It’s rather amusing watching homebirth advocates thrashing about on the Web, Facebook and Twitter trying to deal with the new paper in the Journal of Medical Ethics equating homebirth to driving without putting a seatbelt on your child.
Before I address what they will do, I can tell you with absolutely certainty what they WON’T do. Despite the fact that the paper indicates that ethicists have now joined obstetricians, neonatologists, and pediatricians to declare that scientific evidence demonstrates that homebirth is not safe, advocates will not even give the slightest consideration to reevaluating their cult-like belief in the safety of homebirth.
It is this, more than anything else, that demonstrates that homebirth has nothing to do with science. For homebirth advocates, the purported safety of homebirth is an article of faith every bit as inviolable as the notion of intelligent design is for creationists. In other words, it is non-falsifiable, a hallmark of a non-scientific claim.
- Homebirth advocates will NOT stop to reflect on the fact that the only people who claim homebirth is safe are homebirth advocates themselves.
- They will NOT undertake a systematic review of the scientific literature that encompasses ALL recent papers on homebirth, not merely the ones they like or the ones they feel confident they can address.
- Homebirth advocates will NOT under any circumstances entertain the notion that they are wrong in their slavish devotion to anything that increases the autonomy of midwives.
- Homebirth advocates will NOT under any circumstances consider that their obsession with process has compromised outcomes.
What will they do?
1. They will fling citations of out of date papers or irrelevant papers. They will cite crappy studies by people like Ank de Jonge who have sliced and diced the data in a thousand ways in a fruitless effort to pretend that homebirth is safe.
2. They will whine that “everything has risks” as if that means they don’t have to consider the specific risks of homebirth.
3. The will invoke the evil triumvirate of doctors/drug companies/formula manufacturers to insinuate that a Professor of Philosophy at Oxford is somehow part of their evil plan to take over the world by making everyone deliver by C-section and then bottle feed.
4. Many will simply ignore what they cannot rebut in the hopes that their followers won’t notice the difference.
In other words, they will do everything in their power to avoid reassessing their immutable belief in the safety of homebirth.
It will be fun to watch homebirth advocates twist themselves into knots to justify ignoring not just obstetricians, neonatologists, and pediatricians, but now ethicists as well.
Your name says it all. You are as one sided as the home birth crazies that think it’s the best for everyone. A scheduled elective c-section is a horrible choice for some mothers the same as a home birth is for others. Can you consider the concept of fair evaluation and realize good and bad exist on both sides. Goog homebirth Does exist, just like Bad hospital births and visa versa. Moms can’t make good, informed choices with blind, one-sided info, like yours and those you are advocating against. Intolerance does not lead to better human experiences. Please be more considerate and Profession, for goodness sake!
Stick around a bit and read some more posts. You might be surprised by what you find…
I just Like random Capitalization.
Is the new identity of the Internet troll now the EffinGrammer/Puntuation/Capitaliztion nazi?
Awesome how well people pay attention to what people are actually trying to say. That’s called “sarcasm”, sweetie. Often hard to portray in informal writing. Kind of like Emphasis.
🙂 🙂 🙂 these drive ya crazy too? Have a nice day!
To reiterate the original point, it was simply: best choice = informed choice.
Hey, I told you I LIKED it, and yo call me a “nazi”?
Oh. SEE? My point about paying attention exactly! Lol:-)
Since the rest of your comment is a strawman, I figured it is worth ignoring.
Lets have a show of hands ladies, who, currently, provides care for pregnant persons?
I do. Your point?
A question, not a point.
Why are you asking the question?
You answered with out thinking about it first, funny. Just a question.
What’s the point of your question?
who, currently works with pregnant persons. Not hard people, yes or not, thats it, nothing more.
What’s your favorite pizza topping?
exactly just a question, now your thinking.
My thinking what?
pizza topping?
Your thinking is mistaken if you’re thinking she would get this joke.
BTW:
No, that’s not what you asked. You asked for a show of hands of ladies who provide care for pregnant women. You did not say anything about those of us who are either not ladies and/or care for pregnant women.
Ladies/gentlemen thank you for the correction 😉
Amanda is a homebirth midwife at New Life Midwifery in Michigan.
She got her midwifery “education” here:
http://www.traditionalmidwife.com
That website is frightening. The “hands-on” workshops aren’t even required! How does one become a midwife via correspondence course?
That depends on your definition of “provide care”. You can keep your hand down.
I do have a comment; you state that home birth is like driving without your child in a seat belt, my children go to school every day not in a seat belt. To school and from school five days a week, a long with a bus full of unrestrained persons. My mother, father, aunts, uncles, cousins, friends and ALL of their children ride the bus unrestrained throughout their childhood. Not one of them has died as a result from not using a seat belt while being transported. How many children ride the bus, everyday, with no seat belt? I will say millions of children daily. How many die, as a direct result, from not being restrained while being transported two times a day, five days a week? Im sure, that you rode seat beltless as a child/young adult since vehicles did not have seat belts at that time. Some how you survived. Sure, there are always extenuating circumstances, but maybe you should try to be a tid bit more aware when arguing semantics 🙂
WOW.
Way to miss the point.
WOW, some people miss the boat….
I thought we were talking about buses, not boats.
We did conclude elsewhere that crab fishing on the Bering Sea is safer than home birth.
Mrs. Amy is the one likening birth to transportation and its safety devices. Some will miss the car, boat, and plane. Why not wait for natural, or God, selection to kill off all the home birthers and vaxer then fight it out then? (insert eye roll) If what you say about home birth is correct, its a great way to control the population, since according to you, they are dropping like bugs at a bug zapper. You in cahoots with Bill Gates?
I digress…Seriously, why do you care if anyone dies while having a home birth? What direct impact does it have on your life? It does gives you something to blog about. Its not taking business away from you, since you have not practiced in years. At least the money you paid for your prestigious degree is something you are falling back on. Do you really make more money blogging then practicing? Was medicine too hard for you? I know you had kids to raise, but seams like you are wasting that degree. Like you talk the talk but don’t walk the walk. Have you ever released your stats while you were practicing? Digression again, sorry…
If you are not a practicing ob, (didn’t you let your licence go?) should you be in the fighting ring with others who are currently practicing? Obviously we would not take nutritional advise from you, but you sure as hell will bash anyone who is contradictory to your cause.
I understand, haters keep you going. I am nothing compared to your education, as you will continue to point out, because that is all you can do to your opposition.
My kids still go to school with out a seat belt daily, regardless of the safety designs, you can not eliminate the risk of injury or death…in ANYTHING. As long as abortion, soda, cigarettes, and alcohol are legal, they kill far more innocent people then home birth and there are tons of warning about their adverse effects. Yet, the grand Ol’ U S of A says we can make our own choices about how we choose to kill ourselves. Give your warning, present what you want, but the freedom to choose should be the peoples. Get mad, call people names, what ever.
I will leave on this, “women wave your pantyhose sing the chorus here it goes!”
Babies who died at homebirth didn’t get to make that choice.
and a person killed by a drunk driver didnt have a choice either.
The chance that a drunk driver will get in an accident, and thus even have the CHANCE of hurting someone else, is about 20 times less than the chance of a child dying in childbirth.
According to the National Highway Traffic Safety Administration (NHTSA) 32,885 people died in traffic crashes in 2010 in the United States (latest figures available),
In 2010, 24,586 infants died before their first birthday, reflecting an infant mortality rate of 6.15 deaths per 1,000 live births. http://mchb.hrsa.gov/
MATH Y U SO HARD
Google search shows her as a midwife with a high school education plus “traditional midwifery” school.
But Yelp says she does pediatric care up to 2 months of age, so she’s pretty smart. /snark.
Only if you don’t know how to do arithmetic.
32,885/300,000,000= 0.11/1000
That means that infant mortality is 600X higher than highway mortality.
Death due to road traffic accidents is one of the major reasons of childhood mortality
(Durkin et al., 1999).
When we assess risk, all we are doing is estimating the probability of something happening. This works when one is considering large numbers of people, but it doesn’t mean much on an individual basis: what matters to us is whether something happens or not. Nobody can offer us the certainty that a risk won’t happen. Nor is there much advantage in being compared to people whose circumstances, lifestyle, state of health and all sorts of other factors may be quite different from our own.
Every time we get into a car, there is a statistical risk of our being involved in a road traffic accident. How we drive that car – the amount of care, attention, experience, ability and familiarity we have – alters the likelihood of this happening dramatically. However, the effect of these factors is impossible to calculate.
As you have pointed out, you can turn information into anything you want to portray.
Well except insurance companies are measuring things like experience, attention, and ability when it comes to driving cars. That’s why they set different rates for different groups of people. Similarly, we are able to measure the risks of birth attendants and their experience, education, and ability. Which is how we know that it is much safer to give birth in a hospital with an experienced provider than at home with a CPM or DEM.
