One of the biggest lies of the many lies told by homebirth advocates is that unexpected childbirth complications can be managed by immediate transfer to the hospital.

Some can, but the worst emergencies cannot. Why? Because in the case of a serious emergency, the baby is often left without oxygen. Think about it: could you hold your breath until you got from your living room to the closest hospital — even by ambulance? If not, why would you imagine that a baby could do it and survive?

[pullquote align=”right” cite=”” link=”” color=”” class=”” size=””]Could you hold your breath from your living room to the closest hospital?[/pullquote]

Umbilical cord prolapse is just such an emergency. If the umbilical cord falls out of the uterus into the vagina or even out of the vagina, the blood vessels in the cord constrict in response to the change in temperature, just as they are supposed to do after a baby is born. The baby’s blood supply, and therefore its oxygen, is cut off.

Even if the blood vessels don’t constrict, the cord can get compressed between the baby’s head and the mother’s pelvis. That’s why in the event of a cord prolapse the attendant is supposed to reach into the vagina and exert upward pressure on the baby’s head to keep it from squeezing the cord. Emergency C-section is needed to save the baby’s life and the attendant must keep her hand in the vagina until the baby is delivered.

In childbirth emergencies, “time is brain.” Brain cells begin to die within 5 minutes of being deprived of oxygen. It almost always take more time to get to a hospital, no matter how close, than it takes to injure a baby’s brain.

The latest homebirth death is a perfect example.

A reader sent me this story:

“I wanted to share with you the horrific experience I had that I know will never leave my heart or my mind.

Working at a big hospital we get a lot of home birth transfers and we always take care of them the same way we would a person who chose to deliver in a hospital.

However recently we got a call from our charge nurse that we were getting a home birth transfer via ambulance with a cord prolapse and to get the OR set up.

When the mom arrived in the hospital she was on hands and knees on the gurney with a student midwife behind her with a hand in her vagina. We moved quickly and got the mother onto the OR tables and many people worked together to get an IV started and get her prepped and ready for surgery.

One of our labor nurses took the place of the student midwife and put her hand on the baby’s head to relieve the pressure and she felt absolutely no pulse from the umbilical cord. She knew sitting under that drape that this baby was already gone.

We got a very sketchy and incomplete history of this mom. We found out the student midwife had told the mother that she was fully dilated, but when the on call doctor checked her she was 8 centimeters.

This mother was over 40 weeks pregnant and had ruptured hours before at home with thick green meconium. Tell my why at that point would you not immediately transfer your patient to the hospital to give her baby the best chance of survival. Instead they did nothing.

We still don’t know what exactly happened at home that day. The midwife stated that she had performed an episiotomy and I guess at that point they realized this baby had a cord prolapse and she shoved her ungloved hand up the woman’s vagina in a panicked state.

We had initially thought we heard the baby’s heartbeat in the 110’s, but that was more likely the pulse of the mother. When we finally got this baby out, which took several minutes due to the position of the baby and the size, she was covered and stained in thick green meconium.

This precious baby was gone before she got to us yet we rushed around frantically trying to get this baby out ASAP to give her the best chance of being resuscitated. The baby scored apgars if 0-0-0. They coded the baby for 15-20 min before calling it.

We at the hospital did not have a fighting chance to save this baby despite all of our best efforts. It’s not fair to blame the hospital staff for causing traumatic birth experiences when they are the homebirth midwives are the ones who screwed up. Where does their accountability lie?

This delivery could have 100% been a successful delivery and saved this woman the pain of burying her child and explaining to her 3 year old why her baby sister she had been excited to meet was gone. As we heard the NICU team frantically trying to get any signs of life from this baby and finally called it, it was heartbreaking for everyone in that room. The on call doctor who inherited this disaster was so distraught that she almost could not finish the case.

This poor mother had delivered her first child in our hospital with a highly skilled ob fairly quickly and uneventfully, so I’m sure she was assured by her LAY midwife and accompanying student that she was low risk and could absolutely deliver in the comfort of her own home. She was most likely told that hospitals only want to strap you down to a bed and deliver how the doctor feels most comfortable. That is not at all the case! She was sold on this romanticized fantasy of channeling her inner goddess and doing what her body was created to do with the prying gloved hands and irritating monitoring.

The fact remains that this perfect baby did not have to die. Had this mother been transferred as soon as she ruptured thick meconium she would have been taking her baby home in her arms instead of making funeral arrangements. The hands off approach is a complete gamble and you have no idea what hand you will be dealt. Tragically this mom learned this the hard way. Homebirth mothers only worry about their experience and what they want and they don’t take the health of their baby in to account when they have these reckless disasters.”

Rest In peace, Baby.

And for those thinking about homebirth, think again.

The obstetrician wrote:

Occasionally I’m asked why we so often congratulate women on “beautifully natural births?” Some have commented, “all births are beautiful, why do you specifically call out natural births as though medicated births are somehow less beautiful?” …

I realize that this is a marketing message. This physician is trolling for more business and he believes he knows where he can get it.

