It’s probably the most egregious violation of professional conduct that any obstetrician-gynecologist can commit. I’m talking about the sexual exploitation of a patient.

You might think that such a doctor would be a pariah among patients, especially after a conviction, and the decision by the California Board of Medicine to place him on probation for 7 years, but you’d be wrong about this doctor. He is currently soliciting donations from patients and supporters for his latest legal woes, precipitated by routinely ignoring hospital policy, and women are proudly giving money.

What group of women would deliberately ignore a conviction for sexual exploitation and rally around a doctor in spite of it? Homebirth advocates, of course. They have chosen to ignore the behavior of Dr. Stuart Fischbein because he provides back up for homebirth midwives.

Dr. Fischbein is widely hailed within homebirth circles. He works with Ricki Lake on her website, and is routinely praised for his public “Letter to ACOG” condemning their stance on a variety of issues. I can only imagine what happened at the headquarters of ACOG when they received the letter. They must have been shocked and then laughed out loud at the audacity of a doctor convicted of sexual exploitation daring to lecture them on their responsibilities to patients.

The offense was described by the Ventura County Star:

His patient, identified in Medical Board records as S.K., was 14 years younger than he and earning her doctorate degree in psychology. She came to Fischbein’s office in Century City with her fiancee. They wanted to have a baby.

… He performed surgery … to remove a mass in her uterus and called her “sweet pea” in the recovery room. He sat at her bedside for long intimate talks, testifying in a hearing he viewed her as not just a patient, but as a woman…

S.K. said Fischbein told her he would be a better father than her fiancee. He persuaded her to leave him.

They talked about the ethics of doctor-patient relationships. She said he told her he dated “bushels” of patients. Fischbein denied the comment or any other relationship with a patient.

She said he advised her not to have sex for four to six weeks after surgery. Fischbein said in court he didn’t remember the discussion.

Five days after she was released from the hospital and eight days after surgery, he called and asked to visit her at her home in Los Angeles. They had sex then and again two days later at Fischbein’s home.

He testified it was consensual. She said she viewed him as a doctor who had performed a surgery that was going to enable her to have a baby. He had become a hero who seemed almost “godlike.” And he was interested in her.

“I would have done anything he would have told me to do,” said the woman, who is suing Fischbein. “I look back with my hindsight and with my mind today and say, How could I have done this?'”

The contrast between this description and the accolades of his supporters are jarring, to say the least.

The post by Rixa Freeze on her website Stand and Deliver is typical of the response of the homebirth community to Dr. Fischbein’s latest legal difficulties.

…[A] wonderful obstetrician, Dr. Stuart Fischbein, is being threatened with disciplinary action by his hospital “for violating hospital policies.” The hospital has already suspended the privileges of the two CNMs he works with, and now he faces a possible loss of his livelihood…

Dr. Fischbein is a vocal supporter of midwifery and home birth. His collaborative midwife practice had a primary c-section rate last year of only 5% … and an overall rate of 12% … compared to his colleagues’ 29%…

So what can you do to help?

1. Contribute to Dr. Fischbein’s Legal Aid Fund. Make Paypal Payment to angelfischs@yahoo.com or mail a check payable to Alan J. Sedley, Attorney at Law…

Dr. Fischbein claims that he is being faced with the loss of hospital privileges for repeatedly violating hospital policy on VBACs and breech deliveries. That is certainly possible since subjecting the hospital, nurses and other doctors to the risk of legal liability that they have chosen not to undertake is certainly a reason for losing privileges. However, the peer review process is protected by strict confidentiality on the part of the hospital. There is no way to know whether this is the primary or only cause for the peer review.

I take a dim view of soliciting money from patients and supporters for a legal defense when those patients and supporters have no way of knowing what the actual charges are. It seems only reasonable that if Dr. Fischbein is soliciting money for his legal defense, he should waive the hospital’s mandated confidentiality, so that they can tell their side of the story.

Homebirth advocates have every right to forgive Dr. Fischbein for sexual exploitation. Yet I feel compelled to ask: Is homebirth so important that any doctor who supports it, even one who has acknowledged sexually exploiting a patient, is worthy of the designation “Dr. Wonderful?”