As you have pointed out, you can turn information into anything you want to portray.
No, I did not point that out. I demonstrated one way to make a meaningful comparison since you don’t appear to know how.
A risk assessment is all we have to work with before we make a choice, so we do that. They are hard to calculate and hard to understand so they take a lot of work.
Even though driving is far safer than either giving birth in a hospital or being born in a hospital, we still make calculations before getting into a car. How well is it maintained? How experienced is the driver and what is their condition? What’s the weather like? Are there seatbelts, airbags, restraints? We try to reduce the risk. Given the choice between driving on black ice and driving on a dry road, we do not choose the black ice.
Giving birth in a hospital is much more dangerous than driving, even driving drunk. If someone considers driving drunk to be an unnecessary risk, why would they not consider home birth an unnecessary risk? Especially if their attendant lacks the training to understand risk?
As you have pointed out, you can turn information into anything you want to portray.
I really love this. Did you ever read Ionesco’s Rhinoceros? I did, in high school. It contains this exchange:
LOGICIAN [to the Old Gentleman]: Here is an example of a syllogism. The cat has four paws. Isidore and Fricot both have four paws. Therefore Isidore and Fricot are cats.
OLD GENTLEMAN [to the Logician]: My dog has got four paws.
LOGICIAN [to the Old Gentleman]: Then it’s a cat.
One of my high school classmates concluded that logic was unreliable and could say anything you wanted it to and that you might as well rely on faith.
She was wrong. The LOGICIAN’s “syllogism” was not a syllogism. The defence is not to simply make up something you feel like believing and believe that. The defense is to undersand the structure of a syllogism, why it works and why the LOGICIAN cannot conclude that Isidore and Fricot are cats.
Similarly, you don’t understand how to compare numbers meaningfully but that doesn’t mean that nobody does. Many of the folks here understand very well how to compare numbers. Some are research scientists. They don’t just make things up and assert that the numbers can say whatever they want, they challenge one another until they understand precisely what something means.
Yes, because we have millions of kids taking trips in cars multiple times a day. You do anything that many times, and even something unlikely is going happen a lot.
You apparently missed my comment above:
“The problem with drunk driving is not the absolute risk, it is the prevalence. We have way too many people drinking and driving way too often.”
Non-drunken driving is even safer than drunk driving, but occurs even more often. OF COURSE, there are going to be adverse outcomes.
That’s why we minimize the effect of them by insisting on proper safety equipment, such as seatbelts and carseats.
BTW, did you all know that 45% of all traffic accidents in the US occur in parking lots? I learned that the other day.
When we assess risk, all we are doing is estimating the probability of something happening. This works when one is considering large numbers of people, but it doesn’t mean much on an individual basis: what matters to us is whether something happens or not. Nobody can offer us the certainty that a risk won’t happen.
That there is what we call an own-goal.
How many people drove drunk and how many times? How many people gave birth?
If you do the math, the chance of drunk driver dying in a single 8 mile drive is 2/1 000 000.
The problem with drunk driving is not the absolute risk, it is the prevalence. We have way too many people drinking and driving way too often.
If childbirth were as common as drunk driving, the deaths would be monumental.
You’re forgetting that most people ride in cars every year for seventy years. US neonatal mortality (death before 28 days) is 0.425%, and we’ll look at that as a measure of how dangerous birth is instead of infant mortality (death before one year).
The odds of a US resident dying in a car accident in a given year: 0.0107%
The odds of dying in a car accident before they turn 70: 0.743%
But let’s compare the relevant time period.
Odds of dying in a car accident in any given 28-day period: 0.000817%
Odds of dying of any cause in the first 28 days of life: 0.425%
Birth is 520 times as dangerous as riding in a car.
And car accident fatalities continue to fall thanks in large part to better technology.
Moreover, traffic fatalities are generally measured in deaths per passenger-mile or per vehicle mile. In 2010, there were
2,967,000,000,000 vehicle-miles.
I trust the majority of posters here can do the math.
What’s the denominator for the traffic fatality figure, Ms. Matson-Kesti?
… let’s give her time to look up “denominator” in her spiritual midwifery text.
Which is why drunk-drivin education and road and car safety is taken so seriously, and why sane people want the choice of birth control to be easily accessible to all so that all pregnancies are wanted.
Some people care if innocent babies die preventable deaths, strange as it may seem to you. You sound like every other homebirth advocate who thinks the baby is just a prop in the mother’s performance.
This is one of the worst things I’ve read here. So, Amanda, you don’t care if babies are dying because their mothers are not just being given incorrect information, but are being actively lied to about the safety of home birth?
Nice.
Not only does she not care, but she’s a goddamned midwife who is attending births while telling herself some babies aren’t meant to live because of “natural selection.” Somebody throw this asshole under a school bus, I’m done.
Still with the school buses — seriously, the time on the school bus is one of the safest things your child will do all day. They’re statistically more likely to die of an accident in your own house than they are on a school bus.
Some of us care about children who aren’t our own. Some of us look on in horror as our loved ones plan homebirths and seek facts to present them with. Some of us are a little younger than other readers, but despise the lies of alternative medicine and want to be ready when our friends and siblings begin procreating.
Well, clearly, “medicine is too hard” for you. By your logic, we shouldn’t have any laws, right, because why should I care if somebody dies of something that could easily have been prevented?
Seriously, why do you care if anyone dies while having a home birth?
I don’t know…maybe some of us are upset at the idea of a person dying unnecessarily and don’t want it to happen if it can be prevented. Crazy idea, I know, but there it is.
Because those dead babies totally made the conscious choice to die.
If you have a pretend qualification that wouldn’t be accepted in any other developed country, you probably shouldn’t be criticising Dr Amy’s qualifications.
I’ve noticed that the homebirth advocates who post here tend to have a very poor grasp of irony.
Last time I checked, hamsters do not need midwives, they seem to do very well when left alone to birth, crazy shit hey?
Well, sure, except for all the baby hamsters that die. Could you cite some numbers on hamster neonatal mortality to back up your claim?
I bred teddy bear hamsters as a kid, they all lived, I sold them to pet stores for money.
Except for the ones that get eaten. But hey, some litters were just meant to be eaten, right?
natural selection.
Lovely point in a greater discussion of the risks to HUMAN babies.
Some of us aren’t that cavalier about our babies.
That’s the joke. My hamster gave birth in the other corner of my bedroom while I slept, which makes me just as qualified as many people who hang out a shingle as human homebirth midwives.
School buses don’t need seatbelts because the seats are designed to cocoon children larger than a typical 4-5 year old. In fact, they’ve studied this, and full size school buses are safer WITHOUT seatbelts because of the risk of abdominal injury from a poorly fitting belt, misuse, delay in getting students evacuated, etc. The yellow school bus is the absolute safest vehicle on the road. They are large, visible, have special traffic rules and specially trained drivers and safety protocols. When they are in accidents, the accidents are almost always minor. Even bad bus accidents rarely result in fatalities or serious injury, and the worst injury is often to the driver (the only one who wears a belt, because he’s in the riskiest seat on the bus). School buses are designed to absorb crash impacts below the level where the students actually sit. Your child is about 100 times safer on the school bus than properly restrained in your own car.
So, your metaphor here is not really at all valid. If home birth were as safe as riding the bus, this blog would not exist.
Have you even an ounce of curiosity as to why that is?
School buses are designed differently than cars because seatbelts can decrease safety as easily as they can increase it. Children can not be trusted to use their seatbelts reliably and correctly, which can be a cause of injury in and of itself. The driver of the bus needs to be able to focus on driving and can’t be supervising the seatbelt use of the children. So, school buses have high, padded seats to absorb the impact of a collision and prevent kids from flying around the bus.
Passengers on school buses sit higher than other vehicles. School buses are heavy. If you managed to make it through high school physics, it should be pretty obvious to you why that is a benefit. In fact, the most dangerous part of riding in a school bus is getting on and off the bus. Some argue that adding seatbelts to buses decreases the number of seats that can be accommodated, which decreases safety, because as fewer children can be accommodated on the bus, more will be forced to use other, less safe transportation methods.
Your argument is wrong on multiple levels. Firstly, the risks associated with riding a school bus without a seatbelt are probably similar to riding in your car *with* a seatbelt. Children on buses are restrained. The method is just different. So you are the one pointlessly arguing semantics.
Secondly, just because you don’t know anyone who died riding a school bus doesn’t mean it is risk free. Children have died in bus accidents. Just as children have died in car accidents despite wearing their seatbelts. That doesn’t mean seatbelts are unnecessary.
Only 1% of traffic fatalities involving school age children during school transportation hours are school bus related. When you consider that more children ride the bus than are driven or drive, that’s pretty striking.
