Sometimes I get discouraged.

This blog rests on the premise that anyone is capable of learning the basics of science, medicine and logic and using that knowledge to see through the quacktivist claims of the purveyors of pseudoscience. But then I read about the pure idiocy spewed forth on a topic like Group B Strep and I wonder if that is an over-optimistic sentiment.

How could anyone be stupid enough to believe that washing your vagina out with soap will prevent neonatal meningitis or pneumonia? (Feminist Breeder, I’m thinking of you, among others.)

Let’s step back for a moment and consider what you ought to know before you can make an informed decision to decline antibiotics for Group B Strep (GBS) and to substitute washing the vagina with Hibiclens (chlorhexidine) instead.

1. How does GBS hurt babies?

2. What are the chances of a baby contracting GBS?

3. What is the neonatal death rate of GBS?

4. How does IV antibiotics change the risk of a baby contracting and dying of GBS?

5. Has Hibiclens been shown to be as effective as IV antibiotics?

The latest information on Group B Strep can be found in the Prevention of Early Onset Group B Streptococcal Disease in Newborns published in the April edition of the journal Obstetrics and Gynecology.

1. How does GBS hurt babies?

Group B streptococci … emerged as an important cause of perinatal morbidity and mortality in the 1970s. Between 10% and 30% of pregnant women are colonized with GBS in the vagina or rectum… Invasive group B streptococcal disease in the newborn is characterized primarily by sepsis and pneumonia, or, less frequently, meningitis.

2. What are the chances of a baby contracting GBS?

For the past 30 years, GBS has been the most common cause of neonatal sepsis. The actual incidence is 1.7/1000 live births (approximately 7200 cases per year).

3. What is the neonatal death rate of GBS?

More than 15% of affected infants will die (approximately 1080 deaths).

4. How does IV antibiotics change the risk of a baby contracting and dying of GBS?

Since the early 1990s, national guidelines have resulted in an 80% decrease in the incidence of early-onset group B streptococcal sepsis, from 1.7 cases to less than 0.4 cases per 1,000 live births.

5. Has any other treatment been shown in large clinical trials to be as effective as IV antibiotics?

No, absolutely not.

In fact, large scale studies done the use of Hibiclens in low resources settings where IV antibiotics are unavailable show that it is in INEFFECTIVE in preventing neonatal group B strep sepsis. For example:

Chlorhexidine Vaginal and Infant Wipes to Reduce Perinatal Mortality and Morbidity: A Randomized Controlled Trial:

… We performed a placebo-controlled, randomized trial of chlorhexidine vaginal and neonatal wipes to reduce neonatal sepsis and mortality in three hospitals in Pakistan….

RESULTS: From 2005 to 2008, 5,008 laboring women and their neonates were randomly assigned to receive either chlorhexidine wipes (n=2,505) or wipes with a saline placebo (n=2,503). The primary outcome was similar in the chlorhexidine and control groups (3.1% compared with 3.4%; relative risk 0.91, 95% confidence interval 0.67–1.24) as was the composite rate of neonatal sepsis or 28-day perinatal mortality (3.8% compared with 3.9%, relative risk 0.96, 95% confidence interval 0.73–1.27)…

CONCLUSION: Using maternal chlorhexidine vaginal wipes during labor and neonatal chlorhexidine wipes does not reduce maternal and perinatal mortality or neonatal sepsis…

What is Hibiclens anyway?

The active ingredient in Hibiclens is chlorhexidine gluconate also known as (1,1′-hexamethylene bis [5-(p-chlorophenyl) biguanide]di-D-gluconate). According to the FDA:

… adequate and well-controlled studies in pregnant women have not been done. Because animal reproduction studies are not always predictive of human response, this drug should be used during pregnancy only if clearly needed.

And:

It is not known whether this drug is excreted in human milk. Because many drugs are excreted in human milk, caution should be exercised …

Why are homebirth and natural childbirth advocates washing the vagina out with Hibiclens instead of using IV antibiotics?

It certainly can’t be because it works, since large scale studies show that it doesn’t.

It certainly can’t be because it doesn’t matter since GBS is the leading infectious cause of newborn death.

