the respondents (47 percent) thought that women were able to tolerate more pain than men as compared to 15 percent who felt that men were able to tolerate more pain than women...

These erroneous attitudes are particularly prevalent in regard to childbirth:

Bendelow found that "the perceived superiority of capacities of endurance is double-edged for women — the assumption that they may be able to 'cope' better may lead to the expectation that they can put up with more pain, that their pain does not need to be taken so seriously." Crook and Tunks point to the influence of the psychoprophylaxis movement in the United States with its implicit assumption that it is good to experience childbirth without the aid of analgesia. As a result, some women who have "gone through psychoprophylaxis classes, feel guilty if they relent at the last minute and ask for an epidural"; according to the authors, "these attitudes imply that we have a value system endorsed by some parts of our population that suggest women should be encouraged to keep a stiff upper lip."

The authors believe that people discount women's expressions of pain.

A deeper examination of why women are treated this
way is explored by several feminist authors. They attribute it to a long history within our culture of regarding women's reasoning capacity as limited and of viewing women's opinions as "unreflective, emotional, or immature." In particular, in relation to medical decision-making, women’s moral identity is "often not recognized..."

Some researchers have argued that a "bias toward psychogenic causation for disorders in women has occurred even in well defined painful biological processes: 'Despite the well documented presence of organic etiologic factors, the therapeutic literature is characterized by an unscientific recourse to psychogenesis and a correspondingly inadequate, even derisive approach to their management.'" These findings are consistent with studies reporting that female pain patients are less likely than their male counterparts to be taken seriously or are more likely to receive sedatives than opioids for the treatment of their pain.

It is not a coincidence that the philosophy of "natural" childbirth was promulgated by white, male physicians steeped in the ethos that women's pain was not worthy of serious consideration. Their claims that childbirth pain is socially constructed, that women can and should manage pain through psychological means, and that women are "empowered" by pain are simply elaborate justifications for not acknowledging and not treating the pain of women. It is also not a coincidence that the ONLY form of pain thought to be "empowering" is a type of pain that ONLY women can experience.

Those claims can and should be rejected as expressions of sexism. Women's experience of severe pain in labor is real, authentic, and biologically based. Respect for women demands that we acknowledge that pain, not minimize it, and not suggest that it should be psychologically managed. There is no reason take the word of a bunch of middle aged white men, steeped in a medical culture that minimized and ignored pain in women, for what women are "supposed" to feel in labor.

Stuntbirth: "I'm such a UCer ..."

2008-07-30T08:21:00.005-04:00

You just can't make this stuff up.

One of the commenters has coined a new expression for UC (unassisted childbirth). She called it "stuntbirth", and I find that designation quite apt.

I've made no secret of my conviction that UC is an irresponsible stunt, undertaken for no better reason that bragging rights. Indeed, as a cultural construct, UC shares many similarities with "extreme" sports. Advocates emphasize the fact that it is transgressive, is "authentic", values process over outcome, creates a sense of belonging, and produces feelings of empowerment.

Several people argued that UC is not about bragging rights. Never fear; we can always depend on homebirth advocates to come to my rescue. They are busily bragging on MDC right now, and their boasts are as inane as I could possibly need to bolster my claim.

Consider these comments (decorated with bouncing smilies, of course) on a thread counseling a woman that there will almost never be a reason for her to abandon UC and seek medical care:

I'm such a uc'er.. I didn't go to the docs for a pp hemorhage
I'm such a uc'er.. I didn't hear the heartbeat until I was 37 weeks
I'm such a uc'er.. I sung l.o.u.d songs whist having waves
I'm such a uc'er.. I (keep it going mamas..)

I'm such a ucer...I check my own cervix.
I'm such a ucer...I had to guess at my due date.

I'm such a UCer that I managed/healed a postpartum intrauterine infection on my own, with herbs and supplements...never really occurred to me to call a doc or go to ER.

Evidently, when the goal is bragging rights for a "stuntbirth," the more irresponsible the stunt, the more you can brag about it.

None of these "mamas" has the winning boast in the bragging contest. That dubious distinction would go to the woman who would be able to boast, after her experience described recently on MDC:

I'm such a ucer ... my baby died during labor and I didn't know it and proceeded to deliver a dead baby in front of my young children.

The impact of expectations

2008-07-28T19:27:00.002-04:00

I just read an extraordinary story in the Irish Independent about the pernicious effect of unreasonable expectations of childbirth. In Scarred by motherhood, Jo Baker writes:

... After three days of labour, and two nights without sleep, I consented to an induction and, six hours after that, asked for pain relief. Within an hour of the drug being administered I was screwing up what was left of my concentration to sign a consent form for an emergency caesarean.

The baby was in danger, and that was all that mattered now. When they finally handed over my baby I didn't get that rush of love some women talk about. He lay on my chest, light as a doll, and I didn't know what to do with him. Though the midwife commented on what a neat job it was, my caesarean wound looked appalling to me.

But I had only myself to blame: if only I'd said no to the induction, if only I hadn't asked for pain relief, this wouldn't have happened. Other women managed it, why couldn't I? I'd failed as a mother at the first fence. And at every fence after that, it seemed.

These feelings of inadequacy persisted and Jo found an outlet:

Then, one day, as he was crying for his breakfast, the last sterile spoon slipped out of my hand, and something inside me cracked. I picked up the spoon, washed it, put it back in the steriliser. I opened a drawer, took out a knife, and cut myself on the forearm.

Afterwards, I covered the cut up and fed the baby, and pretended nothing had happened. But a few days later I was in the kitchen again with the knife in my hand. I took to wearing long sleeves. When my arms got too obviously scarred I started on my legs: it was easier to keep them covered...

Jo was shaken out of her self-blame:

At one check-up, impressed with the baby's development, the health visitor said I was doing a brilliant job. I was stunned. I knew my baby was amazing, it just hadn't occurred to me that it had anything to do with me. Perhaps I wasn't inadequate after all.

Jo had an epiphany.

Not long after that I went to cut myself for the last time. I was in the kitchen, knife in hand, when something made me glance round into the dining-room. My little boy was in his highchair, leaning to one side to see what I was up to. He smiled when he caught my eye, and I smiled back. I felt sick. I put the knife down. What if I hadn't looked round? What if I'd gone on, and he'd seen me do it? What if it had become his earliest memory? It was one thing punishing myself, it was something else entirely to hurt him, too. That really would be failing at motherhood.

And that's when the realisation sank in: so I was awful at childbirth. So what? It could just join the long list of things I do badly. All that mattered now was loving him, and fortunately it turns out I'm really good at that.

I'm glad that Jo realizes that loving her baby is far more important than how her baby was born. Hopefully, over time she will come to understand that she is not "awful at childbirth". The goal is to have a healthy baby. She did whatever was necessary to make that happen. That means that she was 100% successful at childbirth.

Medicine values judgment; homebirth advocacy insists on certainty

2008-07-27T18:20:00.002-04:00

Homebirth advocates include a spectrum of opinion, but on one point everyone seems to agree: complications are rare. There's just one problem. Complications are not rare, they're common.

