Serena Williams holds many wonderful statistical records in tennis, but recently she nearly became a tragic maternal mortality statistic. Her experience further illuminates the shape of the maternal mortality problem.

Maternal mortality is disproportionately a problem of black women with pre-existing health conditions. All too often it involves poor medical care, specifically assuming pregnancy complications are rare when they are common. In Williams case, she literally had to save her own life.

[pullquote align=”right” cite=”” link=”” color=”” class=”” size=””]Serena Williams literally had to save her own life.[/pullquote]

According to Vogue Magazine:

Though she had an enviably easy pregnancy, what followed was the greatest medical ordeal of a life that has been punctuated by them. Olympia was born by emergency C-section after her heart rate dove dangerously low during contractions…

The next day, while recovering in the hospital, Serena suddenly felt short of breath. Because of her history of blood clots, and because she was off her daily anticoagulant regimen due to the recent surgery, she immediately assumed she was having another pulmonary embolism.

Williams had a history of a near fatal pulmonary embolism. A blood clot that developed in her leg traveled to her lungs and almost killed her. The problem was so serious and the risk of recurrence (and death) was so high that Williams needed to take anticoagulants daily. This is a major isue in and of itself but is further exacerbated by pregnancy which always increases the risk of blood clots above a woman’s pre-pregnancy risk.

A history of pulmonary embolus requires specialized management in pregnancy. The best daily anti-coagulant, coumadin (warfarin) is teratogenetic. Pregnant women must be switch to an anti-coagulant compatible with pregnancy, typically injectible heparin. The anti-coagulant must be carefully dosed during the last weeks of pregnancy and suspended altogether during labor in order to prevent excessive bleeding at the time of birth; the risk of excessive bleeding is even higher if a C-section is needed.

In the immediate aftermath of birth, the risk of blood clots remains very high so anticoagulants must be restarted within 6-12 hours after vaginal birth and between 12-24 hours after a C-section. While anticoagulants are suspended, the mother is extremely vulnerable and should be monitored closely.

Instead, Williams had to diagnose her own life threatening complication and then convince the nurse of its seriousness.

She walked out of the hospital room so her mother wouldn’t worry and told the nearest nurse, between gasps, that she needed a CT scan with contrast and IV heparin (a blood thinner) right away. The nurse thought her pain medicine might be making her confused.

The nurse thought the pain medication might be making her confused? Did the nurse have any idea of the risks to this particular patient? Apparently not. Instead, like all too many people who care for pregnant and postpartum women she assumed that everything was fine.

But Serena insisted, and soon enough a doctor was performing an ultrasound of her legs. “I was like, a Doppler? I told you, I need a CT scan and a heparin drip,” she remembers telling the team. The ultrasound revealed nothing, so they sent her for the CT, and sure enough, several small blood clots had settled in her lungs. Minutes later she was on the drip. “I was like, listen to Dr. Williams!”

Williams was absolutely correct. She needed an immediate CT scan (the appropriate diagnostic test for a pulmonary embolus) and IV heparin. Instead she was subjected to a useless screening test that wasted precious time. There is no excuse for the delay in her treatment.

But this was just the first chapter of a six-day drama. Her fresh C-section wound popped open from the intense coughing spells caused by the pulmonary embolism, and when she returned to surgery, they found that a large hematoma had flooded her abdomen, the result of a medical catch-22 in which the potentially lifesaving blood thinner caused hemorrhaging at the site of her C-section. She returned yet again to the OR to have a filter inserted into a major vein, in order to prevent more clots from dislodging and traveling into her lungs.

These were unfortunate complications that could have been predicted, but almost certainly could not have been prevented. Preventing a pulmonary embolus took priority over everything including bleeding into her incision. You can replace blood loss, but it is almost impossible to save someone from a massive pulmonary embolus. The decision to place a filter into her inferior vena cava was the appropriate response. It’s an invasive procedure but it prevents blood clots from traveling to the lungs and eliminates the need for any anti-coagulation.

Williams’ near death experience highlights the failure of our healthcare system in preventing maternal mortality. We know who is at risk and we know how to minimize that risk, yet in practice we ignore those risks, fail to employ the interventions that are needed, and falsely reassure women when they tell us they are ill.

The true scandal here is not that Williams nearly died; that was foreseeable. The scandal is that Williams had to save her own life; that’s inexcusable!

Volvos are widely recognized as the safest cars on the road.

The National Highway Traffic Safety Administration announced today [June 7. 2017] that Volvo Cars will receive an award for its continued focus on safety. Of course, Volvo changed the car industry—and essentially invented the concept of highway safety—in 1959 when it released a patent for the three-point seatbelt to other automotive companies…

The NHTSA agrees that Volvo is the leading company in automotive safety technologies, as it looks for the most cutting-edge safety systems and holds its cars to the highest standard of protection. To do this, Volvo needs the most adept safety consultants to help build cars that will keep its drivers in one piece and significantly decrease fatalities on the road. The NHTSA has found these qualities in Magdalena Lindman and Per Lenhoff, both high-ranking members of the Volvo Cars Safety Centre. They developed many of the challenges in Volvo’s rigorous safety testing program, analyzing countless real-life accidents and simulating them to prepare each new Volvo for any dangerous situation.

For most parents, the welfare of their babies is paramount; therefore Volvos, as the safest cars, are optimal for babies. Any mother who doesn’t drive a Volvo is a sub-optimal parent, right? She is obviously too lazy and self-absorbed to put her child’s wellbeing first.

[pullquote align=”right” cite=”” link=”” color=”” class=”” size=””]A good mother drives a Volvo; breastfeeding is not enough.[/pullquote]

Wait, what? You disagree? But it’s not a matter of opinion; it’s SCIENCE. Science shows — both in the lab and on the road — that Volvos have the most advanced safety features and the best safety records. Disagreeing that Volvos are optimal is an effort to compensate for your sense of inferiority from your failure to provide your child with the very best.