It certainly can’t be because IV antibiotics don’t work since they have reduced neonatal GBS deaths by 80%.

It certainly can’t be because Hibiclens [chlorhexidine gluconate also known as (1,1′-hexamethylene bis [5-(p-chlorophenyl) biguanide]di-D-gluconate)] is “natural.”

So why do women like The Feminist Reader wash their vaginas out with soap to prevent their babies from dying of Group B strep pneumonia or meningitis?

Because it fulfills the MOST important criteria for an NCB “treatment”; it is a form of ignorant, immature, self absorbed defiance of authority. And if that isn’t a good enough reason for NCB advocates to risk killing their babies, what is?

What a coincidence!

In honor of Mother’s Day, Ina May Gaskin, godmother of gobbledly-gook in midwifery has discovered that there is a “crisis” in maternity care, a crisis so enormous, so comprehensive, involving so many well white women that it can only be solved by … midwives!

Isn’t that amazing. Just like Amy Romano, but completely independently, both midwives realized that all solutions to problems in maternity care involve paying more money to more midwives. But while Amy Romano preferred to write a subtle, understated smear that tugs at your heart strings, Ina May shows us how it’s really done.

1. Declare that there is a “maternity crisis.”

That’s where both she and Amy Romano started.

2. Supply an anecdote to “prove” that obstetricians don’t know what they are doing.

It is absolutely critical to the natural childbirth project to convince women that doctors don’t know what they are doing, and willfully and cheerfully risk the lives of women and babies to promote a secret agenda.

Romano chose a heart tugging anecdote where an non-obstetrician made a mistake. Ina May goes for farce when recounting the story of a North Carolina obstetrician who made the mistake of believing a patient and failed to diagnosis a hysterical pregnancy (pseudocyesis).

According to midwifery “logic,” if one obstetrician makes one mistake (or, as in Romano’s case, a non-obstetrician fails to diagnose an obstetrics problem) that means that ALL obstetricians, everywhere and at all times, cannot possible be trusted to do anything right.

3. Insist that the dramatic progress of modern obstetrics is an illusion and that obstetricians oppressed midwives because they were afraid of economic competition. As Marketing Professor Craig Thompson has written:

“… [T]he cultural dominance of medicalized childbirth is explained as the historical artifact of a fin de siecle struggle between midwives and physicians, where the latter group held a decided economic and sociocultural advantage. As this critical narrative goes, the medical profession leveraged its emerging economic-political clout and cultural affinities toward ideals of scientific progress and technological control to displace midwives (both socially and legally) as the authoritative source of childbirth knowledge.”

4. Lie about the scientific facts.

Ina May claims that the World Health Organization recommended a 10-15% C0-section rate, and “neglects” to mention that the recommendation has been WITHRAWN because, as the WHO acknowledged, it was fabricated without any scientific evidence to support it.

Ms. Gaskin claims that the maternal mortality rate doubled in the past generation, when that is flat out false. The purported “increase” is almost entirely due to two separate revisions in birth certificates that enlarged the classification of maternal death to include deaths that previously would not have been included. In addition, Ms. Gaskin conveniently “forgets” to mention that maternal mortality has actually DROPPED in the past two years for which we have data.

Ina May also neglects to mention the fact that in the 100 years after its advent, modern obstetrics dropped the neonatal mortality rate 90% and the maternal mortality rate 99%.

5. Cynically ignore the real crisis in the care of women around the world who die for lack of access to modern obstetric care, and pretend that the “crisis” is that there aren’t more midwives to care for well white women in first world countries. Cynically ignore the fact that the leading causes of maternal mortality in the US are complications of pregnancy and pre-existing medical conditions like heart disease and kidney disease. Midwives can have no impact on these deaths because they don’t care for these patients.

6. Insist that obstetricians overuse technology, AND at the very same time, under-use it. The battle cry of midwifery advocates is usually that obstetricians have “ruined” birth with their insistence on using technology, yet both Romano and Gaskin have invoked medical mistakes where the under-use of technology led to the bad outcome.