Why the disconnect? Partly it is because of the underlying, and erroneous, belief that if it is "natural", it must be good. Therefore, the way childbirth occurs in nature can't have many complications if it is to be "good". Yet there is another, more profound reason that speaks to the deepest longings of homebirth advocates, the desire for certainty. Homebirth advocacy is made up of a few simple rules: "nature" is always right, everything must be allowed to happen naturally, interfering is what causes complications, etc. All of them can be summed up conveniently in the aphorism: Trust Birth.

Homebirth midwifery requires very little in the way of training (compared to other forms of midwifery) because very little knowledge is supposedly needed. Keep your hands off and call 911 in the rare case that a disaster occurs. In the meantime, you are free to let labor to drag out endlessly, and, to encourage the mother not to give in to the basic human desire for pain relief.

Obstetrics, on the other hand, presupposes that childbirth is complicated, complications are fairly common and judgment is key to ensuring good outcomes. In other words, you can't simply sit back and assume that everything is going to turn out fine. Since the chances are relatively high that complications will develop, observation is critical; detecting early signs of complications is desirable; and judgment is needed to interpret the early signs and determine a course of action.

Why do obstetricians spend four years beyond medical school delivering hundreds or thousands of babies before they're allowed to practice on their own? If you believe that judgment is a critical element in providing safe care, you are committed to a long period of training. The only way to acquire good judgment is by experience with a large and varied array of situations.

Homebirth midwifery assumes that one size fits all. Just stand back and everything will be fine. Obstetrics, in contrast, assumes that reasoning and judgment will often be required, and makes every effort to hone those skills. Homebirth midwifery laughs when a woman has an "unnecessary" Cesarean for a baby who turns out to be healthy; if only the doctor had "trusted" birth, everything would have been fine. Homebirth midwifery is shocked when a baby who is assumed to be fine emerges dead. Yet that kind of outcome can only occur when the practitioner is not paying attention, is not reasoning, is not using judgment to distinguish between the theory of "trusting" childbirth and the reality of the woman in front of her.

"Trust birth" is a one size fits all strategy. It provides comforting certainty. Obstetrics is individualized and uncertain. That makes it far more difficult, but it also makes it safer.

Garbage in, garbage out; Murphy and Fullerton's "optimality" index

2008-07-25T20:12:00.003-04:00

We have been discussing Murphy and Fullerton's "Optimality Index" in the comments section, and I'd like to promote the discussion to the main page.

Drs. Murphy and Fullerton created the Optimality Index. Rather than looking at adverse outcomes, Murphy and Fullerton believe that childbirth can best be analyzed by comparing individual outcomes with optimal outcomes. The prefer this approach because it deliberately incorporates specific beliefs about what constitutes optimal care. For example, traditional medical studies would consider the birth of a healthy baby to a healthy mother the optimal outcome; the Optimality Index would subtract points from a perfect score because, in their view, having an epidural is a non-optimal outcome.

The following will cause you to lose points on the "optimality index":

NST
biophysical profile
prescription medication of any kind
induction
augmentation
any medication in labor
epidural
continuous fetal monitoring
directed pushing
less than 45 deg. head elevation at birth
perineal laceration

But that's not even the worst part. The worst part is that any of these events are coded as EQUIVALENT to:

cord prolapse
severe pre-eclampsia
eclampsia
abruption
shoulder dystocia
intraventricular hemorrhage
NEC
pneumonia
renal failure
neonatal seizures
PERINATAL DEATH!!!

So if you have an NST, biophysical profile, induction, any medication in labor, an epidural,continuous fetal monitoring, directed pushing, less than 45 deg. head elevation at birth, a perineal laceration and a LIVE BABY your optimality index is 47.

If you have none of those things and a DEAD BABY, your optimality index is 56.

Murphy and Fullerton were quite forthright about their aims in their first paper about the optimality index, Measuring outcomes of midwifery care: development of an instrument to assess optimality:

"Research on the outcomes of midwifery care is hampered by the lack of appropriate instruments that measure both process and outcomes of care in lower risk women. This article describes an effort to adapt an existing measurement instrument focused on the optimal outcomes of care (The Optimality Index-US) to reflect the contemporary style of U.S.-based nurse-midwifery practice..."

The optimality index has two primary explicit motivations and one primary implicit motivation:

First, it is designed to give far MORE weight to process than to outcome; a perinatal death is equivalent to having an epidural.

Second, it is designed to measure how closely a birth adheres to the values of midwives.

Third, it implicitly dismisses the opinion of the mother by assigning it no value at all.

Ultimately, the optimality index tells us nothing about birth, but a great deal about the midwives who designed it and the midwifery organizations who support it: It does not matter very much to them whether the baby lives or dies. Conforming to the ideals of midwifery is very important to them. The mother's opinion, needs and desires are meaningless.

Murphy and Fullerton should be embarrassed for proposing such an index and midwifery organizations should be embarrassed for supporting it. Personally, I think the name should be change from "Optimality Index" to "Inanity Index".

"Normal birth", does it exist or is it just a value judgment?

2008-07-24T20:03:00.001-04:00

If you search for scientific papers about "normal birth", you will find very few prior to 2007 when the expression was popularized by midwifery organizations. The Royal College of Midwives started their "Campaign for Normal Birth", and papers began to appear with titles like "Preserving Normal Birth" and "Normal Birth: Women's Stories". What does it really mean to call a birth "normal"? Does it reflect actual statistics on what birth is like or is it merely a value judgment? Is birth "normal" when it follows a particular course, or is it "normal" by virtue of fulfilling the function of producing a healthy baby for a healthy mother?

I would argue that the biggest difference between the medical model and the "normal birth" paradigm is that the medical model derives from statistical analysis and focuses on the functional outcome of birth, whereas the "normal birth" paradigm makes explicit value judgments ("normal" is superior) and is obsessed by process, rather than outcome.

Doctors describe "normal" with reference to large populations. How do we know what a normal blood sugar is? We look at the distribution of blood sugar levels through the population and the functional results. Normal is the statistical range of blood sugars compatible with healthy bodily function. This has two important corollaries. 1 There is no particular value assigned to normal blood sugar, beyond the value of avoiding illness. 2 A blood sugar level is normal regardless of how the level was attained. A blood sugar of 100 is normal regardless of whether it occurs spontaneously in a non-diabetic individual or whether it occurs after a dose of insulin in a diabetic.

When it comes to childbirth, also, doctors describe "normal" with reference to large populations. How do we know what the normal length of labor is? Doctors look at the distibution of labor lengths throughout the population. "Normal" is the statistical range of labor length compatible with minimal complications. The same two corollaries that applied to blood sugar also apply to length of labor. There is no particular value assigned to a labor of normal length, and, more importantly, a normal length of labor does not depend on whether it occurs spontaneously or whether it occurs because of pitocin augmentation.

The "normal birth" paradigm is very different. Because of the value judgment that "normal" is superior, every effort is made to pretend that all spontaneous variations are "normal". In fact, for all intents and purposes, spontaneous IS "normal". Hence, getting stuck at 8 cm for 5 hours is "normal" and should simply be observed. The "normal birth" paradigm is obsessed with process. A pitocin induced labor that follows the curve is not "normal" (even though it falls well within the statistical guidelines for length of labor) because it did not happen spontaneously.