In a recent post (Homebirth kills babies) I analyzed the data in the Linked Birth Infant Death database and demonstrated that homebirth with a direct entry midwife has almost triple the neonatal death rate of hospital birth for comparable risk women. Similar results were presented at the Pedatric Academic Societies May 2009 meeting.

According to the Medscape article:

Dr. Michael H. Malloy, at the University of Texas Medical Branch in Galveston, compared a range of adverse outcomes among infants by delivery attendant type and site of delivery occurring in the U.S. over a recent 5-year period…

The present analysis was limited to term (37-to-42 weeks), singleton, vaginal deliveries.

“I decided to restrict the analysis to this low-risk population because they would be the best candidates for home delivery,” Dr. Malloy said.

During the study period, there were 10,330,214 (88.5%) hospital physician-attended births available for analysis; 1,237,129 (10.6%) hospital-CNMW births … 13,529 (0.1%) home-CNMW births; 42,375 (0.4%) home-other nurse midwife …

The number of neonatal deaths for each of the categories was respectively 6,992; 614… 14; 75

The neonatal death rates in each group were 0.68/1000 hospital MD births; 0.5/1000 hospital CNM births, 1/1000 home CNM births and 1.7/1000 homebirth direct entry midwives. These are almost exactly the same as the death rates that I calculated from the same database for the 2 year period 2003-2004.

In both cases, homebirth with a direct entry midwife has triple the rate of neonatal death as low risk hospital birth. In both cases, homebirth with a direct entry midwife (such as a CPM) is the most dangerous form of planned birth in the US.

As Dr. Malloy explains:

“However, while there were only 14 neonatal deaths occurring in association with a home-CNMW assisted delivery, the risk of death was more than two-fold higher for CNMW-home deliveries and four-fold higher for deliveries by other midwives versus CNMW-hospital deliveries.

The prevalence Apgar scores of less than 4 was eight times higher for CNMW-home deliveries than for CNMW-hospital deliveries. What’s more, the risk of neonatal mortality and low Apgar scores was still increased for CNMW-home deliveries versus CNMW-hospital deliveries after adjusting for multiple potential confounders (including maternal age, race, education, parity, presence of one or more medical or labor complications, presence of an anomaly in infant, gestational age, and infant sex).

“The increased risk of low Apgar scores among infants delivered at home suggests that the causal pathway to the increased risk of neonatal mortality may be through the occurrence of asphyxiating conditions at birth that are not easily handled by the home environment,” Dr. Malloy noted.

Overall, the results demonstrate that the safest setting for a delivery is an in-hospital delivery attended by a CNMW, and women who decide to deliver in the home “need to recognize the greater risk associated with that choice,” he said.

Finally, as for why in-hospital CNMW deliveries had a lower risk of mortality in his study than in-hospital physician deliveries, Dr. Malloy said he assumes it’s because physicians are delivering a higher risk population, which he could not completely control for in his logistic regression analysis.

Dr. Malloy would be expected to be very sympathetic to homebirth. He has published several papers on C-sections and neonatal mortality in association with Drs. MacDorman and Declerq alleging (and then forced to back track) on claims that C-sections increase the risk of neonatal death.

Dr. Malloy’s data confirms what anyone can see for themselves. The existing US statistics on homebirth shows that homebirth with a direct entry midwife has triple the rate of neonatal mortality of low risk hospital birth. It is the most dangerous form of planned birth in the US.

If women want to have a homebirth, they can, but as Dr. Malloy states, they “need to recognize the greater risk associated with that choice.”

Ahh, the irony. Christian Conservatives have a sordid history of trying to force religion into medicine.

According to them, Jesus does not allow abortions, so laws should prevent abortion, or, failing that, should place innumerable roadblocks in the way of women who want abortions.

According to them, Jesus wants all life to be preserved, so they mustered a public campaign to prevent Terri Schiavo’s husband from honoring her wishes and allowing her to die.

According to them, Jesus considers homosexuality to be an abomination, so discrimination against gay people should be enshrined in law.