You use the safest possible car seat? Are we supposed to be impressed by that? Let’s face it, safe car seats are the bare minimum; “Volvos are Best.”

You worry that if you bought a Volvo, you couldn’t afford your mortgage or food for your older children? Get your priorities in order. There is NOTHING more important than providing your baby with optimal transportation.

You feel guilty that you didn’t buy a Volvo? Sorry, but your guilt is not a reason to deny the truth. It is more important to protect babies lives than to protect your feelings.

You feel bad that you can’t afford a Volvo? Good! You should feel bad. How dare you have children if you don’t intend to buy the optimal car?

Wait, what? You think there is more to raising children than the car your drive? What’s more important than whether your infant lives or dies?

You think your own needs and priorities matter? Get a grip. Only selfish mothers consider their own needs.

How do Volvos compare with breastfeeding? Car accidents are a major cause of infant mortality. Safer cars save lives. Breastfeeding is not nearly so important. The benefits of breastfeeding in industrialized countries are trivial, limited to 8% fewer colds and episodes of diarrheal illness across the entire population of infants in the first year. In other words, the majority of infants will experience NO benefit from breastfeeding.

How dare a women gloat that she is breastfeeding and therefore providing her infants with optimal nutrition if she doesn’t drive a Volvo to provide her infant with optimal transportation?

A good mother drives a Volvo; breastfeeding is not enough.

The folks at VBACFacts are shocked, shocked that breech vaginal birth is discouraged.

It’s time to summon all that passion you have for patient autonomy and take some action!

Let’s support Dr. Annette Fineberg and flood this hospital with letters!

The following is copied from a fellow birth advocate in California:

“I’m so sad right now. Like in tears.

Dr. Annette Fineberg at Sutter Davis is being pressured to stop supporting vaginal breeches. She’s by far our best option around.

She’s asking for our help collecting stories to convince the administrators to continue to allow her to openly offer this option. This is huge! …

Dr. Fineberg is one of very few OBs within driving distance of the Bay Area skilled in breech birth. She’s also the only ‘local’ OB breech expert who actively supports/encourages people with breech babies to birth in non-lithotomy positions and labor in the tub prior to stage two — and she is the only one who doesn’t pressure them to get epidurals.

According to Dr. Fineberg:

[pullquote align=”right” cite=”” link=”” color=”” class=”” size=””]The death rate from vaginal breech is more than 1000% higher than the death rate from SIDS.[/pullquote]

I am getting a lot of pressure to stop attending breech and despite my best efforts to get privileges at a tertiary care hospital with neonatology, it is not happening.

Why is Dr.Fineberg being “pressured”? Because breech deaths are vanishing and no one wants to bring them back.

What’s the death rate from vaginal breech. It is approximately 6/1000. That sounds like a small number, too small to be concerning, right? Not exactly. The death rate from vaginal breech is more than 1000% higher than the death rate from SIDS. It doesn’t sound like a trivial risk of death when you put it like that, does it?

We have spent literally millions of dollars trying to change the habits of parents and caregivers in order to prevent SIDS deaths. We’ve heavily promoted a regimen of putting babies to sleep on their backs even though that does not happen in nature, leads to poorer quality sleep, and has created an epidemic (200,000 cases per year) of tiny babies wearing tiny helmets to correct iatrogenic plagiocephaly (flat head syndrome).

We think that’s entirely appropriate in order to prevent deaths from SIDS that occur at the rate of 0.54/1000 babies. Doesn’t it make sense that we would want to prevent the much greater (6/1000) risk of death from breech birth?

There’s even greater urgency for hospitals and malpractice insurers to prevent death from breech birth. When a baby dies fo SIDS because a parent or caregiver put the baby to sleep face down, there may be recriminations but there is generally no one to be sued. In contrast when a baby dies as a result of attempted breech birth, there’s always someone or several someones with deep pockets (including neonatologists and others who had nothing to do with the decision) who can be sued.

While parents might not sue for a baby who dies, they will almost certainly sue for a baby who sustains severe brain damage because the costs of caring for such children are astronomical. No matter how much the mother avers that she understands the risk, no matter how many consent forms she signs, she will insist in her lawsuit that she didn’t understand that it could happen to her baby and she certainly didn’t understand the aftermath of caring for a severely disabled child. When hospitals prohibit breech vaginal births, they aren’t merely protecting babies; they are protecting themselves and their staff.

Does a mother have a right to have a breech vaginal birth? Of course she does, just like she has the right to lay her baby face down to sleep. Neither is illegal and both are fully within the purview of autonomous adults. But that doesn’t mean she has a right to force hospitals and doctors to attend her while she attempts that breech vaginal birth just like it doesn’t mean that she has the right to force daycare centers to put her baby to sleep facedown.

If you met a mother who proudly told you that she ignores the “back to sleep” recommendation because the risk of SIDS is tiny, would you be impressed? Would you consider her a brave, transgressive proponent of maternal autonomy or would you be horrified that she was willing to risk her baby’s life? I suspect that most people would be horrified.

So why would anyone be impressed with a mother who wished to to expose her baby to a 1000% times greater risk of death at vaginal birth? Breech deaths are vanishing; why would anyone want to bring them back?

One of the greatest ironies of the anti-vaccine movement is that its proponents imagine themselves to be deep, incisive thinkers when they are the exact opposite. Their beliefs reflect immature cognitive errors and a spectacular failure of critical thinking.

There are a lot of different definitions of critical thinking, including:

[Critical thinking is] thinking about one’s thinking in a manner designed to organize and clarify, raise the efficiency of, and recognize errors and biases in one’s own thinking.

[perfectpullquote align=”right” cite=”” link=”” color=”” class=”” size=””]Anti-vaxxers never ask themselves what they DON’T know.[/perfectpullquote]

Critical thinking is often contrasted with traditional education techniques like lectures and memorization. Whereas lectures and memorization result in students who remember the important dates of the Revolutionary War, for example, critical thinking leads to students who understand why the war happened.