Which is it? Do obstetricians overuse or under-use technology? Or does it not really matter, when the goal is to use any means at hand to disparage obstetrics and encourage mistrust of obstetricians?

7. Sadly, but firmly insinuate that obstetricians don’t want to help women; they want to make money, show off, and get to their golf games as quickly as possible. Regretfully, but firmly imply that obstetricians actually want to HURT women by imposing their fancy technologies to ruin otherwise perfect labors simply so that they can apply even more technology.

And declare (this is the big finish), the only way you can prevent obstetricians from victimizing you, hurting you and profiting from you is …. give more money to midwives.

Tina Fey takes on homebirth.

Obviously this is a parody. If it were a real homebirth video there would be an inflatable kiddie pool filled with fecally contaminated water.

Amy Romano is at it again.

Romano, like everyone else at her employer the Childbirth Connection, has a vested interest in portraying the maternity system in crisis. This is a classic tactic in “alternative health.”

As I wrote in The playbook for challenging conventional medicine:

The first step is to portray the particular discipline as “in crisis”. [According to Paul Wolpe in the paper The Holistic Heresy: Strategies of Ideological Challenge in the Medical Profession]:

“… Modern medicine’s conquering of infecious disease set up a quasi-religious belief in its ability to reduce suffering and disease now seems stalled by a of medical economic, organizational, and social problems. [Critics try] to portray the biomedical orthodoxy as responsible for the problems confronting organized medicine .., and suggests that orthodoxy is ill suited to solve the developing challenges to care…”

This is certainly the tactic adopted by homebirth midwifery. The “crisis” is the rising C-section rate, which is portrayed as unjustified, intolerable, unaffordable and injurious. A secondary “crisis” (which is fabricated) is the rate of infant mortality (the wrong statistic) and the rate of maternal mortality (which is falsely portrayed as rising).

And this is the tactic Romano uses in the piece she wrote for The Health Care Blog, A Mother’s Day Manifesto: Blood, Toil, Tears, and Sweat. Romano tells the story of “Near Miss Mom” who suffered a late postpartum hemorrhage (9 days after birth), a rare postpartum complication. Near Miss Mom went to the emergency room, but the doctor who saw her there failed to recognize the seriousness of her condition and therefore failed to refer her immediately to an obstetrician. Indeed, Romano acknowledges the problem was quickly diagnosed by an obstetrician:

When she finally reached Near Miss Mom’s bedside, it didn’t take her long to call a Code Red and assemble the team for the emergency hysterectomy.

Romano presents the error of the emergency room doctor as a Mother’s Day parable on the “crisis” in maternity care. There just one teensy, weensy problem. This was NOT a near miss maternity event and it is unfortunate that Ms. Romano has chosen to misrepresent it as such.

This is an example of a patient presenting to the emergency room with a rare complication who should have had an immediate specialist consult, but did not. Late postpartum hemorrhage is typically due to sub-involution of the placental bed. Most physicians, like this ED doc, have never seen a case and therefore may fail to recognize it.

This was a mistake on the part of one physician (failure to obtain immediate specialist consultation) and not a systemic failure. If an emergency room doctor failed to recognize a complaint of jaw stiffness and drooling as tetanus, we would not conclude that it was a “neurology near miss” and indict the neurology care “system.”

That’s not to say that there isn’t room for improvement in maternity care, but it is deeply cynical to use the case of an emergency room doctor failing to diagnose a rare postpartum complication as a failure of maternity care and deeply cynical to use it as a Mother’s Day parable.

When I created Hurt by Homebirth, I anticipated stories of homebirth gone wrong. I anticipated stories of life threatening disasters that occurred without warning, like abruption, and babies who succumbed to lack of oxygen during labor and were unexpectedly born without a pulse. I did not anticipate many stories like Angela’s story.

Angela was born at home apparently healthy, developed subtle signs of severe illness and died less than 24 hours after birth. It is strikingly similar to Mary Beth’s story and Wren’s story. If these stories on Hurt by Homebirth are any indication, such tragedies may be far more common than we realize. Moreover, they represented yet another unjustified assumption at the heart of homebirth advocacy.