Since they appear to believe that medical decisions (even other people’s medical decisions) should be made with regard to what Jesus would want, I’d like to know: who would Jesus insure? *

I’m no theologian, but I feel confident that Jesus would not approve of our current method of providing healthcare.

Would Jesus tie health insurance to employment? I doubt it. He made manifest his concern for the poor and downtrodden, so it is doubtful that he would want their miseries magnified by denying them access to healthcare.

Would Jesus allow pre-existing conditions to be exempted? Not likely. He ministered to the sick without regard for how long they had been sick before he arrived. It is impossible to imagine him declaring: “I’m here to relieve your suffering, but only new illnesses, not those that existed before I came to your valley.”

Would Jesus consider it a priority to preserve existing insurance companies? Would he reject a public option for health insurance because it threatened the profits of insurance giants? Once again, not likely. He would not put profits ahead of the life and health of innocent people.

Who would Jesus insure? The conclusion is inescapable. He would insure everyone. He would insist that it was the moral responsibility of those who have health insurance to make it available to those who don’t. And the way we do that is by providing a public option for health insurance, exactly the same option that the elderly now enjoy.

So I have a suggestion. For those who believe that we should make healthcare decisions based on what Jesus would do, how about making healthcare insurance decisions based on what Jesus would do? Obama may be anathema to many Conservative Christians, but it is impossible to deny that his plan for healthcare reform bears the closest resemblance to what Jesus would do.

WWJI: Who would Jesus insure? Everyone, of course.

* I know that is “whom would Jesus insure” is grammatically correct, but “who would Jesus insure” sounds better.

The history of medicine is replete with theories that reflect religious beliefs rather than scientific facts. One of the most interesting, and most instructive examples of this phenomenon is the claim that masturbation causes insanity.

Masturbatory insanity pre-occupied medical professionals for almost 250 years. It arose apparently de novo in Europe in the early eighteenth century, and was not finally put to rest until the middle of the twentieth century. Its history of the idea is recounted exhaustively in the scientific paper Masturbatory Insanity: The History of an Idea by E.H. Hare published in the Journal of Mental Science in January, 1962.

Classical medical professionals made no reference to any harmful effects of masturbation. It was not until the early eighteenth century that the idea gained currency upon publication of the book Onania, or the Heinous Sin of Self-Pollution. The author is believed to have been a “clergyman turned quack” and not a reputable medical professional. Like most quacks he advertised an extremely expensive secret remedy.

The assertions gained wide popularity, though. Voltaire, writing in his Dictionnaire Philosophiqe in 1764 reports that the book was then in its 80th edition.

The idea passed into the realm of official medical thought with Tissot’s Onania, or a Treatise upon the Disorders produced by Masturbation in 1758. According to Tissot:

…[L]oss of semen … occasions general debility and so opens the way to consumption, deterioration of eyesight, disorders of digestion, impotence, and so on…[T]he more serious effects are on the nervous system and this is due to the sexual act causing an increased flow of blood to the brain. “This increase of blood explains how these excesses produce insanity. The quantity of blood distending the nerves weakens them; and they are less able to resist impressions, whereby they are enfeebled.”

During the following years anatomical and pathological study revealed that disease was caused by structural abnormality or derangement, and the claim that masturbation could cause “deterioration of the eyesight, disorders of digestion, etc.” lost currency. But medical professionals refused to give up the idea that masturbation was harmful and the locus of harm became mental health.

According to Esquirol, writing in 1838:

… it (masturbation) may be a forerunner of mania, of dementia and even of senile dementia; it leads to melancholy and suicide; … it is a grave obstacle to cure in those of the insane who frequently resort to it during their illness

The view that masturbation causes insanity was refined over time to a specific form of insanity. In his classification of mental disorders written in 1863, Skae asserts:

The third natural family I would assign to the masturbators… I think it cannot be denied that that vice produces a group of symptoms which are quite characteristic and easily recognized, and give to the cases a special natural history: the peculiar imbecility and shy habits of the very youthful victim; the suspicion and fear and dread and suicidal impulses and scared look and feeble body of the older offenders, passing gradually into Dementia or Fatuity.