In my view there are four pillars to critical thinking and those pillars can be expressed as self-directed questions.

1. What do I know?

2. How do I know it?

3. What don’t I know?

4. How can I learn it?

What do I know?

Both critical thinkers and uncritical thinkers like anti-vaxxers are clear on what they know. The differences are encompassed by answers to the other three questions.

How do I know what I know?

For uncritical thinkers like anti-vaxxers, the answer is simple and concise. They “know” that vaccines are harmful because someone else told them so. They like to dress it up in their own minds by insisting that they “did their research,” but what they really mean is that they ignored experts and chose to believe random people on the internet.

Anti-vaxxers have never seen the inside of a laboratory or a medical library, the places where real medical research occurs. Most have never read a single scientific paper beyond the abstract and wouldn’t understand one if they did. They lack basic knowledge of immunology, statistics and the scientific method. They have the cognitive maturity of a four year old who imagines that addition and subtraction reflect the sum total of knowledge in mathematics. They are so limited in their understanding of science that they don’t even understand their limitations.

Anti-vaxxers imagine themselves as bold thinkers because they reject the assertions of experts without realizing that reflexively rejecting experts is the same as reflexively embracing them. Neither involves thinking; both are responses to authority.

In contrast, critical thinkers know what they know by reading authoritative texts and scientific literature. In addition to reading expert literature that confirms their beliefs, they are fully conversant with the scientific literature that questions their beliefs or contradicts them.

The breadth of knowledge of vaccine experts exceeds that of anti-vaxxers by orders of magnitude.

What don’t I know?

This is where the rubber hits the road in critical thinking. Critical thinkers always ask themselves what they don’t know, recognizing that gaps in knowledge can lead to faulty reasoning.

Anti-vaxxers never ask themselves what they don’t know. Their cognitive immaturity (and their vanity) leads them to imagine that they know everything worth knowing.

That cognitive immaturity is reflected in their style of argument, best captured by the phrase: “but what about?”. They parachute on to skeptic blogs and Facebook pages and offer what they believe to be devastating rejoinders: “But what about this out of date paper?” “But what about the blathering of this anti-vaxxer who once taught an extension course at Harvard?” “But what about the fact that cases of this disease dropped between epidemics before the existence of vaccines?”

They lack the critical thinking skills to answer their own questions. Since they have no understanding of the scientific method, they can’t appreciate that a single, out of date paper is meaningless; only the breadth of the entire literature matters. Since they are incapable of reading that literature, they have no idea what their preferred paper actually shows; they only know what some other anti-vaxxers told them it shows. They don’t even know if the paper was contradicted by subsequent research or even retracted due to violating principles of scientific reporting. Since they have no understanding of statistics they are ignorant of the fact that disease incidence can fall from one year to the next without it being evidence that the disease is disappearing. And although they claim to reject arguments from authority they are quick to embrace arguments from anti-vax celebrities.

How can I learn what I don’t know?

Anti-vaxxers don’t know what they don’t know so they are unlikely to ask themselves this question spontaneously. However, as soon as they engage with people who know a great deal more (which is nearly everyone who has professional education and training), they become aware that there’s lots they don’t know.

Critical thinkers will attempt to remedy their deficits. They will do background research in science and statistics; they will review the entire literature; they will seek out help reading and interpreting scientific papers. Anti-vaxxers, who are cognitively immature, will respond immaturely — accusing anyone who knows more of being a shill for the pharmaceutical industry. It’s the intellectual equivalent of calling your opponent a poopy-head.

Anti-vaccine advocacy reflects a spectacular failure of critical thinking because it is missing one of the pillars: interrogating oneself to determine what you don’t know, not merely what you do know. Anti-vaxxers flatter themselves by imagining that they are engaged in deep thinking when they haven’t been thinking at all, just dumbly imbibing, believing and repeating nonsense from other equally ignorant fools.

Raw water. It’s the latest health craze, and no, I’m not making it up.

According to the Washington Post:

Hold your canteen under a natural spring and you’ll come away with crystal clear water, potentially brimming with beneficial bacteria as well as minerals from the earth.

That’s what proponents of the “raw water” movement are banking on: selling people on the idea of drinking water that contains the things they say nature intended without the chemicals, such as chlorine, often used in urban water treatment processes.

In some areas of the country, including the West Coast, it has become a high-dollar commodity — water captured in glass bottles and sold straight to you.

“Naturally probiotic. Perfected by nature,” boasts Live Water, which sells raw water sourced from Oregon’s Opal Spring.

It signals a rise of what I call “raw stupidity,” to distinguish it from highly processed stupidity.

[pullquote align=”right” cite=”” link=”” color=”” class=”” size=””]Raw stupidity arises spontaneously from deeply held, nonsensical beliefs.[/pullquote]

What’s the difference?

Highly processed stupidity does not arise spontaneously but requires technology for propagation. Anti-vax is the classic example; indeed it’s the stupidity equivalent of Cheetos. The anti-vax movement has existed for more than 200 years, but it didn’t really take off until the advent of computers, Wi-Fi and Facebook.

No one wakes up one morning and says, “I think vaccines, which I know absolutely nothing about, lead to unusual diseases, which I also know absolutely nothing about.” Most anti-vaxxers adopt views they have acquired from proselytizing of other, equally ignorant anti-vaxxers. The primary mode of transmission is through websites and Facebook groups.

Moreover, highly processed stupidity seeks to claim the mantle of science and technology by invoking the copy-paste skills of its advocates who faithfully reproduce long lists of scientific citations that they have never read and wouldn’t understand if they did read. Andrew Wakefield is its avatar, a “scientist” who faked his science for profit and lost his medical license as a result.

The raw water craze, in contrast, is raw stupidity. Like most raw stupidity, it arises spontaneously from two deeply held nonsensical beliefs:

1. If it’s natural, it must be good.
2. It’s true if I can see it with my unaided eyes.

Everyone knows that nature is benevolent, that lions lie down with lambs, that the population of the earth used to be much larger and decreased steadily with the advent of technology, and that health is all about eating as nature intended.

