Hannah Dahlen tries to lie with statistics … again

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I’ve written many times before about the endless efforts of midwives to demonize interventions in childbirth.

Australian midwife Hannah Dahlen seems to be leading the charge and doesn’t shirk from using deceitful statistics and crappy research to do it.

Dahlen can’t seem to make up her mind about the actual “harms” from interventions. On any given day she might be suggesting that C-section might destroy the infant microbiome, or maybe C-sections might change the epigenetics of neonatal DNA. Today, birth interventions might increase the risk of suicide.

Her central contention is this:

So death from suicide and trauma rises significantly between nine and 12 months after birth; it is nearly four times the rate compared to the first three months following birth.

And:

The women who died had higher rates of intervention in birth, higher rates of early-term births, pregnancy complications and neonatal intensive care admissions. They also tended to have babies who were born with a low birth weight and were ten times more likely than other women to have their baby die.

Her “research” was published in a journal I’ve never heard of, with an impact factor of 2.8. To put that in perspective, high quality journals have impact factors ranging from 30-50.

It’s hardly surprisingly that Dahlen had to resort to publishing in one of the lowest ranked journal in the world. The “research” is crap.

Here is the central claim:

So death from suicide and trauma rises significantly between nine and 12 months after birth; it is nearly four times the rate compared to the first three months following birth.

Sounds impressive until you give it a modicum of thought.

1. Why are suicide and trauma lumped together? There’s a big difference (in cause, effect, a preventive approaches) between dying at your own hand and dying in a car accident. There is no possible justification for including trauma in an analysis like this besides artificially inflating the purported scope of the problem.

2. How does the supposed high suicide rate in the postpartum year compare to the suicide rate for women in the same age group who did not give birth in the past year? Dahlen doesn’t bother to tell us. So we have no idea whether the rate of suicide and trauma is any different following childbirth than it is in women who haven’t given birth. That’s a stunning oversight.

3. Dahlen notes that the suicide rate in the 4th quarter of the postpartum year is more than 3 times higher than the 1st quarter of the postpartum year and implies that this is a dramatic rise. However, it is equally likely that the suicide rate in 3 months after birth drops and then rises again to baseline over the rest of the year. Without the background rate of suicide in women of childbearing years, it is impossible to determine what has actually happened.

4. Dahlen acknowledges that the woman who died of suicide and trauma differed substantially from the rest of the population.

A large proportion of women who died from suicide (73%) had a history of mental illness or substance abuse, or both. Most of the women who died because of accidental injury also had a history of mental illness or substance abuse (or both).

How does that compare to non-postpartum women who commit suicide? Dahlen does’t bother to check. What is the suicide and trauma profile of the other 27% of women? Does it mimic that of women with previous mental illness or substance abuse? Dahlen doesn’t bother to check.

5. Dahlen acknowledges that the neonatal death rates among the women who subsequently died of suicide or trauma were 10 times higher than the death rate of women who did not die of suicide or trauma. Yet she did not ask the glaringly obvious follow up question. Was the purported increase in maternal death from suicide or trauma the result of grief and loss, and not the result of being postpartum.

The bottom line is that Dahlen could not get this paper published in anything other than an extremely low ranking journal because the paper doesn’t show anything. Dahlen waves a bunch of statistics around but fails to investigate whether those isolated statistics mean anything at all, let alone anything about suicide in the postpartum year.

Dahlen’s solution is to provide more “services” to women in the postpartum year. Yet Dahlen utterly failed to show (she didn’t even bother attempt to show) that being postpartum is the relevant risk factor, let alone that more services would decrease the rate of bad outcomes.

If this is what passes for quantitative “research” in Australian midwifery, the solution may not be more services for patients, but better basic math and logic education for midwives.

  • Jessica Atchison

    Also…how many of those suicides can be laid at the feet of sanctimommies who go out of their way to make new mothers feel crappy because they didn’t give birth the “right” way?

  • Anne

    From the article on The Conversation-

    “Women may commit suicide because of mental health disorders, which were either pre-existing or developed during pregnancy or after they gave birth. Traumatic births or lack of support before and after the birth (or both) can also be contributing factors.”

    As there was no reference, I am not sure from whence the authors’ conclude a relationship between “traumatic birth” and suicide . My prior reading does not associate suicide or PND strongly with the birth type, rather that psychosocial risk factors are the main ones. Becoming a parent is a “stressful” life event, which can precipitate a psychological illness.

    Much more importantly- how does one define a traumatic birth? Trauma is a subjective experience, and must invite incorrect classification, especially in this type of research- retrospective collection from statutory datasets.

    While I appreciate the authors looking into late maternal death, I agree with other commenters that making the above statement (and others) is mischievous. The take home message I had from reading the paper was- more resources for women/families at the lower SE end of the spectrum. Spinning it to focus on someone’s arbitrary definition of “traumatic” birth as a preventable risk factor is obfuscation at best.

  • Lizzie Dee

    Using statistics like this is what put me off statistics. When they are simple like this, they don’t tell you anything at all – and when they are complex and detailed, I can’t understand them!

    73% were mentally ill or abused substances. In what proportion? Were the other 27% quite cheerful and rational? What time span, age group? What about women between 3 and 9 months post partum? What about childless women?

    But the main false assumption is that a birth with interventions is by definition traumatic. It is a bit of a no brainer that a traumatic birth, especially one that led to death or disability might indeed cause PPD – but given that death or disability are even more likely if there are no interventions, what was the suicide rate in women who had disappointing all natural births? Are we meant to conclude that having and IV or being asked three times if you want an epidural causes suicide?