Obstetricians are focused on functional outcome. A "normal birth" is one that gives a healthy baby to a healthy mother. In contrast, believers in the "normal birth" paradigm actually spend time debating whether a women who has a C-section has had ANY "birth" let alone a "normal birth". The "normal birth" paradigm uses the word "normal" in the same way as homophobes refer to heterosexual relationships as "normal"; it claims or implies that C-section birth is "abnormal" in the same way that some people refer to disabled people as "abnormal". The "normal birth" paradigm uses the word "normal" in the worst possible sense; as a value judgment where "normal" is superior and everything else is "abnormal".

Latest on MDC: massive maternal hemorrhage

2008-07-24T16:10:00.002-04:00

Be sure to check out the latest UC story on MDC. A grand multip had a UC for her 7th baby. She had a massive postpartum hemorrhage (she can't figure out why; she did everything she was supposed to and it made no difference). None of her herbal "remedies" had any effect as she began to pour her entire blood volume on the floor. The ambulance got there very quickly and transported her immediately. Her blood pressure during transport was 50/30 and she went into shock. At the hospital, she received 4 units of blood and barely survived. She could not manage to sit up or roll over without dizziness for days.

It is mind boggling. This woman very mearly left 7 children motherless all so she could have her birth "experience". She was saved by paramedics, doctors, blood transfusions and luck. Had she lived farther from the hospital, she would have bled to death.

Controlling comments

2008-07-23T08:29:00.003-04:00

I have written in the past that professional homebirth advocates never appear anywhere that they can be questioned by other professionals. They don't present their data at scientific conferences, they rarely submit it to scientific journals and they don't appear anywhere they can be questioned by other medical professionals. That is deliberate. They know that the only lay people can be scammed, and that their scams would be revealed immediately if they were force to answer medical questions.

They do the same thing on the web. It is called "moderating comments". I don't mean moderating comments to remove spam. That can be done automatically with a captcha program. I mean personally reviewing all comments and publishing only those that are complementary or do not ask difficult questions. A new homebirth blogger has appeared and she is doing the same thing.

Dr. Tienchin Ho is a bariatric (weight loss) surgeon who has retired to care for her children. She had one C-section, followed by a homebirth (with an OB friend available as back up). She posts on MDC and the "Normal" Birth Forum. I have questioned her claims there, but she did not respond. Now she has a blog, and this is what she wrote recently:

Critics of home birth claim:

Babies born to parents who plan home births have triple the neonatal mortality of babies born to parents who plan hospital births.

There is no scientific data to support this.

That's funny. I provided Dr. Ho with copious scientific data to support this claim, including a long explanation of the fact that the Johnson and Daviss study ACTUALLY shows homebirth to have a neonatal death rate almost TRIPLE that of hospital birth in the same year, and a link to the CDC 2003-2004 data that shows that homebirth with a DEM has triple the neonatal mortality rate of low risk birth.

Home birth critics cite various sources of mortality (death) rates for babies that are not even about planned home or planned hospital births. Having a baby at home with an experienced attendant and appropriate equipment is not the same as having a baby in the car on the way to the hospital. Information taken from birth certificates suffers from this problem since birth certificates only report where each birth actually happened, not where it was planned. Sources with the birth certificate error include the Pang study and the CDC Wonder 2003 – 2004 dataset.

That's right, Dr. Ho. That means that while NO homebirths with a DEM present were planned hospital births, many hospital births were originally planned homebirths. Therefore, the CDC statistics for 2003-2004 which show homebirth with a DEM to have triple the neonatal mortality rate of low risk hospital birth actually UNDERCOUNT homebirth complications. The real risk of neonatal death at homebirth is even HIGHER than what the CDC data shows.

How a death is classified depends on when it happened. Looking at how many deaths happen during labor is not the same as how many happen during the first seven days of life... This simple error occurs when comparing the combined intrapartum and neonatal mortality rate in the Johnson-Daviss study to rates of neonatal mortality alone.

There are two problems with that claim, Dr. Ho. The first is that Johnson and Daviss made up their own definition of "intrapartum death". We know that because they included at least one liveborn baby (with an Apgar score) in their group of "intrapartum" deaths. Second, even if it were true that the "intrapartum" deaths in the J&D study really occurred during labor, you can't just forget about them. You must compare them to the intrapartum death rate in the hospital. If there were 5 intrapartum deaths in the J&D study, that's an intrapartum death rate of 1/1000. That's 3-4 times higher than intrapartum death rates of ALL risk categories in the hospital. You can't simply discard the babies who died intrapartum and pretend that they never existed. ANY way that you slice and dice the data, it still shows that homebirth with a CPM in 2000 has a much higher rate of neonatal mortality than hospital birth.

Let's see if Dr. Ho will reply. I've posted a shortened version of this in the comments section of her website, so she knows that it exists.

What is "normal"?

2008-07-22T08:05:00.000-04:00

Homebirth advocates like to pretend that almost anything that happens is "normal" simply by virtue of the fact that it happened. Are you still pregnant 3 weeks after your due date? Must be normal, since it happened. Are you in labor and stuck at 8 cm for the past 6 hours? Must be normal, since it has happened to some women in the past, and a few have even gone on to deliver live babies.

The corollary of the homebirth fantasy that almost everything is "normal" is the conviction that medical definitions of "normal" are utterly arbitrary and exist merely for the convenience of doctors. Nothing could be further from the truth. Often, "normal" is based on knowing the outcomes from previous experience. We can confidently say that having an Apgar score of 1 at 5 minutes of life is not normal, because babies who have Apgar scores of 1 at 5 minutes always have serious medical problems of one kind or another.

Sometimes "normal" is defined as a range. That is not an accident, and it does not mean that a range was chosen arbitrarily. A normal range in medicine is almost always based on a basic and widely accepted form of statistical analysis, the standard deviation.

There is an excellent simple explanation of standard deviation on SensibleTalk.com. It is written for journalists who have no background in statistics:

Let's say you are writing a story about nutrition. You need to look at people's typical daily calorie consumption. Like most data, the numbers for people's typical consumption probably will turn out to be normally distributed. That is, for most people, their consumption will be close to the mean, while fewer people eat a lot more or a lot less than the mean.

When you think about it, that's just common sense. Not that many people are getting by on a single serving of kelp and rice. Or on eight meals of steak and milkshakes. Most people lie somewhere in between.

When you graph the data with calories on the x-axis and numbers of people on the y-axis, you will get a bell shaped curve.

The curve is a graphical representation of all the possible things that can happen. The important point, though, is that every possible thing that can happen is not necessarily normal. How do we tell the difference between normal and abnormal? We start by calculating the standard deviation. The formula for calculating the standard deviation is complicated, but the result is relatively simple to understand. The standard deviation is a reflection of distribution of all possible outcomes.

Mathematically, one standard deviation on each side of the mean (the average) encompasses 68% of individuals. Two standard deviations encompasses 95% of individuals. Therefore, only 5% of individuals will be outside of two standard deviations from the mean. This is always true, regardless of whether the bell curve is tall and narrow or short and extended. "Normal" is usual defined as within two standard deviations. That means that "normal" is a range, but the range is hardly arbitrary. It reflects the actual distribution of results among large populations of human beings.

