Barely 2 weeks after I wrote the post about the invisibility of women’s needs, Science and Sensibility features guest blogger Dr. Michael Klein who has written a post about epidural anesthesia that entirely leaves out the most important benefit of epidurals, its ability to relieve the agonizing pain of childbirth.

I’ve mentioned Canadian family practice physician Michael Klein before. I wrote about Dr. Klein’s personal opinion that “a few” preventable perinatal deaths are worth it in order to lower the C-section rate.

Now Dr. Klein attempts to explain Epidural Analgesia—a delicate dance between its positive role and unwanted side effects, while rendering women’s need for pain relief utterly invisible. In a 1200 word post, Dr. Klein utterly fails to mention the excruciating pain of childbirth. There is not a single word about how women feel about pain and pain relief in labor.

He does manage to hit all the high points of the NCB campaign to render women’s pain invisible.

The “risks” of epidural anesthesia are accorded a prominent place, but apparently there was no room to include just how often these “risks” occur, thereby depriving readers of any context to evaluate these risks. He’s so desperate to vilify epidurals that he actually includes inadequate pain relief as a “risk.” There’s no mention of the fact that approximately 98.5% of women have excellent pain relief from an epidural, but we’re supposed to consider the 1.5% failure rate a reason to avoid the 98.5% chance of outstanding pain relief?

As I said above, there is not even one word devoted to how women want to manage their own pain, but Dr. Klein has plenty of words about what women should want. Apparently, Dr. Klein thinks the days before adequate pain relief were just dandy:

Prior to the ready availability of epidural analgesia in labour and delivery departments, maternity nurses used their skills to reassure, massage, breathe with the woman through contractions, and employ a range of other methods to handle labour pain.

And:

Prior to the availability of epidural analgesia, the childbirth education movement utilized a variety of techniques that were physiologically and psychologically helpful to reduce pain, such as breathing and imagery. These methods began to take hold in the culture in the 1950s and 1960s but today are less prominent in many childbirth education classes. Some classes are more focused on teaching women compliance with particular hospital technological methods and approaches, routines and policies, rather than on teaching women coping skills.

Imagine that. Childbirth classes teach women what to expect in labor instead of how to have the labor that Dr. Klein approves. And let’s not forget one of the conspiracy theories to which NCB advocates appear addicted: childbirth classes indoctrinate women to comply with hospital policies.

What kind of labor does Dr. Klein in his wisdom approve?

Backed by randomized studies, it has become apparent that this emotional and physical continuous supportfrom a doula gives a woman more confidence and ability to work with her labour.

More confidence? To work with her labor? Sure, when women’s need for pain relief is invisible, there’s no reason to worry about whether doulas relieve pain.

Dr. Klein in his wisdom frowns upon epidurals but loves other methods of pain relief, no matter how unnatural they are:

Pain moderation by transcutaneous nerve stimulation (TNS) or intradermal water injections can be very helpful … Other non-pharmacological methods like water baths or showers or movement, including the use of birth balls, are also helpful for many women who find that partial pain relief is sufficient to help them through contractions.

That’s really funny. It’s okay to put a needle in your back and inject something that won’t provide adequate pain relief (water), but it’s not okay to inject local anesthetic that will provide complete pain relief.

Dr. Klein, I have a simple question for you: How dare you?

How dare you write a piece about epidural anesthesia that includes not one word devoted the agony of labor pain?

How dare you write a piece about epidural anesthesia that includes not one word about what women think about pain and pain relief in labor?

In short, how dare you render women’s need for pain relief in labor utterly invisble?

The Childbirth Connection is the leading lobbying group for natural childbirth advocacy. As their website explains:

… [O]ur organization has … carried out media outreach, and developed a broad range of clinical, educational and advocacy programs; dozens of consumer and professional publications; many conferences and symposia; and numerous surveys and program evaluations…

No doubt they are qualified to lobby on behalf of their personal beliefs, but are they really qualified to offer medical advice to pregnant women?

They claim to be deeply concerned about offering accurate summaries and interpretations of the scientific evidence on which modern obstetrics is based. Among their stated goals:

* To exercise their legal right to informed consent and informed refusal, women need access to full and accurate information based on the best available research about all options for care from early in pregnancy through the postpartum period…

* Caregivers and institutions have the responsibility to provide evidence-based care that respects and supports the innate physiology of pregnancy, labor and birth, and the mother/baby connection, and addresses the family’s needs, values and preferences.

I can’t disagree with those goals. But is the Childbirth Connection capable of accurate assessing the obstetric scientific evidence in order to provide accurate information?

Considering that we are discussing the massive scientific literature of obstetrics, you might think that the Childbirth Connection would have obstetricians among its reviewers, but you’d be wrong. There is not a single obstetrician on the Board or staff of the organization.

In fact, there is no one who has an MD and no one who has a PhD in a scientific field. Therefore, the Childbirth Connection has no way of vetting their publications to be sure that they accurately represent the current state of obstetrics and obstetric research. And that failure to appropriate vet their medical and scientific claims is glaringly obvious to anyone who DOES routinely read the scientific literature.