    I had a traumatic time. I had interventions. I have a disabled child. I am still here. It wasn’t the interventions that were the problem. No-one is going to dispute that all women could benefit from more support through what can be difficult months – but if the “support” is in the form of telling you you were traumatised, I doubt it will help.

  • Sue

    And another one on The Conversation: ”One-on-One Midwife Care linked to lower risk of premature birth”.

    The Cochrane review actually found that:
    “We included 13 trials involving 16,242 women. Women who had midwife-led continuity models of care were less likely to experience regional analgesia (average risk ratio (RR) 0.83, 95% confidence interval (CI) 0.76 to 0.90), episiotomy (average RR 0.84, 95% CI 0.76 to 0.92), and instrumental birth (average RR 0.88, 95% CI 0.81 to 0.96), and were more likely to experience no intrapartum analgesia/anaesthesia (average RR 1.16, 95% CI 1.04 to 1.31), spontaneous vaginal birth (average RR 1.05, 95% CI 1.03 to 1.08), attendance at birth by a known midwife (average RR 7.83, 95% CI 4.15 to 14.80), and a longer mean length of labour (hours) (mean difference (hours) 0.50, 95% CI 0.27 to 0.74). There were no differences between groups for caesarean births (average RR 0.93, 95% CI 0.84 to 1.02).

    Women who were randomised to receive midwife-led continuity models of care were less likely to experience preterm birth (average RR 0.77, 95% CI 0.62 to 0.94) and fetal loss before 24 weeks’ gestation (average RR 0.81, 95% CI 0.66 to 0.99), although there were no differences in fetal loss/neonatal death of at least 24 weeks (average RR 1.00, 95% CI 0.67 to 1.51) or in overall fetal/neonatal death (average RR 0.84, 95% CI 0.71 to 1.00).

    Due to a lack of consistency in measuring women’s satisfaction and assessing the cost of various maternity models, these outcomes were reported narratively. The majority of included studies reported a higher rate of maternal satisfaction in the midwifery-led continuity care model. Similarly there was a trend towards a cost-saving effect for midwife-led continuity care compared to other care models.””

    So, women with midwife-led models got less pain relief despite having longer labors, but did not have a lower rate of cesarean section or fetal/neonatal death, and the ”trend-towards cost-saving effect” was not significant.

    See how it reads differently when you look at all the findings?

    • KarenJJ

      If I understand correctly, after all that, they only found a significant ‘benefit’ being that there were less pre-term births?

      I can’t imagine why that would be, except for a mistake in data collection or an anomaly..

      • Sue

        Precisely, Karen. I can’t see how it is plausible that the midwife effect made pregnancies last longer.

        I found it amusing, however, that Prof Dahlen said ”less babies die” and another prof said ”it costs less” – but neither statement was supported by the findings of the study.

        The other thing I’ve noticed is that Dahlen never comes back to answer queries or criticisms.

        • KarenJJ

          It’s so frustrating. Midwifery could be looking at how to improve things for women post-partum and and how reach women at risk, but they are so stuck in trying to demonise interventions and obstetrics that they don’t seem to get to it.

          • AmyP

            For instance, there’s six week gap in the US between discharge and the postpartum appointment, and a lot of stuff happens during those six weeks. Improving care during that time would be a good goal.

          • suchende

            I was basically told not to worry about baby blues until my 6 week appt. No coping mechanisms were recommended. My body was behaving as it never had before but I never called the OB because I was sick to death of hearing that everything horrible and painful and uncomfortable was “normal” as I had my entire pregnancy.

            The CPM answer to all this is: eat weird things like placentas and herbs and chat with your BFF the midwife. Um, no.

      • areawomanpdx

        It’s probably because they transferred care to an OB when the woman went into labor.

    • araikwao

      The lower usage of analgesia is hardly surprising given that midwives (in my area of Australia, at least) actively withhold it.

  • Squillo

    OT–The EFF is assisting another plaintiff filing a lawsuit over multiple bogus DMCA takedowns. From the filing, it sounds as if Liberation Music pulled much the same stunt as Gina Crossley-Corcoran. One hopes that if Amy doesn’t prevail in her suit, Lessig & EFF prevail in theirs, which looks to this non-attorney to be as close to a slam-dunk as one could find.

    • KarenJJ

      ROFL – someone filed a bogus DMCA against Lawrence Lessig? Ex Professor at Harvard Law School and former board member of EFF?

      http://en.wikipedia.org/wiki/Lawrence_Lessig

      That’s just.. umm..

      • KarenJJ
      • Kalacirya

        It’s a pretty poor idea.

        • Squillo

          If you read the complaint, Lessig’s use of Liberation’s IP was as close to text-book fair use as it’s possible to come when using a creative work. I don’t know what Liberation’s law-monkeys were smoking.

          • suchende

            It was probably a bot. Which have been upheld as legal in some jurisdictions despite clearly being unable to contemplate fair use.

      • Squillo

        It’s an Aussie firm, so perhaps they weren’t familiar with Lessig. They’re about to be educamated.

        • KarenJJ

          It’s daft Australian Day I suppose. Appropriate on a Hannah Dahlen topic post.

  • realityycheque

    I would assume that trauma deaths would be lower in the first quarter after birth anyway… particularly in those who’ve had c-sections or episiotomies/significant tears or unwell children.