This theory was elaborated by Spitzka (1887):

… the typical age of onset of masturbatic insanity is between 13 and 20 years; it is at least five times as common in males as in females because of the greater rarity of masturbation in females; in the majority of cases there is a rapid decline into agitated dementia, but where deterioration is less rapid “the obtrusive selfishness, cunning, deception, maliciousness and cruelty of such patients” is such that “the [doctor] may find it impossible to reconcile himself to regarding them as anything else than repulsive eye-sores and a source of contamination to other patients, physically and morally.”

In retrospect, Spitzka and others were describing schizophrenia. As Hare explains how masturbation came to be associated with a specific form of insanity:

Nor is it difficult, from our present standpoint, to see how this came about. Masturbation is most commonly and most frequently practised during adolescence and therefore most likely to be observed when mental disease insidiously deprives an adolescent of his normal social inhibitions.

As the field of psychiatry developed, it was recognized that excessive or public masturbation was a symptom of serious psychiatric illness, not its cause. Even then, the psychiatric profession only gradually gave up the notion of masturbation as harmful, downgrading it from psychosis to neurosis and ultimately acknowledging it as normal behavior.

The story of masturbatory insanity is a cautionary tale. It reflects the injection of religion into medicine, characterizing a behavior as harmful because religion says it is harmful, rather than relying on scientific evidence. We may imagine that, in our purported sophistication, we would never fall prey to such ludicrous theories. But, in fact, similar efforts are ongoing, with religious conservatives trying to persuade the public that homosexuality is deviant behavior and that abortion is physically harmful.

The story of masturbatory insanity should remind us to be aware of the intersection of religion and culture with contemporary medicine. Great harm can occur when religion is confused with medicine and medicine is harnessed for religious ends.

A pervasive theme in “alternative” health is the notion of the brilliant heretic. Believers argue that science is transformed by brilliant heretics whose fabulous theories are initially rejected, but ultimately accepted as the new orthodoxy.

Alternative health practitioners, with no embarrassment at their own presumption, routinely liken themselves to Galileo and Darwin. Today their brilliant theories of homeopathy, therapeutic touch and the like are rejected but ultimately they will be acknowledged as truth. As usual, their claim is based on a lack of knowledge about science, and ignorance of history.

As explained in The Holistic Heresy: Strategies of Ideological Challenge in the Medical Profession by Paul Wolpe, alternative health practitioners believe:

[Alternative health] is the inevitable (or desirable) next step in the history of medicine, and like other heroes of medical history who were initially rejected by the orthodoxy of the day … the [alternative health practitioner] is simply ahead of his time. Innovation is always initially resisted … Holistic heretics portray themselves as mavericks, leaders, with every expectation that soon all of medicine will, by necessity, follow in their footsteps.

It is a breathtaking conceit, and it betrays a profound lack of understanding of the history of science.

1. The conceit rests on the notion that revolutionary ideas are dreamed up by mavericks, but nothing could be further from the truth. Revolutionary scientific ideas are not dreamed up; they are the inevitable result of massive data collection. Galileo did not dream up the idea of a sun-centered solar system. He collected data with his new telescope, data never before available, and the sun-centered solar system was the only theory consistent with the data he had collected.

Similarly, Darwin did not dream up evolution. He collected data during his years of exploration on the Beagle, much of it previously unavailable. A theory of evolution was the only theory consistent with the data that he had collected.

In contrast, belief in alternative health has no basis in scientific fact. It has been dreamed up by its various adherents and practitioners. Far from depending on scientific evidence, it eschews the need for scientific evidence.

2. The notion of the heretical maverick betrays a lack of historical knowledge. Galileo and Darwin were considered heretics by religious leaders, not by other scientists. Their ideas swept across the scientific world precisely because of their explanatory power and the data that they had to back them up.

In the world of science, it was already well established that the orthodoxy could not explain what everyone had observed. Long before Galileo, scientists understood that the Biblical theory of the earth-centered universe did not accord with astronomical evidence. Long before Darwin, fossil discoveries had called into question the Biblical creation story.

Mainstream medical science has been astoundingly successful in both theory and practice. The power of the germ theory of disease or the molecular structure of DNA rests on their ability to explain what we observe, are confirmed by experimental data, and result in highly effective treatments and cure.