That’s a process of self-selection, though, isn’t it? I am alive right now commenting on this blog. My relative who was thrown out the closed window of a car when she was not wearing a seat belt is not here commenting on this blog, because she’s dead.
School buses used to be designed with seat belts, but no one used them. I rode in a bus with seat belts as a child and everyone mostly whipped the belts at each other, hitting our friends and enemies with the buckles.
I do know that the seat backs are designed with extra cushioning to protect passengers in a front or rear impact collision. Other than that I don’t know much about school bus safety.
Someone used that exact argument with me last week about car seats. “We all survived.” Uh, duh. But I knew people that didn’t, and know of more. Also, again, morbidity.
Amanda in her own words:
“Meet the Midwife
After having my first daughter, in the hospital, I just knew there had to be a better way! In my search I found midwifery. The first month I started as a apprenticing midwife I was pregnant. I had the the privlege of attening many home births and attending midwifery school, the best childbirth education class by far. So baby two and three are born at home with a midwife. My fourth birth is very special to me, we had an unassisted home birth. Meaning that no trained birth attendent was there (unless you count, me, but Iam the midwife and in labor) Our daughter was born into her fathers hands. In the company of her grandmother, fallowed by grandma’s camera. Iam a breast feeding, no vacinateing, no circing, cloth diapering, loving, natural mama.”
http://newlifemidwifery.tripod.com
Oh gawd. Every time I someone crowing about not vaccinating their kids, I want to punch them in the face.
Riding the school bus next to her unvaccinated kids probably doubles the risk of riding the school bus.
Wait, if the birth that was “special” to her was unattended, why did she become a midwife? Isn’t she then part of what makes birth less “special” (by her logic)?
It’s too bad that her midwifery correspondence school does not require competence in grammar or spelling.
How can someone put something like that up on a business website???
Dunning-Kruger effect.
MANA announces their study has been published. I have yet to find a link to the actual study.
http://midwife.org/Journal-of-Midwifery-Women-s-Health
That’s as close as I can get.
My gosh you must have been dropped on head at birth Amy!
I guess I should have added a #5 to my list of possible responses from homebirth advocates.
5. Some homebirth advocates, thoroughly incapable of mounting an intellectual response of of any sort, will fling moronic, grade school insults.
Thanks for point out what I forgot.
“Facts do not cease to exist because they are ignored.” –Aldous Huxley
Totally OT, but curious about expert opinions here regarding this article that is anti-Gardisil http://www.thedailysheeple.com/lead-developer-of-hpv-vaccines-comes-clean-warns-parents-young-girls-its-all-a-giant-deadly-scam_012014
Snopes has debunked this. Quoted from that site which has the entire quote in context from the CBS interview:
Read more at http://www.snopes.com/medical/drugs/gardasil.asp#C69ssycgqlQOLbcZ.99
A 2009 CBS News
interview with Dr. Harper is often cited as contradicting this
assessment, but it does not: Dr. Harper did not state during that
interview that Gardasil doesn’t work, is dangerous, or wasn’t tested.
Given questions about how long the vaccine is effective for, she
questioned the efficacy of giving shots to girls as young as 11 years
old in parts of the world (such as the U.S.) where women regularly
undergo safety Pap screening repeatedly over their lifetimes, saying
that the chances of their contracting cervical cancer may be less than
the “small” risks associated with the vaccine. But Dr. Harper also
noted that the risks of death surrounding the administration of Gardasil
were “very rare,” and that she “agrees with Merck and the CDC that
Gardasil is safe for most girls and women.”
Wow, I agree with onandoff, that is a ballsy bait and switch.
The ONLY ACTUAL quote from Dr Harper:
“About eight in every ten women who have been sexually active will have H.P.V. at some stage of their life. Normally there are no symptoms, and in 98 per cent of cases it clears itself. But in those cases where it doesn’t, and isn’t treated, it can lead to pre-cancerous cells which may develop into cervical cancer.” – Dr. Diane Harper
http://www.theguardian.com/media/greenslade/2009/oct/10/sundayexpress-express-newspapers
From the Guardian, Harper is quoted thus:
“I did not say that Cervarix was as deadly as cervical cancer. I did not say that Cervarix could be riskier or more deadly than cervical cancer.
I did not say that Cervarix was controversial, I stated that Cervarix is not a ‘controversial drug’. I did not ‘hit out’ – I was contacted by the press for facts. And this was not an exclusive interview.”
In other words, Anti vax folks:
“You keep using that word. I do not think it means what you think it means”.
Insert Inigo Montoya gifs here…
Another common failure of the antivax crowd to use reasoning to think through what they are posting. Science is always going to tell you there’s a risk. EBM is risk-adverse. It’s going to list risks FIRST because those small risks are what EBM wants to ultimately completely exclude. This is what makes EBM so prone to being torn into by anti-science loons. They do it with the words of the scientists and researchers themselves. I have written here before that my favourite prof in college often said that the nature of the scientific method is to disprove oneself. Science will never say something is *impossible* or *perfectly safe*. The best that science will ever say is that something is VERY VERY safe based on available data. Only non-EBM makes wild claims of no risks, and the only non-EBM modality with no risk is homeopathy since it’s water. LOL. And you can still argue there’s a risk there if someone goes without conventional treatment because they believe homeopathy will cure them.
Is the Snopes quote in error?
Click on the first link provided in Update #1 in thedailysheeple article. It says exactly the opposite of what they claim it says. Kind of ballsy.
I notice this is really common in the antivax crowd. I once took apart a website designed to scare new mums into not vaccinating. I just followed the links and did a little google reseach. For example, I recall that the first sentence of that particular site was that vaccine manufacturers don’t list the ingredients of their product anywhere. Of course, they do, and in detail, and so I posted the list. The next series of links were to really out of date studies (from the 30’s and 40’s on “natural cures” for polio). I picked one of those studies. And tore it apart. The other links didn’t actually support the anti-vax position. In a matter of an hour or so, I had taken the site apart, and nearly got myself removed from the board. The first of many times… LOL
I keep seeing this article posted to my friends’ facebook feeds and I’ve responded to it many times. I work as a cytotechnologist and a large part of my job is screening pap tests for HPV associated changes and pre-cancerous cells. HPV
is implicated in virtually every case of cervical cancer, which is one
of the leading causes of women’s cancer deaths worldwide. I see women every week at the gyn conference who face terrible decisions about their future
fertility after being diagnosed with pre-cancerous lesions of the
cervix, and it is heartbreaking. This disease is no joke, and is
endemic throughout the world. The CDC estimates that 90% of Americans
will contract an HPV infection at some point in their life, and condoms are
not effective at preventing the spread of this disease.
I am confused why the most recent recommendations are that we are NOT to obtain the first Pap until the woman reaches age 21 (a very astute 14 y/o whom I was working up for von Willebrand’s Disease said “I’m supposed to get my first Pap after I start having sex, right? – the public health campaign was quite effective for her, but, no, the stone etchings change every 3 years or so), yet we are supposed to recommend HPV vax at age 12. The available forms are Bivalent (HPV 16 and 18) or quadrivalent (HPV 6,8,16 and 18) which still leaves about a dozen HR-HPVs that are associated with about 25% of cervical cancer. I am also concerned that the Gardisil folks came out with the full court press when their rainmaker NSAIDs came under 1-800-badmed assault when people started dropping dead from heart attacks. EVIDENCE BASED MEDICINE usually has a money incentive hidden somewhere.
After thirty years, I don’t know how to do a Pap smear anymore. We did a darned good job of decreasing cervical cancer with the old glass slide and hair spray technology. Now the liquid preps and genotyping and whatnot are working on the asymptote – perhaps to the point of diminishing returns. It used to be that you would just have the woman come back in a year “for her gyn annual”. Now, some come back in 3 years, some in 5 years. Some come back in 6 months for a genotype, some never need another pap at all. The law of unintended consequences will legislate a lot of “lost to follow-up” and patient confusion in that mish-mash. It might be an academically elegant algorithm, but I wonder if that 14 year old will be able to recite it to me in 7 years.
So many women contract HPV when they first start having sex that the rates of LSIL we see in that population would lead to vast overtreatment. Most of those infections clear spontaneously. Cervical cancer is a disease that evolves slowly over the course of a decade or more and has clearly recognizable pre-cancerous stages. The recommendations changed to prevent overtreatment in the young while still being assured of catching and treating anything that is likely to become cancer.
Vyx, I am with you on that 100%. But all that rationale would seem to weigh AGAINST recommending HPV vax as well. The indolent nature of the disease seems to make HPV Vax of the adolescent “overtreatment” as well. I think it is a lot of expense for very little gain and enough risk to cancel the benefit.
Well a LEEP is no joke for future fertility. Much better to have young women who never need to wonder if their cervix will be competent to hold a pregnancy.