    I know that in the first month postpartum, I mostly stayed quietly inside with my baby, both getting used to motherhood and allowing a tear to heal. I wouldn’t be getting up and cleaning out the gutters, climbing a ladder to paint the weather boards and even things like gardening and driving my car were significantly limited in those early weeks (can imagine c-section mothers wouldn’t be very likely to be up and driving either)… so wouldn’t it stand to reason that their immobility and restricted exposure to higher risk situations during this time would bring down the rate of traumatic death?

    By the forth quarter of the pp year I was back to my normal activities.

  • auntbea

    “During the 6-year time period, 37 deaths occurred within 42 days following birth with 92 deaths occurring in the interval between 42 and 365 days”.

    So… the risk of death on a given day in the first three-months PP is about three times greater than the risk of death after three months, but her conclusion is that we need to pay more attention to the later period?

    • Michelle

      Looking at what is said in the article, I’d suspect what is happening here is the deaths in the earlier stages tend to have the deaths clustering around causes like haemorrhage, blood clots and high blood pressure (basically medical causes). These need different sorts of interventions, and the articles says generally we are pretty good at dealing with them and providing the necessary support for new mothers in the short term.

      Late maternal deaths cluster around other causes –

      e.g.”Trauma, including suicide, accidental injury, motor traffic accidents, and homicides, is the leading nonobstetric cause of late maternal death in the United States [10] and accounted for 73% of all maternal deaths (early and late) in NSW over an eight-year study period [3]. These nonmedical deaths, and most notably, the late maternal deaths, are underreported [11] and are not as well documented or acknowledged as the obstetric causes listed above.” (from the linked research article via The Conversation)

      So the focus of concern is these late maternal deaths which occur later, after that support fades away. Some cannot be readily modified like car accidents, but deaths from suicide and some of the other causes could be with proper ongoing mental health care (including proper recognition and treatment of post-natal depression), treatment for co-morbidities like substance abuse, family support especially where neonatal death has occurred etc. This would be where my reading of the article diverges as for example the research gives the figures for rates of suicide 4.4/100 000 for women but in the year after birth suicide and accidental death which may contain some suicides (it can be hard to differentiate in say an event like overdose whether this was deliberate or accidental and this may get put in the ‘accidental’ group) are the two leading causes at 62% of all causes of death in that group. I’d take that as in that group it’s a much higher rate than for all women but could be wrong.

      I think given that, it’s not that hard to consider that during pregnancy, childbirth and the immediate post-natal period there is a lot of support there, but later that support largely disappears and that later time can be a time when mothers may be at risk especially if they have recognised co-morbidities and other stressors or contributing factors going on which can contribute to a poor outcome. As pointed out in the article, for instance neonatal death rates among the women who subsequently died of suicide or
      trauma were 10 times higher than the death rate of women who did not die of suicide or trauma. So that’s why she says “It suggests mothers may need support from integrated health and community services for the first year of their child’s life.” I don’t think this should be entirely discounted, nor should the need for ongoing support and intervention past the first 6 weeks to 3 months even if there isn’t a direct correlation.

  • Sullivan ThePoop

    This is listed in the methods, but I cannot find it in the paper.

    2.3. Data AnalysisDescriptive statistics (frequencies and proportions) were calculated. Demographics comparisons, events by time from birth, and risk of death by suicide were compared to the general female population. All analyses were conducted using IBM SPSS v.19.

    Is she saying the general population of females in general (makes the most sense) or the females who did not die, or who had less birth trauma? Horrible!

    • Amy Tuteur, MD

      I suspect it is all women, which is not the appropriate comparison group. The correct comparison group would be all women of childbearing age.

    • auntbea

      I found this: “The risk of death by intentional means (suicide) in the cohort was also examined in comparison to the age-specific death rates in the Australian population with a resulting relative risk of suicide of 0.9 (95% CI; 0.29–2.59).”

  • Meerkat

    Somewhat OT, but I am curious about something. After my C- section quite a few people at the hospital including nurses and doctors kept asking me if somebody will help me with the baby at home. I said yes, but what would they do if I told them no?

    • amazonmom

      If someone would have no support at home the staff would dig a little further into the situation where I work. Our Microsoft/Google moms with large incomes get referrals to postpartum doulas and nurses. If there is a partner involved we try to see about the feasibility of them staying home for a few days. Parents with few resources get a visit from social work because there is help available for them depending upon the situation. We hate sending people home into a difficult situation.

  • R T

    We all KNOW mental health support for women following childbirth is lacking and although its changing, there is still stigma and ignorance surrounding PPD. However, it is not appropriate to manipulate this emotional topic and use it to promote the “natural childbirth” movement. Women who give birth at home and accomplish their “ideal” birth still can and DO develop PPD and they can and often DO still face the same struggle to get help and support. I agree with her it’s an important topic and area of research, but natural childbirth is not the answer! In fact, this idea hurts the women who carry additional shame and confusion for developing PPD even though they did everything “right” according to the NCBers.

  • Mel

    Noticed something odd in Table One: Demographics and birth outcomes. First is that that is a bad title for the table. The two groups are differentiated between life/death outcomes not by the actual birth outcomes.

    Second is that the last table line compares the perinatal mortality rates between the entire cohort and the group of women who died. The author chose to highlight that the p value is significant. So, the author thought she’d have to check that the risk of dying for women who died is higher the risk of dying for women who did not die. Huh.

    • Sullivan ThePoop

      Yes, the graphs and tables are a nightmare. Also, I know this isprobably nitpicking, but the works cited are giving me a headache. I tried to go looking for two different things and had to give up because even though she had multiple citings for one sentence none of them answered my question about the sentence. WTH?

