Judith Rooks models ethical behavior for homebirth midwives

Got ethics ?

A birth activist once told me that she had heard Judith Rooks express regret for undertaking a study on VBACs in birth centers. Rooks had been confident that the study would show that it is safe to have a VBAC in a birth center, but it showed the opposite. Prior to the study, VBAC was considered a reasonable option for birth centers; after the study it was prohibited. Yet even though she was disappointed with the results, even though they showed the opposite of what she had wanted to show, she published them anyway, because that’s what ethics requires.

I don’t know if the story is true, but it was one of the first things I thought of when listening to Rooks testify before the Oregon legislature about the appalling rate of death at the hands of Oregon homebirth midwives (8X higher than the death rate in the hospital). She sounded deeply grieved to have to report that homebirth, which she supports, is unsafe as practiced by Oregon homebirth midwives, yet she reported it anyway, because that’s what ethics requires.

Her testimony highlights the profoundly unethical behavior of the Midwives Alliance of North America (MANA), Melissa Cheyney, and the midwifery hierarchy of Oregon. All three conspired to commit what amounts to fraud: for many years they have been deliberately hiding that homebirth with a homebirth midwife has an appalling neonatal death rate both in Oregon and in the country as a whole. It is the midwifery equivalent of the Vioxx debacle. Although the hierarchy at the Merck drug company was aware that the pain killer Vioxx increased the risk of death from heart attack and stroke, they marketed it anyway. They took the position that it was more important to make money from Vioxx than to protect consumers. It eventually caught up with them. To date, Merck has paid out billions to the thousands of families of those who died as a result of taking Vioxx.

MANA, Melissa Cheyney and other homebirth midwifery executives have knowingly and deliberately taken the position that it is more important to be able to work as homebirth midwives than to protect mothers and babies. In many ways, the case for hiding the appalling death rates at homebirth is more compelling economically than the case for bringing Vioxx to market. While Vioxx represented a significant share of Merck’s income, it was no where near 100% because they have many other products. In contrast, homebirth midwifery usually accounts for 100% of the income of homebirth midwives. Revealing the truth about homebirth deaths would have a major impact on the ability of homebirth midwives to attract clients and make money.

I suspect, though, that money was not the only or even the primary motivation behind the unethical behavior of Melissa Cheyney and MANA.

We are currently immersed in a virtual epidemic of unethical behavior among scientific researchers. It is so easy and so tempting to report fraudulent results that it happens all the time. Partly it is the tremendous pressure to publish scientific papers, but often it is the result of a researcher believing so profoundly that his theory is correct that he (or she) feels no guilt about “massaging” the data to support the theory. They don’t believe that they are committing fraud because they are sure that future data will ultimately prove them right, but they can’t wait for future data because people can benefit from the theory now. Couple that with the fact that scientific journals rarely demand that a finding be reproduced before publication and you have the perfect formula for the plethora of scientific papers routinely published even though they are junk.

I have no way of knowing, of course, but I suspect that something similar has been going on at MANA. It started in 2005 with the Johnson and Daviss BMJ paper that claimed to show that homebirth was safe even though the data showed that homebirth nearly tripled the risk of neonatal death. And it has continued ever since with Melissa Cheyney and MANA waiting desperately for the data that would show homebirth to be as safe as they know it is. That data never came because homebirth midwives are grossly undereducated, grossly undertrained, unsafe practitioners. The longer they waited for confirmation of what they believed, the more they were required to contort themselves to hide the data they had. One thing is sure: they demonstrated consciousness of guilt by deliberately hiding the information from American women.

Many of their tactics over the years demonstrated their consciousness of guilt, but none more so than the decision to share the data only with those who, after being appropriately vetted, would sign a non-disclosure agreement complete with legal punishments for those who shared the data with anyone else. In other words, they understood that the death rates were so hideous that they had to take the incredibly heavy handed and revealing step of announcing legal punishments with anyone daring to share the truth with American women, the one group that was most entitled to have the information.

It appears that MANA, Melissa Cheyney and the midwifery hierarchy never considered their ethical obligations, and not just their obligation to release the data. Almost any other professional organization, when confronted with the evidence that their practitioners were responsible for an appallingly high death rate, would have instituted plans for improving outcomes. It seems never to have crossed the minds of Cheyney and others in MANA. Babies dying preventable deaths? Sad, but apparently a small price to pay for the freedom to be a pretend “midwife” and charge women for services that are apparently literally worse than nothing. The folks at Merck having nothing on Melissa Cheyney and MANA when it comes to the cold blooded sacrifice of innocent people (babies, no less) on the alter of expediency.

Now, of course, their efforts to hide data have been eclipsed by states collecting their own data and they have no one but themselves to blame. As I have written in the past, the biggest mistake that homebirth midwives ever made was their campaign to obtain licensure. They didn’t want to do it, but they wanted insurance reimbursement so badly (and insurance companies will only reimburse licensed practitioners) that they took the risk and it has blown up in their faces. You can fool some of the state legislatures some of the time, but not all of them, and it is hard to fool insurance companies at all. It was inevitable that they were going to demand data, and collect it themselves if need be. Now that data is coming in and it is very, very ugly. What insurance company is going to be willing to reimburse providers that have appalling death rates and, almost certainly, appalling injury rates? And birth injuries are not cheap. They can cost hundreds of thousands of dollars in acute care (think head cooling to minimize neonatal brain damage) and millions in chronic care for those left permanently impaired.