So when we look at how long a first labor lasts, for example, we can graph the labors of large numbers of women and we will get a bell curve. Ninety-five percent of women will fall within two standard deviations of the mean. It is only those women who are outside of two standard deviations that are considered abnormal. That does not mean that a woman whose labor is lasting longer than two standard deviations from the mean cannot possibly have a vaginal delivery, but it does mean that a woman whose labor is lasting longer than two standard deviations from the mean is very unlikely to have a vaginal delivery.

The bottom line is this: defining normal as a range is not arbitrary. It is a reflection of what we know about human variation. The range of normal ALREADY accounts for most of human variation. Anything that lies outside the range of normal is very unlikely to be normal.

Revisting the MDC homebirth complications poll

2008-07-20T10:00:00.002-04:00

In February I wrote about the homebirth complication poll on MDC. Since then it has been updated and the findings are still startling. They should be required reading for anyone claiming that homebirth with a DEM is safe. What is most suprising is not just the volume of disastrous complications, but the sheer magnitude of the disasters. Most of these complications are rarely seen outside of the third world.

For example, a case of eclampsia:

I tried a homebirth with #1 and my BP went out of control during labor. In fact at one point, I passed out and started seizing. The midwife called 911 and I woke up in the ambulance. I had to have an emergency C-section at the hospital since my BP was something like 240/200 right before I was put under.

Or massive neonatal brain damage:

Dd2 was supposed to be a HBAC with a CPM- we transferred after I stalled out (8cm for 5 hours) after nearly 48 hours of labor and her heart rate was getting concerning. I had another c/s, she had seizures and spent 2 weeks in the NICU. She had had a massive stroke at some point and suffered severe brain damage. She's doing well now, thankfully (as well as you can do with half your brain).

A tragic, preventable neonatal death:

My third babe also got stuck, but the midwife I had believed that everything would work its way out. I was at 9cm for almost 6 hours. She finally found her way out. She passed massive amounts of mec and had shoulder dystocia. She had to be transported to the hospital by ambulance where she died 22 hours after birth from severe mec aspiration syndrome.

These horrific complications all resulted from the inability of DEMs to accept reality. Birth is NOT trustworthy. Serious complications are NOT rare. Pre-eclampsia should NEVER be ignored. The Friedman curve is NOT an conspiracy to ruin birth "experiences"; falling off the curve is an indication of serious abnormalities. Unless, and until homebirth advocates can accept reality, homebirth will never be safe.

Experience changes everything

2008-07-18T08:50:00.002-04:00

Last February, I wrote about Apprentice Midwife whose posts flaunted the lack of basic knowledge that is so characteristic of direct entry midwifery (Homebirth ignorance 101). In the interim, Apprentice Midwife went on a medical mission to the Phillipines, and has been profoundly affected by her experience (What did I gain, learn?).

It turns out that birth is very, very different than what she had thought. For example:

... Another birth that I observed, the mom not only hemorrhaged over 1200cc, but she also tore horrendously. As one of the very experienced and very skilled midwives was starting to suture her labial tear, she found the tear inside to be incredibly extensive. Mom tore all the way back to her ischial spines, not only exposing them - but her nerves as well. Baby also had to be resuscitated, and that was my first trip to the local hospital... Their world there is a LOT different than what we see here in home births. Far more scary, far more complication-filled.

Apprentice Midwife reflects:

It was always frustrating for me to hear how "dangerous" childbirth is, and how fast things can go south. To hear that home birth is dangerous and reckless and shouldn't be done. I had always attributed it to what people in the hospital see, but never REALLY thought about it literally... Yes, there are those beautifully perfect births, but they also see lots of risk factors and complications. Had my introduction to midwifery and childbirth been in the Philippines, I'd be the same with caution and even some fear. I'm thankful that I haven't had to deal with much complication, and the complication that I have dealt with here, seems like nothing compared to a few things I witnessed in MMC...

She describes how her experience has transformed her:

During the first birth that I observed at MMC, I was put off a bit. And that sounds horrible. Understand that I come from very hands-off midwifery. So to see the midwife pulling on the baby once crowned, then to see the baby vigorously bulb suctioned, then to see mom's fundus literally mashed upon...I was a bit horrified. I was saddened, and for a moment I wondered why I had come. It was after this that I went to the Ped Ward of the hospital, and I understood. It's far better to take actions to prevent or roughly handle a complication, than it is to end up at DMC. It was still hard for me to watch, as my training screams something completely different when it comes to bulb or deep suctioning...but I understood more...

Ironically, on a midwifery mission to the Phillipines, Apprentice Midwife learned the fundamental principle of modern American obstetrics: It is far better to take action to prevent or roughly handle a complications, then to deal with the results of the complication. It's a basic principle of all medicine; prevention is better than treatment.

Apprentice Midwife also learned something about herself. Her beliefs about childbirth had been shaped by her lack of experience. She says: "Had my introduction to midwifery and childbirth been in the Philippines, I'd be the same with caution and even some fear." She understands that the difference between herself and the midwives in the Phillipines is NOT philosophy, and is NOT socialization. It is experience. And that is the difference between most direct entry midwives and obstetricians (or CNMs). It is not philosophy and it is not socialization. It is experience.

Geradine Simkins explains the MANA statistics

2008-07-16T15:29:00.002-04:00

No, she did not respond to my request that MANA release its safety statistics. However, she did give a presentation at a recent conference sponsored by the National Aboriginal Health Organization (www.naho.ca). Her presentation included a detailed poster that explains the MANA statistics project. Of note:

MANA has collected data on planned midwife attended home births since 1993.

Data collection includes "evaluation of all aspects of midwifery care in terms of safety, optimal maternal, fetal, and family outcomes,and cost effectiveness.

Data collection "uses a very extensive data form! ~360 questions."

MANA estimates approximately 20,000 cases will be in the database by the end of 2008.

MANA has NO INTENTION of every releasing the statistics to the public. Only "qualified researchers" will be granted access based on "an application process/review."

This information confirms what we already know about the the MANA database. It is the largest database of its kind, it gathers copious information, and its results are hidden from the public. One detail is quite suprising, however, raising questions about whether the content of the database has been manipulated. According to Ms. Simkins, the database is projected to contain approximately 20,000 records collected over the past 15 years. This does not make sense in light of the fact that MANA recorded 5000+ deliveries in the year 2000 (in the Johnson and Daviss BMJ study, which used their data). At a minimum, we would expect AT LEAST 5000 deliveries per year in 2001-2008. Where are those other patient records?

Another puzzling detail is that the dataset is supposed to be "complete" by the end of 2008. What does that mean? Are they going to stop collecting statistics? Are they going to stop analyzing safety statistics? Moreover, MANA has been publicly offering access to the database since at least the summer of 2006, so why are they now claiming that the data won't be available until the end of 2008? Is that simply to silence critics who know about the existence of the database and have already asked for access? I know of several people who have already been refused, although no one was told that the data was not yet available.

Regardless, MANA has an ethical obligation to release the safety data, broken down by year, for all the years that they have collected data. Anything else must be viewed as an effort hide the data from the public and as almost certainly an effort to prevent the public from learning that MANA's own statistics show that homebirth increases the risk of neonatal death.