    • auntbea

      I think that is perinatal mortality of the BABY, not the mother. You wouldn’t be able to get out a coefficient on death of the mother with the data split along that variable.

  • Zornorph

    I wonder if being shamed and/or disappointed that they didn’t have a ‘perfect birth story’ has ever caused a woman to off herself. In which case, the NCB people would be somewhat responsible for her death. Yeah, you won’t see them investigate that.

    • R T

      Oh, I’m sure it has contributed before. Of course, I doubt it could be held fully responsible as the cause, but no doubt it has contributed!

    • amazonmom

      In the throes of PPD I was sure failing to do things the NCB way meant I had failed my child miserably. Constantly hearing I just needed to try harder to exclusively breastfeed when nothing in the world would have made it work just made it worse. I was sure that meant my baby was better off without me. I put all the blame on my suicidal ideation on my illness and not the NCB movement, but the emphasis on just needing to try harder and do things the NCB way can very well shove a vulnerable person over the edge. The mindless pushers of NCB ideals either have no idea of the harm they are doing to vulnerable women or they just don’t care, which is extremely scary to think about.

    • Ob in OZ

      Over and over again the disappointment written on the mom’s face when the birth did not follow the plan. Occassionally the thank you as my baby and I are both healthy and well (an apology yesterday for swearing at me – much appreciated). Too many with the dejected look at their child and everyone around them. We now “debrief” patients (not sure after looking it up how this qualifies as a miedical term. Shouldn’t we talk to the and answer their questions?) again and again. We try to say the right things so they hopefully understand and accept the circumstances at hand, but you only find out if your successful, from my perspective, when they come back pregnant again. Either they are open-minded and accept the outcome and have moved on, or they now want to reject everything that was done and make every conversation and argument. At that point my nly goal is to try to at least deliver at the hospital so we have the opportunity for ongoing discussions (I can handle swearing in labor- it’s really ok), and if it comes to it pick up the pieces in an emergency.
      Which brings up yesterday’s topic. I would say exhaustion may have caused me to make a few stupid mistakes in clinic or over the phone (my 50 yr old mother did not need MGS04 for preeclampsia when she was apparently asking what to make me when I went home for the weekend laundry drop/refridgerator raid-love you mom), but the long hours and hard work made emergencies seem routine, and I have reasonable confidence that I can “get out of trouble” if needed, even if it’s the patient that causes the trouble. I believe that allows me to negotiate with patients more readily and thus be a bit more liberal with patient’s requests than the younger doctors who have not seen enough problems to be able to avoid the really bad stuff.

      Wow. For someone who is supposedly busy that was longwinded.

      • Lizzie Dee

        Over and over again the disappointment written on the mom’s face when the birth did not follow the plan.

        Given that you are busy, could you explain that a bit more? Are these just thwarted “all natural” mothers?

        I can’t express this very well, given that my own births were a long time ago, but I have a suspicion that a focus on the actual moment of birth is more than a bit of a problem. All that anticipation, all that effort….

        I had a conversation with my daughter the other day about a kind of temporary disconnect between the imagined baby one has been carrying, feeling, talking to, and this real infant now in your arms. (In my case, in NICU) When my second one was handed to me, the main thing I felt was nonplussed – even though her safe arrival was an enormous relief. Some hours later, I was euphoric and as high as a kite, but the actual moment was somehow an anticlimax to such a big build up. As I had never believed that birth had much to do with one’s qualities as a mother, it didn’t trouble me, but if, sold on the images and hype, you do have high expectations then that is a problem.

        • Ob in OZ

          Some days I’m not busy, just feeling guilty that I’m not doing the things I should be doing instead of this. I think you have expressed yourself and the issue very well. As has come up on this blog repeatedly, and is in my mind the whole point, is that having a baby is about having a baby, who is born and cared for and becomes an adult. Hopefully they are born healthy and stay that way. We make decisions every day for years that are importnat in some ways, but in the great scheme of things have very little impact on what our children become. What school, what sport, what food all seem important at the time, but so are who their friends are, how late they stay out, and so on. If your at that stage of parenthood, how importnat does it seem as to how long or if you breastfed them, or how they entered the world? The point made repeatedly here is however, that WHERE they enter the world is incredibly impotant, as it is more likely that something bad could happen in labor compared to wearing a seatbelt on the way home.
          To answer, my take is that anyone with a “birth plan” sets themselves up for dissappointment, and like we discussed earlier, it is then just a matter of severity as to whether the dissappointment passes and they refocus on being a mother, or they dwell on their experience and become depressed. or blame the hospital and then its post-traumatic stress disorder, or they go off ther deep end next time and try to deliver at home. That being said, there are plenty of angry patients now because they didn’t get the c-section they want. But to be honest, no one really is fighting their battle.

    • Bambi Chapman

      I’m going to put myself out there. Dealing with not only my daughter dying, but the treatment from the NCB/HB camp did seriously impact my mental health. There have been multiple occasions where I have had to break down and ask for help because I was scared of what I could do. The rejection after I began speaking up was one of the things that really triggered me. I had all of my “friends” turning on me. It was bad. I can honestly say that if it hadn’t been for my husband and family and my stubbornness, I probably wouldn’t be here. They really don’t realize how their actions impact others and especially when they don’t know/care where that person is and how vulnerable they may be. Ideology comes before people regardless.

      • Lizzie Dee

        Bambi, how could it not affect you? Either of those things is devastating, both of them awful. I remember reading one of your early posts, and your anguish was palpable.

        The treatment you got from those who bleat about “support” was disgusting.