Judith Rooks modeled ethical behavior for midwives and it would behoove them to follow her example and release the data they are hiding and take the steps necessary to improve safety. I have little hope that will happen. The way I see it, the disclosure of the appalling death rates is not the end for the CPM credential, although I suspect that is where it will lead us. Rather, like Winston Churchill once said in another context:

Now this is not the end. It is not even the beginning of the end. But it is, perhaps, the end of the beginning.

It is the end of period in which homebirth midwives were able to hide the dead babies, and, as such, marks an important turning point toward the inevitable abolition of the CPM credential. CPMs are not eligible for licensure in any other first world country. It is time to insist that they are not eligible for licensure in the US, either.

  • Hannah

    On the wider subject of dodgy research ethics in medicine, Ben Goldacre’s new book, which deals, widely, with this subject, is now out in the US:

    http://www.amazon.com/Bad-Pharma-Companies-Mislead-Patients/dp/0865478007

  • OBPI Mama

    Birth injuries are certainly not cheap… so true! My son has one due to TERRIBLE decisions my homebirth midwife made (of course, my guilt to live with is that I chose a homebirth and my son has to live with a disability the rest of his life). His first year of life, our medical bills were over $110,000 (it was a lot to us even though I know some families have it way worse). We exceed our deductible every year and have a list of things that they don’t cover that we pay oop. Last year when we tried to find a different insurance, as soon as they heard my son’s injury, our would-be premiums tripled what they originally quoted. Had I not been in the denial stage of the grieving process my son’s first 2 years of life, I might have taken measures that would have enabled us to have a bank account for his medical bills and “extras” (things his center wants him to be in for strengthening that insurance does not cover) and held a midwife accountable for her extremely poor judgements. My own fault all around. Anyway, great post! It sucks when things don’t pan out how we expect, but being a grown-up means accepting the truth and learning to change our perspective because of it (it took me 4 years to fully do this in my turnaround about homebirths though I was going through the grieving process for quite a long time too). Good for the researcher for speaking the truth even when it’s hard.

    • Allie P

      I am so sorry for your family’s misfortune, your son’s challenges, and the troubles you’ve had getting insurance. I wish you the best. Please keep getting your story out there. It’s important for people to see that there’s another side of this that organizations like MANA and homebirth friendly sites try to hide and delete.

    • Lisa from NY

      I am so sorry for your difficulties. I have friends who are convinced beyond a reasonable doubt that homebirths are safer. By sharing your story, hopefully someone will be alerted to the dangers of homebirths.

  • Not My Normal Nym

    There are very few comments on this post compared with what you usually see on this blog, yet the information couldn’t be more damning. Says a lot.

  • Krissy

    In my experience with OHLA, the license is just a scam. When a midwife has a license it provides a false sense of security for the mother (like me) to believe I am in experienced, knowledgeable hands. However, I think mandatory licensing for these lesser midwives just helps them collect health insurance money, mine collected $6800.00 without even delivering my baby. Now it looks like the OHLA complaint I made in September of 2010 will only benefit OHLA by giving them money from the fines they will impose eventually if this complaint is ever resolved. I have had no information provided to me by OHLA. I only know what is happening by looking at the website. CPM and LPM and whatever they come up with do not belong with a license. We have CNM’s for that. If they get all midwives to be licensed through OHLA it will just fuel the fire for more undereducated, negligent women to call themselves professional midwives, while OHLA collects more license fees and disciplinary action fees and “midwives” get thousands more dollars due to being able to take insurance.

    • Guestll

      May I ask why the midwives who collected didn’t end up delivering your baby?

      • Krissy

        Because I labored for 32 hours without being able to urinate fully and my bladder distended too much. The midwives said I was dehydrated, that “my body was using it all up” and kept giving me water and IV fluids. We had an emergency c-section. The midwives even charged me for the time they spent in the hospital waiting for me to get out of surgery, I didn’t even know they were still there.

        • fiftyfifty1

          This seriously makes me mad. They can give IV fluids but they can’t palpate a bladder or do a cath? Talk about iatrogenic! Don’t get your patients into something you can’t get them out of is the rule I learned in my medical training.

          • Dr Kitty

            Jeebus!

            SO…they thought you were oliguric, and instead of wondering WHY you weren’t passing much urine, they decided you were dry and gave you fluids, and when you STILL weren’t passing much urine decided to give you more fluids.

            They were happy to keep an woman in prolonged labour with oliguria not responding to IV fluids at home.

            Stellar care.

            This is what happens when people with little understanding of human physiology and anatomy are in charge of labour.

            There is a minimum amount of urine you should be making. if you aren’t making it ether you are dehydrated, your kidneys aren’t working, or you can’t pass what you are making.

            You exclude the first by giving fluids, the third by catheterising, and in a hospital can exclude the second with a renal function blood test. At home if you have catheterised and no urine has flowed, and given fluids and no urine has flowed- you should assume a renal cause and get to a hospital.

            What you DON’T do is just keep pushing fluids.