The paradigmatic example of raw stupidity is flat eartherism. Obviously the earth is flat because it looks flat. Obviously the earth can’t be round because the people in Australia would fall off.

The belief in the beneficial properties of raw water is similar. It couldn’t possibly be more natural than bubbling up direct from the ground, right? It’s clear; you can’t see any bacteria or parasites so there aren’t any bacteria or parasites. So what if large animals or even people defecate nearby? Everyone knows that feces contains only beneficial bacteria because it comes directly from inside all natural fauna.

In addition to raw stupidity and highly processed stupidity, there’s an amalgamation involving both.

Consider the wisdom of Kelly Brogan, MD holistic psychiatrist. What’s a holistic psychiatrist? It’s a pro-wrestler of healthcare, a fraud who profits from the gullible.

Goodbye to germ theory! Can we really maintain the childish illusion that there are a handful of identified “bad germs” out there trying to kill us?

Brogan is obviously invoking raw stupidity: we can’t see bacteria and even if we could they would be beneficial because they are natural. On the other hand, Brogan transmits her stupidity almost exclusively through technology and invokes the imprimatur of science by constantly alluding to her medical degree. It’s the clever combination of both raw stupidity and the highly processed stupidity of someone like Andrew Wakefield that makes her particularly dangerous.

It’s hard to know what to do about either raw stupidity or highly processed stupidity. As Einstein supposedly said:

Only two things are infinite, the universe and human stupidity, and I’m not sure about the former.

Perhaps we should just take the natural approach and let only the fittest survive. Those who are stupid enough to buy raw water or believe a quack like Kelly Brogan are swimming in the shallow end of the gene pool as it is. Unfortunately, there’s no drug to treat stupidity; sadly, we’re limited to hoping it will burn itself out.

Every maternal death is an extraordinary tragedy, but Erica Garner’s death seems particularly bitter in its irony.

According to NPR:

She entered the public eye in July 2014 when her father, Eric Garner, died after being put in a chokehold by a New York City police officer. Eric Garner was seen on video saying, “I can’t breathe” 11 times before he died.

Why did Erica Garner die? She died because she couldn’t breathe.

[pullquote align=”right” cite=”” link=”” color=”” class=”” size=””]She died because she couldn’t breathe.[/pullquote]

Erica Garner had been in a coma since Dec. 23, when she had an asthma attack that triggered a heart attack, according to the New York Daily News.

“When her son was born in August, she named her newborn after her father,” the newspaper reports. “Garner suffered her first heart attack shortly after the delivery, with doctors saying the pregnancy stressed her already enlarged heart.”

Eric Garner became an icon in the Black Lives Matter movement. Now Erica Garner appears destined to become a icon in the effort to reduce black maternal mortality. In many ways, she is emblematic of the current crisis of black maternal mortality.

Prior to 1999, Erica Garner’s death would not have been included in maternal mortality statistics for two reasons. First, occurring as it did four months after the birth of her son, it would have been considered a “late” maternal death; US mortality statistics which included deaths up to 42 days after delivery. Second, Garner did not die of a pregnancy complication but of pre-existing diseases (heart disease and asthma). Indeed, researchers have found that anywhere from 75-100% of the recently reported increase in US maternal mortality is the result of expanding the classification of maternal deaths.

Erica Garner’s death is emblematic of US maternal deaths in several other ways. She was black and black women die at 3X the rate of other American women.

She appears to have had pre-existing heart disease (an “enlarged” heart). Heart disease is the leading cause (and fastest growing cause) of maternal mortality in the US. What causes an enlarged heart and how did it contribute to Garner’s death?

An enlarged heart can reflect a dilatation of the chambers of the heart (dilated cardiomyopathy) or an increase in the size of the heart muscle (hypertrophic cardiomyopathy).

According to the American Heart Association:

Dilated cardiomyopathy (DCM) is the most common type, occurring mostly in adults 20 to 60. It affects the heart’s ventricles and atria, the lower and upper chambers of the heart, respectively.

Frequently the disease starts in the left ventricle, the heart’s main pumping chamber. The heart muscle begins to dilate, meaning it stretches and becomes thinner. Consequently, the inside of the chamber enlarges. The problem often spreads to the right ventricle and then to the atria.

As the heart chambers dilate, the heart muscle doesn’t contract normally and cannot pump blood very well…

Often, cause of dilated cardiomyopathy isn’t known. Up to one-third of the people of those who have it inherit it from their parents.

Some diseases, conditions and substances also can cause the disease, such as:
Coronary heart disease, heart attack, high blood pressure, diabetes …
Complications during the last month of pregnancy or within 5 months of birth

Dilated cardiomyopathy that develops at the end of pregnancy or within 5 months postpartum is known as peripartum cardiomyopathy.

Alternatively, an enlarged heart can be a pre-existing condition that occurred independent of pregnancy.

Hypertrophic cardiomyopathy (HCM) is very common and can affect people of any age. It affects men and women equally. It is a common cause of sudden cardiac arrest in young people, including young athletes…

Hypertrophic cardiomyopathy occurs if heart muscle cells enlarge and cause the walls of the ventricles (usually the left ventricle) to thickenHypertrophic cardiomyopathy usually is inherited. It’s caused by a change in some of the genes in heart muscle proteins. HCM also can develop over time because of high blood pressure or aging. Diseases such as diabetes or thyroid disease can cause hypertrophic cardiomyopathy. However, the cause of the disease isn’t known.

Peripartum cardiomyopathy usually leads to heart failure (inability of the heart to pump effectively) and not a heart attack (myocardial infarction or MI). Hypertrophic cardiomyopathy can lead to an MI when the enlarged heart’s increased need for oxygen can’t be met by the ineffectively beating heart. Of course it is impossible to know what happened to Garner simply based on news reports since mainstream media sources tend to use terms like heart attack, heart failure and cardiac arrest interchangeably even though they mean very different things.