Homebirth advocates routinely counsel women to “trust birth” or, as in the startlingly stupid formulation of the CIMS’ Mother Friendly Childbirth Initiative:

Women and babies have the inherent wisdom necessary for birth.

Let’s leave aside for the moment the fact that neither women nor babies have “inherent wisdom” about birth. Let’s also leave aside the fact that childbirth is, and has always been, in every time place and culture, a leading cause of death of young women, and the leading cause of death of infants. Even if birth were trustworthy (and it most definitely is not), a newborn can face a host of common, yet deadly threats.

Homebirth advocates explicitly counsel “trust,” but can a newborn be trusted to master breathing difficulties, circulatory problems and infections?

Within the first 24 hours, a newborn must:

1. Learn to breathe

Babies are born with non-functioning, collapsed lungs. The baby must generated the force necessary to expand those lungs (think blowing up a balloon), must be able to keep the lungs fully expanded (special substances produced in the lungs make it easier to do so), and must master and be able to sustain the effort of regular breathing.

2. Switch its circulatory system from fetal pathways that transport oxygen from the placenta to new pathways that transport oxygen from the lungs.

The fetal circulation bypasses the non-functioning lungs, whereas after birth all blood must circulate through the lungs to pick up oxygen. Bypass routes exist in both the heart and the lung blood vessels. Those bypass routes must close in order for the baby to survive.

3. Fight off the bacteria and viruses encountered in the vagina.

The primary infectious threat to newborns is not bacteria and viruses in the air, but bacteria and viruses in the vagina. Group B strep and herpes are potentially deadly threats that can begin attacking a baby during birth. Because of their immature immune systems, newborns are uniquely vulnerable to these threats.

Problems with any of these three tasks, particularly early problems, may show only the most subtle signs, signs that may not be recognized by anyone but a medical professional.

1. It is obvious whether or not a baby begins breathing, but it may not be apparent that a baby is having trouble keeping his or her lungs open or maintaining the fast breathing rate that newborns require. Newly expanded lungs have a tendency to collapse and it takes a considerable amount of effort to keep them open.

The baby produces a substance (surfactant) that dramatically lowers the amount of effort needed to keep the lungs open, but even slightly premature babies may not have the amount of surfactant needed. The problem is often not immediately apparent, since the baby does begin breathing and maintains a normal breathing rate. However, the effort required is enormous and within hours, the baby begins to tire, can no longer fully inflate his or her lungs and therefore cannot get enough oxygen. The signs are subtle, and a parent may not realize that there is a problem until the baby stops breathing altogether.

2. If the the fetal circulatory bypass of the lungs fails to close, the baby will breathe, but won’t send nearly enough blood through the lungs to pick up adequate oxygen. If the bypass stays wide open, the baby will turn blue (cyanotic heart disease). Even then, a parent may attribute the baby’s poor coloring to the unusual coloring of newborns.

If the bypass remains only partially open, the signs will be even more subtle and even harder to recognize. The parent may not realize there is a problem until the baby stops breathing altogether.

3. The infectious threat is particularly insidious. A baby may be born appearing entirely healthy, but the bacteria picked up in the vagina (such as Group B strep) may already be invading and multiplying in the baby’s tissues, particularly the baby’s lungs.

When an older child develops pneumonia, it’s hard to miss. The child is usually coughing, has a fever, and may complain of chest pain. In contrast, a newborn can quickly develop pneumonia without ever coughing and with only a low grade fever if any. Over time, the baby very gradually develops subtle breathing difficulties such as small noises during breathing. The baby continues to struggle, getting ever more ill, but the parent may not realize that there is a problem until the baby stops breathing altogether.

There’s a theme here: the signs of serious newborn illness are subtle can often can be diagnosed only by a medical professional. In a hospital, the baby can be examined by a pediatrician. Even more importantly, there are always nurses about, nurses who have been specifically trained to recognize subtle signs of newborn illness. At home, there is only the midwife. Homebirth midwives have very little training in recognizing newborn problems (after all, there aren’t supposed to be any problems) and are gone within an hour or so. The parents are on their own, without any counseling about what to look for.