To Ricki Lake and Abby Epstein

2008-07-16T12:45:00.003-04:00

Ricki Lake and Abby Epstein have set up a new website to promote their film The Business of Being Born. The website has a message board, so I submitted a question:

I am wondering how you feel about the fact that the Midwives Alliance of North America (MANA) is currently withholding the safety data that they have collected since 2001.

According to a public statement by MANA (http://www.narm.org/pdffiles/2006_summernews.pdf), these statistics are available only to those who can prove they will use them for "the advancement of midwifery". Even then, you must sign a legal non-disclosure agreement to prevent sharing of the data with anyone else.

Don't you think that MANA is ethically obligated to release the safety data they have collected? Their refusal to release it publicly, and their insistence that anyone who sees it must be vetted and sign a confidentiality agreement in advance suggests that MANA's own data shows that homebirth increases the risk of neonatal death.

This is especially important in light of the fact that the US government has begun collecting data on place of delivery and birth attendant. The first dataset (2003-2004) was recently released at the CDC Wonder website and it shows that the most dangerous form of planned birth in the US is homebirth with a direct entry midwife. In fact, the risk of neonatal death at homebirth with a direct entry midwife is triple that of low risk birth in the hospital.

Shouldn’t MANA release its data so we can be sure that it does not confirm the CDC statistics?

The comments are moderated and posted on an RSS feed. I wonder if they will post my comment. I wonder about two other things, too:

Are Ricki Lake and Abby Epstein aware that MANA is suppressing its own homebirth safety data?

If they are not aware, will they make an effort to find out why MANA will not let women see the safety data that it has collected?

Obstetric malpractice suits: facts vs. myths

2008-07-15T10:21:00.002-04:00

What are the medico-legal realities of obstetric practice and how do they impact the provision of obstetric care? There is a great deal of misinformation on this topic propagated by homebirth advocates. Let's look at the reality.

According to James M. Shwayder, MD, JD, Liability in High-Risk Obstetrics, in the Obstetrics and Gynecology Clinics of North America:

Litigation centers on errors of omission or commission. Thus prime areas for obstetrical litigation comprise the following:

1. Errors or omission in antenatal screening and diagnosis
2. Errors in ultrasound diagnosis
3. The neurologically impaired infant
4. Neonatal encephalopathy
5. Stillborn or neonatal death
6. Shoulder dystocia, with either brachial plexus injury or hypoxic injury
7. Vaginal birth after cesarean section
8. Operative vaginal delivery
9. Training programs (Resident supervision markedly impacts litigation exposure. Increased used of nurse midwives and nurse practitioners may increase ones liability exposure.)

Three factors jump out at the reader:

1. Of the 9 most common reasons for obstetric malpractice suits, 6 allege failure to perform a C-section or failure to perform a C-section sooner.

2. Fully 8 out of 9 of the most common reasons allege failure to use more technology or to properly interpret the technology that was used.

3. Supervision and backup of other providers is a significant source of obstetric malpractice claims.

Not surprisingly, therefore, the recommendations for avoiding obstetric lawsuits include:

Antenatal screening and diagnosis

ACOG now recommends offering antenatal screening for chromosomal abnormalities to all pregnancy patients regardless of age. In addition, the broader availability of nuchal translucency screening establishes a standard of care in which most patients should be offered the opportunity for first trimester screening. A physician failing to offer patients such diagnostic testing is at risk for suit...

Antepartum fetal assessment

High-risk pregnancies require antepartum fetal surveillance. Fetal heart rate monitoring, ultrasound surveillance, amniotic fluid volumes, Doppler studies, and cordocentesis are appropriate in pregnancies complicated by conditions such as intrauterine growth restriction, twins, diabetes, hypertension, severe preeclampsia, and sensitization, among others. Guidelines for appropriate use establish an accepted standard of care. Deviating from these guidelines requires substantiated decision making; otherwise, physicians are at risk of a malpractice suit in the event of an adverse outcome.

Intrapartum liability

Obvious liability lies with an adverse fetal or neonatal outcome. Intrapartum management undergoes close scrutiny. The most devastating outcomes,and thus costly awards, center on neurologically impaired infants and babies with permanent neurologic deficits after shoulder dystocia.

Neurologically impaired infants

It is clear that careful attention to labor progress and fetal status, including adequate documentation, enhances defensibility. Intrapartum fetal heart rate changes must be recognized and responded to appropriately. Prompt intervention and operative delivery, if indicated, minimize allegations of negligence.

Shoulder dystocia

Shoulder dystocia is an infrequent, and often unpredictable, nightmare for the obstetrician. However, the law evaluates whether the complication was foreseeable and, if not, whether appropriate maneuvers performed. Recognized risk factors include a prior pregnancy complicated by shoulder dystocia and resultant Erb’s palsy, macrosomia, and a midpelvic operative delivery in fetuses with an estimated weight over 4000 grams. An estimated fetal weight over 5000 grams in nondiabetic pregnancies and over 4500 grams in diabetic pregnancies has been offered as justification for a primary cesarean section. Thus, a physician who overlooks the prior obstetrical history, does not estimate the fetal weight in labor, or who pursues a midpelvic operative delivery in larger infants subjects him or herself to a claim of negligence.

Vaginal birth after Cesarean section

Vaginal birth after cesarean section has come under great scrutiny. It is a safe alternative in well-selected patients delivering in hospitals with appropriate resources. However, recognized risks and the dire consequences have prompted some states to impose practice guidelines for VBAC. Physicians should document discussions of the risks and benefits of VBAC and the hospital's capabilities, with signed patient consent. Immediate physician availability and operative capabilities are required. If this cannot be offered, then the patient should be transferred to a facility with these capabilities.

Supervision of midwives

Certified nurse midwives often have independent practice authority. However, collaborative agreements may be required to independently prescribe medications. Written protocols, including scope of practice and referral guidelines should be in place and carefully followed. Hospital protocols and guidelines often dictate the level of supervision and consultation required. A physician employing a midwife is liable for any acts under the doctrine of respondeat superior. Vicarious liability occurs as it would for an employer liable for the wrong of an employee if it was committed within the scope of employment. Thus, guidelines and protocols must be followed to maintain defensibility of a case.

I have highlighted some of the legal requirements of obstetric practice. The justice system does not consider these tests, techniques and procedures to be discretionary. Any doctor who ignores them or does not use them can easily be charged with negligence.

Electronic fetal monitoring: facts vs. myths

2008-07-14T17:00:00.003-04:00

In light of the ongoing discussion in the comments section about electronic fetal monitoring, it seems worthwhile to review the current state of scientific evidence. A recent comprehensive treatment of issues in fetal monitoring, Medical Legal Issues in Fetal Monitoring (Clin Perinatol 34 (2007) 329–343), seems especially relevant because it addresses the way in which controversies in fetal monitoring are handled within the court system. The review lays out the issues:

... [EFMs] virtues are disparaged in various "evidence-based" articles that suggest that auscultation is comparable to EFM, or that EFM needlessly increases the operative delivery rate, but offers no benefit in prevention of neurologic injury or perinatal mortality...