          • Krissy

            The sad truth is they did do one catheter and got 500ml out. I wonder should that not have caused alarm? Don’t you think they should have said something? The investigator midwife from OHLA told me she could not believe a licensed midwife would not understand that I had a problem with urination and needed to go to the hospital. When I finally got to the hospital the doctor got 1100ml out of my bladder. He said the distention of my bladder prevented me from progressing further. My son’t head was crooked and had a cord draped over his shoulder. Not to mention the chorioamnionitis that was setting in after they broke my water without telling me, ( I thought I had urinated on them). When I asked the midwife who owned the birth center why they did not do a catheter again after the first one since it had a large amount of urine or why they could not keep a catheter in, she said it would have been uncomfortable for me.Yet they continued to push fluids. I went home with a catheter for 8 days and a lacerated bladder. Yeah, thanks… that was much better than just having a catheter and a vaginal birth in the hospital. I feel so lame, so stupid. I can’t help but blame myself.

          • Dr Kitty

            You did nothing wrong other than put your trust in the wrong people.

            Their care was negligent.
            Damn right 500mls should have caused alarm.

            I am so sorry you went through all of that.

            I hope you have written to your legislative representative with your story, as you are proof that birth with incompetent care givers causes more than “just” stillbirth.

  • Renee Martin

    Remember, just because data is collected, does not mean it is guaranteed to be made public, shared when needed, or even used at all (see: CO).

    Judith is extra awesome because she got the data, and presented it, earlier than planned, so that it could be part of this lawmaking decision. The report wasn’t suppose to be released until June, IIRC, which would have been too late for this licensing bill. It would have been so easy to do nothing instead.

    Had a DEM supporter, or even just someone that didn’t really care, been in charge, they could have (at best) let it be released on time, well after the new laws were written (and passed/failed). That she was willing to get this data into the hands of those who need it most, in time, is wonderful, and shows that she cares about babies and families, unlike MANA.

    • m

      I have spent years trying to argue against Dr. Amy. In the last few months I have begun to ask if maybe she hasn’t been right all along.

      I still believe that home birth can be a good option for a very small, well screened, very low risk population. Those women comprise a very small number of potential clients.
      Unfortunately for women, the ones who don’t qualify seem to be the majority of DEM and CPM clients.

      • fiftyfifty1

        And even those well screened low risk mothers should be attended by providers with real training (CNMs) if they are going to homebirth. My mother was a low risk as it is possible to get. The DEM still almost managed to kill my baby sibling (loosely tied the cord with a shoelace, it slipped off and baby would have bled to death if a family member hadn’t happened to check the diaper).

    • Squillo

      I wonder what kind of blowback Rooks is getting from this.

  • c

    Thank you for this! I attempted a home birth in 2010 in Oregon, under the belief that it was “as safe or safer than hospital birth”. My midwife let my pre-e develop (I didn’t know I had it until after but she must have known from my BP/edema/protein in urine) until at 40 weeks 5 days, I had a NST that showed no movement and my BP was through the roof and I had an emergency c-section. I would have NEVER EVER have risked a home birth if I thought it was a risk, in fact I thought I was being safer and helping to avoid a c-section.

    This year I gave birth to a second child with an OB in a hospital and my pre-e was caught early (same exact thing as last time but instead of ignoring it, we tried to manage it) and we did an induction at 39 weeks (it failed because the baby had a cord around her neck, in fact in the c-section they couldn’t get her out with the length that was available without untangling her) but I could have potentially avoided a c-section with my first because we could have induced. Instead my midwife ignored it and it got to the critical point — which was much more traumatic for me! What kind of model is this? Ignore all issues until it gets to the emergency point? I had no idea. My second c-section was relaxed, believe it or not, and a much better experience because it was planned, the reasons were discussed, I knew and trusted my OB, I wasn’t just dumped at the hospital at 40+ weeks and left to fend for myself.

    I am so angry that the Business of Being Born movie convinced me to even attempt this, and I am furious that MANA is hiding this data from us. Not only should homebirths be illegal, there should be jail time for anyone who knowingly hid this information.

    • Bombshellrisa

      That must have been so scary for you, I am sorry.

      • c

        Scary yes, but also a really tough recovery for me on the first one because my blood pressure stayed high after the birth and I was on BP meds for two weeks. It would have never happened like that with an OB. But I am thankful too, I had planned a water birth at home, which means that c-section might have saved my baby’s life in more than one way.

    • OBPI Mama

      I also thought homebirths were safer for women too. Being lied to is no fun. My son was injured because of my homebirth. Had we transferred due to my neon red signs (I wasn’t because of midwife’s arrogance of homebirth’s safety), I would have had a c-section and he would be healthy. Instead he HAS to be my brave, determined, amazing boy because of my midwife and I’s terrible decisions… he could have just been amazing and learned the other things as he grew… not because he had to be that way since a newborn. My c-sections have been peaceful and wonderful while my homebirth was traumatic and almost deadly.

  • Yesacsection

    I would hate to be in Judith Rooks shoes right now.