There is one warning sign that every parent of a newborn should be taught to attend to: a baby who refuses to nurse.

Nursing takes effort away from breathing. A baby using every bit of its energy to get enough oxygen has no effort to spare. The baby may latch willingly but quickly become hypoxic and release the latch in order to expend its effort breathing.

Homebirth involves a great deal of misplace trust. It’s bad enough that homebirth advocates trust birth, but most don’t know enough about childbirth to know any better. But does anyone really “trust” a newborn to master breathing problems or fight off serious infections without help?

Who is supposed to be trusting whom here? Should a homebirth advocate trust her baby to handle serious health problems? Or should a newborn be able to trust his or her mother to give birth in a place where those with the requisite training and experience can diagnose subtle signs of serious illness?

These questions never crossed the minds of mothers and fathers who lost apparently healthy babies in the hours after homebirth. They have generously shared their pain in the hope that it will cross yours.

Yesterday, I reviewed the editorial in the journal Obstetrics and Gynecology that argues ethical principles encourage obstetrician participation in homebirth. Today, as promised, I’ll address the companion paper that argues the opposite.

In Obstetric Ethics: An Essential Dimension of Planned Home Birth, Drs. Chervenak, McCullough and Arabin, invoke basic principles of medical ethics to argue that the increased mortality risk of homebirth means that obstetricians are ethically mandated not to participate in homebirth. The same ethical principles further obligate obstetricians to counsel women against having a homebirth.

The authors begin by reviewing claiming that obstetricians have two principal ethical obligations to their pregnant patients, and immediately place themselves on shaky ground:

The obstetrician has both autonomy-based and beneficence-based obligations to the pregnant patient and beneficence-based obligations to the fetal patient.Respect for the pregnant woman’s autonomy obligates the obstetrician to empower her autonomy in the informed consent process by providing her with clinically relevant information about her pregnancy and the medically reasonable alternatives for its management. Obstetricians serve as important advocates of the pregnant woman’s autonomy.

Making judgments about what is medically reasonable is beneficence-based. This ethical principle obligates the obstetrician to seek the greater balance of clinical goods over clinical harms for both the pregnant and fetal patient, as these goods and harms are understood from an evidence-based, clinical perspective.

Why are the authors on shaky ground? Because they present autonomy and fetal beneficence as equivalent and they are not. In almost every situation,the autonomy of the pregnant patient trumps fetal beneficence. A pregnant women is free to refuse any and all medical interventions that may save the life of her fetus as long as she understands and accepts the increased risk of death.

Then the authors venture out on to even shakier ground:

Pregnant women also have beneficence-based obligations to the fetal patient and the child it is expected to become, to take reasonable clinical risks. When a clinical intervention is reliably expected to benefit the fetal patient and child it is expected to become and there are not unreasonable clinical risks to the pregnant woman, she is ethically obligated to authorize and accept such intervention.

In referencing this claim, the authors the authors cite … themselves, specifically McCullough and Chervenak’s book Ethics in Obstetrics and Gynecology, published in 1994. They overstate their case. While many obstetricians and ethicists believe that maternal beneficence based obligations exist, it is far from clear what they entail.

The authors claim:

… Hospital birth does not create unreasonable risk to the pregnant woman but confers significant clinical benefit on her. The pregnant woman therefore has a beneficence-based obligation to the child the fetal patient will soon become to accept these clinical risks.

That claim is simply untrue. If a woman chooses to smoke during pregnancy, she is legally and ethically entitled to do so, even though smoking has a demonstrable deleterious effect on fetal health. Similarly, if a woman chooses to give birth outside a hospital,she is legally and ethically entitled to do so, even though homebirth has a demonstrable increased risk of perinatal mortality.

Does that mean that obstetricians are ethically mandated to participate homebirth? No, it does not, for reasons that have nothing to do with beneficence based obligations. Maternal autonomy is a negative right; it is the right to be left alone. In contrast, there is no positive right to a homebirth. While we cannot prevent a mother from choosing homebirth, there is no ethical obligation to facilitate homebirth, and certainly there is no ethical obligation on the part of the obstetrician to participate in a situation that increases medical risk to the neonate and very likely to the mother as well.