...Pertinently, these articles and editorials do not call for the abandonment of EFM.

...Notwithstanding these developments, many lawsuits still involve allegations (and rebuttals) that the obstetrician either failed to recognize or act upon abnormal FHR patterns and that failure resulted in perinatal brain injury that could have been prevented.

The authors, Cohen and Shifrin, widely acknowledged to be experts in EFM, favor EFM over routine auscultation for the following reasons:

[We] resort to EFM as the primary screening test for intrapartum fetal asphyxia because of the limited predictive value of any other clinical risk factors during labor-including auscultation... EFM permits continuous accurate monitoring, permits using the fetus as its own control, evaluates tolerance of a fetus to stress of the individual uterine contraction, and permits the diagnosis of potentially catastrophic events in a timely fashion... There is no example of hypoxia or death on a monitor without warning. It provides a permanent record, subject to later review. With regard to auscultation, there is no study that supports the contention that auscultation is a reliable determinant of the fetal condition or of the need to intervene. Even those who find EFM useless for the purpose of preventing injury or death concede its ability to detect fetal hypoxia.

The authors conclude with an excellent summary of the current role of EFM in obstetrics and in obstetric malpractice suits:

Despite the persisting debates over its role and benefits, it is likely that EFM will remain a standard part of obstetric care for the foreseeable future. As such, it will also remain a focus of attention in obstetric negligence lawsuits. It must be remembered that in most cases the monitor pattern does not dictate the timing of intervention, but rather is used to keep mother and fetus out of harm’s way...

There is widespread agreement that improvement in perinatal outcome is possible, that the events of labor can contribute significantly to perinatal hazards, and that reviewing adverse outcomes and making obstetric units more reliable in terms of communication and interpretation of tracings will enhance outcome. (my emphasis) That notwithstanding, we do not yet know the totality of injury related to the intrapartum period irrespective of the mechanism. The estimates of the role of hypoxia vary widely, in great measure due to incompatible definitions and limited follow-up... In this respect, newer developments in pediatric neuroradiology and to some extent a more insightful approach to EFM may indeed help us understand these matters and at the same time improve outcome. It seems that we best protect ourselves in medicolegal matters when we protect the mother and the fetus during labor.

The bottom line is this: Neither doctors nor malpractice lawyers believe that the scientific evidence shows that intermittent auscultation is as effective as EFM, and that, therefore, the standard of care is the use of EFM. Essentially the only people who believe that the totality of the scientific evidence favors intermittent auscultation are "natural" childbirth and homebirth advocates.

An open letter to Geradine Simkins, President of the Midwives Alliance of North America

2008-07-12T13:16:00.004-04:00

Geradine Simkins, President
Midwives Alliance of North America
611 Pennsylvania Avenue SE # 1700
Washington, DC
20003-4303

Dear Ms. Simkins:

Your public claim that "doctors ignore evidence" on homebirth safety is shocking (President’s Editorial, July 11, 2008). As you know, your organization, the Midwives Alliance of North America, is currently HIDING your OWN safety statistics on homebirth. YOUR OWN evidence almost certainly shows that homebirth with a midwife increases the risk of neonatal death compared to hospital birth for low risk women.

MANA collaborated with Johnson and Daviss on the CPM 2000 project published as a paper in the British Medical Journal in 2005; Ken Johnson is the former Director of Research for MANA and the study was funded by money from a homebirth advocacy foundation. That paper ACTUALLY showed that homebirth in 2000 had almost TRIPLE the neonatal death rate of low risk hospital birth in 2000. Using the same data collection techniques, MANA has continued to collect safety data from 2001 up to the present.

The data has been processed and analyzed and MANA has publicly offered the data to midwifery organizations who can demonstrate that they will use it for the "advancement of midwifery". The data is evidently so sensitive that MANA has protected it with a legal non-disclosure agreement. According to the Summer 2006 bulletin (http://www.narm.org/pdffiles/2006_summernews.pdf) of your sister organization NARM (North American Registry of Midwives):

How can you get access to the MANA data on homebirth from the years 2001-2006?

The association then needs to contact the Director of Research on association letterhead, with the following:

a. A statement that the decision has been made by the group
b. A list of participating members
c. The name of a contact person who has been chosen to manage the account
d. The name of the association official authorized to sign the contract for the account

4) The DOR will then send a contract which contains two parts:
a. The agreement between the association and the Midwives Alliance for the account
b. A Non-disclosure Agreement which prohibits inappropriate use of the data...

Ms. Simkins, MANA has an ethical obligation to release the safety data it has collected. American women are entitled to a complete, public presentation of MANA's safety data. There should be no requirement for vetting and there should be no requirement for a legal non-disclosure agreement.

Contrary to your claim, and as the AMA is certainly aware, virtually all the existing evidence shows that homebirth increases the risk of neonatal death. Your own safety statistics almost certainly confirm this is detail. Hiding the data is unethical. Please release the MANA safety statistics to the public immediately.

Sincerely,
Amy B. Tuteur, MD

Don't listen, because you might learn something!

2008-07-10T14:38:00.005-04:00

I was intrigued by the way that Henci Goer attempted to "end" the disccusion of the Johnson and Daviss statistics. Of course her comments included no scientific evidence and of course they were filled with insults directed at me, but I was suprised by how honest she was about her true motivation in suppressing discussion.

...Maria's confusion illustrates the serious problems someone like Tuteur causes for people who want to understand an issue outside of their sphere of expertise. They fall into the trap of thinking they are hearing a legitimate difference of opinion by experts of similar standing when they are not. You know this is so in Amy's case because of her continuing to repeat the same accusation after her basic error was pointed out to her--more than once, I should add. However, the result of her tactics is that those wanting to understand the issue may end up throwing up their hands in frustration, thinking neither side has the right of it or it's just too complicated for the nonexpert to understand. That's a win for the Tuteurs of this world.

Her mud slinging also serves a purpose. Even if you try to ignore it or understand that it applies to her, it plants the pernicious idea that you can't trust anybody: everyone in the debate has an agenda and will cherry pick or distort data to support their position. Ernst's post suggests this. That's another win for the Tuteurs of this world...(my emphasis)

This diatribe is startling in its unwitting honesty.

Simply put, she makes two points:

If you listen to Amy Tuteur, you might end up thinking that the issue is complicated and requires expert analysis.

If you listen to Amy Tuteur, you might end up thinking that homebirth advocates like Goer have an agenda and will cherry pick and distort data to support their position.

Well, at least she understands what I am trying to do. Yes, I am trying to show that the issue is complicated and requires expert analysis. Yes, I am trying to show that Goer, and Johnson and Daviss have an agenda and repeatedly and deliberately cherry pick and distort the data to support their position.

Homebirth advocates rely on well known principles of human psychology to limit the knowledge and understanding of women. It is known that when people are provided with one side of an argument, even when they KNOW that they have been provided with only one side of an argument, they cannot accurately assess how their understanding would change when provided with all relevant information. Moreover, and this is especially relevant to the discussion of homebirth safety, the less information people have, the more confident they are in the rightness of their decisions, particlarly when those decisions are wrong.