Consider the issue of labor induction. Amy Romano, previously of Lamaze International and now working for the Childbirth Connection, describes information purported to be the “best evidence” on labor induction as “a systematic review of the highest quality research.” It is nothing of the kind.

An obstetrician would start a review of the literature on induction by reading a chapter in an obstetrics text that provides an overview. “Induction in Labor” in Williams Obstetrics is a relatively short chapter (6 pages) and reviews more than 100 scientific papers on the topic. Then an obstetrician would proceed to a literature search to review the scientific papers submitted in the last 1-3 years since the textbook was published. In the last two years alone several hundred papers have been published on labor induction

In contrast, the Childbirth Connection reviewed only 4 scientific papers on the topic! Not only does this fail to meet the criteria of a systematic review, it barely skims the surface. So if the Childbirth Connection failed to review the majority of the literature on labor induction, what did they do? They cherry picked a few papers that reached conclusions that they liked and IGNORED everything else.

And what does the Childbirth Connection’s “evidence” purportedly show?

They acknowledge that induction has definitely been shown to improve outcomes in the three most common medical indications for induction:

* Pregnancy lasting beyond 41 weeks [note: outcomes improve at 41 weeks a week before the traditional cutoff of 42 weeks]

* Prelabor rupture of membranes (PROM) at term (37-42 weeks)

* Increased blood pressure near the end of pregnancy

Then there are medical indications where the medical evidence is not as strong, primarily because there have not been enough studies done yet. The Childbirth Connection mentions them and misrepresents the scientific evidence about them.

Preterm prelabor rupture of the membranes (PPROM)- Here the Childbirth Connection misrepresents current obstetrical practice. In premature rupture of membranes, the benefit to the baby of more time in the uterus outweighs the risk of infection, so the recommendation is NOT to induce unless an infection develops.

Gestational diabetes requiring insulin – Again the Childbirth Connection misrepresents the situation. First they fail to mention Type 1 (insulin dependent diabetes) at all, despite the fact that it is a major medical indication for labor induction. The stillbirth rate in insulin dependent diabetes is more than triple the rare for non-diabetic mothers. Insulin dependent GESTATIONAL diabetes is a much less common phenomenon, and therefore, as the Mozurkewich paper acknowledges, there is little evidence available on induction in that setting. However, it is hardly unreasonable to assume that insulin dependent gestational diabetes poses the same harms to babies and to proceed under that assumption until further data is available.

Intrauterine growth restriction (IUGR) at term – Yet another misrepresentation. The Childbirth Connection claims that “more and better studies” are needed to determine if induction improves outcomes in IUGR. But IUGR is KNOWN to be responsible for a significant proportion of stillbirths. There is no treatment for IUGR, so the best hope for preventing stillbirth is to deliver the baby.

How does the Childbirth Connection summarize the medical indications awaiting more studies?

What common “reasons” for induction are not supported by rigorous research?

For a surprising number of conditions, the effectiveness of induction has not been proven (Mozurkewich and colleagues 2009, a systematic review). Yet many women have induced labor with the understanding that they or their babies will benefit. More or larger studies are needed to confirm the benefits and harms of induction in these situations.

In other words, they imply that these are not “reasons” for induction, that they will produce no benefit, and therefore we should wait for more evidence. But we KNOW that insulin dependent diabetes increases the risk of stillbirth and we KNOW that IUGR increases the risk of stillbirth. No obstetrician is misrepresenting the evidence when he or she recommends induction to prevent stillbirth in this situation. And no one is recommending induction for preterm rupture of membranes so it’s ucclear why this was included among spurious “reasons” for induction.

What might the average woman take away from this Childbirth Connection publication?

It seems to me that they are supposed to take away the following impressions:

Inductions are bad.
Don’t trust your obstetrician.
Obstetricians ignore scientific evidence.
There is no reason to induce for insulin gestational diabetes or IUGR.

And all four are wrong.

They really have nerve to represent this as “best evidence.” It isn’t a complete review of the evidence. It isn’t the best evidence. And even the minimal evidence that has been presented has been misrepresented by the Childbirth Connection.

They have no business giving medical advice to women. They lack the qualifications, and based on this piece and others like it, they lack the ability to review the massive scientific literature of modern obstetrics.

They are certainly entitled to promote their personal agenda, but they are not entitled to give erroneous “medical advice” to do so.

The Midwives Alliance of North America (MANA) is aware and has been aware for some time that homebirth has an unacceptably high rate of neonatal death. Their own data makes that clear and that’s why they are hiding it. In fact, there now trying to “reframe the conversation,” a classic public relations ploy designed to conceal an unpalatable truth.

I have been pounding away at this point for more than four years. I first wrote about it in January 2007 (Why is MANA hiding its data?):

… The [Johnson and Daviss BMJ 2005 study] included data from the year 2000 only, but MANA (Midwives Alliance of North America) has continued the collections of statistics. This could be a valuable resource for women wondering about the safety of homebirth. There’s a problem, though. No one is allowed to see those statistics. Well, that’s not quite right. You can have access to the statistics only if you “use the data for the advancement of midwifery”.