The proximate cause of Garner’s death was not pregnancy or cardiovascular disease, but asthma. Pre-existing chronic health conditions like asthma are the second leading cause of US maternal deaths.`A severe asthma attack leads to a decrease in oxygen because the patient literally cannot breathe. Garner’s heart was already compromised twice over, first by the enlargement and then by any damage sustained as a result of the heart attack that occurred in the days after her baby’s birth. It seems as though her heart simply could not tolerate any additional damage and she suffered a cardiac arrest. Although she was resuscitated at a hospital, she had sustained severe brain damage and died as a result.

Erica Garner could be the face of American maternal mortality. She was black; her death took place months after delivery; she suffered from heart disease and asthma and they combined to kill her.

Is her death emblematic of systemic racism? That’s difficult to say. So far there have been no accusations of poor medical care. She died of the diseases that probably existed prior to her pregnancy. It may be impossible to determine if racism was a factor in the development of those diseases.

A mother puts Mountain Dew in her baby’s bottles, by age 2 the child is suffering massive tooth decay. Who’s to blame?

Most of us would have no qualms about blaming the mother who put the soda in the baby’s bottles. The mother did not intend that the child’s teeth should rot, but she bears responsibility nonetheless.

[pullquote align=”right” cite=”” link=”” color=”” class=”” size=””]There’s nothing beautiful about the preventable death of a baby.[/pullquote]

A mother fails to put her toddler in a car seat for a trip to the grocery store. Along the way the car is hit by another driver, the baby is ejected through the windshield and dies on the pavement. Who’s to blame?

Most of us would have no qualms about blaming the mother who failed to put the child in a car seat. The mother did not intend for the toddler to die, but she bears responsibility nonetheless.

A mother decides to give birth outside the hospital despite having a history of two previous C-sections. Her uterus ruptures during labor and the baby dies. Who’s to blame?

According to homebirth advocates: no one.

Terall was hoping to have a natural birth since both of her sons were c-section births and extremely hard on her body. Terall did the research and found the perfect Birthing Center for her. They respected her birthing plan and she was confident in the facility… On her due date, 12/28, she went into labor at the center. Her contractions became more severe. In the midst of a contraction Terall felt a huge burst in her stomach…there was an excruciating pain that never went away…almost like a constant contraction. Something was severely wrong.

…[W]hen the midwife checked their son’s heartbeat there was none to be found. Terall was rushed by ambulance to the closest hospital…but it was too late. Terall’s uterus ruptured due to scars from her previous c-sections and dislodged the baby and the placenta causing their son to lose oxygen and blood flow. Terall was rushed into the operating room to stop her internal bleeding…

Who’s to blame?

The mother feels guilty:

…She said “I am so sorry. I thought I was making the right choice, I thought having you naturally in a tub, without drugs would be best. I wanted you to hear beautiful music when you entered this world. I didn’t know, sweetie….

But instead of accepting responsibility for choosing to attempt a VBAC outside of a hospital, she  blames those who performed her previous C-sections:

I didn’t know that having c sections with your brothers would come back to haunt me and ultimately kill you. I didn’t know my scar tissue was going to rupture and force you out of my womb…. Mommy didn’t know… I didn’t know. I will always love you my perfect boy. I am grateful for Love Song, Memories fade and this…these photographs will be all I will ever have of my baby.”

From the comments:

You are not to blame; it wasn’t something that you saw coming!!

And:

This was NOT your fault, it wasn’t because you choose vbac. You choose the option you thought wss safest and had the lowest risks. Please do not blame yourself for doing what you thought was best.

And:

Please do not allow the enemy to to fill your mind with lies. This is not your fault.

I shared the story on my Facebook page under the comment “Another baby who didn’t have to die” and got this in response:

Your … a piece of shit for taking this beautiful sad story and turning it into propaganda. Things happen. I feel terrible for the loss of this family. But, this ob is a shitty person who needs to have her license revoked vbac is common it has its risks just like any birth. I fully plan on vbac with my next.

There’s nothing beautiful about the preventable death of a baby whether that death occurs at homebirth or when a child is ejected through the windshield during an accident. I suspect that the same people who are counseling this mother not to blame herself because she “didn’t see it coming,” would not be so sanguine about the dead child ejected through the windshield. Obviously that mother didn’t see that coming either, but that would not have absolved her of blame.

What does it mean to blame someone for a bad health outcome?

A 2015 paper, Who can blame who for what and how in responsibility for health?, attempts to answer the question.

The concept of personal responsibility for health forms part of the political and philosophical landscape of professional health care, and yet it is poorly understood. Responsibility can be presented as a tripartite concept consisting of (1) a moral agent having (2) responsibilities understood as obligations and (3) being held responsible for them, that is being blamed in failing to meet them.

In the case of the child with rotten teeth, we believe that her mother is a moral agent who shirked the obligation of protecting the child’s teeth by putting Mountain Dew in baby bottles and should be held responsible for the massive tooth decay.

In the case of baby who died on the pavement, we believe that his mother is a moral agent who ignore her obligation of protecting the child by putting him in a car seat and should be held responsible in part for the child’s death.

What’s supposedly different about homebirth?

It can’t be that homebirth supporters believe that the mother is not a moral agent. And it can’t be because they believe the mother has no moral obligation to consider the baby’s survival; these are the same folks who experience spasms of indignation over women who don’t attend assiduously to prenatal nutrition.

It can’t be the fact that the mother never anticipated the outcome. The mother who failed to put her baby in a car seat for a trip to the grocery store never anticipated that she would be involved in an auto accident along the way.

The problem seems to occur for homebirth advocates in connecting the failure to meet obligation to responsibility for the outcome. Yes, the mother had an obligation to consider injury or death of the baby as a consequence of her choice, but, uniquely in this situation, we aren’t supposed to blame her for ignoring that obligation.