Acknowledging that a pregnant woman has the right to smoke during pregnancy (a negative right) does not mean that an obstetrician is obligated to give her cigarettes (a positive right). Acknowledging that a pregnant woman has the right to give birth in her own home does not mean that an obstetrician is obligated to attend, to back up her midwife or to participate in any way.

Chervenak et al. (as well as the authors of the companion paper) fail to address what is, in my judgment, the real ethical issue for obstetricians posed by homebirth: women definitely have the right to choose the increased risk of perinatal death inherent in planned homebirth, but that’s not what they are choosing. Most women choosing homebirth are grossly misinformed about the risks. In other words, they are not giving informed consent.

The editorial section of this month’s issue of the journal Obstetrics and Gynecology addresses the issue of obstetrician participation in homebirth. Although it it not presented in this way, it appears that the journal asked the question “is obstetrician participation in homebirth ethical?” and commissioned one group to argue “yes” and the other to argue “no.”

The first group argues that medical ethics allows obstetricians to participate; the second asserts that obstetrician participation in homebirth violates their ethical responsibilities. Both raise important ethical issues and both, in my judgment, fail to address critical points.

What Are Physicians’ Ethical Obligations When Patient Choices May Carry Increased Risk? is written by Jeffrey Ecker and Howard Minkoff. The authors succinctly frame the issues:

… 1) When does respect for patient choice and autonomy become support for poor decision-making? 2) When is participation not respectful but enabling? …

Their answer to the questions is succinct, too:

… Weighing benefits and burdens should focus not on RR [relative risk] … but absolute risk … It is the absolute risk of adverse outcome (eg, 1/1,000 risk of neonatal mortality) that can be balanced against the benefits valued by a patient in choosing a particular choice (the comfort and control of delivery at home; a decrease in obstetrical interventions). As noted for home birth, the magnitude of the RR in comparison to a hospital birth remains unsettled but even in those studies that show a difference, the absolute risk remains low…

Ecker and Minkoff acknowledge that we don’t really know the absolute risk of homebirth in the US; they simply assume it is comparable to the risk in other first world countries. It’s a completely unjustified assumption for reasons they fail to address.

First, they appear to assume that homebirth in the US occurs under the supervision of midwives trained to the same standards as European, Canadian and Australian midwives. They don’t seem to realize that there is an entire class of self proclaimed homebirth midwives (certified professional midwives or CPMs) who have nothing more than a post high school “certificate.” They have less education and training than midwives in any other first world country, and, indeed, would be ineligible for licensure in any other industrialized nation. Their education and training is grossly substandard.

Second, they appear to be unaware of the fact that a huge database of American homebirths exists, the data on 18,000 homebirth attended by CPMs, collected by MANA (the Midwives Alliance of North America), the organization that represents CPMs. Throughout the years that the data was collected, MANA repeatedly proclaimed that the data would be used to prove the safety of homebirth. Now that the data have been analyzed, MANA is refusing to release the death rates. The MANA data almost certainly shows that homebirth has an unacceptably high rate of neonatal death.

Third, they appear to be unaware of the fact that individual states such as Colorado have collected data on planned homebirth with a licensed midwife, and the death rates are nothing short of appalling. Moreover, US data on homebirth shows that homebirth with a CPM has a higher death rate than homebirth with a certified nurse midwife (CNM), the type of midwife with training equivalent to European, Canadian and Australian midwives.

So the absolute risk of American homebirth is known, but being hidden by homebirth midwives, and the absolute risk varies widely depending on attendant.

The authors also fail to address a more important issue. Homebirth practitioners are not honest about homebirth risks. Indeed, in the homebirth community, it is axiomatic that homebirths are “as safe or safer” than hospital births. The entire argument of Ecker and Minkoff is predicated on patients’ willingly accepting an increase in absolute risk, but they don’t seem to realize that most women choosing homebirth don’t believe there is an increased risk of death associated with homebirth.