  • hurricanewarningdc

    This is so absurdly stupid that I can’t even finish reading this blog post. It’s not Dr. Amy’s fault; it’s that the wacko about whom she’s writing is too moronic to stomach.

  • Young CC Prof

    So extrinsic causes of death are very low among women in the first 3 months after giving birth, eh? Perhaps it’s because new mothers, I don’t know, DRIVE LESS, because they are stuck at home with a newborn and usually not working?

    I LOVE statistics, and I freaking hate it when people toss them like pasta salad and draw all these unwarranted conclusions.

    • Mel

      Actually, the paper’s author can’t even make that claim. The best I can figure from her data the following conclusions could be reached:
      A. Perinatal death in the year after giving birth is strongly correlated to:

  • Dr Kitty

    If you’re lumping trauma in with suicide, why not murder?

    Murder, usually by a current or former intimate partner, is still a horrifyingly common way for pregnant women and new mothers to die.

    Maybe Ms Dahlen isn’t as interested in the kind of intervention and support needed to stop domestic violence.

    This article suggests that maternal mortality due to trauma can be attributed to auto accidents in 44% of cases and murder in 31% of cases. Suicide is responsible for 10%.

    http://www.medicalnewstoday.com/releases/20316.php

    I would LOVE to see Ms Dahlen try to argue that CS cause men to kill the mothers of their children.

    • PJ

      Those are statistics for the US, though. The homicide figures seem to account for a much smaller proportion of deaths in Australia. Although one wonders if any of the “accidental” deaths category should really be attributed to homicide (and not potentially just suicide, as Dahlen suggests).

      • Dr Kitty

        UK statistics
        http://www.rcpe.ac.uk/journal/issue/journal_35_4/why%20mothers%20die.pdf
        “the most common cause of Coincidental death is not road traffic accidents, but murder. Eleven women died as a result of homicide, and each was killed by her male partner”

        15 women died due to suicide or “psychiatric causes” in the same period.

        The pertinent piece of info: ” when Late deaths are included, psychiatric disease is the leading cause of maternal death”.
        Which rather suggests it is about who you include and exclude.

      • Sullivan ThePoop

        Not too much though. The only homicide she reports is from intimate partner violence and that is estimated to happen in 17-27% of pregnancies.

    • Sullivan ThePoop

      it looks like the way it is set up is with accidental death/homicide and suicide is in another category.

    • Kerlyssa

      Still works for them. Ladies: get a c/s and your SO will kill you with an axe.

      So bad for the baby!

  • The Bofa on the Sofa

    The women who died had higher rates of intervention in birth, higher rates of early-term births, pregnancy complications and neonatal intensive care admissions.

    I guess I don’t understand. If they had higher rates of early-term births, pregnancy complications, and neonatal intensive care, then of course they had higher rates of intervention. Because interventions are more likely when there are complications.

    So even if we accept the claim that these women are more likely to commit suicide (which is not actually established as to more likely than whom?), how do we get to the conclusion that it’s the interventions that are the problem?

    • PollyPocket

      And the women who committed suicide had a higher rate of substance abuse, which is a causative factor in preterm birth, low birth weight, and perinatal complications.

      So, a know risk factor for requiring interventions is also a known risk factor for suicide. And the fact that the two are then positively correlated is meaningful in some way?

      • PJ

        It’s possible that women who have traumatic deliveries are more likely to have psychological problems that lead to suicide. And of course things like domestic violence and drug abuse are associated with both psychological problems and complications at birth. In a sense it doesn’t really matter if the traumatic delivery is what causes the suicide–if it gives us a tool for identifying women who may be at risk, that in itself is useful. Risk factors such as domestic violence may be difficult to identify.

    • Sue

      And given that there was an association between neonatal death and maternal death, wouldn’t you expect ”interventions” that prevent neonatal death to also be associated with reduced maternal death?

  • Alenushka

    My mother committed suicide after visiting US. Ergo, visiting US is dangerous for Russian women with mental illness.

    • LynnetteHafkenIBCLC

      I’m so sorry for you and your family.

      • Alenushka

        Thank you. It happened many years ago and it was very hard.

        • Sue

          Thanks- your point is well-made.

  • Amy M

    I realize I am opening myself up to major criticism/out and out ridicule here, but I am genuinely confused. I don’t understand: is Hannah D attempting to say that interventions during birth lead to more deaths in the first year postpartum? I read the article Dr. Amy linked to, and she seemed to be saying that she thought women, especially women with a history of drug abuse, domestic violence and/or mental illness, could use more support in the year post-partum, especially if they had difficult pregnancies, deliveries, nicu babies, or if the babies died. Despite Hannah D’s history of nutjobbery, I can’t really argue with that point, if indeed, that is what she is trying to say.

    Also, I imagine that anyone with a history of mental illness, and/or domestic violence and/or substance abuse is at greater risk of post partum depression, and therefore at greater risk of post-partum suicide. Also, women with those risk factors are also at greater risk of delivering prematurely (and having interventions I’m looking at you Hannah), hence having NICU babies, more likely having babies with special needs, or losing the babies depending on how premature/sick they are at birth, and adding an additional risk factor for PPD. I did not, however, see any mention of PPD in the linked article, though I may have missed it.

    Anyway, if Hannah D. is blaming the interventions, then she is looking at it the wrong way ’round, as clearly the interventions are a mere by-product of the greater problem (substance abuse, domestic violence and mental illness leading to pregnancy complications directly or indirectly.)

    Anyway, am I totally off the mark here? If so, I apologize for being a moron, and please don’t rip me to shreds.