In contrast, alternative medicine exists independent of scientific observation. Its theories have poor explanatory power and are directly contradicted by copious scientific evidence. The treatments of alternative health are notoriously ineffective. Although anecdotes abound, scientific studies of “alternative” health treatments have yet to identify a single one that works.

3. New theories may be resisted by older scientists because they upset the orthodoxy, but they are not resisted by the scientific world. That’s the point of peer reviewed scientific journals. Scientists present their evidence, and other scientists decide whether that evidence supports a new theory.

For example, early in my medical career a scientist claimed that ulcers were caused not by acid, but by the H. pylori bacteria. The initial reaction of the medical world was disbelief. However, when doctors saw the data, and when the original studies were quickly reproduced by other scientists, doctors accepted the theory, created treatments based on the discovery and moved on.

In medicine, as in all science, the data comes first, the theory follows. In “alternative” health, the theory exists independent of the evidence, and no one even bothers to collect evidence. The idea that alternative health will ultimately be accepted as true is ludicrous.

The idea that heroic geniuses dream up new scientific theories that are initially rejected but ultimately embraced by other scientists is a fairy tale. It betrays a lack of understanding about how science works, and a lack of knowledge about what actually happened to people like Galileo and Darwin.

The Holistic Heresy: Strategies of Ideological Challenge in the Medical Profession, by Paul Wolpe, is about doctors who promote “alternative” medicine, but it applies to any practitioner who challenges the fundamentals of any branch of medicine. According to Wolpe, an attack on an established discipline in medicine includes four specific elements. The critic:

must portray the discourse as in crisis, must provide an alternative ideology to rescue the discourse, must legitimize their ideology through appeal to a reframed historical myth, and must portray the orthodoxy as a betrayer of the discourse.

The authors applies his analysis to “alternative” medicine in general, but we are will look at homebirth midwifery in particular.

The first step is to portray the particular discipline as “in crisis”.

… 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).

As Wolpe points out, the critic “rarely paints its opponent in terms of benign neglect”, but, rather, claims that it is evil. Therefore, the rising C-section rate is never portrayed by homebirth advocates as the regrettable but inevitable result of the desire to prevent all possible neonatal death and injury, but, instead, is characterized as the result of the obstetrician’s desire to get rich, to “get home for dinner”, or simply to ruin a woman’s birth experience.

Next, the critic offers the new philosophy, positioning it as the replacement for the old:

… The heretical ideology is drawn as much as possible from existing strains in the discourse, strains usually ignored, slighted, or marginalized in the orthodox ideology… The heretic draws from the marginalized or folk knowledge of the tradition and elevates the constructs found there to primary importance…

… [G]reat pains are usually taken … to show that the alien ideas are not in fact alien at all, but have existed in the discourse in a different form. [Critics] often import foreign, folk, and traditional forms of healing into their practices, [carefully describing] them as wholly compatible with Western medicine, scientifically valid, or historically present in other forms. (The ‘placebo’ effect, for example, is elevated to a central place in holistic medicine, and described as demonstrating the ‘power of the mind’, which is in turn said to be a central tenet of Eastern and Native healing forms. The orthodoxy is censured for slighting this most important healing modality.) …

What does the critic offer instead?

The [critic] blurs the line between disease and health as it is usually drawn in Western medicine, and extends the range of therapeutic intervention beyond the bounds of manifest pathology. At one end is a concentration on pre-morbid states, or prevention…

Attention to the pre-morbid state is complemented by an expansion of the post-morbid state. The goal of holistic health is more than the absence of disease; it is a state of optimal functioning, often referred to as ‘wellness’… [which] greatly expands the role of the HMD in medical intervention …

In the words of homebirth midwifery: pregnancy is “not a disease”, but nonetheless it requires extensive prenatal visits, preparation and education. In addition:

The [alternative practitioner] caters to the consumer; the customer is always right, and the seller does not know better than the buyer what the buyer really want or needs…

And:

The use of touch and intimacy, the central role of patient education, and the use of Eastern and Native American medical forms and philosophies all serve to create a ritualized encounter that opens the way for ideological display. [Alternative providers] try to forge affective connections with patients by sharing their own feelings and experiences and using noninstrumental touching to develop intimacy.