Or the LEEP can cause scar tissue that prevents dilation and leads to a c-section. Which isn’t as bad as incompetent cervix, but still avoidable.
There is no need to do a LEEP for an adolescent for LSIL. Indeed, it probably isn’t needed for any age woman with LSIL. HSIL in the adolescent is a bit more problematic. Wouldn’t it be good to at least know it is there? The calculus of the current algorithms is that it would take so many hundreds of thousands of colposcopies and cervical biopsies for a HSIL Pap in a woman under 21 to prevent one case of invasive cervical cancer – and that case will just have to be collateral damage. There is a very utilitarian ethic (cost/benefit analysis) to nearly every public health screening test and vaccination program. For example, there is a small but real risk of GB Syndrome associated with flu vaccination. If you get it, there can be devastating consequences. But those that do are just considered collateral damage required to achieve the greater good of the benefits of less morbidity and mortality from influenza. Health care workers have very little autonomy to reject the flu vaccination and they will likely be fired if they don’t assume the risk.
That’s not quite the same thing. The probability of a healthy adult being hospitalized from flu exceeds the probability of GBS, so the person getting the shot derives benefit along with risk.
But then again, the thousands of false positives on a cancer screening also suffer in some ways, the emotional stress, the follow-up testing, etc.
“There is a very utilitarian ethic (cost/benefit analysis) to nearly every public health screening test and vaccination program.”
There’s a cost/benefit analysis to *every* decision we make in life. Think of wearing a seatbelt: Most of the time in a crash it prevents you from smashing through the windshield and dying that way. But every once in a long while it actually makes a crash worse by trapping you in a burning or submerged car. But the odds are greatly in your favor when you wear the seatbelt. Same with vaccinations. Same with cervical cancer screening. We may miss the 1 in a million (billion?) girl that develops cervical cancer before age 21. But what about all the deaths among babies that were born premature due to incompetent cervix due to LEEPs on teens who very likely would have cleared even an HSIL on their own.
I didn’t say we should be doing LEEP to treat an LSIL. My comment was in response to your questioning the usefulness of the HPV vaccine. We can treat HSIL so that it never progresses to cervical cancer, but it’s much better to never need to do that treatment in the first place. I.E. prevent a HSIL and you never need to do a LEEP.
Well, if you DIDN’T SAY IT, you came awfully close:
A quote from your post:
“Well if we don’t diagnose LSIL in patients under 21 there’s no need to send them to colpo, no LEEP, no cold knife cone, no loss of future fertility.”
Maybe you meant to say HSIL instead of LSIL.
No, I didn’t mean to say HSIL. women with an LSIL are referred to
colposcopy because up to 30% of those women may harbor a concurrent
HSIL. Cytology is a great screening tool, but it’s not perfect. Colpo
is also a great tool, but again not perfect. The number of under 21’s
who’d be referred to colpo would be huge, some of those women may be diagnosed with a CIN II after colpo and biopsy. This is the category where they start to think about LEEP. Surely, many of those would be unnecessary.
Infection happens in adolescence. The sequel of cancer happens to women in their late 20s, 30s, etc.
I am not arguing against the current algorithm. However, it has made it a bit difficult to work out appropriate recall letters due to all the permutations. And I can tell you from personnel experience that it is VERY confusing to patients who used to remember to schedule their “gyn annual Pap” on their birthday or their last child’s birthday. AND the new Pap algorithms, in my mind at least, seem to show that HPV Vax is not needed either. ALL of the research was done prior to the current algorithm which came out in what, September of 2012?
I don’t understand your logic at all. The new Pap algorithms say we don’t need the vaccine?
The vaccine is best given BEFORE a young person becomes sexually active. We don’t currently know how long it lasts, but the latest studies say at least 8 years. (I assume that eventually, the long-term surveillance studies will pick up waning immunity. So far they haven’t.)
So, vaccinate at 12, prevent HPV infection at 16, prevent cancer at 28. That’s the theory.
The theory behind delaying and reducing Paps has to do with the rate at which infection turns into abnormalities into cancer.
What do you see as the risks of the vaccine? Doesn’t it have a rather excellent safety record?
It wouldn’t lead to “vast overtreatment” if you don’t treat it from the onset of intercourse to (whenever) age 21+. A liquid based Pap is an EXCELLENT way to get a specimen for other STDs and if HPV is documented, it provides an EXCELLENT opportunity to discuss safe sex practices and condom use. AND it documents when the “ground zero” infection was acquired, what the genotype/genotypes is/are so you can add 10 years to it and heighten your surveillance.
Well if we don’t diagnose LSIL in patients under 21 there’s no need to send them to colpo, no LEEP, no cold knife cone, no loss of future fertility.
Since condoms don’t protect against HPV infection, a young woman can still contract an infection while practicing safe sex.
Current liquid based sequencing doesn’t give a genotype, only subdivides into low-risk and high-risk categories. Even with the high-risk subtypes 80% of infections clear spontaneously. There’s no telling which women will have the HPV E6 and E7 genes incorporate.
As an individual, I do think it is much harder for women and clinicians to follow the new schedule (at least a yearly exam got women in to see their docs every year). As a professional, there is no need for us to screen women every year, especially as the liquid based paps are considerably more expensive for the patient than the old smear and fix paps we used to see.
“Current liquid based sequencing doesn’t give a genotype, only subdivides into low-risk and high-risk categories. Even with the high-risk subtypes 80% of infections clear spontaneously. There’s no telling which women will have the HPV E6 and E7 genes incorporate”
**********************************
Actually, it can if you check the right box on the request form. Check out the latest ACOG Bulletin on Paps on what you do for an ASCUS with +HR-HPV. There are two choices. 1) repeat the Pap in 6months or 2) get a HPV 16/18 genotype and colpo if positive
At least in our laboratory a HPV genotype result is either high-risk (which includes 16,18, and several others) or low-risk (which includes 6, 11, and several others). This result doesn’t specifically tell the clinician which specific HPV strain the patient has, you would need to do PCR to differentiate.
We can also do a high-risk mRNA screening, which is potentially more useful as it demonstrates integration of the viral genome.
“Since condoms don’t protect against HPV infection, a young woman can still contract an infection while practicing safe sex.”
Sure they do, just not 100%.
What is the “perfect use” prevention rate of condoms against HPV?
I’m not sure. HPV is an infection of epidermal tissue, so infection only requires skin to skin contact.
I don’t know. I don’t think anyone knows. It’s hard enough to measure a perfect use pregnancy rate, and pregnancy is an easy to detect condition. HPV infection can be hard to detect. But there are plenty of indirect studies that show that women who report using condoms “always” have lower rates of abnormal paps and genital warts.
This idea that “condoms don’t protect against HPV” is a big talking point among the abstinence-only crowd. It is true that condoms only cover the penis. They don’t cover the scrotum. So if a man carried HPV on his scrotum it could touch a vulva during PIV sex and then the vulva might get HPV. And HPV-caused vulva cancer does exist (I have seen a total of 3 cases of it in my ~15 years in medicine, if I were a gyno that number would be higher). In addition, fingers and mouths can track around virus. But condoms do keep HPV from being deposited right at the cervix by the penis. The cervix is especially susceptible to infection because it has a velvety mucous membrane surface unlike regular skin which has more layers of protective keratin. This is especially true in teens. The cervix of a teen actually looks bloody red and velvety over a big portion of its surface (it’s rather shocking the first time you see this as a student), whereas that of an older woman looks pale and smooth. That’s why it’s super easy to pick up an STD as a teen. Not only are you more likely to be switching partners and forgetting condoms, but also your cervix is like a germ sponge at that age.
Really interesting. I had no idea.
O/T: In a recent WebMD article on dip in CS rates quotes a doctor, saying: “Maiman said the cesarean rate is so high because doctors fear malpractice lawsuits. “The pressure is on physician practices because it takes so much time and energy to stay with a patient for hours for a vaginal delivery, compared to the quickness of a cesarean,” he said. “Most of the lawsuits are for the failure to do a cesarean in a timely fashion.”
http://www.m.webmd.com/baby/news/20140123/first-time-cesarean-rates-dipped-in-2012-cdc
Is this true? Maybe I’m naive, but my first assumption, unless they’ve shown otherwise, is that health professionals make decisions based on the health of their patients, not their own legal worries.
It’s a very common myth among NCB advocates, that doctors do c-sections out of either impatience, hope of getting paid more, or out of fear of lawsuits. However, countries or hospital systems where doctors are paid on salary and go home on time whether the baby’s arrived or not have similar c-section rates. Countries with a different malpractice system have similar rates.
The article also says: “Putting financial pressure on hospitals could reduce the cesarean rate further, Maiman said.”
That would be a very bad idea. Delivery decisions should ALWAYS be made on a case by case basis, and I would hate to see a mother or baby subjected to an excessively risky vaginal birth because the hospital had already done “too many” c-sections that month. The best hospitals would suffer under this plan, because their greater number of high risk patients would drive up the c-section rate.