In fact, as early as summer 2006, MANA had already instituted elaborate procedures to hide the neonatal death rate of homebirth, including a non-disclosure agreement with legal penalties for anyone allowed to see the data prohibiting them from letting anyone else see the results.

In July 2008, MANA President Geradine Simkins explained the database:

Data collection includes “evaluation of all aspects of midwifery care in terms of safety, optimal maternal, fetal, and family outcomes,and cost effectiveness.

Data collection “uses a very extensive data form! ~360 questions.”

MANA estimates approximately 20,000 cases will be in the database by the end of 2008.

It does not take a rocket scientist to speculate that MANA is hiding its own safety data because that data shows that homebirth increases the risk of neonatal death. Indeed, MANA has made it clear that it has no intention of ever releasing homebirth death rates to the public, and has attempted to justify this by invoking, then twisting the meaning of “community based research.”

From the MANA Handbook for Researchers Interested in Obtaining Access to the MANASTATS Database:

The MANA DOR endorses the principles of Community-Based Participatory Research (CBPR), … a collaborative approach in which research takes place in community settings and involves community members in the design and implementation of research projects… The MANA DOR is responsible for representing the midwifery community in its relationship with investigators… Therefore the MANA DOR expects all investigators interested in collaboration with this community to consider how they can cooperate with these principles, and to describe how they intend to do so in their request for data access.

But community based participatory research is designed to protect the PATIENTS not the providers. And patients deserve to know how many babies died at the hands of homebirth midwives in the past decade.

I have been hammering away at this issue in the past 4 years in every possible forum and with every professional homebirth advocate I could find … and the silence has been deafening. I’m not surprised about the silence from MANA. It would serve no purpose for them to openly acknowledge that they are hiding the homebirth death rate, and there is no way they could deny that they are hiding it. I am, however, a bit surprised by the silence of professional homebirth advocates.

At first I thought that professional homebirth advocates were silent because they did not know the truth, but after 4 years and a myriad of on-line encounters, I’ve begun to wonder if many professional homebirth advocates have confirmed that MANA has found the homebirth death rate to be unacceptably high, and they have joined in the effort to hide that information.

Ina May Gaskin is the founder of MANA and is a very active professional homebirth advocate. I’ve asked her repeatedly, in a variety of different forums, why MANA is hiding the homebirth death rate and whether she thinks it is ethical for MANA to hide the homebirth death rate. She has never even acknowledged the question.

Amy Romano offered this disingenuous attempt to justify MANA’s behavior:

I’m irritated that you don’t seem to have read or tried to understand my post and have just shown up to copy and paste the same comment you’ve been leaving around the web. But I will go ahead and respond just to say that I have no affiliation with MANA other than that when I was practicing I contributed data to the MANAStats database… I have read their policies and procedures governing access to MANAStats data and … I see a pretty straightforward process that … the research benefit the community. In general I am an advocate of open access to data on the principle that it accelerates the pace of scientific discovery. But I don’t see, from my interpretation of their policies, anything that puts up unnecessary barriers.

As a contributor to the database, Romano actually qualifies for access. Yet she does not seem to have taken advantage of that access. Apparently, she doesn’t care about the MANA homebirth death rates, which is inexcusable since she is all over the web claiming that homebirth is safe.

But when it comes to nerve, no one tops Amie Newman of RH Reality Check. When confronted with the fact that MANA is hiding their neonatal death rate, she had this to say:

I 100% believe that women deserve the right to know how safe planned homebirth is with a Certified Professional Midwife. I also 100% believe that we have that information currently.

In other words, it supposedly makes no difference that MANA is hiding their death rates for 18,000 homebirths, because we already know all we need to know.

Curiously, not a single professional homebirth advocate has offered to question MANA about their neonatal death rate, or issued a public plea for MANA to reveal their death rate. Which makes me wonder … how many of them already know the truth? How many professional homebirth advocates are aware of exactly how many of those 18,000 babies died at the hands of homebirth midwives, and are colluding in hiding that data from the public?

When it comes to the people at MANA, like Melissa Cheyney and Geradine Simkins, I don’t know how they can live with themselves. They know that homebirth kills babies and they are working very hard to make sure that American women do not find out the truth. But how about the rest of the professional homebirth advocates? How can they live with themselves, continuing to tout the safety of homebirth, while knowing all along that the single largest database of American homebirth shows precisely the opposite?

In December CNN published a story that received a lot of attention and approval among homebirth and natural childbirth advocates, Mom defies doctor, has baby her way. Mom, Aneka, made the decision to risk her life and the baby’s life based on the flimsiest of reasons, she watched Ricki Lake’s documentary, The Business of Being Born.

She found support for her decision from ICAN (the International Cesarean Awareness Network):

“She asked me if I could find someone who would deliver her vaginally,” remembers Bobbie Humphrey, who works with ICAN. “She started to cry because she’d heard ‘no, no, no you can’t do this’ so many times.”

But Humphrey told her yes, that she knew of a midwife who would be willing to deliver her baby at home.