But the attempt to assert that the mother is not responsible when a baby dies at homebirth is deeply undercut by the notion that she deserves praise if the VBAC attempt is successful and the baby survives. Praise is the flip side of blame. In order for someone to be eligible for praise in the healthcare setting, they must be acknowledged to be moral agents with healthcare obligations that they have fulfilled. Therefore, they must be eligible for blame when they fail to fulfill those same obligations.

So who’s to blame when a baby dies at homebirth? The mother is to blame … no matter how desperately homebirth advocates wish to pretend otherwise.

What if in response to a famine in Sub-Saharan Africa, an international aid organization sent sterling silverware?

When questioned, the organization replied that most wealthy Americans don’t eat with plastic utensils and prefer sterling, so why shouldn’t the poor have what the wealthy have?

[pullquote align=”right” cite=”” link=”” color=”” class=”” size=””]It’s soft bigotry to imagine that what dying black women need is what wealthy white women want.[/pullquote]

Outrageous, right? The quality of the utensils makes no difference when people are starving. They desperately need food, utensils be damned. It’s a form of soft bigotry to imagine that what starving black Africans need is what wealthy white Americans want.

It’s the same form of soft bigotry that animates the obsession with C-section rates and breastfeeding rates. The biggest problem in contemporary obstetrics today, in the US as well as around the world, is that women and babies who need high tech care are dying due to lack of it. To obsess about C-section rates and breastfeeding rates among those starving for high tech care is every bit as ugly as obsessing about flatware for those starving for food.

This thread pontificating on intervention rates by Dr. Neel Shah is an example of the ugly obsession.

British physician Matthew Fenech wrote to Shah:

Agree with a lot of what Neel is writing, especially relative lack of attn paid to postpartum period. But assertion that HCPs “cause harm by intervening too much, too soon” is entirely unsubstantiated, & adds to the toxic ‘anti-medical’ feeling that sadly colours this discussion.

I could have written that tweet. Indeed, I have been writing to and about Dr. Shah in the same vein for years. He’s decided to ignore me; I don’t blame him. When you don’t have the evidence to argue with someone, it is better to ignore them and he lacks the evidence to argue with me.

He’s still responding to Dr. Fenech, however.

He writes:

1/ There IS a toxic “anti-medical” faction in the public debate to improve childbirth…they are wrong. Medicine saves lives.
But there’s an equally toxic faction that lacks the humility to recognize the limits & pitfalls of medicine–even in the face of overwhelming evidence:

He continues with this:

2/ To my colleagues who do not believe mothers are harmed when medical intervention is used “too much too soon,” start with global picture. No country on earth sees benefit to c-section rates above about 19%
(note long tail, indicating countries > 50%) https://jamanetwork.com/journals/jama/fullarticle/2473490

But that’s not what the accompanying graph show (it’s labeled neonatal mortality but the one for maternal mortality is similar). Indeed it shows the OPPOSITE. Extraordinarily high C-section rates are perfectly compatible with low maternal and neonatal mortality rates. For example, Italy, which has a C-section rate over 40% has some of the lowest maternal and neonatal mortality rates in the world.

Shah’s thread ends with this:

8/ @MattFenech83 not alone in view that harm from too much is “unsubstantiated”
I look forward to debating Baha Sibai at 2018 @ACOG_AM & making the case: increasing vaginal deliveries globally will improve safety + long-term health of our mothers & babies annualmeeting.acog.org/wp-content/upl…

Increasing vaginal deliveries globally is as likely to improve safety and long term health as sending sterling silver utensils to famine areas and for the exact same reason. It responds to the desperate need of a suffering group by sending NOT what the suffering need, but what the privileged want.

Consider the United States. We are and have always been in the midst of a crisis of black maternal and neonatal mortality. Medically complex black women and their babies are dying for lack of access to high risk obstetric and neonatal care. The leading causes of death for pregnant women are cardiac disease and chronic pre-existing diseases; the leading causes of death for newborns are prematurity and congenital anomalies.

What do they need? They need greater access to high tech care, more perinatologists, obstetric ICUs, extra monitoring and extra training for health professionals in managing complications.

What are we offering them? Efforts to lower the C-section rate and extremely aggressive efforts to promote breastfeeding. How will lowering the C-section rate improve outcomes for black women dying of cardiac disease and chronic pre-existing disease? It won’t. How will increasing breastfeeding rates improve outcomes for black babies dying of prematurity and congenital anomalies? It won’t.

This recent article in the Washington Post, aptly titled A pregnant woman went to the ‘hospital from hell’ short of breath. Six hours later, she was dead, illustrates the problem.

Somesha Ayobo weighed 520 pounds and had been diagnosed with pre-eclampsia.

After Ayobo arrived at UMC, the medical staff quickly confirmed that her breathing trouble was severe, according to Health Department records. The amount of oxygen in her blood was just 61 percent of normal levels: She and her baby were effectively suffocating.

Ayobo, whom the records do not name but refer to as “Patient #90,” was given oxygen that restored her blood to normal levels…

Then she languished in the ER for 6 hours until she had a cardiac arrest.

…[S]he was rushed to the main operating room in a last-ditch effort to save her baby.

Once there, the medical staff realized they did not have appropriate equipment for neonatal care, according to the report. They again moved Ayobo, this time to the labor and delivery unit’s operating room, on a different floor.

The result:

Ayobo was dead. Her death certificate, reviewed by The Post, lists four possible causes, a catalogue of overlapping debilities that in some combination killed her: cardiopulmonary arrest, hypoxia, pulmonary edema and morbid obesity.

Phoenix lay with tubes snaking from her tiny body in the hospital’s neonatal intensive care unit. She was transferred that night to Children’s National Medical Center in Northwest Washington.

The baby died several days later.

Ayobo and her daughter died preventable deaths because they didn’t receive the high tech care that they needed; indeed it appears that they received virtually no care at all for 6 hours.