To use the language with which they framed the initial questions, obstetricians who participate in homebirth are merely enabling poor patient decision making. Most patients who choose homebirth have not given informed consent since they lack information on the real risks of homebirth, and have been told by their homebirth practitioners to ignore the information supplied by the obstetrician.

For me, the most remarkable thing about the Ecker and Minkoff piece is the stunning naivete regarding legal liability. The entire argument rests on the belief that a small increase in absolute risk of perinatal death is “acceptable.” But if the American legal system has taught obstetricians anything, it is that ANY increased risk of perinatal death, no matter how small, is utterly unacceptable.

The liability issue is further complicated by the fact that patients also think that any increase in the risk of perinatal death is unacceptable. When choosing homebirth, they aren’t choosing an increased absolute risk of death; they are pretending that there is no absolute risk of death. That’s why they often turn around and sue the obstetrician even if he or she warned them against homebirth, arguing that they didn’t “understand” that there was any increased risk of perinatal death.

Despite all this, Ecker and Minkoff conclude:

In sum, physicians are obliged to use their skills to minimize risks, even for women who have shunned physician’ recommendations and advice..

As far as I’m concerned, that’s an inexplicable non-sequitur. There’s a big difference between something being ethically acceptable and being ethical mandated. Ecker and Minkoff have made an argument (in my judgment a poor argument) that it is ethically acceptable for obstetricians to support and participate in homebirth. But obstetricians are not obliged to use their skills for any particular patient, unless they have agreed to care for her, and they are certainly not obligated to practice medicine in ways that violate their understanding of appropriate medical care.

Obstetricians are free to support and participate in homebirth if they want to do so. And it is certainly ethically acceptable to suggest that a small absolute increase in perinatal mortality MIGHT be acceptable in certain circumstances. However those circumstances include an accurate assessment of the absolute increase in risk, high level education and training for midwives, transparency on the part of CPMs in revealing their death rates from past cases and on an ongoing basis, and a legal system that agrees that a small absolute increase in perinatal mortality at homebirth is acceptable.

None of those conditions obtain at the moment and their advent is not even on the horizon. If Drs. Ecker and Minkoff want to support and participate in homebirths, they are free to do so, but they are not ethically obligated to do so, and neither is any other obstetrician.

Tomorrow, I’ll look at the paper presenting the opposite point of view.

Yesterday a typical NCB commenter parachuted in to share her wisdom with us. She treated us to the usual parade of goofy “scientific” claims, errors in basic logic and ad hominem attacks. Then she topped it off with the NCB icing on the cake:

i attribute this to my lack of anxiety and the fact i felt very safe and comfortable. being in my home with my two midwives and husband was exactly what i needed in order to relax and give birth without fear.

This is a classic example of “magical thinking,” the belief that one’s thoughts have the power to influence outcomes, and it is unfortunately endemic among homebirth and NCB advocates.

Magical thinking is a form of immature cognitive reasoning. It is typically associated with young children who believe that their “bad” thoughts can cause bad things to happen. That’s why young children may blame themselves when a parent dies. They believe that previous angry thoughts about the parent have the power to actually hurt the parent.

Magical thinking is very common among NCB advocates. Using a similar form of immature cognitive reasoning, NCB advocates actually believe that their positive thoughts have the power to make their labor better, shorter, easier, safer, etc.

In its most ridiculous incarnation, birth affirmations, the immature and magical nature of the “reasoning” is obvious. The idea that “fear” causes childbirth pain and complications is just a less inane version of magical thinking. Even for some believers in NCB the claim “my thoughts have the power to make my labor uncomplicated” sounds silly. So they resort to what seems reasonable to them: “my lack of fear has the power to make my labor uncomplicated.” It’s just a different form of the same immature reasoning, that thoughts have the power to control outcomes.

Interestingly, while NCB advocates believe passionately, as passionately as any three year old, that their thoughts have the power to affect outcomes, they use this belief to different effect. Small children typically employ magical thinking to blame themselves erroneously for bad outcomes. NCB advocates, in contrast, employ magical thinking to take credit erroneously for good outcomes.