Aneka and her son were lucky. They survived her risky choice, but Aneka and her on line supporters had no clue it was just a matter of luck:

“People were e-mailing Aneka saying ‘congratulations, you’re a role model,” Humphrey says.

Another woman did try to emulate her, with tragic results:

A girl who I went to college with had a baby around 10 last night & both are in critical condition. This is her 4th baby. She had 3 previous c-sections & was trying for a VBAC homebirth. Her uterus ruptured in several places & she lost a lot of blood. She is intubated & had 2 blood transfusions. She isn’t out of the woods yet, by any means. The baby was born blue & unresponsive, was resusitated, but showing signs of possible brain damage. She was flown to a different hospital than her mom. The baby is being kept in some sort of induced unconscious state currently. Please keep Lori & baby Vera in your thoughts & prayers!! Thanks.

Apparently Lori transferred to the hospital at some point during the homebirth attempt. Her sister-in-law wrote on her personal blog:

… Lori lost a lot of blood because the uterus tore in several places; the docs had to replace her blood twice over. She has been in the OR at Lehigh Valley Hospital from 10pm (1/27) til now 4:20am (1/28). When I left the hospital at 4:20am, the OR team was just finishing up. I was not able to see Lori or the baby. Right now, Lori will remain intubated for the next couple of days, and in the ICU. The doctor said she is not out of the woods, she is still critical, and has a long road to recovery.

Baby Vera is also having difficulties… Somewhere in the process of removing the baby, she lost oxygen. She was born blue and flaccid and needed resuscitative measures. She pinked up and her heart rate became strong, but she remained unresponsive and could not breathe on her own. Vera was medivaced via helicopter to Jefferson Hospital in Philadephia for a cooling process. The docs are hoping that by placing Vera’s brain and body in a slightly hyperthermic [sic] state, that her little body will reset. She is responding to pain, but her pupils are still not dilating. Vera is also considered critical.

Lori’s friend posted updates on the message board:

Lori is doing better. Her blood work, urine output, and vitals signs are strong and look good. When the nurses lighten her sedation, Lori is fighting against the breathing tube, which is a good sign (she knows it’s there)….

Vera, however, is not doing as well as the doctors wanted. She has little brain activity and her pupils remain unreactive. She is still intubated and in critical condition. They have her doing the cooling treatment and will be on it for 72 hours…

Update 1/29:
Lori is doing much better – breathing & talking on her own. She still has a long recovery, though.

The doctors are trying [cooling] treatment with baby Vera. The treatment is 3 days, then it’s just watch & wait to see what happens.

All of this leaves me with questions for the folks at ICAN who encourage women to take these life threatening risks:

Will you use Lori as a role model for VBA3C? Or will you wash your hands of her and pretend this never happened?

Update (2/3/11): According to the neonatalogists “…the MRI showed that a large amount of fluid had collected (hydrocephalus) and was putting pressure on parts of the brain, actually moving sections into different areas (herniation). The EEG showed minimal electrical activity from the cerebral hemispheres. The neurologist stated that there is some brain swelling as well as significant brain damage in a large part of her brain, but she is NOT brain dead. Vera still has some reflexes. What they believe Vera has is HIE, Hypoxic Ischemic Encephalopathy.”

Update (2/12/11): Vera died last night.

The Midwives Alliance of North America (MANA), the organization that represents homebirth midwives*, thinks it’s time to reframe the debate about homebirth safety.

According to a MANA press release issue two days ago:

We believe it is time to re-frame this conversation. Midwives and obstetricians have been debating the safety of homebirth for far too long. In North America today planned homebirth for healthy women, attended by skilled providers, with access to medical consultation when necessary, is a safe option….

In other words, as the evidence mounts that homebirth leads to preventable neonatal deaths, we should stop talking about it.

Evidently, MANA and homebirth midwives have decided to copy the tactics used by the tobacco industry to divert attention from the fact that cigarette cause preventable deaths. SourceWatch explains the tobacco industry’s attempt to reframe the debate:

The “reframe the debate” strategy consists of moving the topic of a contentious dispute onto a wholly different topic. This involves making dire predictions of a more extreme outcome, portraying the original action as dangerous, tying activists to the dangerous outcome, linking the originally-proposed action to a fear-inducing outcome …

As the Tobacco Institute explained to its members:

Our judgement, confirmed by research, was that the battle could not be waged successfully over the health issue. It was imperative, in our judgement, to shift the battleground from health to a field more distant and less volatile…

Evidently MANA has made the same calculation. As I have detailed many times in the past (So tell me again why MANA is hiding its own homebirth safety data), MANA’s own data shows that homebirth has an unacceptably high rate of neonatal death. MANA knows that “the battle [can] not be waged successfully over the health issue” of homebirth safety. Therefore they have to “reframe the conversation.”

Let’s compare the tactics used in the MANA press release with the tactics of the tobacco industry.