An experiment described by Kahneman and Tversky, writing in Preference, Belief, and Similarity (pg. 730) illustrates this point:

Participants were presented with factual information about several court cases. In each case, the information was divided into three parts: background data, the plaintiff's argument, and the defendant's argument. Four groups of subjects participated in this study. One group received only the background data. Two other groups received the background data and the arguments for one of the two sides ... The arguments ... contained no new evidence: they merely elaborated the facts ... A fourth group was given all the information presented to the jury. The subjects were all asked to predict the percentage of people in the jury who would vote for the plaintiff. The responses of the people who received one-sided evidence were strongly biased in the direction of the information they had received. Although the partaicipants knew that their evidence was one-sided, they were not able to make the proper adjustment. In most cases, those who received all the evidence were more accurate in predicting the jury vote than those who received only one side. However, the subjects in the one-sided condition were generally more confident in their prediction than those who received borth sides. Thus, subjects predicted the jury's decision with greater confidence when they had only one-half, rather than all, of the evidence presented to it.

Henci Goer and other homebirth advocates apparently feel that they MUST suppress information, delete relevant information, remove any evidence that professional agreement exists, in order to maintain their hold on women. The less you know, the more likely you are to believe them.

This, more than anything else, if the fundamental difference between Henci Goer and me. She is afraid that knowledge and information will "confuse" women, about both the honesty of her arguments and her motivations for selectively presenting data. In contrast, I am sure that more information is better. I believe that women should have the EXACT SAME information that I have; nothing should be hidden for fear of "confusing" women. I have complete confidence that the more women know, the better equipped they will be to make decisions for themselves and their families. The bottom line:

I trust women; Goer does not.

A professor of statistics says ...

2008-07-09T12:30:00.002-04:00

Bravo, maria! Maria asked Henci Goer the question that sparked the debate on her site. She has not settled for the non-answer that Goer supplies or for the fact that my posts were deleted. She went to someone whom she believes is an independent expert.

Ok, I posted this to a prof. in statistics and here is his response:

The study I am looking at is this study:
http://www.bmj.com/cgi/content/full/330/7505/1416

The following explanation was given by Johnson and Daviss about their study:
http://understandingbirthbetter.com/section.php?ID=31&Lang=En&Nav=Section

Some people say they have used the wrong comparison groups and that the correct comparison would prove that homebirth has triple the neonatality rate of hospital birth.

***
OK, here’s my take on it…

When I read the executive summary of the BMJ, I was struck by it’s modest claims in the results. By modest, I mean that it essentially reported the percentages of differing outcomes within it’s own data set. It was the conclusion, however, that struck me: it claims that their study group was similar to a group not in the study, namely, low risk hospital births in the US.

That seems to be the basis of the criticism. The comparison group has one obvious difference that masks for lots of other potential discrepancies: it was retrospective data. The authors of the study actually point this out in the study, however, so, to me, it isn’t fair to fault them for making the comparison. Perhaps they could have added a footnote to the conclusion in the exec summary, but that’s a bit picky. The disclaimer is clear in the discussion section:

"Regardless of methodology, residual confounding of comparisons between home and hospital births will always be a possibility. Women choosing home birth (or who would be willing to be randomised to birth site in a randomised trial) may differ for unmeasured variables from women choosing hospital birth…."

Consistent with this disclaimer, the biggest factor (in my opinion) is the demographics of their study group. This is visible in Table 1, which shows the characteristics of the mothers in the two groups:

- More women above the age of 25
- Likelihood of having already given birth is much higher
- Typical education levels are higher
- 95% had partners—which I would wager is significantly larger than the comparison group, whose rate is reported as N/A

Their study group is a self-selecting subpopulation of women—they are different from other women in ways that move them to choose a birth method that is out of the "main stream." This fact alone (supported by the items I just listed) suggests to me that they were better prepared for birth, and more aware of risks and of ways to handle them.

They did attempt to sort the data from the Nat. Center for Health Stats into "low risk" mothers, in order to make a better comparison. Assuming that sorting method valid, they arrive at the result that their group is, essentially, equivalent to the in hospital "low risk" group. Not shocking, given the kind of mom in their population.

I hope this is helpful.
***

Now my question is, what numbers did Amy Tuteur use to come to her comparison of homebirth being triple the risk of hospital birth. Where can I find these numbers and how are they a better comparison?

I think in the end, on one hand, eventhough this study has lots of merrit, the homebirth advocates should maybe not take it as a decisive study about the safety of homebirth, as they tend to do now, saying 'see!'

However, I do not think Amy's claims are grounded either so I would like to present to this prof. the numbers Amy is talking about and see what he comes up with.

Henci, would you please refer me to where I can find the numbers Amy is talking about? My apologies if they are posted here before!

Thanks!
maria.

ps: I asked two other people knowledgeable in statistics to look at this and I am waiting for their responses as well

****

Maria, I will refer you to the data and explain what I am talking about. Don't hesitate to ask additional questions or request additional data if you think it will be helpful.

The original problem:

According to Johnson and Davis, when analyzing the different intervention rates of home and hospital:

We compared medical intervention rates for the planned home births with data from birth certificates for all 3 360 868 singleton, vertex births at 37 weeks or more gestation in the United States in 2000, as reported by the National Center for Health Statistics [Births: final data for 2000. National vital statistics reports. Martin JA, Hamilton BE, Ventura SJ, Mencaker F, Park MM. Hyattsville, MD: National Center for Health Statistics, 2002;50(5)]

When analyzing the different mortality rate of home and hospital, Johnson and Davis used a group derived from out of date homebirth studies. I have always thought that was strange. Why not use the neonatal mortality data of the group that served as the comparison for interventions?

I went back and looked at the neonatal mortality data for this group, the EXACT group that Johnson and Daviss felt was the perfect comparison for intervention rates. I did this by reviewing the exact same paper that Johnson and Daviss used... Looking at the raw data we find a death rate of 0.9/1000 (white women, age 20-44, 37+ weeks, 2500+gm).

The hospital neonatal death rate for white babies at term of 0.9/1000 is not corrected for congenital anomalies, pre-existing medical conditions, pregnancy complications or multiple births. The true rate is substantially lower. Nonetheless, we can make an important comparison. Johnson and Daviss reported a neonatal death rate at homebirth of 2.7/1000 (uncorrected for congenital anomalies, breech or twins). The neonatal death rate in the comparison group THAT THEY USED was less than 0.9/1000.

So now we have an explanation for why Johnson and Daviss used two different comparison groups. They used one group (births in the year 2000) for comparing medical interventions. The neonatal death rate in that exact group was 0.9/1000, half the rate of neonatal deaths at homebirth. They supressed that information by using an entirely different group (drawn primarily from the 1970's and 1980's) instead of using the death rate from the year 2000.

Here's where you can find more about the new explanation: Johnson and Daviss acknowledge the validity of my criticism.

Johnson and Daviss have recently "re-analyzed" their own data and lowered the homebirth neonatal mortality rate: Johnson and Daviss: If at first you can't trick them, try, try again.