Don’t get me wrong. I’m not arguing that there are no iatrogenic complications to C-sections and I’m not arguing that a 32% C-section rate is necessary. I find such a high rate difficult to understand since I had a C-section rate of 16% when I practiced obstetrics. My point is that high C-section rates and low breastfeeding rates don’t kill very many (if any) mothers and babies while literally hundreds of women and thousands of babies are dying in the US due to lack of high tech care.

It is immoral to focus on the lowering the C-section rate or raising the breastfeeding rate — obsessions of privileged, white natural childbirth advocates — instead of focusing on preventing the deaths of black mothers and babies. It’s the soft bigotry of imaging that what white women want is what black women need. Like sending sterling silverware to the starving, it’s grotesque.

Nothing demonstrates the incredible privilege and mind boggling self-absorption of Western, white natural childbirth advocates than the belief that giving birth at home is an accomplishment.

The (undoubtedly privileged) folks at Sammiches & Psych Meds credulously report this mother’s unassisted homebirth, This Home Birth Story Proves Just How F**king Strong Moms Are:

[pullquote align=”right” cite=”” link=”” color=”” class=”” size=””]Women like Marissa who have homebirths are not f**king strong, they’re just f**king privileged and they dont’ even have the decency to acknowledge it.[/pullquote]

In the photo, Marissa looks gorgeous – you would never guess she just endured a 36-hour, drug-free labor …

Then what? When the magic moment was upon them, Marissa trusted her body and let it do the pushing as she sat on the toilet after attempting to remain in bed and couldn’t because it “felt too ‘unnatural.’” The head descended and as she felt that uncomfortable ‘ring of fire’ feeling, she stood up, held onto a towel rack and delivered her baby.

Marissa boasts:

“I’ve never felt so powerful and accomplished in my entire life. Our bodies are truly amazing!!” Ain’t that the damn truth!

No, it’s not the truth; it is so selfish and clueless as to be ugly.

Why isn’t birth an accomplishment for the hundreds of thousands of women do the exact same thing every day, or die trying as in the image above from Afghanistan? Those are black women, brown women, poor women. They have no choice but to labor in excruciating pain at home without possibility of relief and die in agony if the baby doesn’t fit, or bleed to death from massive hemorrhage, or suffocate, racked by the seizures of eclampsia. Just how f**king strong are they?

According to NATO of Canada:

Afghanistan has the highest infant mortality rate in the world with 117.23 deaths per 1 000 live births! The maternal mortality rate is the 22nd highest in the world with 460 deaths per 100 000 live births. This is certainly an improvement from 1 400 deaths per 100 000 live births in 2008 when the Taliban was in power, but it is not nearly enough of an improvement.

Are Afghan women empowered by birth? Hardly, but they don’t count because the “accomplishment” is not giving birth and surviving. It’s having access to excellent health care and state of the art pain relief and then refusing it.

How about the women who are permanently disabled by childbirth? How about Esther?

Esther gave birth to her second child, Manuel, less than one year ago. She was encouraged to stay at home to deliver the baby, where she labored for three days with the help of a traditional birth attendant. Fortunately, she gave birth to a lively baby boy. However, after four days she noticed she was leaking urine and was unable to control it…

Her husband decided that he couldn’t tolerate the smell of Esther in the house, so he left her and went away to Uganda with their cattle. Her in-laws asked her to leave the house and so she was forced to return home with her mother.

Esther “trusted her body” exactly the same way that Marissa did. If anything, her experience was much more difficult because it lasted longer and she had no choice but to endure it. How f**king strong is Esther? How powerful and accomplished is she while leaking urine into her vagina from an obstetric fistula?

Oh, right, we’ve already established that black, brown and poor women from developing countries don’t accomplish anything by giving birth without medical care because it is the refusal of medical care that’s the “accomplishment” not the birth itself.

Lest you think that maternal morbidity and mortality are problems only in the developing world, reading the ProPublica/NPR series on US maternal mortality should set you straight. The most recent piece is How Hospitals Are Failing Black Mothers:

Researchers have found that women who deliver at these so-called “black-serving” hospitals are more likely to have serious complications — from infections to birth-related embolisms to emergency hysterectomies — than mothers who deliver at institutions that serve fewer black women…

ProPublica did its own analysis …

We, too, found the same broad pattern identified in previous studies — that women who hemorrhage at disproportionately black-serving hospitals are far more likely to wind up with severe complications, from hysterectomies, which are more directly related to hemorrhage, to pulmonary embolisms, which can be indirectly related…

This is not the developing world, and it isn’t the world of rural poverty.

We found, for example, that SUNY Downstate, where 90 percent of the women who give birth are black, has one of the highest complication rates for hemorrhage across all three states. On average, 34 percent of women who hemorrhage while giving birth at New York hospitals experience significant complications. At SUNY Downstate, it’s 62 percent.

Just how f**king strong are those black women suffering hemorrhages, hysterectomies and death?

Oops, I forgot; they don’t count because they’re black and many are poor. In order to be “f**king strong, you must be white, privileged and have easy access to the highest quality medical care.

Many people have professed themselves to be shocked by the ProPublica/NPR series, but there’s nothing new there. Black women have been dying in the US for lack of high risk obstetrical care for decades.

Why has no one been paying attention? Because the provision of obstetric care has been warped by the natural childbirth industry of privileged white women. They believe that when it comes to obstetric care “less is more.” They believe that refusing obstetric care is a sign of power, when, in reality, it is nothing more than a sign of privilege.

Black women don’t fit that narrative. For them, less isn’t more; it isn’t even enough to save their lives.

Their tragedies have been ignored. The public health discussion has been dominated by those who decry the C-section rate and the rate of other interventions, the obsessions of the privileged.

Homebirth is the designer handbag of birth. Owning a designer handbag doesn’t make a woman powerful or accomplished; it simply a sign of status for those women who already have power and privilege. Women like Marissa are not f**king strong, they’re just f**king privileged and they don’t even have the decency to acknowledge it.

It’s time for another year end round up. These were the most popular posts of the year, starting with the most popular:

Ten Month Mamas cheer a mother to her baby’s death

Homebirth, like most of alternative health, is about two things. Not mother and baby; don’t be silly! It’s about defiance and denial.