Nonetheless the message Dr. Christopher Stroud is promoting is what is carefully crafted to be a dog-whistle for its intended recipients.

[pullquote align=”right” cite=”” link=”” color=”” class=”” size=””]Congratulating a woman for having a vaginal birth rather than a C-section is like congratulating a woman for being fertile rather than infertile.[/pullquote]

A dog-whistle is:

… messaging employing coded language that appears to mean one thing to the general population but has an additional, different, or more specific resonance for a targeted subgroup. The analogy is to a dog whistle, whose ultrasonic whistling sound is heard by dogs but inaudible to humans.

Stroud’s marketing means one thing to the general public, but another to natural childbirth advocates:

When we congratulate a mother on a “beautifully natural birth,” we are actually congratulating her on achieving her goal; we’re calling out her success in her unique, personal journey; the achievement that she, for a variety of reasons, may have thought unachievable. We’re not in any way valuing a non-medicated birth over a birth aided by epidural anesthesia, or a successful VBAC over a scheduled repeat cesarean section, for example. Rather, we’re saying, often shouting, “you did it; you made it; you are strong, brave and wonderful.” The cheers are about victory; victory over doubt; victory over adversity; victory over what is too often bad advice from previous providers…

As an important aside, it is undeniable, however, that many women who desire an non-medicated birth experience feel as though they have to fight against the hospital staff and their providers to achieve what they want. We see many women for their second pregnancy after they’ve had a bad experience in pursuing natural birth in their first pregnancy. So when these women finally achieve what they have so desperately wanted there is a great sense of accomplishment; of overcoming what may have seemed insurmountable, and that leads to great celebration and elation. This experience is not better or more worthy of celebration than an uneventful labor with the use of an epidural, for instance, but the celebration is often just “louder.”

Silly me! I thought birth was about having a healthy baby! But in 630 words, “baby” is only mentioned once.

Dr. Stroud would like his marketing targets to think that he believes that unmedicated vaginal birth without interventions is more beautiful than any other birth.

The message was received loud and clear.

As one commentor noted:

This post was amazing! I switched to Strouds practice after having a pretty traumatic birth experience that ended in a c section with my first baby. From there, I specifically sought out Strouds practice which has allowed me to attempt 2 VBACs and has fully supported them. By having a supportive provider, it made me felt so empowered and made things so positive the next 2 times around. thank you for ALL you do for women and their families.

Let’s leave aside for the moment the question of why privileged white women deserve praise for something poor women and women of color are forced to do every single day in developing countries. Let’s examine instead the two most disturbing aspects of this marketing message, an obstetrician’s belief that any form of birth is better than any other and the ugly ableism that it implies.

Physicians are people. Obviously they are going to have private views that some patient choices are better than others, but in my judgment those private views are just that: private. A doctor may feel that waiting for marriage is “better” than pre-marital sex, but that view has no place in counseling a patient about contraception. He may feel that a biological child is “better” than an adopted child, but that view has no place in counseling an infertile patient, nor should it be broadcast to promote his infertility practice. Similarly, he may feel that an unmedicated vaginal birth without interventions is “better” than any other birth, but that view, like views on pre-marital sex and adoption, has no place in counseling patients nor should it be broadcast to promote his obstetric practice.

What personally bothers me more, however, is the ugly ableism behind the sentiment. The ability to have a vaginal birth without interventions rests on biological factors beyond a patient’s control. Women have no control over the size and shape of their pelvis, the size and position of their babies and whether or not they develop complications like gestational diabetes or pre-eclampsia, yet all these factors can be limiting factors when attempting vaginal birth. To praise a woman for having a vaginal birth rather than a C-section is to praise her for being lucky. Indeed, it’s similar to praising a woman for being fertile rather than infertile.

Dr. Stroud’s claim that women who have a vaginal birth without interventions have had to fight harder is patently absurd. There’s simply no question that it is more difficult to obtain a maternal C-section on request than an unmedicated vaginal birth. So why isn’t that more beautiful than a vaginal birth?

The most pernicious notion in all of this, a notion that Dr. Stroud does not question, is that one type of birth is more praiseworthy than any other. That notion was promulgated and has been promoted by the natural childbirth industry and is fundamentally misogynist. It is a form of biological essentialism that imagines that all women are alike, that one size birth ought to fit everyone and that those for whom it does not fit (or those who simply don’t want a one-size-fits-all birth) are lesser women.

That view is not beautiful; it’s astoundingly ugly.

It’s not unusual for new mothers to seek out other new mothers for support. They share information and experiences about birth, breastfeeding, sleeping and the awe of having created a new life.

In contrast, in freebirth groups they share information about their dead babies. It’s not really surprising that there are lots of deaths in freebirth groups since freebirth (also known as unassisted childbirth or wild pregnancy) is birth without medical assistance of any kind. Even so, I’m surprised at just how many deaths there are.