If most doctors are making the decision prudently, in the patients’ best interest, whatever the resulting c-section rate is must be the ideal rate.
Note that this particular NCB advocate is Dr. Mitchell Maiman, chairman of obstetrics and gynecology at Staten Island University Hospital in New York City.
http://www.skepticalob.com/2011/11/we-cant-control-c-section-rates-if-we.html
Also http://www.skepticalob.com/2008/08/how-to-lower-c-section-rate-step-1-look.html
Thanks, for both of those links! Good reading.
That comment about financial incentives/disincentives rankled me as well. A very bad idea!
It’s a stupid and senseless myth anyway, because nobody is “surprised” by the amount of weird hour work required of an obstetrician. It’s part and parcel of the specialty – if these Dr’s were interested in office hours, there are certainly specialties which keep regular office hours and pay more or the same that they could have tried to match into. People go into obstetrics because they care about womens reproductive health, not to get rich.
This is the quote that intrigues me:
The risks to the mother and baby are much higher in a cesarean birth than in a vaginal birth, Maiman said.
[…]”It’s also worse for the baby as multiple studies have proven.”
… Risks to the baby include injury during delivery, breathing problems and the potential need for intensive care.
Yes, that caught my eye as well. It seems an incomplete statement. If a doctor decides a CS is the best course, I would imagine it means the CS is, in that specific case, less risky than a vaginal delivery.
He seems to be talking about delivery before 39 weeks, not c-section specifically. As Amy Tuteur, MD likes to point out, the risks he lists don’t include death because c-section prevents death.
But this guy is chair of obstetrics and gynecology at a teaching hospital. He’s credible.
That makes more sense, if he’s referring to delivery before 39 wks. And you’re right about his credentials, which is why I knew he had to know his stuff (or some of it!) and wondered if there was more to whole lawsuit fears than I assumed. WebMB may not be portraying the entirety of statements clearly, either.
I don’t think so. From my reading he was only talking about C-sections. The C-section rate can be most impacted by preventing the first C-section. The best way to prevent the first C-section is not to induce a green cervix. There is actually an app for that – you put in Dilation, Effacement, Consistency, Position and Station (and a parity modifier) and it will calculate the Bishop Score and the predicted C-section rate. Great tool to show a patient who is TOBP with swollen feet and back ache and indigestion and “all of us Smith’s have our babies by 37 weeks and they all come out just fine” so when can you induce me? My sister uses Dr Jones and he induces all of his patients at 38 weeks. I should have used him.”
Ooh!! I want that. What’s it called?
attitude devant, it is called” Bishop’s Score calc.” by Gregory P. Moore, MD. I got it as a iPhone app. A reviewer for a similar app (Bishop’s score) critiqued that no references were given for that app to support the “calculated” C-section rates. For example, a Bishop’s of 0, 1, 2 or 3 is given a C/S rate of 45%; 4, 5 and 6 is 10% and 7 and 8 is 1.4% for a primigravida. It might be a tad intellectually dishonest, but more often than not I can give the impatient primigravida a rationale (a 45% C/S rate) why I am not scheduling her induction without her muttering what an unsympathetic doctor I am and what bad “bedside manner” I have.
“Cesarean rates also varied depending on the stage of pregnancy. Each week from 37 weeks’ gestation and beyond saw declines in C-sections, with the biggest drop at 38 weeks, when the baby is nearly ready to be born. Full term is usually considered 40 weeks.”
OK, this is what I get from that quote – C/S before 37 weeks are usually due to maternal/fetal conditions such as severe toxemia, poorly controlled diabetes and chronic HTN, IUGR with fetal jeopardy and preterm labor with fetal malpresentation. Although I have railed against 39 week Nazis, the 39 week rule (I think the seminal papers came out in the NEJM in 2010), inductions at 38 weeks with a green cervix can be projected to have a 40% C/S rate. I still think there is a benefit to making repeat C/S less onerous in the 38th week to prevent iatrogenic urgent/emergent C-sections and in multiparas with an advanced Bishops score who live a considerable distance from the hospital and/or a history of fast labors.
http://www.nejm.org/doi/full/10.1056/NEJMoa0803267
The paper was published Jan 8, 2009. It is probably the most important factor in the cited plateau-ing and decrease in C/S rates since 2009.
As many people have said before, lawsuits only happen when there has been some harm to the baby. This is becoming less common since it was shown that cerebral palsy isn’t necessarily an intra-partum event, but generally a live baby with brief breathing issues who might need a short NICU stay is seen as a better outcome than either death or hypoxic damage.
So, docs are doing too many c/s because VBs take too long. That’s bad. They’re also doing too many because they’re afraid of getting sued for not doing a C/S soon enough. Which is also bad?
I am of mixed opinion here, since I have chronic health issues.
SOME physicians assess risk based on patient outcome. SOME physicians value process or whatever their governing body insists on over the health of their patients. And SOME physicians are older, set in their ways, and just do it that way BECAUSE. I’ve run the gamut.
As for my specific experience with OB/GYN care, my physician invited us to take photographs in the OR, something that is hotly contested in ORs around here during c-section births, because she said, “If I screw up, I’m going to be worrying about a lot more than whether you have photos and videos of it.” Amen.
Tracy Cassels of Evolutionary Parenting opts for response #1:
http://evolutionaryparenting.com/my-pet-peeves-generalizing-data-to-the-wrong-group/
I saw this and thought it was interesting. A Facebook page devoted to debunking antivaxxers lies comes down on someone for debunking homebirth lies. I guess dead babies via birth are just stupid woman problems, unlike vaccination…
https://www.facebook.com/photo.php?fbid=641862689217077&set=a.414675905269091.96547.414643305272351&type=1&theater¬if_t=photo_reply
I can’t seem to link to the page. Fail.
It’s Refutations to Anti-Vax memes – great page!
Twelve. Twelve. They lost twelve children. Please tell me this is Photoshopped. My God.
Never mind. 🙁
http://www.findagrave.com/cgi-bin/fg.cgi?page=gr&GRid=22644320
(realise I’m talking to myself here but) Jacob and Elizabeth Bridge had 17 children. 5 lived.
Unbelievable. Wish I could find out which illness(es) plagued the family in 1865, 1884, and 1890…
I’m guessing yellow fever and/or cholera
Did some research on historical sites. Trixie was correct — but also smallpox and influenza.
May I ask where you found that info? I found the family’s census info up to around 1930 (surviving members) but failed to find the cause of death. I did find that 1890 was a particularly bad year for influenza.
Just so very sad, I can’t even imagine.
Geneology-quest.com has a page on American epidemics
Sadie, the last born, arrived when Elizabeth Bridge was 47. She died two years later. This woman bore children throughout most of her adult life, only to lose the vast majority of them. It boggles the mind, it truly does.
Guestll, Latrobe PA ( home of the family) has an active historical society. There are contact emails and phone numbers on their website.
I suppose typhoid fever would also be a possibility.
Or diphtheria.
Looking at the dates, only one was a baby, the rest were lost from age 7 to age 20.
My great-great grandmother had 8 kids through the 1890s and early 1900s, buried five. Two were babies, two were 10 or 12 or something. Her firstborn survived all the childhood diseases, but had the bad luck to have been born male in Europe in the early 1890s and died in the trenches.
One of my relatives survived the trenches but died of Spanish Flu weeks before he was due to get on the ship to come back to Australia.
Poor Queen Anne spent her entire adult life either pregnant or mourning yet another lost baby or child. Seventeen pregnancies, and not one child outlived her. How did she take such an active part in the politics of the day, and what would her marriage have been like with all those tragedies?
Somehow I think Queen Anne would have leapt on the chance to give birth in hospital, access proper medical care, have her children vaccinated etc. etc. Today she’d have had access to contraception, so chances are she would have had a much smaller number of children, and been able to watch practically all of them grow up healthy.
In the cemetery near my house, there is a ring of graves for a family that lived in the area in the mid-1800s. Mother, father, and I think eight children, seven who died in childhood, most before the age of two. The mother died within a year or two of the last child being born. I think either the youngest or the second youngest survived to age 40. Each child had his or her own grave and stone, which leads me to think this was probably a relatively well off family…. if they could afford so much grave space, I wonder if they could also afford the medical treatments of the day. I first saw these graves after my own baby daughter died, and I couldn’t believe that any family could live through that much tragedy. It still boggles my mind.
My paternal great-grandmother had thirteen children, eleven survived. Ten girls and a boy, the last born at age 40, at which point, according to family lore, she “ceased relations” with my great-grandfather. He wanted an heir and he got one.
My paternal grandmother had thirteen kids as well, her first baby died at the age of 5 months after having a high fever.