Choice and responsibility

MANA:

First, we must understand the bio-ethical principle of autonomy as it relates to the human right of self-determination in making health care choices. Only then can we support women in their mastery of self-determination as they navigate the complicated worlds of obstetrics and maternity care and attempt to make good decisions for themselves and their families.

Tobacco industry:

[C]reate a campaign which frames and answers this question: Does America want prohibition? Will we tolerate a puritanical wave to infringe, to restrict and possibly to eliminate personal freedoms and individual choices?

Broaden the issue

MANA:

… [W]e can no longer tolerate the abysmal maternal and child health disparities that exist for our most vulnerable women and populations of color. We have our plates full with the daunting task of improving the health status of all women and infants in the United States within a social justice framework.

Tobacco industry:

The tobacco industry typically diverts attention away from a problematic topic by broadening the issue to encompass other issues. For example, the industry broadened problem of secondhand tobacco smoke or environmental tobacco smoke into a discussion of overall indoor air quality, and moved discussion of the issue to include pollutants in the air other than tobacco smoke, such as wood smoke or automobile exhaust, or shifted the focus to the efficiency (or lack thereof) of mechanical ventilation systems.

Change the focus MANA:

… We must address the fact that certain costly obstetrical practices that are not supported by science are overused, while other beneficial, low-tech practices are overlooked. Of particular concern to the Midwives Alliance and the clients we serve is the trend of increasing rates of cesarean sections, contributing to increased rates of premature birth, low birth weight infants and rising healthcare costs, while women across the country still struggle to find providers willing to attend vaginal births after cesarean (VBACs).

Tobacco industry:

…Finally, we try to change the focus on the issues. Cigarette tax become[s] an issue of fairness and effective tax policy. Cigarette marketing is an issue of freedom of commercial speech. Environmental tobacco smoke becomes an issue of accommodation. Cigarette-related fires become an issue of prudent fire safety programs. And so on.

Clearly MANA and the tobacco industry have followed the same playbook for the same reason: to divert attention from the issue of safety.

The MANA press release concludes:

… We can no longer be diverted by the distractions of disagreements among maternity professionals. We have serious work to do that cannot wait…

But homebirth safety is NOT a distraction. It is the central issue. And the only people who “cannot wait” to confirm the fact that homebirth has an unacceptably high rate of neonatal death are homebirth midwives.

The Midwives Alliance of North America already KNOWS that homebirth increases the risk of neonatal death; their own data tells them so, and that’s why they are desperately trying to hide that data. MANA “cannot wait” because they understand that more research will only confirm that fact. They need to act now before everyone learns that homebirth kills babies.

*American midwives who hold a post high school certificate (CPMs and LMs), as opposed to American certified nurse midwives and European, Canadian and Australia midwives who have university degrees

Several days ago I wrote about the philosophy of natural childbirth advocacy and its indifference to women’s need for pain relief (Natural childbirth and the invisibility of women’s needs). To the extent that natural childbirth advocates acknowledge the existence of childbirth pain, they subscribe to the “if only” school of pain management.

The “if only” school insists that a woman would not experience childbirth as agonizing …

… if only she were more knowledgeable about childbirth.
… if she hadn’t been socialized to believe that labor is painful
… if only she had eaten right and exercised.
… if only she had better support.
… if only she hadn’t had an IV and/or electronic fetal monitoring.

In other words, the “if only” crowd believes that pain is not intrinsic to childbirth; it’s someone’s fault. But pain is intrinsic to childbirth, and to understand why, requires knowledge of the neurological basis of pain itself.

Contrary to the false dichotomy of “good” pain and “bad” pain imagined by natural childbirth, which has no basis in neurology, there are two sources of pain in childbirth, exactly the same as the two sources that exist everywhere else in the body. These two types of pain are visceral and parietal (or somatic) pain.

Here’s the technical explanation from a paper written by a certified nurse midwife:

… During the dilatation phase of labor (first stage), visceral pain predominates, with pain (nociceptive) stimuli arising from mechanical distention of the lower uterine segment and cervical dilatation… These nociceptive stimuli of the dilatation phase are predominantly transmitted to the posterior nerve root ganglia at T10 through L1. Similar to other types of visceral pain, labor pain may be progressively referred to the abdominal wall, lumbosacral region, iliac crests, gluteal areas, and thighs… As the pelvic or descent phase of labor advances (late first stage and second stage), somatic pain predominates from distention and traction on pelvic structures surrounding the vaginal vault and from distention of the pelvic floor and perineum. Sharp and generally well localized, these stimuli are transmitted via the pudendal nerve through the anterior rami of S2 through S4.

Translation:

The pain of contractions is visceral pain caused by the uterine effort to push the baby into the vagina. This visceral pain is the type of pain that comes from internal organs, exactly the same as the visceral pain of a gall bladder attack or a kidney stone. The visceral pain signals are transmitted to the spinal cord through the spinal nerves of the lower thoracic and upper lumbar vertebrae and thence to the brain.

The vaginal and perineal pain of the end of labor is parietal or somatic pain. Parietal pain is sharp and well localized. The parietal pain impulses of crowning and birth are transmitted to the spinal cord through the spinal nerves of the sacral vertebrae and thence to the brain.