[pullquote align=”right” cite=”” link=”” color=”” class=”” size=””]How many babies have to die preventable deaths before these women wake up to the harm they are causing?
[/pullquote]

Several weeks ago I shared a story about a recent freebirth death of baby Journey Moon:

So the surges keep coming every day, but still no baby. Just making me more and more tired and my body ache everywhere. Nothing I could do would ease the pain but I tried so hard to stay positive.

My water broke the evening of the 4th and was discolored. Since I was 42 weeks I thought it was normal. But as the days went by it got more foul smelling and turned a sick poop color which was constantly leaking and the baby stopped moving on the 6th.

I woke on the 7th with so much pain and pouring meconium that Chris and I agreed it was time to transfer.

Not surprisingly, Journey Moon was dead.

The widespread publicity about that death did not stop another mother from letting her baby die at freebirth.

As Katie Paulson reported on Patheos, the mother reached out to her freebirth group after 6 nights of prodromal labor and 48 hours of ruptured membranes.

At this point, the mother is beginning to doubt her choice of moving forward with the labor at home. However, the group cheers her on, encourages her that the issues are normal, and provide suggestions to help the labor progress…

The mother seemed to be satisfied with the responses she received from her friends in the group. After a few exchanges, the mother left the conversation. Then the group went completely silent. For more than two days, members bumped the thread, tagged the mother, and tried to get her to respond to ensure she was ok.

She was okay but her baby was born dead.

Freebirth is an incredibly fringe practice yet there have been two deaths in just a few weeks. But that’s not all. In this particular freebirth group of only 400 members, 3 others immediately responded with stories about the deaths of THEIR babies.

It has been 4 years since my daughter was born sleeping… I’m here if you need to talk.

And:

I lost my daughter at 8 hours old 11 weeks ago to group B streptococcus.

And this:

We will be praying for you! My son died shortly after birth in June…

Notice a theme? Lots of women have let their babies die in a cult-like devotion to a bizarre practice that has no parallel in other times, places and cultures.

I know that freebirthers are emotionally immature: supremely egotistical, reflexively defiant of authority, unwilling to admit mistakes, incapable of accepting responsibility for their own actions and entirely devoid of any empathy for their suffering babies. Even so, they should be capable of learning. The only question is how many babies have to die preventable deaths before these women wake up to the harm they are causing.

Imagine if every time a gay man or woman interacted with the healthcare system he or she was offered gay conversion therapy, instructed that heterosexuality was normal and forced to sign a consent form for medical care that proclaimed “Hetero is Best”?

Ugly, right?

As GLAAD explains:

Anti-LGBTQ activists have argued for years that sexual orientation is a choice and changeable – but only for people attracted to the same sex, not heterosexuals. They often claim “homosexuality” is not real, but rather a form of mental illness or an emotional disorder that can be “cured” through psychological or religious intervention. Anti-LGBTQ activists claim that being attracted to the same sex is a curable condition, and therefore people attracted to the same sex do not need or deserve equal treatment under the law or protection from discrimination.

Now consider that every time a pregnant women or new mother interacts with the medical system, she is pressured to breastfeed, instructed that breastfeeding is normal and forced every time she opened a can of formula to read that “Breast is Best.”

[pullquote align=”right” cite=”” link=”” color=”” class=”” size=””]Both assume that individuals cannot figure out what is right for themselves and must be pressured into the “best” choice.[/pullquote]

Why?

Breastfeeding professionals and advocates have argued for years that breastfeeding is nothing more than a choice and those who can’t or don’t want to breastfeed could do so if they really tried. They often claim that breastfeeding difficulties aren’t real, but rather a mindset foisted on women by the formula industry, a mindset that can only be counteracted with aggressive efforts to promote breastfeeding. Professional breastfeeding advocates often claim that women who choose formula feeding do not need or deserve equal treatment by medical professionals, hospitals and public health campaigns.

Ugly, right?

How do these efforts impact those who are supposed to be “supported” by them?

GLAAD:

The American Psychiatric Association has condemned the “treatment” of “homosexuality,” saying, “The potential risks of ‘reparative therapy’ are great, including depression, anxiety and self destructive behavior, since therapist alignment with societal prejudices against homosexuality may reinforce self-hatred already experienced by the patient.”

Similarly, it’s pretty clear that aggressive breastfeeding promotion has significant psychological risks to the mother above and beyond the risks to babies from insufficient breastmilk. Aggressive breastfeeding promotion can lead to postpartum depression, pospartum anxiety and self destructive behavior since such efforts reinforce the self hatred already experienced by many of these women.

Why do advocates engage in these pressure campaigns?

Gay conversion therapy is pressed on gay people by parents, religious leaders and others who truly care about them. There’s no question that it is much easier to be a heterosexual in our society, that gay people face terrible prejudice and that religious leaders fear for the immortal souls of those who are gay. In addition, parents and religious leaders often erroneously conclude that it is a licentious society that encourages young people to be gay.

As a result, they force gay people into conversion programs because they love them and want what’s best for them. It literally never occurs to them that gay people can figure out for themselves what is best.