Seeing that they were farmers, poor and lived in a very small rural area, I find it surprising that they never lost another baby.
My great-grandmother was described as being “always pregnant” by my grandmother. She had 6 daughters survive and only one son make it far enough to even be named. He died of pyloric stenosis in infancy. OTOH, all the daughters who made it past infancy alive lived to be at least 88 (all but one lived past 90, two are still alive at 99 and 93–or maybe she’s 94 by now). This all gave me the impression that men were terribly fragile and prone to dying with little provocation. Also that modern medicine, which might have saved my poor great-uncle, is a good thing.
Of the 4 children Mary Shelley gave birth to, only 1 lived to be an adult. By the time she was 25 she had lost 3 children and her husband. Not surprisingly, she was haunted by these losses.
Doubtful. This seems real enough to me. This is my number one argument to anti-vaxxers: go visit an old graveyard and look at the rows and rows of tiny little graves. Look at the date markers for children who didn’t make it out of infancy or the first years of life. Then tell me that vaccines don’t matter or that childhood illnesses aren’t serious.
God. I know you’re not an anti-vaxxer. I just get so angry about it. Vaccines are the reason I have two healthy little kids sleeping downstairs right now. We should all be on our knees every day thanking God for them, and instead these assholes, privileged ignorant fucks, are spreading the idea that vaccines are somehow evil or harmful and it just makes me rage.
The professional advocates, as much as I wish they would reevaluate, stand to lose too much by accepting the actual numbers and admitting that they were wrong. That kind of reversal takes integrity, and quite frankly the data has been pointedly in one direction for the last couple of years. I think they would have at least stopped being quite so vigorous in selling other people on risking their children’s lives and health.
Hopefully this analogy will be able to give home birth *parents* another perspective though, one which may enable them to see through the lies and manipulation on this issue. It can be embarrassing to come to the realization that the choice you thought was safe was anything but safe, but isn’t that better than the alternative of continuing to make an unsafe choice because reevaluating your conclusions is too uncomfortable to think about?
And on that note, I would like to announce the safe arrival of PrecipMom “back to the hospital” baby #2, born this week. We are both doing well, and received excellent care. I don’t think we had even a single member of staff with a less than pleasant attitude, and even the food was better this go around.
Congratulations! Yaaaay babies!
Yay new baby!!!!!
And yes. Ultimately, parents are the ones who need the data.
Congratulations and enjoy!
Congratulations!
Congratulations!
mazel tov!
This is wonderful news!!! Congrats!
Mazal tov on your new baby!
I think they would have at least stopped being quite so vigorous in
selling other people on risking their children’s lives and health.
If anything, I think the pro-homebirth propaganda has increased in the past few years, BECAUSE the risks are being better documented. 30, 40 years ago, homebirth was something unheard of, except maybe for poor black women in the South who did not have access to hospitals. There certainly were fewer pseudo-midwives [and almost no CNMs in the US; there were only two schools teaching midwifery when I went to the UK]. It certainly did not have the cachet it has now for middle and upper class white women. So denial of risk becomes ever more important or the whole edifice falls apart.
Who says to a friend, “What? You were so STUPID you didn’t go to the hospital?” No, nowadays you practically have to defend your choice of a hospital birth.
Congratulations on the safe arrival!
Congratulations! I remember your first “bounce back to the hospital” baby when you dug at Dr Klein and his evil-epis stance. I wondered then how you should call yourself now. PrepiMom, maybe?
So happy you’re both healthy and well.
OT: Dr Amy, I really think your voice is making a difference. I’ve been arguing for a couple fays now on a post on my Ob said what. People were claiming homebirth is safer as usual. One other person and I refuted it. They’ve continued to argue but most actually conceded that homebirth does increase the rate of death and brain damage. They have since posted variations of “well even if there’s a higher death rate there are still other benefits/overall risk is low” blah blah. Anyway, my point is that a year or two ago, I don’t think they would have even admitted that. The change, in my view, can be credited to you for shouting the facts loud and clear and furthering this movement. Well done, Doctor.
Fays=days. Also I think there were a few posters from here over there. Here’s a link to the discussion.
http://myobsaidwhat.com/2014/01/23/thoughtful-thursday-it-is-not-your-fault/
Don’t discount yourself! Dr Amy’s blog would fall on deaf ears if it weren’t for regular people like you and me linking to it and talking about it. We are all part of the success you noted. Good job everyone!
OMG, I’m one of the people who didn’t like that post. For awhile I thought I was the only non home birth person who read that blog.
I’m a person who thought home birth sounded unsafe before the studies proved it.
Mom of 2, Thanks for your participation in that. I had linked to the letter of a CNM which she presented to the Oregon Legislature. That kinda took the wind out of their sails since it was not an evil OB seeking to protect his ill-gotten income. I found it interesting that one of the posters went to great lengths to question the validity of the stats. She found it hard to believe that there were NO INTRAPARTUM deaths in the hospital cohort. “Intrapartum” is the time from onset of labor to delivery. As Dr Amy has said, she had never heard of one, much less seen one in a hospital. How hard is it for a birth certificate to have a place to ask: “where did you intend to deliver the baby?”, “where was the baby born?’ and “was the baby alive at 7 days of age (or whatever age is defined as a ‘neonate’?” The saga continues….
omg, so I got the peer review guidelines for the utah midwives organization. Its all about not hurting the other midwives feelings, and you aren’t allowed to discuss any illegal actions or misconduct. I’m going to contrast this with actual peer review in hospitals on safer midwifery utah. What a freaking joke these midwives are.
Seriously? How does one go about getting those guidelines? I would like a copy myself…
https://www.facebook.com/groups/548968125157986/files/
its the top file. If they delete I have one saved on my computer and will be sharing it online via my Safer Midwifery in Utah blog.
OT update: Marlise Munoz is to be removed from life support. The judge agreed with her husband.
http://www.bbc.co.uk/news/world-us-canada-25889728
One has to wonder whether the decision would have been taken had there not been clear evidence that the fetus was seriously abnormal.
If the fetus had even looked mildly viable, of course those poor people would still be in hell.
Chilling. It’s clear that some people (with power) really do see women as only incubators, and that the life of the fetus is the only thing that matters.
At least it’s finally over and the family can bury her.
That was so silly. I mean, ethical issues aside, did anyone actually think it was ever going to work and result in a viable baby?
Sadly, yes. CNN found this guy back at Christmas:
http://www.cnn.com/2013/12/24/health/pregnant-life-support-texas/
” “We don’t have very precise measurements of fetal wellbeing,” Dr. Edmund LaGamma, neonatologist at New York Medical College in Valhalla, New York, who is not involved with the case.
“Based on the available facts, LaGamma said, there is a possibility of a good outcome for a fetus born to a woman in Munoz’s situation.”
Which is irrelevant, because, pay attention, SHE DID NOT WANT TO HAVE HER LIFE ARTIFICIALLY SUSTAINED.
Directed at that OB, not Box of Salt.
I fervently pray that the ordeal ends Monday and nobody files an appeal. I believe mom died when her fetus was but 14 weeks gestation. How much more merciful and clear sighted would it have been to have let nature takes its course then.
More details from our side of the pond:
http://www.cnn.com/2014/01/24/health/pregnant-brain-dead-woman-texas/index.html?hpt=hp_t2
Funny enough I wrote a paper on this exact thing in college 10,000 years ago. It was not well recepted by my hippie home birthing professor.
OT sorta, but the car analogy works on so many levels: http://twopedsinapod.com/2014/01/21/vaccines.aspx
http://abclocal.go.com/wabc/story?section=news&id=9404030
I wonder how long til a stuntbirther tries to copy this one on purpose? Amazonian streams are so last year. (And my sincere congratulations to the family in this story, who seem like perfectly wonderful people).
Such a cute baby! Glad everything ended well.
Oh, another thing they will say is “But, but, but… There are *some* homebirth midwives who are really great! Mine was amazing.” Totally oblivious to poor outcomes their midwife may have had or not realizing that she may just be lucky this far in her career, or maybe really is one of the few. Who cares? Most of them are horrible. I’m happy to throw that baby out with the bath water.
(“Mine was amazing” means the baby didn’t die.)
not necessarily. Sometimes the baby dies and the mom still thinks the midwife was “amazing.” Not exactly sure what a midwife has to do to be considered amazing, but keeping the baby alive apparently isn’t one of the requirements.
The second I hear the word “amazing” in reference to a birth or a midwife, the first thing that pops into my head is that I’m dealing with someone who would never be able to admit when the emperor is wearing no clothes. There’s just something about that word and everyone claiming how “amazing” someone was or wasn’t. Be skilled, be inspiring, be encouraging, kind, whatever… have an actual attribute beyond “amazing.”
I know what you mean, but I would say that my two medicated hospital births were amazing, in that all births are amazing, sort of mechanically and biologically.