An epidural blocks the visceral pain of labor by “numbing” the nerves that transmit the pain to the spinal cord. The parietal pain of labor can be eliminated by “numbing” the spinal nerves that transmit the pain or, in the case of local anesthesia, by “numbing” the nerves located where the pain begins.

The key point is that the two types of labor pain are exactly the same as the two types of pain that can occur in other parts of the body. The nerve impulses are the same, they travel to the spinal cord on similar pathways, and they are sent to the brain in exactly the same way. They can also be abolished in exactly the same way.

Therefore, to understand why the “if only” school of management is wrong, not only in their understanding of pain, but also in their claims about what can and cannot “cause” pain, it helps to apply their claims to other forms of pain.

Consider gall bladder pain, a classic form of visceral pain that occurs when the gall bladder attempts to squeeze out bile but cannot because the duct is blocked by gallstones. Would a patient in the midst of a gall bladder “attack” have less pain if only she were more knowledgeable about gall bladder attacks? If she hadn’t been socialized to believe that gall bladder attacks are painful? If only she had eaten right and exercised? If only she had better support? If only she hadn’t had an IV and/or electronic blood pressure monitoring? The answers of course are no, no, no, no and no.

And why are all the answers “no”? Because gall bladder pain arises from the contractions of the gall bladder attempting to push out a gallstone, is transmitted to the spinal nerves and thence to the brain. The pain impulses from a gall bladder attack aren’t modified by knowledge, socialization, diet and exercise, nursing support or the presence of basic medical safety measures. There’s no reason to expect that they would be modified by these factors. Similarly, there’s no reason to expect that labor pain would be modified by these factors, either.

How about parietal pain? Consider pain from a broken bone, and ask the same questions. The answers will be “no” once again and for exactly the same reason. Just like knowledge, socialization, diet and exercise, nursing support or the presence of basic medical safety measures would not be expected to modify the pain of a broken bone, they cannot be expected to modify the pain of crowning and birth, either.

So why does childbirth hurt? Because of the pain! The pain that is produced by nerve signals, transmitted to the spinal cord, and carried to the brain in exactly the same way as visceral and parietal pain from any other part of the body.

There is no scientific basis for the claims of the “if only” school of childbirth pain. It’s just another attempt to render women’s needs invisible.

One of the biggest problems in homebirth midwifery is that homebirth midwives* don’t know what they don’t know. Their background in obstetrics, science and statistics is very limited; so limited, in fact, that they have no idea how little they know compared to those who have far more education and training in these subjects.

The classic paper on this phenomenon is Unskilled and Unaware of It: How Difficulties in Recognizing One’s Own Incompetence Lead to Inflated Self-Assessments by Kruger and Dunning published in Journal of Personality and Social Psychology in 1999. The paper reports on a variety of experiments that were used to evaluate individuals’ actual performance compared to predicted performance.

For example, study subjects were given a test of basic logic:

…Participants … completed a 20-item logical reasoning test that we created using questions taken from a Law School Admissions Test (LSAT) test preparation guide. Afterward, participants … compared their “general logical reasoning ability” with that of other students from their psychology class by providing their percentile ranking. Second, they estimated how their score on the test would compare with that of their classmates, again on a percentile scale. Finally, they estimated how many test questions (out of 20) they thought they had answered correctly…

The results are displayed in the following graph:

The dark lines represent the test subjects’ rating of their logical reasoning ability and the score they predicted they would get. The dotted line represents the actual score. The graph demonstrates that the ability to correctly predict one’s score is directly related to the actual score. Those who scored poorest on the test of logic grossly overestimated their ability; those who did slightly better slightly overestimated their performance; and those who scored moderately well were accurate in predicting their own performance.

In other words, those who knew the least were also the least capable in understanding how little they knew.

The authors also found that improving the subjects knowledge of logic led to more realistic personal assessments. They divided a new group of test subjects in two. One half received a lesson in logic before the test; the other half received a lesson in an unrelated subject. Those who received the lesson in logic were much more likely to accurately predict performance on the test.

… Before receiving the training packet, these participants [in the lowest quartile] believed that their ability fell in the 55th percentile, that their performance on the test fell in the 51st percentile, and that they had answered 5.3 problems [out of 10] correctly. After training, these same participants thought their ability fell in the 44th percentile, their test in the 32nd percentile, and that they had answered only 1.0 problems correctly…

No such increase in calibration was found for bottom-quartile participants in the untrained group.

As the authors explain:

Participants scoring in the bottom quartile on a test of logic grossly overestimated their test performance — but became significantly more calibrated after their logical reasoning skills were improved. In contrast, those in the bottom quartile who did not receive this aid continued to hold the mistaken impression that they had performed just fine.

Why hadn’t the study participants realized their own deficiencies in basic logic simply by interacting over the course of their lifetime with other people who knew more basic logic?

… [S]ome tasks and settings preclude people from receiving self-correcting information that would reveal the suboptimal nature of their decisions. [And], even if people receive negative feedback, they still must come to an accurate understanding of why that failure has occurred.