Breastfeeding professionals and advocates promote breastfeeding so aggressively because they really feel it is best for babies and best for mothers. They claim all sorts of benefits of breastfeeding and all sorts of risks of formula feeding. In addition, breastfeeding professionals and advocates are sure that it is formula companies that pressure women to give up breastfeeding or choose not breastfeed in the first place.

As a result, they lock up formula, promote breastfeeeding contracts and force pregnant women and new mothers into programs like the Baby Friendly Hospital Initiative because they truly care about babies and mothers and want what’s best for them. It literally never occurs to them that mothers can figure out for themselves which feeding method — breastfeeding, bottle feeding or a combination of both — is best for their babies, their families and themselves.

Gay conversion therapy is FAR WORSE than aggressive breastfeeding promotion efforts. Sexual orientation, of course, is never a choice whereas breastfeeding sometimes is. On the other hand, being gay comes with more risks to safety and wellbeing in our still homophobic society than the faux “risks” of formula feeding. The worries of parents and religious leaders sadly reflect reality and imagining that things could be “better” if only gay people accepted that heterosexuality is best is hardly irrational.

But gay conversion therapy is immoral, unethical and anti-scientific. And although it is worse than aggressive breastfeeding promotion, it shares many commonalities.

1. Both presume choice when there is no choice.
2. Both share a fundamental misunderstanding of biology and evolution; just because something is natural doesn’t make it perfect.
3. Both assume that the biological norm is what all people should strive to attain.
4. Both imagine that “glamorization” of gay lifestyles by the entertainment industry or of formula feeding by the formula industry are far more influential than they are.
5. Both rest on the belief that individuals cannot figure out what is right for themselves and must be pressured into the “best” choice.

Gay conversion therapy is anathema and has been rightly condemned by medical professionals including the American Psychiatric Association, the American Psychological Association, the American Medical Association, the National Mental Health Association and the American Academy of Pediatrics. This represents a profound change from their previous positions on the issue.

Aggressive breastfeeding promotion is also to be deplored. It should be condemned by both medical and mental health professionals. I have no doubt that it will ultimately be properly condemned; in the meantime we should be doing everything possible to hasten that day and to support all women regardless of how they choose to feed their babies.

The most tragic of the many ironies of the natural childbirth movement is that the recommendations proposed in good faith to improve outcomes for babies and women has ended up killing them.

This is particularly true in the case of maternal mortality. For years the conventional wisdom has been that outcomes improve as interventions are reduced. Indeed, most midwifery academics and some obstetric academics have insisted in the strongest possible terms that reducing the C-section rate is the key to reducing the maternal death rate.

[pullquote align=”right” cite=”” link=”” color=”” class=”” size=””]Childbirth is inherently dangerous. When providers forget that, women pay with their lives.[/pullquote]

Sadly, the data has shown precisely the opposite. Women die from lack of high tech interventions, or lack of access to them, NOT too many interventions.

Obstetric experts are finally beginning to recognize that the two greatest threats to women’s health in and after childbirth are low index of suspicion and reluctance to deploy high tech interventions in a timely fashion.

The lead paper in this week’s New England Journal of Medicine is What We Can Do about Maternal Mortality — And How to Do It Quickly by Susan Mann, MD et al.

Dr. Mann and colleagues offer four separate methods for reducing maternal mortality as quickly as possible.

1. AIM bundles

The Alliance for Innovation on Maternal Health … created several “bundles” of best practices for improving safety in maternity care, to help clinicians, the obstetrical team, and facilities consistently manage the care of high-risk pregnant women, including those with the three most common preventable complications identified by the CDC [postpartum hemorrhage, severe hypertension, and venous thromboembolism].

AIM bundles include readiness, recognition, response, and reporting protocols. As part of ensuring facility readiness, the protocols can be customized for the individual unit, posted, reviewed regularly, and made accessible to all clinicians. Although management may vary from institution to institution, each unit can be required to demonstrate readiness to deal with emergencies 24/7. Institution-specific, standard protocols need to meet expectations for rapid treatment response in all hospitals, including small, critical access hospitals… (my emphasis)

2. Preparation for complications, particularly in high risk women

Second, all hospitals can implement multidisciplinary staff meetings or huddles to assess and review each obstetrical patient’s risk factors, including determining the hemorrhage-risk level … Approximately 50% of U.S. hospitals provide care for three or fewer deliveries per day, but the need to identify women at risk is equally important for these small obstetrics services. Indeed, with fewer staff members and resources, it’s important that obstetrical, anesthesia, and nursing staff have a shared mental model of obstetrical patients’ risks and how the needs of those patients, given their risk levels, can be met in the context of the needs of all other hospitalized patients…

3. Drill for emergencies

[I]n situ simulations can elucidate for staff members the critical timing and logistics involved in such emergencies — how long it takes to get products from the blood bank, for example, or where to find a hemorrhage cart or infrequently used medications or devices. Simulations allow staff to review the protocol adopted by the obstetrics service. Because severe maternity-related events are rare and often unpredictable, and because members of the care team may not know each other, it is important to train for low-probability but high-risk events — much as professional pilots’ standard operating procedures include training in flight simulators for such events… (my emphasis)

4. Timely transfer to high resource hospitals

Fourth, hospitals can use the Maternal Health Compact.4 The compact ensures readiness by formalizing existing relationships between lower-resource hospitals that transfer pregnant women when they require higher levels of maternal care and the referral hospitals. These connections can be activated by lower-resource hospitals to get immediate consultation in the event of an unexpected obstetrical emergency whose care demands exceed their resources…

These recommendations involve using more interventions, more quickly and more often.