    Many years ago, before I went to graduate school I would have argued with Dr. Amy about the prevalence of fraud in the scientific community. However, it really is not hard to find. My first Ph.D. advisor was up for tenure, and tried to make some of my experiments look better than they were by adding fake data points. I confronted the behavior at the advisor/advisee level, then at the department level, and finally at a committee level. It happened three times! In the end, I changed Ph.D. advisors and academic institutions because they did not consider it as serious as I had. They said since it had not yet reached a scientific journal, and had only occurred on the internet in saved powerpoint presentations and in posters, that it was a stupid mistake made by someone nervous and under pressure for tenure. The rationale was that it was a bad decision that would not be repeated.

    I do remember spending hours/days/weeks trying to find a way to rationalize my former advisor’s behavior and debating what to do–that person was very important in my early graduate career, taught me many very positive things, was well respected by the community, and previously had my trust. That group of people made me question if I was overreacting or being ‘too ethical’. I am confident now that I was not, but it was very very difficult to feel so alone. But, as another commentator said, these things to get ferreted out. Last fall when I presented my current work, I ran into a former faculty member of the department at a conference. They congratulated me on my work, and told me they wished they had done more because this person has created nothing but trouble and now they have a lot more to do to fix it.

    So it does happen. I think it is typical in every aspect of life to dismiss the flaws in people you see as colleagues as minor mistakes that won’t happen again, and also very typical to protect your self interest. Yay to Judith who is doing the right thing and reporting as science and ethics demand.

    • Renee Martin

      She is retiring after this, so Im sure she will be fine. I am so glad that she stayed long enough to do this project, or it may never have been reported.

    • One of my favorite purchases was “my first book of business ethics”. It’s a board book (like for toddlers) put out by Quirk. Notable inclusions:

      Necessity knows no Law
      They Owe Me
      Where’s the Harm
      It’s Ethical if it ain’t Against the Law

      It’s like a academic dishonesty bingo sheet! I don’t know what you could have done more, outside of narcing them out to the publishers or the conference organizers. And, for the record, it is not a “mistake” to alter data– it is a deliberate act. I am very sorry this happened to you– it is very lonely. I tried to act against plagiarism at the medical school/ resident level, and encountered a complete lack of departmental support. These weren’t even careers being ruined, this would have been people repeating rotation projects, and I ran into the same attitude.

  • Hearsay

    I’m not leaving my name here, although Dr. Amy and I have corresponded, and she can tell from my email, which is my real email, exactly who I am. I live and practice obstetrics in Oregon, and I take homebirth transports (because ethically, that’s what you do–if a woman needs help, you help her), so I have to work with these people, and I so not wish endanger the health of their clients by making them reluctant to bring moms in.

    But what I have to say is this: one of my colleagues here was in a close friendship with Melissa Cheyney and very supportive of her. When I first started reading this blog, I asked him about that MANA data. “Oh, it’s bad, and she knows it’s bad,” he said. Why is she refusing to release it then, was my next question. His reply? “Well it’s her big project” he said. “She wanted to make her reputation on it.” He then went on to imply that she was hoping to show something positive with the data, maybe improvement over time.

    Mind you, this was over two years ago. So, all this time, if we are to believe what this doctor had to say, Dr. Cheney has ignored her ethical obligation as a state official, an academic, a practitioner, and a human being, to share what she knows. What can you say about a person like that?

    • The Bofa on the Sofa

      See my comment the other day about why MANA won’t provide any leadership in improving safety. As I said, too many careers depend on the midwifery/homebirth model, and for MANA to step up and do the right thing would constitute a 180 degree turn for them, and ultimately ruin the careers of the people who have created it.

      I didn’t mention any names.

    • Durango

      That sickens me.

    • Mrs. W

      A person like that has failed to recognize direct culpability for the harm that might accrue as a result of the information not being available.

    • moto_librarian

      Rest assured, Ms. Cheney; you have definitely secured your reputation with me as an unethical human being.

      • I don’t have a creative name

        Isn’t she also the one who claimed that Dr. Amy quit practicing due to post partum psychosis, with NOTHING to back up such a claim, just a pathetic attempt to discredit the person who most shines the light on her lies and delusions?

        Yeah. I tend to think she probably doesn’t care that most people find her completely unethical. All that matters is The Cause.

    • theadequatemother

      I guess she will make her reputation on it…just not in the way she envisioned.

    • The Computer Ate My Nym

      “Well it’s her big project” he said. “She wanted to make her reputation on it.”

      The Tuskegee Syphilis Study was someone’s big project and they were hoping to make their reputation on it. They did, but not in the way they intended.

      • attitude devant

        Yeah, CAMN, I thought of Tuskegee too.

    • MnaMna

      Hi Missy! *waves* We all know that you read here so you can screen cap us and whine about meen Dr. Amy to your students. Take this comment and stick it in your anthropology conference presentation.

      • Susan

        Maybe you should have included a photo so you can claim copyright infringement when she does what you ask?

        • MnaMna

          Shhh Susan you’re going to scare her away from the bait that my latest lay-lawyer and I are setting. What are you, some kind of stalker troll? 😉

    • Captain Obvious

      The way I see it, many women will still Homebirth regardless of the data. Melissa should have just published the data so women can know the risks and decide if the benefits outweigh them. That is informed consent isn’t it. I bet many would still homebirth. She wouldn’t have had to hide important data for years that only makes her look disingenuous. Now she has a scandal to explain which may actually drive more away then if she had just published the data and planned strategies to improve education, training, and accountibility, and demand mandatory licencing and malpractice. I could only hope women who have had poor outcomes could have some type of justice against MANA for their blatant conspiracy to hide the information that they needed to make an informed choice. The hardcore homebirthers will still do it, but women on the fence considering Homebirth because they were told lies is where the crime lies.