Extending the analogy of magical thinking as “icing on the cake,” we can come up with a “recipe” for the typical NCB advocate.

Mix:

2 parts ignorance of basic science

1 part inability to reason logically

and

3 parts ad hominem attacks (e.g. “Dr. Amy is mean to me”)

and bake for 9 months.

Cool and frost liberally with magical thinking.

Voila! An NCB advocate.

Recipe variation: Increase ignorance of basic science to 3 parts to create a homebirth advocate.

The Lamaze blog Science and Sensibility has inaugurated a “Legal Corner” to explore legal issues surrounding maternity care. A lawyer has been recruited to write the first two post on informed consent. Natural childbirth advocates may be surprised to find that their made up theories of informed consent, including fabricated notions of medical assault and the bizarre, hyperbolic accusations of “birth rape” have no basis in the law.

Montana lawyer Casey Magan starts with a brief explanation of informed consent:

Informed consent is a legal and ethical requirement founded on the notion of personal autonomy and self-determination. In its simplest form, it means that, in non-emergency situations, it is your right as the patient to decide what treatment to agree to, or refuse, based upon your physician’s disclosure of all material facts relating to the proposed treatment or procedure. A failure to provide appropriate informed consent can be “medical battery,” an unlawful touching that takes away a patient’s right to make her own health care decisions. (my emphasis)

In contrast to the claims of natural childbirth advocates, informed consent doctrine does NOT mean that when a patient says “no” her medical providers must respond as she wishes.

Magan provides three examples, only one of which requires the provider to honor the patient’s request.

1. As you walk the halls to advance labor, a nurse firmly escorts you back to your room, explaining that hospital policy requires you to stay within the labor and delivery department—if not your room or bed;

2. When you ask for a glass of water, you are instead poked with an IV;

3. A doctor comes into your room and forcefully lobbies that he be able to use Pitocin to induce labor.

Magan explains:

Informed consent provides an easy analysis in just one of the three examples – that of the physician’s desire to use Pitocin. Because, under the doctrine of informed consent, if you are capable of giving consent, and do not agree to a certain treatment or procedure, the doctor may not administer it, no matter how much he or she would like to. (my emphasis)

That also means that just because a woman disagrees with a hospital policy does not mean that she is exempted from following it. Indeed, Magan points out:

… Your birth plan is not a contract, and neither your maternity care provider, nor the hospital, has to comply with it.

Can a hospital kick you out or a provider refuse to care for you if you don’t comply? Yes they can.

There are limitations, of course:

… They cannot kick you out if you are in active labor (when the cervix is about 3 – 4 cm), or any other condition that may be considered an “emergency” without violating state and federal law. (e.g., Emergency Medical Treatment & Active Labor Act (EMTALA). Similarly, a physician may not abandon you, meaning he or she cannot “fire” you as a patient without reasonable notice when you still require medical attention.

You can only invoke EMTALA in a medical emergency, but the informed consent rules apply to non-emergency situations and apply only when a patient is capable of giving consent. When an emergency occurs, consent for emergency treatment is considered as implied, and it easy to argue that a woman in active labor is not capable of giving informed consent in the midst of a complex medical situation.

Therefore, when an obstetrician performs an episiotomy in anticipation of a possible shoulder dystocia, it does not matter that the patient has expressly refused an episiotomy before labor began and it does not matter that the patient expressly refuses the episiotomy at the moment it is performed. Consent for life saving treatment in the face of emergency situations is implied.

Magan explains that women have the right to:

Request or refuse treatment, to the extent permitted by law. However you do not have the right to demand inappropriate or medically unnecessary treatment or services.(my emphasis)

The bottom line? You have a right to complete explanations, but you have no right to have your demands met. You have the right to express your preferences, but the doctor may refuse to care for you and the hospital may refuse to admit you. You have the right to be admitted in a medical emergency, but informed consent doctrine is predicated on being obtained during a NON-emergency situation and the law treats consent for life saving treatment in an emergency as implied, even if you did not consent.

Simply put, informed consent doctrine does not mean that doctors and hospitals must abide by your wishes or that ignoring those wishes constitutes a breach of informed consent.