    • Amy Tuteur, MD

      Here’s what she says in another interview:

      “She says mental health disorders and drug and alcohol abuse are key factors in the suicide rate among mothers. But she says the rate is also a reflection of a model of care that is not providing enough social and psychological support for mothers.

      ”One in 10 women are coming out of childbirth traumatised, with post-traumatic stress disorder. That’s a real worry,” she says. ”If you are coming out of childbirth feeling devastated, like a failure, unable to get on with life, those interactions with your baby are fundamentally wiring that baby’s brain and there are psychological implications for children.”

      http://www.crookwellgazette.com.au/story/1696039/even-in-the-safest-country-in-the-world-birth-is-a-risk/

      • stacey

        OH the IRONY.
        WHO is making these women feel like failures?
        Who is telling moms birth will be a perfect, easy blissful (even orgasmic!), empowering experience?
        Who is causing more death and damage by promoting non intervention and hands off policies?
        Who is overloading moms with pressure of the “necessity” of instant bonding, and all the little things that “ruin” the bond?

        NCBers, HBers, and trust birth MWs, thats who.
        You wanna help moms be less traumatized? Make sure they understand what birth is really about, what to really expect, offer prompt pain relief, evidence based care, and counseling if theres a scary event. Take moms concerns seriously, instead of demanding they trust birth.

        • Dr Kitty

          Hmm, Isreali study about PTSD being directly related to traumatic childbirth anyone?

          http://www.ncbi.nlm.nih.gov/pubmed/22891394

          Oh, wait, that is the study that suggests CS is not associated with PTSD, and that offering adequate analgesia during labour may prevent PTSD. Ms Dahlen probably won’t approve.

          • Sue

            ”offering adequate analgesia during labour may prevent PTSD”

            And meanwhile the recent Cochrane review of midwife-led care found that those mothers had longer labors but were less likely to receive analgesia…

      • PJ

        Doesn’t this speak to much of what you yourself say–that NCB ideals set women up to feel like failures when their births don’t go as planned?

        (More generally, how valid is the claim that 10% of Australian new mothers suffer from post-traumatic stress disorder?)

        • Amy Tuteur, MD

          Feeling like a failure for not having an NCB and committing suicide are miles apart. I have never suggested that women are more lilkely to commit suicide if they are disappointed in their birth experience, but Dahlen is trying to imply that women are more likely to commit suicide if they have interventions during children.

          In the piece on The Conversation, Dahlen throws in a million caveats and subtle distinctions basically acknowledging that she has shown nothing, but how many women will actually read the paper, let alone undertand the subtleties?

          Dahlen published the paper to use it as a cudgel against modern obstetrics. Someone needs to call her on the fact that the paper is garbage.

    • Amy Tuteur, MD

      “The more complex, but equally relevant, argument about how women understand safety and how safety is examined scientifically is debated less and considered less valid by some. Cultural, emotional, psychological and spiritual safety rarely appear in the mainstream debates about the safety of homebirth, yet qualitative research would indicate this dominates in women’s decision-making regarding choice of place of birth.16,17 With suicide a leading cause of maternal death in Australia18, the uK and uSA, we can no longer dismiss the importance of women’s psychological wellbeing.

      http://www.ranzcog.edu.au/publication/oandg-magazine/doc_download/766-28-can-we-reach-middle-ground.html

    • Amy Tuteur, MD

      Dahlen is spokesperson for the Australian College of Midwives, which had this to say:

      “Providing recommendations about more access to continuity of care in hospitals, counselling of women following traumatic births and a recognition of the impact of birth trauma on women’s psychological wellbeing would have been welcomed, but were dismissed as irrelevant. With post traumatic stress disorders now affecting a significant number of women who give birth and suicide as one of the leading causes of maternal death we cannot ignore the ramifications of birth trauma.

      http://midwives.rentsoft.biz/lib/pdf/Final%20Media%20release%20on%20Coroners%20case%20SA_June2012.pdf

      • PJ

        I don’t really understand what your beef is with this?

        • Kerlyssa

          Lying to patients about their health risks is not an acceptable method of handling trauma in adults. The existence of mental health issues/social issues does not support her ‘solution’ of misrepresenting the risks of HB vs hospital.

    • PJ

      I don’t really understand the criticism either, to be honest. I think the association between more complicated births (and thus interventions) and an increased risk of death by trauma later on is a valid point to make. Sure, it’s valid to question why she doesn’t explore the reasons behind this link (although aren’t they kind of obvious?) but I don’t see any reason to conclude she’s demonising interventions as inherently bad. It’s useful information to know because it can help with identifying women who might be at risk later on.

      I think there are valid reasons for looking at suicide and other kinds of trauma together. As she points out, it’s quite possible that some of the incidents coded as accidental were actually intentional in nature. (Though it is odd not to compare the risk of accidental injury with women in the population in general.) Even if the risk of suicide at 9-12 months reaches baseline levels (though again it’s odd not to specify), it’s still relevant insofar as identifying the characteristics of women most at risk enables appropriate intervention.

      • Amy Tuteur, MD

        The issue is that the paper showed nothing, but she’s already using it to bash modern obstetrics and promote midwifery care.

        I suspect that this is part of an overall stragety for dealing with the mounting evidence that homebirth isn’t safe, midwifery care isn’t particularly beneficial and that modern obstetrics is evidence based while midwifery is not. The argument goes like this: Sure more babies die when we withhold interventions or promote homebirth, but WAIT, modern obstetrics can’t be safe is so many women die of suicide and trauma in the postpartum year! That must mean that obstetricians are doing something wrong and that something is using too many interventions.