      • DiomedesV

        Is it about encouraging more women to homebirth, or is it just about being right?

    • Squillo

      The irony. Here’s Cheyney talking to ABC News for their story on licensing and Shahzad Sheikh’s death:

      Cheyney’s primary concern is that the state track birth outcomes with midwives so that there can be “quality assurance.”

      “Oregon just passed a house bill that enables us to capture both planned
      place of delivery [home versus hospital] and birth outcome,” she said.
      “Licensed midwifes are also now required to report their outcomes, so
      with this new data we can hopefully form evidence-based guidelines for
      how to regulate midwives.”

      • The Bofa on the Sofa

        The phrase, “Hoisted by one’s own petard” comes to mind, but I am not sure Missy will be honest enough to recognize it.

        • Squillo

          Yeah, one hopes.

    • Sue

      Even if it were true (that she wanted to show an improvement), where is her campaign to maximise safety ? (ie risking out, using trained providers, early transfer etc)

    • fiftyfifty1

      One of your colleagues supported Melissa Cheyney? Why?!

  • Mrs. W

    I can only hope this marks the beginning of the end of substandard care for pregnant women and their children. Properly educated and trained midwives can be an important part of a maternity care system – however, it should not be forgotten that pregnancy and childbirth is a particularly vulnerable time for the health of women and children. As a result, women and children deserve the highest standard of care during pregnancy and childbirth, not the lowest.

  • Susan

    Great post Amy. My first response reading it is of course she did that because that’s what real professionals do. It was part of my wake up call when I became a nurse after being immersed in homebirth culture. It was obvious that doctors and nurses generally are open to changing their practices based on new research. We are always having to say, well, we used to do X but it’s been shown Y is better. The CNM’s that delivered my daughter, I believe, were like Rooks, one went on to teach actually in Oregon. They didn’t seem to have their heads in the sand about risk, in fact, so many years ago, they told me if my baby had an estimated fetal weight of 9 lbs that there would be no homebirth; this was despite the fact my son had weighed 9#8 and a 15 minute second stage. The only legal midwives should be midwives that have the education to understand that it’s a profession not a religion.

    • PH Student

      My CNM had had two home births with her children, yet she decided to become a CNM and attend hospital births. That fact was never, ever lost on me.

      • Guestll

        My RM tried for a homebirth with her first and called time on a transfer in order to get an epidural. That was wasn’t lost on me either.

  • PoopDoc

    I still cannot wrap my head around why anyone with knowledge of the above would try to have a home birth. As a parent I want to minimize risk to my children. And 10x the risk (even if it is still low probability) is still 10x the risk.

    • Mrs. W

      People decide to do risky things every day – the thing I have a problem with is people choosing homebirth without realizing the risky nature of the choice. Many are told it is safe or safer than hospital birth – and that is the message that needs to be changed. People might still choose home birth, but I would hope that those who do so, do so with eyes wide open.

      • Elle

        And when they are told this, it is usually by people who a). stand to make money off them, or b). are so invested in homebirth as an ideal that they are blinded to facts (or both). Although knowing the risks and choosing to go for it anyway opens up a whole different can of worms…

      • Guestll

        I think that would necessitate a huge shift in the culture around homebirth. It’s one thing to do it if you believe, as I did, that it is as safe as hospital birth. It’s something else entirely to do it and know that the risks are that much greater. What does that say about priorities, values, ethics?

    • CSM

      Several reasons: irrational fear of anything ‘hospital’, financial burden if no health insurance, a firm belief that the stats are all made up by the big brother, a firm belief in her body’s ability to birth, a fast an easy previous labour/birth…remember – as odd as it is, to me anyway – that for some people statistics and other forms of objective reality aren’t really ‘legit’, that’s not what they base their choices on.

  • DiomedesV

    “Partly it is the tremendous pressure to publish scientific papers, but
    often it is the result of a researcher believing so profoundly that his
    theory is correct that he (or she) feels no guilt about “massaging” the
    data to support the theory.”

    I think the latter is very common, but I’m not sure that it’s always even conscious. I’ve seen papers where the data clearly went the other way, or at best didn’t support a trend, but the authors were desperate to fit their data within the prevailing paradigm so they engaged in some hand-waving. The reviewers either didn’t catch it or were on the same page.

    In my experience this happens for at least two reasons: 1) journals don’t like to print papers with negative results, and 2) many authors are not smart enough to write an interesting paper with the data they have.

    I’ve read reviews where the editor rejected the paper because the results were negative, and suggested a lower tier journal for publication. In one case this was for a well designed, highly rigorous empirical study of a colleague (not in medicine, obviously) where getting a negative result had major implications for a theory that interests a lot of people. Baffling.

    Sometimes a paper is no better than its reviewers (and editors). If you’re wondering why the reviewers let a paper go, think of the fact that peer review means just that. And some fields are just less rigorous overall.