Third, the critic attempts to gain legitimacy by “rewriting” the history of the discipline:

Heretics try to rewrite the discourse’s historiography to emphasize their own ideological positions. In doing so, they make heroes out of the orthodoxy’s secondary players and emphasize heretical themes in the orthodoxy’s heroes.

Hence the rewriting of the history of Semmelweis and puerperal sepsis to make Semmelweis the “discoverer” of puerperal sepsis, and to protray him as the man who could have cured puerperal sepsis if other orthodox physicians had not stood in his way and hounded him to insanity.

Another favored theme:

… Holistic heretics portray themselves as mavericks, leaders, with every expectation that soon all of medicine will, by necessity, follow in their footsteps.

Ultimately:

Biomedicine is portrayed as a bureaucratic juggernaut whose judgments are accepted uncritically by adherents. Technological wizardry is used as proof of sophistication without truly exploring all roads to healing their patients…

Promiscuous use of drugs and surgery represent not cures, but substitutes for curative action. They are distributed without thought and without recognition of their power to do harm…

The heretical attack both blames the orthodoxy for the crisis and for failing to accept the heretic’s remedial ideological position. The orthodoxy has betrayed the discourse through its inaction, and no longer deserves to be its guardian. The heretic is the true keeper of the flame, the savior of the discourse, and should ascend to the position of power in place of the orthodoxy.

Natural childbirth advocates, like many Americans, have trouble evaluating risk. They have difficulty understanding relative risk (how one risk compares to another risk) and they have difficulty evaluating sources for the accuracy of their claims. There is an additional component to risk assessment for natural childbirth advocates. They are often factually misinformed about the actual risks. Nowhere is that more apparent than in their almost complete lack of knowledge about the inherent risks of pregnancy and childbirth.

The first clue to this serious misunderstanding is the claim that childbirth must be safe because it is “natural”. Natural does not mean safe, and we are pretty clear about that in other areas of life. For example, natural disasters, such as hurricanes and earthquakes are 100% natural. Nonetheless, we know that they are responsible for a tremendous amount of death, suffering and destruction. Natural means one thing only: it happens in nature. It tells us absolutely nothing about whether it causes death or other serious effects.

The second clue to this serious misunderstanding is the claim that childbirth must be safe because “we are still here”. This is evidence of basic lack of knowledge about biology. The fact that “we are still here” only tells us that in every generation, the number of people who lived exceeded the number who died. It doesn’t tell us anything about the ratio. So, for example the population will grow at a certain rate if each couple has 3 surviving children. It does not matter whether the couple had 3 children, all of whom survived, or 10 children, 7 of whom died.

We know from the biology of other animals that reproduction has a tremendous amount of wastage. We’ve all seen nature shows about sea turtles who lay hundreds of eggs, with the result that only a few baby turtles survive the treacherous walk across the beach to the safety of the ocean. We know that some animals, like salmon, give up their own lives in the process of reproduction. The fact is, there is a tremendous amount of wastage in human reproduction also. The miscarriage rate for established pregnancies is 20%. That means that 1 in 5 pregnancies will not survive to result in a live birth. Pregnancy and childbirth also have a “wastage” rate. In nature, many women and babies did not survive the process. That is a natural part of human reproduction.

Let’s take a look at historical evidence about death in pregnancy and childbirth. Irvine Loudon is one of the premier historians working to understand the history of human pregnancy and birth. In the article Maternal mortality in the past and its relevance to developing countries today, there is extensive exploration of the historical data on maternal mortality in the United Kingdom. Looking at the maternal mortality data for 1872-1876, we find a maternal mortality rate of approximately 400/100,000 with the following causes:

cause of death %
Puerperal fever 55.5
Hemorrhage 22.5
Eclampsia 11.6
Miscarriage and abortion 4.0
Postpartum psychosis 2.5
Embolism 2.0
Ectopic 0.2
Other 0.8

By contrast, the maternal mortality rate today is in the range of 10/100,000.