        • Amy M

          Ok, the paper showed nothing, but isn’t she sort of accidentally highlighting the areas that need improvement, which have nothing to do with homebirth or midwifery? Meaning, the population of women with mental illness, history of substance abuse and domestic violence? Surely proper support, pre-and post-natal care for them would go a long way towards preventing those deaths? Of course, that has nothing to do with birth interventions, unless of course proper prenatal care might lead to a reduction in [interventions] if the babies are healthier at birth. Would midwives even be able to provide the support that population would require? Probably not, since they’d need mental health professionals, social workers and counselors,no?

          • Amy Tuteur, MD

            She didn’t demonstrate any difference between the suicide rate of women in the 4th quarter of the postpartum year and women of the same age who weren’t pregnant.

            Suicide is a leading cause of death for ALL women of reproductive age. For all we know, based on the data presented, it is entirely possible that childbirth LOWERS the risk of suicide and it rises back to baseline over the remainder of the year.

            The paper showed nothing, so you can’t draw any conclusions from nothing.

          • Elle

            Perhaps she is highlighting areas that need improvement, in which case it’s even more disturbing that she’s willing to exploit these very real needs in order to fuel her delusion that “birth interventions” are, in and of themselves, evil.

      • auntbea

        I think it is reasonable, knowing what we know about HD, to expect that she would at some point use these findings to somehow vilify interventions. But I don’t see that in the paper itself.

      • Ob in OZ

        It is really hard to read a terrible study in its entirety, even when motivated. I think there are valid points made about risk factors being identified antepartum and intrapartum that may point to postpartum interventions in order to decrease the risk of a postpartum disaster. This article discusses this but doesn’t demonstrate it. The concern is how studies like this are then discussed and used to support someone’s alterior motives. Dr Tuteur is predicting the future a bit, but in the short time that this junk study has been out, it seems she is right in how the information will be manipulated for a cause. Bad to say without evidence, but I think the postpartum depression rate is much higher because of disappointment with the experience, and not a better understanding and reporting of the diagnosis. Would love to do a study, but I’m supposed to be busy (love a quiet labor ward to allow conversations like this- on to facebook!).

        • Lizzie Dee

          How much is really understood about PPD? Is there any point in making a distinction between women who struggle with difficult feelings in what can be difficult circumstances and women who are seriously ill with depression? I believe that one warning sign is a prior history of depression – are there women who ONLY get depressed after childbirth?

          Weird confession: I had a serious bout of reactive depression in my late teens – to the point where suicide seemed like a viable option. When things get tough, my thoughts still have a tendency to wander in that direction. Once I had children, those thoughts would not get very far, because leaving my children motherless was literally unthinkable. (I have had less severe/treatable bouts of depression when my children were older.) But I do know enough to know that in very severe depression one’s thinking gets completely skewed. And, of course, post partum psychosis is something else again.

          So: I had several factors which indicated the liklihood of PPD, but I escaped it. Has anyone ever studied those who should be depressed but aren’t?

          • Ob in OZ

            You make excellent points and I appreciate your willingness to “confess” regarding your personal history.
            1) In my mind, a diagnosis of PPD is for research. Patients vary from blues to severe depression, and should be helped reguardless. Some need to talk, or a parents group etc, others need treatment which to this day can mean electroconvolsive therapy. Fascinating stuff.
            2) some people only get it postpartum, but like you said they were probably struggling before.
            3)Technically speaking, you would probably be diagnosed with postpartum depression, or depression which relapsed postpartum, as suicidal thoughts would be a concern. The fact that you said you wouldn’t act on them means you were coping well enough to not need admission to the hospital and more intensive therapy. Provided you told someone what you were thinking at the time.
            4) I read a bit and haven’t seen anything that rings a bell, but I would say risk factors are just that, risk factors. There are very few absolutes in medicine. most people who are at risk for PPD still don’t get it (I think, because these days labeling people with disease is quite common. If 80% of women get the postpartum blues, wouldn’t the other 20 be the ones that are diseased). Hope I responded appropriately

  • AllieFoyle

    This is just playing the game. How do you get people to believe that you’re an expert in something you actually know very little of substance about, beyond your quasi-religious ideology? You publish rubbishy papers in journals that have low standards and create a sort of credential trail. It’s a sleazy way of building up the facade of authority and respectability. And it works to an extent because many people just see the citations and magazine blurbs and don’t have the knowledge base to evaluate them critically.

    She’s now created a link between interventions and suicide. She and all her midwifey friends will trot it out all the time now. They’re creating a body of literature that supports their ideology and will use it to lure the unsuspecting and vulnerable.

    • Amy Tuteur, MD

      Exactly! You said it far more clearly and eloquently than I did!

    • Kalacirya

      Taking the old Hugo Schwyzer route to legitimacy (although he did mainstream non-scientific publications).

    • almostfearless

      This applies to not just NCB but all kinds of crunchy ideas about parenting. I think this site and badscience.com should be required reading for all parents. Now I know to ask — well was it an observational study? How many subjects? What paper was it published in? Anyone else verify it? Because even journalists get sucked in presenting this fake science in the interest of being ‘balanced’ but end up adding even more credibility to the ‘personalities’ who are putting forward these theories out of self-interest.

  • anonymous

    “Trauma includes accidental injury, transport accidents and homicide, and suicide is death as a result of intentional self-harm….So death from suicide and trauma rises significantly between nine and 12 months after birth; it is nearly four times the rate compared to the first three months following birth.”