That’s why homebirth midwives have no idea how little they know. Because homebirth midwives never encounter anyone in their training besides other homebirth midwives, they have no opportunity to observe that many other health professionals have a much larger knowledge base and a much greater skill set. When disasters do occur at homebirth, midwives fail to understand that they were responsible and simply dismiss tragedies with the all purpose adage that “some babies die.”

Moreover:

… [I]ncompetent individuals may be unable to take full advantage of one particular kind of feedback: social comparison. One of the ways people gain insight into their own competence is by watching the behavior of others… However, [our study] showed that incompetent individuals are unable to take full advantage of such opportunities. Compared with their more expert peers, they were less able to spot competence when they saw it, and as a consequence, were less able to learn that their ability estimates were incorrect.

This problem is greatly aggravated in homebirth midwifery because homebirth midwives are literally taught to view anyone who does things differently as objects of contempt. Doctors are supposedly greedy, incompetent and ignore scientific evidence. This attitude is best illustrated by the perjorative appellation of certified nurse midwives as “medwives.” Though CNMs have far more education and training than homebirth midwives, homebirth midwives prefer to pretend that CNMs spent that extra time being “socialized” (i.e. brainwashed) in “techno-medicine.”

The authors conclude:

… [W]e present this article as an exploration into why people tend to hold overly optimistic and miscalibrated views about themselves. We propose that those with limited knowledge in a domain suffer a dual burden: Not only do they reach mistaken conclusions and make regrettable errors, but their incompetence robs them of the ability to realize it.

Similarly, homebirth midwives hold overly optimistic views about their knowledge base and their clinical skills. Not only do they reach mistaken conclusions and make deadly errors, but their incompetence robs them of the ability to realize it.

*American midwives who hold a post high school certificate (CPMs and LMs), as opposed to American certified nurse midwives and European, Canadian and Australia midwives who have university degrees

I have often commented that the philosophy of “natural” mothering (natural childbirth, lactivism, attachment parenting) rests on fundamental assumptions that are often unrecognized and therefore unexamined. Last week I wrote about the social construction of risk within our culture and the social imperative that everyone (mothers and doctors) do everything possible to minimize risks to babies without ever considering the trade-offs that reducing specific risks imply.

But risk is not the only thing that is socially constructed within the philosophy of “natural” mothering. Women’s needs are also socially constructed; specifically, in the philosophy of natural mothering, women’s needs are rendered invisible. Natural childbirth advocacy and its approach to the issue of pain in labor is perhaps the paradigmatic example of the way in which natural mothering erases the needs of women.

Natural childbirth advocacy uses several different strategies to render women’s needs invisible. To understand how these strategies work it makes sense to start with the empirical facts that most of us agree upon:

1. Childbirth is excruciatingly painful. Indeed the pain of childbirth is so impressive that ancient cultures imagined that the only possible explanation was divine punishment of women for their transgressions.

2. Severe pain should be treated. No one would ever suggests that cancer pain be ignored or that pain from a broken bone should go untreated.

3. Medical professionals have an obligation to treat pain. Every human being is entitled to the medical treatment of pain if that’s what he or she desires.

Natural childbirth advocates employ a variety of strategies to render invisible women’s need for pain relief. The first strategy is to insist that a mother’s need for pain relief is insignificant when compared to the “risks” of epidurals. This strategy is all the more remarkable when one considers that the “risks” of epidurals are not empirical, but purely speculative. Presumably, the baby has a need and a right, to avoid any potentially harmful effects from epidurals that might be discovered as some unspecified future time. And that need (even though theoretical) trumps the mother’s need for pain relief, despite the fact pain of this magnitude would always be treated if it were from any other source.

The intellectual sophistry of such a claim is all too apparent. The natural childbirth project involves invoking risks that may not even exist and inflating both the severity and the likelihood of such risks. And it rests on the assumption that no matter how theoretical or how small these risks may be, they automatically trump a woman’s need for pain relief. A woman’s need for pain relief is therefore of no consequence and not even worthy of consideration.

Even when natural childbirth advocates concede that women might feel a need for pain relief, they employ a variety of strategies to diminish the importance of that need. These strategies involve

Blaming the woman for her own pain – if she did it “right,” childbirth would not be painful.
Blaming the woman for not using “natural” methods of pain relief – regardless of their questionable value in providing adequate relief.
Blaming the woman for not embracing the pain as an “empowering” aspect of her biological destiny.

Simply put, according to natural childbirth dogma, a woman’s pain in labor is irrelevant, of no importance compared to the baby’s need to avoid theoretical risks, and her own fault.

It is important to note that in natural childbirth philosophy, it makes no difference how small the risk to the baby might be, and it makes no difference how large the mother’s need for pain relief might be. To put that in perspective, it helps to consider another, far more trivial, example of balancing risk and need that all mothers must address.