I found this gem at http://www.mamamia.com.au/news/home-birth-like-putting-childs-seat-belt/
“If high tech medicine were good for birth then the US would be number one in the world for great outcomes…instead we are BELOW Ethiopia for outcomes.”
Ummmm… no.
Neonatal mortality per 1,000 live births (according to the WHO)
US: 4/1,000
Australia: 3/ 1,000
Ethiopia: 29/ 1,000
Math. Maybe they didn’t quite understand the way it works.
Maybe they just repeat things they’ve heard without checking to see if it is true or not. Maybe they just make things up.
The latter. Someone made it up, no one bothered to question it because it sounded good.
Well, it certainly sounds like it would further the NCB agenda, but when you really think about it, it doesn’t really sound right. Ethiopia? Come on, even this ol’ NCBer can see the ridiculousness of that claim.
Yes, you have to be pretty thick to fall for that.
Surrrrre the outcomes in Ethiopia are better than the USA… That’s why my patients from Ethiopia were so excited to get to have their babies in a hospital. The oldest woman in one particular community was the “midwife” and once she moved to DC from Ethiopia she decreed that all women would go to a doctor for prenatal care and all women would deliver in the hospital. If a man dared make his wife not go to the hospital or the doctor the elders would perform the community shaming ritual on him and shun him for a period of time.
I had an Ethiopian friend say much the same to a doula who was planning a homebirth-of course, she had seen homebirth in Ethiopia. She saw
Women injured in child birth or die and babies who didn’t make it. She couldn’t understand someone wanting to replicate those circumstances.
Babies die in hospitals in Somalia, too!
Yay Australia!! (where HB is truly fringe!)
That works if the only outcome measured is the intervention rate.
Ha, this makes me think of this article about Dr. Catherine Hamlin and the comments by the current CEO of Hamline Fistula Ethiopia, about how she couldn’t continue to be a doula after seeing real suffering in Ethiopian women.
http://www.dailylife.com.au/life-and-love/real-life/how-catherine-hamlin-brought-safe-birthing-to-ethiopia-20140122-318nx.html
I think you can find part of the answer to the comments on some of the news stories: http://www.nbcnews.com/health/home-birth-risky-not-putting-childs-seat-belt-researchers-warn-2D11980648
“This was influenced by hospitals protecting their bottom line” “This can’t be true because it doesn’t make sense to me.” “The researchers are male.”
I especially liked the guy who came to tell us about how his ex-wife had to have an “appeaseodtomy” to get her first baby out, then had two successful home births. (I assume he meant episiotomy?)
its when you get the appendix out thru an episotomy (duh)
I thought it was when you appease someone by only pretending to perform a surgical procedure.
Trust Appendix!
Forgive him, he was a high forceps delivery.
To be fair, terminology can be hard unless you have a grasp of the underlying linguistical constructs. That said, I still almost died (no pun intended) when I saw a dad saying how much he liked the “postmortem” ward at the local hospital when he meant to say “postpartum.”
“This can’t be true because it doesn’t make sense to me.” I. DIE. I’m using that to win all my arguments from here on out.
“hospitals protecting their bottom line.” I don’t think they realize that hospitals and doctors aren’t threatened by the small number of people who choose homebirths. Doctors don’t like the trauma that comes with being forced to deal with the aftermath of a homebirth gone wrong.
Exactly. We don’t like homebirth cases that go so badly that upper management hires trauma counselors to attend the case review and talk to the staff involved. Hospital cases go badly too sometimes but when it’s a homebirth the “if only” makes things much harder on the staff.
Yeah, OB/Gyns spend hours every day prescribing birth control pills and tying tubes and putting in IUDs and Nexplanons and ordering Depo shots. Because of their efforts the average woman now has 2 kids instead of the 12+ that she would have had without the OB. In other words, OBs themselves reduce their birthing business by over 80% by helping women prevent pregnancies. And yet we are supposed to believe that OBs are getting all bent out of shape about the 1% of birthing business they are losing to homebirth midwives? Please.
Baby CC Prof is actually napping, so I was inspired to do a little library research and math. I’ve come to the conclusion that, by the numbers, home birth is WORSE than skipping a carseat.
According to the CDC vital statistics report, in 1960, 3,581 children under 10 died in motor vehicle accidents. At that time, the US boasted approximately 40 million children under 10, for an annual risk of .00009, about 1 in 10,000. Multiply that by 10, that’s a cumulative risk of 1 in 1000, for your child’s first ten years of life.
This isn’t the risk of skipping a carseat once. It’s your child’s total risk of dying if you not only skip a car seat, but drive him in a car with no anti-lock brakes, no airbags, non-tempered windshields, no crumple zones, and no seatbelts, every day until age 10.
Risk of dying at home birth? Roughly 3 in 1000, as per various articles quoted here.
So, home birth. It’s three times worse than driving with no modern safety features at all!
Wow. Thank you for this analysis.
Just terrific! Yesterday on the MyOBSaidWhat site “It’s not your fault” an HB mom said, “Sure there are risks of home birth, but my child and I have a greater chance of dying in a car accident”. I was attempted to do an analysis like yours but I thought it would just fall on deaf ears. Besides, your calculations and analogic factors are perfect.
I wonder what the addition of “modern safety features” (analogous to the modern OB unit) would do to the calculation. Home birth would probably be at least 10 times riskier than driving
No need to wonder in vain! Recent vital statistics reports are much easier to read that the archival ones. According to the recently released 2010 report at http://www.cdc.gov/nchs/data/nvsr/nvsr61/nvsr61_04.pdf:
During 2010, a total of 1418 children under 10 died in transportation accidents, for a death rate of roughly 2.2 per 100,000 per year, or 22 per 100,000 total by age 10. (Remember, home birth: approximately 300 per 100,000, so more than 10 times as bad.)
Of course, the auto death rate shoots up at adolescence. Teens are dumb, and learning to drive is the most dangerous thing your average American kid needs to do.
Based on the same report, your child’s total risk of dying in a car accident by age 25: 188 per 100,000. Still about half the death rate of home birth.
It would be very interesting to also include a comparison of injury statistics.
Good grief….you are able to put that together while sleep deprived from caring for a newborn? Colour me impressed! I have a 6 week old and am happy if I get my shoes on the right feet most days!
Good job! 🙂
Math is easy. Figuring out why my pumping bra was in the garbage can this morning, or what I ate today, THAT I have no freaking clue.
I once sleepily tossed mine into the bin when I meant to throw it into the dirty laundry basket and the pads into the bin (they landed in the basket instead). Looked at it dumbly for a few moments while my brain was catching up to figure out what was wrong with the picture.
For anyone who is interested, here is part 2 of my coverage of the utah midwives association meeting that took place in response to a preventable death by a serially negligent midwife.
http://safermidwiferyutah.wordpress.com/2014/01/24/remember-this-meeting-is-being-recorded-part-2/
The baby and the mother are never mentioned. They do profess their love for the other midwife and are sorry that she ‘had to be the catalyst’. they downplay the whole thing with icky phrases like “a bit of a scare”. God. Can these women immediately exit the planet?
Dr. Amy, you hit this one out of the park. My hat is off to you. And thank you for being a rational voice in this discussion!
I have to say, the comparison to car seats was absolutely brilliant, and I’m suggesting completely intentional.
Because we know that the same groups that push HB are going to be also gung ho about car seats (note the direction here – pro HB to pro Car seat, not necessarily the other way around). Thus, someone comes out and says, “HB is like not using a car seat”, how can they respond? “No it’s not”? Won’t stand up.
They can’t even pass it off as relative vs absolute risk.
Brilliant.
You’d think, but they find a way to rationalize it anyway. A lot of the online car seat fanatics got their start on MDC.
I always thought it was fairly loony that a lot of the Boob-Nazis & Carseat-Nazis were also anti-vaccine, because they preach “OMG SAFETY” and quote the WHO, AAP, etc. chapter-and-verse, and then turn around and ignore vaccination recommendations from those same groups…. it just hit me that of those three, it’s actually MOST selfish to not vaccinate (assuming it’s not medically contraindicated.)
…I mean, if you formula-feed or fail to rear-face your 5 year old in the car, you’re “risking” your child’s well-being (note air-quotes; I did both myself, so no offense meant!) But if you do not vaccinate your precious indigo-child, then you’re putting potentially thousands of others at risk, including infants too young to be vaccinated, immunocompromised ill folks, and the elderly.
So – way to go, crunchy mafia, you’re taking selfishness to a whole new level of assholery….