    Tenuous links.

    Tenuous links.

    So basically, trauma is basically anything out of the control of the person in the study. She may as well have claimed that the color of the hospital gown had something to do with it. This is not how statistics and ex-post facto analysis works. Show me demographic information on the homicide rate for each woman in the study and we’ll talk. Lumping accidents, murder, and suicide together is almost like saying “death in general.”

  • courtney

    “They also tended to have babies who were born with a low birth weight
    and were ten times more likely than other women to have their baby die.”

    If they are ten times more likely to have a baby die then wouldn’t that be a contradiction to homebirth since homebirth increases the risk that the baby will die?

    Offering additional services = getting additional paychecks

  • KarenJJ

    Found it. A sensible opinion article, with Hannah Dahlen quoted about suicide statistics. Although re-reading it, she doesn’t say anything much substantial about it and seemed as though she was trying to link it to PTSD.

    http://www.watoday.com.au/comment/no-right-or-wrong-way-to-give-birth-20130816-2s202.html

  • LibrarianSarah

    “high quality journals have impact factors ranging from 50-100.”

    Have they change the way they calculate impact factors? Because if I recall correctly, the impact factor for Nature is in the 30s and I can’t remember ever seeing an impact factor even close to 100.

    • Amy Tuteur, MD

      I don’t know. NEJM has an impact factor of 51.

      • LibrarianSarah

        Yeah I’ve heard of a few in the 50s which is really rare but never anywhere close to 100. I checked and Nature has an impact factor of 38.597. The lowest impact factor I’ve ever heard of was “Medical Hypothesis” which was 1.054. But that journal is notoriously shitty.

        • The Bofa on the Sofa

          At a journal editor symposium yesterday, an important theme was “don’t judge a paper by the impact factor of the journal.” These were editors from pretty high quality journals (IFs near 20), so not whining underachievers.

          I agree with that. There is plenty of perfectly good science that is reported in low-profile journals. In fact, from a scientific standpoint, there should be no difference in the standards of quality of the work based on the journal. When I review papers, I do not excuse poor methods and conclusions in lesser journals. The difference in low IF journals is in the significance of the work, and the level of interest to the community at large. More specialized and narrow interest work goes to more specialized journals. Since fewer people are interested in it, fewer people cite it, which is what determines the IF.

          Criticize the paper on its merits, or lack thereof, not on where it is published (assuming it is in the recognized literature)

          • Amy Tuteur, MD

            What do you think of the quality of this paper.

          • The Bofa on the Sofa

            I didn’t read it.

          • auntbea

            I make allowances for really bad papers submitted to really bad journals Because those papers have to go *somewhere*. And the sooner that paper gets into a journal that no one reads, the less likely I will be to see it again in my review box.

        • Amy Tuteur, MD

          I changed it to 30-50 to remove outliers.

    • Anonymous

      There are a few that are high. If I remember right, there’s a journal in CS called “Lecture notes in Computer Science” that is very, very high last I checked.

    • PJ

      I don’t think this range is right either. I know for example that the Physical Review collection of journals are very good quality, well regarded journals, but only have impact factors ranging from 2.3-7.2. Maybe medicine is different, but still.

      • LibrarianSarah

        Even if they are of very good quality, they can still have a low impact factor if they are relatively unknown. Impact factor is based on how many times a given journal is cited by other academics in paper. Hence why NEJM has a pretty high impact factor because that would be one of the first places a lot of academics will go when looking for articles on a medical subject.

        It has evened out more with the switch from paper journals to databases but still less known journals get shafted regardless of their quality.

        • PJ

          But that’s my point–they’re well-known and, as far as I know (since I am not actually a physicist) well-cited!p

      • auntbea

        I think medicine IS different, since the field is just so large. Plus I imagine something like the Lancet gets non-academic cites. The universally acknowledged top journal in my field has an impact factor of, maybe, five? Very high quality work, but the field is just small, so there aren’t that many people around to be citing any single paper.

  • KarenJJ

    Oh geez she is embarrassing. It almost makes me want to hang up my vegemite jar in shame and hand over my milo and tim tam stash..

    • Anonymous

      Tim Tams are awesome. When I was living in Asia we had an Aussie living with us and she found them in a shop near the college we were attending. Good stuff.

    • Dr Kitty

      Who cares about the Vegemite and Milo, both of which, BTW, I can now buy in my local supermarket in the “ethnic foods” section. Yeah it’s Belfast, “ethnic” means you don’t know how to answer the question “are you Protestant or Catholic?”.
      The Milo is right between the Ting and the Frugo.

      Do you have any Cherry Ripes?

      • KarenJJ

        No way am I handing over Cherry Ripes…

        Besides, I ate them all…

    • MichelleJo

      Sorry Karen, it sounds like a good comment, but could you translate? Thanks.

      • KarenJJ

        I take it that you are unfamiliar with Australian cuisine?

      • Dr Kitty

        Milo is a chocolate malt powder that you mix with milk to make a popular childhood drink.
        Vegemite is the Australian form of yeast extract that they eat instead of the British Marmite, it is a thick tarry substance spread in sandwiches or toast.
        Tim Tams are chocolate biscuits.

        Translation- KarenJJ feels embarrassed on behalf of all Australians and wishes to renounce her country because HD is THAT much of an idiot. 🙂

        Also- Google is your friend.

    • Bombshellrisa

      Yeah, you could send that all my way. I have become familiar with all those things through trips to World Market and I have a craving for Tim Tams….