    • auntbea

      I am going to agree that there is an epidemic of bad research. I am not going to agree that there is an epidemic of fraud as Dr. Amy claimed — perhaps I am really naive, or maybe I just have good taste in colleagues, but I think most people who devote their lives to research are intellectually honest, at least about their own field. And those that aren’t generally get their comeuppance.

      • theadequatemother

        There have been some major cases of fraud lately with significant numbers of papers retracted.

        We’ve had two researchers in anesthesia (one in Japan and one in Germany, I believe) where it was determined that the work was fraudulant…as in the data were fabricated. Two researchers may not sound like much, but in each case between 30 and 50 original studies were retracted and many reviews and metanalyses and texts had to be either withdrawn, ammended or redone as a consequence.

        It certainly feels like an epidemic.

        • Wow. That’s a LOT of original studies…

          • auntbea

            It’s easy to be prolific when you just make &^%!^# up!

          • theadequatemother

            its interesting though, how far it went over how many years before it was caught.

        • Do you remember the 1998 Anesthesiology article where the editorial plagiarized a ASA refresher course? Do you know what happened to the individual accused of plagiarism? He became the neurologist in chief at Tufts.

          “…comes to the Medical Center with a distinguished background in academic and clinical neurology… the author of more than 130 publications including original peer-reviewed articles… has received substantial and ongoing NIH research
          funding. He serves on editorial boards of several scientific peer-reviewed journals and study sections of the NIH and the American Heart Association.”

      • DiomedesV

        I don’t think there’s an epidemic of fraud per se. I think that there are more papers published each year (total) and that therefore, the total number of fraudulent papers has gone up. I’m not sure if there’s more detection. I only know of one researcher in my field who was fraudulent, and the vast majority of the people I know are very conscientious.

        Still, actual fraud is much less of a problem than poor critical reasoning and unconscious massaging of data either for the purpose of getting the paper into a better journal (or any journal at all) or because the author is not bright enough to turn a negative result into an interesting paper anyway (although that can be very hard, depending upon how straightforward the paper was supposed to be). Again, poor work is both more prevalent and more difficult to call out than fraud because it is vastly more common.

  • stenvenywrites

    At the same time they have been pressuring for licensure, homebirth midwives have also been increasingly willing to accept high-risk clients. So incredibly short-sighted of them and counterproductive: couldn’t they see that If the outcomes for LOW-risk pregnancies posed a financial risk for insurers, then factoring in the outcomes of vbac homebirths, breech homebirths, etc, would send insurers running for the hills? For the life of me I can not understand that business model.

    • DiomedesV

      This is not surprising at all. Midwives, like everyone else, are self-serving. If they’re smart, they know that regulation won’t catch up with them for a long time, and in the meantime they want to make money. This kind of behavior is extremely common–think financial sector–why should midwives be any different? Why should any individual midwife act in a manner that is best for the field as a whole?

      The fact that individuals can’t be expected to act in the long-term interests of anyone else, and often (and understandably) prioritize their own short-term interests or possibly unpredictable long-term interests is precisely why regulation is needed.

      • The Bofa on the Sofa

        Midwives, like everyone else, are self-serving.

        It’s interesting how far this goes, though. For example, I have lamented many times about how silent the ACNM has been on the issue of allowing CPMs to practice. You would think they would be actually MORE self-serving, since CPMs are less qualified, and are competitors. Yet, the sisterhood is so strong.

        I don’t understand that.

        • DiomedesV

          Are CNMs really challenged by CPMs? The vast majority of CNMs do not practice OOH. They run birth centres sometimes, but more often they are attached to a hospital in a birth center or work in the hospital. Remember, <1% of women give birth at home. I don't call that competition in any meaningful sense of the world. Just as CPMs are not competition for OBs, I don't think they're competition for most CNMs. Until they are, perhaps the ACNM sees little gain in getting involved, especially when you consider that they all kind of believe more or less in the same paradigm of natural birth.

          • The Bofa on the Sofa

            Fair point, although I would think that if the ACNM had standards, they would want to distinguish themselves from CPMs, because the two are so easily confused.

          • Squillo

            You’d think so, but I don’t think they see it as a huge problem. (Yet.) Their primary goals seem to be establishing themselves as independent providers and increasing access to midwifery care (and reimbursement). These goals are very similar to CPM goals, they’re not going to go up against them because they have little to gain by doing so; the arguments they’d have to use would likely be similar to those used against them. That may change if the safety problems surrounding CPMs get more traction publicly. They did take a stance against govt. reimbursement of PEP-trained CPMs, and they took some heat for that. Since then, it seems to be all about “building bridges”.

            And it may also be a case of “the enemy of enemy is my friend.”

          • AlexisRT

            Yes, CNMs and CPMs have an overlapping goal, that of removing collaborative practice and formal oversight agreements and establishing themselves as independent providers. Removing that requirement was a big issue where I used to live (NY) though a CPM alone is not adequate for licensure there.

          • Bombshellrisa

            I know that I want them to, simply because of the services that a CNM can provide. You see these CPMs billing themselves as “women’s healthcare providers” and saying that they can provide well woman care and birth control. A CNM can do annual exams and prescribe birth control. Since CPMs want to be called “experts in normal birth” and “caregivers for the pregnancy year”, if I was a CNM I would be screaming as loudly as I could that I could do that AND continue to care for women at all stages of their fertility.