Henci Goer's theory of information access

2008-07-07T23:34:00.002-04:00

Over the last several days, Henci Goer has deleted multiple posts of mine that offered detailed analysis of current homebirth controversies and links so people could read them for themselves. Now she posts this gem:

...In light of what has gone on with this thread, I will add a new rule: You will respect my authority as moderator to declare a moratorium on a topic. I posted that there had been enough information and resource links on the issue of the MANA 2000 home birth neonatal mortality statistics for people to make their own evaluations...

Here is my response (soon to be deleted there, but still available here):

You're joking, right?

YOU decided that there is "enough" information and resource links. What do you think is going to happen if there are more? Do you expect people to fall down dead from information overload?

There is absolutely no legitimate reason to limit the presentation of relevant information. The ONLY reason to limit the presentation of relevant information is to prevent people from finding out the truth.

I have no need to continue this discussion. I think I have made my point and hammered it home repeatedly. I only dropped in because you wrote about me personally and you lied. I honestly cannot believe that you were so careless. It is so easy to find out the truth about me and my credentials, but you never even bothered. Your contempt for the truth about something so obvious and easily checked should be a warning to others about your contempt for the truth about obstetrics.

Newest Cochrane review on delayed cord clamping

2008-07-06T19:52:00.002-04:00

The latest version of the Cochrane review of delayed cord clamping was published this month in Obstetrics and Gynecology. Effect of Timing of Umbilical Cord Clamping at Birth of Term Infants on Mother and Baby Outcomes confirms yet again that the benefits of delayed cord clamping have been oversold.

We included 11 trials of 2989 mothers and their babies... For neonatal outcomes, our review showed both benefits and harms for late cord clamping. Following birth, there was a significant increase in infants needing phototherapy for jaundice (RR 0.59, 95% CI 0.38 to 0.92; five trials of 1762 infants) in the late compared with early clamping group. This was accompanied by significant increases in newborn hemoglobin levels in the late cord clamping group compared with early cord clamping (weighted mean difference 2.17 g/dL; 95% CI 0.28 to 4.06; three trials of 671 infants), although this effect did not persist past six months. Infant ferritin levels remained higher in the late clamping group than the early clamping group at six months.

There are two important things to note about the results of this study:

First, contrary to the claims of homebirth advocates, delayed cord clamping does not affect oxygenation.

Second, increased newborn hemoglobin levels can cause harm as well as a benefit. The delayed cord clamping group was more likely to require phototherapy than the early cord clamping group. In other words, if the baby has normal to high hemoglobin levels to begin with, delaying cord clamping can lead to pathologically high levels of hemoglobin.

The bottom line is that delayed cord clamping provides limited benefits to a limited subset of infants, and is also capable of causing harm.

Henci Goer responds as predicted

2008-07-05T23:05:00.003-04:00

Henci Goer has made me look like I can predict the future.I have been waiting for several days for her to address the fact that the Johnson and Daviss study ACTUALLY showed that homebirth has a neonatal death rate that is triple that of hospital birth. Here's what I wrote 10 hours ago:

Head over to Henci Goer's "Normal" Birth Forum and see how she is struggling, too. I've made two main claims that she KNOWS are true. First she deleted the claims and the supporting data. Then she had the unmitigated gall to pretend that I hadn't presented the supporting data. That was easy for everyone to understand; THEY had already seen it. Therefore, she let me put the links back up. Over the last several days, she has struggled to come up with a response. She's apparently in a bind. She obviously knows what the truth is and does not want to be caught in a falsehood. On the other hand, she certainly does not want women to know that my claims are true.

I expect that her answer will be the usual mix of aspersions about my credentials, and some baffling, high faluntin' conglomeration of technical language that will mean nothing and will allow her to pretend she has answered when she has not. It would be much easier, and far more ethical, to simply tell the truth.

Here's how she finally responded:

...Anyone who wants a calm, reasoned, scholarly explanation of the caveats of making appropriate statistical comparisons with the MANA 2000 study should [read Understanding Birth Better]. It does a better job of responding to Tuteur than I can do, which is not surprising since the author is an epidemiologist, and I am not.

As for Amy's mention of other deaths that I omitted from my calculation, this is a prime example of how she misuses data. The "other deaths" were not neonatal deaths. They were intrapartum deaths and therefore were not relevant to a comparison with hospital-based neonatal deaths. Indeed, Amy's persistent confusion over what is encompassed by "neonatal deaths"--this is not the first time I have pointed this out to her in this Forum--brings to mind Andrew Zang's comment: "He [or, in this case, she] uses statistics the way a drunken man uses lamposts--more for support than illumination.

FACT: Johnson and Daviss have now "adjusted" their data to claim that the neonatal death rate at homebirth in 2000 was 1.1/1000. Goer has not disputed that and has not explained why they "suddenly" realized that they made a mistake in their own paper.

FACT: The neonatal death rate for low and moderate risk women in the hospital in 2000 was 0.34/1000. Therefore, the neonatal death rate at homebirth in 2000 was TRIPLE the neonatal death rate in the hospital. Goer has not denied that either.

She can try to change the subject, she can try to pretend it doesn't matter, she can cast insults in my direction, but no one is fooled.

Addendum (7/6, 1:17 PM): No doubt people will be shocked, shocked to learn that Henci Goer responded to the simple, direct questions by deleting them.

So here's where I am with this: Aside from responding to Amy's assertion that she is qualified to discuss mortality stats and I am not, I have deleted Amy's posts along with your responses to Amy's attacks on my integrity. ... I think there is enough information in this thread and the links and sources provided in the posts that anyone who wants to make their own evaluation of the Johnson and Daviss paper, can do so. Therefore, I would like first to thank those of you who contributed positively to the discussion and second to declare that we are done with the topic of the MANA 2000 stillbirth and neonatal mortality statistics.

She doesn't appear to think much of the intelligence of her own readers if she believes they will be fooled by this.

Even such a short paragraph contains a lie. I never said that Goer is unqualified to discuss statistics. Quite the contrary. I said that she is qualified to discuss statistics and therefore, she knows what I have claimed is true. That's why it is so important to expunge any reference to it.

A nasty question

2008-07-04T11:08:00.003-04:00

In large part, "natural" childbirth advocacy is about some women demeaning other women for having different preferences. Sometimes the putdowns are subtle; often they are not. One of the nastiest putdowns, in my view, the seemingly innocent question: "What are the risks of NOT having pain relief?" That brief query captures a great deal of the meanspiritedness of "natural" childbirth advocacy. It's the same as saying: "What's the big deal? It's not like pain is going to kill you. Why should you treat the pain of childbirth, when if you just do what I do (What? You're not as brave, strong and special as me?) you will be rewarded with the most delightful boost in low self esteem."

Let’s do a little thought experiment. Imagine if we substituted labor pain with the erectile dysfunction. After all:

"Does erectile dysfunction really need to be treated as if it were a medical event? It just "naturally" happens to some men. It's not like they are even suffering pain. They've simply lost the ability to have intercourse, which is hardly life threatening. And let's be honest here, treatment for ED has RISKS. If you take Viagra, you could have a heart attack. In contrast, what are the risks of NOT treating erectile dysfunction?"

It is astounding to me how so many women are so dismissive and cruel when it comes to the suffering of other women. They would not be so dismissive to men about the inability to have an erection. Why is the former less important than the latter?