So how did experts get it so wrong?

In my judgment their were two major errors:

The first was the belief, promoted as forcefully as possible by midwives, in the Panglossian paradigm of natural childbirth, presuming that if something is natural, it must be best. The Panglossian paradigm imagines that everything that exists in nature today is the product of intense natural selection and represents the perfect solution to a particular evolutionary problem. For example, “normal” birth represents the best possible way of giving birth and is to be emulated as closely as possible.

But as evolutionary biologist Stephen J. Gould pointed out, an existing natural feature may not be the result of evolutionary pressure at all; it may be an incidental feature of a solution to an entirely different problem or it may represent the limits of genetic adaptation.

The Panglossian paradigm has led maternity providers to the erroneous conclusion that we should have a low index of suspicion for life threatening complications in childbirth. But the fact that childbirth is natural is entirely compatible with the fact that it is inherently dangerous, representing as it does one of the leading causes of death of young women and THE leading cause of death of children in every time, place and culture.

The second major error was the willingness to pretend that correlation is causation. The C-section rate rose during the same years that the maternal mortality rate rose. Ergo, C-sections cause maternal mortality. Women who experienced numerous interventions are more likely to die than women who didn’t. Ergo it must be interventions that are killing women.

Both are plausible, but have repeatedly been demonstrated to be wrong. Women aren’t dying because of too many interventions in childbirth; they’re dying because there are not enough.

We’ve made significant errors, but we can fix those errors.

Every woman, no matter how few risk factors, faces the possibility of death in childbirth. When maternity providers lose sight of that reality — or worse, deny that reality — women pay with their lives.

Yesterday I wrote about doula Maddie McMahon who equated obstetric providers who do vaginal exams with sexual predators.

Midwives shld be debating the pros and cons of routine VEs and exploring the evidence, or lack of, for regularly fossicking around in a normal labour. I’m just a woman telling you that you need a damn good reason to finger me. Just telling me I’m Xcm is not a good enough reason.

What led her to make such an absurd, vulgar statement? She and other midwives/natural childbirth advocates were losing an argument. Her ugly comment was part of the extended effort at whataboutism that is the current go-to tactic of those who are forced to defend the indefensible.

[pullquote align=”right” cite=”” link=”” color=”” class=”” size=””]When you can’t defend your actions, derail the discussion.[/pullquote]

MacMahon’s offensive comment was made in a Twitter thread on consent, specifically that women are not adequately counseled about the risks of vaginal birth and the increased risk of forceps used instead of C-sections. It was started by one woman’s heartbreaking admission.

This may sound dramatic, and may offend some, but speaking from the lived experience of life after forceps birth injury some days I feel I would rather have died, or my baby died, than the everyday reality of these injuries.

This woman, who may be suffering from incontinence and sexual dysfunction, had dared to question two sacred precepts of natural childbirth advocacy: 1. there are no risks to vaginal birth and 2.vaginal birth is always better than a C-section.

Worst of all, no one from the natural childbirth community could come up with remotely plausible defense of withholding critical information from women. Recognizing their inability to defend the indefensible, they resorted to whataboutism.

According to Merriam-Webster:

Whataboutism gives a clue to its meaning in its name. It is not merely the changing of a subject (“What about the economy?”) to deflect away from an earlier subject as a political strategy; it’s essentially a reversal of accusation, arguing that an opponent is guilty of an offense just as egregious or worse than what the original party was accused of doing, however unconnected the offenses may be.

The tactic behind whataboutism has been around for a long time. Rhetoricians generally consider it to be a form of tu quoque, which means “you too” in Latin and involves charging your accuser with whatever it is you’ve just been accused of rather than refuting the truth of the accusation made against you.

The classic example of whataboutism in midwifery/natural childbirth advocacy is responding to the preventable death of a baby at homebirth with “babies die in the hospital, too!” (BDIHT)

It’s not clear to me that those who invoke BDIHT understand that the babies who die in the hospital are very different from those who die at homebirth. The babies who die in the hospital typically die of UNpreventable causes such as prematurity and congenital anomalies, whereas babies who die at homebirth die PREVENTABLE deaths as a result of being deprived of access to the lifesaving treatments of the hospital.