          • areawomanpdx

            Oh, plenty of CPMs claim to care for women at all stages of fertility…

          • areawomanpdx

            Here in Oregon, 5% of women give birth outside the hospital…

        • Bombshellrisa

          It’s funny, if there are problems with a home or birth center birth, the CPMs seek out the hospitals where there are CNMs even if they are farther away. That happened to a poster here. The CPMs have said terrible things about Sally Avenson (a CNM at UW Hospital), but they have their clients taken over there despite the traffic and the toll bridge and the fact that there is a hospital three minutes from the birth center because Sally is known to be supportive of CPMs.

          • Karen in SC

            When minutes = brain, that is appalling.

            If I ever did decide to become a DEM, I’d get a sleek retro motorhome and have a driver to transport to hospital parking lot in the early stages of labor. Knowing my generally conservative nature, I’d have about a 80% transfer rate. But that’s okay since I will get paid up front and won’t give refunds.

            Hmmm maybe that’s a decent business plan. Could I charge extra if I grew my grey hair long and braided it?

          • Bombshellrisa

            Heck, charge your clients to braid THEIR hair and repackage it as some kind of relaxation package.
            Some of the disgruntled hospital transfer clients were accusing the midwives of transfering them to the hospital so that the midwife could bill for the care and an emergency transfer, as well as make another $750 for their “stay at the hospital as a support person” fee.

          • auntbea

            I would be much happier to pay someone to put my hair in a pretty braid than I would to have them help me squeeze out a blue baby with no painkillers. One of those things I can do on my own….

          • Dr Kitty

            Completely OT : for those of us who can’t braid hair, YouTube Lilith Moon.

          • Karen in SC

            There’s even more money in this than I thought! Would that hurt my repeat business, do you think?

          • Bombshellrisa

            Hasn’t hurt the CPMs here. As long as you have a pretty motor home for them to be in during the early stages of labor, they will love you. Just make talk a lot about feelings and wear lots of crystals. Oh, and if you don’t knit, you will have to learn. Don’t worry, I was taught by an enterprising 10 year old, it’s not that hard.

          • Karen in SC

            I can knit!! and I can scrapbook so providing a unique keepsake album could be an extra charge. Off to search motor home sales now…..

          • Bombshellrisa

            Make sure it’s pretty or make sure you know how to make it pretty. I have heard women complain bitterly after a homebirth or birth center transfer how “ugly” the hospital is. Apparently it’s more important to have lace curtains and candles. Life saving equipment, medicine and teams of trained professionals do not compare.

          • Amazed

            I am currently a redhead (almost Gina’s colour but at least I admit that mine is fake, ha-ha). I quite like myself this way. You can place extra charge for women like me to keep the fake hair colour by natural colouring agents throughout pregnancy.

          • Certified Hamster Midwife

            Form your gray hair into dreadlocks. Charge triple.

          • AlexisRT

            I was under the impression they liked Group Health for transfers if they could go there (and I believe Sally has or had privileges there).

          • Bombshellrisa

            Depends which CPMs-Eastside Birth Center in Bellevue likes Valley Medical Center, I think that Seattle Home Maternity favors anywhere Sally has privileges (I know she delivers at Swedish and Heather Chorley has been a back up midwife for her, despite their vast differences in licensure and experience.) and Eastside Midwives and Lake Washington midwives favor UW Hospital. A lot of the women who choose PSBC do so because it’s so close to Evergreen, there needs to be a real transfer plan explanation for those women, so they understand the process and that just because Evergreen is closest doesn’t mean that they will end up there.

      • Eddie

        What is funny about this, though, is that consumers in general innately trust those pushing “natural” things, as if they are not susceptible to this human failing. Governments follow. Thus, supplements not being regulated and manufacturers being able to say almost any old thing in advertising. So many people have this blind trust that “natural is better,” even when it is provably false and just a silly assumption to have. Midwives not only believe this themselves, but use it to make money.

        I agree completely. It is no surprise that midwives would do this, given the chance, as even recent history is rife with examples of other groups of people doing so. Doesn’t make it acceptable, ever, of course. It explains it, but doesn’t excuse it. Merck was rightfully punished for its behavior, and the people who buried the MANA data should be punished as well.

        • DiomedesV

          Sure, the naturalist fallacy is silly, but most of the time, it’s probably benign, albeit more expensive.

          The imposition of regulation on medicine is partly what has changed medicine from a bunch of quacks selling tinctures door-to-door to a reputable field with accountability. It’s not really because doctors are innately better human beings. It’s because we recognize that everyone is flawed and decided that the implications of that are far greater in medicine than anywhere else and decided to regulate.

          • anonomom_LLLL_IBCLC

            Well, and also, the placebo effect is real — taking something you believe will help you usually will help you a little bit. It’s just too bad someone unethical has to profit off of this effect.

    • DiomedesV

      This prioritizing of self and short-term interests is only facilitated by the belief that “birth is safe.” I doubt that many midwives really even think that what they’re doing is risky, even the ones who take high risk cases. It’s easy to act in your own interest when you don’t really believe you’re harming anyone. And quite frankly, many of them work for parents who also think its safe and/or are willing to take the risks for benefits to themselves. Which makes it even easier.