What were maternal mortality rates prior to the late 19th century? According to the works of other historians which Louden quotes:

They found maternal mortality rates were certainly higher at 400-500 per 100000 births throughout the 19th century. It was a bit higher at the beginning of the 19th century and was up to perhaps 1000 per 100000 births in the early part of the 18th century. I have a graph in my book [Loudon I. Death in childbirth. Oxford: Clarendon Press, 1992] that shows maternal mortality stretching back in history and, as you go back, it goes up very slightly and then we lose track because there really are no data as yet.

This data is fairly consistent with the maternal mortality rates that we see today in parts of the world that don’t have access to modern obstetrics.

What conclusion can we draw from this data?

Giving birth is and has always been inherently dangerous. From the early 18th century on back, 1% or more of births resulted in the death of the mother. To put a 1% maternal mortality rate in perspective, it is twice as high as the mortality rate for receiving a kidney transplant, and a bit less than half the mortality rate of having “triple bypass” heart surgery.What’s really amazing to consider is that the chance of the baby dying was always dramatically higher.

It’s only a matter of time until Kate begs Jon to come home.

Jon’s finally gotten Kate’s attention. Not by moving out, or gallivanting around with tarty women. She doesn’t care about that. He’s gotten her attention by threatening what she loves most in this world and I don’t mean her children. Jon has jeopardized Kate’s diva-dom, the gravy train she has ridden to celebrity and a bizarre haircut.

The ratings for Jon and Kate Plus Eight have dropped like a rock. From a high of 10.5 million viewers at the end of last season, only 3.5 million viewers tuned in for the most recent episode. People aren’t interested in watching a couple going through a messy divorce, and that’s hardly surprising. As I wrote last spring (Why are we fascinated with big families?):

I suspect we are fascinated because we stand in awe of the commitment required to deliberately choose a large family: the commitment to parenting as a lifestyle choice and the commitment to marriage that lies at the core of the decision to have many, many children.

In contemporary America, such a commitment is not only unfashionable; it is unfathomable.

If contemporary America could be distilled to one imperative, it would be this: The highest calling is self-actualization. Or, more colloquially, “it’s all about me.” In other words, being happy (and being happy is considered the highest state of being) requires doing what you want, when you want to, unfettered by obligations and commitments. Children are an obligation, a temporary detour on the road to a life devoted to self.

By separating and planning to divorce, Jon and Kate have demonstrated that they are just like everyone else. Both of them abandoned their commitment, and decided “it’s all about me.”

Kate put stardom ahead of being with her husband and family. He asked to her to stop traveling and spend more time with him and the kids. She needed the rush of attention, the entourage and the extra money that came from turning the children into an industry, not merely a TV show. The books and the speaking tours were necessary steps in building that industry. Visions of celebrity endorsements danced in her head.

Jon, for his part, has decided to meet this rejection with a startling display of immaturity, self-absorption and naivite. He is relying upon Michael Lohan for advice. You may remember him as the dysfunctional father of Lindsay Lohan, newly released from jail. Perfect! They can trade tips about how divorced dads can still profit from their children’s celebrity while failing to act like real fathers and stick around to raise their kids.

Jon and Kate have destroyed the main appeal of their show by putting their own desires ahead of the needs of their children, and the viewers have been quick to react. The drop in ratings is only a part of it.

While Jon and Kate have been very careful to keep their religious fundamentalism out of the TV show (probably on the advice of the network), the books and speaking engagements directly exploited that element. The books are published by a Christian publisher and are filled with Biblical quotes and testimonials about the role of their faith in their lives. The audiences for their speaking tours were conservative Christians. Needless to say, divorce will kill that market completely.

Kate wanted a divorce because Jon was interfering with the building of her personal celebrity and her financial empire. But forcing Jon out, though good for a temporary boost in ratings, will destroy the show and the money and celebrity that go with it. I suspect that it is only a matter of time before Kate begs Jon to come back.

The possibility of getting back together, with its inherent tension and doubt, would be a ratings bonanza, and the effort to repair their marriage back together would rescue her standing within the conservative Christian community. Imagine the rapturous greeting Kate would get if she claimed that it was their strong religious faith that led to a reconciliation.

Oh, and it might be good for the children, too, but who cares about them?