The BDIHT partisans tend to be woefully ignorant of basic arithmetic, specifically the concept of rate. Many more babies are born in hospitals than at home; therefore, comparing actual numbers of deaths in each birthplace is meaningless. If ten babies die in a hospital that delivers 10,000 babies, the rate of death is 1/1000. If two babies die in one hundred homebirths, the rate of death is 20 per 1000, 20X HIGHER than the rate of death in the hospital.

In this case midwives/advocates started out with “what about consent for homebirth” implying both that obstetricians don’t counsel women about homebirth and that therefore it’s okay for midwives to fail to counsel women about the risks of vaginal birth.

When they couldn’t derail the discussion — the tactic wasn’t working very well since most women are counseled about homebirth and they don’t want it — the midwives/natural childbirth advocates then retorted with “what about vaginal exams?” They know “many” women who receive vaginal exams without consent and against their will.

That tactic wasn’t working very well, either, since everyone agreed that women should not have vaginal exams without consent, so the whataboutism was ratcheted up to imply that those who do vaginal exams are sexual predators. It seems that MacMahon — puffed up with the self-righteousness to which natural childbirth advocates are addicted — was “reasoning” that denying women information about the risks of vaginal birth is okay because obstetricians are abusing women for sexual gratification.

That did finally derail the discussion as had been intended all along.

Over the course of three days and hundreds of tweets midwives/natural childbirth advocates had refused to address the concerns of the woman who started the thread with her heartbreaking lament. Why? Not as a defense of hiding the risks of vaginal birth, since that is indefensible, but as a defense against their own cognitive dissonance. MacMahon could not tolerate the idea that natural childbirth advocates are as paternalistic as the doctors they rail against. To protect HERSELF, she fabricated the slur that anything she fails to do is okay since doctors are worse.

UK midwives and natural childbirth advocates have been back-footed by the disastrous revelations of dozens, possibly hundreds, of preventable deaths at the hands of midwives clinging to the rigid, failed philosophy that vaginal birth is best. But they’re not going down without a fight and whataboutism is a key tactic in their efforts to avoid culpability for their indefensible failures.

If you want to see how badly the midwifery philosophy of “normal” birth has been discredited, there’s no better place to look than the UK.

For over a decade the Royal College of Midwives, the midwifery trade union, promoted a Campaign for Normal Birth on the grounds that it would save money, save lives and improve patient satisfaction. It was a spectacular failure. Dozens, perhaps hundreds, of babies and mothers were injured or died preventable deaths because they were deprived of appropriate monitoring and necessary interventions. Maternity liability payments ballooned to nearly £2bn per year. As a result, the RCM was forced to shutter its Campaign.

[pullquote align=”right” cite=”” link=”” color=”” class=”” size=””]Demonizing obstetricians by equating them with sexual predators.[/pullquote]

The RCM has yet to take responsibility for the fact that they wasted both lives and money promoting their ideological agenda. They did acknowledge that not only did they fail to improve patient satisfaction, they made women feel worse. RCM head Cathy Warwick admitted it had ‘created the wrong idea’:

‘There was a danger that if you just talk about normal births, and particularly if you call it a campaign, it … sounds as if you’re only interested in women who have a vaginal birth without intervention,’ she told The Times.

‘What we don’t want to do is in any way contribute to any sense that a woman has failed because she hasn’t had a normal birth. Unfortunately that seems to be how some women feel.’

The Campaign for Normal Birth was a spectacular failure on every level but that has not prompted much soul searching from prominent midwives. Indeed, the opposite has been happening; in their frustration they have been becoming, if possibly, more ideologically rigid.

In particular they’ve escalated their language, referring to obstetrical care in terms designed to vilify providers who disagree and incite the natural childbirth faithful. We’ve become used to their cries of “birth rape” that simultaneously demean survivors of actual rape, and maternity providers who are trying to save lives. The latest vulgarity is the attempt to equate vaginal exams with sexual assault.

According to doula Maddie McMahon:

Midwives shld be debating the pros and cons of routine VEs and exploring the evidence, or lack of, for regularly fossicking around in a normal labour. I’m just a woman telling you that you need a damn good reason to finger me. Just telling me I’m Xcm is not a good enough reason.

What is fingering?

Fingering is the use of fingers or hands to sexually stimulate the vulva, vagina or the anus. It may be done for sexual arousal or foreplay, mutual masturbation, or constitute the entire sexual encounter.

Why use vulgar sexual language to describe an obstetric exam?

1. To demonize maternity providers, particularly obstetricians, by equating them with sexual predators.

2. To discredit obstetrics as sexual predation.

3. To shock and gain attention.

4. To rile up natural childbirth advocates.

5. To vent frustration that women do not want what natural childbirth advocates believe they should want.

Why is so much rage directed toward a minor obstetric exam done to determine how labor is progressing?

Because checking cervical dilatation holds the same place in maternity care as taking a temperature does in general medical care. Just as taking a temperature allows a provider to find a fever and then address the problem, doing a vaginal exam allows a provider to diagnose a dysfunctional labor and then address the problem.