    • Bombshellrisa

      Of course, they would have to be doing actual prenatal testing and care to catch some of the high risk cases. Pamela Hines-Powell said that she didn’t even see a reason to be checking for fetal heart tones “Well, I know that prenatally there is really NO reason to HAVE to listen to the baby’s heartbeat – it’s sometimes nice if you’re wondering about viability, but if you are feeling baby move around (or even if not), it’s not a requirement. Just one of those things that we do to connect to the baby.” If she is not willing to do something so basic, do you think she is having her patients tested for GD or taking their blood pressure at regular intervals?

      • Susan

        Gives new validity to WNL meaning “we never look”… we never listen?

        • Bombshellrisa

          Lol. The part about “connecting with the baby” is just too ridiculous. If a pregnant woman comes into the ER or is admitted to the hospital for something other than complications with her pregnancy, fetal heart tones are still checked when vitals are taken. I can’t imagine a nurse explaining away why they weren’t checked “Oh, well, she says the baby is moving around, we felt that we didn’t want to connect with the baby right now so we didn’t take a listen”.

          • auntbea

            Eavesdropping is rude.

          • Liz

            I have talked to moms who went to the ER things like a UTI during pregnancy and the ER doc/nurse did not do an ultrasound or attempt to listen to FHT. One mom wanted an ultrasound to make sure the baby was ok and had to wait days because they couldn’t fit her in.

  • Dr Kitty

    Well said.

  • Alenushka

    Vioxx story was appalling. I now do my best to avoid taking meds that have been on the market less than 5 years. That was my doctor’s sage advice.

    • Ceridwen

      The thing that is interesting is that Vioxx isn’t actually any more dangerous than several other prescription NSAIDs. Hiding the evidence was actually a much bigger issue in many ways than the relative safety of Vioxx compared to similar meds. And Merck rightfully got smacked down pretty hard for it.

      In my view, this situation with homebirth is much worse, since the risk is not just being actively hidden but is dramatically worse than the other available options. Far more so than Vioxx vs. many other Rx NSAIDs. If you find the Vioxx story appalling, the homebirth story should make you absolutely livid.

      • The Computer Ate My Nym

        I agree. If Merck hadn’t tried to hide the data, Vioxx would be on the market now. Probably with a black box warning, but on the market, possibly with an indication for prevention of colon cancer in young people (low risk for heart disease) with familial polyposis (high risk for cancer.)

        I don’t know why people try to fake data in science. You can’t fool reality and you will eventually be found out. If anyone repeats your experiments anywhere, any time, they’ll know that you cheated. If no one does, it probably wasn’t very interesting anyway.

        • Sue

          Ironically, Vioxx is probably safer than aspirin, if you compare gastro-intestinal bleeding deaths – and yet, it’s always used as a stick to beat medicine. If I understand correctly, Vioxx increased the cardiac death rate in people with cardiac risk factors. IF people like this were risked out, there may be a group that would benefit from its use instead of other non-steroidals.

          • Dr Kitty

            I spend a lot of time trying to switch patients with CVD risk factors from Diclofenac to Naproxen…and even when told of the risks many prefer not to switch, because Diclofenac works better for them than the other NSAIDs.

          • The Computer Ate My Nym

            IMHO, the reason the Vioxx story should be used to beat medicine is that Merck lied. They knew perfectly well that there was a cardiac risk and they withheld that information. That should not happen. Ever. Silly analogy, but if a blood bank sends out ONE unit of mismatched blood, it gets investigated and often penalized. It simply should never happen under any circumstances.

            If they hadn’t lied, i.e. they’d genuinely not observed the increased risk in the initial studies I would say that they were being treated far too harshly and the criticism was unjust. I suspect they wanted to be able to sell their product as the first line drug for all circumstances and didn’t want black box warnings getting in the way of that.

            One unfortunate consequence of the whole Vioxx thing is that pharma firms are much more reluctant to allow clinical trials for secondary indications now. They’re afraid that someone will find an adverse effect and they’ll be in the same kind of deep doodoo that Merck is in. This is a problem since the best use of the drug is often not the original intended or first discovered use. (Aspirin was originally used for fever. In children. It’s really a cardiac drug…) Anyway, I hope that drug companies recover their backbone at some point and start allowing research again or we’re in real trouble in terms of the future of medicine.

          • I have heard (but haven’t verified) that the reduction in risk of GI bleeds was not significant. The increase in cardiac risk is for all comers, but the absolute risk is smaller obviously if your absolute risk is already low. My dad took it for his knee and nothing else really worked as well.
            It is really too bad– it was a good analgesic and if they had just followed the damn rules they’d be selling it today. I think they’d be able to skate past the black box too…

        • Kalacirya

          It’s actually a shame, because my understanding of the situation was that Vioxx was a very effective drug for arthritis. Also I’ve read that potentially changing the dosing could allow patients to get the benefit while lowering the cardiovascular side effect risk. But it’s off the market now because of gross irresponsibility.

  • Laural

    Excellent post. Love the quote, just a nice piece- makes me want to applaud at my computer screen.