Pointing that GLARING fallacy out got me kicked out of a community group. The WHO is good enough for them until … well, it’s not. My car seat is a piece of crap and I turned my son around early because I had a hard time getting the seat to safely sit per manufacturer instruction. I have a busted body and so it’s not easy for me to climb in the car, straddle the seat and adjust the strapping every time I use it, as was suggested to me. LOL. As in, I’m not f-ing doing that. Holy shit, you’d think I was tying him to the roof. People I didn’t know came out of the woodwork to admonish me. Never mind that it was per manufacture instructions in the first place to flip it around, and I don’t have hundreds of dollars to spend on a new seat.
That’s kind of the reason why I feel ambivalent about the extension of car seat laws to older and older children. Yes, it’s safer, that’s clear, but the absolute risk is pretty darned small. There are plenty of things more dangerous than driving around an eight-year-old in a regular seatbelt that are quite legal and acceptable, and there are costs to the laws that may go unrecognized.
It’s not just the cost of buying booster seats, it’s that the legal requirement for them it makes it harder to carpool and ride share, which makes it harder to live without a car, or even live as a one-car family. Discouraging carpooling also increases traffic jams around schools and whatnot, which actually makes things less safe, especially for pedestrians. Which discourages walking or biking, which has its own financial and non-financial costs. In short, the mandatory carseat laws reinforce our car-centric culture.
Should you keep your kid in some form of specialized seat until he’s big enough that the seatbelt works optimally? Definitely. Should it be the law? For babies and toddlers, sure, but for school-aged kids, I don’t know.
Boosters are pretty cheap and portable. You can get a low back booster at Walmart for $13. There is even an inflatable booster on the market that can easily be packed in a child’s backpack. There’s really no excuse not to use one until a child can pass the 5-step test. I completely disagree that needing a booster makes carpooling more difficult. It’s a matter of laziness not to use one.
Yes, the absolute risk on any single trip is low, but remember, we aren’t just talking about risk of death. There’s also the risk of horrific injury that can come from the child submarining under the lap belt, causing it to impact the soft internal organs instead of the hips. For $13, you can prevent that pretty effectively.
If you Google Seatbelt Syndrome, you can read more about it. Children just don’t have the pellvic structure to safely ride in a seatbelt alone.
More info: http://www.thecarseatlady.com/booster_seats/booster_seats_11.html
While respecting your choice, I just wanted to mention that convertible car seats that will rear face a typical 3 year old can be had for about $80. For $40, you can get a seat that will rear-face most kids til 2. It’s worthwhile to double check that your seat is installed with the top tether attached when your child is forward facing.
Ha I wish! Not where I live. With taxes, even the cheapest seats are over a hundred bucks and they don’t fit properly in my car. I did find a seat that was better suited but it cost 300 dollars. And the 40 dollar carseat doesn’t exist here: maybe as a bucket seat, but I doubt even that. In fact, I don’t know of any brands sold here that drop below around a hundred+ and upwards of 200-500 dollars is a more typical range, granted I wouldn’t pay more that 200 or 300 even if I had it laying around. Considering today I’m thinking about what to pawn to get by until the 1st, I don’t think that’s happening.
You cannot advertise or purchase a used seat even if you know the person well. Although, gasp, I break the rules there as well, and am the happy recipient of a car seat passed down from a friend, and again, I will be getting the next size up from her, or I wouldn’t even have one at all since my ex took both car seats we had, despite the fact I’m the custodial parent, and won’t give them back! They both cost about 200 dollars and they never quite fit properly in my car anyway, even after a fancy pants carseat tech came and showed me that it was as easy as climbing into the car, getting on top of the child and car seat, and manually adjusting the straps every time by violently rocking the seat side to side. Nimble those car seat techs. 🙂 Hahahaha. No. Anyway, I guess it’s just as well, but the hand me down one doesn’t really fit great, either. I have leather seats and I need to jam a book under the carseat to stop it from moving or falling sideways. LOL Regardless, without money it’s hard to put gas IN the car to drive it, so hey, there’s that. No money- no gas- Safety first!
Are you in Canada? At any rate, please don’t put a book under the car seat, please see a tech again. If it’s falling over like that it cannot do its job in a crash. I sympathize with how difficult they are to install. It sounds like you may need a locking clip. Or there may be programs in your area that will give you a proper seat at low or no cost.
I just read “Super Freakonomics” by Levitt & Dubner (great book) and it includes quite an interesting discussion on booster seats for older/taller kids and the (comparatively small) safety margin they provide. It was certainly interesting reading.
Of course the statement that “homebirth is safe” is falsifiable. You regularly review papers that falsify that assertion.
The statement that “there is an undetectable force that created the world in such a way that it can more parsimoniously be explained without reference to an undetectable force” is unfalsifiable. Russel’s Teapot is unfalsifiable. http://en.wikipedia.org/wiki/Russell%27s_teapot
“Homebirth is safe” is more aptly compared to an article of faith.
Reminds me of “the thing which made the thing which had no known maker” by Nonstampcollector.
I was quite stunned to find “The Positive Birth Movement”‘s twitter feed on this after all – a homebirth disaster has to be an immensely positive thing? (Not.)
I think anyone who is genuinely an advocate for women’s reproductive choice (whether in birthing or elsewhere) is going to stand up for EBM because it’s the right thing to do.
What really gets me is I know women who are “thought leaders” in our community who have privately acknowledged to me that they know I am right, they just don’t want me sharing the information with others. That’s where things get really disturbing to me. They KNOW better and in that way they become as paternalistic as those they claim they are replacing.
Do you think this will turn up on Henci Goer’s site? From reading this website (The Skeptical OB I mean), I’ve learned there are the hardcore NCB tribe who will just write this off along with anything they don’t want to hear or believe. But, there truly is a (smallish, I suppose) contingent of fence-sitters who want to know the truth and will turn to science if they find this new information. There are posters here who say they used to be homebirth advocates but were open-minded to learning, and once hearing the truth (or in some cases learning it the hard way), left that community. I’ve read a few blogs, probably because various posters here led me to them, where women who were interested in homebirth changed their minds before the baby came because they got new information about safety (often specifically pertaining to their pregnancy, but still….).
So yeah, anyone with a financial dog in the game will fight this sort of thing tooth and nail, and do her best to convince her paying clients that “homebirth is as safe as or safer than hospital birth.” But the actual women having the babies tend to be a bit more cautious. It is still only a tiny percentage that have their babies OOH, and the really hardcore ones will find ways to justify the risks. Maybe they are drug addicts and want to avoid the system. Maybe they have no health insurance. Maybe they are abuse survivors and their fear of hospitals/doctors/birth/etc outweighs their fears of the risks they are taking with their and their babies’ lives. Maybe they are genuinely ignorant of the risks they are taking, and they think they are doing something healthier. Doesn’t have to make sense to us.
Ultimately, I think this message is starting to get out there though, and that is a good thing. Hopefully, the small number of homebirths will decrease further, so fewer women and babies are endangered.
It’s unclear what “homebirth advocate” means. It sounds to me like “anyone who thinks home birth is a reasonable choice and shares their thoughts with their friends and/or the general public” but in this post it seems to be a True Scotsman: “anyone who thinks that home birth is a reasonable choice and doesn’t immediately change their minds upon hearing about or reading a paper in the Journal of Medical Ethics.” If that’s the meaning then the whole post is unfalsifiable.
If instead of “homebirth advocate” Amy Tuteur, MD said “Melissa Cheyney, Henci Goer and Ina May Gaskin” she’d have some nice falsifiable statements. We look at how they react and compare with the predictions in the post. They react as predicted and yay, Amy Tuteur, MD is correct.
It’s more important TO ME that the message is being picked up by publicly-funded health agencies (it seems insurance companies are reasonably less likely to jump on the OOH bandwagon) that would very much like to download costs to midwifery because, frankly, it costs more in the short-term for in hospital delivery. If women know that this isn’t in their best interest, hopefully this will stem the tide of NCB washing into our public health systems. My area currently is seriously lacking in OB/GYN coverage and patients are being streamed into midwifery. While midwife standards here are higher than they are for a CPM, they’re still not nearly as good as OB/GYN standards. I don’t think midwives should be practicing without a clear hierarchy, with OB/GYN at the helm, and I do not think the current system serves women well, especially not first time mums like myself who had NO IDEA that I would receive subpar care. Like all parallel medical services, it falls to the patient to figure out who is legitimately skilled and who is not: EXCEPT, most women having babies are in their twenties and early thirties and I personally didn’t have the kind of life-experience necessary to question whether or not my government would provide me with sub par care and just assumed that if the government was paying, it must be safe, and the midwifery community capitalizes on this by running advertisements (which OB/GYN are not permitted to do) advertising themselves as being less interventionist, less c-section (no shit, Sherlock, but you’d have to read between the lines to understand why), and better outcomes. Of COURSE they have better outcomes because everyone else is transferred out, but they have the nerve to not share that. It’s an unfair playing field for women to assess risk and had I not happened to be extremely tokophobic (enough to want a c-section on demand), I never would’ve found out!