According to the paleo-fantasy of natural birth, women are “designed” to give birth, birth in nature is nearly always perfect and interventions in labor deface the pristine nature of “unhindered” birth. The facts are that women aren’t designed, birth in nature has high rates of perinatal and maternal mortality and unhindered birth is often a recipe for a painful death.

No matter! If you don’t take a temperature, you can’t find a fever. If you don’t do a vaginal exam you can’t diagnose labor dysfunction and if you don’t know about it you won’t do anything. Evidently doing nothing is the goal of UK midwifery care.

Which begs the question: if the entire point of UK midwifery care is to do nothing as often as possible, why have midwives?

They don’t lower the cost of care so they aren’t protecting NHS finances.

They don’t save more lives than obstetricians so they aren’t protecting babies’ and mothers’ lives.

And many women are extremely dissatisfied with the care they provide so they aren’t protecting women from psychological birth trauma.

What are they protecting?

They’re protecting birth! Never mind that is not a priority of women. It’s a priority of UK midwives and doulas and regrettably, they seem to think their priorities are the only ones that matter.

Are women receiving the information they need to make informed decisions about vaginal birth and C-sections?

This may sound dramatic, and may offend some, but speaking from the lived experience of life after forceps birth injury some days I feel I would rather have died, or my baby died, than the everyday reality of these injuries…

I feel obstetricians need to know the lived reality when forceps go wrong. First do no harm. I cannot understand how and why my body was harmed in this way as part of my medical ‘care’. I feel they should be banned then alternatives would have to be found.

After reading this women’s heartbreaking Twitter comments I created a survey to ask women about whether they received counseling about the risks childbirth injuries from vaginal birth and whether they would have benefited from that information.

[pullquote align=”right” cite=”” link=”” color=”” class=”” size=””]When women aren’t counseled on the risks of vaginal birth they are deprived of the opportunity to make informed decisions.[/pullquote]

So far 563 women have taken the survey and they indicate overwhelmingly that they did not receive the counseling to which they are entitled.

1. The most common serious longterm complication of vaginal birth is urinary incontinence. According to the recent paper Long-term risks and benefits associated with cesarean delivery for mother, baby, and subsequent pregnancies: Systematic review and meta-analysis nearly 15% of women will eventually suffer from some degree of urinary incontinence. This can be a life limiting condition yet women report that they were not counseled about the possibility.

Over 90% of women were not warned about this serious long term risk.

2. Pelvic organ prolapse is also a serious risk ultimately affecting 6% of women. Pelvic organ prolapse can cause a variety of unpleasant symptoms as the uterus, bladder or both protrude through the vaginal opening. It can be the cause of incontinence and can also profoundly impact sexual function. Nonetheless, even fewer women were counseled about this complication.

Over 95% of women recall no counseling about uterine prolapse.

3. Sexual dysfunction is both a short term and a long term complication after vaginal birth. Incontinence and pelvic organ prolapse can contribute to sexual dysfunction but a common complication is painful intercourse (dyspareunia). Accurate statistics are hard to come by and sexual dysfunction can be affected by factors unrelated to childbirth, but the evidence suggests that vaginal birth increases the risk.

Over 95% of women report that they were not counseled about the increased risk of sexual dysfunction after vaginal birth.

4. Not every woman feels the need to be informed of every possible risk, but in this case women overwhelmingly believe that they are entitled to know about the increased long term risk of urinary incontinence, prolapse and sexual dysfunction.

Over 98% of respondents would have preferred to know about these risks.

5. Would more comprehensive counseling change women’s decisions as to mode of birth? Here the results were mixed.

While 56% of women believed it would make them more inclined to choose maternal request C-section, 44% did not.

Why do so many clinicians — obstetricians and midwives — fail to provide women with the information they need to make informed decisions about mode of delivery?

I suspect it involves a variety of factors, but two seem to me to be most important.

First, women’s pain and anguish are often discounted. No one cares especially that women are suffering long term serious complications. It almost as if childbirth complications are viewed as women’s lot.

Second, there is a deeply entrenched belief that C-sections are “bad” and vaginal birth is “better.” C-sections are demonized in every possible way with some natural childbirth advocates going so far as to say that women who have babies by C-section haven’t really given birth.

Of course most women would prefer an uncomplicated vaginal birth to major abdominal surgery, but that’s not an accurate depiction of the choice women actually face. For many women the choice is between a vaginal birth with injuries and complications and a C-section which has its own risk of complications. Each women will weight the risks differently but when they aren’t being counseled on the risks of vaginal birth they are deprived of the opportunity to make informed decisions.

That’s paternalism and it is never appropriate no matter how much providers may believe otherwise.

Earlier this month I wrote about The Lancet series on reducing C-section rates that used a benchmark rate of 10-15%. This despite the fact that the World Health Organization, which made it up, acknowledges there is NO EVIDENCE to support the safety of a 10-15% rate and considerable evidence that the minimum safe C-section rate is 19%.