Consider the issue of driving with a baby in the car. There is no doubt that riding in a car exposes a baby to a real risk of injury and death in a car crash, a risk whose magnitude is far greater than the theoretical risk of an epidural. And consider that the mother’s “need” to go to the grocery store is trivial, and can easily be met at another time without putting the baby in danger of injury or death in a car accident. So why aren’t natural childbirth advocates berating women for driving with infants in their cars? They consider that larger risk socially acceptable. In that case, convenience trumps whatever needs the baby might have.

The reality is that every choice has risks and benefits, and those risks and benefits must weighed against each other. But when a woman’s need for pain relief is rendered invisible, natural childbirth advocates can act as if there is no benefit to pain relief in labor and can pretend that no weighing of risks and benefits is necessary.

It is difficult to imagine any other situation in which ignoring a woman’s severe pain would be socially and ethically acceptable. But for natural childbirth advocates, a woman’s needs are invisible, and therefore merit no consideration.

No surprises here. ACOG looked over the scientific evidence once again and found that it still shows that homebirth increases the risk of neonatal death.

The ACOG practice bulletin, Committee Opinion No. 476: Planned Home Birth appears in the February issue of Obstetrics and Gynecology. The Committee notes that many of the existing scientific papers are of poor quality, and almost all are observational:

Observational studies of planned home birth often are limited by methodological problems, including small sample sizes (Wiegers 1996, Ackermann-Liebrich 1996, Davies 1996, Janssen 2002); lack of an appropriate control group (Woodcock 1995, Anderson 1995, Murphy 1998, Johnson and Daviss 2005); reliance on birth certificate data with inherent ascertainment problems (Wax Maternal and newborn morbidity by birth facility among selected United States 2006 low-risk births 2010, Pang 2002); ascertainment relying on voluntary submission of data or self-reporting (Wiegers 1996, Anderson 1995, Johnson and Daviss 2005, Lindren 2008); a limited ability to accurately distinguish between planned and unplanned home births (Pang 2002, Mori 2008); variation in the skill, training, and certification of the birth attendant (Johnson and Daviss 2005, Pang 2002, Scramm 1978); and an inability to account for and accurately attribute adverse outcomes associated with antepartum or intrapartum transfers (Ackermann-Liebrich 1996, Pang 2002, Parratt 2002).

Then they turn to the most recent Wax study (Home versus hospital birth—process and outcome 2010):

… Although perinatal mortality rates were similar among planned home births and planned hospital births, planned home births were associated with a twofold-increased risk of neonatal death. When limited to only nonanomalous newborns, the increased risk of neonatal death was even higher––almost threefold higher in planned home births. These results did not change when the investigators performed sensitivity analyses excluding older studies or poorer quality studies. No maternal deaths were reported among 10,977 planned home births. When compared with planned hospital births, planned home births are associated with fewer maternal interventions …

They emphasize that all the existing scientific studies that show that homebirth is as safe as hospital birth comes from other countries that have strict selection criteria, dedicated transport systems, and highly trained midwives.

In summary:

… Women inquiring about planned home birth should be informed of its risks and benefits based on recent evidence. Specifically, they should be informed that although the absolute risk may be low, planned home birth is associated with a twofold to threefold increased risk of neonatal death when compared with planned hospital birth. Importantly, women should be informed that the appropriate selection of candidates for home birth; the availability of a certified nurse–midwife, certified midwife, or physician practicing within an integrated and regulated health system; ready access to consultation; and assurance of safe and timely transport to nearby hospitals are critical to reducing perinatal mortality rates and achieving favorable home birth outcomes.

Anyone who has been following this blog will not be surprised since I’ve written about almost all of these studies and pointed out that with the exception on the recent Dutch and Canadian studies (de Jonge 2010, Janssen 2009), there are no properly done studies that show that homebirth is safe. With the exception of the most recent Dutch and Canadian studies, all the existing studies that claim to show that homebirth is safe suffer from serious methodological flaws that render their conclusions invalid.

Although the Committee does not address this issue, recent data from The Netherlands suggests that the results of the de Jonge study are also in question. There may be no difference in mortality rate of midwife attended hospital and homebirth, but obstetricians have better outcomes in hospitals, even when caring for high risk patients, putting the safety of all midwife attended births (hospital or home) in doubt.

I wish the Committee had not place such reliance on the most recent Wax study, because as I wrote when it was released, it’s not a great study. No doubt American homebirth advocates will leap on this to discredit the Committee report, but that’s merely an attempt to divert attention from the key points which are indisputable:

There is not a single study that shows that American homebirth is as safe as hospital birth. All of them suffer from serious methodological flaws, particularly the use of inappropriate control groups designed to make the homebirth outcomes look better by comparison.

The only places where homebirth might potentially be as safe as hospital birth is The Netherlands and Canada, both of which have strict eligibility criteria, dedicated transport systems and highly trained midwives. Of these three criteria, American homebirth lacks ALL of them. And, as I pointed out above, the meaning of the Dutch results are now in doubt since the mortality rates of all midwife attended births are higher than the mortality rates for physician attended hospital births.

So homebirth advocates can jump up and down about the inclusion of the Wax study, but that doesn’t change the basic facts. There is NO evidence to show that American homebirth is safe, and a great deal of evidence to suggest that it is not.