Homebirth especially is about defiance. Women routinely risk their baby’s lives — the greater the risk, the better — while flaunting their transgressiveness before their peers. That’s why there are so many Facebook groups built around the specific complication they are defying. Groups like Ten Month Mamas and its secret section…

Melissa Cheyney and the Midwives Alliance of North America finally acknowledge their hideous death rates

[pullquote align=”right” cite=”” link=”” color=”” class=”” size=””]Pseudoscience is deadly![/pullquote]

I’ve been writing about homebirth for more than a decade. For most of that time, the Midwives Alliance of North America (MANA) and Melissa Cheyney, the Director of Research for MANA have insisted that their data show that homebirth is safe.

In every category — with risks or without — homebirth increases the risk of fetal/neonatal death substantially and often enormously.
In the meantime, the publicly available data on CDC Wonder has made it possible for me to demonstrate that homebirth deaths rates have been 3-7X higher than comparable risk hospital birth. Amos Grunebaum, MD and colleagues have published several papers using the same data and confirming my analysis. The most comprehensive analysis of homebirth death rates was performed by Judith Rooks, CNM MPH for the state of Oregon. Rooks found that homebirth midwives had a perinatal death rate 800% higher than comparable risk hospital birth!

Now, MANA and Cheyney have finally relented and published their own data that shows that PLANNED birth at home or in a birth center (generally just a rented home without special equipment) in the US has death rates EVEN WORSE than we imagined…

If stop signs work, why should my refusal to stop hurt you?

If vaccines work, why should my refusal to vaccinate my children hurt your children?

In the world of anti-vax, this is supposed to be an incisive, penetrating question. Of course, in the world of anti-vax, there’s not a whole lot of thinking going on. To understand the foolishness of the question, it helps to think about a similar issue.

Joe has done his research and decided that stop signs don’t work.
If stop signs work, why should my refusal to stop hurt you? …

Modern Alternative Mama and the ugliest parenting post I’ve ever read

…Kate seems to have forgotten the most monumental parenting mistake she ever made. Six years ago, when her daughter was only 3, her son was todder and she was expecting her third child, she wrote the ugliest parenting post I have ever read. It put her on the map, garnering national attention.

It was a vicious attack on her little girl, titled Mom Confession: I Think I Love My Son a Little Bit More, published on the parenting website Babble. The title, while bad enough, does not convey the full repulsiveness of the piece…

Babies die because lactation consultants lie

…[P]eremptory treatment of mothers by lactation consultants — ignoring their concerns about starving babies, in particular — has been going on for decades, but everything changed when Jillian Johnson shared the story of her son Landon’s death from dehydration due to insufficient breastmilk (If I Had Given Him Just One Bottle, He Would Still Be Alive). The issue rose to public consciousness in a way that it never had before, prompting new attention and hopefully a wholesale review of relentless effort to promote breastfeeding…

Alternative health, Dunning Kruger and the Tuteur Corollary

I’ve spent the last few days wrangling with anti-vaxxers on the Skeptical OB Facebook page. I wasn’t arguing with them since a doctor can no more argue immunology with anti-vaxxers than a mathematician can argue calculus with a four year old. Neither knows enough to come to grips with the actual subject.

Most four year olds would be quick to tell you that they don’t understand calculus, but most anti-vaxxers aren’t nearly so self aware. As victims of the Dunning Kruger effect, they actually think they know what they are talking about…

Pity The Milk Meg, whose self esteem resides in her breasts

… For all we know, Meg, you might be an abysmal mother, regardless of the fact that you shove your breast into your child’s mouth on a regular basis. Ask any child, teenager or adult; I’ve yet to meet anyone who thinks infant feeding has anything to do with good or bad mothering.

Please, Meg, find another source for your self-esteem that is more realistic and less fragile. Resting your self esteem on your ability to lactate makes as much sense as resting your self esteem on your blood count. It’s not merely foolish; it’s pathetic.

Breastfeeding can reduce SIDS risk nearly as much as pacifier use can

…[F]or every 10 non-breastfed babies who were going to die of SIDS, five of them would survive if all of them used pacifiers.

Breastfeeding your baby is nearly as good as a pacifier!

New mother commits suicide over breastfeeding pressure

…Postpartum depression, like all clinical depression, is a multifactorial problem. No one can say for certain what causes it. But we can say for certain that bullying makes it worse. And contemporary breastfeeding advocacy is BY DESIGN a form of bullying.

Yet another homebirth death and yet another wall of denial

…Why did this happen? It happened because R’s mother chose homebirth with undereducated, undertrained, ideologically brainwashed midwives.

It happened because magical thinking — positive affirmations, having no fear — has NO impact on the incidence of complications and death.

It happened because intermittent Doppler monitoring is not as accurate as electronic fetal monitoring…

Autism, bleach and pre-rational beliefs about illness

Yes, this woman is dosing her autistic daughter with BLEACH. Why? Because a quack declared that autism is caused by parasites and that ingesting bleach and bleach enemas can kill those parasites. This was posted in a Facebook group that has thousands of members dedicated to treating autism with bleach.

You don’t need to be a physician to know that bleach is toxic and these parents are literally poisoning her daughter. This is the worst kind of medical child abuse imaginable and sadly her ignorant parents are abusing her not because they don’t care about her but because they do…

Ina May Gaskin and the racism of natural childbirth advocacy

…[T]his is just the latest effort in which natural childbirth advocates in general and Ina May Gaskin in particular engage in medical colonialism, expropriating the tragedies of Black women to advance a philosophy created by and for Western, relatively well-off white women.

Natural childbirth advocates in general and Ina May Gaskin in particular engage medical colonialism.
It goes all the way back to Grantly Dick-Read, the founder of the natural childbirth movement, who was a racist and a eugenicist …

If there’s a theme that unites these twelve posts, it is this: pseudoscience is deadly!