A recent editorial in PLoS Medicine challenges the 10-15% rate on additional grounds: it ignores the outcomes that women value most.

The authors discuss a new paper from China:

[pullquote align=”right” cite=”” link=”” color=”” class=”” size=””]Women value improved long term safety for their babies over increased short term risks to themselves.[/pullquote]

Recent high cesarean section (CS) rates around the world have sparked intense interest in the underlying drivers, partly to inform efforts to reduce CS rates. This week in PLOS Medicine, Long and colleagues report on these trends from multiple perspectives in mainland China, Taiwan, and Hong Kong … These settings—with respective CS rates of 34.9%, 27.4%, and 35%—reside near the top of the CS birth rate tables …

The prospectively registered study stands out among related work because of the meticulous efforts made to understand and contextualise how nonclinical considerations lead to plans for CS births. In addition to detailing why many CS plans are made, the authors also report a recent shift towards placing greater value on vaginal birth in studies from mainland China. The latter observation supports previously reported impressions that removal of China’s one-child policy, in addition to multiple strategies to reduce CS rates, has led to an increase in vaginal births in women who previously gave birth by CS.

Women see C-section as a safer option particularly in light of China’s previous one child policy:

Multiple women described CS as the ‘safe’ choice for birth; quotes detailed CS as a means to avoid ‘any risk’ to their baby, whether ‘immediate complications’ or ‘longer-term child-development’ issues.

Despite the World Health Organization’s insistence that vaginal birth is safer than C-section, data out of China indicates the opposite:

Utilising the combination of large population databases of birth-related events and a high CS-on-maternal-request (CDMR) rate, researchers reported outcomes of over 66,000 first births in Shanghai between 2007 and 2013. Reduced offspring birth trauma, neonatal infection, meconium aspiration syndrome, and hypoxic ischaemic encephalopathy followed CDMR, with no difference in risk of serious maternal complications when compared with a plan for vaginal birth… Overall, these findings suggests that, where women are certain of their plan to have only one child, those with similar characteristics in equivalent healthcare settings may be justified in choosing CS on safety grounds.

In other words, women value improved long term safety for their babies over increased short term risks to themselves. Of course C-section also has long term risks for the mother such as increased uterine rupture and placenta accreta in future pregnancies. But vaginal birth has long term risks to continence and sexual function that are much more common than long term risks of C-section.

Efforts to reduce C-section rates ignore women’s preferences:

The agenda to lower CS rates appears to be driven by WHO’s position statement, which cites a lack of evidence for reduction in maternal and infant mortality at the population level for CS rates above 10%–15%. However, the WHO statement does not reflect the quality-of-life outcomes that appear to be important to women … Long and colleagues’ findings demonstrate that women and clinicians in these settings who plan CS may be voting with their feet to optimise both perceived safety and quality-of-life outcomes. In the United Kingdom and Singapore, where recent person-centred legal developments mean that informed consent to give birth requires that women are informed of (1) risks she considers to be important and (2) reasonable available options, decisions for CS based upon quality-of-life outcomes appear legitimate yet highlight the gulf between WHO priorities (saving lives) and those of women and clinicians making individual birth plans…

The WHO may claim that its priority is saving lives, but to my knowledge there is NO EVIDENCE that reducing C-section rates saves lives. It is theoretically possible, of course, but we should not be setting practice guidelines on theory that isn’t confirmed by scientific study.

The authors conclude:

China is in a strong position to use its high CDMR rates and its population-based birth registries to support studies of birth outcomes beyond mortality and to engage with women to identify outcomes that are important to them. Such a truly woman-centred approach would facilitate birth choices being made in the full knowledge of the balance of risks and benefits.

In contrast, aggressive efforts to reduce C-section rates are the opposite of a woman-centered approach that facilitates birth choices made with thorough information about risks AND benefits and taking into account quality of life outcomes that women value.

Yesterday I came across a heartbreaking comment from a woman suffering from the long term risks of vaginal birth:

This may sound dramatic, and may offend some, but speaking from the lived experience of life after forceps birth injury some days I feel I would rather have died, or my baby died, than the everyday reality of these injuries.

She continued:

I feel obstetricians need to know the lived reality when forceps go wrong. First do no harm. I cannot understand how and why my body was harmed in this way as part of my medical ‘care’. I feel they should be banned then alternatives would have to be found.

She must be miserable to feel this way and her injuries did not have to occur or at least did not have to be this severe. Had she been counseled about the risks and offered a choice between forceps and C-section, she might have chosen C-section and avoided this outcome.

Incontinence and sexual dysfunction are severe consequences that threaten quality of life for many woman. We would never recommend prostate cancer treatment to a man without warning of risks to future continence & sexual function. Yet women are routinely counseled about childbirth without mention of future continence and sexual function and they aren’t counseled about the further increase in risk posed by forceps. That’s unethical!

I created the following survey to find just how many or how few women are counseled about the long term risks to continence and sexual function as a result of vaginal birth. I would be grateful for your parcipation. I will share the results when the survey is ended.

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